Staying attached to your child

Something terrible happened to Hannah Smith when she was 15 months old. Until then, her mother Angela reports, she'd developed normally. She could walk and was starting to say her first words.

Then suddenly she regressed. She lost her balance and those beginnings of speech. It took a long time before she started to progress again.

She may have had a stroke. Her mother believes she may have had an adverse reaction to a vaccination.

But six years later, Hannah is proof that it is possible to recover from such early experiences. Her recovery - although only partial so far - suggests that other children who suffer traumatic events in infancy may be rescued.

Her Mt Eden parents can afford one-to-one therapy with Judith Morris, a private therapist treating children who have been adopted from Russian orphanages and others referred by Child, Youth and Family Services (CYFS) or privately.

But only a handful of children who were abused, neglected or suffered other traumas in infancy are getting this kind of help. Many "fall into the overlaps" between CYFS and the health and education systems, where no one takes responsibility.

When the Weekend Herald visited on a weekday morning, Morris was on the floor of her Glendowie study with Hannah, now 7, racing an electric car around a plastic track.

"Watch the little car," Morris was saying. "Over the bridge, along the rocky road, through the tunnel, into the cage ... "

The cage built across the track had gates that could be opened at each end. When Hannah opened one gate, the little car drove into the cage. As we watched, Hannah learned she could let the car out by lifting the gate at the other end.

"She plays like a much younger child," Morris says. When Hannah came to her 13 months earlier, she had not yet learned the fact, which most infants learn at about 2-years-old, that Mum still existed, even when Hannah couldn't see her.

Morris got Mum to play "peek-a-boo" with Hannah, hiding behind a door and reappearing, to help Hannah learn this basic lesson.

The game with the little car is working on several levels. Firstly, it is teaching Hannah how to trust another person, the therapist.

"When she came, there was no sense she was interested in making a relationship [with] me," Morris says.

Secondly, it is helping her to communicate [with] other people.

"Everything she does I interpret as a need and I respond to that," says Morris. "She was not signalling in a way that made sense to her mother, so her mother couldn't respond."

And thirdly, Morris believes the simple game with the gates is helping Hannah to open gates in her own mind that were blocking her development.

"The little car is her. The little car has lots of obstacles, and she changes the game. She will be trapped in the cage - is she going to be able to get out or not? Today for the first time she saw the opportunity for something that is really different."

Through play and other "trial and error" experiences, experts now believe that children actually build their own brains. American researcher Bruce Perry says the brain is only 15 per cent developed at birth, but reaches 90 per cent of its full adult size by the age of four. In those first four years, brain connections develop in a "use-dependent" way.

"Repetition, repetition, repetition: neural systems - and children - change with repetition," Perry writes.

He believes the first step to start building a child's brain is to form a secure "attachment" to a primary caregiver, typically the mother, who can be trusted to respond to the child's needs. If that base is secure, then the child can take the risk of developing other relationships and trying other experiences.

Perry's research suggests that 60 to 70 per cent of modern children are "securely attached", knowing that they are loved and that their needs will be identified and attended to.

But 15 to 20 per cent have "insecure/avoidant" attachment, feeling that there is no point in sharing their needs and emotions because no one cares about them.

Ten to 15 per cent are "insecure/resistant", knowing they are loved, but with a primary caregiver who is not always there, perhaps because of mental illness, a marriage break-up or poor-quality daycare.

Perry believes that both these insecure groups usually find ways to cope with life. But the final five to 10 per cent of children have totally "disorganised" or "confused" attachment - either because they had no primary caregiver in infancy, or because their primary caregiver was also a source of fear. They tend to become our "problem kids" and, eventually, our dropouts and criminals.

"You can pick them very early," Morris says. "Once you are on a particular trajectory for attachment as a toddler, there's a 70 per cent chance that you will still be on that trajectory as an adult.

"You can identify in those first months of the child's life that things are going wrong. You can intervene then. If you wait till five, or 15, it gets more and more expensive."

These children are not necessarily physically abused.

"Neglect can come out of giving children things, not attention - not understanding why they are crying, so you don't pick the baby up properly," Morris says.

"In the first couple of years of life, the baby is slowly developing an idea about patterns and sequences: if I cry, someone comes and feeds me. If you are responsive to the baby's needs, then the baby cries less, because they know the only time they need to cry is when they need something. Attachment theory says you can never 'spoil' a baby."

Paediatrician Simon Rowley, a trustee of the Brainwave Trust which aims to educate parents about child development, says attachment problems are becoming more obvious as more parents go out to work or have less support at home.

