Therapeutic Childcare – The CARE Approach

Colby Pearce Attachment National Psychology Exam

Earlier this year I set about revising and updating A Short Introduction to Attachment and Attachment Disorder. The second edition is available from December 2016. As part of the revision process I considered what we might mean when talking about therapeutic care of children. This is the CARE Model I came up with:

Be Consistent – Children develop and learn (including new ways of relating) best in a stable care environment where there is consistency in caregiver approach to the child’s care and management across caregivers and across time.

Be Accessible – Children benefit from an enriched experience that their carers are available to them. They learn this best when carers attend to them before the child has done anything to draw attention to themselves.

Be Responsive – Children benefit from an enriched experience that their inner world is understood and their needs will be responded to without them having to go to great lengths to make it so; either through behaviour that communicates internal states or inordinately demanding or deceptive behaviour to secure a response to basic needs (such as the need for attention, acceptance and physical sustenance). Communicating understanding of their inner world in words used by their caregiver and through proactive needs provision is vital for enriching the child’s experience and new learning about caregiver responsiveness.

Be Emotionally-Connected – Children benefit from the experience that their emotions are felt by their caregivers. Their experience of connection is enhanced and the foundations for empathy and self-regulation are promoted. Through their caregivers making an emotional connection with the child’s emotions and restoring calm themselves, the child will themselves be calmed, with the result that the child will to explore a range of emotions (thereby promoting emotional growth) and develop their own capacity for self-regulation of emotion.

13754277_10207024040505557_6258179799568697908_nFor more information about the CARE model and the CARE approach, secure the revised and updated second edition of A Short Introduction to Attachment and Attachment Disorder, available December 2016.

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Therapeutic CARE and the Triple-A method

As a practising Clinical Psychologist and as a father to three boys I often think of child-rearing as akin to being a farmer who grows crops.

The farmer expends significant effort preparing the soil and sowing seeds. Then the farmer waits and hopes. The success of his endeavours is dependent on his preparation of the soil and climatic conditions through the growing period. Until his crop is reaped, the farmer is never completely certain of the outcome of his endeavours.




Similarly, in order to grow up happy, healthy, well-developed and well-adjusted, children require a range of experiences and responses to their needs that, in combination, constitutes child-rearing. The colours on the picture opposite represent important experiences and responses to needs that constitute good CARE.




Black Page




The results of our endeavours in child-rearing are not always obvious, and there may be dark times where we doubt the effectiveness of our endeavours on behalf of our children.






Whole Child




However, little-by-little, where there is good CARE, the whole child will shine through.








Neglectful CARE




Unfortunately, not every child is offered the important experiences and responses to needs that constitute good quality CARE with a consistency that promotes their development, wellbeing and adjustment.





Neglected Child


Where CARE is neglected, the whole child in all of their potential cannot shine through.

In order to be whole, these children require adults in a caregiving role to enrich their experience of CARE and fill in the gaps.

This is the primary task (Kahn, 2005) of therapeutic care; getting back-to-basics and offering enriched experiences of CARE that promotes the child’s development, wellbeing and adjustment.







In the forthcoming revised and updated Second Edition of A Short Introduction to Attachment and Attachment Disorder (available December 2016) I describe in detail what is good quality CARE, how it benefits outcomes for the developing child, and how to enrich CARE to promote attachment security and associated positive developmental, behavioural and mental health outcomes for children.






AAA-Model-of-Therapeutic-CareIn the Triple-A Model of Therapeutic Care I provide a therapeutic CARE framework and a step-by-step approach to the implementation of a therapeutic care approach to children recovering from abuse, neglect and insecurity.


To register your interest in purchasing the revised and updated Second Edition of A Short Introduction to Attachment and Attachment Disorder, please email me at

For more information about the Triple-A Model of Therapeutic Care, currently implemented as a therapeutic care approach among TUSLA foster carers in Donegal Ireland, please click here.

To cite this article, please use the following:

Pearce, C (2016). Therapeutic Care and the Triple-A Method. Attachment and Resilience:


Kahn, W. A. (2005) Holding Fast: The Struggle to Create Resilient                         Caregiving Organisations, Hove and New York: Brunner-Routledge.

