A brief and basic guide to trauma, attachment and adverse childhood experiences
Introduction to Therapeutic foundations
When children and young people come into our care we must not take them at “face value”.
They will often arrive with a myriad of behaviours that challenge us in many ways, the important thing to remember is there are always underlying reasons for this behaviour.
Many of you would have heard of terms such as “therapeutic caring” “therapeutic parenting” or “trauma-informed care” there are many different models, courses and approaches, and many of you might be delivering some form of therapeutic care.
Working therapeutically carers are better able to understand children’s experiences, achieve greater patience and understanding of behaviour and respond helpfully to negative behaviour rather than react to it. For children in care, this therapeutic approach helps them to develop trust and become more receptive to the guidance, love and support of their carers.
Many of you will be familiar with training models, the majority of which are based on original attachment and child-centred theories. Here we give a brief introduction to attachment and adverse childhood experiences (ACEs), the things that need a trauma-informed therapeutic response.
Bruce Perry M.D., PhD
Understanding attachment and attachment styles are fundamental to the foster carer, they impact everything in our children’s lives, their outcomes and our understanding of their behaviour and our work with them.
According to attachment theory, first developed by psychiatrist John Bowlby and psychologist Mary Ainsworth in the 1950s, attachment style is shaped and developed in early childhood in response to our relationships and experiences with our earliest caregivers.
This means that from birth onwards a child will look to their caregiver (mum, dad or other) to meet all their needs. Babies and toddlers rely on adults to quite literally survive, in terms of food, drink, warmth, safety etc. They also look to their caregivers for a sense of who they are, if their caregiver is attentive, loving and ‘attached’ to them they will gain a sense of self-worth and safety, and they will feel significant and important to the caregiver and those around them. If their caregiver is either not meeting these needs, or only occasionally doing so, they will feel unsafe, unwanted and unloved, and not knowing if they will survive from one day to the next.
So these early attachments or lack of them are fundamental to the child’s whole life and way of being, given that relationships, interaction with others, love and emotional security are what are essential to surviving life, love, learning, work and building our own families.
It’s really important to note that these attachment issues affect our children and young people’s perception of all relationships, so even if the foster carer knows they will meet all the child’s needs the child will not, this kind of trust takes a long time to rebuild, sometimes if at all and it will often manifest in different ways in transitions through a child and young persons life.
How does this relate to a child in care?
Looked-after children’s attachments are rarely ‘secure’, they may have parents who have had no role models themselves, have attachment issues of their own and are unable to form strong bonds or attach to their child or be attentive or meet their child’s needs, therefore the child itself then develops attachment issues.
Well-attuned carers can readdress and challenge a child’s attachment styles and early relationships. All relationships are shaped by past relationships, therefore, the child or young person will initially believe we are similar to their original caregiver.
So to begin with when vulnerable children and young people come into our care they will have a view of who we are that may not be correct. If their original caregiver was inconsistent the child will likely not trust that you as the new carer giver will be consistent.
It is therefore important that a looked-after child experiences a good consistent parental figure in foster care through their carer, in order to show the child a new experience, trust and understanding of a caregiver.
This is not always easy as a child may reject a carer over and over again, and they may display angry, destructive and unpredictable contradictory behaviour, carers need to be patient, empathic, responsive, regulated themselves and provide really consistent care.
Secure attachment is evident in a warm and loving bond between parent/caregiver and child. The child feels able to form healthy relationships with their caregiver and those around them and feels loved, cared for and safe.
Children are active and confident in their interactions with others and are likely to continue this into adulthood and are able to form long-term relationships.
Anxious-ambivalent children have a tendency to distrust caregivers, they will feel insecure and will see their environment and the world with fear rather than excitement.
They will constantly seek approval from their caregivers, be hyper-vigilant of their surroundings and be frightened of being abandoned.
They can feel unloved, be emotionally dependent and find it difficult to show love and connection themselves.
Avoidant children are likely to have learned to accept that their physical and emotional needs will be unmet, and they will feel insecure and unloved.
They have difficulties expressing their feelings and emotions and will avoid attaching to caregivers, and close relationships.
Disorganised attachment is a combination of avoidant and anxious attachment, children with disorganised attachment are likely to be very angry and can display rage, they might behave in volatile, aggressive and destructive ways and have difficult relationships with their caregivers.
They tend to avoid getting close to anyone, can easily explode and find it difficult to control emotions.
