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Correspondence to
Dr Corinne A Rees, Tyndalls
Park Children’s Centre,
31 Tyndalls Park Road, Bristol
BS8 1PH, UK;
drcarees@doctors.org.uk
Accepted 28 July 2010
Published Online First
22 September 2010
Arch Dis Child 2011;96:969–976. doi:10.1136/adc.2008.143164
Review
All they need is love? Helping children to recover
from neglect and abuse
Corinne A Rees
ABSTRACT the psychological context of abuse is integral to
Inadequately remedied abuse and neglect has costly safeguarding.
implications for children’s physical and emotional health,
behaviour, growth and development. It is relevant
WHAT DOES RECOVERY MEAN?
to major physical and psychological causes of adult
Achieving recovery means equipping children,
morbidity and mortality, involvement in crime as victim
despite adverse foundations, to function effec-
and perpetrator and parenting difficulties, but not
tively both independently and through relation-
inevitably so. Resilience varies, and its promotion is a
ships. Children’s perceptions of others, themselves
professional priority. Achieving recovery is a complex
and the world, communication, adaptability and
therapeutic task, often extending over years, not
resilience are shaped by the disturbed attachment
simply a matter of providing new parents. Neurobiology
underlying neglect and abuse, often complicated
increasingly explains why this is so. Effective
by intrauterine exposure to drugs, alcohol and
safeguarding means keeping long-term responsibilities
stress, perinatal difficulties, trauma and moves
in mind throughout. Balancing risks and benefits of
(table 1).14 Infants cannot regulate stress inde-
intervention requires consideration of the implications
pendently and depend on well-attuned parents to
of the quality of relationships which neglect and abuse
do so for them. Parents’ effectiveness in doing so
reflect. The aim of this paper is to contribute to the
influences programming of the stress regulation
understanding of recovery, and paediatricians’ roles in
systems, probably influencing gene expression at
achieving it.
an epigenetic level, with life long and potentially
intergenerational implications.7 8 Recovery from
inadequate early care involves managing the con-
INTRODUCTION sequences of ineffective early regulation.
Abuse is about relationships. So is recovery.
Early foundations run deep. For young children,
Whereas physical injury may heal rapidly, conse-
things are as they are: dysfunctional parenting and
quences of its emotional context are wide-ranging,
strategies for living with it become their norm, and
life long and often intergenerational. Children’s
a template for other relationships. Healthy rela-
emotional environment relates by multiple routes
tionships mean learning unfamiliar rules.15 The
to their physical and mental health, growth,
quality of the infant’s fi rst relationship remains
development and behaviour. Early abuse predis-
important, as intuitive as a fi rst language. If this is
poses to adult obesity, depression, cardiovascular
of neglect, a child may need to learn the vocabu-
and respiratory disease, and premature ageing,
lary and grammar of healthy relationships.
and to substance abuse, criminality and victim-
Recovery involves changing fundamental
hood, relationship difficulties and inadequate par-
assumptions which mould feelings and behav-
enting. Its public health implications should make
iour, and influence development. It involves
its remedy a priority of research and practice.1–7
learning the value, purpose and safety of rela-
Identifi able neurobiological consequences of
tionships, self-perception as likeable, worthwhile
abusive parenting help to explain the complexity
and competent, self-awareness, effective verbal
of recovery and the fallacy of supposing children
and non-verbal communication, self-regulation,
safe in the absence of demonstrable trauma.8 –11
adaptability and resilience, adjusting percep-
When safeguarding children, deciding how and
tions of normality and experiencing success. It
when to intervene requires consideration of the
may mean adjusting feelings deriving from early
implications for the long-term task of achieving
trauma which, unprocessed, cause confusingly
recovery of the disturbed relationships surround-
unpredictable changes of mood and behaviour.16
ing neglect and abuse.
Alternative parenting alone is an insufficient
remedy. Recovery is an active therapeutic task, PRINCIPLES AND PRIORITIES
often extending over years. Outcomes for young The legacy of abuse is multifaceted. Recovery is
people leaving care are poor,12 13 and the thera- a complex long-term task, with constantly mov-
peutic efficacy of adoption uncertain. Risks of ing goal posts of maturation and changing per-
removal from home and consequent professional sonal, social and academic demands. Foundations
responsibilities must be realistically balanced remain important, however well the higher devel-
with anticipated benefits. opmental layers are built, although neuronal plas-
Service structures and training need to bridge ticity allows resilience.
the gap between paediatric and Child And Abuse is, essentially, a problem of distorted
Adolescent Mental Health Services (CAMHS) to relationships. While simply providing new par-
ensure that consideration of the implications of ents is rarely sufficient, they are nevertheless the
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Review
principle tool of recovery. A professional priority is to equip
them through advice, support and adequate respite to facili-
tate this.
