Triple-A Caregiving

A Brief Guide to Triple-A Caregiving

By Colby Pearce

Principal Clinical Psychologist, Secure Start 463 Belair Road
BELAIR
SOUTH AUSTRALIA 5052
(08) 82789358
0403350411
Email: colby@securestart.com.au Web: www.securestart.com.au
Blog: www.colbypearce.wordpress.com

© Not to be reprinted without the author’s permission

This paper is an abridged version of the book by the same author: A Short Introduction to Attachment and Attachment Disorder. London: Jessica Kingsley, 2009.

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Attachment Colby Pearce

AAA – ATTACHMENT, ACCESSIBILITY, AROUSAL

Attachment

‘Attachment’ is a term used to describe the dependency relationship a child develops towards his or her primary caregivers. It is first observable during the latter half of the first year of life and develops progressively over the first four years of life. It is most readily observed in the behaviour of children when they are sick, injured, tired, anxious, hungry or thirsty.

It is within the context of attachment relationships that young children learn about being in a relationship with another human being. In association with caregiver accessibility and sensitive responsiveness to their needs, children develop a sense of trust in others. Importantly, through the experience of emotional connectedness with the primary caregiver, children explore and integrate a range of emotions, and through shared emotional experiences the foundations of a capacity for empathy are developed. Through their efforts to please their caregivers and avoid displeasing them, children internalise (that is, understand and accept) social rules and learn to restrict their impulses to engage in seriously aberrant behaviour (i.e. behaviour that is not socially accepted and which compromises the quality of the child’s interactions with others) and extreme displays of negative affect. Children’s behaviour and affect becomes regulated by a concern for maintaining positive and loving relationships with their caregivers, thus establishing the foundations for a life of lawfulness, positive relationships with others and successful care of their own children.

Attachment Representations are the attitudes and beliefs a person develops regarding self, other and their social world. These attitudes and beliefs develop in the context of the infant’s first attachment relationships and reflect the infant’s experience of the accessibility, sensitivity and responsiveness of their primary caregivers. Figure 1 illustrates attachment representations associated with attachment security/disorder and representations of self and other.

The securely attached child develops a mostly positive attachment representation of themself, their caregiver, and their world. In association with their experience of accessible, sensitive and responsive care, they perceive themself as worthwhile/wanted (“I am loved”), safe (“My caregiver protects me from harmful experiences”) and capable (“My caregiver is encouraging and supportive of my efforts”) 1. They develop basic trust, an expectation that the world will generally be safe and that close relationships will be satisfying. The securely attached child has a well-formed conscience, a sense of right and wrong that grows out of their desire to please their attachment figures and avoid displeasing them. The securely attached child shows awareness of their needs, a range of genuine emotion, and the ability to identify and express needs through spoken language. Though elements of negative attachment representations are sometimes in evidence, positive attachment representations predominate.

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Attachmentworking models(Source: Pearce, C. A Short Introduction to Attachment and Attachment Disorder. London, Jessica Kingsley, 2009)

In contrast, the attachment representations of severely maladjusted, attachment-disordered children are essentially negative. In association with rejecting, frightening or abusive care, these children view themselves as worthless (“I am bad and unlovable”), unsafe (“My caregiver will not protected me from traumatic experiences”) and impotent (“It is impossible to get my caregiver to respond consistently to my needs”) 2. They view their caregivers as unreliable, unresponsive, rejecting and threatening. They expect intimate relationships to be undependable and ultimately frustrating of their needs. They use manipulation as a means to make their caregivers and others (e.g. teachers) behave in predictable ways in order to promote feelings of security. Though elements of positive attachment representations are sometimes in evidence, negative attachment representations predominate

The attachment representations of insecure children are neither entirely positive nor negative. Rather, they seem to occupy the middle ground, unsure of themselves, others and their place in the world. These children seem to be more likely to engage in testing behaviour rather than coercive or manipulative behaviour. This is likely to have arisen in the context of inconsistent caregiver accessibility and responsiveness, resulting in a child who is perpetually unsure.

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Accessibility

In the 1930’s, Experimental Psychologist B.F. Skinner developed an apparatus to study learning behaviour in laboratory animals. Referred to as the Skinner Box, this box-like apparatus incorporated a lever or bar, and a food shute. Rats were placed in the Skinner Box and exposed to three learning conditions. In the first condition, a pellet of food was delivered via the shute each time the rat pressed the bar or lever. This condition was referred to as continuous reinforcement. The rats quickly learnt that by pressing the bar or lever they would receive food. In the second condition, a food pellet was delivered randomly, such as on the first, fifth, eighth, or thirteenth, press of the bar or lever. This condition was referred to as intermittent reinforcement. The rats learnt more slowly that by pressing the bar food would be delivered. In the third condition no food was delivered through the shute, no matter how many times the rat pressed the bar or lever. The rats in the first condition appeared to press the bar or lever when they required food. The rats in the third condition soon stopped pressing the bar. The rats in the second condition pressed the bar persistently, even after food was no longer delivered in association with presses of the bar or lever.

