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Infant Mental Health Services: Recognising the Importance of Relationships in the Early Years as the Foundation for Practice-Based Evidence.
“Train up a child in the way he should go: and when he is old, he will not
depart from it.” Proverbs, 22:6.
Contents.
2. Introduction: why babies’ emotional needs have been neglected.
4. In the beginning: evolution and early influences on the mind.
6. Neurobiological development: the significance of brain plasticity.
11. Epigenetic effects of excessive stress at the beginning of life.
14. The importance of the attachment relationship: the first
experiences can lead to resilience or disturbances.
20. The effects of trauma, neglect and disconnectedness: the long-term consequences
of maltreatment.
30. The roots of violence: how moral behaviour depends on early parenting.
31. Implications of the research data: a summary to this point.
35. Caregiving in jeopardy: a knowledge of risk factors means help can be offered
before a baby is traumatised, not after the event.
40. Early intervention services, an overview.
43. Economic benefits of very early intervention.
46. The components of an early intervention service: existing models of delivery.
51. Different approaches to infant mental health interventions: evidence-based
practice and practice-based evidence.
78. Conclusion.
82. Appendix. Risk Factors.
83. References.
‘Traumatic events of the earliest years of infancy and childhood are not
lost but, like a child’s footprints in wet cement, are often preserved
lifelong. Time does not heal the wounds that occur in those earliest years;
time conceals them. They are not lost; they are embodied’ (Felitti, 2010:xiii).
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Introduction.
Probablythemostimportantperiodineveryone’slifeisonetheycannot
remember.Thefirsttwoorthreeyears,thetimebeforememorycanbeverbally
taggedforlaterretrieval,settheirstamponallthatcomesafter.These
experiencesbecomethebasisforthehumansoftwareofrelationshipsandthe
futureresponsetothreat,recordedinprocedural,orimplicit(unquestioned,
inaccessibletolanguage)memory.Evolutionhasequippedhumanswithabrain
thatanticipatesnothingandcanfitinwithmost.‘Atbirthaninfantcandevelop
intoaninfinityofselves,anditsbrainisequippedtodealwiththatuncertainty’
(Donald,2001:211).Butthehumanbrainisdesignedtobecomeananticipatory
machine,usingpastexperiencesallthetimetoforecastthenextmoment.
Theearlyyearscanthus,inmostcases,inthebroadestsenseeitherbepositive,
aswhenachildgainstheresourceofbeingresilientinadversitysothatlater
stressfuleventsdonotbecomeatraumaandtheyhavethecapacityfor
emotionalself-repair;or,whenthereisanyformofmaltreatment,negativeas
whenachild’searly(s)caregivinghaslefta‘basicfault’(Balint,1968)because
therewastoogreatadiscrepancybetweentheinfant’sbiologicalneedsandthe
qualityofcaregivingthatwasavailable.Thisdiscrepancyeasilygetslostor
ignored,itmayremaininvisibleforyears,althoughithasbecomeacentralpart
ofthesoftwareforsurvivalhardwiredintotheneurobiologyofthedeveloping
mindreadytooverridebothrationalityandempathyinadversecircumstances.
Karr-MorseandWiley(1997:278)pinpointthreeobstaclesthatseemtoprevent
usfacingtheunpleasantrealityofanincreasingnumberofbabies(whichiswhy
thepredicamentofrefugeechildrengetsside-lined.‘Thefirstofthesemaybe
grief,angerorsadnessfrompersonalchildhoodexperiences.Sometimesthese
aretoopainfultore-awaken.Theremayalsobesadnessandregretforthe
memorieswemayhaveinadvertentlycreatedforourownchildren.Athird
barriertoactingonthisinformationistofeeloverwhelmedbythedepthand
breadthoftheproblem.’Itishardtofeelhelpless,especiallyifwefacetheworld
fromthepointofviewofthesebabies.Emde(2001:23)drawsattentiontowhy
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theplightofmanybabiescanbehardtocontemplateandsogetspushedaside.
‘Itisoftenpainfulanddifficulttorecogniseandaddressmentalhealthproblems
ininfantsandyoungchildren.’Takingbabiesseriouslyopensanemotional
Pandora’sBox.Helistsfourkindsofmentalsufferingthatallwouldwantto
avoidandsomightprefernottothinkabout.‘Painanddistressfromtrauma,
abuse,orlossofacaregiver;miseryfromneglect;sufferingfromcumulative
stress;andsufferingfromlackofopportunity(ibid).’Distresscanberelieved,
butrescueorrepairmaybenomorethanmythscreatedbywishfulthinking
unlessthehelpisimmediateandspecialised.Theemotionalenvironmentof
infancy,whichfromthebaby’spointofviewconsistsofrelationshipswiththe
parents,willbepreservedonbothapsychologicalandneurologicallevelfor
goodorforill.Paradoxically,relationshipscaneitherbeadisasterorapathway
tohope,as:‘Theessenceofinfantmentalhealthworklieswithintheparent-child
relationship’(SolchanyandBarnard,2001:46).Relationshipsarethemost
importantfactorinababy’slife,literallyvital,andofcoursethiscontinuesever
after.
Inmanyinstanceswhenanolderchildcomestotheattentionofspecialist
helpingservicesprovidedbyEducation,Health,SocialServicesorthevoluntary
sectoritmayappeardifficulttodifferentiatebetweentheeffectsofearly
experiencesandreactionstocurrentfamilydysfunction,whichoftenpredates
thebirthofthechild.Sometimesasimplechangeinparentalunderstanding,
attitudeandbehaviour,ordirecttreatmentofsomeformwiththechild,will
enabletheproblemtobecomeresolved.However,asignificantpopulationof
children,whoseeffectandcostisoutofallproportiontotheirnumber,cannotbe
helpedinthisway.Itisjusttoolate.Thisiswhy,asdetailedbelow:‘Early
interventionfordisadvantagedchildrenandtheirfamiliescanbeasound
economicinvestment’(Barnett,2000:605).Babiescannotwait;foriftheyhave
beenadaptingtoanemotionallyinimicalsettingforanylengthoftimethenthe
damagecausedbyinappropriatecaregivingwillnotbeundonebyachangeof
circumstances,asisalltooclearwithmanychildrenwhohavebeenfosteredor
adopted,andsomuchmoreintensiveandlong-terminterventionsbecome
necessarywithasubsequentlygreaterdrainonresources.Thesearethechildren
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whodonotmakeuseofeducation,whodisrupttheclassroomanddemand
attentionastheybecomeeitherbulliesorvictims,whosometimesharm
themselvesasmuchasothersandwillgoontospreadcollateraldamage
throughouttheirlives.Asteenagerstheyattractdesperatelabelsasan
alternativetoafulfilledlife:conductdisorder,suiciderisk,borderline
personality,disruptivepupil,delinquentordisturbedandmore.Theywillbe
over-representedinthecriminaljusticesystem.Astheymoveintoadulthood
theyareatagreatlyincreasedriskforawiderangeoflife-threateningmental
andphysicalillhealthproblemsthatwilldepletehealthservicebudgetsuntil
theydie(see:http://www.cdc.gov/violenceprevention/acestudy/and
http://www.ajpmonline.org/article/S0749-3797(98)00017-
8/fulltext?refuid=S0266-6138(11)00071-4&refissn=0266-6138).
Inthebeginning.
Babiesareborn‘pre-programmed’toseekoutandadapttotherelationshipthat
theyhavewiththeirparents.Thisisabiologicalgiven,evolution’sanswertothe
prolongedperiodofhelplessnessinchildhoodandtheneedtoadjusttothe
infinitepossibilitiescreatedwithinafamilyininteractionwiththewiderculture.
‘Mostofhumanknowledgecannotbeanticipatedinaspecies-specificgenome…
andthusbraindevelopmentdependsongeneticallybasedavenuesfor
incorporatingexperienceintothedevelopingbrain’(ShonkoffandPhillips,
2000:53).Thehumangeneticpackagetransmitsinitialflexibilityandthe
capacitytoadapttotheenvironment,whicheventhenisincreasedbyepigenetic
processes;evolutionarysuccessforhumansisadaptationtotheimmediate
cultureandunforeseeablesocialdiversityratherthantothephysicalecosystem.
‘Thehumanbrainistheonlybraininthebiospherewhosepotentialcannotbe
realisedonitsown.Itneedstobecomepartofanetworkbeforeitsdesign
featurescanbeexpressed’(Donald,2001:324).
Anisolatedhumancannotexist,wedependonoursocialsurroundingsinorder
tojustbeandbecomewhatweare.‘Havingculturemeanswearetheonly
speciesthatacquirestherulesofitsdailylivingfromtheaccumulatedknowledge
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ofourancestorsratherfromthegenestheypassontous.Ourculturesandnot
ourgenessupplythesolutionsweusetosurviveandprosperinthesocietyof
ourbirth’(Pagel,2012:3),andthefamilyofourbirthistheprototypicalsetting
andconduitforthissurvivalinformation.Thusthegeneticimperativeforthe
babyisfitintowhatyoufind.‘Thechild’sfirstrelationship,theonewiththe
mother,actsasatemplate,asitpermanentlymouldstheindividual’scapacities
toenterintoalllaterrelationships.Theseearlyexperiencesshapethe
developmentofauniquepersonality,itsadaptivecapacitiesaswellas
vulnerabilitiestoandresistancesagainstparticularformsoffuturepathologies’
(Schore,1994:1).Intermsofgenerationalcontinuityoneofthemostimportant
learningexperiencesofinfancyisparenting–thisistheagewhenparenting
classeswouldactuallyhaveaneffectifwecouldmanageit–asparentingisone
ofthosetaken-for-grantedactivitieslearnedinthepre-verbalperiodandlargely
recordedinproceduralmemory.‘Parentalloveispossibleonlybecauseithasits
rootsinformerattachments;empathyandattunementwithanewbornare
enhancedbyrecognitionofwarmstatesorfeelingsfamiliarfromformer
relationships’(BrazeltonandCramer,1991:148).Thuseveryparentwilloneday
besurprisedtoheartheirownparentspeakthroughthem.Thisishardlyanew
observation:‘Asisthemother,soisherdaughter’(Ezekial,16:14).However,in
thecontextofearlyintervention,itisimportanttonotassumethatabackground
ofabusiveparentinginvariablybecomesre-playedinthenextgeneration
(HughesandCosser,2016);thisonlyappliestoaminorityinproportionalterms,
althoughthisisagreatmanyfamiliesintheoverallschemeofthings.
Theminddevelopsthroughoutlifeasthegeneticallyprogrammedconstruction
ofthebrain,intermsofneuro-physiologicalprocesses,anditcontinuesto
respondtosignificantexperienceswithotherpeopleaslongasitexists.
Relationshipschangeminds;andeverythingthought,feltorimaginedhasabasis
inelectrochemicalandneurohormonalprocesseswhosefinalconfiguration
derivesfromtheinteractionbetweenindividualexperience(includinginutero)
andtheparametersofgeneticandepigeneticpotential.Anysystemisatitsmost
adaptablewhileitisbeingbuilt,andhumanbrainsautomaticallyadapttoan
environmentdefinedbythequalityofthecaregivingrelationship.
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Notonlycanbabiesnotwait,butalsotheycannotstandupforthemselveseither.
Inaddition,babieshavenocomparisonsandthequalityofthecaregiving
relationshipisthemajorcomponentoftheirworld.Active,satisfyingand
reciprocalrelationshipswithparentscreatethe‘takenforgranted’basisofa
senseofidentity,self-esteem,appreciationofothersonalllevels,ethical
behaviourandself-control.‘Humanrelationships,andtheeffectsofrelationships
onrelationships,arethebuildingblocksofhealthydevelopment.Fromthe
momentofconceptiontothefinalityofdeath,intimateandcaringrelationships
arethefundamentalmediatorsofsuccessfulhumanadaptation’(Shonkoffand
Phillips,2000:27).Morethanthat,thequalityandcontentofthebaby’s
relationshipwithhisorherparentshasaphysiologicaleffectonthe
neurobiologicalstructureofthegrowingchild’sbrainthatwillbeenduring.
Neurobiologicaldevelopment:thesignificanceofearlyadverse
experiences.
Researchonbraindevelopment,whichhasre-writtenthetextbookssincethe
endofthelastcenturywiththeadventofnewtechniquesforimagingthe
functioningbrain,hasshownthat‘theinfant’stransactionswiththeearly
socioemotionalenvironmentindeliblyinfluencetheevolutionofbrainstructures
responsiblefortheindividual’ssocioemotionalfunctioningfortherestofthe
lifespan’(Schore,1994:540).Karr-MorseandWiley(1997:277),afteranin-
depthreviewofevidencefrommanydifferentdisciplinesonthegenesisof
violentbehaviour,returntothecellularlevel.‘Thestrengthandvulnerabilityof
thehumanbrainlieinitsabilitytoshapeitselftoenableaparticularhuman
beingtosurviveitsenvironment.Ourexperiences,especiallyourearliest
experiences,becomebiologicallyrootedinourbrainstructureandchemistry
fromthetimeofourgestationandmostprofoundlyinthefirstmonthoflife.’
(Forasummaryofresearch,see:Balbernie,2017;BelskyanddeHaan,2011;
Fox,etal.,2010;Gerhardt,2015;Glaser,2000;Hart,2008;Siegel,2012;Teicher
andSamson,2016.)Thebrainisatitsmostadaptable,orplastic,forthefirsttwo
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yearsafterbirth,duringwhichtime‘theprimarycaregiveractsasanexternal
psychobiologicalregulatorofthe‘experience-dependent’growthoftheinfant’s
nervoussystem.Theseearlysocialeventsareimprintedintotheneurobiological
structuresthatarematuringduringthebraingrowthspurtofthefirsttwoyears
oflife,andthereforehavefar-reachingeffects’(Schore,2001b:208).Whatwedo
intimesofstressreflectswhatwasdonetouswhenwewerebabies.
Thepostnatalperiodismarkedbyasequentialproliferationandthenpruningof
synapsesoccurringinsequenceasdifferentfunctionalcapacitieswireup;this
hasbeguninuteroandpost-mortemstudiesdemonstratethat‘theelaborationof
dendrites,spines,andsynapsescontinuestogrowatanearlogarithmicpace
thoughthefirst350-400postnataldays’(TauandPeterson,2010:153).The
brainisatitsmostadaptable,orplastic,forthesefirsttwoorthreeyearsafter
birthasthisistheperiodofmostrapidgrowthandchange.Thegenetically
governedhugepotentialnumberofsynapsesmustbeslimmeddowntobemore
efficientandfitthespaceavailable.‘Byinitiallyoverproducingconnectionsthat
havebeenspreadtoavarietyoftargets,andthenselectingfromamongtheseon
thebasisoftheirdifferentfunctionalcharacteristics,highlypredictableand
functionallyadaptivepatternsofconnectivitycanbegeneratedwithminimal
prespecificationofthedetails’(Deacon,1997:202).Experience-expectantbrain
growthtakesplacewhenthebrainisprimedtoreceiveparticularclassesof
externalinformationinordertobuildbasicskillsinthemostflexibleway.The
processofpruningisamatterofrespondingtotheenvironment,whileitseffects
dependontheareaofthebraininwhichitoccurs.Thegreatestover-abundance
ofsynapsesoccursduringsensitive,orevencritical,periods(theformerbeing
lessall-or-nothing)duringwhichafunctionalareaofthecortexreliesoninput
fromtheenvironmentinordertobecomesuitablyorganised.The‘fittest’,or
mostusedanduseful,synapsesareselected;andinneuraldevelopmentthisisa
matterofthelevelofelectricalactivityandneurotransmitterproduction.‘During
earlychildhood,excesssynapsesareremoved(pruning),andmanyneuronsdie.
Certainneuralcircuitsspecialise(parcellation),andneuronsthatdonotget
sufficientusefailtoconnectintocircuits;theydieortheirdendriteslosetheir
branches.Neuronsthatreceivefrequentuseandexercisegrowlarger,andtheir
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dendritesexpand.Apoptosisservestofinetunethesystemandcontinuesfor
manyyearsafterbirth’(Hart,2008:49).Pruninginareasinvolvedwithhigher
cognitivefunctionscontinuesthroughadolescencewhenthereisasecondphase
ofenhancedneuroplasticity.
Thebrainisinlargepartasocialorgan,designedbyevolutiontochangeininthe
contextofsignificantrelationships.Atthebeginningoflife‘Fromabasic
biologicalperspective,thechild’sneuronalsystem–thestructureand
functioningofthedevelopingbrain–isshapedbytheparent’smoremature
brain.Thisoccurswithinemotionalcommunication’(Siegel,1999:278).Toputit
simply,thebaby’sbrainwilladaptandchangetofitthefamilyenvironment,if
thisishostileordeprivingratherthanlovingitmakesnodifferencetothe
mechanism.‘Itisnowacceptedthatearlychildhoodabusespecificallyalters
limbicsystemmaturation,producingneurobiologicalalterationsthatactasa
biologicalsubstrateforavarietyofpsychiatricconsequences.Theseinclude
affectiveinstability,inefficientstresstolerance,memoryimpairment,
psychosomaticdisorders,anddissociativedisturbances’(Schore,2012:81).
Thereisnodoubtthatexposuretotoxicstressinanyformhasanegativeeffect
onthestructureofthedevelopingbrain.‘Maltreatmentisassociatedwith
reliablemorphologicalalterationsinanteriorcingulate,dorsallateralprefrontal
andorbitofrontalcortex,corpuscallosumandadulthippocampus,andwith
enhancedamygdalaresponsestoemotionalfacesanddiminishedstriatal
responsestoanticipatedrewards’(TeicherandSamson,2016:241).Experience
mightnotchangetheprocessofbraindevelopment,butitdoesmakeadifference
tothefinalproduct–andhowitwillbeused.‘Theseearlyimprintscanbe
remarkablylonglastingbecauseveryearlystressfullifeexperienceshaveleft
emotionalsystemssensitizedordesensitized,withpermanent,epigenetically
inducedhigh-stressreactivityandexcessiveprimary-processnegativisticfeeling’
(PankseppandBiven,2012:434).
Maltreatmentthatoccurswithinthefamilyisparticularlyperniciousasthebrain
is‘designed’toadaptitsstructureinresponsetotheenvironmentofimmediate
relationshipssothat‘trauma,neglect,andrelatedexperiencesofmaltreatment
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suchasprenatalexposuretodrugsoralcoholandimpairedearlybondingall
influencethedevelopingbrain.Theseadverseexperiencesinterferewithnormal
patternsofexperience-guidedneurodevelopmentbycreatingextremeand
abnormalpatternsofneuralandneurohormonalactivity’(Perry,2009:241).
This,itmustbeemphasised,isanormalprocessofenvironmentaladaptation;it
becomesahugedisadvantagewhentheadultenvironmentisobjectively
relativelybenignbuttheprogrammedobservation,interpretationandresponses
oftheindividualareoperatinginveryhostileterritorystill.‘Stress-induced
developmentalmodifications,triggeredbythenatureofexperienceduring
critical,sensitivestages,aredesignedtoallowtheindividualtoadapttohigh
levelsoflife-longstressordeprivationthatmaybesignaledbyearlystressful
experience.Ifanindividualisbornintoamalevolentandstress-filledworld,the
manifestationsofearlystressfulexperienceonlaterdevelopmentmayservean
adaptivepurpose,enablingtheindividualtomobilizeintensefight-flight
responsesorreactaggressivelytochallenge’(Teicher,etal.(2003:39).Itislessa
matterofearlystressdamagingagrowingbrainasitisthecasethatthegrowing
brainmakesanappropriateadaptationtoastressfulenvironment.
Aninfantwhohasdevelopedinsecureattachmenthas,bytheageofoneyear,
encodedwhatcouldbelifelongexpectationsoftheworldandoftheself,along
withafullsetofpathologicalanddangerousoperatinginstructions.‘Repeated
experiencesofterrorandfearcanbeengrainedwithinthecircuitsofthebrainas
statesofmind.Withchronicoccurrence,thesestatescanbecomemorereadily
activated(retrieved)inthefuture,sothattheybecomecharacteristictraitsofthe
individual’(Siegel,2012:55).Thetraumadoesnothavetobedirect,whatababy
seesandhearswillalsodefinetheirenvironmentofadaptedness.Ithasbeen
shownthatexposuretofamilyviolencecausesthesameadaptationsinthe
amygdalaandanteriorinsulaasoccurinsoldiersonthebattlefield,causing
increasedreactivitytothreateningfaceswhichinturnbringsariskof
vulnerabilitytopsychopathology(McCrory,etal.,2011).
Mostadultmentalillnesshassuchanucleusofoldandunrememberedterror
(Read,etal.,2008).‘Structuralandfunctionalabnormalitiesinitiallyattributedto
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psychiatricillnessmaybeamoredirectconsequenceofabuse’(Teicherand
Samson,2016:241).Earlystressfulexperienceswithinthecaregiving
relationshipmayhavea‘pathogenicimpactbymakingtheself-processing
fronto-tempo-parietalsystemmorevulnerable;and…areassociatedwith
sensoryandcognitiveimpairments…whichcancriticallyimpactself-processing’
(Debbane,etal.,2016:9),andthisinvulnerableindividualscanleadtolater
psychosis.Lessextremebutequallyharmfulforboththeindividualandfor
society,babieshavenochoicebuttoadapttotheirenvironment,andthe
behavioursassociatedwithdisorganisedattachmentarenotsomuch“bad”,
rathertheyarefittingtoabadsituation.Asurvivalstatehasbecomea
personalitytraitandthecapacitytohandleanystrongemotioninapro-social
mannercompromised;andtheharmfulchangesinbrainstructureandfunction
associatedwiththisaresimply‘adaptiveresponsestoanearlyenvironment
characterisedbythreat’(McCrory,etal.,2010:1088).Veryyoungchildrenwho
suffermaltreatmenthavethehiddenfoundationsoftheirmindwrecked
comparedwiththosemorefortunate,leadingtophysiologicalchangeswithin
theirneuroanatomythatmaybeimpossibletoreverse.‘Earlysocial,emotional,
andnutritionaldeprivationinhumanshasbeenshowntoresultinreduced
functioningoftheorbitofrontalcortex,thehippocampus,theamygdala,andthe
lateraltemporalcortex.Italsodisruptsthewhite-matterconnectivityinthe
brain–particularlytheuncinatefasciculus,afan-likewhitemattertractthat
connectsfrontalbrainregionstotheamygdalaandtemporalbrainareastothe
limbicareas.Prolongedandchronicstress,includingdisruptedorpoor
mothering,disruptsthebrain’sstress-responsesystem.Thatresultsinexcessive
glucocorticoidrelease,areductioninglucocorticoidreceptors,andultimately
braindegeneration’(Raine,2013:265).Theolderthechildbecomes,thenthe
harderitcanbeto‘re-wire’manyareasofthebrain;whichmeansthatwithout
interventionachildwhohasexperiencedabuseorneglectasaninfantwill
unwittinglycontinuewithpatternsofresponsesthatareengravedinthemindas
sheersurvivalresponses,evenifcircumstanceschange.Thesechangesare
holistic,beginningatthepsychologicallevelandworkingthroughtothe
molecular.Thecorollaryofthisisthatageandtheenergyneededtochangea
mindincreasetogether.