The aim is, through parents’ responses, to help children to
modify their preconceptions of relationships, themselves and
the world, while remedying continuing difficulties reflecting
dysfunctional foundations, helping stress regulation and antic-
ipating problems emerging with increasing demand and matu-
ration. The task is primarily of helping family relationships,
resisting seeing the child as ‘the problem.’ Any relationship is
Table 1 Consequences of neglect and abuse
Failure to achieve conditions allowing recovery
Inability to achieve a stable home; repeated placement breakdowns
Discontinuity in personal and professional relationships
Using relationships
Preconceptions deriving from dysfunctional early parenting
Attention seen as unhelpful or frightening, so avoided
Attention seen as valuable but unreliable, so held by any effective means
Closeness seen ambivalently as valuable but frightening, causing difficulty
handling close relationships
Relationships experienced as chaotic and pervasively negative, affecting ability
to function independently or through others
Inappropriate perceptions of normal
Roles (eg, children holding ‘parental’ responsibilities, close relationships
indistinguishable from others)
Behaviour (eg, absent sexual boundaries; aggression)
Communication difficulty
Poor foundations for verbal and non-verbal communication
Poor concentration affecting reading of social cues
Selective over-reading of anger
Behaviour
Opposition, attention-seeking, overcompliance
Over-reaction to disapproval, rejection, failure
Over-adjustment to others’ expectations
Difficulty relinquishing control
Pre-empting rejection by negative behaviour; ‘testing’ to the limit of tolerance
Impulsivity, inattention, hyperactivity
Self-perception
Poor self esteem
Lack of recognition of emotions, body signals (eg, satiety, toilet needs),
symptoms of illness or injury
Sensory integration problems
Intolerance of touch following abuse
Functioning in the world
Skills not learnt (eg, understimulation, missed schooling)
Self help advanced (eg, avoidance of relationships) or delayed (eg, lack of
opportunity)
Motor development: accelerated (eg, fearlessness, lack of boundaries) or
delayed (eg, lack of opportunity, anxiety)
Lack of imagination or exaggerated fantasy
Difficulty planning and learning from experience
Adaptability
Difficulty regulating stress and emotion
Intolerance of change; obsessionality
Excessive fear; fearlessness; inability to judge risk; hypervigilance
Depression; anxiety; post-traumatic stress disorder
Transition to independence
Confused identity
Poor self-esteem
Delayed or premature separation
Dysfunctional coping strategies (eg, substance abuse; eating disorders; early
sexual activity; promiscuity)
970
a two-way process: parents’ contribution is as important chil-
dren’s.17 Carers have their own responsibilities, vulnerabilities
and preconceptions, and need sensitive support in managing
these.
Adequate parental attachment is the over-riding priority for
every child, and a prerequisite of good recovery (table 2). For
adoptive parents, love for the child is usually the sustaining
hope, and, once established, a safety net allowing tolerance.
Inadequate attachment is, from either perspective, a source of
vulnerability, carrying a risk of cascades and vicious circles of
difficulty. Closeness usually comes in peaks and troughs, often
precipitate. Crises must be anticipated, and services organised
accordingly.
Recovery rarely follows an orderly sequence. Its strands
progress simultaneously as much as sequentially, inter-relate
and merge. Children dip in and out of behaviour adaptive
to previous dysfunctional parenting. It is a process of easing
forward rather than ‘fi xing.’ Building self-esteem is a prior-
ity throughout.14 18 19 Behavioural difficulty should not be
assumed to be inevitable, but equally, its absence is no guaran-
tee of emotional well-being.
Children may fi rst need to learn to value attention. Having
done so, they are liable to remain insecure in its availability.
Parents can safely assume that behaviour achieving inter-
est may be reinforced. So can professionals. For example,
the handling of aggression, sexualised play or alleged abuse
readily establishes a reliable route to attention. Therapeutic
work focused specifically on unwanted behaviour may per-
petuate it.
Children must function in the world while learning how
to do so. They need protective cocoons, but also exposure to
normality if they are ultimately to handle it independently.
By attuning to their feelings but not too much, parents can
ease them towards normal expectations. They need to be
cushioned while they mature sufficiently to understand their
circumstances and their implications.
