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However, Pace et al. Adopting a more fine-grained perspective on attachment, Hodges et al. Interestingly, when comparing the effects of age at placement at different time-points, Hodges et al.

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Late-adopted children's display of many characteristics of disorganization remained unchanged over 2 years, suggesting that they were still struggling with disorganizing emotional responses, but the reduction in avoidance suggests that they had become more able to represent these in the narrative, acknowledging dilemmas and maintaining better functioning in the face of stress. Table 5. Significant and non-significant fine-grained attachment differences between early- and late-adopted children. Furthermore, Pace et al. This suggests that time spent in the adoptive family is an important aspect for developmental catch-up with regard to attachment.

In the subsample of adopted children with family experience before adoption, the amount of time spent with a family before institutionalization was positively related to security. In the same vein, older age at entrance to an institution and shorter experience there were related to higher security and lower insecurity.

However, in the subgroup of adopted children who had spent their whole pre-adoption life in an orphanage, none of these variables showed significant relationships with attachment representations.

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In a follow-up study, Pace et al. These authors found that although linguistic competence did not influence attachment indicators, children with higher intelligence showed more indicators of secure attachment. In line with these latter findings and from a fine-grained perspective, Vorria et al.

Barone and Lionetti found that adopted children classified as disorganized performed worse on emotional competence compared with adopted children with coherent attachment organizations, regardless of security, whereas no difference was found between securely and non-securely attached children. From a fine-grained perspective, Hodges et al. Furthermore, children with more peer problems showed more denial of distress and catastrophes, and less realistic mastery, as well as fewer instances of children helping other children. Quantitative and qualitative studies have shown that adoptive parents' attachment representations play an important role in determining the newly formed relationship with their adopted child across time Steele et al.

Two studies, reported in three papers Pace and Zavattini, ; Barone and Lionetti, ; Pace et al. No significant concordance was found between children's and fathers' attachment. In contrast, Pace and Zavattini and Pace et al. Specifically, Pace et al. Two studies, reported in six papers Steele et al. Steele et al. Subsequently, Steele et al. Detailed findings are presented in Table 6.

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Table 6. Associations between parental attachment and fine-grained child attachment aspects. By contrast, when neither parent's AAI was secure i. Finally, in a qualitative approach, Steele et al. Although both children showed indices of Insecurity in their story stem completions early in the placement, at 2-year follow-up, the story stem completions of the adopted child placed with the secure parent showed many themes indicative of Security, whereas those of the adopted child placed with the insecure-dismissing parent continued to show a preponderance of themes indicative of Insecurity, Disorganization, and Defensive Avoidance Steele et al.

In this regard, Steele et al. First, they stated that parents' secure-autonomous states of mind might be associated with open and flexible processing of affect, which in turn helps the child to modulate negative affect.

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Furthermore, Steele et al. This stance nurtures a similar ability for the child to integrate a range of feeling states because the new parental environment supports exploration and integrative efforts. Although, to the best of our knowledge, both perspectives—affect-regulatory and mentalizing—have not been thoroughly tested empirically to date, Steele et al. As explained above, story stems consist of mildly stressful scenarios that are part of everyday childhood experience Steele et al. As such, story stems not only tap into children's attachment representations by evoking something about the content of the child's perceptions and experiences of relationships with significant others.

Story stems also immediately evoke the affects and the coping and defensive strategies children have available to manage emotionally challenging situations. Perhaps the most important function of IWMs is to regulate the individual's experience of intense emotion and to direct the individual's behavioral and psychological responses. In sum, the representations make up the initial content of IWMs, informing one's sense of self, others, and what to expect, but also immediately evoke affect-regulation and behavioral strategies, particularly when distressed—that is, when the attachment system is activated.

In addition to the attachment and affect-regulatory perspectives, a third perspective on NSSTs, that of mentalizing Fonagy et al.

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Mentalizing refers to the capacity to understand one's own and others' behaviors as motivated from an internal world feelings, thoughts, desires, anxieties, etc. Fonagy and Allison describe how secure attachment relationships ensure normal family discourse and playful interactions offering the necessary opportunities to learn about the links between internal states and actions that scaffold the development of mentalizing.

However, early adversity, as is experienced by many adopted children, interferes with the development of mentalizing capacities in two possible ways. First, these children have suffered at least one discontinuity in their early attachment relationships, and thus have had less consistent scaffolding opportunities regarding mentalizing.