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Epigeneticeffectsofexcessivestressatthebeginningoflife.
Thequalityofthefirstrelationshipwithcaregiversisalsothoughttoaffecthow
manyofanindividual’sgenesare‘expressed’(switchedonoroff),settingthe
limitsofwhatwillorwillnotbepossibleinthefutureonabasicbiologicallevel.
Whatarecalledepigeneticmechanismsmayalteragene’sfunctionwithout
affectingitssequence(thesequenceisinherited),andthesehavethecapacityto
changegeneexpressioninresponsetoenvironmentalpressures,arapidformof
structuraladaptation,byaddingachemicalsignatureabove(thustheepi)the
genethatcandeterminewhetherornot,orwhen,itisexpressed.Collectively
thesesignatures,ormarkers,areknownastheepigenomeanditstaskisto
programmethegenome.‘Epigeneticpatternsaregeneratedduringcellular
differentiationbyahighlyprogrammedandorganizedprocess.Nevertheless,
theyaredynamicandresponsivetotheenvironmentespeciallyduringthe
criticalperiodsofgestationandearlylifeaswellaslaterinlife.Thissensitivityof
theepigeneticmachinerytotheenvironmentoffersaconduitthroughwhichthe
environmentcansculptthegenomeandhavealong-termimpactonhealth’
(Szyf,2009:879).Pre-birthinfluencesareparticularlysignificant,see
(http://www.beginbeforebirth.org).
Thisisamechanismthatbothpermitsandprohibitsthebiologicalbuilding
blocksbehindcertaincharacteristicsandbehaviours.(SeeBuchan,2010,fora
clearintroductiontothistopic.)‘Epigeneticsreferstochemicalmodificationsto
theDNAortothehistoneproteinsthatarephysicallyassociatedwiththeDNA…’
(Meaney,2013:100).Roughlyspeaking,thegenecontrolstheproductionof
aminoacidsthatcreatethecellularbuildingblocksofappropriateprotein.But:
‘Structuralgenes…arecodesforresourcesneededfordevelopment.Theyare
notthecodesforthecourseandend-pointsofdevelopmentitself’(Richardson,
2008:30).DNAiswrappedaroundahistone-basedproteincalledchromatin
whosestructuremaybeextensivelyamended,mostcommonlybymethylation
butalsobyphosphorylation,acetylationandwhatischarminglyknownas
ubiquitination(whichmustcoverallbets),allformingthebasesofhistone
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modifyingenzymes(Syf,2009).Withinthedevelopingmindneurobiological
signalinginresponsetoextremeenvironmentalchallengessetsoffthe
productionofgeneregulatoryproteins,whichthenattractorrepeltheenzymes
thatinturnaddorremoveepigeneticmarkerstoaltertheformandstructureof
DNA.‘Forthegrowingbrainofayoungchild,thesocialworldsuppliesthemost
importantexperiencesinfluencingtheexpressionandregulationofgenes’
(Siegel,2012:32).Epigeneticmarkersswitchfunctionalcharacteristicofthe
geneonandoffbycontrollinghowmuchproteinismanufactured,sothat‘these
epigeneticmarksontheDNAandthehistoneproteinsofthechromatinregulate
thestructureandoperationofthegenome.Thus,epigeneticsisdefinedasa
functionalmodificationtotheDNAthatdoesnotinvolveanalterationof
sequence’(Meaney,2013:105).Althoughepigeneticmarkingsarelonglasting
theyarealsopotentiallycapableofbeingreversed(Syf,2009)byboth
psychotherapeuticandpharmacologicaltreatments.Animalstudiesshowthat
epigeneticmodificationsmaybeinheritedduringmitosis(andsometimesin
meiosis)andcanbetransmittedtothenextgeneration.Theyalsodemonstrate
that‘abundantmaternalcaresetsinmotionaseriesofepigeneticchangesin
gene-expressionpatternsthatmake‘well-loved’animalsmoreresilientwith
robust,life-longresistanceagainstvariousstressors’(PankseppandBiven,
2012:308).Contrary,onecouldspeculatethatepigenetictransmissionmightbe
whyafewbabiesadoptedatbirthhavelatersevereemotionalstruggles
regardlessofhow‘good’theintermediateparentinghasbeen–theycarry
survivaltraitsappropriatetotheabusivechildhoodenvironmentofaparent.
Lessfar-fetchedmaybe,studieshavenowshownthat‘theepigenomeofa
prenatallydevelopinginfantissensitivetothemother’sexperiences,the
prenatalenvironment,andeventheexperienceofbirth’(RothandSweatt,2011:
404).Insuchinstancessuchthingsasmaternalstressorrestricteddietmay
havecausedepigeneticchangesinutero.So,withacertainelementoftruth,one
couldsaythatearlyinterventionwithinthefieldofinfantmentalhealthinvolves
notonlymicrobrainsurgerybutalsogeneticmodification-nopressure!
Generegulationhasevolvedtoimportcontextonacellularlevel.‘Epigenetic
findingsstronglysuggestthathistory,politics,socialenvironments,racism,and
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discriminationmustbegivenconsiderationequaltoorgreaterthanthatof
immediatefamilycircumstances,thusposingchallengingquestionsforthe
locationofresponsibilityforillhealth’(Lock,2013:1897).Theemotional
environment,especiallyduringpregnancyandinfancy,activatesandsilences
usefulandunhelpfulgenesthatarecrucialformentalwellbeing,affectregulation
andsocialandemotionaldevelopment.Natureissituatedwithinnurtureasthe
genomecannotoperatewithnoconnectiontoitssocialsetting;and:‘Forthe
developinginfantthemotheressentiallyistheenvironment’(Schore,1994:78).
Thisisnotanewobservation,Winnicott(1971:53)observedthatatthestartof
life‘thebehaviouroftheenvironmentispartoftheindividual’sownpersonal
development…’
Alongitudinalstudyhasexaminedepigeneticchangesintheglucocorticoid
receptorgenethatplaysacrucialroleinstressregulationbynegativelyaffecting
theHPAaxis.Childrenexposedtophysicalabusedisplayedaspecificepigenetic
effectwithmoremethylationofseveralkeychromosomalsitesimplicatedina
rangeofbiologicalfunctionsincludinghealthybraindevelopment,oneofwhich
wasreducedglucocorticoidreceptorswhichwouldimpairnegativefeedbackof
theHPAsystemresultinginstressregulationproblems(Romens,etal.,2014).
Wealsonowknowthatadultstestedasinsecureininfancyhavedifferentneural
responsesfromthesecurelyattachedinaselfcontrolparadigmwheretheywere
askedtoup-regulatetheexperienceofpositiveaffect,showinggreateractivation
intheprefrontalregionsinvolvedwithcognitivecontrolandreducedco-
activationofthenucleusaccumbens(asourceofemotionalresponses)withthe
prefrontalcortexsuchaswouldindicatearelativeinefficiencyinregulating
positiveaffect(Moutsiana,etal.,2014).Thesetwosetsofobservedstructural
changesinthebrainwouldleadtoproblemsofselfcontrol,whichhaslongbeen
regardedasvirtuallysynonymouswithqualityofattachment(andwithsuccess
inmanyareasoflife),sothattheflexibleandrelativelyefficientaffectregulation
andcapacitytointroducethoughtbetweenimpulseandaction,thattogether
conferresilienceandsuccesstothesecure,islacking.ThelongitudinalDunedin
Studyhasdemonstratedthatchildhoodself-control,whenseparatedoutfrom
socialclassandintelligence,isaverystrongpredictorforphysicalhealth,
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substancedependence,personalfinancesandcriminaloffendinginadulthood
(Moffitt,etal.,2011).Thereisapricetopayforanysocietythatdoesnot
prioritizesupportingtheearlycaregivingrelationship.
Theimportanceoftheattachmentrelationship.
Attachmenttheory,developedbytheBritishPsychiatristandPsychoanalystJohn
Bowlby,hasprovidedaframeworkforstudiesonboththeimmediateandlong-
termeffectsofearlyrelationshipexperiencesonthemindandbehaviourofthe
developingchild.‘Ourmostdistinctiveandimportanthumanabilities–our
capacitiesforlearning,invention,andinnovation;andfortradition,culture,and
morality–arerootedinrelationshipsbetweenparentsandchildren’(Gopnik,
2016:22).Attachmentresearchhasintegratedtheinner,psychological,world
withtheouterworldofbehaviourtodemonstratethat‘thepatterningor
organizationofattachmentrelationshipsduringinfancyisassociatedwith
characteristicprocessesofemotionalregulation,socialrelatedness,accessto
autobiographicalmemory,andthedevelopmentofself-reflectionandnarrative’
(Siegel,1999:67).Attachmenttheoryandalargeandgrowingbodyofresearch
convergetoagreethat‘aninfant’sformationofanattachmenttoacaregiverisa
keydevelopmentaltaskthatinfluencesnotonlythechild’srepresentationsof
selfandother,butalsostrategiesforprocessingattachment-relatedthoughts
andfeelings…(and)mayberelatedtoriskforpsychopathologyorto
psychologicalresilienceinadulthood’(Dozier,etal.,2008:718).However,the
attachmentparadigmcoversonlyapartofhumandevelopmentandany
theorizingorinterventionthatonlyreliesonthisapproachruntheriskof
becomingsomewhatone-dimensional.
FollowingthecreationbyAinsworthandcolleagues(1978)oftheStrange
SituationProcedure,attachmentbehaviourwasinitiallysplitintothree
observablecategories.Themajorityofchildren(about65%)demonstratesecure
attachment,tobecontrastedwithanxious-avoidant,anxious-ambivalentand,a
laterconceptualisation,disorganised-disorientedorcontrollingpatternsof
.
15
attachment.Theorganisedpatternsofanxiousattachmentcanbethoughtofas
clustersofgoal-directedactivitywhoseaimistomaintainthebestavailable
emotionalandphysicalconnection,asthechildseesit,withthecaregiver.‘Each
ofthethreepatternsreflectsastrategyforenlistingthecaregiverintheservice
ofalleviatingstress.Thesecureinfantexploresfreelyandseekscontactwiththe
attachmentfigureasnecessary.Theavoidantinfantfocusesonexploration,and
monitorsandmaintainsproximitytotheattachmentfigure,butdoesnotexpress
attachmentneedsinordertoavoidriskingrejection.Theresistantinfantis
preoccupiedwiththeavailabilityofaninconsistentcaregiver,makingrepeated
high-intensitydemandstoensurethatatleastsomeofthelatterelicitattention’
(Goldberg,2000:23).Thedifferentcategoriesofattachment,onceinplace,
demonstratethedependantchild’schosenmethodofaffectregulation;thiswill
haveabiginfluenceoninternalandinterpersonalprocesses.‘Eachattachment
patternreflectsadifferentecologicallycontingentstrategydesignedtosolve
adaptiveproblemsposedbydifferentrearingenvironments’(Simpson,
1999:125).Babiesandtoddlers,ofcourse,havenomeansofmaking
comparisonsandsothisisjustthewaytheworldofrelationshipsandemotions
goesandcanbeexpectedtocarryongoing.Theyhavejustadaptedtothe
situationathand.Theobservedpatternsofattachmentbehaviourarethechild’s
automaticresponsetothefamilyemotionalhabitat;secureattachmentisno
more‘good’thaninsecureattachmentis‘bad’–thinkinginthesetermsisatrap
oflanguagewiththe‘in’prefixacuefornegativevalue.Evolutionarytheory
speaksof‘conditionaladaptation’,anditisworthexplainingthisinratheralong
quoteasremovingvaluejudgementsasfaraspossibleopensspaceinthemind
forempathyandthinking.Thishypothesisalsoreinforcestheimportanceof
lookingtochangethewholeenvironment(preferablybeforethechildisborn)
ratherthansolelyaimingtofixaprobleminthechildorparent(s),theparents
alsoareadaptingtocircumstances.
‘Fromwithinsuchaperspective,thehighlysusceptiblechildwho
respondstoadangerousenvironmentbydevelopinginsecure
attachments,adoptinganopportunisticinterpersonalorientation,and
sustaininganearlysexualdebutisnolessfunctionalthanthecontext-
.
16
sensitivechildwhorespondstoawell-resourcedandsupportivesocial
environmentbydevelopingtheopposingcharacteristicsandorientations.
Afurtherimplicationisthateffortstoreducethepainandsufferingof
childrengrowingupunderstressfulconditionsneedtotakeinto
considerationthelocalsenseinwhichriskyandseeminglyself-destructive
behaviorsmaybeadaptive.Childrenhaveevolvedtofunction
competently,thatis,tosurviveandultimatelyreproduce,inavarietyof
contexts.Thedefaultassumptionshouldbethatalternativepatternsof
developmentinresponsetobothstressfulandsupportiveenvironmental
conditions(withintherangeencounteredoverhumanevolution)
constituteadaptivevariation'(Ellis,etal.,2011:10).
Secureattachmentisabroad-bandprotectivefactor,conferringconfidenceand
adaptability,althoughnotatotalguaranteeoffuturementalhealth,andwithout
thisemotionalresourceneitherchildnoradultwillfeelfreetomakethemostof
theirlife’spossibilities.Inlaterlifesecurechildrenandadultscanbothaskfor
helpandself-repair,andaremorelikelytoberesilientinthefaceofadversity.
Theyalsodemonstrateimprovedexecutivefunctionperformance(Bernier,etal.,
2012),anadvantageinallwalksoflife.Aninsecurechild,ontheotherhand,has
toomanyanxietiesthatgetinthewayofinvestigatingtheworld,sohorizons
staysafelynear.Researchmakesitclearthat‘Ingeneral,securechildrenshow
moreconcentratedexplorationofnovelstimuliandmorefocussedattention
duringtasks.Secureattachmentprovidesthebest-knownpsychological
preconditionfortension-freeplayfulexploration’(Grossmann,etal.,1999:781).
Largelyasaconsequenceoftheimpactofallformsofinsecureattachmentonthe
capacitytobeplayful,curious,formpositiverelationshipswithpeersandadults,
theabilitytoexertself-control,co-operationandcognitiveskills,thisisapoor
startinaschoolcareer;andisapredictorforacademicfailureanddropoutin
lateryears(Ramsdal,etal.,2015).
Bythetimeinfantsenterintotheirsecondyearoflifethereareconsistent
observabledifferencesintheirbehaviourthatdependuponthelevelofsecurity
theyhaveexperiencedintherelationshipwiththeirparents.Thompson
.
17
(1999:274)givesasummaryofdecadesofresearchtodescribehow‘securely
attachedchildrenshowgreaterenthusiasm,compliance,andpositiveaffect(and
lessfrustrationandaggression)duringsharedtaskswiththeirmother,aswellas
affectivesharingandcomplianceduringfreeplaywiththeirmothers.Securely
attachedinfantstendtomaintainmoreharmoniousrelationswithparentsinthe
secondyear.’Attachmentrelationshipsprovidethelaunchpad,iftheyarefirm
andtrustworthythenbetterthetake-offandthemoresuccessfulistheflight.
Thisinfluencecanbelonglasting;asshownbyalongitudinalstudyofhigh-risk
infantswhereinfantsecuritywasshowntobeassociatedwiththesuccessornot
ofparticipants’romanticrelationshipsinyoungadulthood(Roisman,etal.,
2005).
Thethreedifferentcategoriesofinsecure,oranxious,attachmentmakethechild
increasinglyvulnerabletolife’sevents;butapartfromthemostserious
classification,insecureattachmentbyitselfisnotnecessarilyadisorder,
althoughitcanleadtoone.Goldberg(2000:209)summariseshowintherelevant
researchhere.‘Averycommonfindingisthatthehistoryofpsychiatricpatients
isriddledwithnegativeattachment-relatedexperiencessuchasloss,abuseor
conflict.’Insecureattachmentisariskfactorthatwillinteractwithotherrisks
presentintheemotionalandphysicalenvironmentofthegrowingchild;the
levelofattachmentdisturbanceisequivalenttoalevelofvulnerabilitythatis
difficulttochangewithouthelp.Itisworthnotingthatalongitudinalstudyof
high-riskinfantsshowed‘substantialshiftingtowardsinsecurityinlate
adolescence,particularlytowardsthedismissingclassification’(Weinfield,etal.,
2004:89).Conversely,disorganisedattachmentinveryyoungchildrenwas
significantlyrelatedtolateadolescentinsecurity.Researchshowshowin
adolescenceinsecurityislinkedtoconductproblems(Allen,etal.,1997;
RosensteinandHorowitz,1996).Itisimportanttobearinmindthatinitial‘good
enough’attachmentcanbelostinthefaceoflatersevereadversecircumstances
andsotraumaresponseserviceswillalwaysbenecessary;initialsecure
attachmentdoesnotconfertotalinvulnerability.
.
18
Childrenwithproblemsrelatedtoinsecureattachmentbegintosoakup
statutoryresourcesfromearlyonwhenexternalisingbehaviour(aggression,
non-compliance,negativeandimmaturebehaviours,etc.)demandsaresponse
(Speltz,etal.,1990).ThisisprobablythelargestgroupofchildrenthatSocial
Services,SpecialEducationandtheChildandAdolescentMentalHealthService
areexpectedtodealwith.‘Thesocialandeconomiccostsofthesetypesof
disordersarestaggering’(Greenberg,etal.,1997:197).Ithasbeenestimatedthat
‘InEnglandthecostsofmentalill-healtharegreaterthanthetotalcostsofcrime,
andthereiseveryreasontobelievethatthisisalsothecaseintheUKasawhole’
(FriedliandParsonage,2007:16).Studieshaveconsistentlydemonstrated‘ahigh
rateofinsecureattachmentsamongclinic-referredboysandtheirmothers’(ibid,
p.216);thesameappliestochildreninspecialeducationalprovision(E.B.D.
schools).Arecentstudycomparedemotionallydisturbedchildrenwithtwo
controlgroupsfromotherschoolsettings.Mostofthesechildrenhadbeen
diagnosedashavingattentiondeficitdisorder,therestaseitherconduct
disorderordepression,withhalfthesamplehavingmorethanonediagnosis.
Theywerefoundtobe‘strikinglydifferentfromtheircounterpartsinregular
classroomsintheextenttowhichtheyhadexperiencedmajordisruptionsin
theirrelationshipswithbothmothersandfathers’(Kobaketal.,2001:252).The
differentcategoriesofinsecureattachmentareinthemselvesriskfactorsthat
predisposetowardsspecificdifficultiesinlaterlife.
Avoidantattachmentisastrategyoftendevelopedbyaninfantwhoseparents(or
nannies)havediscouragedovertsignsofeitheraffectionordistress,andwhodo
notreadilyoffersympathyorcomfort.Itischaracterisedbyminimalexpressions
ofemotioninthepresenceofacaregiverwhohaspreviouslybeenconsistently
rejectingorignoringof,orinsensitiveto,suchemotions.Theconvictionthat
othersdonotseeyouassomeoneworthloving,orevenrespondingto,canlead
tolowself-esteemandsubsequentaggression.Closerelationshipsareavoidedas
thechildgetsolder,andsuchadultsmaymasktheirinsecuritybybecoming
addictedtowork,acquisitionsorachievement,orretreatbehindobsessionaland
ritualisticbehaviours.‘Avoidantattachmentwouldalsoseemtobeacomponent
ofcompulsivepersonalitytraits.Atitsextreme,thecompulsivepersonalityisthe
.
19
nightmareversionoftheuptight,authoritarianfatherwhoisdeterminedto
banishallemotions.Helivesinaconstrictedworld,hisattentionsnarrowedto
schedules,rules,andtidiness;andheisobsessedwithtrivia’(Karen,1994:391).
Theisolatedchild‘whoalsohasanavoidantattachmenthistoryandperhaps
certaingeneticleanings,may,ifthingscontinuetogopoorly,developintoa
schizoidpersonality’(ibid).Avoidantattachment,inthewrongcircumstancesis
aprecursorofdissociativeidentitydisorderandconductdisorder.
Ambivalent,orresistant,attachmentstemsfromtheinfant’sexperienceof
inconsistentparentingwhenthechildisneverquitesureifhisorher
expressionsofanxietyanddistresswillbesuitablyattendedtoattherighttime.
Theywillmaximisetheexpressionofnegativeemotionsanddisplaysof
attachmentbehavioursinanattempttocapturetheattentionoftheir
inconsistentlyresponsiveandattentivecaregiver.Thereisalackofconsistent
nurturingandprotectionfromtheparentthatmakesithardfortheinfanttofeel
thatexploringtheworldisasafeoption.Thusthechildhasalowthresholdfor
distress,butnoconfidencethatcomfortwillbeforthcoming.Thechildhardly
everisreturnedtohomeostasisbytheircaregiver.Whenupsetheorshetriesto
getclosetothecaregiver,butonlytobecomeangryandresistcontact.This
patterncanbecarriedintoadulthoodandthererevealsitselfinrelationship
difficultieswherethereiseitherawithdrawalfromothersoracompulsiontobe
dependent.Thisisthehystericalpersonalitywho‘fleesfromintimacy,and,like
theambivalentchild,shetendstobedemandingorclingy,immature,andeasily
overwhelmedbyherownemotions’(Karen,1994:392).Alongitudinalstudy
foundthatadolescentsdiagnosedwithanxietydisordersweresignificantlymore
likelytohavehadresistantattachmentswiththeirparentswhentheywere
infants(Warren,etal.,1997).
Avoidantandambivalentattachmentsmaybeanxious,buttheyhaveworked
withinthefamilyandtheyarecoherentandprovidethechild(andgrown-up)
withsomesortofunconscioussetofstrategiesforrelatingtoothers.Anxiously
insecurechildrenhaveadaptedintheirownwaytoboththebehaviourandthe
zonesofemotionalcomfortoftheirparents.Theseareinternalworkingmodels
.
20
ofwhatonceactuallydid,andisnowexpectedto,occurininterpersonal
exchanges.Atleastsomethingispredictableandthesearenotunkindcaregivers,
andacertainamountofmeaningandsatisfactioncanbegainedwithinmature
relationships.Thisisnottrueforthemostseriousformofinsecureattachment,
labelledasdisorganisedandcontrolling,whichiscausedbypathological
conditionsandgivesrisetopathologicalwaysofrelating.
Theeffectoftrauma,neglectanddisconnectednessontheattachment
responseandlong-termdevelopment.
