̽��ֱ�� of Cambridge - Robbie Duschinsky

Family court decisions distorted by misuse of key research, say experts

cjb250 — Tue, 12 Jan 2021 16:29:23 +0000

Seventy experts from across the globe argue that widespread misunderstandings around attachment research have hampered its accurate implementation, with potentially negative consequences for decisions in family courts.

In response, they have published an international consensus statement in Attachment & Human Development that aims “to counter misinformation and help steer family court applications of attachment theory in a supportive, evidence-based direction on matters related to child protection and custody decisions”.

In the statement, the group sets out three principles from attachment research which they say should guide decision-making: the child’s need for familiar, non-abusive caregivers; the value of continuity of good-enough care; and the benefits of networks of familiar relationships.

Attachment research investigates the strong affectional bonds – ‘attachments’ – that individuals form to others in order to achieve comfort and protection. Children are born with a predisposition to develop these bonds with ‘attachment figures’ in their lives. This often includes the child’s parents, but many children develop attachment relationships with additional caregivers, such as grandparents. Children wish to turn to their attachment figures when upset.

̽��ֱ��quality of an attachment relationship – how readily a child will turn to their caregiver and accept comfort – is indicated by behaviour suggestive of whether or not they expect their attachment figures to respond sensitively to their signals in times of need. Indeed, the most important predictor of children’s attachment quality is caregiver ‘sensitivity’: the ability to perceive, interpret and respond in a timely manner and appropriately to children’s signals.

Attachment research is applied in many settings, including in family court decision-making regarding child custody and child protection. Court practice needs to follow the best interests of the child, but this can be difficult to determine. There is an increasing focus on the interactions and relationships between children and their caregivers, which in turn has led to interest in using attachment theory and measures to help guide decision-making.

Dr Robbie Duschinsky from the ̽��ֱ�� of Cambridge, said: “ ̽��ֱ��decisions reached by family courts can have a major impact on a child’s life, but as we’ve seen, these decisions may be based on incorrect understanding and assumptions. By outlining potential issues and presenting principles to guide the decision-making process, we hope to better inform and hence empower courts to act in a child’s best interests.”

One example is the mistaken assumption that attachment quality equals relationship quality, and that it is possible to judge attachment quality by looking at isolated behaviours. In fact, there are many other important aspects of child-caregiver relationships, such as play, supervision and teaching, and specific behaviours such as crying can depend on largely constitutional factors such as temperament.

There are also misunderstandings regarding the importance of developing attachment to one particular caregiver rather than to more than one, with the theory misinterpreted as placing an emphasis on one ‘psychological parent’, typically the mother. In this line of reasoning, it is often assumed that an attachment relationship with one person is at the expense of other attachment relationships, and that best-interest decisions should maximise the likelihood of secure attachment with one primary caregiver. However, children can develop and maintain secure attachment relationships to multiple caregivers simultaneously, and a network of attachment relationships may well constitute a protective factor in child development.

In other cases, attachment theory has been held to categorically prescribe joint physical custody, with equal time allocation regardless of child age, including overnights and transitions between family homes every day or every other day. Yet, there is a notable scarcity of empirical research on attachment in relation to child custody, time allocation, and overnight arrangements.

Dr Tommie Forslund from Stockholm ̽��ֱ�� said: “Misunderstandings can have important consequences for children and their caregivers. In some cases, they can lead to an ill-informed dismissal of the relevance of attachment by court professionals or, conversely, to the overuse of attachment ideas and measures, with practice unmoored from evidence.

“We need to make sure that courts are aware of the limits of current understanding as well as the nuances of attachment theory and research before seeking to apply it to their decision-making.”

̽��ֱ��researchers have also advised caution in using assessments of attachment quality in the family courts.

Professor Pehr Granqvist from Stockholm ̽��ֱ�� added: “Courts need to bear in mind that while assessments of attachment quality may be suitable for helping target supportive interventions, there are different opinions even among those of us who specialise in attachment research regarding the potential usefulness of these assessments when it comes to decision-making regarding child protection.

“Validated in group-level research, attachment measures have insufficient precision for individual level prediction. If used at all, assessments of attachment quality should never be used in isolation but only as part of a larger assessment battery that assigns more weight to direct assessments of caregiving behaviour. Importantly, attachment assessments must only be used by formally trained observers who follow standardised protocols.”