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Strengths-based therapeutic foster care

Triple-A is an approach to the therapeutic care of children that emphasises human connection. It is relational, practical and rooted in conventional caregiving practices. As such, it is an enrichment programme, as opposed to a wholesale alternative to conventional caregiving and relating. It is also strengths-based. A core premise is that people already do and know about the importance of the approaches recommended; albeit on an implicit (that is, semi-conscious) level. In Triple-A, we make therapeutic aspects of caregiving and relating conscious and organise them so that they are implemented mindfully and predictably with children.

Triple-A is not just a set of strategies. It incorporates a way of thinking about, caring about and relating with children. It also incorporates self-care strategies to support the caregivers.

Triple-A is represents a fusion of Attachment Theory, Neurobiology and Learning Theory. It’s broad applicability is represented in the author’s published works concerning attachment and trauma and the promotion of resilience in all children.

There is a five-module training package – spanning 2.5 days of training. Triple-A is available as a group training and implementation programme.

For more information visit here:

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Media Release: South Australian Program Embraced by Foster Carers in Ireland

Triple-A Day OneAn Australian-developed program for foster carers is receiving unreserved support in Donegal, Ireland.

Known as the Triple-A Model of Therapeutic Care, the program is currently being delivered by Secure Attachment Matters Ireland with support from TUSLA, the Irish Government Child and Family Agency.

In week 4 of a five-week implementation program, 100% of foster carers have indicated that they would recommend the program to others week by week; with many suggesting it should be compulsory training for all new foster carers entering the role.

Others have suggested that this is training all (foster) parents should receive.

The Triple-A Model of Therapeutic Care is authored by South Australian Clinical Psychologist, Colby Pearce. The three “A’s” in “Triple-A” stand for Attachment, Arousal, and Accessibility (to needs provision).  The program is based in the sciences of human relationships, brain development and learning.

There is a focus on achieving strong, enduring and therapeutic connections between deeply hurt and troubled children and those who care for them. The methods are practical, user-friendly and achievable.

There is also a focus on the wellbeing of those who care for these children. Being a foster parent can be a difficult and thankless role and foster carers can experience their own trauma upon being exposed to what has occurred to the children in their care.  Foster parents are vital to all our efforts to help children recover from abuse and neglect and lead happy, healthy productive lives. Any therapeutic caregiving program needs to focus on foster carer wellbeing as well.

For more information about Triple-A contact the author, Colby Pearce, at



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Foster Carer Wellbeing

Caring for children who are recovering from abuse and neglect is often a difficult and thankless vocation.

Children are inconsistently appreciative of your efforts on their behalf; if at all.

The professionals whose task it is to support you do not live in your house, in your shoes, and do not always seem to understand the challenges you face.

Just as the role of foster parent can be rewarding and fulfilling in those times and in those moments when the child in your care shows glimpses of joy in living and relating to others, the role of foster parent is also:

  • Exhausting
  • Overwhelming
  • Frustrating
  • Anxiety evoking.

The diagram below illustrates why this is a problem.

arousal and wellbeing

Arousal refers to the level of activation of our nervous system.

For later reference, it refers to how fast our internal ‘motor’ is running.

Arousal reflects our physical, emotional and psychological (mind) state.

arousal and wellbeing expanded

Arousal is like the temperature of your body. Too high or too low, there is a problem.

You cannot perform at your best as a carer  when you are feeling:

  • Exhausted;
  • Overwhelmed;
  • Frustrated; or
  • Anxiety.

As far as possible, you need to maintain a consistent state of wellbeing to perform at your best, just as you take active steps to stave off fever or hyperthermia. It is that important!

Over the four-week implementation programme for the Triple-A Model of Therapeutic Care, we recommend one evidence-based wellbeing task per week that is just for you and your own wellbeing. The tasks incorporate the promotion of realistic and helpful ideas about the contribution you are making to the recovery of a child who has experienced abuse and neglect. They also incorporate the promotion of behaviours association with wellbeing; just as Triple-A incorporates a mindset and behaviours for the promotion of recovery from abuse and neglect for the child in your care.