Adjustment problems in children might be seen to arise in the context of care that reflects conditions two and three referred to above; that is, care that involves inconsistent needs provision or a persistent failure to offer needs provision. As a result, maladjusted children often become inordinately preoccupied with accessibility and sensitive responsiveness to perceived needs. This manifests in persistent requests of their caregivers with respect to perceived needs (arising under conditions akin to condition two), coercive attempts to draw attention to perceived needs (i.e. manipulation), and acts of deceit (eg stealing) to secure access to perceived needs (arising under conditions akin to condition three). Perceived needs may reflect actual, current needs, such as the need for food, drink, clothing, shelter, assistance and protection. However, among maladjusted children, perceived needs often reflect needs that, historically, were unmet and/or inconsistently responded to, under conditions where care was deficient or inconsistent. Deficient or inconsistent care can arise in association with recurrent illness in the child during its first two years of life (e.g. chronic reflux and colic, recurrent ear infections and tonsillitis, asthma), failure of the parent to bond to the infant/child, institutional care environments where there is a large ratio of children to adults and children are left unsoothed and not responded to for protracted periods of time, and in association with caregiver mental health problems, substance misuse, domestic disturbance, illness and incapacity.

A further consequence of inconsistent and inadequate needs provision is that many maladjusted children fail to develop a clear idea of how to consistently, successfully and pro-socially access needs provision. Rather, they throw at their caregivers a diverse range of behaviours and affective displays in the frantic hope that one might elicit needs provision, or secure access to needs provision via manipulation or deceit. The failure to develop and demonstrate consistent, successful and socially-sanctioned strategies to access needs provision is most obvious among children whose early attachments might be classified as Disorganised. The defining feature of the disorganised/disoriented infant3 and child is that they exhibit no consistent or organised attachment behaviour in response to reunions with their caregiver. Rather, they display bizarre and contradictory behaviours, such as seeking to be close to their caregiver but with their gaze averted, approaching the caregiver only to stop and stare before reaching them, engaging with and disengaging from their caregiver simultaneously, and incomplete movements and affective displays. In addition, Disorganised/Disoriented infants exhibit signs of worry in the presence of their caregiver, such that they might sit on the caregivers lap but with eyes averted, or might allow the caregiver to hold them but with their limbs stiff. They might also be observed to avoid or fail to seek out their caregiver when distressed or frightened and attempt to leave with a stranger rather than their caregiver. Disorganised attachment behaviour becomes self-reinforcing as adults fail to understand, feel overwhelmed by, and institute behavioural sanctions in response to behaviour that is perceived by them as aberrant and/or age-inappropriate, notwithstanding the fact that it was the child’s own manner of signalling that they required a response to a perceived need.

The inability to consistently and successfully access needs provision reinforces the maladjusted child’s perception of the world and others as harsh and uncaring, and of themselves as bad, unlovable and powerless. This promotes anxiety and maintains heightened arousal levels, which, in turn, results in problems of emotional and behavioural control. The maladjusted child requires understanding of what their behaviour represents and a response to the need as well as the behaviour. In addition, the maladjusted child requires assistance to develop clear, consistent, successful and socially-sanctioned strategies to access needs provision.

Arousal

The brains of maladjusted children are often chronically over-aroused in association with the child having been traumatised and/or inconsistently soothed in their primary dependency relationships. This leaves the child susceptible to anxiety and associated problems with learning, affect regulation (i.e. the ability to control the intensity of one’s emotions) and behavioural control.

Figure 2 illustrates the relationship between stress/arousal and performance/learning. A certain degree of arousal is necessary for peak performance and learning. However, there is a threshold beyond which performance and learning decline in association with increases in stress and arousal. This is best illustrated by the example of walking a balance beam. Most people can successfully negotiate their way across a balance beam raised off the ground by a house brick at each end. They consider themselves able and have no concerns for their physical safety. However, place the same balance beam between the windows of two adjacent buildings ten stories off the ground and most people would experience heightened states of anxiety/overarousal. They would be overwhelmed by fear regarding their physical safety. They would doubt their ability to successfully negotiate the balance beam. They would lose coordination and their performance would suffer accordingly, thus confirming their fear that they will be harmed and exacerbating their anxiety/overarousal. In association with their own chronically over-aroused state, the performance and learning of maladjusted children is similarly compromised.