"We have to make sure the children are getting good quality childcare, ideally being looked after in the first two years on a one-to-one basis by someone who can provide an attachment relationship.

"Good quality means people who are educated about childhood development, who know that play is important, that a sense of humour is important, that imagination is good, that getting your hands wet and dirty outside is good, and that sitting in front of a TV screen is not terribly good."

Former psychologist Marin Adams says problems often stem from parents who are addicted to alcohol or drugs, have other mental health problems, or suffer from domestic violence.

"Domestic violence peaks in pregnancy and the early years. That is a very primary period in attachment," she says.

When Hannah first came to her, Morris initially sent her to North Shore therapist Samantha Standley, who works on a child's basic reflexes. Standley says babies are born with a primitive "Moro reflex" which causes them to scream and fling out, then close up their arms at anything unexpected, such as a door slamming.

"That should be gone by two to four months, but a lot of children I see still have this reflex, so you have kids in a state of fight and flight all the time."

She sets them daily exercises involving very slow, gentle movement or rotation, often in almost fetal positions. She also uses music therapy, where the children play musical instruments or listen to tapes of musical tones.

In theory, other children like Hannah should also be getting help. CYFS, the Education Ministry's Special Education branch and district health boards all have early intervention teams aiming to pick up children with attachment problems early.

Sue Hutchinson, acting manager of CYFS' Auckland specialist services, says most children who come into CYFS care have disorganised attachment. The service aims to build a secure attachment for each child, either with its natural parents or with other family members or new caregivers.

When children are referred to it after disclosing or being suspected of abuse, they may be interviewed at Puawaitahi, the "one-stop shop" opposite Starship Children's Hospital where CYFS, police and health staff work together to minimise the trauma for victims.

One-way glass on the side of a playroom allows a psychologist to watch while a parent plays with a child.

"A lot of parents project unresolved issues on to their child," says psychotherapist Mandy Maoate. "It's amazing. I've had an example of a 9-year-old boy and all Mum can see is a 30-year-old man that she was abused by."

Hutchinson quotes another mother who was so competitive with her 8- or 9-year-old son that he could never win any game.

"She was focused on the task to beat him. He slowly got angry and went back to being non-communicative. That was a Mum who hadn't been nurtured herself and saw her son getting something that perhaps she needs."

The psychologist helps the parent and child to play more - well, playfully.

"Play is crucial in attachment and bonding," Maoate says. "If you can play with your child and be fully available, then that does wonders for the relationship."

A Takapuna CYFS social worker, Laurel Webb, runs a "match and attach" scheme for children aged nine to 12 who haven't been able to get on with a succession of caregivers. These children have often developed difficult behaviours and Webb's job is to find them just the right caregivers who can bond with them permanently.

"It's like falling in love," she says.

Parents or preschool teachers with difficult children can call in Special Education early intervention teams, who also use play along with speech-language therapy and other techniques to help children and families.

Once they reach school, resource teachers of learning and behaviour (RTLBs) can be called on to help students with problems. Paul White, the principal of Clayton Park School who manages an RTLB group in Manurewa schools, says the RTLBs deal with "moderate" cases that can be resolved in a few weeks by helping teachers to handle them. Children with more serious problems are referred to Special Education psychologists or to district health board mental health units. Hugh Clarkson, a psychiatrist at Counties-Manukau's child and adolescent mental health unit Whirinaki, says his team will sometimes see a child for a year or more.

"We work with the whole family if we can. We may bring them into a play room situation and assess how the child is playing and how the parents respond to the child's play," he says.

"It's getting the parent to become interested in the child's play and responding to the emotional signals the child is sending out, because attachment improves as those emotional signals are received and fed back, such as saying to the child, 'You sound angry.'

"Recognising that the child has an emotional life allows the child to respond."

A government scheme called "Strengthening Families" provides local co-ordinators who can call together all agencies working with a particular child or family.

In West Auckland, the Dayspring Trust plans to extend its work with families in crisis to provide a specific service for children with poor attachment and their parents, including special parenting education, individual therapy and training and consultation for professionals.

The problem is that all these services still fail to reach many of those five to 10 per cent of children with disorganised attachment.

"We see less than 1 per cent. The Ministry of Health would like us to see 3 per cent," says Clarkson.

"We don't have a funding problem. We have a problem of qualified people we can employ. We have been running at 50 per cent of the provision for staffing for quite a number of years."

