Article Text
Abstract
Inadequately remedied abuse and neglect has costly implications for children's physical and emotional health, behaviour, growth and development. It is relevant to major physical and psychological causes of adult morbidity and mortality, involvement in crime as victim and perpetrator and parenting difficulties, but not inevitably so. Resilience varies, and its promotion is a professional priority. Achieving recovery is a complex therapeutic task, often extending over years, not simply a matter of providing new parents. Neurobiology increasingly explains why this is so. Effective safeguarding means keeping long-term responsibilities in mind throughout. Balancing risks and benefits of intervention requires consideration of the implications of the quality of relationships which neglect and abuse reflect. The aim of this paper is to contribute to the understanding of recovery, and paediatricians' roles in achieving it.
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Introduction
Abuse is about relationships. So is recovery. Whereas physical injury may heal rapidly, consequences of its emotional context are wide-ranging, life long and often intergenerational. Children's emotional environment relates by multiple routes to their physical and mental health, growth, development and behaviour. Early abuse predisposes to adult obesity, depression, cardiovascular and respiratory disease, and premature ageing, and to substance abuse, criminality and victimhood, relationship difficulties and inadequate parenting. Its public health implications should make its remedy a priority of research and practice.1,–,7
Identifiable neurobiological consequences of abusive parenting help to explain the complexity of recovery and the fallacy of supposing children safe in the absence of demonstrable trauma.8,–,11 When safeguarding children, deciding how and when to intervene requires consideration of the implications for the long-term task of achieving recovery of the disturbed relationships surrounding neglect and abuse.
Alternative parenting alone is an insufficient remedy. Recovery is an active therapeutic task, often extending over years. Outcomes for young people leaving care are poor,12 13 and the therapeutic efficacy of adoption uncertain. Risks of removal from home and consequent professional responsibilities must be realistically balanced with anticipated benefits.
Service structures and training need to bridge the gap between paediatric and Child And Adolescent Mental Health Services (CAMHS) to ensure that consideration of the implications of the psychological context of abuse is integral to safeguarding.
What does recovery mean?
Achieving recovery means equipping children, despite adverse foundations, to function effectively both independently and through relationships. Children's perceptions of others, themselves and the world, communication, adaptability and resilience are shaped by the disturbed attachment underlying neglect and abuse, often complicated by intrauterine exposure to drugs, alcohol and stress, perinatal difficulties, trauma and moves (table 1).14 Infants cannot regulate stress independently and depend on well-attuned parents to do so for them. Parents' effectiveness in doing so influences programming of the stress regulation systems, probably influencing gene expression at an epigenetic level, with life long and potentially intergenerational implications.7 8 Recovery from inadequate early care involves managing the consequences of ineffective early regulation.
Early foundations run deep. For young children, things are as they are: dysfunctional parenting and strategies for living with it become their norm, and a template for other relationships. Healthy relationships mean learning unfamiliar rules.15 The quality of the infant's first relationship remains important, as intuitive as a first language. If this is of neglect, a child may need to learn the vocabulary and grammar of healthy relationships.
Recovery involves changing fundamental assumptions which mould feelings and behaviour, and influence development. It involves learning the value, purpose and safety of relationships, self-perception as likeable, worthwhile and competent, self-awareness, effective verbal and non-verbal communication, self-regulation, adaptability and resilience, adjusting perceptions of normality and experiencing success. It may mean adjusting feelings deriving from early trauma which, unprocessed, cause confusingly unpredictable changes of mood and behaviour.16
Principles and priorities
The legacy of abuse is multifaceted. Recovery is a complex long-term task, with constantly moving goal posts of maturation and changing personal, social and academic demands. Foundations remain important, however well the higher developmental layers are built, although neuronal plasticity allows resilience.
Abuse is, essentially, a problem of distorted relationships. While simply providing new parents is rarely sufficient, they are nevertheless the principle tool of recovery. A professional priority is to equip them through advice, support and adequate respite to facilitate this.
