One of the speakers at the DI conference, in Sofia at the start of the month, was Dr Peter Fuggle, director of clinical and service improvement at the Anna Freud National Centre for Children and Families in the UK. He talked about the Anna Freud Centre’s approach to helping children who have been institutionalised.
He started by explaining that the attachment difficulties that are seen almost universally in children who have been institutionalised, particularly those who were institutionalised from a young age, result in a decreased ‘mentalizing capacity’. Mentalizing is the imaginative activy of making sense of behaviour of the self and of others, through understanding mental states (feelings and emotions). It is hard for children who were institutionalised from a young age to understand and regulate their own emotions and feelings, because they have not had the experience of adults teaching them to do those things, like most children in families do.
Separate from this presentation, I have also come across a talk by Dr Laura Steckley about children who are neglected as babies and toddlers, who do not have an adult who responds to their needs and who help them co-regulate their emotions and stress levels. She mentioned something similar to Dr Fuggle, that being unable to lower stress levels, it is very hard for these children to learn how to think. Because the high stress levels lead to a state of flight or fight, which does not leave much room for thinking.
In the long-term, the lack of attachment and the experience of not having people to respond to your needs, even if you express them, leads to a very basic mistrust of other people. This is called an epistemic mistrust. It is understandable that when the child’s experience has consistently been that other people will not be there for him when he needs them or when he needs their help, he learns that it is not a good idea to lean on others or to trust them.
Dr Fuggle emphasised that epistemic mistrust is not a disorder – even though it can cause serious problems -. it is an appropriate adaptation to the life experiences that the child has had.
This epistemic mistrust does have serious consequences, however, when the child is placed in a family after deinstitutionalisation – no matter if that is reintegration with his own family, or adoption or placement in foster care. This lack of trust leads the child to feel that he has to be self-reliant, not depending on anyone, because in his mind, depending on someone always ends in rejection. This means that the child is usual very distant to his parents/caregivers, rejecting their attempts to get close to him or to help him. Sometimes, this can involve very challenging and even agressive behaviour.
For the parents or caregivers, this is a big blow. They are trying to do what they can for the child, trying to help him and approach him, and they are constantly rejected and failing in their attempts. This can cause them to lose confidence in themselves and their ability to care for children. In the long-term it can lead to them trying to protect themselves from the hurt of rejection and failure by attributing negative things to the child and distancing themselves, at which point they will be less able to empathise with the child anymore and their chances of really reaching the child become even smaller.
This makes it essential that extensive training and support is offered to these parents and caregiver. Both to help them understand what they should expect and to give them the tools to help the child, and not to be broken down in the process themselves.
The problem, in this situation, is that the children most in need of help, are the ones least likely to ask for help. They have not learned how to ask for help. And they have not learned that it can be useful to do so.
Dr Fuggle introduced AMBIT, Adaptive Mentalisation-Based Integration Treatment, developed by the Anna Freud Centre. It is used to help children who do not seek help, using a community-based approach. Instead of sending the child to a professional and trying to build up enough of a trust relationship for the child to actually share information or ask for help, they look at the relationships that a child already has. This may be a friend, a teacher or a sports coach whom the child confides in. While this individual may not have the expertise needed to help the child, they do have something much harder to establish: the trust of the child. So the approach is to surround the person whom the child trusts already with professional help and support and to help that person help the child.
Another aspect of the approach is to model help-seeking for the child. So, when a child tells an adult about something he is struggling with, this adult will make a phone call to a colleague or a professional from a different field while they are with the child, and ask for help in dealing with the situation. Showing the child in a practical way the advantages of reaching out for help. If the child asks ‘but don’t you know how to deal with it?’, the adult will answer that they do have some idea of what to do, but that it helps to get the input from someone else on it and to make decisions together.
I was very impressed with this approach, and with the remark that even when it seems like the child has no relationships in their life, there will always be someone they trust more than others, it is just that very few people take the effort to look closely enough to find out about this.
This is definitely something that I will keep in mind and will try to apply in my work.
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