̽��ֱ��experts propose three fundamental principles, based on more than half a century of research, which they argue can be used as a basis for court practitioners:

̽��ֱ��need for familiar, non-abusive caregivers – For child protection practice, for example, this implies that all non-abusive and non-neglecting family-based care is likely to be better than institutional care.
̽��ֱ��value of continuity of good-enough care – ‘Good-enough’ care signifies an adequate level of meeting the child’s needs over time. ̽��ֱ��group urges family courts to examine and support caregivers’ abilities to provide ‘good-enough’ caregiving, rather than placing children in out-of-home custody with the hope of ‘optimal’ care. Major separations from caregivers constitute risk factors in child development that should be prevented whenever possible.
̽��ֱ��benefits of networks of attachment relationships – Decision-making concerning child custody should assign weight to supporting children’s ability to develop and maintain attachment relationships with both their caregivers, except when there is threat to the child’s welfare and safety or one of the parents wants to ‘opt out’.

Reference
Attachment Goes to Court: Child Protection and Custody Issues. Attachment & Human Development; 11 Jan 2021; DOI: 10.1080/14616734.2020.1840762

Family courts are misunderstanding and misusing research around how children form close relationships with their caregivers, say an international group of experts.

̽��ֱ��decisions reached by family courts can have a major impact on a child’s life, but as we’ve seen, these decisions may be based on incorrect understanding and assumptions

Robbie Duschinsky

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Experts express concerns over infant mental health assessment

cjb250 — Wed, 11 Oct 2017 08:55:14 +0000

̽��ֱ��consensus statement, published in the journal Attachment & Human Development, highlights the appropriate use and current limitations of a classification known as ‘Disorganised Infant Attachment’, which has been in use for over 30 years. ̽��ֱ��statement has been led by Professor Pehr Granqvist from Stockholm ̽��ֱ�� and Dr Robbie Duschinsky from the ̽��ֱ�� of Cambridge. Among the authors of the consensus statement are the originators of the classification, Mary Main and Judith Solomon. ̽��ֱ��classification is based on the ‘attachment theory’ proposed by renowned psychologist John Bowlby in 1969.

Bowlby emphasised that when infants get upset, they tend to turn to their familiar caregivers (usually their parents). However, attachment theory suggests that an infant who has been exposed to 'alarming behaviour' by their caregiver will experience conflict about whether or not it is safe to turn to the caregiver for comfort. One kind of alarming behaviour by a caregiver is abuse of the child.

However, other behaviours can also cause such conflict. For example, the authors point to a meta-analytic study in 2010 by Chantal Cyr ( ̽��ֱ�� of Quebec, Montreal) and colleagues at the ̽��ֱ�� of Leiden, which found that when families had five or more socioeconomic risk factors – such as living in poverty, drug addiction, or not graduating from high school – then rates of Disorganised Infant Attachment were comparable to those in families where there is known to be abuse. This is understood to be because adults in such circumstances can exhibit alarming behaviours such as withdrawal from interacting with the child, or frightened behaviours as they interact with the child while also thinking about the dangers and adversity they face in their lives.

A classification of Disorganised Infant Attachment is assigned when an infant aged 12-20 months demonstrates certain behaviours during a so-called ‘Strange Situation’, where the care-giver departs the room, leaving the baby with a stranger – potentially upsetting the infant – before returning. ̽��ֱ��assessor looks for behaviours suggesting conflict about going to the caregiver for comfort; for instance, if on reunion with the caregiver, an infant falls to the floor, looking disoriented.

There has been a growth in recent years of social workers and clinicians using assessment of disorganised attachment to screen for child abuse. However, the consensus statement argues that this is a misapplication.

Not all abused children receive a disorganised attachment classification, so some abused infants will be missed if this assessment is relied upon alone; and many non-abused children do receive a disorganised classification, as a variety of alarming caregiver behaviours can predispose conflict behaviours, not just abuse.

“There are all kinds of things that might make a child alarmed by his or her care-giver,” says Dr Duschinsky from the Department of Public Health and Primary Care at Cambridge, one of the lead authors of the statement. “While the Disorganised Infant Attachment classification does offer some general indications regarding the history and future mental health of the child, it is much too blunt an instrument to be used for child protection assessment.” ̽��ֱ��consensus statement suggests that while the Disorganised Infant Attachment classification has its limitations, it can still be useful when used as part of a battery of tests, but it should not be relied on its own. ̽��ֱ��authors also conclude that the real practical utility of attachment theory and research resides in supporting understanding of families and in providing evidence-based, supportive interventions. Rather than press the disorganised classification as it stands inappropriately into service for child protection assessments, the consensus statement states that further work is a priority to see whether the classification can be further specified and validated for this purpose.