Table 2 Tasks to be achieved for competent adulthood
Understanding of relationships
Understanding of the value, safety, reliability and predictability of relationships
Effective strategies for using relationships
Appropriate concepts of normal behaviour, roles and responsibilities
Effective verbal and non-verbal communication
Intuitive attunement to others’ feelings; empathy
Understanding of pragmatics, nuance, words for feeling, facial expression
Understanding of self
Good self esteem; coherent life story; healthy identity
Awareness of personal strengths and limitations; valued roles and
responsibilities; ability to exercise choice
Safe personal boundaries
Understanding of the world
Awareness of danger; ability to judge and manage risk
Education; practical independence skills
Parenting skills
Adaptability and resilience
Safe coping and stress-regulation strategies
Tolerance of change; ability to relinquish control
Effective executive function: planning, concentration, learning from experience
Ability to regulate emotion, anxiety, temper, mood
Ability to ‘reframe,’ accept and learn from difficult experiences
Ability to use services effectively
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Allowance is less readily made at school. Difficulty relin-
quishing attention and control, regulating stress and handling
change, and vulnerability to failure and rejection make school
demanding. Many children struggle to succeed socially, aca-
demically and behaviourally. Teachers, like parents, need to
see through the child’s eyes, recognise the preconceptions,
feelings and regulatory difficulty underlying their behaviour,
and understand the process of recovery. 20 Addressing problems
promptly helps to avert vicious circles. However, development
of ability, academic, physical or creative, is equally important.
Children need success and normality as much as remedy of
weaker areas.
The hope is gradually to weave in resilience and personal
responsibility, conveying that although the past cannot be
changed, it need not dominate the future, and may be used
well. To achieve this, children need a realistic story, which
protects identity and self-esteem by explaining the origins of
their parents’ difficulties.
Table 3 Questions to consider in safeguarding, to facilitate recovery
What is the apparent emotional context of abuse? (eg, quality of parental
attachment; violence; rejection)
What are the probable consequences, if uncorrected, for:
Understanding and use of relationships?
Self-perception?
Stress regulation?
Development?
Physical and mental health?
What are the contributory factors? Which are remediable? How soon?
Parental (eg, temper, attention-deficit/hyperactivity disorder, drugs, alcohol,
depression)
Child-related (eg, attention-deficit/hyperactivity disorder, behaviour problems)
Environmental (eg, inadequate support)
Does the child see relationships as valuable, safe, predictable? Do they seek
attention less or more than usual, inconsistently or appropriately?
Does the child adjust to different relationships?
What is the child’s perception of normality? (eg, parental roles, authority, sexual
boundaries)
To whom does the child have important attachments?
What are the apparent current manifestations of dysfunctional relationships?
Behaviour
Concentration, impulsivity, hyperactivity
Developmental pattern; use of learnt skills
Physical health (eg, growth, immunity, gastrointestinal function)
What would be the purpose of alternative care?
Is the child likely to achieve a new home and adequate attachment?
What are the probable implications of delay?
What are the risks to achieving alternative care, and implications for
placement choice of:
Pre-existing attachments; quality of sibling relationships; anticipated contact
arrangements?
Ability to share attention?
Behaviour?
The child’s wishes, feelings and understanding of their circumstances?
What are the implications for placement of past sexual abuse?
To whom/with what is there sexualised behaviour? (eg, carers, siblings, toys)
Does the child respond to boundaries for sexualised behaviour? Does it have a
compulsive quality?
Does the child have a safe means of achieving attention/closeness?
What are the implications for placing with other children?
What characteristics would a new family need?
What preparation is needed for the child and for new parents, to achieve an
alternative home?
Arch Dis Child 2011;96:969–976. doi:10.1136/adc.2008.143164
Review
Key elements of professional services are continuity, avail-
ability, insight into carers’ and children’s feelings, and prag-
matism focused on priorities. The task involves forethought
and attention to detail, but with an eye always on the whole
picture. Evidence, as it develops, requires wise application,
because of the multifactorial complexity of the task.
SAFEGUARDING AS A ROUTE TO RECOVERY
Whereas ‘safeguarding’ and ‘child protection’ imply defensive
purpose, they need to be seen as routes to recovery (table 3).