ArousalandPerformance

(Source: Pearce, C. A Short Introduction to Attachment and Attachment Disorder. London, Jessica Kingsley, 2009)

Figure 3 illustrates how the chronically over-aroused state experienced by maladjusted children impacts adversely on their behaviour and emotions. In contrast to well-adjusted children, whose normal states of arousal rarely reach the so-called ‘threshold to madness’, or “anxiety threshold”, beyond which the organism has to release pent-up anxiety or suffer negative physical and emotional consequences, the chronically over-aroused, maladjusted child exists much closer to this threshold. Stimuli and events that have a comparatively minor impact on the well-adjusted child can much more readily push the maladjusted child past the ‘threshold to madness’, whereupon they seek to reduce arousal through aggressive and destructive behaviours (Fight), hyperactive behaviour (Flight) and/or dissociative behaviours (Freeze). The flight/fight/freeze response to heightened levels of anxiety/over-arousal is considered to have been naturally selected through evolution in order to achieve safety and wellbeing in the face of threats to the organism, much as attachment is thought to have developed through evolutionary processes. Seen in this way, aggressive, destructive, hyperactive and disengaged behaviours exhibited by maladjusted children are a necessary response to overarousal as their purpose is to neutralise a perceived threat. They should be met with understanding, empathy and other measures to assist the child to reduce arousal as opposed to anger and discipline alone, the latter only serving to perpetuate the child’s unsustainable levels of over-arousal and associated fight/flight/freeze response. Thus, arousal management is a key aspect to the care and management of maladjusted children.

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Figure 3. Patterns of Arousal and Over-Arousal

(Source: Pearce, C. A Short Introduction to Attachment and Attachment Disorder. London, Jessica Kingsley, 2009)

AAA – THE AETIOLOGY OF MALADJUSTMENT

The ability to gain access to need provision is a source of comfort for most people. As discussed earlier, maladjusted children have typically experienced inconsistent accessibility to needs provision, such that they become preoccupied with it. For these children the inability to consistently access needs provision is a source of significant worry, further elevating their already chronically high levels of arousal. Chronically high levels of arousal make maladjusted children prone to problems of emotional and behavioural control (e.g. temper tantrums). In turn, problems of emotional and behavioural control brings maladjusted children into conflict with others, thereby reinforcing their perception of themselves as bad and others as uncaring (negative attachment representations). Negative attachment representations undermine trust in others and result in diminished expectations of deservedness in the maladjusted child. A lack of trust in others and low expectations of deservedness result in increased preoccupation with accessibility to needs provision and worry about it, such that the cycle is perpetuated. This is the aetiology of maladjustment and is represented in Figure 4.

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Figure 4 The Aetiology of Maladjustment

(Source: Pearce, C.M. (2010). An Integration of Theory, Science and Reflective Clinical Practice in the Care and Management of Attachment-Disordered Children – A Triple A Approach. Educational and Child Psychology (Special Issue on Attachment), 27 (3): 73-86)

Although addressing one will create flow on effects in the others, the maladjusted child requires a response to each of the following: arousal, attachment representations and accessibility to needs provision. In doing so the aim is to promote positive adjustment and emotional wellbeing, as represented in Figure 5.

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Figure 5 The Aetiology of Positive Adjustment and Emotional Wellbeing

 

AAA Caregiving – First Principles

When considering what forms of care maladjusted children require, it is helpful to consider the conditions under which secure primary-attachment relationships develop. When children are born they are totally dependent on adults to care for and protect them. They are innately endowed with the capacity to call attention to their fundamental needs, but do not have the capacity to satisfy their needs themselves. They rely on adults to do so. They also rely on adults to make all the necessary decisions and take such action as keeps them safe from harm and promote their development. During the second year of life and in association with the infant’s capacity to move, the caring adult supervises them closely and maintains clear and consistent boundaries to keep them safe from harm. In addition, throughout the child’s infancy the caring adult demonstrates an awareness of the importance of maintaining stability and consistency of routines in order to facilitate a functional understanding of how one lives one’s life. The maintenance of routines is a source of comfort and reassurance to the child as it facilitates an understanding of the predictability of events and the behaviour and responsiveness of others.

When they are cared for by adults who consistently and accurately attend to their physical and emotional needs, infants develop a perception that adults are accessible, concerned about them, understand, and can be relied upon to respond to their needs sensitively. Similarly, in association with their experience of adults making decisions and taking action to keep them safe from harm and promote their development, children develop a perception that their caregivers care about them. These perceptions and beliefs allow the child confidently to go forth into the world, exploring and accepting challenges without inordinate fear of failure, such that all aspects of their development and adjustment are then promoted.