Maltreatmentandtraumawithinthefamilywillshattertheprotectiveshieldthat
allyoungchildrenexpecttheirparentstoprovide.Inmany,notall,casesthe
behaviourpatternassociatedwithdisorganisedattachmentisamarkerfor
maltreatmentwithinthefamily.Whatisknowninattachmentresearchas
disorganisedattachmentfrequentlyoccurswhentheparenteitherhassomany
unresolvedemotionalissuesfromtheirownpastthattheyhavenomentalspace
leftoverfortheirbabyor,graver,posessomeformofthreat.Thetwoconditions
mayco-occur.Ineithercasethecaregiverisunabletosoothe,comfortand
containtheirdistressedoranxiouschildandsotheattachmentsystemremains
inoverdrive,thereisnoreturntorest.Thechildmay,intheworstinstances,be
driventotakepsychologicalrefugeindissociation,splittingtheurgesofthe
biologicallybasedattachmentsystemforproximityawayfromtheawareness
thatthecaregiverhasamindthatholdshostile,abusiveorneglectfulthoughts
directedtowardstheircharge.Herethechildstruggleswithalackofcoherent
andorganisedstrategiestodealwithstressandemotionalregulation,andshows
behavioursthatappearcontradictory,misdirected,dissociatedorfearfulinthe
presenceofthecaregiver.Fearhascometobeassociatedwithparental
behaviourandattitudessincetheattachmentsystemcannotbede-activatedby
thepresenceoftheputativecaregiver–whoisfrequentlyexperiencedasa
scaregiver.Againthismaynotbeamatterofobviousmaltreatment,butmay
occurwhen‘disruptedparentalresponsestoinfantattachmentbehaviorare
extremeenough,andcontradictoryenough,thatavoidantorambivalent
.
21
strategiescannotbeorganizedinrelationtothecaregiver;thatis,suchstrategies
donotworkwellenoughtomaintainamodicumofproximityandprotection.
Thesedisruptedandcontradictoryparentalresponses,inturn,generate
complementarypatternsofdisorganizedhelplessandcontradictoryresponses
fromtheinfantaroundtheneedforclosenessandcomfort’(Lyons-Ruthand
Jacobvitz,2008:675).Suchapatternofinteractioncanbeequallydifficultto
recogniseandtreatasfirstlytheparentsmaygenuinelyfeeltheyaredoingthe
besttheycanandsecondlynoimmediatetraumamaybevisible;andifthe
problemderivesfromconflictualrelationshipsinthecaregiver’sownchildhood
thatnowunintentionallyinformpatternsofcaretheninfantparent
psychotherapy,overanextendedperiodoftime,maybenecessarytoaddress
suchunconsciousdynamicsthathavebecomeprojectedontotheinfant.
Babiesareborntoseekaconnectionwithacaregiver,andwhenthisinherited
behaviouralmotivationsystemisnotadequatelyrespondedtothenthe
subsequentanxietykicksintheattachmentsystem.Thebabyortoddleris
biologicallyimpelledtoseeksafetythroughphysicalandemotionalclosenessto
thecaregiverwhenworried.Whentheparentisoutoftouchorthesourceoffear
(andthismaybetheresultofneglect)theparadoxcannotberesolved;evena
caregiverwhoappearstobedoingalltherightthingsbutwhoharbourshostile
orresentfulthoughtsagainstthebaby(andthesemaybeunconscious)will
createthesameclashbetweenbiologyandpsychology.Whenthereisno
predictablesolutiontoresolvetheoppositepullsofapproachandavoidanceand
thechild’sfaithintheworldofrelationshipsisdemolishedbytheir‘scaregiver’,
thenheorsheisleftwithnocoherentmeansofrelatingtootherpeople.There
canbeatragicsymmetryhere,withsomemothersbecomingfearfuloreven
aversiveofthebabywhensignalsofdistressarousestrongconflictualfeelings
derivedfromtheirownbabyhoodthattheyareunabletomanage.A‘ghostinthe
nursery.’‘TheghostsrepresenttheunconsciousrepetitionofthepastIthe
presentthroughpunitiveorneglectfulcaregivingpractices,whichthenow-
parentinternalizedasachildinaneffortatself-protectionbybecominglikethe
abusiveparent’(Lieberman,IppenandVanHorn,2015:167).Allformsofmisery
arebadforbabiesandsmallchildren;butwhereasitmaytakeaseveretrauma
.
22
tocreatedisorganisedattachmentwhenachildstartsoffwithsecurity,fora
childwhoseparenthasconsistentlyfoundithardtoattuneandrespond
appropriatelyarelativelymildmisfortunemaycementdisorganizationintothe
foundationsoftheirpersonality.Achildclosetoacliffwillfalloffwithonlya
smallnudge,whereasonestandingbackwouldnotevenregisteradanger.
Secureattachmentconfersthemosthardinessandemotionalroomto
manoeuvre;disorganisedattachmentmeansyoumightstumbleatanymoment.
Themainaimofallformsofearlyinterventionistopreventthemanydifferent
parentingconditionsthatmayleadtodisorganizedattachmentintheshortterm,
withmaltreatmentbeingthemostobvious,butnottheonly,cause.Aninfant
mentalhealthinterventionfocusesonthepresentwhileholdingthecaregiver’s
pastinmind;itisamatterofinterveningpre-emptively,withalwaysaneye
towardsthefuture.‘Abuseandneglectinthefirstyearsoflifehaveaparticularly
pervasiveimpact.Pre-nataldevelopmentandthefirsttwoyearsoflifearethe
timewhenthegenetic,organic,andneurochemicalfoundationsforimpulse
controlarebeingcreated.Itisalsothetimewhenthecapacityforrational
thinkingandsensitivitytootherpeoplearebeingrooted–ornot–inthechild’s
personality’(Karr-Morse&Wiley,1997:45).Fromanevolutionaryperspective
thisiswhatwewouldexpect,thecaregivingenvironmentispreparingthechild
withtheskillsandtraitsthatwillhelphimorhersurvivetoreproductiveage.
Evolutiontakesnonoticeofpersonalhappiness,justgeneticsurvival.‘Stress-
induceddevelopmentalmodifications,triggeredbythenatureofexperience
duringcritical,sensitivestages,aredesignedtoallowtheindividualtoadaptto
highlevelsoflife-longstressordeprivationthatmaybesignaledbyearly
stressfulexperience.Ifanindividualisbornintoamalevolentandstress-filled
world,themanifestationsofearlystressfulexperienceonlaterdevelopmentmay
serveanadaptivepurpose,enablingtheindividualtomobilizeintensefight-flight
responsesorreactaggressivelytochallenge’(Teicher,etal.2003:39).Anyearly
interventionservicethatreducesthepossibilityofmaltreatmentor‘out-of-
touchness’duringinfancyhasthepotentialtoreducethelong-termcosttoboth
theindividualandsociety.Butatthesametimeitisimportanttokeepinmind
thatthereareother,lessvisiblepathstodisorganizedattachmentthatwillhave
.
23
asimilareffectonthedevelopingchild’sbehaviorinthelongterm.(Itis
importanttobearinmindthatmeasuringattachmentstatus,eitherbythe
StrangeSituationorobservation,isnotinfallibleandthechild’sbehaviourmay
beinfluencedonthedaybymanyotherunknownfactors;thusmaltreatment
doesnotalwaysleadtodisorganizedattachmentanddisorganisedattachment
doesnotinvariablyindicateabackgroundofmaltreatment.)Thebehaviours
associatedwithdisorganizedattachmentarenotinvariablytobetakenas
symptomsofabuseorasareasonfortraumatizingachildbyremovingthem
fromtheirfamily.Itisprimarilytheaccumulatedexperienceoftoxicstressfrom
severeadverseexperiencesthatcausesthelong-termnegativedevelopmental
outcomes.
Theswatheofinterpersonalexperiencewithintheboundariesofattachment
relationshipsinthefirsttwoyearsoflifethatcancreatedisorganized
attachmentmayresultinstructurallimitationsoftheinfant’searlydeveloping
rightbrainanditisthesethatliebehindtheobservedbehaviours.Thisisthe
hemispherethatlargelyholdstheattachmentsoftwareandisdominantforthe
unconsciousprocessingofsocialandemotionalinformation,theregulationof
bodilystates,thecapacitytocopewithemotionalstress,theabilityto
understandtheemotionalstatesofothers(empathy)andthesenseofabodily
andemotionalself.‘Itisnowacceptedthatearlychildhoodabusespecifically
alterslimbicsystemmaturation,producingneurobiologicalalterationsthatact
asabiologicalsubstrateforavarietyofpsychiatricconsequences.Theseinclude
affectiveinstability,inefficientstresstolerance,memoryimpairment,
psychosomaticdisorders,anddissociativedisturbances’(Schore,2012:81).
Thesechildrenfromvulnerablefamiliesbecomevulnerableadults.
Theenduringfunctionalcopingdeficitsofthedisorganisedattachmentpattern
associatedwiththespectrumofinsensitivityandinappropriateresponsesthat
rangesfromjustbeingoutoftouchtomaltreatmentreflectastructuraldefectof
therightorbitofrontalcortex.Dysfunctioninthisbrainareamayresultin
personalityandemotionaldeficitsthatparallelcriminalpsychopathicbehaviour,
forexamplealackofemotionalcomprehensionandaffectregulationcoupled
.
24
withahair-triggerstressresponse.Atthesametime,experiencesofprolonged
andfrequentepisodesofunregulatedstressinbabieswhoseemotionsare
uncontainedorpredominantlyfearfulcanbedeemedtoxic.Theyhave
devastatingeffectsontheestablishmentofpsycho-physiologicalregulationand
theestablishmentofstableandtrustingrelationshipsinthefirstyearoflife.The
impactofmaltreatmentatthisearlystageofbraindevelopment,ofmaximum
neuroplasticity,canleadtoanincreaseinthelikelihoodofthedevelopmentof
seriousmentalillnessatadolescence.‘Byunderminingtheneuralintegrityof
brainregionssustainingflexibleandrobustemotionregulation,aswellasself-
referentialandmetacognitiveprocessing,theearlydisruptionofthestress
regulatorysystemmay…makeanimportantcontributiontopsychosisrisk’
(Debbane,etal.,2016:5).Thedifferentcategoriesofattachmentaremerelya
measureofthechild’sability–ornot–toselfregulateandself-protect.
Disorganizedattachmentisanadaptationtorelationshiprisksinthefirstyears
oflifeanditscharacteristicsareappropriatesurvivalresponsesinthat
environment,thesearestrategiesformanagingtheunmanageable.
Theimpactofearlyabuseandneglectcanshowonaphysicallevelalmost
immediately,asithasbeenfoundthattherateofdisorganisedattachment
associatedwithfailuretothriveisextremelyhigh(Wood,etal.,2000).Froma
life-pathperspectiveithasbeenclearlydemonstratedthatchildrenwhohave
sufferedearlyneglectandabusearefarmorelikelytosufferfromserious
illnesseswhentheyareadults,thustakingupanexcessiveanddisproportional
amountofhealthserviceresources,andtheyarealsoatagreatlyincreasedrisk
ofearlydeathfrombothphysicaldiseasesandsuicide(Felitti,etal.,1998;
http://www.cdc.gov/violenceprevention/acestudy/).Humanbabies(and
children)havenoinheritedbiologicalresponsetothreatfromwithinthefamily
beyondthestressresponses,itwasnotaproblemevolutionhadto‘solve’,andso
thelong-termeffectsofsuchabnormalbehaviourcanlastalifetime.The
AdverseChildhoodExperiencesStudyhasmatchedthelifetime(ashortone)of
negativephysicalandmentalhealthdifficultiesthatstemfrommaltreatment
withtheresearchonthecumulativeeffectsoftraumaonthestressresponsein
thedevelopingbrainaswellastheresultingimpairmentinmultiplebrain
.
25
structuresandfunctionsthataccumulatewithincreasingexposuretodifferent
formsofnegativeandtraumaticexperiences(Anda,etal.,2006),andthe
youngerthechildiswhenthisbeginsthenthemoresevereistheoutcome.‘Child
maltreatmentposessevererisksforlong-termmaladjustmentandthe
developmentofpsychopathology.Childmaltreatmentexemplifiesapathogenic
environmentthatisfarbeyondtherangeofwhatisnormativelyencountered
andengenderssubstantialriskformaladaptationacrossdiversedomainsof
biologicalandpsychologicaldevelopment.Boththeproximalenvironmentofthe
immediatefamilyandthemoredistalfactorsassociatedwiththecultureand
community,aswellasthetransactionsthatoccuramongtheseecological
contexts,conspiretounderminenormalbiologicalandpsychological
developmentalprocessesinmaltreatedchildren’(Cicchetti,etal.,2006:624),
withseriousnegativeconsequencesfortheindividual.
‘Exposuretochildhoodadversityleadstotheearlyinitiationofdrug,
alcohol,andnicotineuseandriskysexualbehaviorsandaccountsfor
50-70%ofthepopulationattributableriskforalcoholism,drug
abuse,depressionandsuicide.Italsosubstantiallyincreasesrisk
factorsforischemicheartdisease,liverdiseaseandobesity.This
powerfuladverserelationshipisbestunderstoodasacascade.
Exposuretoearlyadversityalterstrajectoriesofbraindevelopment,
whichinturn,leadstosocial,emotionalandcognitiveimpairment,
followedbytheadoptionofhealthriskbehaviors’(Teicher,etal.,
2010:112).
Disorganizedattachment,frequentlyamarkerformaltreatment(butagainit
mustnotbeassumedthatmaltreatmentinevitablyliesbehinddisorganized
attachment),isamajorriskfactorthat,inthe‘wrong’circumstances,candisrupt
manydifferentareasofdevelopment.Itisalsoamarkerforotherrisks.Ina
summaryofresearchMossetal.(1999:160)concludethat‘Disorganized/
controllingattachmentispredictiveofthedevelopmentofbehaviouralproblems
atpreschoolandschoolageinbothhigh-riskandnormalsamples.Studies
indicatethatbothexternalizingandinternalizingsymptomscharacterizethe
.
26
behaviourproblemsofdisorganizedschool-agedchildrenbetween5and9years
ofage.Althoughatpreschoolandearlyschoolage,itisprimarilyanaggressive,
disruptivebehaviourpatternthatisassociatedwithdisorganization,anxieties
andfearsrelatedtoperformance,abilities,andself-worthbecomemore
pronouncedinmiddlechildhood.’Disorganizedattachmentpredominatesin
childrenreferredtoCAMHS(Green,etal.,2007).Childrenwhohavebeen
assessedashavingdisorganizedattachmentat5-7yearsmessuptheir
education;theyhavepoorerskillsatmathsage8(Moss,etal.1998)andshow
impairedformaloperationalskillsandself-regulationat17yearsofage
(Jacobson,etal.1994).Thesetwostudiessuggestthatlowself-esteemandlack
ofconfidenceinschoolmediatedthepoorperformance,thusexacerbatingthe
problemswithself-esteemthatisknowntogowithdisorganizedattachment
anyway(Cassidy,1988).Playandcuriosityareimpossiblewhentheattachment
systemisonsuchahighalert,solearninganythingbutsurvivalskillsgoesoutof
thewindow;theybecomeemotionallyandscholasticallyilliterateversionsof
BearGrylls–scary-andafatlotofuseintermsofcontributingintosociety.
Aprospectivestudyofanon-clinicalpopulationhasexaminedthelong-term
consequencesofdifferentattachmentpatternsinchildren,differentiating
betweenthosewithmotherandfather(VerschuerenandMarcoen,1999;
Verschueren,2001).Childrenwhohaddisorganisedattachmentwiththeir
fathersshowedhighlevelsofinternalisingbehaviourswhentheywere5;andby
9yearsofage(byteacherreport)theyhadinternalisingproblems,extremely
poorsocialadjustmentandlowself-esteem.Childrenwithdisorganisedmaternal
attachment(notthesameones)weresixtimesmorelikelytoberejectedbytheir
peergroupthanaverage(morethantwicetherateforavoidantchildren).Ifthe
childwasunfortunateenoughtohavedisorganisedattachmentwithboth
parentstheyhadbothsetsofdifficulties.Suchfrightenedandunhappychildren
oftenupsetandalienatetheirpeers,creatinganegativefeedbackcyclethat
increasestheirdefences.
Theproblemsassociatedwithpoorqualityofattachmentbetweenchildand
parentsbegintobevisiblealmoststraightaway.‘Childrenontrajectories
.
27
towardsseriousexternalizingproblemsarelikelytohaveinsecure,particularly
disorganized,attachmentsinthefirstyear’(Shaw,etal.,1996:697).Inaddition,
itisnowacceptedthat‘severelycompromisedattachmenthistoriesare…
associatedwithbrainorganizationsthatareinefficientinregulatingaffective
statesandcopingwithstress,andthereforeengendermaladaptiveinfantmental
health’(Schore,2001:16).Itisthiswired-incompromisedabilityforself-control,
alackofcopingmechanismsonaneurologicallevelfordealingwithinternaland
externalstressesandfrustrations,whichconfersahighvulnerabilityforlater
emotional,relationalandmentalhealthproblems.TheMinnesotaStudy,
followinghighriskchildrenfrombeforebirthforaboutthirtyyearsnow,has
foundthatalltypesofabuseinthefirstyearsrelatedtosignificantemotional
problemsinadolescence,andpredictedtheneedfortreatment.Outofallthe
childrentheyhadfollowedsincebirth90%ofthesamplewhohadbeen
maltreatedqualifiedforatleastonepsychiatricdiagnosisbyage17.Itturnedout
thateveryformofabusewasrelatedtodelinquency,withahistoryof
psychologicalunavailabilitybeingthestrongestpredictor.Neglectalsopredicted
delinquency,althoughthesechildrentendednottobeangryordefiant.
Witnessingparentalviolencecorrelatedwithexternalisingproblemsforboysat
age16andinternalisingproblemsforgirls.Thiswasindependentofother
predictorssuchasabuseorneglect(Sroufe,etal.,2005).Inaddition,suicidal
behaviourinadolescenceisstronglyinfluencedbyunresolved-disorganised
attachment,withgirlsbeingathighestrisk(Adam,etal.1996).
Childmaltreatmentdoesnotspringfromnowhere,andolderchildrenwhocome
intothechildprotectionsystemalmostalwayshaveahistoryofgriefgoingback
tobabyhood.Thepeakageforbeingmurderedisunderone.Theriskpretty
muchdoublesifthereisanon-biologicallyrelatedadultinthehousehold(Daly
andWilson,1998).Earlyintervention,wherevulnerableandoverstressed
parentscanbeidentifiedandsupportedbeforethebabysuffers,beforetheir
ownemotionallybarrenandterrifyingpastbecomesentangledinthe
relationship(andexpectations)withtheirbaby,isanessentialpreventative
serviceifwewanttoavoidasteadygrowthinthenumberofreferralstoadult
mentalhealthservices.‘Childabusehasacausalroleinmostmentalhealth
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28
problems,includingdepression,anxietydisorders,PTSD,eatingdisorders,
substanceabuse,personalitydisorders,anddissociativedisorder.Psychiatric
patientssubjectedtochildhoodsexualorphysicalabusehaveearlierfirst
admissionsandlongerandmorefrequenthospitalizations,spendlongertimein
seclusion,receivemoremedication,aremorelikelytoself-mutilate,andhave
highersymptomseverity’(Read,etal.,2008:218).Takingdisorganized
attachmentasamarkerforchildabuse(butnotassumingflagrantabusealways
liesbehindit),oritsprecursorsasahighrisk,makesitanimportanttargetfor
preventativeservices,whichcanbeginatconception,offeringhelponthebasis
ofriskbeforethechildsuffers.
Asummaryoftheresearchontheconnectionsbetweenearlyattachment
experiencesandadultpsychopathology(Dozier,etal.,1999)lookedat
‘attachmentrelatedcircumstances’andtheireffectonlatermentalhealth
problems.‘Losspredictsmultipledisorders,includingdepression,anxiety,and
antisocialpersonalitydisorder…Depressionisassociatedgenerallywiththe
earlylossofthemother.Majordepressioninparticular…hasbeenfoundtobe
relatedtopermanentlossofacaregiver,whereasdepressioncharacterizedby
angerandotherexternalizingsymptomshasbeenfoundtoberelatedto
separation.Anxietyappearstobeassociatedmorecloselywiththreatsofloss
andinstabilitythanwithpermanentloss.Antisocialpersonalitydisorderis
associatedwithlossthroughdesertion,separationanddivorce’(ibid,513).It
appearsthatthequalityofachild’searlyparentingcanputthemonthepathway
todifferentdestinations.‘Affectiveandanxietydisorderstendtobeassociated
mostfrequentlywithparentalrejectioncombinedwithloss.Antisocial
personalitydisordersaremostfrequentlyassociatedwithparentalrejection,
harshdiscipline,andinadequatecontrol.Eatingdisordersareassociatedwith
maternalrejectionandoverprotectioncombinedwithpaternalneglect,and
borderlinepersonalitydisorderisassociatedmostconsistentlywithparental
neglect’(ibid,514)Severallongitudinalstudieshavedemonstratedthelink
betweendifficultfamilyenvironmentsandtheirinfluenceonthebabyandthe
developmentofdissociative,borderlineandconductdisordersinyoungadults
(Lyons-Ruth,2008).
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29
Theearlyrelationshipbetweencaregiverandbabywillactasanexternalsystem
forthechild’sinternalregulationofaffect.Attachmentis,inmanyways,a
measureofself-controlandemotionalregulation.Thegrowinginfant,whobegan
totallydependentonmotherforsoothing,stimulationandemotionalregulation,
graduallyclaimstheabilitytomanagealone.Theircortexlearnstodowhatthe
caregiver’scortexhadtodoforthem.Inotherwords‘earlydevelopmententails
thegradualtransitionfromextremedependenceonotherstomanagetheworld
forustoacquiringthecompetenciesneededtomanagetheworldforoneself’
(ShonkoffandPhillips,2000:121).Caregiversmaintainthebabywithin
comfortable,oracceptable,feelingstatesbyintuitivelyrecognisingwhattheir
childisexperiencingandhowtheycanhelptorestoreequilibrium.Theparents’
abilitytodothisdependsontheirbaby’sgrandparents.Inordertoachievesuch
sensitivitytheadult’semotionalawarenessisatakenforgrantedresourcethat
enablesanautomaticacknowledgementofneedandasubsequentresponse.‘A
caretakerwithapredispositiontoseerelationshipsintermsofmentalcontents
permitsthenormalgrowthoftheinfant’smentalfunction.Hisorhermental
stateanticipatedandactedon,theinfantwillbesecureinattachment’(Fonagy,
etal.,1991:214).Comfortisnotalwaysanautomaticpresence;indire
circumstancesitcanseemunattainableandinternalpeaceisimpossible.
Thesecurechild(andadult)hasthepsychologicalandneurologicalcapacityto
self-modulaterecognisedaffects.Thecapacityforself-controlandthecategoryof
attachmentarefairlysynonymous.Responsestostressfulorexciting
circumstancescanbethoughtaboutratherthanactedout.‘Asaresultofbeing
exposedtotheprimarycaregiver’sregulatorycapacities,theinfant’sexpanding
adaptiveabilitytoevaluateonamoment-to-momentbasisstressfulchangesin
theexternalenvironment,especiallythesocialenvironment,allowshimorherto
begintoformcoherentresponsestocopewithstressors’(Schore,2001:14).