This means recognising the long-term implications of early
dysfunctional relationships, the progressive irreversibility
with age of their impact on brain growth, 21 the possibility
of critical developmental periods, and the diminishing like-
lihood of fi nding and retaining alternative parents. 22 –24 It
requires an eye as much on the long-term as on immediate
protection. Consideration of the emotional environment and
family attachments must be integral to safeguarding: psycho-
logical well-being and behaviour determine the likelihood of
achieving a home, adequate attachment and recovery.
Most abusing birth-parents experienced similarly dysfunc-
tional parenting, often leading to substance abuse, learning
difficulties, psychiatric illness and temper problems. 22 Many
are vulnerable to rejection, and lack negotiating skills, self-
esteem, trust, agency and adequate intuitive attunement to
promote secure attachment. Their children’s needs, once
neglected, are complex. Skilled support is needed to achieve
sufficient change soon enough. Even if they cannot, their role
matters, whether providing significant items or information
for their child or ‘giving permission’ to move.
Decisions to remove children from home should be tem-
pered by awareness of the responsibility which follows—
effectively, if not legally, contributing to corporate parenting.
An alternative home needs a defi ned purpose, with tasks nec-
essary to achieve this identified. For example, beyond imme-
diate safety follows assessment of where optimal permanent
parental attachment may be achieved. Answering this involves
considering factors contributing risk (eg, parents’ traumatic
childhoods, substance abuse, temper dysregulation), which
are remediable, to what extent, how soon, the likelihood and
the implications of delay. It involves assessing the quality of
attachment, parents’ capacity to change, and children’s prin-
cipal relationships within and outside the extended family,
including with siblings. It involves identifying current physi-
cal, developmental and emotional manifestations of dysfunc-
tional parenting and their implications if uncorrected.
The probable efficacy of alternative parenting requires real-
istic consideration: the assumption behind removal is that out-
comes will improve. Few who remain in care fare well: adoption
is encouraged instead, but many for whom it is intended fail
to achieve or sustain it;22 its therapeutic use is incompletely
evaluated from the perspective of children or adopters, not
least because outcomes follow long after intervention. 23
Every move is a risk requiring planning, preparation and
support. Children’s reactions to separation from everything
familiar are readily misattributed to previous parenting.
Emergency moves without preparation compound the trauma
and must be fully justified. Abuse is often longstanding; chil-
dren are usually at some level attached to the most dysfunc-
tional parents. Many have been warned about strangers, to
fear authority and that if they misbehave they will be taken
away. Reinforcement of the perception that close relationships
are transient, love fi nite, acceptance conditional and atten-
tion to be grasped by any effective means have long-term
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implications for self-image, the perceived safety of closeness
and behaviour.
Moving with siblings can be protective, or not. 25 26 Children’s
relationships reflect parenting. Attention-thirsty siblings often
resemble see-saws, thriving on each other’s misdemeanours,
one’s success driving the other to insecurity-fuelled challenge.
Many who have been ‘parent’ or protector struggle to relin-
quish control. Selective rejection causes particular vulnerabil-
ity in new homes. 24 Persistent sexualised behaviour between
siblings compromises recovery. However, dysfunctional rela-
tionships do not preclude closeness or mutual dependency but
may mask them: separation brings loss, blame and guilt.
Insecure children and new parents make a hazardous combi-
nation. The behaviour of distressed children may overwhelm
carers unfamiliar with their easier attributes, without a safety-
net of mutual attachment. Children who have experienced dis-
rupted placements may seek to pre-empt rejection. Those who
perceive acceptance as conditional on ‘behaving’ may test to
the limit of parental tolerance. They have no basis for under-
standing that parents are ‘for ever’—perhaps even useful. Their
experience is that, at best, close relationships do not sustain;
at worst, that they are unhelpful, unpredictable or frightening.
They cannot know whom new carers will resemble and may
experiment with maladaptive, once effective behaviour. They
understand dysfunctional relationships, but not healthy ones.
Identifying optimal carers, stabilisation, development of
attachment and recovery are active tasks requiring profes-
sional planning and attention to detail. Assessment, helped by
professional continuity, involves identifying issues essential
to the choice and preparation of carers (eg, difficulty sharing
attention, maladaptive attention-seeking, sexualised behav-
iour) and protective relationships.
‘WHAT HAVE WE DONE?’: SUPPORTING ADOPTERS
Most adopt because of infertility, 22 facing substantial adjust-
ment from the hope of pregnancy to the reality of parenting
traumatised children. The magnitude of change in lifestyle
and family relationships may be unanticipated despite prepa-
ration. Intellectual understanding is often a far cry from the
experienced reality.