He says children don't fall through the cracks. "We have more overlaps than cracks. People fall through the overlaps, because we are not able to force people into therapy or into working with us. We have a society that is voluntary, which I rather like."

Victoria University psychologist Wendy Kelly says perhaps a quarter of the children with disorganised attachment are symptom-free and "just get on with life", but many of the rest who need therapy don't get it.

"I think it is patchy," she says. "It should be more automatic. If you have a child who has had two or three placements, you can predict [they are] going to have problems, so let's get in at the beginning."

Lope Ginnen, a family lawyer on the Brainwave Trust, says extended family members and friends are often too slow to intervene when they can see "borderline cases" of abuse or neglect.

"We still have a strong concern about the adults and how they might perceive our actions and we don't realise how dangerous some situations are for children," she says.

"Calling CYFS is one option. There are other options, like talking to the parent about your concern. One of the common themes in cases of children being neglected is social isolation of the parent, so maybe one way that we can act is to try to engage that parent."

New Plymouth paediatrician Robin Fancourt, who founded the Children's Agenda group, says we need much lower student-to-staff ratios in preschools and more co-operation between agencies. In Blenheim where she previously worked, she set up a team of visiting teachers, Plunket nurses and others to swap notes with her about children of concern.

In the long term, we also need to look at the factors that cause poor attachment in the first place. Perry argues that we are suffering from "relationship poverty" in the midst of material abundance.

Our species evolved as hunter-gatherers and lived in bands of 40 or 50 people for perhaps 200,000 years before the invention of agriculture just 10,000 years ago. "For each child under 6, there were four developmentally more mature persons who could protect, educate, enrich and nurture the developing child - a ratio of 4:1," Perry writes. "In contrast, our modern world is defining a ratio of one caregiver to four children as a 'best practice' ratio for young children, one-sixteenth of the relational ratio our brain is designed for.

"Our children spend hours each day watching television. They spend few hours in the day on socio-emotional learning opportunities created by interactions with older children, younger children, aunts, uncles, nephews, grandparents or neighbours."

A weekly therapy session by itself, he says, is not enough to counter this imbalance. A child who has not attached securely to a caregiver needs a "therapeutic web" of people interacting with them.

"The neglected, maltreated child is all too often an infant emotionally," he writes. The child may be 5, but requires the kind of one-to-one interaction that normally only babies get.

"Unfortunately our systems rarely are capable of providing this level of reparative interaction," Perry says.

"We tend to be stingy with our relational attentions in these therapeutic pre-school and school settings, choosing to label these children with pejorative diagnostic labels rather than understand their developmental difficulties as a very predictable consequence of a chaotic, relationally distorted and impoverished early life."

Preventing Violence in the Home is collecting donated goods on September 30 for a giant fundraising garage sale, Get Organised Auckland, (09) 270 2545.

Project a success - but no more cash

Schools, police and social agencies came together last year to help 20 boys with difficulties - but the money for the project has not been renewed.

The innovative $50,000 scheme, Awhinatia Te Whanau, asked four Manurewa primary schools to each nominate five children aged 7 to 12 who would get the most benefit from intensive social support. All were boys.

Each boy was assessed by health and education agencies, police and Child, Youth and Family Services and a joint plan for each one was drawn up with the boy's family.

A co-ordinator made sure the boys and their parents got to their appointments, if necessary arranging transport through the Clendon-Manurewa Whanau Family Support Service.

Marin Adams, who co-ordinated the scheme in its later months, said half the boys improved their classroom achievement, 56 per cent improved their application and 89 per cent improved their behaviour.

It was no easy ride. One of the schools in the scheme says one of its five boys involved made no progress, in another case it proved impossible to get a boy's father to change, and two others are still on the behaviour-calming drug Ritalin.

Only one of their five made major progress - a boy whose father had left but has now returned to the family home.

Shirley Maihi, head of Finlayson Park School, says tracking down the father made a big difference for two of her pupils in the scheme.

"In a lot of these cases the father had been excluded on the mother's instructions, not through the courts or anything. It was just really trying to work with the father to make them realise that it was their responsibility," she says.

"In one case the father moved from way down country back to live with the mother, with some really good results. The other one moved into the same district and took control of the child. That made a huge difference."

As at the first school, two of the boys at Finlayson Park are still on Ritalin.

But, considering where the boys started, Maihi says it was "a huge success".

"If half of them have been caught and put on the right track, it will save a lot of money in the future," she says.

"What's $50,000? I really believe in schemes like this one. The Government should look at more personnel, even in clusters of schools. In all decile-one schools there is an absolute need."