However,whentheinfanthasbeenexposedtorelationshipslikelytoengender
disorganised,orcontrolling,attachmenttheyhavenochoiceaboutadaptingto
theseemotionalconditions,leadingto‘brainorganizationsthatareinefficientin
regulatingaffectivestatesandcopingwithstress’(ibid:16).Aninabilitytothink
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30
aboutothers’feelingscoupledwithanequalinabilitytocontrolimpulseswill
haveseriouslong-termconsequencesthatwillrippleoutwardsfromthechild.
‘Widespreadtraumatodevelopingnervoussystemsispotentiallyascatastrophic
tohumansocietyasthegreenhousegasesaretotheplanet’(Karr-Morseand
Wiley,2012:249).Politiciansseemkeenonpromotingandsubsidising‘clean’
energytopreventglobalwarming;afractionofthatinvestmentinparent-baby
relationshipswouldequallyprotectoutfutureemotionalenvironment.
Therootsofviolence.
Infantswhohavesufferedadverserelationshipsgoontobecometeenagersand
adultswhoaregrosslyover-representedinthecriminaljusticesystem.Thisis
notonlyadirectdrainonresources;italsosignifiesalargepopulationwhoare
notinapositiontocontributetothewidersociety(thesameappliestothose
whoneverleavetheirdependencyonmentalhealthprovision).Delinquent,
antisocialandviolentbehaviour,frequentlyassociatedwithnosenseofeither
empathyorremorse,hasbeentracedbacktobeingonthereceivingendofabuse
andneglectduringthefirsttwoyearsoflife(deZulueta,1993;Karr-Morse&
Wiley,1997;TheWaveReport,2005,fromhttp://www.wavetrust.org/key-
publications/reports/all).Evenhavingaconsciencecannotbetakenforgranted,
asithasbeendemonstratedthatthisiscultivatedby‘caregiverswhoarewarm
andprovideclearexpectationsforchildbehaviourthatareconsistently
reinforced’(ShonkoffandPhillips,2000:243).Thecapacityforemotional
regulationandself-controlisvirtuallysynonymouswiththequalityof
attachmentinearlychildhood.Thisisthetimewhentheneurologicaland
hormonalfoundationsformentalandemotionalhealtharebeinglaiddown;and
ahard-wireshair-triggerfightandflightresponsewilldonobodyanyfavours.
Ithasbeenfoundthatattachmentproblemsinadolescencepredictlatercriminal
behaviour(Allen,etal.,1996);andanattachmentbasedstudyofprisonerswith
apsychiatricdisorderconfirmedthehypothesisthat‘criminalityarisesinthe
contextofweakbondingwithindividualsandsocialinstitutionsandthe
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31
relativelyreadydismissalofattachmentobjects.Criminalbehaviourmaybeseen
asasociallymaladaptiveformofresolvingtraumaandabuse…Violentactsare
committedinplaceofexperiencedangerconcerningneglect,rejectionand
maltreatment.Committingantisocialactsisfacilitatedbyanonreflectivestance
regardingthevictim’(Fonagy,etal.,1997:255).AsdeZulueta(1993:76)putsit,
violence‘isthemanifestationofattachmentbehaviourgonewrong.’Theability
tobemindfulofanother’smind,andthusmindhowyoutreatthem,isderived
fromtheinfant’srelationshipwiththeircaregiver.
Implicationsoftheresearchdata.
Iftheearlyrelationshipbetweenthebabyandhisorherparentsisgiventhe
attentionitdeservesthenthishastwomajorimplications.-Firstly,manylater
emotionalandmentalhealthproblemscanonlybereworkedinasimilarfireas
forgedthem.Long-term,intensiveand(thistime)thought-aboutrelationships
maybenecessarytohelpthosewhocarrythementalimprintofearlytrauma
andneglect.Foraslongasthebrainretainssufficientplasticityintherelevant
areasthenitsneurochemicalstructurewillcontinuetoadapttotheeffectof
affect.Evidencesuggeststhatpsychotherapy‘probablyinitiallychangesthe
functionalconnectionsamongneurones,andthenlaterconvertsthesefunctional
changesintochangesintheactualstructureofthecerebralcortexitself’
(Vaughan,1997:68).Butlesseffortwouldhavebeencalledforwhenthemind
was,bydesign,morereadilyadaptable.–Secondly,byrecognisingthatthe
parent-infantrelationshipisthecrucibleforchangeanddevelopment,forgood
orill,wecanlookbeyondtheindividualstothewiderconditionsthatimpinge
uponthisrelationship.Lookingforreasonsremovesblame.Everyparentalways
doesthebesttheycanfortheirbabywithinwhatispossibleforthem.Abroader
perspective,tryingtounderstandratherthanpassingjudgement,pointstothe
importanceofacatalogueofknownriskfactors.Itisfeasibletoanticipatewhat
sortofsituationtendstoleadtoinsecureattachment,andthusoffertreatmentor
someotherformofhelpbeforeanythinggoesdrasticallywrong.Thatis,before
responsesgetso‘hard-wired’intothebrainthattheybecomeincreasinglyhard
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32
tochange.Itishardtoholdinmindthenumberofriskssomefamilieshaveto
contendwithandnotfeelhumbledbyhowwelltheycope.Butbeingawareof
theriskfactorsmeansinterventionhasabetterchanceofbeingatthe
preventativeendofthespectrumratherthanthereactive.Thesecanbeapplied
beforethebabyisborn,andaninfantmentalhealthteamwillworkwithfamilies
duringpregnancy,especiallyiftheparent-fetalattachmentisnotaswewould
wantittobe-anunhappystateofaffairsthathasasmanynegativeconsequences
asithascauses(Cataudella,etal.,2016).
Theideaofprovidingspecializedservicesthattargettherelationshipbetween
caregiver(usuallybutnotinvariablyabiologicalparent)andbabyortoddleris
onethathasbecomeincreasinglymainstreamoverthelasttwodecades,and
clinicalprovisioninthestatutoryandvoluntarysectorshasbeguntobuildup.
Suchearlyinterventionisproactiveratherthanwaitingforaproblemtoarise.
Theprimeaimistopreventmaltreatment.Itisimportanttohaveathandthe
rationalebehindsuchprovision;andsuchinitiativesasthe‘1001CriticalDays’
campaignandtherecentAPPGReport‘BuildingGreaterBritons’(2015),aswell
asabroadrangeofgoodbriefingpapersfromtheNSPCC,haveencourageda
widesurgeofinterest(www.1001criticaldays.co.uk)thathasthepotentialto
openupalotofopportunitiesacrosstheUK.
Infantmentalhealthinterventionisahighlyskilledspecialitybutmanydifferent
professionsneedtobeinvolved.Thenumberofqualifiedpractitionersininfant-
parentpsychotherapyissteadilygrowingwithcoursesavailablethroughthe
AnnaFreudCentre,OXPIP,TheTavistockCentreandTheSchoolofInfantMental
Health.Thesearepost-professionalqualificationtrainings,psychodynamically
based,andaproperlytrainedclinicianmeritsahighpayband,anathemainthe
currentclimateoffrugalitywhereCAMHSmanagersarereducingthegradeand
payofthemostqualifiedandexperiencedclinicianswherevertheycan.Butyou
donothavetobeapsychotherapisttobeaninfantmentalhealthspecialist;and
thereareotherequallyusefulinterventionssuchasInteractionGuidanceand
therapeuticgroupsalongthelinesofMellowParentingandCircleofSecurity.
Midwivesandhealthvisitors(thebestearlywarningsystemforadultproblems
.
33
thatwehave)arecentralastheyareuniversalandnotstigmatising,andbothare
nowspecialisinginearlydetectionandinterventionwithvulnerablefamilies.An
infantmentalhealthteamshouldbebothmultidisciplinaryandarelationship-
basedorganisation(Bertacci,1996),againquitecontrarytothefranticpressure
ofareducedCAMHSfacedwithmorereferralsthantheycanhopetoofferan
adequateserviceto;andinthesamespirit,treatmentmustfollowthecaregiving
relationshipsratherthanaritualistictime-limitingformulaandso,insome
cases,mightneedtobeopen-ended;suchacavalierattitudetotheethosof
meetingtargetsmaycauseorganisationalstressandbadfeeling.
Anobviousproblemforthestatutorysectoristhatinearlyintervention,which
ideallycanbeginduringpregnancyandthencontinueupuntilatleastthesecond
birthday,isthatthereisstrictlyspeakingnoindividuallyidentifiedpatient.The
‘patient’isthecaregivingrelationship,whichhopefullyincludesbothmotherand
fatherandallthattheirbackgroundandtheindividualbabytogethercontribute.
Butparents/carersmustchoosetobeengaged;soanyfileneedstobeopenedin
theirnamenotthechild’s,bothforclearethicalreasonsandalsoforanychild
protectionconcerns(theremaybechildrenwithdifferentsurnamesinthesame
family)and,especiallyimportant,foreaseofcommunicationwithadultservices
whentheyareinvolved.Andwhointheirrightmindwouldknowinglywant
theirbaby,oranybodyelse’s,tocollectamentalhealthrecord?Thisthen
deprivesanyCAMHSofnumbers,somayberesistedpurelytomeettargets.
ThereisalsoatendencyforCAMHSservicestobelargelyclinic-based.They
generallydolesshomevisitingthanadultteamsorcommunityworkersfroma
children’scentre.Thisishardlythebestplacetoworkwithavulnerablefamily
wherethenormalheightenedstressandanxietycausedbyanewbabyis
amplifiedbythesenseofbeingjudged,letalonetheanxietiesthatcanariseina
noisywaitingroom;andCAMHSmighthavenegativeassociationsfortheparent.
Betterforthecliniciantocontaintheanxietyofahomevisit(unlessunsafe),
wheremorecanbelearnedfromasingleobservationthanastringofclinic
sessions,thantheparentshavingthehassleoftransportinganinfant,plusallthe
attendantclobberandpossiblyasibling.Anotherreasontokeepinfantmental
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34
healthservicesdistantfromCAMHSisthatalmostinvariablythefamilyhasnot
requestedhelp,ithasbeensuggestedbysomeprofessionalsuchasamidwife,
healthvisitororchildrencentreworker.EveryreferraltoCAMHShasmotivated
parentsaskingfortheirchildtobe‘fixed’;ininfantmentalhealththereisusually
nochildwithasymptom(thoughbabiescanhaveemotionalandmentalhealth
difficulties)astheprimeaimistomaintainhealthysocialandemotional
developmentasfaraspossible.Atthisagemost‘problems’beginasanintangible
withinthecaregivingrelationship,andthat,asariskanalysisshows,canhavea
multitudeofsources.Thisiswhyanearlyinterventionteamneedstobothbe
highlyskilled,close,creativeandmultidisciplinary;andthenatureofthe
personalcommitmenttothiswork,withmorestressandlesswaitingtimes,
demandsanorganisationallyunrulyteam-ifnotthereisaproblem.Insome
regionssuchateammaybemoreefficientandcreativeinthevoluntarysector
(seewww.pipuk.org.uk)andfeelmoresupportedandcontainedwithinthe
focussedandskilledbustleofachildren’scentrethana‘formal’mentalhealth
setting.
Thereisabreadthofevidence-basedpracticeinthefieldofearlyintervention,as
detailedbelow;although,basedonthe‘goldstandard‘ofRCTs,someofthe
populationleveleffectsareprettysmall.(Forexamplessee:www.aimh.org.uk).
Onereasonforthisisthatpoverty,whichamplifiesandconcentratesallthe
otherrisks,remainsthesourceofmajorstressonparentsandallthe
psychologicalinterventionsintheworldwillnotaffectthat.Thisdiversityshows
thenecessityforsettingupappropriatelytrainedteamshousingmultipleskills
ratherthanstickingtoasinglemethodofoffering‘therapeutic’helpto
vulnerablefamilies.
Inaveryroughandreadywaytherapeuticinterventionscoveringthefirst1001
criticaldayscanbecategorisedaseithergroups,whereparentsareheldby
relationshipsasopposedtotaught,orindividualworkwiththeprimecaregiver
tochangebehavioureitherdirectlyorthroughanalterationinthewayinwhich
bothparentingandthebabyareviewed.Thesearedetailedbelow.Butinthe
realandmessyworldtherearenotsuchclear-cutdifferencesandaflexible
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35
approachisthemostrealistic.Theexamplesinthispaperarenotexhaustive,I
amsureIhavenotreadeverythingbyalongchalk,butarebackedupby
practice-basedevidence.Thesearebestdeliveredfromachildren’scentre
offeringuniversalservicesasthat,coupledwithanattitudeofhelpingall
vulnerablefamilies(whocomefromeverystrataofsociety)lowersthe
reluctanceofparentstobecomeinvolvedasfarasispossible.
Caregivinginjeopardy.
Wheneveranewbabyarrivesonthesceneitisstressfulforfamily.Thatisjust
thewaynaturehassetusup;wehavethemostextendedperiodofjuvenile
dependencyofanyspeciesandworriesabouttheyoungshouldactivatethe
caregivingsystem,sountiladulthood(andbeyond)childrenaredesignedtotax
theirparents.Hardluck.Thisisbothnormalandcanbethoughtofasa
spectrum;atoneendallconcernedarefairlycoolandhaveconfidencethat
althoughtherewillinevitablybeupsetsanddramasthesewillbeabletobe
overcome,whileattheredendtheadditionalresponsibilityofababycan
actuallybeastresstoofar.Ofcourseveryfewparentsanticipatethelatter,
althoughwedomeetparents-to-bewhoresentordreadhavingababy,
sometimestothepointoffear.Thisiswherethesensitivemidwifeiscrucialin
enlistingspecialisthelpinthepre-natalperiod.
Aparentwhocarriesaburdenofanxietyfrommultiplesourceswillnotbeable
togreetthebabywithanopenmind.Caregiverswhocanholdtheirchildin
mindatalltimescreatesecureattachment,thebestfoundationforbuildingall
thelaterskillsthatnormaldevelopmentwillmakepossible.Amindfullof
stressorshaslessspaceforthechild.Thereisalargebodyofresearchonrisk
factors,withgeneralagreementonwhattheseareandhowtheyaffectparenting.
(E.g.Balbernie,2002;FonagyandHiggitt,2000;Karr-MorseandWiley,1997&
2012,2000;Sameroff,2000;Zeanah,etal.,1997.)TheAdverseChildhood
ExperiencesStudy,wherethesampleismiddleclassandaffluent,hasclearly
shownhowabuildupofrisksinthefamilyenvironmentisapredictorfor,
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36
amongotherthings,seriousphysicalandmentalillheath,beingbotha
perpetratorandvictimofdomesticviolenceandforsubstanceabuse(Felittiet
al.,1998).Theserisksareeasilyspotted(seeappendix),again,inthepre-natal
periodthemidwifeisinthebestpositiontodothis,andthenthehealthvisitor
takesovertheroleofearlywarningsystemforthementalhealthofthenext
generation.
Theparent-babyrelationshipisalwayslocatedinamuchwiderecological
context,withinwhicharefoundbothriskandprotectivefactors(Osofskyand
Thompson,2000).Whathasbeencalled‘familywell-being’,withoutwhich
developmentallyappropriateparentingwillbestressfulanddifficult,isa
compositeofmanydifferentcomponents(Newland,2015),whichiswhyearly
interventionisbuiltuponaknowledgeofrisks(seeappendix1).Thesecanharm
thebabydirectly(e.g.pollution,unhealthyhousing)butmostlyaretitratedinto
therelationshipviatheireffectsontheparents’functioning,sincetheydictate
thebaby’simmediateexperiences.TheMillenniumCohortStudyhasconfirmed
that:‘Thegreaterthenumberofrisksexperiencedbythechild,thegreaterthe
problemsthatthechildwillfaceduringthelifecourse’(SabatesandDex,2012:
22).
Nurtureandnaturecannolongerberegardedasdiscretelyseparateissues.
‘Geneticsusceptibilitiesareactivatedanddisplayedinthecontextof
environmentalinfluences.Braindevelopmentisexquisitelytunedto
environmentalinputsthat,inturn,shapeitsemergingarchitecture.The
environmentprovidedbythechild’sfirstcaregivershasprofoundeffectson
virtuallyeveryfacetofearlydevelopment,rangingfromthehealthandintegrity
ofthebabyatbirthtothechild’sreadinesstostartschoolatage5’(Shonkoffand
Phillips,2000:219).Thisevengoesdowntothegeneticlevel,asthrough
epigeneticchangescaregivingcancause‘long-lastingdifferencesingenescritical
forbehavior,stressresponsivity,metaboliccontrolandautoimmunityleadingto
emergenceofdiseaselaterinlife’(Syf,2009:879).Someparentsareover-
burdenedbynegativefactors,pastandpresent,whicharebeyondtheircontrol.
.
37
Theyneednon-judgementalassistanceassoonaspossibleifwewanttobreak
thecycleofemotionaldeprivation.
Some(butcertainlynotall)oftheriskfactorsknowntoadverselyaffectthe
parent-babyrelationshipare:problemsintrinsictothebaby,suchaslowbirth
weightorcongenitalabnormalities;aparentwholackstheabilitytosensitively
attunetothebaby’sneeds,whodoesnotinteractwiththeirinfantormaltreats
himorher;oneorbothparentsstrugglingwithamentalhealthoraddiction
problem,orwithabackgroundofabuse,neglectorlossintheirownchildhood;
inadequateincomeorsub-standardhousing,familydysfunctionand(extremely
harmful)domesticviolence(Brigg-Gowan,etal.,2010);singleteenagemother
withoutsupport.(TheseexamplesfromLandy,2000:345;andseealsoSameroff,
2000:12.)Somanyfactorsexternaltothebabyandparentcanmessuptheir
relationshipthatproblemsherecanbetakenasasignthatthechild,without
intervention,willgrowupstrugglingwithemotionalharassmentfrommany
differentdirections.Interventionmayhavetobeonmultiplelevelsassuggested
byLisaNewland(2015)whohasbuiltatheoryofchangeonherfamilyWell-
BeingModel,wherethestrongestinterventionswouldaddressfamilyself-
sufficiency,developmentalparentingandchildwell-beingsimultaneously.She
pointstotheimportanceofappropriateclinicalservicesandtheuseofhome-
basedinterventions,backedupbyparentingeducationandfamilysupport
programmes(ibid:10).
Aworkingassumptionthatcandirectbothearlyandlaterinterventionisthat
‘attachmentdisruptionmaybeamarkerorsummaryvariableforanumberof
pathogenicfactorsinthechild’senvironment’(Kobaketal.,2001:254).Thebaby
hasnocomparisons,whatismetissimplyhowthewholeworldisorganised
(andwhyshoulditchange?)andthisiswhatwillbeautomaticallyadaptedto.
Theimmediaterelationshipbasedenvironmentprogrammesinemotional
softwarefairlyrapidly.‘Asasourceofrisk,thehomemayreflectanatmosphere
ofdisorganization,neglect,orfrankabuse.Asasourceofresilienceandgrowth–
promotion,itischaracterizedbyregularizeddailyroutinesandbothaphysical
.
38
andapsychologicalmilieuthatsupportshealthychild-caregiverinteractionsand
richopportunitiesforlearning’(ShonkoffandPhillips,2000:345).
Theresearchonriskfactorsmeansthatbabieswhomightbelikelytohave
adversedevelopmentalpathwaysthroughlife,becauseofstressesintheirinitial
relationshipwiththeirparents,canbeidentifiedearlyon.Eventheunbornchild
cannotbeassumedtobesafe.Thefoetuscanbedirectlyharmedbyanumberof
toxins(includingtheeffectsofstressonthemother)whichcancausedisability,
regulatorydisorders,attentiondifficultiesorskilldeficits;anyoneofwhichmay
makeithardfortheneonatetosettleintoanattachmentrelationship.‘Children
bornalreadyimpairedaremorelikelytobethebruntofdestructiveparenting
behavioursandabuse’(Karr-Morse&Wiley,1997:55).Amajorrisk,thesingle
biggestcauseofcognitivedelayindevelopedcountries,ismaternalalcohol
consumptionduringpregnancy.Itisnowacceptedthat:‘theteratogeniceffects
ofalcoholarenotlimitedtoheavychronicexposure,ortoexposureduringa
specifictimeduringthegestationperiod(Fitzgerald,etal.,2000:129).Foran
excellentworkingsummaryonfoetalalcoholspectrumdiagnosis,childoutcomes
andparentalhelpseeShah,etal.,2015.
Overandabovetheeffectsofthedrugontheembryo,achildborntoparents
withaddictionproblemsmaywelldevelopattachmentdifficultiesasaddictionin
anyformflagsupanattachment-relateddisorder,insofarasitgivestheillusion
ofa‘safe’dependencywheretheobjectofdesireiscontrollable.Avulnerable
babydoesnothavetoexperiencedistressanddamagethatheorshecannot
comprehendbeforehelpisoffered.Thegreaterthenumberofriskfactorsfound
inafamily’stotalecologythenthegreatertheneedforimmediateassistance.But
sadly,themoreafamilyisunderstressthentheharderitbecomestomakefull
useofanyhelpavailable.Onlyarelationshipcanchangearelationship,butifyou
aregrounddownbyinnerandoutercircumstancesanewrelationshipishardto
contemplate.
However,alongwithpressuresonthecaregivingrelationshiptherewillalways
bestrengthsthatcanbebuiltupon.Improvingparentingcapability,ifitistobe
.
39
positiveforthefamily,mustalsobuildupontheprotectivefactorswithinand
aroundtheparents.Topromoteinfantwellbeingitisnecessarytopromotethe
proficiencyoftheparents.Ifafamilyistargetedforservicessolelyonthebasisof
theknownriskfactorswhichareknowntocorrelatewithchildmaltreatment
thismayindeedemployscarceresourcesforthosemostinneed,butontheother
handitmightalienatefamilieswho(justifiably)donotwanttobelabelledas
potential‘bad’parentsorabusers.Avisiblytargetedservicewillinevitably
discouragethemostvulnerableasthefearofhavingachildremovedwill
overwhelmrationalthought.
Risksidentifysusceptibility;theyarenotaninfallibleforecastofdisaster.And
maltreatmentmayoccurinhigh-incomefamilieswithalltheadvantagesoflife.