Adopters’ feelings are frequently not as they anticipated
or their friends and relatives assume, causing fear, self-doubt
and guilt: reassurance is needed of their normality. Loss fre-
quently resurfaces, bringing unintended comparison with
imagined birth children. Distressed children’s behaviour may
raise uncomfortable reminders of dysfunctional birth-parents;
occasionally it revives unanticipated feelings from adopters’
pasts. New adopters face disturbing uncertainty that attach-
ment will grow. Instinctive protection of children already in
the family makes newcomers vulnerable, particularly if inse-
curity establishes behaviour upsetting to them as a reliable
route to attention.
Adopters often feel frighteningly inept, faced with the
confusing behaviour of children new to their care. Enabling
parents to see through their eyes helps behaviour which other-
wise feels undermining, personal, confusing and manipulative
to be recognised as the learnt self-protective strategy it rep-
resents. Children’s perceptions are judged by piecing together
what is known or assumed of their earlier experiences, along-
side their current behaviour.14
Behaviour generally serves a purpose. It is determined by
the anticipated response, which may, however, be founded
in early parenting. Attention and control are usually central
issues—the extent to which attention is perceived as valuable,
972
safe and reliable and control as safely relinquished. Belief that
attention is valuable but unreliable results in grasping it by
any effective means, positive or negative, that it is dangerous
or unhelpful in autistic-like avoidance. Belief that control is
not safely relinquished encourages opposition, intolerance of
change and obsessionality. Following neglect, behaviour is fre-
quently further coloured by impulsivity, anxiety, fear of rejec-
tion and consequences of traumatic ‘fl ashbacks.’16
The abnormal may be a child’s normal, established through
early experience. For example, sexualised play with dolls may
have as little emotional significance as feeding them if sexual
activity has been commonplace. It should be seen though chil-
dren’s, not adults’, eyes. Sexualised behaviour towards carers,
learnt to achieve approval, attention or closeness, may, per-
plexingly, provoke criticism or rejection and sometimes denial
of physical closeness.
Simple principles go far: fi rst, consistent expectations and
consequences of behaviour, and attention for what is wanted.
Some children up the stakes with behaviour which few can
ignore (eg, smearing, endangerment, hurting others). Parents
are encouraged to empathise with the feelings underlying
behaviour, and with those evoked by necessary consequences.
Clear but unemotional boundary setting is the aim, variably
achieved, and rarely so by tired, stressed parents: self-care is a
responsibility, not a luxury.
Perseverance is needed when poor self-esteem and unfamil-
iarity with success cause rejection of praise and sabotage of
celebration; removing treats may prove ineffective discipline.
Challenging behaviour may drive adopters to guilt-inducing
responses. However, normal parents teach children about
normal relationships, and that anger does not mean rejection.
Difficult times allow modelling of apology and reconciliation.
Parenting traumatised children involves taking on their trou-
bles, and difficult feelings feel difficult.
For some, closeness naturally grows. Others need consid-
erable support. Demystifying attachment helps adopters to
apply experience from other relationships, reducing factors
which interfere (eg, fatigue, stress) while increasing those
which help (eg, shared calm). 27
Paediatricians need to be equipped to offer timely support,
feeding into other services, or obviating the need (table 4).
UNREGULATED STRESS
Difficulty handling stress is a common, costly legacy of
early trauma. Western medicine is ill-equipped conceptu-
ally and structurally to address it, straddling mind and body
and defying specialisation. Development of understanding
is jigsaw-like. Pieces can be described, their position some-
times not. Children cannot wait for evidence: practice requires
pragmatism.
The hypothalamus–pituitary–adrenal (HPA) axis, dopamine
and serotonin systems, are programmed in pregnancy and
postnatally. 28 Infants rely on parents to regulate their stress.
Poor attunement allows overactive programming, or some-
times downregulation, perhaps following unremitting stress.