The aim is, through parents' responses, to help children to modify their preconceptions of relationships, themselves and the world, while remedying continuing difficulties reflecting dysfunctional foundations, helping stress regulation and anticipating problems emerging with increasing demand and maturation. The task is primarily of helping family relationships, resisting seeing the child as ‘the problem.’ Any relationship is a two-way process: parents' contribution is as important children's.17 Carers have their own responsibilities, vulnerabilities and preconceptions, and need sensitive support in managing these.
Adequate parental attachment is the over-riding priority for every child, and a prerequisite of good recovery (table 2). For adoptive parents, love for the child is usually the sustaining hope, and, once established, a safety net allowing tolerance. Inadequate attachment is, from either perspective, a source of vulnerability, carrying a risk of cascades and vicious circles of difficulty. Closeness usually comes in peaks and troughs, often precipitate. Crises must be anticipated, and services organised accordingly.
Recovery rarely follows an orderly sequence. Its strands progress simultaneously as much as sequentially, inter-relate and merge. Children dip in and out of behaviour adaptive to previous dysfunctional parenting. It is a process of easing forward rather than ‘fixing.’ Building self-esteem is a priority throughout.14 18 19 Behavioural difficulty should not be assumed to be inevitable, but equally, its absence is no guarantee of emotional well-being.
Children may first need to learn to value attention. Having done so, they are liable to remain insecure in its availability. Parents can safely assume that behaviour achieving interest may be reinforced. So can professionals. For example, the handling of aggression, sexualised play or alleged abuse readily establishes a reliable route to attention. Therapeutic work focused specifically on unwanted behaviour may perpetuate it.
Children must function in the world while learning how to do so. They need protective cocoons, but also exposure to normality if they are ultimately to handle it independently. By attuning to their feelings but not too much, parents can ease them towards normal expectations. They need to be cushioned while they mature sufficiently to understand their circumstances and their implications.
Allowance is less readily made at school. Difficulty relinquishing attention and control, regulating stress and handling change, and vulnerability to failure and rejection make school demanding. Many children struggle to succeed socially, academically and behaviourally. Teachers, like parents, need to see through the child's eyes, recognise the preconceptions, feelings and regulatory difficulty underlying their behaviour, and understand the process of recovery.20 Addressing problems promptly helps to avert vicious circles. However, development of ability, academic, physical or creative, is equally important. Children need success and normality as much as remedy of weaker areas.
The hope is gradually to weave in resilience and personal responsibility, conveying that although the past cannot be changed, it need not dominate the future, and may be used well. To achieve this, children need a realistic story, which protects identity and self-esteem by explaining the origins of their parents' difficulties.
Key elements of professional services are continuity, availability, insight into carers' and children's feelings, and pragmatism focused on priorities. The task involves forethought and attention to detail, but with an eye always on the whole picture. Evidence, as it develops, requires wise application, because of the multifactorial complexity of the task.
Safeguarding as a route to recovery
Whereas ‘safeguarding’ and ‘child protection’ imply defensive purpose, they need to be seen as routes to recovery (table 3). This means recognising the long-term implications of early dysfunctional relationships, the progressive irreversibility with age of their impact on brain growth,21 the possibility of critical developmental periods, and the diminishing likelihood of finding and retaining alternative parents.22,–,24 It requires an eye as much on the long-term as on immediate protection. Consideration of the emotional environment and family attachments must be integral to safeguarding: psychological well-being and behaviour determine the likelihood of achieving a home, adequate attachment and recovery.
Most abusing birth-parents experienced similarly dysfunctional parenting, often leading to substance abuse, learning difficulties, psychiatric illness and temper problems.22 Many are vulnerable to rejection, and lack negotiating skills, self-esteem, trust, agency and adequate intuitive attunement to promote secure attachment. Their children's needs, once neglected, are complex. Skilled support is needed to achieve sufficient change soon enough. Even if they cannot, their role matters, whether providing significant items or information for their child or ‘giving permission’ to move.
Decisions to remove children from home should be tempered by awareness of the responsibility which follows—effectively, if not legally, contributing to corporate parenting. An alternative home needs a defined purpose, with tasks necessary to achieve this identified. For example, beyond immediate safety follows assessment of where optimal permanent parental attachment may be achieved. Answering this involves considering factors contributing risk (eg, parents' traumatic childhoods, substance abuse, temper dysregulation), which are remediable, to what extent, how soon, the likelihood and the implications of delay. It involves assessing the quality of attachment, parents' capacity to change, and children's principal relationships within and outside the extended family, including with siblings. It involves identifying current physical, developmental and emotional manifestations of dysfunctional parenting and their implications if uncorrected.