Dr Duschinsky’s own research – including a second paper published this month – has drawn upon John Bowlby’s historical archive at the Wellcome Library, London. This work fed directly into the consensus statement providing greater conceptual clarity about the nature of infant conflict behaviour. “It is unusual for historical work to feed into modern practice guidelines,” he says, “but my work shows that Bowlby’s ideas is still of relevance today.”

Dr Duschinsky is supported by a Wellcome Trust New Investigator Award.

Reference
Granqvist, P, et al. Disorganized attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers. Attachment & Human Development; Published online 26 Jul 2017; DOI: 10.1080/14616734.2017.1354040

Solomon, J, et al. Toward an architecture of attachment disorganization: John Bowlby’s published and unpublished reflections. Clinical Child Psychology and Psychiatry; Published online 9 August 2017; DOI: 10.1177/1359104517721959

Forty world experts on child development and mental health have released a joint statement calling for caution when applying an influential classification for assessing infant mental health and potential cases of abuse.

̽��ֱ��Disorganised Infant Attachment classification [...] is much too blunt an instrument to be used for child protection assessment

Robbie Duschinsky

Joe Szilagyi

Toddler

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Questions of life and death

amb206 — Fri, 04 Nov 2016 12:30:00 +0000

Toast is burning in one of the ward kitchens at St Christopher’s Hospice in south London. Members of the nursing staff rush to open the windows, laughing at this minor disaster. In a room down the corridor a young man called Kevin is confronting a future in which he will play no part. He’s married with two young children – and has terminal cancer. Imagining his boys growing up without him is more painful than the disease destroying him. Kevin and his wife have accepted that he will soon be gone: she wants him to die at home but he doesn’t want to frighten his sons.

These are just two of the moments captured in ̽��ֱ��Time to Die a documentary made in the 1990s by Nikki Stockley. Commissioned by the BBC, the film addresses a subject that remains taboo for many of us: death. Stockley focuses on three people whose lives are ending. They and those they love share their feelings. Doris hopes she won’t linger: she doesn’t want to die “inch by inch”. Hazel has lost interest in clothes and no longer looks in the mirror. She has told the hospice staff that she wants to die at home. Her boyfriend fears he would not cope; often he feels like running away.

Earlier this year, academics from three different disciplines (Emma Wilson, Professor of French Literature and the Visual Arts, Dr Stephen Barclay, Senior Lecturer in General Practice and Palliative Care, and Dr Robbie Duschinsky, Lecturer in Social Sciences) sat down to plan a seminar series that would encourage a broad dialogue about care and dying, using the medium of film as a framework. Wilson, who has a specialist interest in film, proposed that ̽��ֱ��Time to Die would make a powerful starting point.

Wilson said: “What I admire so much about Nikki’s documentary is the openness of the interviews, Nikki’s presence, her connection to her subjects, allowing complex emotions to be put into words. It feels like a work of accompaniment, very patient, very calm, opening up possibilities for a non-intrusive presence of the camera in this community, and a tender, caring work of editing, piecing together a visual narrative.”

̽��ֱ��first of five seminars planned for the current academic year took place last week. Revd Dr Derek J Fraser, lead chaplain at Addenbrooke’s Hospital, talked about the role of his team in supporting patients and those close to them. A screening of ̽��ֱ��Time to Die was followed by a Q and A. Stockley took questions from an audience who included health professionals, members of the public, counsellors and representatives from local hospices. ̽��ֱ��making of a documentary about so sensitive a topic prompted questions about the relationships involved and the editing process.

Stockley spent four weeks filming at St Christopher’s. ̽��ֱ��Time to Die is, perhaps most importantly, a tribute to those it features, the patients and staff of a hospice acknowledged to be a pioneer in end-of-life care. She spoke of the closeness that developed between her team and the people they filmed – and her own emotional response. “I needed to remind myself that my sadness was nothing compared to those I was filming.” She also talked about the difficulty of negotiating a commission to make a film looking at death.

Junior doctors can expect to deal with as many as 40 to 50 deaths a year in the course of their work. Yet most people, in a society that protects itself from the reality of human frailty and mortality, have never witnessed death close up. Stockley suggested that film could offer a “safe way” of exploring some of the things we ask ourselves (how do people die, what’s it like to die) but seldom give voice to. Even the staff at St Christopher’s seldom talk about their own deaths. Medical statisticians have their devised their own code for death – they call it 'negative patient outcome'.