Abnormal salivary cortisol, reflecting HPA function, correlates
with conduct disorder and attention-deficit/hyperactivity dis-
order (ADHD)29 30 and continues into adulthood, accompany-
ing depression and post-traumatic stress disorder. 31 32 It may
contribute to somatiform problems. 33 Dysregulated stress
compromises family stability and attachment, and often per-
sists despite adoption. 22
Difficulty handling stress and excitement is manifest as
frustration, anxiety, temper, inattention and ‘spoiled’ treats
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Table 4 Tool kit for supporting new adopters
Helping adopters to understand complex feelings
Complex feelings are normal and rarely anticipated. (eg, unreality, inadequacy,
revived feelings re childlessness)
Prolonged infertility can cause idealisation of parenthood: post-adoption
depression is common
Negative feelings feel out of line with others’ expectations, causing guilt
Fear that attachment will not grow is common and distressing
Helping adopters to understand and build attachment
Understanding of adult relationships can be applied to facilitating parent–child
attachment
Attachment is a two-way process, needing attention to each side of the
relationship
The core of attachment is sensitive, timely attunement to the child’s feelings and
needs
Stress, anxiety, fatigue and lack of opportunity adversely affect attunement;
shared emotions and I:I time help it
Development of attachment is usually gradual and fluctuating
Attachment usually develops with one parent more rapidly than with the other
and with one child more rapidly than another
Early signs of developing attachment are readily overlooked: identifying them
reduces anxiety
Helping adopters to see through the child’s eyes
The child cannot know whom new parents resemble and may test out previously
effective behavioural strategies
Behaviour serves a purpose to which attention and control are usually central:
undesirable behaviour will have been learnt by its effect
Children may provoke familiar patterns of dysfunctional parenting
The child’s behaviour is likely to reflect preconceptions of relationships derived
from earlier experiences
Principles of initial care
Make self-care a priority (eg, relaxation, exercise, ‘adult time’)
Minimise practical demands
Protect normality (eg, nursery attendance)
Create a ‘place of safety’ through boundaries, routine, consistency and empathy
Include shared fun and calm (eg, massage)
Structure the day so that success outweighs failure
Give attention selectively for desired behaviour
Ensure that parents are in control (eg, diversion, or offering simple choices to
manage children’s difficulty in relinquishing control)
Empathise with feelings underlying behaviour while maintaining consistent
boundaries
Use difficult times to model apology, reconciliation and stress regulation
Principles of emotional care
Introduce from the outset a realistic story, protective of self-esteem and identity
Create opportunity to discuss difficult issues
1:1 time; shared activities which allow conversation
Third party approach (eg, stories, ‘adopted’ pets)
Initiate mention of difficult topics
Routinely talk about feelings
Creativity (eg, drawing, music, pretend play, puppets)
Make self esteem a priority (eg, facilitate success, challenge, friendship)
Manage sexualised behaviour
Safe practical boundaries (own room; discrete supervision of play)
Teach safe means of physical affection; unemotional boundary setting
and celebrations. Anger, often compounded by fear of failure,
poor negotiating ability, anxiety, difficulty handling change,
ADHD—and adolescence—carries risk of rejection at home
and school. Anger towards birth parents may be focused onto
adopters, often fuelled by ambivalence to closeness. Children
mirror parental stress, and exposure to violence may predis-
pose neurobiologically to temper. For some, all emotion is as
experienced as one: anger is selectively and excessively identi-
fied and expressed. 34 Others fail to express emotion. Behaviour
Arch Dis Child 2011;96:969–976. doi:10.1136/adc.2008.143164
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regarded in toddlers as ‘tantrums’ is seen in older children, or
without attachment, as ‘violence,’ which feels personal, reject-
ing and frightening. Children ‘erupt over nothing,’ ‘fl aring
from 0 to 100, nothing between,’ eyes changing, control lost,
often likened to Jekyll and Hyde.
Parental stress regulation is a prerequisite of that of children,
teaching them by role model, discussion and play to calm
through others and independently, demonstrating apology
and reconciliation, boosting self esteem and helping emotional
literacy. Children can be encouraged to create their own ‘calm
corner,’ to use frequently to give positive associations, and
not only when calming is needed. Reduction in salivary cor-
tisols suggests benefit from input designed to help regulation
though relationships. 35 – 37 Treating ADHD allows emotional
awareness and regulation; risperidone helps some to manage
temper. 38
Clinical measures of autonomic arousal, their predictive
value and the management of under- and overactive responses
need development ( box 1). Practical approaches such as creativ-
ity, physical activity, massage, meditation (influencing HPA
activity)39 and yoga40 warrant exploration alongside neurop-
harmacology. However, for some, ‘mind clearing’ relaxation
techniques allow intrusive traumatic fl ashbacks, so applica-
tion needs caution.
TO LABEL OR NOT?