The probable efficacy of alternative parenting requires realistic consideration: the assumption behind removal is that outcomes will improve. Few who remain in care fare well: adoption is encouraged instead, but many for whom it is intended fail to achieve or sustain it;22 its therapeutic use is incompletely evaluated from the perspective of children or adopters, not least because outcomes follow long after intervention.23
Every move is a risk requiring planning, preparation and support. Children's reactions to separation from everything familiar are readily misattributed to previous parenting. Emergency moves without preparation compound the trauma and must be fully justified. Abuse is often longstanding; children are usually at some level attached to the most dysfunctional parents. Many have been warned about strangers, to fear authority and that if they misbehave they will be taken away. Reinforcement of the perception that close relationships are transient, love finite, acceptance conditional and attention to be grasped by any effective means have long-term implications for self-image, the perceived safety of closeness and behaviour.
Moving with siblings can be protective, or not.25 26 Children's relationships reflect parenting. Attention-thirsty siblings often resemble see-saws, thriving on each other's misdemeanours, one's success driving the other to insecurity-fuelled challenge. Many who have been ‘parent’ or protector struggle to relinquish control. Selective rejection causes particular vulnerability in new homes.24 Persistent sexualised behaviour between siblings compromises recovery. However, dysfunctional relationships do not preclude closeness or mutual dependency but may mask them: separation brings loss, blame and guilt.
Insecure children and new parents make a hazardous combination. The behaviour of distressed children may overwhelm carers unfamiliar with their easier attributes, without a safety-net of mutual attachment. Children who have experienced disrupted placements may seek to pre-empt rejection. Those who perceive acceptance as conditional on ‘behaving’ may test to the limit of parental tolerance. They have no basis for understanding that parents are ‘for ever’—perhaps even useful. Their experience is that, at best, close relationships do not sustain; at worst, that they are unhelpful, unpredictable or frightening. They cannot know whom new carers will resemble and may experiment with maladaptive, once effective behaviour. They understand dysfunctional relationships, but not healthy ones.
Identifying optimal carers, stabilisation, development of attachment and recovery are active tasks requiring professional planning and attention to detail. Assessment, helped by professional continuity, involves identifying issues essential to the choice and preparation of carers (eg, difficulty sharing attention, maladaptive attention-seeking, sexualised behaviour) and protective relationships.
‘What have we done?’: supporting adopters
Most adopt because of infertility,22 facing substantial adjustment from the hope of pregnancy to the reality of parenting traumatised children. The magnitude of change in lifestyle and family relationships may be unanticipated despite preparation. Intellectual understanding is often a far cry from the experienced reality.
Adopters' feelings are frequently not as they anticipated or their friends and relatives assume, causing fear, self-doubt and guilt: reassurance is needed of their normality. Loss frequently resurfaces, bringing unintended comparison with imagined birth children. Distressed children's behaviour may raise uncomfortable reminders of dysfunctional birth-parents; occasionally it revives unanticipated feelings from adopters' pasts. New adopters face disturbing uncertainty that attachment will grow. Instinctive protection of children already in the family makes newcomers vulnerable, particularly if insecurity establishes behaviour upsetting to them as a reliable route to attention.
Adopters often feel frighteningly inept, faced with the confusing behaviour of children new to their care. Enabling parents to see through their eyes helps behaviour which otherwise feels undermining, personal, confusing and manipulative to be recognised as the learnt self-protective strategy it represents. Children's perceptions are judged by piecing together what is known or assumed of their earlier experiences, alongside their current behaviour.14
Behaviour generally serves a purpose. It is determined by the anticipated response, which may, however, be founded in early parenting. Attention and control are usually central issues—the extent to which attention is perceived as valuable, safe and reliable and control as safely relinquished. Belief that attention is valuable but unreliable results in grasping it by any effective means, positive or negative, that it is dangerous or unhelpful in autistic-like avoidance. Belief that control is not safely relinquished encourages opposition, intolerance of change and obsessionality. Following neglect, behaviour is frequently further coloured by impulsivity, anxiety, fear of rejection and consequences of traumatic ‘flashbacks.’16
The abnormal may be a child's normal, established through early experience. For example, sexualised play with dolls may have as little emotional significance as feeding them if sexual activity has been commonplace. It should be seen though children's, not adults', eyes. Sexualised behaviour towards carers, learnt to achieve approval, attention or closeness, may, perplexingly, provoke criticism or rejection and sometimes denial of physical closeness.
