The case for public health policy engagement – a series of case studies
Dr Robbie Duschinsky, of Cambridge’s Primary Care Unit at the School of Clinical Medicine, mobilised international colleagues to ensure draft NICE guidelines that had the potential to impact on the experiences and outcomes of children suspected of being the victims of maltreatment were revised to reflect the most robust and up-to-date evidence.
Dr Duschinsky is a social scientist whose research integrates approaches from psychology, sociology, history and philosophy. He leads the Applied Social Science Research Group and since 2014 has held a New Investigator Award from the Wellcome Trust for research into debates about infant attachment and maltreatment, and the significance of attachment relationships for child health and wellbeing. The research also examines the practical implications of these debates for clinicians and social welfare practitioners.
In 2015, the National Collaborating Centre for Mental Health released the NICE-commissioned Clinical Guidelines for Attachment in Children and Young People Who Are Adopted from Care, in Care or at High Risk of Going into Care draft for consultation. 1 The National Institute for Health and Care Excellence (NICE) is an independent organisation which develops national guidance to enable health and social care professionals to provide high quality care based on the best evidence. Their guidance would impact upon the care of vulnerable individuals across the country.
Dr Duschinsky, who monitored relevant consultations, carefully reviewed the guidelines. While they were an excellent synthesis of the available evidence, he pinpointed specific issues in how in the guidelines characterised the infant disorganised attachment classification. Critically, the guidelines advised on how this classification could be translated into clinical practice and assessments. This included a proposal which appeared to suggest that children suspected of experiencing maltreatment should be screened by clinicians using assessment for disorganised attachment. Dr Duschinsky and his colleagues were concerned as the evidence did not suggest this, and the guidelines might misdirect clinicians and social workers.
Working around sensitive issues of close relationships and maltreatment, my colleagues and I feel it is important to try to ensure that clinicians and social workers can draw on a solid understanding of theory and research in their work with families. – Dr Duschinsky
Dr Duschinsky mobilised an international group of collaborators from the University of California, Berkeley – including colleagues from the Berkeley laboratory who had first introduced the classification – the Harvard Medical School, and Northumbria University, to formulate a response to the draft guidelines. Their comments addressed the characterisation of disorganised attachment at theoretical and observational levels, updated the use of empirical research on antecedents to disorganised attachment, and made proposals for the more appropriate use of attachment assessments in cases of suspected maltreatment.
The updated NICE guidelines were published in November 2015. 2 In response to the consultation feedback, the Guideline Committee substantially amended the account of disorganised attachment, in the discussion of theory, of assessment measures, and of the available evidence. For example, on the advice of Duschinsky and colleagues, the guidelines now state:
“Neither the behaviour described by the Main and Solomon indices, nor a classification of disorganised attachment in the SSP, can be used in any valid way to assess a child for maltreatment. Although correlated with it, maltreatment cannot be inferred from infant disorganised attachment […].” 3
Current work includes conceptualising attachment and maltreatment processes and longitudinal research on the long-term implications of infant mental health for adult physical health and health-related behaviours. The team is also examining the extent to which safeguarding practice and assessments of children made by GPs, clinical psychologists and social workers are impacted by biases which stem from their own childhood experiences. This work represents an innovative line of inquiry exploring how early experiences can shape future decision-making as well as mental and physical health.
- Adshead, Gwen, and Kerry Bluglass. “Attachment representations in mothers with abnormal illness behaviour by proxy.” The British Journal of Psychiatry 187.4 (2005): 328-333.
- Cyr, Chantal, et al. “Attachment security and disorganization in maltreating and high-risk families: A series of meta-analyses.” Development and Psychopathology 22.1 (2010): 87-108.
- Puig, Jennifer, et al. “Predicting adult physical illness from infant attachment: A prospective longitudinal study.” Health Psychology 32.4 (2013): 409-17
- Reijman, Sophie, et al. “Autonomic reactivity to infant crying in maltreating mothers.” Child Maltreatment (2014) 19. 2 101-112.
- Spangler, Gottfried, and Peter Zimmermann. “Emotional and adrenocortical regulation in early adolescence: Prediction by attachment security and disorganization in infancy.” International Journal of Behavioral Development 38.2 (2014): 142-154.
- “Children’s Attachment, Attachment in children and young people who are adopted from care, in care or at high risk of going into care, Clinical Guidelines, Methods, evidence and recommendations, Draft for consultation,” National Institute for Health and Care Excellence, May 2015, accessed 4 March 2016, http://www.nice.org.uk/guidance/NG26/documents/childrens-attachment-full-guideline2. ↩
- “Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care, Overview, Guidance,” National Institute for Health and Care Excellence, accessed 4 March 2016, https://www.nice.org.uk/guidance/ng26. ↩
- “Children’s attachment, Attachment in children and young people who are adopted from care, in care or at high risk of going into care, NICE Guideline 26, Methods, evidence and recommendations, November 2015, Final,” National Institute for Health and Care Excellence, accessed 4 March 2016, http://www.nice.org.uk/guidance/ng26/evidence/full-guideline-2180188189. ↩