Thismeansthatinterventionsmusthaveastrength-basedorientation(notsolely
adeficitmodel)whichhasthepotentialtobemoreinclusive,withabetter
capacitytoengagewithotherpartneragenciesinthecommunityarounda
resilienceframeworkwhichcanhelpeveryoneinvolvedseehowtheirworkcan
contributetopreventingmaltreatment.Themostimportantprotectivefactors
foranyfamilyareasfollows(Browne,2014:4).(1)Parentalresilience:Managing
stressandfunctioningwellwhenfacedwithchallengesandadversities.(2)Social
connections:Havingasenseofconnectednesswithconstructive,supportive
people,networksandinstitutions.(3)Knowledgeofparentingandchild
development:Understandingparentingbestpracticesanddevelopmentally
appropriatechildskillsandbehaviours.(4)Concretesupportintimesofneed:
Identifying,accessingandreceivingneededadult,childandfamilyservices.(5)
Socialandemotionalcompetenceofchildren:Formingsecureadultandpeer
relationships;experiencingregulatingandexpressingemotions.(6)Nurturing
attachment:Providingparent-childexperiencesthatlaythefoundationfora
warmsecurebond.Lookingatthislist(alsoseeOsofskyandThompson,2000)it
isclearthatchildren’scentresarecentraltoprevention,althoughthiscannotbe
adequatelydoneunlesstheyhavealargewell-qualifiedmulti-disciplinaryteam;
whichinthecurrentclimateoflocalauthoritiesfarmingthemouttoprofit-
makingcharitieswhoparebackonstaffassoonastheycantosavemoneyis
unlikelytohappen.
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40
Gettingthefirst,prototypical,importantrelationshipofanyone’slifemoreor
lessrightisanecessity,notaluxury.Thisisthemostsensibleandeconomictime
toputintherapeuticresources.Andfurthermore,uniquetothisstageoflife,one
canguaranteethatthechildbothwantstoco-operateandhasnotgotstuckin
thetrapofgainingself-esteemfromantisocialacts.Thisissociety’sbestchance
tohelpitself.‘Theinteractiveprocessmostprotectiveagainstlaterviolent
behaviourbeginsinthefirstyearafterbirth:theformationofasecure
attachmentrelationshipwithaprimarycaregiver.Hereinonerelationshiplies
thefoundationofthreekeyprotectivefactorsthatmitigateagainstlater
aggression:thelearningofempathyoremotionalattachmenttoothers;the
opportunitytolearncontrolandbalancefeelings,especiallythosethatcanbe
destructive;andtheopportunitytodevelopcapacitiesforhigherlevelsof
cognitiveprocessing’(Karr-Morse&Wiley,1997:184).
Theanalysisofriskfactors,which:‘isanexerciseinestimatingprobabilities,not
findingcauses’(Sameroff,2000:28),showsclearlyhowtherelationshipswithina
familycanbedistortedbyexternalpressureswhichneedinterventiononasocial
levelasmuch(ifnotmore)astheiremotionalconsequencesneedhelpona
personallevel.Forinstance,thesinglemostimportantbroadriskfactorthat
predictslatermaladjustmentispoverty(Brooks-Gunn,etal.,2000;Halpern,
1993),sincethisamplifiesandconcentratesalltheotherrisks.‘Lowincome
createsaparticularlystressfulcontextinwhichpositiveinteractionswith
childrenarethreatened,andpunitiveorotherwisenegativerelationshipsmay
result.Thehighprevalenceofdepression,attachmentdifficulties,and
posttraumaticstressamongmotherslivinginpovertyservestounderminetheir
developmentofempathy,sensitivity,andresponsivenesstotheirchildren,which
canleadtodiminishedparentingbehavioursandthusdecreasedlearning
opportunitiesandpoorerdevelopmentaloutcomes’(ShonkoffandPhillips,
2000:353).Thislineofinfluenceiscomplicated;beingpoordoesnotmake
anyoneapoorparent,butpovertyisassociatedwitharaftofstressorsthat
impactthecaregivingrelationshipthroughmanydifferentroutes,andimplies
diminishedresourcestobuyoneselfoutoftrouble.Also,manyrecent
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41
neuroimagingresearchprojectshaveshownthatachildrearedinpovertyhas
fairlysevereneurologicalshortcomingsthroughnofaultoftheirown.
‘(E)xposuretopovertyduringearlychildhoodisassociatedwithsmallerwhite
matter,corticalgraymatter,andhippocampalandamygdalavolumesmeasured
atschoolage/earlyadolescence’(Luby,etal.,2013:7).Theeffectsofinadequate
financialresourcescanbepartiallyaddressedinmanyinstances,andmustbeas
anurgencyinmanycases,ascanotheradversefactors,butultimatelyittakes
individualisedresponsivecareandatherapeuticrelationshiptochangeapattern
ofcaregivingthatisbasedonanunconsciousfrombabyhood.
EarlyInterventionServices:anoverview.
ThemajorreviewbytheAmericanNationalResearchCouncil(partofthe
NationalAcademyofSciences)ofmanydifferentlinesofresearchcarriedouton
thedevelopmentofchildren,summarisesaconservativecoreofreplicated
findingsoverthirtyyearsofevaluatingearlyinterventionprogrammes.
(Shonkoff&Phillips,2000:342)Toparaphraseslightly,andomittingtheir
extensivereferences,theseareasfollows:
•Well-designedandsuccessfullyimplementedinterventionscanenhancethe
short-termperformanceofchildrenlivinginpoverty.
•Suchinterventionscanpromotesignificantshort-termgainsonstandardised
cognitiveandsocialmeasuresforyoungchildrenwithdevelopmentaldelaysor
disabilities.
•Short-termimpactsonthecognitivedevelopmentofyoungchildrenlivingin
high-riskenvironmentsaregreaterwhentheinterventionisgoal-directedand
child-focussedincomparisontogenericfamilysupportprograms.
•Measured,short-termimpactsonthecognitiveandsocialdevelopmentof
youngchildrenwithdevelopmentaldisabilitiesaregreaterwhenthe
interventionismorestructuredandfocussedonthechild-caregiverrelationship.
•Short-termI.Q.gainsassociatedwithhigh-qualitypreschoolinterventionsfor
childrenlivinginpovertytypicallyfadeoutduringmiddlechildhood,afterthe
interventionhasbeencompleted;however,long-termbenefitsinhigher
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42
academicachievement,lowerratesofgraderetention(repeatingayear),and
decreasedreferralforspecialeducationserviceshavebeenreplicated.
•Extendedlongitudinalinvestigationsintotheadolescentandadultyearsare
relativelyuncommonbutprovidedocumentationofdifferencesbetweenthe
interventionandcontrolgroupsforeconomicallydisadvantagedchildreninhigh
schoolgraduation,income,welfaredependence,andcriminalbehaviour.
•Analysesoftheeconomiccostsandbenefitsofearlychildhoodinterventionfor
low-incomechildrenhavedemonstratedmedium-andlong-termbenefitsto
familiesaswellassavingsinpublicexpenditureforspecialeducation,welfare
assistance,andcriminaljustice.
Relationship-basedinterventionstargetthecreationofsupportiveandnurturing
parent-infantinteractionsbecausetheseareassociatedwithawiderangeof
healthydevelopmentaloutcomes.Findingsfromameta-analysisindicatethat
‘supportiveparent-childinteractionsweremaximisedwhenstudieswerenon-
random,directlytargetedtheparent-childdyad,orwereshorterinduration(in
months).Furthermore…interventionsthatusedaprofessionalintervenorand
freeplay-tasksduringassessmentwerethemosteffective’(Mortensenand
Mastergeorge,2014:348).Ontheotherhand,thereappearstobearelativelack
ofevidencethatwide-scaleprojectsthatbroadlytargetageneralpopulation
havemuchlong-termeffect.AttheendofareviewofAmericanFederalandState
interventions,suchasHeadStart,Farran(2000:525)findsitdishearteningthat:
‘Agreatdealofmoneywasspentonprogramsthathavenotbeenshowntobe
moreeffectivethandoingnothingatall.’Thisisareminderthatfamiliesdonot
existinisolation.
Whereachildappearstohaveadisadvantagedstartinlifethewholecontextof
thebaby-parentrelationshipneedstobetakenintoaccount.‘Competenceisthe
resultofacomplexinterplaybetweenchildrenwitharangeofpersonalities,the
variationsintheirfamilies,andtheireconomic,social,andcommunityresources’
(Sameroff,2000:9).Therearealargenumberoftherapeuticinterventionsthat
havebeendemonstratedtohelptherelationshipbetweenparentandinfant,but
resultscannotbesustainedinavacuum.Noneoftheprogrammesreviewedby
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43
Farran(2000:525)‘madeanydifferencetotheincome,housingconditions,or
employmentoftheparentsinvolved,despitethefactthatthefamilieswereoften
chosenbecausetheyhadextremelylowincomes.’Exactlythesameadverse
influencesthathaveimpingedontheadultmembersofthefamilywillprobably
continuetoexertaneffectonthechildthroughouthisorherdevelopment,
makingspecificpredictionsdifficultunlesswiderissues(suchasstandardsof
educationandemploymentprospects)arealsotackledheadon.‘Thatistosay,
significantmedium-andlong-termbenefitsofearlychildhoodinterventionmay
beviewedasacontinuingdevelopmentalpathwaythatiscontingentonachain
ofpositiveeffectsthatincreasetheprobabilityofremainingontrack’(Shonkoff
andPhillips,2000:352).Perhapsitwillnotbepossibletogaugethemost
importantlong-terneffectofearlyinterventionuntilfollow-upstudiesare
carriedoutontheseinfantswhentheyhavebecomeparentsinturn.
Someoftheeconomicbenefitsofveryearlyintervention.
Thereareanumberofstudiesthathavedemonstratedthelong-termcost
benefitsofhelpingvulnerablefamiliesprovidethesortofemotional
environmentfortheirbabiesandtoddlersthatingeneralleadstosecure
attachment.Parentingneedonlybe‘goodenough’.Forinstance,thePerryPre-
schoolHighscopeProgrammehasdataspanningfortyyears,showingthatfor
every$1spentinsettingupandrunningtheirpre-schoolnurseryinitiativeina
high-riskareatheyfindthatalmost$13weresavedintermsoflaterservicesnot
accessedwhenparticipantswerefollowedupatage40.(High/ScopePerry
PreschoolProgram,follow-upreportin2005,online.)Anotherlongitudinal
study,knownastheElmiraHomeVisitingProject,hasshownthatspecialised
earlysupportforvulnerablefirst-timemothershadpaidbackitscostsbyfour
years.Ata15-yearfollowupthesavingsexceededthecostsoftheprogrambya
factoroffour(Oldsetal,1999).Caldwellin1992analyzedthecostsrelatedto
childmaltreatmentanditsconsequencesinMichigan.Thesecostswere
comparedwiththecostsofprovidingpreventionservicestoallfirsttime
parents.Thecomparisonyieldeda19to1advantagetopreventioni.e.forevery
dollarspentonprevention19dollarsweresaved.Consideringthecollateral
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44
damagethatabusedchildrenspreadaroundthem,thisisgoodvalue.
(https://www.msu.edu/user/bob/cost.html)TheChildren’sTrustFundin
Michigancontinuestotargetthepreventionofmaltreatmentas‘Researchshows
thatforevery$1spentonchildabuseandneglectprevention,$7willnotbe
spentonpublicly-funded,crisis-orientedprogrammingsuchasprotective
services,fostercare,specialeducation,andcounselingwiththeexceptionof
juveniledelinquencyoradultincarceration’
(http://www.michigan.gov/ctf/0,1607,7-196--232496--,00.html).
Karolyetal(1998)inalargestudybytheRandCorporationsummarisethecosts
benefitsofinvestinginearlychildhoodinterventionasfollows:-
• Programsthattargetchildrenandfamilieswhowillbenefitmostfromthe
servicesofferedhavethehighestchanceofrepayingtheircosts.
• Thelongerthefollow-upthemorelikelythatsavingsgeneratedbythe
programmewilloutweighthecosts.
• Manyoftheprogrammesalsoinfluencetheoutcomeforthemotherand
notonlythechild.
Generalinterventionassumptions:-
• Bettertotreatthefamilythanthechildalone.
• Earlierthebetter,interventionsininfancypreferredtotoddlerhoodetc.
• Higherintensityofinterventionbetter.
• Training,background,supervisionandpersonalityoftheservice
providingpersonnelmatters.
• Tailormadeinterventionspreferred.
Theexpenseofnotinterveningisinthedirectandindirectcostsofsuchlater
anti-socialbehaviour,suchasthoseassociatedwithconductdisorder.Ithasbeen
calculatedthatayoungadultwhoeventuallysufferssocialexclusiondueto
conductproblemwillcoststhecountrythreeandahalftimesmorethan
someonewithnoproblem;whileconductdisorderwillincurcostsoftentimes
higherthanhavingnoproblem(Scott,Knapp,HendersonandMaughan,2001).A
conservativeestimate(soitwillgrowyearonyear)isthatpreventingconduct
disordersinthosechildrenwhoaremostdisturbedwouldsavearound£150,000
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45
oflifetimecostsforeachindividual;andpromotingpositivementalhealthin
thosechildrenwithmoderatementalhealthwouldyieldlifetimecostbenefitsto
eachofabout£75,000(FriedliandParsonage,2007).Thisanalysisdidnottake
intoaccountthemonetaryimplicationsofthenegativeinfluencethesechildren
haveuponothers,suchasallthedisruptiontheycauseintheclassroomandthe
long-termeffectsoftheviolencetheymayinflictonother–notleastfuture
partnersandchildren.Takingtheabovefigures,thetotalvalueofthebenefitsof
preventioninaone-yearcohortofchildrenintheUKis£5.25billion,andthe
valueofpromotingpositivementalhealthcomesto£23.625billion(ibid,p.20).
Itisestimatedthatthecostoftreatingcommonmentalhealthproblemssuchas
anxiety,depressionandpersonalitydisorderswillincreasefrom£24.3billionto
£38.7billioninthenext20years.Thecostoftreatingchildandadolescent
mentalhealthproblemsisestimatedtodouble(McCrone,etal.2008).IntheUK
theoverallcostofmentalhealthproblemswas£115billionin2006/07.In2002
wefindthat20%ofthetotalburdenofdiseaseintheUKwasattributableto
mentalillness,comparedwith17.2%forcardiovasculardiseaseand15.5%for
cancer(Friedli&Parsonage,2007).Mentalillnesscontributessignificantlyto
crimesofviolence(Arseneault,etal.,2000).ArecentstudybytheNew
EconomicsFoundation(2009)forActionforChildren,‘BackingtheFuture’
showstheeconomicbenefitsofearlyintervention,clearlydifferentiatingthe
differentbenefitstosociety,withthelong-termsavingsbeingseveral
magnitudesgreaterthanthecostsofsettinguppreventativeservices.
Earlyinterventionisstillwellworththeeffortandallocationofresourcesevenif
theimmediatesuccessrateseemsrelativelylow.‘Tobeworthundertaking,the
interventionthusneedsasuccessrateofonlyonein25forconductdisorderand
onein55forconductproblems.Inotherwords,thepotentialbenefitsareso
largerelativetocoststhatinterventionisworthwhile,evenifitseffectivenessis
verylimited’(FriedliandParsonage,2007).Sinclair,writingforTheWork
Foundationandcomingfromabackgroundinpracticaleconomics,isclear.
‘Dysfunctionalparentingandchildrenatriskrepresentclassicmarketfailure.
Thisiswherethegovernmentwillgetthegreatestrateofreturnsformoney
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46
invested’(Sinclair,2007:54).Simplypreventingtheoccurrenceofearlychild
maltreatmentor,ifthathasbeenimpossible,offeringpromptandappropriate
treatmenthasalong-termbenefitthatisenormousintermsofservicesnot
calledupontointerveneinthechild’sfuture.‘Childmaltreatmentposessevere
risksforlong-termmaladjustmentandthedevelopmentofpsychopathology.
Childmaltreatmentexemplifiesapathogenicenvironmentthatisfarbeyondthe
rangeofwhatisnormativelyencounteredandengenderssubstantialriskfor
maladaptationacrossdiversedomainsofbiologicalandpsychological
development’(Cicchetti,RogoschandToth,2006:624).Ahostofresearchfrom
differentdisciplinesconvergestoshowhowtraumainthefirstfewyearsoflifeis
‘thefrequentcauseofphysicalandmentalillness,schoolunderachievementand
failure,substanceabuse,maltreatment,andcriminalbehavior’(Harris,
LiebermanandMarans,2007:393).
ThecomponentsofanEarlyInterventionservice.
Tworeviewsexaminewhatappearstobenecessaryforearlyintervention
servicesforhigh-riskparentsandbabiesiftheyaretomeetthemanydifferent
needsofthisgroup(ZerotoThree,1998,18(4);Shonkoff&Phillips,2000:360-
367).Theguidingprincipleofearlyinterventionisthatservicesneedtobe
carefullytailoredtotheirdifferentclientpopulations;thereisnosingleanswer.
Forinstance,findingsfromahomevisitingserviceforhigh-riskmothersand
babiesindicated‘thathigher-riskmothersbenefitedmorefromamentalhealth
curriculumthananeducationalcurriculumwhereaslower-riskmothers
benefitedmorefromtheeducationalcurriculumthanthementalhealth
curriculum’(Berlin,et.al.,1998:13).Thereisasecondandequallyimportant
principlethatisattheheartofpracticalservicedelivery.Anyintervention,
regardlessoftechniqueortheory,isonlyaseffectiveasthequalityofthe
relationshipsthatinfantmentalhealthpractitionerscanbuildupwiththe
familiestheybecomeinvolvedwith.‘Newrelationalexperiencesintherapyare
thecoreofthehealingprocess.Thepresenceofanauthentic,empathic,and
responsiveconnectionbetweenclientandtherapistcanfosterhealingandthe
subsequentdevelopmentofasenseofrelationalcompetencefortheclient,which
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47
entailstheabilitytobringaboutchange,andtheexperienceoffeelingeffectivein
connection.Inmother-infanttherapy,thissenseofefficacyistransposedtothe
mothermovingoutofisolationandintoamorereciprocalandsatisfying
relationshipwithherbaby’(Paris,SpielmanandBolton,2009:305).
Relationshipsandtheeffectofrelationshipsuponrelationshipsareagaincentral.
Anoverviewofearlyinterventionprogrammesargues‘thattheparent’s
relationshipwiththeintervenerservesastheengineoftherapeuticchange’
(Berlin,etal.,2008:747).Thusitisagiven(oftenignored)thatanyprogramme
thataimstoimprovetherelationshipbetweenparentandbabycanonlydeliver
ifitisembeddedwithina‘relationship-basedorganization’wherethequalityof
therelationshipswithintheteammatchthequalityoftherelationshipstheyaim
tofosterwithinthefamiliesbeingsupported.‘Thereisadefiniteparallel
betweentherelationshipsthatlinestaffformwithfamiliesandtheirchildren
andtherelationshipthatstaffformwithadministratorsandsupportstaffofthe
organization’(Bertacchi,1996:3).Twokeycomponentshereareexternal
consultationandfluidreflectivesupervisionforallstaff.‘Arelationship-based
organizationwillcometoacceptthatstaffareitsprizedpossession’(ibid:7).
Creatingandmaintainingarelationship-basedservicehasbecomeavery
difficulttaskwithinapublicsectordominatedbytargetswithamanagerial
culturebasedonsuchmistrustthateverymovemustbecontrolledbyapolicy
andmanagersbecomedemotedtomeremonitors.
Servicescanberoughlydividedbetweenthosethatarecentre-basedandthose
thataredeliveredinthehome.‘Center-basedservicesaremorelikelythan
home-basedprogramstotargetchildrendirectly–especiallyintermsoftheir
cognitiveandlanguagedevelopment’(Berlin,et.al.,1998:7).Whereas‘Home-
basedservices,whichvirtuallyalwaysincludethechild’sprinciplecaregiver,
maybeespeciallywell-suitedtoenhancingparents’well-beingandthechild-
parentrelationship’(ibid,p.6).Earlyinterventionservicesaremosteffective
whenthetwoapproachesareoneandthesamesothat,forinstance,the
Children’sCentrecanreferimmediatelytoamorespecialised,tierthree,infant
mentalhealthserviceforimmediatework;andatthesametimethecentrecan
takeupandsupportisolatedfamiliesreferredtotheinfantmentalhealthteam
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48
fromanothersource.Bothteamsarethenabletoworkinatotallyintegrated,
andminimallystigmatisingmannerthatcanlead,forexample,tomutuallyrun
therapeuticgroupssuchasMellowBabies(http://www.mellowparenting.org).
However,earlyinterventionhasalwaystobetailoredtothesettingandneedsof
thefamiliesinvolvedsothat,forinstance,successfulhelpcanequallybegivento
high-riskmothersandtheirbabieswithinaprison(Baradon,etal.,2008)orina
residentialsettingforsubstanceabusingmothersandtheirbabies(Pajulo,etal.
2012).Whateverthesetting,itisimportantthatservicesaretargeted
appropriately,theaimofeveryprovisionshouldbeclear.‘Foryoungchildren
wheredevelopmentmaybecompromisedbyanimpoverished,disorganized,or
abusiveenvironment…interventionsthataretailoredtospecificneedshave
beenshowntobemoreeffectiveinproducingdesiredchildandfamilyoutcomes
thanservicesthatprovidegenericadviceandsupport’(ShonkoffandPhillips,
2000:360).
Preventativeinterventionsalsoneedtobecarefullytailoredtomeettherapidly
progressiveorganisationofdevelopmentalcompetencies(andoccasional
incompetencies)associatedwithearlychilddevelopment,somethingthatcalls
forspecialistknowledge.‘Toeffectchangeinthecourseofpsychological
developmentandavertpsychopathologicaloutcomes,preventativeinterventions
informedbyanorganizationalperspectiveshouldfocusonpromoting
competenciesandreducingineffectiveresolutionofthestage-salient
developmentalissuesthatemergeatdifferentperiodsinontogenesis’(Cicchetti,
RogoschandToth,2006:623).Evidencealsosupportstheprinciplethat
proactiveprogrammes,thosethataretrulypreventative,beginningeitherpre-
natallyoratbirth,havethegreatestandmostsustainedeffect.‘Thereisastrong
indicationthatwhilegainsmadethroughproactiveinterventionsaresustained,
andevenincreased,overtimethosemadethroughreactiveinterventionstendto
fade’(MacLeodandNelson,2000:1141).Suchservicescanbeeitheruniversalor
targetedonanindividualbasis.Thispointsuptheimportanceofanintegrated
approachacrossallprofessionsconcernedwithbabies,sothatchildren’scentre,
midwives,obstetriciansandgeneralpractitionersallseethemselvesasavery
earlywarningsystem.Theearlierweintervenethebetter.Babiescan’twait.The
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bestresultsareattainedwithstrength-basedapproachesthatfocusonparental
empowermentandinvolvement.Thisishighlyskilledworkwhichdemandswell
skilled,welltrainedandwellpaidstaffwhohavethecompetenciesneededto
gaugewhenandhowtointervene;andthisincludestherecognitionthat
continuedprofessionaldevelopmentisessential,notaluxurythatcanbecutto
savemoney.‘Harnessingthepowerofrelationshipstoinfluencerelationships
andhoningcapacityforreflection-in-actionarefundamentaltohigh-quality
professionaldevelopmentforthoseservingveryyoungchildrenandtheir
families’(Seibal,2011:49).