The Triple-A Model of Therapeutic Care is currently being implemented with TUSLA foster carers in Donegal, Ireland. For more information about Triple-A email me at

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Foster Care Enriched

AAA-Model-of-Therapeutic-CarePeople often ask: What can I do to help this child?

This is an interesting question.

Which of the following statements best reflects the answer you would like to receive to this question, were you asking it?

  1. This is what you are doing wrong.
  2. This is what you should be doing.
  3. This is what you are doing right!

Which are you more likely to keep doing over time:

  1. What you already know and do, that is helpful for the child in you care?
  2. A completely new regime of care and management strategies?

The Triple-A approach confines itself to conventional care and relational strategies.

That is, it confines itself to what you already do and what you already know, even if that knowing and doing is implicit – that is, you do it without always being consciously aware of it.

The Triple-A approach selects particular aspects of caring and relating that provide strong foundations for the child’s development and asks you to do them consciously (that is, thoughtfully) and in an organised and ordered (that is predictable) way.

Triple-A is an enrichment process, rather than a behaviour change process.

Triple-A involves promoting three key (that is, needed) experiences that children who are raised in stable and loving homes have from infancy and which satisfy their needs and lay the foundations for a successful and satisfying life:

  • That adults in a caregiving role are accessible (Parents hover and check on with regularity and frequency and return after separations)
  • That adults in a caregiving role are understanding (Baby gets fed, cuddled, changed, burped, played with without having to ask)
  • That adults in a caregiving role are emotionally connected (When baby is sad/happy, parents are sad/happy)

Put another way, Triple-A promotes experiences that adults in a caregiving role are physically, emotionally and cognitively connected with them.

In doing so, Triple-A enriches the child’s experience of reparative aspects of caregiving and relating that strengthen the child and the foundations upon which all future growth occurs.

For more information about the Triple-A Model of Therapeutic Care email me at



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Therapeutic Fostering

Why have Therapeutic Models of Care?

In an online survey of carers of ‘looked-after-children’ (defined as children who do not live with a birth parent(s) and are in a relative or kinship care placement, adoptive placement, foster placement or residential care placement), in which responses were received from 157 carers over a one-week period in September/October 2014, only 16% reported using a known Model of Care to inform their caregiving.

This begs the following question: What do carers rely on to inform their care of these often troubled and challenging children?



Advice? (only half of respondents in the carer survey reported that they are supported in the role by a social worker)

Is this a problem?

Well, lets look at some figures for adult outcomes for children raised in out-of-home care:

  • Those with 3 or fewer placements were more likely to finish school 1 (65% of children in foster care experienced 7 or more changes in placement 2)
  • Three times more likely than the general population to be living in poverty 2
  • Up to nine times more likely to become homeless 3
  • Five times more likely to have PTSD 4
  • Up to ten times less likely to complete a bachelor degree 2
  • Sixty-six times more likely to have children needing public care 5

Children in out-of-home care require more than conventional care based on instinct and experience alone.

We need to do better at supporting carers of these vulnerable children with therapeutic approaches to caregiving that are user-friendly, evidence-based and sustainable over time.

The Triple-A Model of Therapeutic Care was developed across almost twenty-five years of my work as an applied researcher and clinician.

There are a number of therapeutic models of care on offer to individuals and organisations who support looked-after-children and those who care for them.

Nearly all are embedded in attachment theory.

Many incorporate emerging knowledge about the effects of trauma in the first care environment on the developing brain (a.k.a. Neurobiology of Trauma).

Triple-A incorporates both.

So, what is its point of difference?

Before I answer, let me return to the results of the carer survey.

Participants in the survey were provided with a list of behaviours commonly observed among children in out-of-home care and have a history of early or developmental trauma (a.k.a. abuse and neglect), as presented under the heading “Manifestations” in the table below taken from Pearce, C. A Short Introduction to Attachment and Attachment Disorder. Jessica Kingsley, London. Participants were asked What behaviours do you typically see in the children in your care that cause you concern?

Behaviours AAA

The most commonly reported behaviour concerned children being demanding; that is preoccupied with their needs and controlling the accessibility and responsiveness of their caregiver.

