Child and Adolescent Psychiatry

Coping with Adversity 289

Mechanisms

A rather diverse list of adversities has been given above. It is now worth
considering what they have in common, and how they may disrupt normal
development. The environments that damage children tend to be:

disorganised, inconsistent and unpredictable;

harsh and punitive;

dangerous, frightening and anxiety-provoking;

lacking in stimulation;

lacking in individuals who respond sensitively to the child’s need.

These adverse features can be present in the immediate environment of
the family, and/or in the wider social community in which the child lives.
Their impact on the child is likely to be due not only to the number of
adverse risk factors, but also the extent to which they are constant and
widespread as opposed to intermittent and limited in scope.
The experiences may exert their harmful effects by hindering the
development of healthy responsiveness and social development, which
depend on:

1 well-modulated emotional regulation;
2 secure attachment relationships;
3 competent social perception and skills.

Evidence is accumulating that each of these is damaged by chronic
adversity.
Emotional regulation can be measured: behaviourally in the ability to
exert self-control when frustrated, in contrast to explosive outbursts with
little provocation; physiologically in terms of arousal (for example, heart
and respiration rate, blood pressure, skin conductance), and; biochemically
in terms of levels of hormones affected by stress, such as adrenaline and
noradrenaline, and cortisol. Animal, and now human, studies are finding
that in the abused young, these systems are far more prone to show
large reactions to relatively small stimuli, and to take far longer to down-
regulate. Thus, for example, the diurnal cortisol rhythm of children taken
into foster care because of abusive parenting is abnormal. Encouragingly,
it becomes more normal after a year in stable foster care.
Secure attachment relationships are compromised by adverse parenting,
which is associated with increased rates of all types of insecurity. A dis-
missive parenting style is associated with an avoidant attachment pattern,
an ambivalent parenting style by a resistant pattern, and an unpredictable,
abusive parenting style by a disorganised pattern. Insecure attachment is
in turn associated with more psychopathology and worse functioning. On
the more positive side, there have now been over 70 controlled studies
confirming that interventions that increase parental sensitivity and quality
lead to more secure attachment patterns (see Chapter 32).
The social understanding and skills of abused children are usually al-
tered. Their perception and interpretation of social cues make them more
likely to infer hostile intent, and they are more likely to believe that an