By “first principles” it is meant that the caregivers of maladjusted children should provide the kind of structured, understanding, responsive and regulated care environment that supports and nurtures the development of secure attachment relationships in young children and facilitates their positive socialisation. In practice, maladjusted children are typically directed rather than asked with respect to caregiver expectations concerning their behaviour, have most decisions regarding their care and wellbeing made for them by their caregivers, but have opportunities to experience adults as understanding, interested, responsive and fun. Importantly, caregivers of maladjusted children need to be authoritative, which means that have to set and maintain clear and consistent boundaries and avoid fighting battles with the child that they may ultimately lose. To regularly and repeatedly lose battles with a child weakens the adult and increases the child’s insecurity and associated maladjustment.

Finally, the most important achievements of the first two years of any infant’s life (which are particularly important goals in the care of a maladjusted child) are the development of a positive sense of self, other and the world (secure attachment representations) and the capacity to self- regulate emotion and arousal. These achievements arise in association with the infant’s experience and perception that adults are accessible, understanding and responsive to their needs. All other developmental achievements (e.g. bladder and bowel control; pro-social behaviour) follow on from these achievements. Hence, reassuring the child about caregiver accessibility and responsiveness is the first principle in caring for the maladjusted child.

AAA Caregiving – Addressing Accessibility Preoccupations

The inability to consistently and successfully access needs provision reinforces the maladjusted child’s perception of the world and others as harsh and uncaring, and of themselves as bad, unlovable and powerless. This generates anxiety and maintains heightened arousal levels, which, in turn, results in problems of emotional and behavioural control and problems in relatedness to others. The maladjusted child requires verbalisation of understanding regarding what their behaviour represents and a response to the need as well as the behaviour. In addition, the maladjusted child requires assistance to develop clear, consistent, successful and socially- approved strategies to access needs provision.

Verbalising Understanding of Accessibility Preoccupations

In association with their excessive worry regarding adult accessibility and sensitive responsiveness, the maladjusted child is often preoccupied with maintaining engagement with, and control over, the behaviour and feelings of others. This manifests in excessive clinginess, attention-seeking behaviour, demanding behaviour, and overtly controlling and manipulative behaviours (e.g. superficial charm and/or bossiness). The purpose of these behaviours is to reassure the child regarding accessibility to needs provision. Unfortunately, as many such behaviours are deemed age-inappropriate or otherwise deviant, and are either ignored or punished, the maladjusted child often experiences others as mean and uncaring, with resultant feelings of anger leading to distancing behaviour, followed by coercive attempts to re-connect. In order to address this, caregivers of maladjusted children should verbalise understanding of children’s accessibility concerns, provide reassurance and explain to the child how to access needs provision in a socially-approved manner. Due to the children’s high anxiety, the child’s understanding of how to successfully access needs provision in a socially-approved manner is only made possible by reducing anxiety through verbalisation of understanding, as verbalisation of understanding is reassuring to children.

Statements that communicate understanding of accessibility preoccupations include:

I think that you believe that I will forget about you if we are not always together.
I think that you believe I won’t notice or understand when you really need me/something. You believe that if I don’t do it [get it for you] now I will forget.
You worry that I won’t come back for you.
You worry that I don’t like you anymore.
You know you have done something wrong and you worry that I won’t like/love you anymore.

Emotional Connectedness

The maladjusted child’s twin motivations to ensure accessibility and punish and distance caregivers creates conflicting behaviour that leaves caregivers feeling like a yoyo. The maladjusted child draws the caregiver in to assure accessibility but, finding closeness uncomfortable, pushes them away again. A similar thing happens when a maladjusted child finds they cannot control caregiver behaviour to assure needs provision. This kind of approach-avoid behaviour is synonymous with disorganised attachment representations that commonly result in maladjustment.

In order to avoid cycling between closeness and distance, and reinforcing the same in the child, caregivers of maladjusted children are advised to maintain a smaller range of emotional connectedness to the child, being neither too close nor too distant. A consistent range of affect and associated behaviour that is neither too close nor too distant is reassuring for the maladjusted child, avoids over-stimulating them and puts the adult back in control of their emotional presentation.

This approach can be extended to the caregiver’s management of aberrant behaviour and affect. When the child is misbehaving, some accepted wisdom is to ignore it. However, this increases accessibility concerns leading to an exacerbation of the problem. A better strategy is to show a degree of genuine emotion and verbalise the rest (e.g. “I can see you are angry. I am angry too” [slightly angry tone]. Why don’t we have a hug so we both feel better.”). It is important to show a degree of emotion as it represents an attunement experience whereby the child feels emotionally connected to the adult, which is what they crave and which typically manifests in their coercive attempts to make others feel bad because they do. Using this method, the child feels understood, is not threatened by too much closeness or distance, and the caregiver has the opportunity to intervene and soothe.