Carer Survey 1

Viewed in terms of the Triple-A Model, the data looks like this:

Carer Survey 2


The most commonly reported behaviours that carers of looked-after-children report as causing them concern are under the heading “accessibility to needs provision”. And, yet, other therapeutic models of care do not address this issue directly.

The most significant difference between Triple-A and other therapeutic models of care is that Triple-A draws on the science of human learning to facilitate a better understanding of the looked-after-child’s inordinate preoccupation with their needs and with accessibility to needs provision.

What is Triple-A?

The Triple-A Model of Therapeutic Care is a tripartite model that addresses the impact of abuse and neglect on three key areas of the child’s psychological functioning 6:

  • Attachment (science of relationships and social-emotional development)
  • Arousal (psycho-physiology of emotion and behaviour activation systems – a.k.a. “Neurobiology of Trauma”)
  • Accessibility to needs provision (science of human behaviour).

The Triple-A Model of Therapeutic Care is a step-by-step approach that:

  • Offers children experiences that support the promotion of secure attachment, thereby restoring the foundations for a happy and successful life after experienced abuse and neglect.
  • Offers children experiences that promote feelings of safety in relationships to reduce anxiety proneness and promote new learning and the development of brain structures responsible for thoughtful consideration, planning and effective action.
  • Offers children experiences that facilitate new learning that their needs are understood and important and will be met reliably and predictably through conventional care.

The Triple-A Model of Therapeutic Care is concerned with carer wellbeing and incorporates information and strategies for preventing vicarious trauma (a.k.a. compassion fatigue) among carers of children recovering from abuse and neglect.

The Triple-A Model of Therapeutic Care incorporates a built-in evaluation methodology. Ongoing evaluation shows that implementation of the Triple-A Model of Therapeutic Care results in targeted changes in caregiving behaviour. Children to whom the Triple-A Model of Therapeutic Care is delivered show evidence of:

  • Improved attachment security (they increase their independent play, reflecting an emergent secure base);
  • Reduced arousal (they sleep better, they waken happier, they have fewer emotional outbursts and their outbursts are of shorter duration); and
  • Reduced preoccupation with their needs (they are less demanding/coercive/ preoccupied with needs/wishes).

The Triple-A Model of Therapeutic Care© can be delivered to alternate care programs internationally and is scheduled to begin implementation in Donegal, Ireland in January 2016.

UK/Ireland Consultants:

John Gibson:

Tina Hendry:

Robin Barker:

For more information about Triple-A, contact the author, Colby Pearce, at

For more about Colby’s contribution to international thinking about attachment, resilience, mental health and recovery from child abuse and neglect, please refer to the publication list below.

Pearce, C.M (2012). Repairing Attachments. BACP Children and Young People, 28-32

Pearce, C.M. (2011). A Short Introduction to Promoting Resilience in Children. London:          JKP

Pearce, C.M. (2011). The Comeback Kid. Junior Magazine

Pearce, C.M. (2011) Attached to the Unattached. SEN Magazine

Pearce, C.M. (2010). An Integration of Theory, Science and Reflective Clinical Practice in        the Care and Management of Attachment-Disordered Children – A Triple A Approach.        Educational and Child Psychology (Special Issue on Attachment), 27 (3): 73-86 

Pearce, C.M. (2009) A Short Introduction to Attachment and Attachment Disorder.                   London: JKP

Pearce, C.M., Martin., G., & Wood, K. (1995). Significance of Touch for Perceptions of              Parenting andPsychological Adjustment Among Adolescents. Journal of the Academy          of Child and Adolescent Psychiatry, 34 : 160-167.

Pearce, C.M., & Martin, G. (1994). Predicting Suicide Attempts Among Adolescents. Acta        Psychiatrica Scandinavica, 90 : 324-328.

Pearce, C.M., & Martin, G. (1993). Locus of Control as an Indicator of Risk for Suicidal               Behaviour Among Adolescents. Acta Psychiatrica Scandinavica, 88 : 409-414.

Allison, S., Pearce, C., Martin, G., Miller, K., & Long, R. (1995). Parental Influence,                     Pessimism, and Adolescent Suicide. Archives of Suicide Research, 1 : 229-242.