What is an example of the impact of attachment styles?
One of the most illustrative ways of understanding these styles has been looking at how children might respond in a situation where the mother is present, then leaves the room and returns (you can see videos of these on YouTube) I am sure many of you will resonate with some or all of these descriptions, and recognise many or all of these behaviours from your own work and experiences with children and young people.
The child will explore the room with the mother, be upset by their separation, give a warm greeting upon return and seek physical touch and comfort upon reunion.
The child ignores the mother when she is present, shows little distress when they are separated and turns away from Mum when she returns.
Little exploration with their mother in the room, stays close to their mother, very distressed upon separation, is ambivalent or angry and resisted physical contact when she returns.
The child shows confusion about avoiding or approaching the mother, this child is the most distressed when they are separated and acts confused and dazed when the mother returns.
Adverse childhood experiences (ACEs)
As carers we look after the most vulnerable children and young people in our society, we all face challenges but for the majority of the vulnerable children we care for the environments they grow up in, their family life and their experiences are adverse, which may have a traumatic and lifelong impact on their physical and mental health development and attachments.
Adverse Childhood Experiences (ACEs) was a term originally developed in the US for the Adverse Childhood Experiences Survey which found as the number of ACEs increased in the population studied, so did the risk of experiencing a range of mental and physical health conditions in adulthood. There have been numerous other studies which have found similar findings, including in Wales and England (please see the links section at the end).
ACEs can be single or ongoing events or situations or threats to safety, they are highly stressful and occur during childhood or adolescence. In order to survive such difficult experiences significant social, emotional, neurobiological, psychological and behavioural adaptations need to be made.
- Trauma – is the term used to describe the impact of ACEs on a person’s mental health.
- Adversity – is the term used to describe the experience and situation that resulted in ACEs.
The adaptations children and young people make due to ACEs are;
- In the first instance – Survival of the immediate environment.
- Find ways to mitigate or tolerate adversity.
- Look for safety and control that they can put in place.
- Make sense of their experience.
Examples from foster carers on how ACEs can affect a child:
They were not able to know exactly what the issue was around food, but in taking into account that this was most likely triggered by a past experience we decided to work with the child to make a meal plan for the week and we asked him if he would like to help cook, as he was likely needing to feel more in control.
In just one week there was a marked change in the child’s behaviour and he now eats a variety of things, loves helping with the cooking, choosing his meals and even likes to try new things.”
“Every day our young lady, aged 13, would happily go to school in the morning but by mid-morning break was insisting on coming home and the school would ring me unable to placate her.
She would come home and after about half an hour saying she felt fine to go back to school. After a while, I noticed that she would immediately go into the bathroom on getting home and when I gently enquired a little more she confirmed she was coming home to use the toilet as she couldn’t bear the smell or feel of the student’s toilets at school and felt unsafe in them.
She eventually disclosed that as a child (around 6yrs old) she was with her mother “on the run” from social services and for a time lived in someone’s attic, where she and her siblings had to use a bucket as a toilet, often without the help from their mother who was under the influence of drugs and alcohol. She said there was a smell and ‘feeling’ in the school toilets that reminded her of this time, it was obviously triggering her and it was really traumatising her.
I worked with the school, who were amazing, and they allowed the young lady to use one of the single staff toilets, she never had to come home again at break time, and it facilitated some gentle curiosity and exploration of those disclosures and past experiences.”
What would be classed as an adverse experience?
- Maltreatment – includes abuse, physical, sexual, emotional, neglect, and poverty.
- Adjustment – this would be moving to a new area, losing friends and social connections, migrating, refugees and asylum seekers or ending a socially significant or emotionally important relationship.
- Adult responsibilities – children looking after adults or siblings, accepting financial responsibility for others and child labour.
- Bereavement and survivorship – the death of the carer giver or sibling, surviving illness or injury, surviving an accident, terror attack or natural disaster.
- Prejudice – hate crime, victimisation and discrimination, exposure to prejudice due to LGBT+, disability, sexism, racism, and religion.
- Violence and coercion – Inhumane treatment, household and family adversity.
Children with ACEs can suffer in later life from conditions such as PTSD, anxiety, depression, self-harm, chronic health problems, sexualised behaviour, sexual exploitation, substance abuse, and violence. It can also change brain development and can affect the way the body responds to stress.