Emotional Refuelling

By the age of approximately five months most infants become very selective about whom they want to respond to their needs. Prior to this they are generally happy to be cared for by any caring adult. From five months of age they tend to want the adult or adults who care for them the most. This is when the attachment relationship is actively developing and emerging. Quality of care is particularly important during this period in influencing the type of attachment that will develop.

From about the age of eight months the infant develops the capacity to move. Once they can do so, secure infants will begin to explore their environment while also seeking temporary reunions with their preferred caregivers for emotional refuelling. In association with repeated experiences of separation, reunion and emotional refuelling, secure infants develop an appreciation of the fact that their caregivers are accessible, and that they can depend on their caring adults to be aware of and responsive to their needs without the requirement of being with them all of the time. In effect, they learn that the can divulge responsibility for needs provision to the person or persons whom they experience as sensitive and responsive to their needs and better able to cope with their world (i.e. the attachment figures).

Some maladjusted children, being drastically short on secure feelings, might display a tendency to seek an inordinate amount of emotional refuelling from their primary caregivers. As such, they are often perceived to be clingy and demanding of closeness to their caregivers. Most prefer to keep their caregivers close by and under their direct influence in order to be assured of needs provision. However, as the people who they first loved and depended upon were also the people who hurt them or let them down, the maladjusted child will also reject closeness to their current caregivers. The result is that maladjusted children alternate between a need for closeness to their current caregivers and a need to distance them. This is confusing and distressing to many caregivers of maladjusted children, who feel like they are on an emotional rollercoaster, from which they chose to exit via themselves seeking too much closeness to, or distance from, the child. The result is a strengthening of the maladjusted child’s approach-avoid behaviour as they redouble their efforts to keep their caregivers under their direct influence, and at a safe emotional distance. Keeping their caregivers under their influence is especially important to maladjusted children as it engenders feelings of safety and wellbeing in association with a perception that they can control their accessibility to needs provision.

Emotional Refuelling in Reverse involves the caregiver of the maladjusted child checking in on the child at regular intervals prior to the child initiating closeness (and, subsequently, distance). That is, the caregiver moves away from the child but frequently and regularly checks in on them. Checking in on the child might range from sharing a brief hug to simply letting the child know what you are nearby. Emotional Refuelling in Reverse can be extended to anticipating and responding to the child’s needs prior to the child doing anything to elicit a caregiver response.

Emotional Refuelling in Reverse puts the caring adult back in control of the provision of secure feelings. This is very important because until such time as the maladjusted child is exposed to adult caregiving behaviour that occurs independently of any action on their part their will continue to believe that the only way to access needs provision from adults is to be in charge themselves. It also assists the child to better-tolerate the required degree of physical and emotional separation referred to above (See Emotional Connectedness). In addition, it reassures the maladjusted child that, though they may not be physically present, caring adults are aware of their child and concerned about their needs and wellbeing. In doing so, it represents a further step towards promoting secure attachment representations and reducing anxiety/arousal.

Specific Use: Sleep Problems

An example of where the use of Emotional Refuelling in Reverse might be applied is with children who have difficulty with bedtime and achieving sleep onset.

Sleep involves increased separation. Increased separation is anxiety-evoking for many children, particularly insecure and maladjusted children. Anxiety involves heightened levels of arousal. Heightened levels of arousal are not conducive to sleep onset. Many children protest separation and will follow after their caregivers. Others will call out and/or leave their bedrooms in search of their caregivers. Others still will seek to sleep in the bed of their caregivers, or seek to have their caregiver sleep in the child’s own bed.

Where the above sleep problems exist, Emotional Refuelling in Reverse assists with keeping the child in their bed, promotes tolerance of separation and facilitates sleep onset by reducing arousal. Emotional Refuelling in Reverse for sleep involves the caregiver advising the child that they will return shortly to check in on them. The caregiver should define “shortly” either through the use of time (e.g. five minutes) or some activity that has temporal relevance to the child (e.g. “I’ll be back to check on you just as soon as I have put the kettle on / made a coffee”). The caregiver should ensure that they return at-least two times before the child goes to sleep, so the child is reassured that the caregiver will return. The caregiver should advise the child that they should try to stay awake until the caregiver returns. This kind of paradoxical instruction circumvents battles. Battles regarding sleep onset increase the child’s arousal and are counter- productive to initiating sleep onset. Rather, content in the knowledge that they have permission to stay awake and that they caregiver will check in on them, the child will often fall asleep quickly and without fuss.