TheUKSureStartinitiativehasevolvedintoanearlyinterventionthatcombines
centrebasedprovisionwithoutreachworkdeliveredtothesurrounding
community.AlthoughtheinitialevaluationofthemyriadofdifferentSureStart
schemeswasdisappointing,thishaschangedwithtime.Onereasonisthatthe
servicedeliveryisnowbasedinChildren’sCentresandthefirstwaveoffamilies
accessingtheseearlyinterventionshasbeenworkedthroughandnowhelpcan
beconsistentlyonofferfromconceptiontopre-schoolage.Children’sCentres
areperfectlyplacedtodeliver‘wraparound’servicesrangingfromspecialist
infantmentalhealthteamstothefullgamutofdifferentparentinggroups
available.Suchservicesbecomeacceptedsimplybyvirtueofbeingthere.Studies
comparingoutcomesforchildreninSecureStartareaswiththoselackingthis
inputhavefoundthattheformer‘showedbettersocialdevelopment,exhibiting
morepositivesocialbehaviourandgreaterindependence/selfregulationthan
theircounterpartsinnon-SureStartareas…Also,familiesinSureStartareas
reportedusingmorechildandfamily-relatedservicesthanfamiliesinnon-Sure
Startareas’(Melhuish,BelskyandBarnes,2010:160).
Evenifaninterventionseemstofitthebill,thereisnoguaranteeitwilldeliver
resultsunlesstheservicecreatedisappropriatelyfundedandstaffed.Therecan
bean‘implementationgap’setupby‘thediscrepancybetweentheintervention
thatprogramdesignersplanandtheinterventionthatfamiliesreceive’(Barnard,
1998:23).Thiscanleadtoalowerthanexpectedtake-upofservices.‘Theimpact
ofqualityhasbeenshowntobeparticularlyimportantforchildrenfromfamilies
.
50
whobeartheburdenofmultiplerisk-factors’(ShonkoffandPhillips,2000:362).
Everyonewantsthebestfortheirbaby,nobodysetsouttobea‘bad’parent,but
manyhavenochoiceaboutwhatisonofferandnobodyatallhashadachoice
abouthowtheywereparented.
Theintensityanddurationofanyinterventionareobviouslyimportant,butas
aspectsofqualitytheyarehardtomeasure.Fewresearchershaveaddressed
thesevariables,astherearefrequentlyethicalimplicationstoconducting
randomisedexperimentalstudiesonavulnerable,clinical,population.However,
therearesomesuggestivedata.IthasbeenfoundthatI.Q.scoresmeasuredat36
monthsincreasedwiththeamountoftimesachildattendedadaycentre,the
numberofhomevisitsandthefrequencywithwhichparentsattendedrelevant
meetings(Ramey,etal.,1992).Greaterinvolvementwithhelpingservices,
whetherinthehomeoracentre,wasalsoassociatedwithhigherratingsofthe
familyhomeenvironmentwhenthechildwasoneyearold,andhigherI.Q.scores
atagethree.Forproactivepreventativeinterventions‘whichmeasuredchild
maltreatmentasanoutcome;effectsizesincreasedasthelengthofthe
interventionincreased’(MacLeodandNelson,2000:1143).Motherswhoactively
participatedinthePrenatal/EarlyInfancyProjectfortwoyearswerelesslikely
toabusetheirchildrenthanthosemotherswhohadonlybeenengagedfornine
months.Andafifteenyearslaterfollow-upshowedaninverserelationbetween
theamountofservicereceivedandanumberofnegativematernaloutcomes,
includingchildmaltreatment,repeatpregnancy,welfaredependence,substance
abuseandbrusheswiththelaw(Olds,etal.,1997;Olds,2006).Twostudiesofa
homevisitingserviceforinfantsinfamilieslivinginpoverty,whereoneused
randomassignmenttosetupatreatmentandcontrolgroup,foundthatweekly
visitsresultedinhigherchilddevelopmenttestscoresthanfortnightlyvisits,
whichinturnobtainedhigherscoresthanmonthlyvisits(PowellandGrantham-
McGregor,1989).Theonlymeta-analysisofhomevisitingprogrammesthathas
beendoneconfirmstheobvious,thatefficiencyincreaseswithfrequencyof
visits.Ingeneralitisclearthatintensive‘homevisitingforlow-incomeorat-risk
familiesimprovesmaternalbehavior’(Nievar,VanEgerenandPollard,
2010:511).
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51
Itseemsatruismtostressthatqualityofserviceprovisionisentirelydependent
onthecalibreofthestaff.‘Earlyinterventionserviceproviderscarryout
intensiveandemotionallydemandingwork.Theirpersonalcharacteristics–
especiallytheirabilitytobeemotionallyavailableandempathic–andtheir
trainingandworkexperienceinfluencethewaysinwhichtheydeliverservices’
(Berlin,etal.,1998:8).Infantmentalhealthservicesdemandacoreofspecialised
knowledgeandskillscongruentwiththewiderangeofriskfactorsand
developmentalissuesthatneedtobeconsidered.Goodreflectivesupervisionis
essentialtoavoidtheriskofdefensiveavoidance,vicarioustraumatisation,
counter-transferencecollusionandburnout.Inmanywaysonlyadedicated,
specialised,well-functioningteamcanhopetomovebetweensuchmattersas
discordantattachmentrelationships,adultmentalhealthandsubstanceabuse,
andtheproblemsforceduponafamilybypoverty.‘Inthiscontext,theultimate
impactofanyinterventionisdependentuponbothstaffexpertiseandthequality
andcontinuityofthepersonalrelationshipestablishedbetweentheservice
providerandthefamilythatisbeingserved’(ShonkoffandPhillips,2000:365).
Differentapproachestoinfantmentalhealthinterventions.
Itappears,then,thatwell-plannedandwell-fundedservicesforbabiesand
parentsatriskcanredirectalikelydevelopmentalpathwayalonganew,
healthierdirection.‘Programsthatcombinechild-focussededucationalactivities
withexplicitattentiontoparent-childinteractionpatternsandrelationship
buildingappeartohavethegreatestimpacts’(ShonkoffandPhillips,2000:379).
Whereas‘servicesthataresupportedbymoremodestbudgetsandarebasedon
genericsupport,oftenwithoutacleardelineationofinterventionstrategies
matcheddirectlytomeasurableobjectives,appeartobelesseffectiveforfamilies
facingsignificantrisk’(ibid).Earlyinterventioncanhaveadifferingemphasison
twoapproaches:thefirstisprevention(targetingapopulation,orafamily,
identifiedbyriskfactoranalysis),andthesecondistreatment(workingwith
referredcaseswheresomethinghasalreadygoneamiss).Thisisarather
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52
artificialdivide,sinceinpracticebothgoalsarecompatiblewitheachother
withinasingleprogramme;e.g.workingwithfamiliesatriskwillinevitably
reveal‘hidden’disturbancesthatneedtobereferredontoamorespecialised
therapeuticservice.However,conceptualisingearlyinterventionservicesinthis
waydoesprovideaframeworkforexaminingtheresultsofprojectsthatwere
setupwithdifferentaimsandmethods.Whateverthemodeofintervention,
though,thereareunlikelytobetheclear,measurableandrapidresultsbeloved
bycommissionersandmanagers.Ittakestimetobuildarelationship,andifyour
backgroundhasgivenyouanassociationbetweencloseand‘caring’
relationshipsandmaltreatmenttheninterestandkindnesscanbeterrifying–
‘Wecannotinterruptcyclesofdisorganisedattachmentunlessweprovidea
havenofsafetyformothers’(SladeandSadler,2013:34).Thislastquoteleadsto
anobviouscaveat;thegreatermajority,ifnotall,theinterventionsmentioned
belowhavebeentargetedatmothers,andasawholeissueofZerotoThree(May
2015Vol.35,No.5)hasfocussedon,fathersareconspicuousbytheirabsence
whichhardlymatchesreality.
Preventativeserviceswillusuallybeeithercentre-orhome-based,justasmost
treatmentoptionsareeitherclinic-orhome-basedaswell.(Andmanyfamilies
willbeabletomakeuseofeithersitefordifferentservices.)Anexampleofa
centre-basedearlyintervention/preventativeserviceistheCarolina
AbecedarianProjectwherehigh-riskchildrenreceivedintensiveearlyeducation
fivedaysaweek,beginningatsixweeksandendingatfiveyears.Twogroupsof
similarbabieswereselected,allwithmotherswhohadeducationaldifficulties.
Thecontrolgroup,whoonlyreceivedfreemilkandnappies,wereall(except
one)eventuallyassessedasbeingretardedorofborderlineintelligence.Inthe
interventiongroupallthechildrentestedwithinthenormalrangeofintelligence
byagethree;byage15theyscoredsignificantlyhigheringeneralknowledge,
readingandmathematics,andonly24%(48%inthecontrolgroup)needed
specialeducationservices(CampbellandRamey,1994&1995).Furthermore,
(accordingtotheproject’swebsite,http://abc.fpg.unc.edu)whenthechildren
reached21yearsofage35%oftheinterventiongroupwereatcollege,compared
to14%inthecontrolgroup;and65%wereinemploymentcomparedto50%in
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53
theothergroup.ThechildrenwhosemothershadthelowestI.Q.appearedto
gainthemostfromthisintervention,andthosewhohadafollow-upprogramme
intoelementaryschoolbenefitedfurtherstill.Ananalysisthatcomparedthe
PerryPre-Schoolproject,mentionedearlier,withtheAbecedarianintervention
notesthatbothhavehas‘statisticallysignificanteffectsonthehealthybehavior
andhealthoftheirparticipants’(Conti,etal.,2015:29).
Anexceptiontothehomeorcentrequandarymightbeservicesforteenage
motherswhichcanbeestablishedwithinaschoolsettingwheretheadditional
provisionofgoodqualitychildcarewouldensurethattheyoungwomencould
finishtheireducationaswell.The‘ChancesforChildren’TeenParent-Infant
ProjectinNewYorkhassuccessfullyimplementedand,usingacontrolgroup,
evaluatedsuchaprogramme.Theyprovideindividual,dyadicandplaytherapies
alongwithparentinggroupsandsupportforthenurserystaff.Theyhavefound
thattheyoungmotherstheyhadworkedwithimprovedtheirinteractionswith
theirinfants‘intheareasofresponsiveness,affectiveavailability,and
directiveness.Inaddition,infantsinthetreatmentgroupwerefoundtoincrease
theirinterestinmother,respondmorepositivelytophysicalcontact,and
improvetheirgeneralemotionaltone,whichthecomparisoninfantsdidnot’
(Mayers,Hagar-BudnyandBuckner,2008:332).Thesamepositiveresultswere
foundinasubsetofyoungmotherswhoremaineddepressed,showingthateven
thenitisstillpossibletoimprovemother-infantinteractions.
Earlyinterventionwithhighrisk,veryvulnerable,familiesneedstobeamulti-
agencyconcern;andthebetterdifferentagenciesworktogetherthenthemore
long-lastingandpositivearetheresultsfortheinfantsinthesefamilies.Agood
example,whichhasbeenevaluatedanumberofdifferenttimes(includingfocus
groupswiththemothersinvolved),istheCanadianinitiativeforhelpingfamilies
wherethereismaternalsubstanceabuse.Thisiscalled‘BreakingtheCycle’
(BTC),andwaslaunchedbysevenpartnerorganisationsin1995.‘Positive
resultsoftheBTCapproachinclude(a)enhancedbirthandperinataloutcomes
forinfantsofsubstance-involvedmotherswhoareengagedearlierinpregnancy,
(b)enhanceddevelopmentaloutcomesofchildrenwhoareinvolved,(c)
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enhancedparentingconfidenceandcompetence,(d)enhancedtreatment
outcomes,and(e)decreasedratesofseparationofmothersandchildren’(Motz,
LeslieandDeMarchi,2007:20).Theinterventionfocusisonthemother-infant
relationshipandinvolvesarangeofdifferentprogrammesbasedonasingle-
accessmodelthatincludesstreetaccessandhomevisiting.
Mostgroup-basedparentingprogrammes(orclasses)willofnecessitybebased
inaChildren’sCentreofsomesort.TheMellowParenting,andespeciallyMellow
Babiesfortheunder-ones,approachisdesignedspecificallyforfamilieswhere
thereisarelationshipproblemwithasmallchild,andhasbeenparticularly
successfulinhelpingmothersandinfantsimprovethequalityoftheir
relationshipandinteractions,withmaternalmoodimprovementandpositive
feedbackfromparentswhoattendedwhencomparedwithawaitinglistcontrol
group(Puckering,2004;Puckeringetal.,2010).Itistheonlyprogramme
specificallydesignedforunderthreesandbasedcompletelyonattachment
theory.–ThereisevenaMellowBumps.Andthishasbeenshowntoincrease
pre-natalattachmentandreducefeelingsofisolationandstigmainvulnerable
women,allofwhoenjoyedtheexperience(BirtwellandPuckering,2013).The
greatermajorityofparentingskillsclassesaregearedto,andaremoreusefulfor,
thosewitholderchildren;anditcouldbearguedthatthereisaninherent
differenceofattitudeandoutlookbetweenagroupandaclass,withtheformer
beinglessintrinsicallyhumiliatingfortheparents.MellowParentingisan
intensiveandcontainingday-longgroupexperienceextendingovermanyweeks
thatengageswithahighriskgroupoffamilieswherechildprotectionissuesare
paramount,domesticviolenceispresent,wherethemotherhasconflictual
relationshipswithherfamilyoforigin,isexperiencingbehaviouralproblems
withherchildandmaybestrugglingwithpsychologicaldifficultiesofherown.
Thisprogrammehasconsistentlyengagedhard-to-reachfamiliesandhas
demonstratedpositivechangesinmother-childinteractions,children’s
behaviouralproblemsandtheirintellectualdevelopment.Apilotstudythat
appliedaslightlymodifiedversionofMellowParentingtoagroupofmothers
sufferingfrompost-nataldepressionhashadencouragingresults.Thedepressed
moodofthemotherschangedsignificantly,observedpositiveinteractions
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55
increasedandnegativereactionswentdown.‘TheMellowBabiesgroup
interventioncanimproveboththementalhealthofwomenwithpostnatal
depressionandtheirinteractionwiththeirbabies’(Puckering,2009:161).The
immediateadvantageofthisgroupapproachisthateachmotherwhoattends
immediatelyfeelslessisolatedandguiltythatshealonefindsparentinga
challenge.Inasimilarspiritedattachment-basedgroupinterventionsetupin
newYorkthatwasevaluatedindetail(butnoRCT,-strictlyspeakingonecould
regardanyRCTasunethicalifatreatmentthatisexpectedtohavepositive
effectsisdenied)theyfoundfoundpositivechangesinthemother-toddler
attachmentrelationshipalthoughithadlessimpactonthemother’soverallstate
ofmindregardingattachment(Steele,Murphy,andSteele,2010).
Another,perhapsmoretechnophile,groupapproachthathasbeenconsistently
abletoimprovethequalityoftherelationshipbetweenparentsandtheirsmall
childrenistheCircleofSecurityintervention,deliveredaspartofanEarlyHead
Startproject.Thismethodcarefullyreviewswithparentsthevideorecordingsof
theStrangeSituationproceduredonebyeachmemberwiththeirchildaspartof
thisgroup-basedprogramme.Oneaimofthisistoemphasisthesophisticated
capabilitiesofyoungchildrenandtodrawtheircaregiver’sattentiontothe
meaningofquitesubtleandsometimeshardtonoticebehaviours.Oneofthe
goalsofthismethodistoteachauser-friendlyversionofattachmenttheoryto
theparents,andthiscanbebaseduponwhatallhaveobservedinthereplaysof
theStrangeSituationprocedures.Thisclinicalservicehasbeenbasedfirmlyona
combinationofattachmentandobjectrelationstheory.‘Theunderlyingstructure
oftheCOSprotocolconsistsofprovidingasecurebasefromwhichcaregivers
canbothlearnabouttheattachmentneedsoftheirchildrenandexploretheir
owninternalobstaclestomeetingthoseneeds’(Cooper,etal.2005:146).Initial
outcomesappeartobepromising;andthisprogrammeiscurrentlyunder
evaluationinanumberofdifferentsites.Alongitudinalstudy(withoutacontrol
group)showedasignificantpositiveimpactontheattachment-caregiving
patternsofhigh-risktoddlers,pre-schoolersandtheirprimarycaregivers
(Hoffman,etal.,2006).AnAustralianclinicalstudyofthismethod,inthiscase
withanagerangeofonetosevenyears,showedsignificantimprovementsfor
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56
parentratingsofchildprotectivefactors,behaviouralconcerns,internalizingand
externalizingsymptomswithaconsistentfindingthatthosechildrenwhobegan
withthemostsevereproblemsshowedthebestimprovement(Huber,etal.,
2015a).Thesameinterventionalsoproducedanimprovementinparental
reflectivefunction,caregivingrepresentationandattachmentsecurityinthe
child,andtherewasasignificantdecreaseinchildrenassessedwith
disorganizedattachment(Huber,etal.,2015b).
Asacontrast,workingmorefromtheconceptofintersubjectivity,afiveweek
therapeuticmusicgroupinaresidentialsettingformotherswithseverepost-
nataldepressionandtheirbabiessignificantlyincreasedtheamountof
intersubjectivesharingbetweeneachmotherandherinfant,andbythefifth
sessionmothershadbecomemoreplayfulontheirowninitiative.‘(M)usicwas
usedasatooltocreatemomentsofrepairandvitality’(VanPuyvelde,etal.,
2014:230).DanielSterndescribedintersubjectivecontactasoccurringwhen:
‘Twopeopleseeandfeelroughlythesamementallandscapeforamomentat
least.’(Stern,2004:75)Hepointsoutthatthisisaprimarymotivationalforce
separatefromattachment,buttogethertheyformamutuallycontributing
system.‘Attachmentkeepspeopleclosesothatintersubjectivitycandevelopor
deepen,andintersubjectivitycreatesconditionsthatareconducivetoforming
attachments’(Stern,2004:102).Attachmentrelatedbehaviourisusuallyan
indicatorofanemergency;itkicksinwhenneededandshouldnotbeinevidence
formostofthetime;whereasintersubjectiveprocessesareoccurringwithinall
interpersonalcontactsandformthebasisofthejoyofparenthoodandthe
satisfactionofallrelationships.Thusinterventionsthatbuildupthe
intersubjectiveresonancebetweenmotherandinfant,suchasprovidedbythis
creative(andfun)useofmusic,createtheconditionswheresecureattachment
canflourish.Thisisalsotheaimofparent-infantpsychotherapy(Balbernie,
2007),asdescribedlater.
Awayfromacentreandintothehome,a20yearresearchprojectfollowingthe
outcomeoftheNurseHomeVisitationProgramisagoodexampleofa
preventativeinterventiontargetinganatriskpopulationinthecommunity.
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57
However,thefamilieschosenwereverylimited,andthehelpwasonlyofferedto
lowincomeunmarriedfirsttimemothers.TheNurseHomeVisitationProgram
involvedtworandomisedtrials(inElmira,NewYork,andMemphis,Tennessee),
plusoneotherwhichisstillinprogress(inDenver).Theinvestigators(Olds,et
al.,1999:44)haveconcludedthat:‘Theprogrambenefitstheneediestfamilies
(lowincomeunmarriedmothers)butprovideslittlebenefittothewider
population.Amonglow-incomeunmarriedwomen,theprogramhelpsreduce
ratesofchildhoodinjuriesandingestionsthatmaybeassociatedwithchild
abuseandneglect,andhelpsmothersdefersubsequentpregnanciesandmove
intotheworkforce.Long-termfollow-upoffamiliesinElmiraindicatesthat
nurse-visitedmotherswerelesslikelytoabuseorneglecttheirchildrenorto
haverapidsuccessivepregnancies.Havingfewerchildrenenabledwomentofind
work,becomeeconomicallyself-sufficient,andeventuallyavoidsubstanceabuse
andcriminalbehaviour.Thechildrenbenefitedtoo.Bythetimethechildren
were15yearsofage,comparedwiththecontrolgroup,theyhadfewerarrests
andconvictions,smokedanddrankless,andhadfewersexualpartners.’The
homevisitingbeganbeforebirthand‘Comparedwithcounterpartsrandomly
assignedtoreceivecomparisonservices,womenwhowerenurse-visited
experiencedgreaterinformalandformalsocialsupport,smokedfewer
cigarettes,hadbetterdiets,andexhibitedfewerkidneyinfectionsbytheendof
pregnancy’(p.45).Fouryearsaftertheirchildrenhadbeenbornthecostofthe
programmewaslessthanthesavingsthathadbeenmade.Thismanualised
intervention‘explicitlypromotedsensitive,responsive,andengagedcaregiving
intheearlyyearsofachild’slife’(p.48).Itwasfoundthatthebiggestobstacleto
benefitingfromtheservicewasthepresenceofdomesticviolence,with
treatmenteffectdiminishingasthelevelofviolenceincreased(Eckenrode,etal.,
2000).Thisstrength-basedprogrammeofinterventionhasbeenre-namedthe
Nurse-FamilyPartnershipandrolledoutintheU.K.whereitisalreadyshowing
positivegainsforsomevulnerablefamiliesstrugglingwithagamutofadverse
experiences(Rowe,2009).However,thisprogrammeonlyhasalongterm
impactonfemalechildren,whobyagenineteenhadfewerarrestsand
convictions;butintermsofhighschoolgraduation,economicproductivity,
numberofsexualpartners,useofbirthcontrol,ratesofpregnancyandchildbirth
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58
anduseofwelfareprogrammestherewerenooveralllong-termtreatment
effects(Eckenrode,etal.,2010).Butthisisexpectableifnoneoftheothersocial
andeconomicrisksandpressureswerealtered.
Asimilarbutmorerelationship-focussedhomevisitingmethodologythanFNP,
withalessnarrowremit,isTheGettingReadyInterventionwhichhasbeen
evaluatedindetailwithfamiliesenrolledintheEarlyHeadStartprogrammein
Americausingarandomisedcontrolstudy.Itwasfoundthat‘theGettingReady
interventionsoffersvalueaddedinthedimensionsofwarmthandsensitivity,
encouragementofautonomy,supportforlearning,andtheappropriatenessof
guidanceanddirectivesofferedbyparents’(Knoche,etal.,2012:453).Another
semi-structuredparentingprogrammeinterventiongroundedinattachment
theorydevelopedbyMaryDozier,AttachmentandBiobehavioralCatch-up,has
beensubjecttoRCTandshowntopromotesecurityofattachmentinhigh-risk
youngfosterchildren(Bernard,etal.,2012;Dozier,etal.,2008).Thisapproach
focusesonspecificparentingbehaviours:nurturance,followingthechild’slead
andreducingfrighteningcaregivingbehaviour.ApilotRCTaimedathelping
substanceabusingmotherswhowerealsoinresidentialtreatmentalsoshowed
thatthecomparativelyshortABCinterventionimprovedtheparentingqualityin
thehomeenvironment(Berlin,etal.,2014).AlaterRCThasdemonstratedthat
thisrelativelyshorttermintervention(tensessions)greatlyimprovesparental
sensitivityanddecreasesintrusiveness,withthegreaterrateofimprovement
beingquiteearlyoninthework(Yarger,etal.,2016).
