Play fills the void

CASE NOTES

PRACTITIONER: Jan Edwards, manager Steps, a therapeutic team.
FIELD: Children and young people with emotional and behavioural difficulties.
LOCATION: County Durham.
CLIENT: Adam Delaney, now seven, was placed in care when just three months old.
CASE HISTORY: Adam’s earliest life experiences were characterised by disruption, instability, inconsistency and a failure to form secure attachments to significant carers. At birth, Adam and his parents underwent a residential placement because of concerns about young maternal age, domestic violence, lack of adequate housing, lack of family support, father’s anger and aggression and mother’s inability to protect. An incident of violence between the parents in the assessment centre meant that a decision was made to place Adam with foster carers. He would have 10 foster placements before the age of three. He was then found carers who were able to provide him with a stable placement and he was referred to the Steps therapeutic team for play therapy to help him resolve his numerous losses and separations and to prepare him for permanency.
DILEMMA: It was being felt generally that Adam’s behavioural difficulties were making him “unplaceable”.
RISK FACTOR: Adam was at risk of being unable to form lifelong attachments with a family.
OUTCOME: Adam has been living successfully with his prospective adoptive carers for over a year. An adoption
order is planned which will hopefully secure his future.


Sometimes young people with behavioural difficulties are buffeted through the care system in a series of broken down placements. This instability has far-reaching repercussions because it prevents any effective therapeutic work tackling the often emotional and attachment problems that lay at the root of such challenging behaviour. And so the cycle continues.

But persevering to provide that plateau of stability can trigger profound changes in a young person’s life. Adam Delaney had experienced 10 placements by the time he was three years old. Taken into care when just three months old he proved difficult to manage at home and school, was wilfully non-compliant and had insecure attachment relationships.

But four years ago came the placement that would provide a foundation for his future. His new carers, like the others in Adam’s life, had felt like giving in but they stuck with him, facilitating a referral to Steps, Durham’s therapeutic team. “Having carers with real stickability paid dividends,” says Jan Edwards, now manager of Steps, who was allocated Adam’s case at the time. “For the first time he had a place of safety and security.”

Some commendable forward-thinking led to the creation of Steps in 1995. Durham’s therapy team works with children and young people aged from three to 21 (or 24 if looked-after children) who have experienced significant trauma.

“All our staff are social workers trained in counselling and therapeutic techniques,” explains Edwards. “As well as direct intervention we also work with the system of professionals around the child. We don’t medicalise the child or view the child as the problem – we take a much broader emotional health view.”

Edwards saw her task as changing the “unplaceable” perception of Adam. She says: “At home and school I observed an attention-needing child who had adopted strategies to get that attention; these had worked for him in previous placements but were not working in his current placement with stable and supportive carers.”

A network of professionals involved with Adam met every six weeks. “We realised that in order to maintain the stability for Adam the placement would need to be well supported,” explains Edwards. “The social worker, health visitor and I provided intensive support in the form of consultation on child development and the impact of trauma and separation and loss, as well as a listening ear. This proved to be invaluable as the carers worked through endless months of Adam not sleeping, eating disturbance and soiling.”

Adam began weekly sessions of play therapy (which would last for the next 30 months) where in a safe place he could explore, through play, his feelings.

However, Edwards began to notice some worrying characteristics. “During sessions I just had a sense of something else going on for Adam: he was clumsy, had an awkward gait and he couldn’t do his shoelaces up, or pedal his bike or climb steps consecutively. And I just thought there was something organically wrong here,” she says.

Despite suspecting that he had dyspraxia (a developmental co-ordination disorder), Edwards could not get Adam assessed by health services. “Because of his young age there would no services for him to have even if he was assessed. So assessments aren’t carried out. The occupational therapy assessment couldn’t give a medical diagnosis but agreed that he did have dyspraxic tendencies. This meant we were able to change the way the carers and school worked with him – and he came on in leaps and bounds.”

Finally, after almost three years Adam was matched with potential adopters. Edwards, who played an integral part in the family finding, was able to provide insight into Adam’s attachment issues. With an adoption order now likely, Edwards is convinced that the network of professionals co-ordinated and motivated by Steps was what made the difference.

“As well as Steps, there were the carers, the social worker, family-finder from adoption team, fostering officer who was supporting the carers, the school and before that the nursery,” she says. “The health visitor played a vital role and had a really good relationship with the carers providing intensive support. And we introduced a play worker (as well as a play therapist) into the carer’s home, to help them introduce the child to play: Adam simply hadn’t known how to play.”

Social workers are sometimes accused of playing with people’s lives: but for Adam Delaney playing was what he needed to help him make sense of his feelings and life.

Arguments for risk

• Therapeutic work could only begin once Adam had some degree of stability. Says Edwards: “He had so many placements we could not start any intervention while he was moving from pillar to post – he had to be in a relatively stable place for us to be able to work with him in a very safe way with his past experiences.”
  
• A network of professionals and intensive support countered further disruption. “It mitigated against the risk of breakdown,” says Edwards. “It was vital that Adam experienced some stability and a template for a good attachment relationship if the plan for permanency through adoption was to succeed.”
  
• Being independent from social work teams means that Steps workers can see cases from a wider perspective.
  
• Through learning to play and long-term play therapy Adam was able to look forward to a future with a new mum and dad with whom he could form secure attachments.

Arguments against risk

• Placement breakdown was all Adam knew. But he was resilient despite the separation and loss, inconsistency, rejection and disruption that he experienced.
  
• While adoption studies have shown that adoption can achieve successful outcomes for children, even for older children, in terms of stability and lifelong attachment relationships, it is hard to achieve. The first three months are so significant in terms of attachment and brain development. We now understand that the neural-pathways are developing in that critical period and babies need that crucial early attachment relationship.
  
• It is likely, even without the therapeutic intervention, that as Adam got older, other professionals will have come into contact with him, particularly once entering the school system. These people may well have identified some of the issues for him, leading to the achievement of desired outcomes for him.

Independent Comment

However well we understand the emotional damage which many children suffer in their early years, we can still find ourselves harbouring the notion that all a young child needs is a loving, supportive placement and everything will come right, writes Patrick Ayre.

This case shows how mistaken this view can be. Without the support co-ordinated by Steps, it seems unlikely that Adam could ever have been placed successfully for adoption. One can envisage a situation in which carer after carer offered him care, warmth and affection, only to find that his behaviour became worse.

No one, however dedicated or committed, would be able to withstand the undermining effect of the apparent failure of their efforts without help.

As Steps identified, this assistance needs to be of three kinds. First, carers would require considerable emotional support to cope with the stress and disappointment which they faced every day. Second, they would need practical support such as a break from the child for part of the day or help with the practical tasks involved in his care. Third, they would need information, consultation and advice.

It would be vital that they should understand the emotional mechanisms at play in this case.

In view of Adam’s experience to date, his courting of negative attention may be seen as a reasonable response on his part, which was only likely to be extinguished when he began to benefit from the therapeutic help which Steps ensured that he was offered.

Patrick Ayre is senior lecturer at the University of Luton and an independent child welfare consultant.