Changing Attachment Representations

The bi-directional arrows in Figure 1 illustrate the fact that the attachment representations under which children operate fluctuate, to an extent. Classifications of Secure, Insecure and Attachment Disordered are meant to reflect the attachment representations under which the child operates predominantly. All people have times then they feel insecure or that the world is against them. Maladjusted children can experience periods of relative security. Caregivers of maladjusted children report that they can often tell which attachment representations predominate by the facial expressions and tone of voice exhibited by the child when they get up in the morning. They commonly misattribute this to Dissociative Identity Disorder (Multiple Personalities), which arises in cases of extreme trauma and fragmented identity development. As attachment representations are fluid and malleable, even the most disturbed children can be assisted to hold and operate increasingly in accordance with positive attachment representations.

Attachment representations can be influenced by external (e.g. caregiving, psychotherapy) and internal (e.g. sleep/dreams, thoughts/cognitions) factors. Insecure and maladjusted children can be encouraged to accept new and more helpful perceptions of themselves, others and their place in the world in association with attention to specific aspects of care. Psychotherapy can also be influential in fostering adherence to positive attachment representations, particularly insofar as it challenges negative attachment representations and associated unhelpful cognitions (thoughts).

Be All-Powerful, All-Understanding, All-Knowing

An attachment figure is a person the child goes to when they are sick, sad, hurt, scared. They are a person whom the child’s perceives to be better able to cope with circumstances that are painful, stressful, frightening. They are a source of comfort and protection for the child. In order to be an attachment figure and be a source of comfort, support and protection for the child, a caregiver needs to be more powerful than the child, more knowing and more understanding. Such a strong person can protect the child in all circumstances, from the child’s perspective. If a child is allowed to be the boss they will never feel truly secure. Similarly, if a child has no boundaries or expectations placed upon them by an authoritative adult, they will think that adults do not care.

One approach that casts the adult in an all-knowing role and facilitates the child’s acceptance of adult authority is teaching the child a new game or activity. Introducing a controlling and otherwise difficult child to a fun or interesting new activity and teaching them how to do it creates an often unique situation where the maladjusted child will accept adult authority and direction in association with being motivated to learn a desired activity or game (e.g. Chess). In addition, if the activity is fun as well, the child experiences pleasure in association with learning and accepting direction from a caring adult. With repeated exposure to such experiences, the child instinctively experiences pleasure and other desirable feelings in association with adults being in charge and teaching them. Psychologists refer to this process as Classical Conditioning and the response engendered to a particular stimulus as a Conditioned Response. It is possible that the desirable conditioned response will generalise to other aspects of the child’s life where they experience the adult in an authoritative role.

Play is also important in the remediation of maladjustment for other reasons. Play offers opportunity for attunement experiences, it promotes positive conceptions of self and other, and it allows the adult to structure and organise the behaviour and affective displays of the child in a non-threatening manner.

Where a child is likely to be contrary, you wish to direct them regarding your wishes and their compliance is non-negotiable, do not ask the child, tell the child. If you ask them, you are effectively giving them a choice regarding whether to comply or not. If they say “no”, you are in a lose-lose situation, in that they either do not do what you expect of them or you precipitate a confrontation that can have the effect of upsetting and alienating the child.

Children respond better to directions and outcomes rather than directions and punishments e.g., Pick up your toys and you can go out and play, rather than Pick up your toys or you’re grounded. Nevertheless, where children remain defiant and discipline is warranted, express empathy for the child’s feelings, but follow through with directions and consequences. Don’t allow the child to set and emotional tone of anger and hostility.

In association with their experience of unreliable and unresponsive care, maladjusted children learn that the only person they can rely on is themselves. This often manifests as an intense need to control their environment and everything in it, including the thoughts, feelings and behaviours of others, a goal they achieve through naughty, coercive/manipulative behaviour. A power struggle can often ensue when the child’s caregivers attempt to assert normal adult authority and direct the child. Maladjusted children often enjoy engaging in power struggles and experience a compulsion to win them. Borrowing from principals implicit in martial arts, the push-pull approach uses the child’s intense desire for control to reinforce adult authority. This is achieved when, rather than directing a child regarding inconsequential (to the adult) matters (e.g. which breakfast cereal to eat, which shirt to wear, which television program to watch during TV time) an adult caregiver offers the child choices and reinforces that they can make this decision. This strategy meets the child’s need for control while also reinforcing the adult’s authority through the offering of choices.