Allison, S., Powrie, R., Pearce, C., & Martin, G. (1995). Continuing Medical Education in          Marital and Family Therapy: A Survey of South Australian Psychiatrists. Australian              and New Zealand Journal of Psychiatry, 29 : 638-644

Martin, G., Rozanes, P., Pearce, C.M., & Allison, S. (1995). Adolescent Suicide, Depression      and Family Dysfunction. Acta Psychiatrica Scandinavica, 92 : 336-344.

Martin, G., Clarke, M., & Pearce, C.M.. (1993). Adolescent Suicide: Music Preference as an      Indicator of Vulnerability. Journal of the American Academy of Child and Adolescent         Psychiatry, 32 : 530-535.

Attachment Colby Pearce   Resilience Colby Pearce


1.Cashmore, J.A. & Paxman, M. (1996). Wards Leaving Care: A Longitudinal Study. Sydney: Department of Community Services

2.Pecora et. al. (2010) Rates of mental, emotional and behavioural disorders among alumni of family foster care ibn the United States: The Casey National Study. In E Fernandez & R. Barth (Eds) How does foster care work? International evidence on outcomes. (pp, 166-186)

3.Casey Family Programs (2001) It’s my life: A framework for you transitioning from foster care to successful adulthood. Casey Family Programs: Seattle

4.Pecora, P.J. (2010). Why current and former recipients of foster care need high quality mental health services. Administration and Policy in Mental Health and Mental Health Services Research. (37(102), 185-190

5.Jackson, S & McPharlin, P. (2006). The education of children in care. The Psychologist, 19(2): 90-93

6.Pearce, C.M. (2010). An Integration of Theory, Science and Reflective Clinical Practice in the Care and Management of Attachment-Disordered Children – A Triple A Approach. Educational and Child Psychology (Special Issue on Attachment), 27 (3): 73-86

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Media Release: Proactive Needs Provision Vital for Recovery From Child Abuse

Castleblayney Presentation ArticleWhat follows is a media release for the event at which I spoke on Thursday the 22nd of October in Castleblayney, Co. Monaghan, Ireland. The clip to the right is the article in The Northern Standard that appeared on 31/10/15.


Preventing the abuse and neglect of children is one of the great imperatives of our time. Helping children who are victims of abuse and neglect to recover and lead happy and productive lives is just as important.

‘Few acts committed in anger or ignorance have such far-reaching negative consequences than the abuse and neglect of children’ says Australian Clinical Psychologist, Colby Pearce.

Also referred to as ‘Complex Developmental Trauma’, child abuse and neglect negatively affects children’s developmental trajectory. Too often the result is lifelong difficulties and deficient care of their own children.

‘A key aspect of preventing the abuse and neglect of future generations of children is helping their parents recover from their own abuse now, while they are still children themselves’, says Pearce. ‘In doing so we change the path of their lives and, potentially, those of their children’.

Pearce is the author of the Triple-A Model of Therapeutic Care, an approach to the care and management of children affected by abuse and neglect. Triple-A, for short, extends what we know and is widely practised in the care of children in out-of-home care.

‘Across twenty-years as a clinician working with children who have experienced abuse and neglect I have observed them to remain intensely preoccupied with controlling and managing their environment, including adults with whom they come into contact, even after they are placed in stable and loving homes. A recent survey we conducted of carers of children in out-of-home care supports this’, says Pearce.

‘Children recovering from abuse and neglect are often incredibly demanding and preoccupied with their needs. Too often, the result is the breakdown of both home and education placements, thus compounding the effects of their early trauma’.

Triple-A extends current thinking and practice to include consideration of what children learn about how to get their needs met while in an abusive and neglectful environment, and how to combat this through conventional approaches to the care of children.

‘Responding to the child’s efforts to achieve satisfaction of their needs teaches the child very little that is useful about the caregiver’s sensitivity and responsiveness. Too often, caregivers feel overwhelmed by the child’s enduring preoccupation with their needs and placements break down. Children achieve new learning that their needs are understood, important and will be responded to without them having to go to great lengths to make it so when their needs are addressed proactively; that is, before they ask’ says Pearce.