‘Normal’ responses to abuse generate characteristics consistent
with, but not necessarily entirely typical of, numerous labels,
including ADHD, autistic spectrum disorder, obsessional com-
pulsive disorder, oppositional disorder, dyspraxia, reactive
attachment disorder, anxiety, depression and post-traumatic
stress disorder. Labels bring variably justified assumption.
Box 1 Stress regulation
Managing parental stress
Reduce anxiety (eg, explaining feelings, attachment, children’s
behaviour)
Recharge (eg, exercise, relaxation)
Managing children’s stress
Reduce anxiety (eg, routine, consistency, reassurance,
allowing success)
Ensure adequate sleep (eg, daytime exercise; calm prebedtime
routine)
Teach calming and stress releasing strategies:
▶ ‘Calm corner’; visualising calm scenes, calming music
▶ Meditation, yoga, etc
▶ Exercise (eg, punch bag, trampoline); singing; dance
▶ ‘Portable’ calming (eg, stress balls; breathing/blowing
games)
Teach body awareness (eg, feeling the heart rate during
calming)
Encourage calming through relationships
▶ Talking about feelings; shared calm; massage
▶ Offering closeness when tired, hurt, etc, even if not
sought
Pre-empt unregulated excitement (eg, birthdays)
Limit high sensory stimulus (eg, computers, fluorescent
lights, crowds)
Consider medication (eg, methylphenidate, risperidone)
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Children characteristically have multiple inter-relating diffi-
culties deriving from early experiences: diagnoses are often a
clumsy fit and diagnosis-based guidelines an incomplete reflec-
tion of their priorities.
Assessment of ‘ADHD,’ ‘autism’ or developmental delay
requires an understanding of the complex inter-relationship
of issues involved, rather than considering these in isolation.
‘ADHD,’ typical and atypical, is an association, a cause and
an effect of disturbed attachment. Familial risk, often com-
pounded by intrauterine substance exposure or violence, is
high and may underlie parents’ substance abuse and temper.
It compromises achievement of a home, mutual attachment,
friendship and self-esteem. Treatment should focus pragmati-
cally on the priority of adequate attachment, helping children
to seek attention appropriately, understand emotion, read
social cues and use psychological help.
Diagnosing ‘reactive attachment disorder’ carries a risk of
identifying the child as the problem. Conceptually, describ-
ing how children understand relationships, and why, may be
safer, recognising that attachment is inevitably vulnerable fol-
lowing neglect, abuse and moves, but dynamic and modifi able
through experience.
Once given, labels can be difficult to shed. Early traumatic
parenting may leave children adept at adjusting to expectations:
they may conform more readily than most to the assumption
brought by labels, with risk of self-fulfi lling prophesy. Facing
adolescence with numerous ‘abnormalities’ compounds vul-
nerable self-esteem and worries about identity and difference.
Labelling can be a route to achieving necessary services
but needs circumspection, balancing disadvantages and
advantages.
PROFESSIONAL RESPONSIBILITIES AND SERVICE
STRUCTURES
Organisation and funding of services should reflect the mul-
tifaceted, long-term nature of recovery, the need for attention
to detail, the inevitability of crises until protective attachment
develops and the inter-relationship of developmental, emo-
tional, behavioural and physical sequelae of abuse, educational
experience and parental well-being. Contributory disciplines
need common understanding to ensure that good psycho-
logical care is integral to practice. Separation of CAMHS and
paediatric services poses particular risk: the gap needs to be
bridged robustly in training and practice.41
Emotional assessment and ‘reading’ of the quality of attach-
ment should be routine in safeguarding. Physical safety may
otherwise be achieved at the cost of emotional harm, damag-
ing relationships overlooked, costly delay allowed and the like-
lihood of successful reparenting compromised. The approach
to achieving physical safety influences recovery. The risk of
moves may be reduced through placement choice, preparation,
and support of carers in the vulnerable early stages. 23
Political and media-driven selective focus on physical pro-
tection is to be resisted, recognising that inadequate emotional
care may carry the greater risk. All who are involved in safe-
guarding need the opportunity to relate the progress of alter-
native care to decisions about intervention.
Children’s emotional needs and behaviour determine the
success or otherwise of reparative placements. Those under-
taking statutory health assessments for children in care should
address these without deflection by the pressure of measurable
targets. Their contribution should be integral to social services
reviews.