Simple principles go far: first, consistent expectations and consequences of behaviour, and attention for what is wanted. Some children up the stakes with behaviour which few can ignore (eg, smearing, endangerment, hurting others). Parents are encouraged to empathise with the feelings underlying behaviour, and with those evoked by necessary consequences. Clear but unemotional boundary setting is the aim, variably achieved, and rarely so by tired, stressed parents: self-care is a responsibility, not a luxury.
Perseverance is needed when poor self-esteem and unfamiliarity with success cause rejection of praise and sabotage of celebration; removing treats may prove ineffective discipline. Challenging behaviour may drive adopters to guilt-inducing responses. However, normal parents teach children about normal relationships, and that anger does not mean rejection. Difficult times allow modelling of apology and reconciliation. Parenting traumatised children involves taking on their troubles, and difficult feelings feel difficult.
For some, closeness naturally grows. Others need considerable support. Demystifying attachment helps adopters to apply experience from other relationships, reducing factors which interfere (eg, fatigue, stress) while increasing those which help (eg, shared calm).27
Paediatricians need to be equipped to offer timely support, feeding into other services, or obviating the need (table 4).
Unregulated stress
Difficulty handling stress is a common, costly legacy of early trauma. Western medicine is ill-equipped conceptually and structurally to address it, straddling mind and body and defying specialisation. Development of understanding is jigsaw-like. Pieces can be described, their position sometimes not. Children cannot wait for evidence: practice requires pragmatism.
The hypothalamus–pituitary–adrenal (HPA) axis, dopamine and serotonin systems, are programmed in pregnancy and postnatally.28 Infants rely on parents to regulate their stress. Poor attunement allows overactive programming, or sometimes downregulation, perhaps following unremitting stress. Abnormal salivary cortisol, reflecting HPA function, correlates with conduct disorder and attention-deficit/hyperactivity disorder (ADHD)29 30 and continues into adulthood, accompanying depression and post-traumatic stress disorder.31 32 It may contribute to somatiform problems.33 Dysregulated stress compromises family stability and attachment, and often persists despite adoption.22
Difficulty handling stress and excitement is manifest as frustration, anxiety, temper, inattention and ‘spoiled’ treats and celebrations. Anger, often compounded by fear of failure, poor negotiating ability, anxiety, difficulty handling change, ADHD—and adolescence—carries risk of rejection at home and school. Anger towards birth parents may be focused onto adopters, often fuelled by ambivalence to closeness. Children mirror parental stress, and exposure to violence may predispose neurobiologically to temper. For some, all emotion is as experienced as one: anger is selectively and excessively identified and expressed.34 Others fail to express emotion. Behaviour regarded in toddlers as ‘tantrums’ is seen in older children, or without attachment, as ‘violence,’ which feels personal, rejecting and frightening. Children ‘erupt over nothing,’ ‘flaring from 0 to 100, nothing between,’ eyes changing, control lost, often likened to Jekyll and Hyde.
Parental stress regulation is a prerequisite of that of children, teaching them by role model, discussion and play to calm through others and independently, demonstrating apology and reconciliation, boosting self esteem and helping emotional literacy. Children can be encouraged to create their own ‘calm corner,’ to use frequently to give positive associations, and not only when calming is needed. Reduction in salivary cortisols suggests benefit from input designed to help regulation though relationships.35,–,37 Treating ADHD allows emotional awareness and regulation; risperidone helps some to manage temper.38
Clinical measures of autonomic arousal, their predictive value and the management of under- and overactive responses need development (box 1). Practical approaches such as creativity, physical activity, massage, meditation (influencing HPA activity)39 and yoga40 warrant exploration alongside neuropharmacology. However, for some, ‘mind clearing’ relaxation techniques allow intrusive traumatic flashbacks, so application needs caution.