In Triple-A, there is an emphasis on conventional approaches to caregiving that are particularly useful in promoting recovery from abuse and neglect.

‘It is important that carers of children who have experienced abuse and neglect are offered advice that draws on their existing skills and practices. Only then will they feel like they have already been making a positive contribution to the recovery of the child or children in their care and continue to implement such practices in a way that further promotes recovery’, says Pearce.

Pearce will be sharing his ideas about promoting children’s recovery from abuse and neglect at the Castleblayney Wellbeing Centre on Thursday the 22nd of October 2015.

The Triple-A Model of Therapeutic Care is approved for implementation in Co. Donegal with the support of TUSLA (Child and Family Agency).

Colby Pearce is an Australian Clinical Psychologist and author of two books, including the bestseller A Short Introduction to Attachment and Attachment Disorder. For more information about Colby or to contact him visit:


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Attachment theory made simple

The following is an excerpt from Carr, S. (2013). Attachment in Sport, Exercise and Wellness. Routledge: London and New York (pp 1-2)

Colby Pearce Attachment National Psychology ExamSome months ago a graduate student came to my office visibly excited after reading the prologue section in Colby Pearce’s (2009) text A Short Introduction to Attachment and Attachment Disorder. The student felt that although he had been studying attachment theory for a number of years he was so intensely focused upon its numerous intricacies and nuances that he had failed to recognise the striking simplicity that underpins this complexity. With Pearce’s permission, I make no apologies for paraphrasing his excellent example below. I agree with my graduate student’s initial interpretation.

Pearce (2009) recites a story about three mice. The first mouse resided in a comfortable house that was furnished and supplied with modern conveniences. Inside the house was a button and a hole in the wall and the mouse was able to press the button to receive tasty food through the hole. The mechanism worked well and the mouse appreciated that when he was hungry he would be able to press the button and consistently receive his food. It was comforting to have this knowledge and the mouse liked the predictable nature of his button, only tending to press it when he really needed food.

In contrast, the second mouse (who lived in an identical house) had the misfortune of dealing with a faulty button mechanism. That is, pressing his button only resulted in food being delivered some of the time. There was no predictability to the button mechanism and on some occasions he would receive food immediately on pressing the button whereas on others he would be required to press it 10 or 20 times. At other times it seemed that no matter how often he pressed it nothing was ever going to happen. His distrust of the button led him to be preoccupied with pressing it, even when he was not actually hungry. He would press it many, many times in order to ensure he would have food when he did grow hungry. When the button was fixed he found it hard to trust that it was now in good working order and spent much time storing up food for a rainy day.

Finally, the third mouse lived in a house with a button that consistently failed to work. In short, he never received any food from his button. He quickly came to the understanding that access to food would require him to employ other means and had no belief in the utility of the button. Even when he moved home and found a house with an effectively functioning button his lack of faith in buttons persisted and he continued to find food the way he always had.

The above story highlights how attachment theory can be seen to be grounded in simple assumptions that retain remarkable logical sense even when talk of mice and food is substituted for young children, emotional care, and security. Pearce (2009) has cleverly recognised this in his prologue. However, although there are some simple logical principles at the core of attachment theory, the fact that Bowlby (1969/1982, 1973, 1980) required close to 1000 pages to articulate his ideas suggests that there are complexities, assumptions, and arguments that cannot be overlooked if one is to begin to develop a fuller understanding of Bowlby’s position. Furthermore, given that attachment theory has been intuitively appealing to researchers whose ideas are allied to contrasting paradigmatic approaches (e.g. Pearce’s example seems couched in behaviourist principles – but attachment theory also reflects ideas that resemble other schools of thought) and from various disciplines it is unsurprising that further methodological and conceptual intricacies have arisen as the ideas have been nurtured  and developed according to the assumptions of differing schools of thought.