974
Paediatricians need to provide advice, rapid availability, con-
tinuity and advocacy, working alongside and feeding into spe-
cialised psychology services and liaising with schools. They
need to understand the nature, purpose, timing and limitations
of therapeutic services. In referring, they should know what
question they are asking. Expertise in helping attachment diffi-
culty is growing.42 – 44 However, pursuing increasingly special-
ised services in a quest to ‘put things right’ sometimes needs to
be discouraged when the natural history realistically requires
easing forward, not ‘fi xing.’ Identifying progress encourages
parents that their care can continue it ( box 2). Confiding in
parents helps closeness; children can communicate in their
own time. However, some feel safer keeping difficult feelings
separate from home. Many need help to establish or protect
relationships—for example, if anger towards birth parents is
projected onto adopters or closeness is feared.
Box 2 Therapeutic services: considerations and
tasks
Considerations
▶ Risk of placement disruption requires urgent assessment
and support
▶ Therapeutic work may be needed before a move to enable
a child to accept new parents
▶ Professional continuity is important to assessment when
children move
▶ New carers need to understand children’s anticipated
feelings and behaviour before placement
▶ Any early therapy should focus on stabilising the
placement
▶ Therapeutic work with a child early in a placement may
affect confiding in and attachment to carers
▶ Work may be principally or entirely through parents
▶ New parents may need therapeutic help with feelings of
loss and inadequacy when parenting a recovering child
▶ More than one modality of care is often needed
▶ Therapy only for the child can label them as the problem,
discouraging working through relationships
▶ ‘Life story work’ may be seen as social services’ job,
whereas it is often integral to necessary Child And
Adolescent Mental Health Services work
▶ Adopters need realistic expectations of recovery and
therapeutic services
▶ Therapeutic support may need to be repeated as children
mature
▶ Service structures need to offer continuous baseline
services with episodic specialised care
Tasks
▶ Preparation for and support following moves
▶ Helping attachment
▶ Behaviour management
▶ Helping children to understand their circumstances,
overcome perceived rejection, address confused identity
▶ Management of depression, obsessional compulsive
disorder, anxiety, ADHD, post-traumatic stress disorder
▶ Addressing feelings underlying dysfunctional coping
strategies
▶ Managing emotional dysregulation and temper
▶ Promoting social skills
▶ Managing sexually abusive behaviour
Arch Dis Child 2011;96:969–976. doi:10.1136/adc.2008.143164
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Continuity matters in understanding children’s and fami-
lies’ needs, avoiding the distortion of the snapshot view. It
helps interpretation of disturbed behaviour following moves,
or when children’s hypervigilance produces overadjustment
to presumed expectations. It reduces the risk of dismissing
behaviour as ‘difficult because it would be.’ Pre-established
trust helps safe management of crises.
Current professional trends do not necessarily suit this work.
Emphasis on evidence leaves vulnerable services where its
absence as often reflects lack of practically applicable research
as of efficacy. Economy-driven drift towards evidence-based
rationing is particularly problematic.
Clinical research is needed into markers of emotional
neglect, and its neurochemistry and pharmacology, including
possible use of oxytocin and vasopressin in helping attach-
ment, fi sh oil supplementation in modifying stress responses
and corticotrophin releasing factor antagonists in managing
HPA axis dysfunction.45 – 47
CONCLUSION
Supporting recovery from abuse and neglect is a long-term
multiprofessional task, requiring a broad perspective, initia-
tive, pragmatism and attention to detail. It involves bridg-
ing gaps between professional groups, particularly between
CAMHS and paediatricians.
Effective safeguarding requires an eye as much on the long
term, as on immediate physical protection, with good emotional
care integral throughout. It involves accepting responsibility to
help those removed from home to achieve a family and adequate
attachment, by assessment, preparation and timely support.
Difficulties relating to abuse and neglect are multifactorial
in cause, manifestation, consequences and management. They
are fundamentally problems of relationships; recovery is prin-
cipally achieved through relationships, requiring attention
to each side of these. The relevance of dysfunctional stress
regulation highlights an important gap in Western medicine.
Research is needed into its clinical assessment, predictive value
and management.
The cost of inadequately remedied abuse to individual
physical and emotional health, the next generation and society
should be a powerful incentive to develop services equipped in
structure, function and ethos to support recovery.
Acknowledgements The author is grateful to A Lister, M Sadlier and
T Woodbridge for their helpful comments.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
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Arch Dis Child 2011;96:969–976. doi:10.1136/adc.2008.143164
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All they need is love? Helping children to

recover from neglect and abuse
Corinne A Rees

Arch Dis Child 2011 96: 969-976 originally published online September
22, 2010
doi: 10.1136/adc.2008.143164

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