If ̽��ֱ��Time to Die is brave, it is also deeply respectful – and quite rightly so. Film, certainly not one made for general viewing, cannot convey the emotional rawness of death. Death has a smell. It can be messy and protracted. It’s exhausting and deeply sad. Death affects the professionals involved as well as patients and their loved ones. At one point in the documentary, a nurse is overcome by emotion and fights back tears. How do we negotiate the line between personal and professional?

Several Cambridge ̽��ֱ�� medical students attended the seminar. Chris Kassam said: “Working with patients at the end of life can leave you feeling overwhelmed by the magnitude of the experience, and the easy option is to withdraw behind a mask of professionalism. I think the film and discussion helped me to realise that what patients and their families may need most at such times is not a doctor but another human being to simply be there with them."

Health care assistants are among the front line staff who get to know patients best. Aiden Ferguson, a healthcare assistant at Addenbrooke's, said the documentary demonstrated that "professionalism is not nearly enough". He commented: " ̽��ֱ��film crystallises the importance of connecting with others in a way that is deeply present and true - and these connections can be forged with patients who have a terminal diagnosis and those who do not, with friends and family, with someone unknown."

Despite the sadness of its subject matter, there is a gentle optimism about ̽��ֱ��Time to Die – and many of the scenes it captures are revelatory. Patients in palliative care, says a nurse, find it “quite comforting” to see other patients immediately after death. St Christopher’s doesn’t cover the faces of those who die. Instead a single flower is placed on the pillow as the body is wheeled away. Interviews with relatives are reminders that life goes on. “I’ve thrown away his toothbrush,” says Kevin’s wife, shortly after his death. “And now I’m looking at the shoes he wore last time he came home.”

Doctors like to fix things: they train in medicine because they like solving problems and want to make people better. In his introduction, Barclay suggested that this impulse is at the root of the profession’s difficulties with handling death and bereavement.

̽��ֱ��Time to Die is a portrait of a hospice dedicated to end-of-life care. A general hospital faces different pressures, many of them driven by time. Fraser said that time was not always the critical factor – it was often a question of finding the right moment and language for a fairly brief conversation. A personal loss had, he said, “changed profoundly” how he approached his role at Addenbrooke’s. “I’ve learnt that there is sometimes nothing to say – no solution. But to validate sadness is so important.”

Among the professionals in the audience was Michelle Reynolds, Acting Head of Staff Counselling at Cambridge ̽��ֱ��’s Counselling Service. She said: “ ̽��ֱ��combination of the film and Fraser’s own testimony made the seminar an evocative experience. Twenty years have passed since the making of the documentary – and the need for good palliative care is as great as ever. Death doesn’t change its impact on the family, friends and the professionals involved. No-one is immune.”

We don’t know when or how we will die: death is one of the life processes that defies organisation. But with careful planning, an acknowledgment of our wishes and the support of skilled professionals and loving family and friends, there is much we can do. ̽��ֱ��Time to Die shows no happy endings but demonstrates how much caring means. Kevin dies at St Christopher’s, as he had wanted, with his wife with him. Hazel dies at home, quietly and gently in her boyfriend’s arms. Standing in a rainswept churchyard after Hazel’s funeral, he is quietly proud.

̽��ֱ��seminar series continues on Wednesday, 9 November 2016 with guest speakers Professor Bee Wee, NHS England's National Clinical Director for End of Life Care and Dr Anna Elsner, ̽��ֱ�� of Zurich. Professor Wee will discuss developments in national policy and practice in palliative and end of life care since the withdrawal of the Liverpool Care Pathway for the Dying. Dr Elsner will discuss a documentary exploring end-of-life care in Switzerland, 'Die weisse Arche'/' ̽��ֱ��white ark' (2015) and the Ars Moriendi (arts of dying) tradition. All welcome, no charge, booking required.

Inset image: Physician; credit: Yuya Tamai.

An ambitious seminar series began last week with a discussion of a remarkable documentary. Filmed in a pioneering hospice, ̽��ֱ��Time to Die addresses a subject that remains taboo for many. Joining the conversation are health professionals, medical students and members of the public, as well as those interested in film and ethics. ̽��ֱ��series continues on 9 November 2016.

̽��ֱ��film and discussion helped me to realise that what patients and their families may need most is not a doctor but another human being to simply be there with them.

Chris Kassam, medical student

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Life and death

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