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Relationship styles in children with a disability

Colby Pearce Attachment National Psychology ExamRelationship Styles in Children with a Disability

Based on John Bowlby’s Attachment Theory

By: Tara Hearne (Psychology Intern at Secure Start®) and Colby Pearce

Relational styles in children can be broken down into four main categories:


A child with a secure relational style has an established sense of trust in their primary caregivers and the world. They feel safe in being able to interact with others and explore their environment with their caregiver acting as a secure base. Children with a secure relational style may show distress at being left by their caregiver but on their caregivers return, are easily comforted and return quickly back to play and exploration. Secure children feel comfortable expressing their emotions and seek and accept comfort from their caregivers when feeling distressed. These children have a positive view of themselves and others.


A child with an insecure-avoidant relational style typically does not show overt signs of distress when left by their caregivers and will avoid contact on their return. They usually show no preference between their caregivers and strangers. Children with an insecure-avoidant relational style appear to be self-reliant and often prefer solitary play. Insecure-avoidant children typically do not seek out comfort when distressed and will usually resist comfort (avert their gaze or fail to return a hug) when it is offered. These children tend to have a positive view of themselves and a negative view of others.


A child with an insecure-ambivalent relational style has a low threshold for distress while also anticipating that comfort will not be forthcoming. They are excessively clingy to their caregivers and upon separation show obvious distress. When their caregiver returns they are not easily comforted and become obsessed with them, oscillating between wanting closeness and feeling angry with their caregiver. Insecure-ambivalent children are often seen as demanding, clingy, immature, angry and easily overwhelmed by their emotions. These children tend to have a negative view of themselves and a positive view of others.


A child with a disorganised relational style often displays inconsistent, contradictory and varied behaviour in response to their caregivers. When reunited with their caregiver, they may greet them but with their gaze averted or by turning away straight after greeting them. They may seek out their caregiver to engage with or be comforted by them but disengage from them immediately after – in a push-pull (“I want you but I don’t want you”) method of interaction. Disorganised children allow their caregiver to hold them but with their limbs stiff or eyes averted. Externalising, disruptive and aggressive behaviours tend to be the predominately seen behaviour problems in children with a disorganised relational style. These children tend to have a negative view of themselves and others.

Relationship style prevalence rates and contributing factors for children with a disability

Studies have found that prevalence rates of secure relationship styles seen in children with a disability tend to be somewhat lower (50%) than for typically developing children (60%). It was also found that if children with a disability did not have a secure relationship style, it was most likely to be disorganised. This is seen at a rate about the same as that of typically developing children who have been traumatised.

The higher rate of disorganised relational style seen in children with a disability is thought to be, in part, a function of stress. Due to physical and cognitive constraints, they have difficulties with everyday tasks and difficulties with judging and dealing with everyday situations. Given these difficulties, it is often the case that children with a disability see their life as one of low controllability, which can lead to general feelings of incompetence and helplessness. This can cause the child to have a near constant feeling of stress.

Frequent and sustained stress leads to an almost permanent state of activation of the biological stress response. Prolonged activation of the stress response leads to a depleted ability to cope with even low levels of stress. This stress response reaction may contribute to the higher prevalence of disorganised relational styles seen in children with a disability. Furthermore, it helps to explain why the rates of disorganised relationships are similar to that of traumatised children – owing, in part, to over-activation of the stress response and sustained feelings of helplessness in both cases.

As well as a heightened stress response, children with a disability may have difficulties early in life with relational/social behaviours. They may be delayed in their ability to exhibit attachment-related behaviours such as smiling, approaching and vocalising, making it more difficult for caregivers to interpret the needs of the child. This can lead to less responsiveness from caregivers in a negative feedback loop – the less the child shows attachment related behaviours, the less the parent responds, then the less the child responds and so on it goes.

The increased level of care children with a disability need, coupled with the inability of the child to respond to interactions in a meaningful way, intensifies the stress felt by both child and caregiver. This, in turn, can negatively impact secure caregiver-child relationship development. In short, children with a disability behave differently to typically developing children; therefore, more is required of caregivers in regards to relationship development and maintenance. Therapeutic relationship enrichment can assist in promoting and enhancing the caregiver-child relationship. The Triple-A Model of Therapeutic Care offers simple, practical, back-to-basics care strategies intended to promote secure relational styles between all children and those who care for them.



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