Finally, Paradoxical Intention, or Reverse Psychology as it is more commonly referred to, is a particularly effective short-term strategy for circumventing the maladjusted child’s attempts to regulate the emotional closeness of caring adults through affective displays, and hence, facilitate adult control over this important aspect of the relationship with the maladjusted child. For instance, some maladjusted children have a tendency to frown and project an outward attitude of hostility or anger in an attempt to distance caring adults. Under such circumstances, the author verbalises to the child that they are right to frown and/or look serious, sad or angry as this is a serious, sad or frustrating time. Furthermore, they are right to not smile. Invariably the child starts to smile. The caring adult should playfully remind them that this is a serious, sad or frustrating time and smiling is not appropriate. The child will then seek to stop smiling, only to burst into laughter. The caring adult should state that it is certainly not a time for laughter. By this time the serious, sad or angry child is in an emotional state fit for meaningful engagement.

Respond to the need as well as the behaviour

Nearly all behaviour is functional and purposeful and children rarely misbehave for misbehaviours sake. Among other things, misbehaviour can serve as an emotional release (such as when children are tired and overaroused) or as a strategy to draw attention to an unmet need. Maladjusted and pre-verbal children are typically unable or unwilling to express their needs directly/verbally and do so through coercive behaviours. From their first day, infants draw attention to their needs through affective displays that might later come to be viewed as developmentally-inappropriate and anti-social. They learn that crying and screaming is an effective way to draw caregiver attention. It is not surprising that this broadens to other aberrant behaviour among toddlers, such as throwing objects, banging doors, turning the TV and lights off and on, etc. Naughty behaviour typically attracts more attention than good behaviour. When the maladjusted child is misbehaving it is important to try and work out what unexpressed need might be giving rise to the behaviour rather than simply responding to the behaviour. To fail to do so can result in inconsistent needs provision and alienation of the maladjusted child.

Verbalise the child’s thoughts and feelings

Maladjusted children typically communicate their thoughts and feelings through aberrant behaviours and affective displays. To encourage them to use their words, verbalise what you think they are thinking about or feeling. Verbalising their thoughts and feelings often results in the child feeling heard and understood, is soothing to the child and makes them less likely to continue to use aberrant behaviour and affective displays to communicate their needs and wishes. It is a much more effective strategy than asking children how they feel or what they think. Asking is akin to an admission to the child that you do not understand.

Examples of verbalising understanding include:

I can see you are cross. I think you believe that I am being mean/don’t care/don’t understand.  

You look happy. I think you had a good day today.

They must have done something to make you mad. I guess they did something that was unfair/mean/nasty.

I can see you feel bad because you know you did something wrong and think I will not like you anymore.

When the request is reasonable but the timing is poor, don’t say “no”, say “yes, when . . .”

Conventional wisdom suggests that children need to accommodate to the refusal of some of their requests. That is, they need to hear “no”. Nevertheless, they also need to hear “yes” and have their requests responded to and validated. Demanding children may make many requests of their caregivers and become increasingly demanding, unsettled and alienated in association with frequent rejection of their wishes. Maladjusted children often experience exaggerated feelings of rejection in association with hearing “no”. Both groups of children may defiantly do what they please in anticipation of a negative caregiver response, resulting in loss of caregiver authority and disruption to caregiver-child relationships. Saying “yes, when . . .” avoids a confrontation, reinforces caregiver authority and promotes a more positive perception of caregiver understanding and responsiveness. It is also a useful strategy for getting children to perform required chores (eg, “yes, you can go next door to play when you have dried the dishes”). Furthermore, it avoids a perception of caregiver inconsistency and reinforcing persistent demanding behaviour that can arise in the context of caring adults initially saying “no” and later saying “yes” in response to persistent demanding.

AAA Caregiving – Managing Arousal

As mentioned earlier, maladjusted children are chronically over-aroused, with the result that they engage in aberrant behaviours and affective displays that serve to release anxiety and restore feelings of wellbeing. A critical aspect of caring for these children is managing their arousal levels. Previously discussed strategies to address accessibility preoccupations and change attachment representations are helpful in alleviating anxiety and reducing arousal levels. For example, communicating sensitivity and understanding of their thoughts, feelings and accessibility concerns/preoccupations through the use of verbalisation and empathy is soothing to these children. Other strategies that are useful in addressing arousal problems include playing quiet classical music while the child sleeps. The rationale here is that the brain is still attending to stimuli in the child’s environment while they are sleeping. Intervening to ensure that these stimuli are soothing is helpful in reducing the child’s basal central nervous system (brain) arousal levels. Caregivers of children who utilise this method report that the child sleeps more soundly and wakes in a happier mood. Relaxation and meditation are likely to also be useful, as are opportunities to engage in physical activity. Carefully managing the child’s exposure to settings and situations where there is a lot of external stimulation (e.g. shopping centres), including many things they cannot control, is generally warranted.