Anotherhome-basedprogrammethatworkedwithhighriskadolescentand
non-adolescentmothersevaluatedresultsaftersixmonthsofteachingparenting
skillsandthebasicsofchilddevelopmentwhilealsomakingalinkwithlocal
communityresources(Culp,etal.1998).Itwasshownthatthesemothers
significantlyimprovedtheirknowledgeofthetaughtsubjectsandtheirempathic
responsiveness,alsotherewasmoreinvolvementwiththecommunityandhome
safetywasenhancedaswell.Thesameapproach(andcurriculum)wasapplied
againtoaninterventiongroupof204andacontrolgroupof150first-time
mothers(Culp,etal.,2004).Comparedtothecontrolgrouptheintervention
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59
mothersshowedthesamegainsasbefore,andalsodemonstratedabetter
understandingofnon-corporalpunishmentalongwithbehavioursthatwere
moreacceptingandrespectfuloftheirinfants.Againwithvulnerableadolescent
mothersapilotintervention(withacontrolgroup)inItalysensiblymixedthree
interventionstrategies:videofeedback,developmentalguidanceandparent-
infantcounselling.Thiswasevaluatedatthreeandsixmonths,andfromthestart
improvedthequalityofinteractionandplaybetweenmotherandinfant,withthe
formerbecominglesscontrolling.Boththemothersandthebabiesshoweda
bettercapacityformutualregulation,withanincreaseinmaternalsensitivity
andinfantcooperation(Crugnola,etal.,2016).
TheequivalentprofessionalsintheUKareHealthVisitors,whohavethe
enormousadvantageoverhomevisitorsinAmericaastheyareuniversal,
‘invisible’andnon-stigmatising.(Thishasunfortunatelychangedinrecentyears
astheprofessionhasbeenhijackedtobecomeabranchofchildprotection.)Itis
literallyvitalthatthisinvaluableserviceremainstakenforgranted.OnceHealth
Visitorschucksomeofthecheckliststheycanreturntobeingthemost
importantadultmentalhealthresourcewehave,theonlyproblembeingthatthe
resultsoftheirworktakeacoupleofdecadestoshowup.TheSolihullApproach
hasshownthatHealthVisitorswhoaretrainedinthisformofreflectivepractice
areabletoworkmoreeffectivelywithchildrenwithlesscomplexsleeping,
feeding,toiletingandbehaviouraldifficultiesandsopreventtheneedtorefer
themtoCAMHS(DouglasandGinty,2001).Healthvisitorsandotherstrainedin
thisapproachconsiderthatitimprovesperceptionandpractice;andforthe
familiesinvolvedthereisasignificantreductionintheseverityofpresenting
difficulties,areductioninparentalanxietyandimprovementsinchildbehaviour
(summarisedinDouglasandRheeston,2009).Itisalsoamethodologythat
appearstoimprovetheabilitytoidentifyandhelpresolveminorproblemsin
youngchildren(Milford,Kleve,LeaandGreenwood,2006).Astudybasedona
differentbutcompatibleapproachwherehighriskfamiliesstudyweregivenan
18monthprogrammeofweeklyhealthvisitorcontact,usingtheFamily
PartnershipModel(Davis,DayandBidmead,2002),suggeststhat‘thisintensive
home-visitingprogrammemayimproveparentinginvulnerablefamiliesand
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60
increaseidentificationofabuseandneglectininfancy’(Barlow,etal.,2007:232).
Thismodelstressestheinterpersonalskillsandpersonalcharacteristicsneeded
inordertoworkinarelationshipbasedwaywithvulnerablefamilies,since‘the
processofhelping,includingthedevelopmentoftheworkingrelationship,is
determinedbywhatboththehelperandparentsbringtotheinteraction’(Davis,
2009:69).
Abridgetoapurelytreatment-basedprogrammeisprovidedbythe
relationship-basedinterventionforveryhigh-riskmotherssetupinLosAngeles.
Thisinvolvedarandomisedtrialtocreateasimilarcomparisongroupwhowere
onlygivenpaediatricappointments.Thesewereallmotherswhoalmost
invariablywouldhavecometotheattentionofaninfantmentalhealthservice,
hadonebeenavailable.Theprojectworkerswereallmentalhealthprofessionals
withexperienceinchilddevelopmentandthefamilysystemsapproach.The
primarygoaloftheinterventionwas‘toofferthemothertheexperienceofa
stabletrustworthyrelationshipthatconveysunderstandingofhersituation,and
thatpromoteshersenseofself-efficacythroughavarietyofspecific
interventions’(Heinicke,etal.,1999:356).Whencomparedwiththecontrol
group‘Themothersbecamemoreresponsivetotheneedsoftheirinfantsand
moreeffectivelyencouragedtheirautonomyandtaskinvolvement.Moreover,
thechildrenintheinterventionasopposedtonon-interventiongroupwere
moresecure,autonomous,andtaskinvolvedonavarietyofindicesat12
months’(p.371).Thetwogroupswerecomparedagainwhenthechildrenwere
twoyearsold,bywhichtime‘themothersexperiencingtheintervention,in
comparisonwiththosethatdidnot,alsousedmoreappropriateformsofcontrol,
andtheirchildrenrespondedmorepositivelytothesecontrols.Motherswhodid
notexperiencethehelpoftheinterventionhadsignificantlymoredifficulty
controllingtheirchildifitwasaboyasopposedtoagirl.Theyusedtheleast
appropriatemethodsofcontrolandtheboysrespondedmorenegativelytothese
controls’(Heinicke,etal.,2001:458).
Asimilarclinical-typeinterventionwascarriedoutinHolland,thedifference
beingthattheriskfactorresidedintheinfant,notinthesurroundingfamily.The
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aimoftheprogrammewastohelpmotherswithinfantswhodemonstratedan
irritabletemperament,sincethereisevidencethatnegativeemotionalityin
babiesleadsontolaterbehaviouralproblems.Motherswerehelpedtorespond
moretobothpositiveandnegativeemotionsintheirchild,andatthesametime
encouragedtoshowlessintrusivebehaviouranddetachedlackofinvolvement.
Thequalityofattachmentbetweenparentandchildappearstobeenhancedby
theparent’sabilityandwillingnesstobesensitivelyresponsivetotheirchild.
Thiswasconfirmedbythefindingthat‘moretoddlerswhosemothers
participatedintheinterventionweresecurelyattachedthanthereweresecurely
attachedcontrolgroupdyads’(vandenBoom,1995:1809).Atagetwoyears,the
mothersintheinterventiongroupstilldemonstratedagreaterresponsiveness
andinvolvementwiththeirtoddlers.Andatthreeyearsbothparentsweremore
attunedtotheirchildthanthoseinthecontrolgroup.‘Interventionchildren
continuedtobemoresecureintheirrelationshipwiththeirmother,exhibited
lessbehaviourproblems,andwerebetterabletomaintainapositiverelationship
withthepeerthanthecontrolgroupchildren’(ibid,p.1811).Helpingparents
respondinamoresensitive,orthoughtful,waytotheirinfantspromotessecure
attachment.Amorerecentattachmentbasedinterventionthatalsotargeted
irritableinfantsinfamiliesstrugglingwithseveresocioeconomicstressisknown
asTheCircleofHomeHealthVisiting.Thethreeonehourhomevisitsaimedto
helpmothersbecomemoreawareoftheirinfants’attachmentbehavioursin
termsoftheiralternatingneedforproximityandthenexploration,andthegoal
wastoincreasematernalresponsivenessanddecreaseintrusiveness.Ina
randomisedcontrolstudytheinterventiongroupshowedsignificantgainsin
thesepositiveattributes(Cassidy,etal.2011).
Depressedmothersareanotherhigh-riskgroup,aswhentheconditionissevere
itwillinterferewiththeabilitytotuneintotheirbaby’ssignalsandprovidea
sensitiveandemotionallynurturingcaregivingenvironment.Post-natal
depressionislinkedtoanincreaseininsecureattachmentintoddlers,
behaviouraldisturbanceathome,lesscreativeplayandgreaterlevelsof
disturbedordisruptivebehaviouratprimaryschool,poorpeerrelationships,
andadecreaseinself-controlwithanincreaseinaggression(Cummingsand
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Davies,1994;Murray,1997;SinclairandMurray,1998;Murrayetal.,1999;
Zeanahetal.,1997).Directmassagewithdepressedmothershasbeenshownto
increasetheircapacitytorecogniseemotionalexpressions,includingnegative
ones,andbemoreaccurateinaffectivelanguagecommunication(Free,etal.,
1996).Althoughthiscouldbeexpectedtoimprovethequalityofattachment,this
wasnotmeasured.However,anotherstudythatcomparedtheeffectoftoddler-
parentpsychotherapybetweentwo,randomlyassigned,groupsofmotherswith
amajordepressivedisorderfoundthatattachmentwasimprovedbytheendof
treatment.Thetwogroupswerefurthercomparedwithanotherwherethe
mothershadnomentalhealthproblems.‘Toddlersofdepressedmotherswho
receivedTPPevidencedratesofsecureattachmentthatwerenodifferentfrom
thoseofthenon-depressedcontrolgroupfollowingtheconclusionofthis
intervention”’(Cicchetti,etal.,1999:58).Theseweremotherswitharelatively
highlevelofincome,educationandfamilysupportwhomaywellhavebeen:
‘betterabletoutilizeaninsight-orientedmodeoftherapythanwomen
confrontedwithamultitudeofdailylivingchallenges’(p.59).Theauthorsofthe
studygoontospeculatethat:‘asmothersbecomefreedfromthe‘ghostsfrom
theirpasts’theirinternalworkingmodelsbecamemorepositiveandtheywere
increasinglyabletofocusonthepresent,includingtheirrelationshipwiththeir
child.’AninterventioninBostonthatoffereddyadictherapywiththeexpress
aimofengagingthemothertoworkwithherdepressionwhileatthesametime
neverloosingsightofboththerelationshipandtheinteractionsbetweenmother
andinfantshowedpromisingresults.Thisdemonstratedimprovementsinthe
mothers’perceptionofparentingwithselfesteemgoingupandparentingstress
goingdown,whichinturnwereassociatedwithbettermother-childinteractions.
Themothers’depressiondistressalsolessened,althoughthisbyitselfdidnot
leadtoanimprovementinparentinginteractions(Paris,BoltonandSpielman,
2011).Interventiontohelpimprovetherelationshipbetweenadepressed
motherandhersmallchilddoesnothavetobecomplicatedorhightec.Ameta-
analysisofapproachesrevealedthat‘Themosteffectiveandrobusttechniqueto
improvematernalsensitivity…wastheuseofbabymassage’(Kersten-Alvarez,et
al.,2011:372);andthisstudy,whichhadstrictinclusioncriteria,infactfoundno
evidencethatindividualinterpersonaltherapyfordepressedmothershadany
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effectonsensitivity.However,theevidencesuggeststhatbabymassagehasthe
mosteffectwhenappliedtomediumriskmothers,thereislittleornopositive
resultsforloworhighriskfamilies(Underdown,etal.,2013).
Asacontrast,anotherapproachtoinfantmentalhealthinterventionisprovided
byInteractionGuidance,whichdoesnotrelyoninsighttobringaboutchangein
theparent-babyrelationship.Thistechniqueusesvideofeedbackinorderto
encouragepositiveaspectsofcaregiver-infantinteraction,helpingparents‘in
gainingenjoymentfromtheirchildandindevelopinganunderstandingoftheir
child’sbehaviouranddevelopmentthroughinteractiveplayexperience’
(McDonough,1993:414).Thisformoftreatmentwasspecificallytailoredto
reachfamiliesover-burdenedwithmultiplerisks,andprobablyexemplifiesthe
strength-basedphilosophyintrinsictoallinfantmentalhealththerapymore
thananyotherapproach(McDonough,2004).Itdoesnotexplicitlyfocuson
exploringthecaregiver’sinternalrepresentationalworldoffeelingsand
memories,althoughsuchmaterialwillbeaddressedifitarisesduringthecourse
ofwork.‘Thisnonintrusivemethodoffamilytreatmenthasproventobe
especiallysuccessfulforinfantswithfailuretothrive,regulationdisorders,and
organicproblems.Parentswhoareeitherresistanttoparticipatinginother
formsofpsychotherapy,oryoung,inexperienced,orcognitivelylimited,respond
positivelytothistreatmentapproach’(McDonough,1993:414).Interaction
Guidancehasalsobeensuccessfullyusedtoimprovesensitivityanddecreasethe
amountofdisruptedcommunicationbetweenmothersandbabieswithfeeding
problems(Benoitetal.,2001);andaslightlymodifiedversionhasbeenshownto
helpmotherswithpostnataldepressionre-connectwiththeirbabies(Vikand
Braten,2009).Thistechniquehasbeenshowntobringaboutfairlyrapid
positivechangesindisruptivecaregivingbehaviour,andthiswasmeasurable
afterthefirstsession(Madigan,Hawkins,GoldbergandBenoit,2006).Video
feedbackofmothersandinfantsusingasplitscreentechnique,sothatbothfaces
canbeviewedsimultaneouslywhiletheyplaytogether,hasalsobeenshownto
beeffectiveinabrieftreatmentinterventionthatcombinesapsychoanalytic
approachwithanin-depthanalysisofimmediateinteractions(Beebe,2003).
Microanalysisoftherecordedinter-communicationwithintheexcerptofplay
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64
revealspatternsofaffectregulationthatcaninformapsychodynamicweaving
togetherofthepresentingdifficulties,theobservedbehaviourofthedyadand
theparent’sownearlyhistory.
ThetechniqueofInteractionGuidance,withitsuseofvideorecordingsto
emphasiseresponsive,positiveandpleasurablemother-infantinteractions,can
beeitherclinic-orhome-based;anditissometimesusedinconjunctionwith,
ratherthanasanalternativeto,morepsychodynamicmethodsoftreatment.The
advantagesofusingvideoaremanifold,allrevolvingaroundthewayinwhich
carefullylookingatafilmedpieceifinteractioncanallowselfreflectionwhilethe
actionis‘cold’,whichinturncanpromoteinsightintowhatisgoingoninthis
particularcaregivingrelationship.Thecarefuluseofvideofeedback‘servesto
activatepowerfulfeelings,basedonearlyattachmentrepresentations,inthe
therapeuticsessionswheretheparentcanbehelpedtobecomeawareofthese
thoughtsandfeelingsthatunderlietheirbehaviorwiththeirchildren,thereby
openingupnewwaysofbeingwiththeirchildren’(Steele,etal.,2014:407).Ifthe
programmeproviderusesastructuredmeansofanalysingthevideoclipthen
thisgivesawaytobothidentifyspecificstrengthsandskillstobeworkedon
whileatthesametimeallowingtheservicetoquantifyandcompareinorderto
collectthedatathatcaninformtheintervention.Aparticularlyusefulmethodfor
analysingfilmedplayisprovidedbytheKeystoInteractiveParentingScale
whichaddstoanyvideo-basedtreatmentbythewayitisabletostandardiseand
codedifferentaspectsofparentingbehaviourwhichinturncanpinpoint,track
andevaluatetheintervention.InaoneyearstudyinKentuckywhereKIPSwas
usedtotrackprogressandparentingoutcomesit‘detectedsignificantchangesin
parentingforagroupoffirst-time,at-riskparents.Theparents’scoresonthe
qualityofparentingstartedatalow-qualitylevelbutroseasparents
participatedinfamilyservices’(Comfort,etal.,2010:37).
Ameta-analysisofearly,attachment-based,interventionssuggeststhat
disorganisedattachmentismostsuccessfullyaddressedbyusingsensitivity-
focussedfeedback(Bakermans-Kranenburg,vanIjzendoornandJuffer,2005).
Attachment-basedvideofeedbackwastheinterventionofchoiceinastudythat
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usedarandomisedcontrolgroupandtargetedhigh-riskfamiliesinorderto
preventexternalisingproblemsinpre-schoolchildren.Thechildrenwereaged7
to10monthswhenthetreatmenttookplace,andvideowasused,intheirwords,
topromotepositiveparenting.Thereweretwopost-interventiontestsatone
monthafter,andthenatage40months;andcomparedwiththecontrolgroup
thoseinthetrialhadlesspreschoolclinicalexternalisingandtotalbehavioural
problems(Velderman,etal.,2006).Theevidence-basedclinicalworkofthis
groupalongwithitsbackgroundinresearch(atLeidenUniversity)hasledtoa
successfulprogrammetoenhanceparentalsensitivitycalledVideo-Feedback
InterventiontoPromotePositiveParenting,orVIPP(Juffer,Bakermans-
KranenburgandvanIJzendoorn,2007).Thisstrategyisafocussedandrelatively
short-terminterventionwithanumberofslightvariations,andithasbeen
appliedtoadoptedinfantsaswellasbabiesofmotherswithaneatingdisorder
andmotherscopingwithababysufferingfromskindisorders.Ithasbeen
showntobeeffectivewhenworkingwithmultiplydisadvantagedfamilieswhere,
comparedtoamatchedcontrolgroup,itimprovedmaternalnon-intrusiveness,
childresponsivenessandinvolvementalthoughithadlittleimpactonmaternal
sensitivity(Negrao,etal.,2014).AninterventionbasedonVIPPhasbeenshown
tobeeffectiveinreducingmothers’useofharshdisciplinemostlywhenthe
mothersarehighlystressed(Pereira,etal.,2014).Ithasbeeneffectivein
enhancingsensitivityandinfantattachmentinfirsttimemotherswhohad
insecureattachmentthemselves(Cassibba,etal.,2015).Thisstrategyhasbeen
subjecttomoreRCTsthanyoucanshakeastickat.However,althoughVIPP
generally(butnotalways)promotesanincreaseinmaternalsensitivitythiscan
sometimeshavenoeffectatalloninfantsecurity(Kalinauskiene,etal.,2009),so
intermsofinfantmentalhealthinterventionthistechniqueprobablyneedstobe
alwayscombinedwithsomethingelsesuchasparent-infantpsychotherapy.‘The
successofvideo-feedbackinterventionsintargetingparentalbehaviorandofPIP
inchangingmaternalmoodandrepresentationsofthechildsuggeststhata
mixedmethodmaybemoreeffectiveinaddressingbehavioraland
representationallevelsintandem’(Fonagy,etal.,2016:109).Intherealworld,
awayfromprojectspoweredbyresearch,itisunlikelythatrelyingonasingle
mechanismofchangewillproducepositiveresults;perhapsbecausefidelityto
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theprocessisbeingplacedabovethetherapeuticrelationship.AsDanielStern
emphasises,inclinicalworkdifferent‘portsofentry’areneededtohelpafamily,
andwhicheverpartofthesystemisworkedwiththerestwillchangeaswell
(Stern,1995).
Videofeedback,incombinationwithinfant-parentpsychotherapy,hasalsobeen
usedsuccessfullytotreatmotherssufferingfromPTSDfollowingahistoryof
violence-relatedtrauma(Schechter,2004;Schechter,etal.,2006).Itwasfound
thatthebaby’sfelt-to-be-intolerabledistress,orcurrentdomesticviolence,
wouldtriggerpasttraumaticmemoriesforthemother,whichthenbecame
confusedwithhercurrentperceptionofthechild.Thisintervention,overonly
threevisits,wasabletosignificantlyreducethedegreeofnegativityandof
distortionofmaternalattributions.Anothershort-termattachment-based
interventionsetouttotargetmaltreatingfamilieswithchildrenbetweenthe
agesofoneandfiveyearsold.ThisinvolvedaRCTbasedonrandomassignment
toeitheratreatmentorcontrolgroup.Theytoousedusingvideofeedbackalong
withfocusseddiscussionaroundattachmentandemotionalregulationwithin
eighthomevisitsofaboutanhourandahalfeach.Comparisonsbetweenpre-
andpost-testscoresrevealedsignificantimprovementsintheinterventiongroup
inparentalsensitivityandchildattachmentsecurity,alongwithareductionin
children’sdisorganizedattachment.Theolderchildreninthetreatmentgroup
alsoshowedlowerlevelsofbothexternalizingandinternalizingbehaviour
(Moss,etal.,2011;Mossetal.,2014).
Anexampleofhowdifferentstrategiesandmethodscanbeappliedisachild-
guidanceclinicinStockholmthatusesbothInteractionGuidanceandinfant-
parentpsychotherapytohelpmothersandbabies,withtheadditionalprovision
ofthreelonggroupsessionseachweek.Theyhavecarriedoutanin-depth
follow-upevaluationoftheirwork.Outoftenrandomlychosenmother-infant
pairsthatwerelookedatonlyonehadnotmadeconsiderableprogressduring
treatment(KarlssonandSkagerberg,1999).Acombinationofintervention
methodsappearedtoachievethemostgains.Similarly,intheU.KtheSunderland
Project,whereHealthVisitorsweretrainedintheuseofPatriciaCrittenden’s
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CareIndexandhowtoapplythistobriefvideorecordingsofmother-babyplay,a
multi-disciplinarymixedinterventionstrategyhasclearlybeenshowntoachieve
measurableimprovementsinahigh-riskpopulation.Svanberg(2005)concludes
that‘Theprocessofvideo-feedbackandthesupportofthehealthvisitor,whoin
his/herturnwassupportedandsupervisebytheparent-infantpsychologists,
enabledtheseparentstoincreasetheirownsensitivitysufficientlytosupport
theirchild’sdevelopmenttowardsasecureattachmentandamoreresilient
future.’Thisapproachroughlydoubledtheproportionofsecureattachmentin
theinterventiongroupwherethemothers’sensitivityandtheinfants’
cooperativenessincreasedsignificantlycomparedwithacontrolgroupreceiving
routinecare(summarisedinSvanberg,2009;alsoSvanberg,etal.2010).
Unfortunately,inspiteofthefactthatacarefulevaluationoftheSunderland
InfantProgrammehasdemonstratedclearandconsiderablelong-termsavingsto
healthandsocialservices(morethanthecosts),ithasbeencloseddown.
AresearchprojectinGenevahascomparedtheresultsachievedbybriefinsight
oriented,infant-parentpsychotherapywiththoseattainedbythemore
behaviouristmethodofvideofeedbackusingInteractionGuidance.Inthe
process,bothformsofinterventionweredemonstratedtobringabout
appreciable,positive,changesinthemother-infantrelationship.Sincethestudy
wascarriedoutonfamilieswhohadbeenreferredtoachildguidanceclinicit
wasfelttobeunethicaltohaveacontrolgroup,althoughcomparisonscouldbe
madewithanon-clinicalbutotherwisematchedsample.Theresultsofboth
formsoftreatmentwereevaluated,and‘markedsymptomreliefwasobservedin
severalareas,withthegreatestimprovementsinsleeping,feedinganddigestion
(i.e.symptomsaffectingphysiologicalfunctions)’(Robert-Tissot,etal.,
1996:105).Ingeneral,mothersbecamelessintrusiveandinfantsmoreco-
operative,withmaternalsensitivitytothebaby’ssignalsincreasingafter
treatment.‘Theresultsofthestudyindicatethatbriefmother-infant
psychotherapieswereeffectiveintreatingcasesconsultingforearlyfunctional
disorders’(p.108).Theonlydifferencesbetweenthetwoapproacheswerethat
InteractionGuidancebroughtaboutmorechangeinmothers’sensitivity,while
psychodynamictherapyhadagreaterimpactonmaternalself-esteem.