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Second, in cases of cumulative adverse experiences e. In the context of adversity, caregivers will be inaccurate in their reflections of the child's state of mind and the behavior of the caregiver will evoke a fear response in the child, increasing the risk of the child developing a disorganized representation of self and interfering with the capacity to reflect on mental states. Hence, such children frequently show contradictory behaviors toward their adoptive parents, oscillating between compliance, dependence, passivity, withdrawal, rejection, hostility, and provocation Steele et al.

These behaviors can make it hard to build an attachment relationship based on trust and a sense of belonging and protection in their adoptive families Slade, ; Steele et al. In this context, as discussed above, research to date has emphasized the importance of a secure attachment state of mind in parents for managing the conflicting and vulnerable representations that adopted children bring with them into their new families Levy and Orlans, ; Schofield and Beek, Little research to date has specifically investigated this mentalizing perspective in adopted children using story stems.

One exception is the study by Pace et al. As discussed earlier, NSSTs, in particular more fine-grained approaches, have proven valuable attachment perspective or at least promising affect-regulatory and mentalizing perspectives in systematically assessing adopted children's internal reality from multiple perspectives Hodges et al. These techniques may also be helpfully used to examine the effects following major change in the child's external situation Hodges et al.

Such changes, besides placement changes, can include therapeutic intervention with a parent and also therapeutic help for children themselves Hodges et al.

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  4. Importantly, this implies that NSSTs allow us to map areas of difficulty so that parents and professionals have a clearer idea of the child's needs and vulnerabilities Hodges et al. More compellingly, Page et al. In sum, with such detailed individual understanding of the child's internal reality, parents and professionals can more sensitively tailor their parenting and their support to fit children's individual needs, thus assisting the children's developmental recovery Hodges et al.

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    The findings of this narrative mixed-methods review of 18 papers in which NSSTs were used to gain insight into aspects of adopted children's aged 3—11 internal reality may be summarized as follows. The review provides some preliminary conclusions about the suitability and value of NSSTs, as well as points to several promising avenues for research and clinical application of NSSTs. However, the small number of studies as well as the large differences in methodology among these studies need to be taken into account when discussing the implications of this body of literature carefully and critically.

    Of special note in this regard are: a different theoretical perspectives and a trend toward a shifting paradigm, rendering b NSSTs not merely valuable as a content-based but also as a performance-based measure; c the value of NSSTs not only from a disorder-oriented but also from a person-centered perspective in diagnosing and assessing adopted children's attachment vulnerabilities and changes therein; d preliminary findings with regard to factors influencing adopted children's attachment representations as assessed by NSSTs.

    Most studies using NSSTs with adopted children to date have used these techniques exclusively as attachment-based instruments to gain insight into adopted children's IWMs. In this regard, NSSTs have proven particularly valuable in an age group for which few self-report attachment measures are available Bosmans and Kerns, , as the opportunity to play allows children to more easily express non-conscious aspects of their internal reality stored in procedural memory, and the possibility of displacement allows children to more easily express content that would otherwise be too anxiety-provoking.

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    In this context, it is important to note that the paucity of studies using NSSTs with adopted children, and the fact that in two of the three studies reported in five papers using the MCAST children's narrative responses were coded exclusively to investigate attachment classifications 6 , preclude any firm conclusions as to the importance of displacement. However, based on our own clinical experience as well as others' Hodges and Steele, ; Hodges et al. The finding that all but a few of the reviewed studies used NSSTs to exclusively assess adopted children's attachment representations is striking, as several authors have suggested that both an affect-regulatory and a mentalizing perspective on NSST responses hold promise in making sense of adopted children's internal reality.

    To date, only one study Pace et al. The discussion about theoretical perspectives as described above goes hand in hand with different, though potentially complementary, perspectives on what children's NSST responses reveal precisely. Most authors emphasize that NSSTs are based on a natural mode of self-expression for children, facilitating direct assessment of representations in a non-intrusive way; whereas some point to the way affect and affect-regulation strategies and mentalizing processes can be shown in a here-and-now playful context.

    Both perspectives may be of additional value to clinical and research practice. With regard to an attachment perspective, NSSTs as an assessment instrument may be of interest to researchers and clinicians alike, as children's narrative responses can be coded at three different levels—categorical, dimensional, and fine-grained—providing three complementary perspectives on the child's IWMs.