AAA Caregiving – Putting it all Together

While the behaviour of maladjusted children is probably of the most immediate concern, it is important that the primary focus is on developing positive relationships, because without this context, no behaviour management strategies will be effective. Maladjusted children are likely to interpret discipline as arbitrary and cruel, so directions and consequences need to be delivered calmly and with empathy rather than with anger. In order to help the child deal with their feelings of shame and rage, interactive repair should be provided as soon as possible after discipline so that the child knows that they will not be rejected because of their behaviour.

Figure 6 illustrates how the above caregiving suggestions can be incorporated into day-to-day behaviour management. In the first step, the child engages in some form of misbehaviour. Rather than verbally admonishing the child or instituting some form of punishment (e.g. time-out), it is important to first take stock of the circumstances under which the behaviour occurred and verbalise regarding the need, the thought and/or the feeling that gave rise to the behaviour. Next, a caregiver should model for the child and encourage proper expression of thoughts, feelings and needs. Then, the caregiver should explain to the child that they have choices regarding their expression of the aforementioned, and the different consequences that arise from each choice. Only after these two steps are followed should the caregiver discipline the child.

Behaviourmanagement

Figure 6 Behaviour Management: Putting the pieces together

(Source: Pearce, C. A Short Introduction to Attachment and Attachment Disorder. London, Jessica Kingsley, 2009)

When the author’s child was three years of age (i.e. newly/incompletely verbal) he would, at times, call out “hungry” or “thirsty”. At other times he had a habit of standing at the refrigerator, looking to see if anyone had noticed him, stomping his foot and affecting a grumpy facial expression. If noone responded to his signal that he was hungry or thirsty or both he would angrily stomp his foot and pull off various notices held to the refrigerator with magnets and throw them to the floor. At such times the author might have chosen to verbally admonish the child and require him to put the notices back on the refrigerator door. To do so would have further upset him as he would have interpreted the author’s response as lacking understanding and being uncaring. Rather, the author would say the following: “N, I see that you are standing at the fridge and that you are cross. I understand that you think that noone has noticed that you would like a drink”. N would sullenly acknowledge “yes”. I would then say: “Well N, you need to say please daddy may I have a drink”. He would quietly say “please daddy may I have something to drink”. I would then say “A bit louder and nicely”. He would say, more loudly and in more polite tones “Please daddy may I have something to drink”. I would respond with “Of course you can. I will get it for you straight away. I will always get you a drink when you need it. All you have to do is say ‘Please daddy may I have something to drink’. However, if you don’t ask and stand at the fridge and stomp, I may get you a drink but I will also tell you off for making a mess of the notices on the fridge. I will even ask you to put them all back”. Although N was only three years of age, this is a vivid example of step one and can be easily applied to the older, maladjusted child.

In the second step, the child subsequently engages in some form of behaviour, good or bad, associated with the aforementioned thought, feeling or need. On this occasion the caregiver again verbalises the thought, feeling or need. In the event that the child drew attention to the thought, feeling or need using prosocial behaviour, the caregiver responds with praise and needs provision. In the event that the child drew attention to the thought, feeling or need using antisocial behaviour, the child is admonished and a consequence may be instituted. Nevertheless, the need is acknowledged and an outcome is negotiated for needs provision. A caregiver should always respond to the need as well as the behaviour (I can see that you are angry and that you think noone has noticed that you would like a drink. We have already spoken about how you should use your words when you would like a drink. I will give you a drink but I would like you to sit in your room for a few moments while I get it).

The final step relates to when a child has made a poor choice regarding the expression of a thought, feeling or need, and a consequence is instituted. The child may become angry and/or distressed regarding the imposition of a consequence. They need to know that there is a rationale as to why a consequence is instituted and that the caregiver understands their thoughts and feeling regarding the consequence. If this important step is missed the maladjusted child is likely to form their own pessimistic, maladaptive view regarding the intentions of the adult. Hence, the caregiver verbalises understanding and the cycle repeats itself (I can see that you are angry that I am sending you to your room and think I am being mean. However, as your parent it is my job to love and care for you and to help you make good choices about behaviour. When I punish you it is to help you to remember to make good choices in future).

See Also: Pearce, C. (2011). A Short Introduction to Promoting Resilience in Children. London, Jessica Kingsley

Resilience Colby Pearce

References

1 Delaney, R.J. (1994). Fostering Changes: Treating Maladjusted Foster Children. Colorado: Corbett.

2 Delaney, R.J. (1994). Fostering Changes: Treating Maladjusted Foster Children. Colorado: Corbett.

3 Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganised/disoriented during Ainsworth strange situations. In M.T. Greenberg, D. Cicchetti, & E.M. Cummings (Eds.), Attachment in the pre- school years: Theory, research and intervention(pp. 121–160). Chicago: University of Chicago Press.