Box 1 Stress regulation
Managing parental stress
Reduce anxiety (eg, explaining feelings, attachment, children's behaviour)
Recharge (eg, exercise, relaxation)
Managing children's stress
Reduce anxiety (eg, routine, consistency, reassurance, allowing success)
Ensure adequate sleep (eg, daytime exercise; calm prebedtime routine)
Teach calming and stress releasing strategies:
▶ ‘Calm corner’; visualising calm scenes, calming music
▶ Meditation, yoga, etc
▶ Exercise (eg, punch bag, trampoline); singing; dance
▶ ‘Portable’ calming (eg, stress balls; breathing/blowing games)
Teach body awareness (eg, feeling the heart rate during calming)
Encourage calming through relationships
▶ Talking about feelings; shared calm; massage
▶ Offering closeness when tired, hurt, etc, even if not sought
Pre-empt unregulated excitement (eg, birthdays)
Limit high sensory stimulus (eg, computers, fluorescent lights, crowds)
Consider medication (eg, methylphenidate, risperidone)
To label or not?
‘Normal’ responses to abuse generate characteristics consistent with, but not necessarily entirely typical of, numerous labels, including ADHD, autistic spectrum disorder, obsessional compulsive disorder, oppositional disorder, dyspraxia, reactive attachment disorder, anxiety, depression and post-traumatic stress disorder. Labels bring variably justified assumption. Children characteristically have multiple inter-relating difficulties deriving from early experiences: diagnoses are often a clumsy fit and diagnosis-based guidelines an incomplete reflection of their priorities.
Assessment of ‘ADHD,’ ‘autism’ or developmental delay requires an understanding of the complex inter-relationship of issues involved, rather than considering these in isolation. ‘ADHD,’ typical and atypical, is an association, a cause and an effect of disturbed attachment. Familial risk, often compounded by intrauterine substance exposure or violence, is high and may underlie parents' substance abuse and temper. It compromises achievement of a home, mutual attachment, friendship and self-esteem. Treatment should focus pragmatically on the priority of adequate attachment, helping children to seek attention appropriately, understand emotion, read social cues and use psychological help.
Diagnosing ‘reactive attachment disorder’ carries a risk of identifying the child as the problem. Conceptually, describing how children understand relationships, and why, may be safer, recognising that attachment is inevitably vulnerable following neglect, abuse and moves, but dynamic and modifiable through experience.
Once given, labels can be difficult to shed. Early traumatic parenting may leave children adept at adjusting to expectations: they may conform more readily than most to the assumption brought by labels, with risk of self-fulfilling prophesy. Facing adolescence with numerous ‘abnormalities’ compounds vulnerable self-esteem and worries about identity and difference.
Labelling can be a route to achieving necessary services but needs circumspection, balancing disadvantages and advantages.
Professional responsibilities and service structures
Organisation and funding of services should reflect the multifaceted, long-term nature of recovery, the need for attention to detail, the inevitability of crises until protective attachment develops and the inter-relationship of developmental, emotional, behavioural and physical sequelae of abuse, educational experience and parental well-being. Contributory disciplines need common understanding to ensure that good psychological care is integral to practice. Separation of CAMHS and paediatric services poses particular risk: the gap needs to be bridged robustly in training and practice.41
Emotional assessment and ‘reading’ of the quality of attachment should be routine in safeguarding. Physical safety may otherwise be achieved at the cost of emotional harm, damaging relationships overlooked, costly delay allowed and the likelihood of successful reparenting compromised. The approach to achieving physical safety influences recovery. The risk of moves may be reduced through placement choice, preparation, and support of carers in the vulnerable early stages.23
Political and media-driven selective focus on physical protection is to be resisted, recognising that inadequate emotional care may carry the greater risk. All who are involved in safeguarding need the opportunity to relate the progress of alternative care to decisions about intervention.
Children's emotional needs and behaviour determine the success or otherwise of reparative placements. Those undertaking statutory health assessments for children in care should address these without deflection by the pressure of measurable targets. Their contribution should be integral to social services reviews.