Research shows that in vulnerable groups such as Looked After Children and young people, individuals are more likely to be exposed to deprivation, family breakdown, family mental illness and substance abuse by caregivers.
(Ford, Vostanis, Meltzer & Goodman, 2007).
(Chambers et al., 2010)
It is important to acknowledge that every child and young person will react very differently as a result of adverse experiences.
Symptoms of ACEs
- Memories – stored not just as memories, could be sounds, smells, smells, tastes, touches, sensations, feelings, physical pain, tiredness, words, or stories.
- Struggles to sleep.
- They may lose their temper more easily than their peers.
Top Tip: A child’s early traumas can be triggered by sounds, smells, tastes, touches, sensations, feelings, physical pain, tiredness, stories and thoughts.
Top Tip: Traumatised children are no longer able to see the world without trauma, they may believe the world is dangerous and they are vulnerable, and they may believe all adults are dangerous as this has been their experience. As a carer we may experience this as a child that notices everything and cannot relax as the feeling of imminent danger may leave a child on edge, and hyper-vigilant.
How can we spot trauma?
It is not often obvious that the behaviour we see today is a result of past ACEs, it may present itself in many different ways:
- Intrusive memories.
- Dissociation – opposite to hyperarousal.
- Depression and low self-esteem.
What can be the Impact of unaddressed ACEs over a lifetime?
- Social and emotional skills and relationships – for life.
- Isolation and distrust of the world.
- Poor social and health outcomes in adolescence including the risk of heart disease, stroke and cancer – due to chronic activation of the sympathetic nervous system.
- Increased risk of depression, anxiety, substance abuse and suicide. (source CDC Kaiser ACE study).
- The cycle of violence – intergenerational trauma, attachment issues.
Maslow’s Hierarchy of Needs
We have put Maslow’s triangle in here as we feel it is a useful and helpful illustration for us as foster carers.
It was created by psychologist Abraham Maslow, and shows for a child to develop and reach their full potential their basic needs have to be met first, they require a secure base of their most basic needs of security, food, shelter, safety, love and belonging before they can develop their own secure sense of self.
Everyone has basic needs, some of these are obvious fundamental things we will offer as a carer i.e. food, warmth and shelter, and when these needs are met they will be motivated to look for safety and survival and will look for an environment where they feel physically and emotionally safe.
At the next level, they will seek experiences that make them feel loved, cared for and accepted by others and belong to a group. Beyond this, they will want to feel good about themselves, feel appreciated, and recognise and receive feedback that leads to a positive self-image.
Once this is met they will then seek higher order needs, ‘self-actualisation’, this is the need to seek new knowledge and understanding, use their talents and challenge themselves to be the best they can be.
Many of the children who come into our care are missing things from the base layers, and a child will not easily engage with things further up the triangle unless these foundations are in place and their needs are met.
How does this look for foster children, it may be, for example, that you can not understand how a new child is not engaging at school, given the amount of support schools are giving them.
It may be that they do not yet feel safe, or have yet to understand that their basic needs are going to now be met, it takes time and they may still be in survival mode. You probably know from your own experiences that if something is going on in your home life, something disruptive and big, it is very hard to concentrate at work.
It is no different for our looked-after children and very often they have been in survival mode for years with the base layers missing or inconsistent.
We hope this brief introduction to the ‘why’ in trauma-informed therapeutic care has interested you to find out the ‘how’ to deliver trauma-informed care, and for those who are doing so to improve and to continue to grow and learn.
There are many different pieces of training, books, and education on therapeutic care, some call it therapeutic parenting. You will find many different models, and how you work with each child will be guided by basic principles.
Learning to deliver trauma-informed therapeutic care is essential in today’s modern fostering landscape, but it takes longer than a couple of days course or reading a book, so be as inquisitive as you can, find out what therapeutic training your LA or Agency provide for you, or try and find some of your own.
When you foster therapeutically it will not only change your children’s lives but yours as well, understanding the underlying reasons for our children’s trauma-driven behaviour changes our practice from reactionary to thoughtful and inquisitive, helps us understand our own emotions and become attuned to the vulnerable children we are caring for and support them in a kind empathic way, giving you the patience and understanding to create a secure, safe, stable and loving fostering family.
- Public Health Wales – Adverse childhood experiences study
- British Medical Journal – Health and financial burden of adverse childhood experiences in England and Wales: a combined primary data study of five surveys:
- Parliament publications and records – Adverse Childhood Experiences
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