Paediatricians need to provide advice, rapid availability, continuity and advocacy, working alongside and feeding into specialised psychology services and liaising with schools. They need to understand the nature, purpose, timing and limitations of therapeutic services. In referring, they should know what question they are asking. Expertise in helping attachment difficulty is growing.42,–,44 However, pursuing increasingly specialised services in a quest to ‘put things right’ sometimes needs to be discouraged when the natural history realistically requires easing forward, not ‘fixing.’ Identifying progress encourages parents that their care can continue it (box 2). Confiding in parents helps closeness; children can communicate in their own time. However, some feel safer keeping difficult feelings separate from home. Many need help to establish or protect relationships—for example, if anger towards birth parents is projected onto adopters or closeness is feared.
Box 2 Therapeutic services: considerations and tasks
Considerations
▶ Risk of placement disruption requires urgent assessment and support
▶ Therapeutic work may be needed before a move to enable a child to accept new parents
▶ Professional continuity is important to assessment when children move
▶ New carers need to understand children's anticipated feelings and behaviour before placement
▶ Any early therapy should focus on stabilising the placement
▶ Therapeutic work with a child early in a placement may affect confiding in and attachment to carers
▶ Work may be principally or entirely through parents
▶ New parents may need therapeutic help with feelings of loss and inadequacy when parenting a recovering child
▶ More than one modality of care is often needed
▶ Therapy only for the child can label them as the problem, discouraging working through relationships
▶ ‘Life story work’ may be seen as social services' job, whereas it is often integral to necessary Child And Adolescent Mental Health Services work
▶ Adopters need realistic expectations of recovery and therapeutic services
▶ Therapeutic support may need to be repeated as children mature
▶ Service structures need to offer continuous baseline services with episodic specialised care
Tasks
▶ Preparation for and support following moves
▶ Helping attachment
▶ Behaviour management
▶ Helping children to understand their circumstances, overcome perceived rejection, address confused identity
▶ Management of depression, obsessional compulsive disorder, anxiety, ADHD, post-traumatic stress disorder
▶ Addressing feelings underlying dysfunctional coping strategies
▶ Managing emotional dysregulation and temper
▶ Promoting social skills
▶ Managing sexually abusive behaviour
Continuity matters in understanding children's and families' needs, avoiding the distortion of the snapshot view. It helps interpretation of disturbed behaviour following moves, or when children's hypervigilance produces overadjustment to presumed expectations. It reduces the risk of dismissing behaviour as ‘difficult because it would be.’ Pre-established trust helps safe management of crises.
Current professional trends do not necessarily suit this work. Emphasis on evidence leaves vulnerable services where its absence as often reflects lack of practically applicable research as of efficacy. Economy-driven drift towards evidence-based rationing is particularly problematic.
Clinical research is needed into markers of emotional neglect, and its neurochemistry and pharmacology, including possible use of oxytocin and vasopressin in helping attachment, fish oil supplementation in modifying stress responses and corticotrophin releasing factor antagonists in managing HPA axis dysfunction.45,–,47
Conclusion
Supporting recovery from abuse and neglect is a long-term multiprofessional task, requiring a broad perspective, initiative, pragmatism and attention to detail. It involves bridging gaps between professional groups, particularly between CAMHS and paediatricians.
Effective safeguarding requires an eye as much on the long term, as on immediate physical protection, with good emotional care integral throughout. It involves accepting responsibility to help those removed from home to achieve a family and adequate attachment, by assessment, preparation and timely support.
Difficulties relating to abuse and neglect are multifactorial in cause, manifestation, consequences and management. They are fundamentally problems of relationships; recovery is principally achieved through relationships, requiring attention to each side of these. The relevance of dysfunctional stress regulation highlights an important gap in Western medicine. Research is needed into its clinical assessment, predictive value and management.
The cost of inadequately remedied abuse to individual physical and emotional health, the next generation and society should be a powerful incentive to develop services equipped in structure, function and ethos to support recovery.
Acknowledgments
The author is grateful to A Lister, M Sadlier and T Woodbridge for their helpful comments.
References
Footnotes
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Competing interests None.
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Provenance and peer review Commissioned; externally peer reviewed.