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ItcouldbearguedthatthetwodifferentapproachesofInteractionGuidanceand
infant-parentpsychotherapywereinfactidenticalintaskwhilebeingdifferent
inmethod,andeachimprovedreflectivefunction,aparentalcapacitythat
promotesandfuseswithsecureattachment.‘Secureattachmentandreflective
functionareoverlappingconstructs,andthevulnerabilityassociatedwith
insecureattachmentliesprimarilyinthechild’sdiffidenceinconceivingofthe
worldintermsofpsychicratherthanphysicalreality’(Fonagy,Gergely,Jurist
andTarget,2002:351).Toalargeextenttheparent’scapacityforreflectingon
theirownsignificantrelationshipsandthefactthatmentalstatesliebehindall
behaviour(aswellastheabilitytopresenttheseinacoherentnarrative-asin
theAdultAttachmentInterview),isasignifierforthelevelofsecurityof
attachmentthattheirchildrenhavewiththem.Asummaryofresearchreaches
theconclusionthat‘thecapacitytomentalizeintheattachmentrelationshipis
partandparcelofsecureattachment’(Allen,FonagyandBateman,2008:101).It
hasbeenfoundthatmotherscomingfromabackgroundofmaltreatmentyet
whohaveachievedgoodreflectivefunctiongenerallyhavesecurechildren,
whichmaystemfromtheir‘abilitytofilternegativebehavioursanddevelopand
promoterelationshipsthatfosterattachmentsecurityandorganization(Ensink,
etal.,2016:16).Thismaywellbeaskillthancanbedevelopedandhonedinthe
holdingenvironmentofinfant-parentpsychotherapy.
Bothparent-infantpsychotherapyandallthedifferentbrandsofvideofeedback
aredifferentportsofentryintotheparent’sinternal(unconscious)
representationsoftheirinfant,providingtheopportunitytofreeupandimprove
theobservationalskillsandempathythatareusuallysotakenforgrantedasto
gounnoticed.‘Acaretakerwithapredispositiontoseerelationshipsintermsof
mentalcontentpermitsthenormalgrowthoftheinfant’smentalfunction.Hisor
hermentalstateanticipatedandactedon,theinfantwillbesecurein
attachment’(Fonagy,Steele,Steele,MoranandHiggitt,1991:214).Again,thisis
anexampleofhowapositiveintersubjectiveoverlapleadstopositivechildsocial
andemotionaldevelopment.Researchhasdemonstratedthat‘negativematernal
caregivingbehaviourisinverselycorrelatedwithmaternalreflectivefunctioning’
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(Grienenberger,KellyandSlade,2005:304).Againinreflectivefunctionmaylie
behindallsuccessfulinterventionsthataimtoimprovethesensitive
responsivenessthatisseentobethebasisofsecureattachment.Ameta-analysis
ofteninterventionstargetingmaternalreflectivefunctionandsensitivitywith
theaimofimprovingthequalityofinfantattachmentfoundthat‘comparedto
infantswhodidnotreceivetheattachmentintervention,infantswhoreceived
theinterventionwerenearlythreetimesaslikelytobesecurelyattached’
(Letourneau,etal.,2015:383),andwhenthelowestqualitytrialwasfactoredout
thiseffectsizeincreasedevenmore.Interventionsthatfocussedonboth
reflectivefunctionandsensitivityproducedthemostbeneficialeffect;and
programmestargetingthemosthigh-riskpopulationshowedthemostbenefit–
‘effectsweregreatestformaltreatedandhighlyirritablechildren’(ibid).
Ithasbeendemonstratedthat‘maternalreflectivefunction,measuredat10
months,islikewiselinkedtoinfantattachmentsecuritymeasuredat14months
usingtheStrangeSituation’(Slade,etal.2005:293).Aninterventioncalled
‘MotheringfromtheInsideOut’basedonthisaspectofattachmenttheoryhas
beenshowntotoimproveparentinginsubstanceabusingmothersand,in
anotherpilotstudy,mothersreceivingtreatmentinanoutpatientmentalhealth
treatmentclinic.Thefocuswasonimprovingthesehigh-riskmothers’capacity
forreflectivefunctioningintheirparentingrole.Therewasarandomisedcontrol
groupreceivingparentingclasses.Itwasfoundthatatpost-treatmentthe
mothersdemonstratedimprovementsinreflectivefunctioning,sensitivityand
parentingbehaviour(Suchman,etal.,2010;Suchman,2016,Suchman,etal.,
2016).Thetherapeutictargethereisthemother’scapacityforemotional
regulationandmentalization,specificallymodulatingnegativeaffectduring
stressfulparentingsituations;andtheprogrammeisdeliveredinacommunity
setting.Anotherstudyexaminingreflectivity,mind-mindednessandbehaviourin
parentsconcludedthat‘directingattentiontowardssupportingthemother’s
capacitytoeffectivelymentalizeislikelytoholdpositiveconsequencesforboth
hermentalexperiencesofthechildandtherelationshipaswellasforher
parentingbehaviourduringinteraction’(Rosenblum,McDonough,Sameroffand
Muzic,2008:374).Aresearchprojectshowedthatmothersofpre-school
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childrenwithbehaviouralandemotionaldifficultieswhoparticipatedina
clinicalinterventionthatincreasedtheirinsightfulnesshadchildrenwhose
problemsdecreased;whereasmotherswhodidnotgainfromthishadchildren
whosebehaviourproblemsincreased(Oppenheim,GoldsmithandKoren-Karie,
2004).
AserviceforvulnerablefamiliesinNewHaven,Connecticut,isbasedonthe
principleofenhancingreflectivefunctioning.Thisisaweeklyhome-visiting
interventioncalledtheMindingtheBabyProgram,andisfocussedonthe
mother-infantrelationshipwiththerelationshipthemothercanslowlyform
withtheworkersbeingthevehicleofchange,recognisingthatinmanyinstances
highriskparents‘mayrebufftheclinicians,forgetappointments,leavehomejust
beforecliniciansareduetoarrive,ordropoutofsightforweeksatatime
(requiringcreativeandpersistenttracking)’(SladeandSadler,2013:34).
(Incidentally,thisdescriptionoftheclientgroupclearlydemonstrateshowinfant
mentalhealthservicesneedtobesitedoutsideofCAMHSwiththelatter’s
philosophyofdefensivegatekeeping,facilequickfixesandquickerthroughputto
massagetargetstatistics.)MindingtheBabyisadynamichybridoftheNurse
FamilyPartnershipandinfant-parentpsychotherapy,basedontheideathat‘an
approachthatwouldencouragemotherstotakenoteofthebaby’sexperiencein
arangeofwayswoulddiminishthelikelihoodofherrespondinginafrightening
orfrightenedwayandpotentiallymaltreatingherchild’(Sadler,etal,2013:393).
Thisformofearlypreventativeinterventioniscurrentlybeingintroducedtothe
UKundertheauspicesoftheNSPCC(Phillips,2013).Apreliminaryevaluation
(Slade,SadlerandMayes,2005)indicatesamarkedgaininmaternalreflective
functioninrelationtothespectrumoftheirchild’sdevelopmentaldomains,and
(usingtheStrangeSituation)nochildrenwithdisorganisedattachment.Forthe
mothers,thetrendwastowardslowerlevelsofdepressionandpost-traumatic
stresssymptomsalongwithhigherlevelsofself-efficacy.AlaterRCTwith
randomassignmentofpre-natalcaregroupsshowed‘amovetowardless
disruptedinteractionsat4months,higherratesofsecureattachmentandlower
ratesofdisorganizedattachmentat12months,andastrongtrendtowardlower
ratesofchildprotectionservicereferralsat24months…(Themothers)alsoare
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attendingtotheirchildren’spediatrichealthvisitsanddelayingsubsequent
childbearing…’(Sadler,etal.,2013:401).
Inpsychodynamicinfant-parentpsychotherapythe‘patient’istherelationship
betweenbabyandcaregiver.Child-parentpsychotherapyhasbeenshowntobe
effectiveinhigh-riskfamilysituationswherethereispresentmaternal
depression,poverty,domesticviolence,motherswithatraumaticchildhoodand
childrenalreadyknowntohavesufferedmaltreatment(Cicchetiietal.1999,
2000,2006;Lieberman,etal.1991,2005,2009).Thisapproachdoesnotsee
currentdifficultiesintheparentchildrelationshipasstemmingjustfromalack
ofparentingskillsorknowledge;rathertheparent’sproblemsinrelating
sensitivelytotheirinfantarelargelycausedbytheconflictualnatureofthe
parent’sinternal,unconscious,representationalmodelsstemmingfromtheir
ownexperiencesinchildhood–theghostsinthenursery.Itistobeexpected
thatthisapproachwoulddirectlyaffectmaternalself-esteem,sinceemotional
difficultiesfrompastrelationshipsareaddressedwithinthecontextofanew
relationshipthatissecureenoughtobothwithstandandencourageexploration.
‘Thequalityoftherelationshipbetweentherapistandparentisperhapsthe
morecrucialininfant-parentpsychotherapythaninanyotherformoftreatment,
becauseitisintendedtobeamutativefactorintheparent’srelationshipwithhis
orherchild’(Lieberman&Pawl,1993:430).
Inastudydesignedtoevaluatetheeffectivenessofinfant-parentpsychotherapy,
whichcomparedaninterventiongroupofmothersandinfantswithasimilar
controlgroup,itwasfoundthat‘Motherswhoformedastrongpositive
relationshipwiththeintervenertendedtobemoreempathictotheirinfantsat
outcome,andtheirchildreninturntendedtoshowlessavoidanceonreunion’
(LiebermanandPaul,1993:434).However,themostimportanttreatment
variableturnedouttobethemother’sability‘touseinfant-parent
psychotherapytoexploreherfeelingstowardsherselfandtowardherchild’
(ibid).Thetworandomlyassignedgroupsofmother-infantdyadswherethe
childhadbeenassessedasdemonstratinginsecureattachmentwerefurther
comparedwithasecondcontrolgroupofsecurelyattachedinfantsandtheir
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mothersinordertoexamineoutcomes.Evaluationtookplacewhenthechildwas
twoyearsold,afteroneyearoftreatment.‘Theinterventiongroupperformed
significantlybetterthantheanxiouscontrolsintheoutcomemeasuresandwas
essentiallyindistinguishablefromthecontrolgroup’(p.440).Thosemothers
whobecamemostengagedinthetherapeuticprocessbecamemoreactively
attunedtotheirchildren,whointurn‘showedlessangerandavoidance,more
securityofattachment,andmorereciprocalpartnershipinthenegotiationof
mother-childconflict’(p.441).Again,itisrelationshipsthatchange
relationships.Thisinterventionevolvedintoaninterventionforthreetofive
yearoldstraumatisedbydomesticabuse;andinarandomisedclinicaltrialthese
children‘improvedsignificantlymorethanchildrenreceivingcasemanagement
plustreatmentasusualinthecommunity,bothindecreasedtotalbehavioural
problemsanddecreasedPTSDsymptoms’(Lieberman,VanHornandIppen,
2005:1246).These‘improvementsinchildren’sbehaviorproblemsandmaternal
symptomsastheresultoftreatmentwithchildparentpsychotherapycontinue
tobeevident6monthsaftertheterminationoftreatmentwhencomparedtothe
controlgroup’(Lieberman,IppenandVanHorn,2006:916).Themethodologyof
thisapproachhasbeencoveredindetail(LiebermanandVanHorn,2008;
Lieberman,IppenandVanHorn,2016),andithasbeensuccessfullyappliedto
situationsofdomesticviolenceintheperinatalperiod(Lieberman,DiazandVan
Horn,2009).Agoodprécisofallstudiesprovingtheefficacyofthisformofchild-
parentpsychotherapycanbefoundonpages49to54inLieberman,Ippenand
VanHorn,2016.CurrentlyaRCTisinplacetoseetheresultsofapplyingthis
approachintheperinatalperiod.
Inanotherwell-controlledstudy,oneyearoldinfantsandtheirmaltreating
familieswererandomlyassignedtoeitherastandardcommunitycontrolgroup,
anotherthatreceivedapsycho-educationalparentingintervention(Nurse
FamilyPartnership)or,thirdly,infant-parentpsychotherapy;andinaddition
therewasamatchednormativesampleofnon-maltreatingfamilies.Atpost-
interventionfollowupatage26monthschildreninthetwotreatmentgroups
demonstratedsubstantialincreasesinsecureattachment,whilethiswasnot
foundinthetwocontrolgroups(Cicchetti,RogoschandToth,2006),withthe
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lowestrateofdisorganizedattachmentintheinfant-parentpsychotherapy
group.Usingavariantofparentinfantpsychotherapywhichfocusesonthe
analyst’sabilityto‘contain’theinfant’sdistressbyinteractingand
communicatingwiththeinfantduringthesessionarandomisedcontroltrialin
Stockholmshowedthatthisformoftreatmentimprovedmotherinfant
relationships,aswellasmaternalsensitivityanddepression(Salomonssonand
Sandell,2011).Whenthesechildrenwerefollowedupatagefourandahalf,and
comparedtothecontrolgroup,theywerefoundtoshowbetterresultsonglobal
functioningandtobelesstroubled(Salomonsson,etal.,2015a).Theirmothers
appearedtohavebeenhelpedwithasenseofpersonalwellbeing,tobecome
moresensitivetotheirbaby’ssufferingandtobettersupportandappreciate
theirchildrenthroughoutinfancyandtoddlerhood(Salomonsson,etal,2015b).
However,infantparentpsychotherapyisnotasstandardisedandstructuredas
someofthemoretechniqueorinstructionalorientedapproachesusedwith
vulnerablefamilies.Thismakesthecontrolledandmanualiseddeliveryof
treatmentthatiscalledforinaRCTmoredifficulttodeliver.Inthereal
therapeuticsituationcliniciansmixandmatchinresponsetotheneedsofboth
caregiverandinfant;andalsointherealworlditisacceptedthatthevehicleof
changeistherelationshipbetweentherapistandthemother-babycouple,hard
toreducetoasetformula.‘Wethinklessofwhatgoesonintrapsychically,and
moreaboutwhatgoesoninterpersonallyandintersubjectively…Thesubject
matteroftherapeuticinterestnolongerresideswithinthepatient-client’smind
norwithinthehomevisitor-therapist’smindbutratherintheproductsoftheir
interaction…Thelargelyunpredictableproductsoftheirinteractionbecomethe
subjectmatterthatbringsaboutchange…Theprocessofinterrelating,itself,
bringsaboutchange.Itbringsaboutnewexperiences,feelings,insights,and
interactionalskills’(Stern,2006:3).Thedynamicsofinfantparent
psychotherapyhavetoincludebeingopenandquickwittedenoughtoplucka
‘momentofmeeting’(TheBostonChangeProcessStudyGroup,2010)outof
chaos.Thismeanstrustingone’sownunconsciousandbeingpreparedto
abandontechniquewhennecessary,somethingmanymightfindhardtodo.One
sizewillneverfitallandeverytechniqueisnomorethanatoolinthebox,tobe
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effectiveinbuildingorrepairinganythingyouneedarangeoftools.The
psychodynamicoutlookgivesdepthtoanyintervention(attachmentisabranch
ofpsychoanalytictheory),butasaninterventionitmaybemoresuccessfulwhen
combinedwithothermodalitiesandasacomponentofamultidisciplinary
relationship-basedteam.
Parentinfantpsychotherapywasthemaintherapeuticmodalityappliedto
improvetherelationshipbetweenmotherandchildinvulnerableandhigh-risk
familiesintheFloridaInfantMentalHealthPilotProgramme.Thisintervention
targetedfamilieswithinfantsatriskofabuseandneglectwhowerelikelytobe
removedfromtheirparentsorwherethishadactuallyoccurred.Therewasno
controlgroup;andgiventhattheprojectwasfundedbythelegislaturethis
wouldnothavebeenethical.Fiftyninepercentoftheprogrammesparticipants
werecourt-orderedtoparticipate,andmanyhadalreadyarecordofmaltreating
theirchildren.Theresultsareimpressivebecauseofthewiderangeoffamily
arrangementsthatfellwithinthescheme,whichwasthuslesschoosyandfar
moreclinicallyrealisticthanmanyotherresearchprojects.Attheendofthis
pilotstudy‘therewerenofurtherreportsofabuseorneglectduringthe
treatmentperiodanduptopost-assessmentforparticipants.Therewasamajor
reductioninreportsofchildabuseandneglect…from97%ofchildrenpriorto
treatmenttononeofthechildrencompletingtreatmentduringthefirstthree
yearsofthepilotproject…(Also),thehealthanddevelopmentalstatusof
childrenimproved’(Osofsky,etal.2007:273).Inadditiontherewasareduction
ofdepressivesymptomsinthecaregiversalongwithameasuredandreported
improvementintheparent-childrelationship.Butalotofeffortwentintothese
achievements,asshouldbeexpectedforhighriskfamilies,anditwasestimated
thatbehindeveryhouroftreatmentwereanothertenspentoneffortstoengage
thefamily.
TheParentInfantPsychotherapy(PIP)clinicattheAnnaFreudCentrehasa
therapeuticfocusontheparent-infantrelationshipasobservedinthemutually
influencinginteractionsinthesessions(Baradon,etal.2005).Heretoo,video
feedbackisanessentialpartoftheprocess.Oneaimofparent-infant
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psychotherapyistointerruptthegenerationalcontinuityofunhelpfulpatternsof
parentingand,atthesametime,toencouragetheestablishmentofasecure
attachmentrelationshipforthechild.AresearchprojectattheAnnaFreud
Centre,inapilotstudy,evaluatedoutcomesusingarangeofpsychometrictools.
Themajorityofparentsfeltthattheirchild’sdevelopmenthadbeenbetterthan
expected.Littlemorethan10-15%hadsignificantconcernsaboutthechildat
followup.Lessthanoneintwentyexperiencedaworsening.Onbothintellectual
andmotordevelopment,asmeasuredwiththeBayleyassessmentof
development,referredfamilieshadinfantssevenpointsbehindtheaverage.By
sixmonthstheywereindistinguishablefromtheaverage,andthisimprovement
hadincreasedslightlyatfollow-up(Fonagy,etal.,2002).However,alater
controlledRCTfromtheAnnaFreudcentrethatlookedatparent-infant
psychotherapyforparentswithmentalhealthproblemsfoundnodifferencein
outcomebetweentreatmentandcontrolgroupsinmeasuresofdevelopment,
caregivinginteraction,maternalreflectivefunctionand(ona12monthfollow
up)infant’sattachmentstatus.Theonlypositiveoutcomeslimitedtothe
treatmentgroupwereareductionofstress,improvedparentalmentalhealth
andmorepositiveparentalrepresentationsoftheirchild(whichmightbe
expectedtohavealongerterm‘sleeper’effect).Overall‘MothersreceivingPIP
feltlesshelpless,lessintrudedupon,moreincontrol,andgenerallylessstressed
bytheirchildcareresponsibilities’(Fonagy,etal.,2016:110).
Another,final,exampleofawell-researched,interventionforparentsandinfants
isthetechniqueofWatch,WaitandWonderusedintheTorontoInfant-Parent
Program.Inthisformofinfant-parentpsychotherapytheparentisencouraged
tobemoredirectlyinvolvedwiththeirchildbyengaginginplayfulinteraction
thatfollowstheleadofthechild.Theparentistheninvitedtoexplorethe
feelingsandthoughtsthatwereevokedbywhatheorsheobservedand
experiencedintheprecedingplaysession.Thismodeoftreatmentalsoappears
tobeapositiveexperiencewithgoodoutcomesformothersstrugglingwith
borderlinepersonalitydisorder(NewmanandStevenson,2008).Allowingthe
childtobespontaneouscanbehardforaparenthauntedby‘ghostsinthe
nursery’,especiallywhenthesearerevenantsofpastabuse;andadefensive
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infant,whoismoreusedtocomplyingtothepatternofavailablecaregivingin
ordertoextractthemaximumavailablesenseoffelt-security,canbeequally
stumped.WhenWatch,WaitandWonderiscombinedwithbothimaginationand
Interactionguidanceitformsthebasisofaproductivegroupapproach,Baby
Watching,whichhasapparentlysuccessfullyengagedhardtoreachmothers
(Celebi,2014).
Aresearchprojectsetouttocomparetheeffectsoftraditionalinfant-parent
psychotherapy(PPT)withWait,WatchandWonder.Abroadrangeofoutcome
measureswasappliedbeforeandaftertreatment,andagainonfollow-upsix
monthslater.Themajorityofchildrenreferredtothisservicewereinsecurely
attached.Highlytrainedcliniciansdeliveredbothformsoftreatment.Itwas
foundthatbytheendoftheinterventiontheWait,WatchandWondermethod
wasassociatedwithamorepronouncedmovetowardssecureattachment.The
infantsinthisgroupalso‘exhibitedagreatercapacitytoregulatetheiremotions
withaconcomitantincreaseincognitiveability’(Cohen,etal.,1999:445).Their
mothers‘reportedmoresatisfactionwithparentingthanmothersinthePPT
groupandlowerlevelsofdepressionattheendoftreatment’(ibid).Bothforms
oftreatmentshowedsimilarpositivegains.‘Theywereassociatedwitha
reductionofpresentingproblems,improvementinthequalityofthemother-
childrelationship,andreductioninparentingstress’(ibid).However,atthesix-
monthfollow-upthetwogroupsweresimilaronallmeasures.TheWait,Watch
andWondergrouphadretaineditspositivegainswhilethegroupreceiving
parent-infantpsychotherapyhadcaughtup.Itwasconcludedthatboth
approachesarehelpful,buttheeffectsofWait,WatchandWondercameabout
morequickly.
Wait,WatchandWonder,withitsdualemphasisonpositiveinteractionand
insight,isahybridofbehavioural(i.e.interactionguidance)andpsychodynamic
approaches.Althoughnotmadeexplicit,thisproceduretooplainlytargetsand
enhancesparentalreflectivefunctionwithanemotionallycontainingsetting.As
withtheothertreatmentmodalitiesthathavebeenmentioned,thistechnique
couldeasilybeofferedinanyCAMHSsettingprovidedthereweresuitably
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qualifiedstaff,since,againtheoretically,theage–rangeforclientsbeginsatzero.
Butthereisanimportantcaveattobeconsidered,sincemaywouldarguethat
infantmentalhealthworkdoesnotnaturallybelonginthesamestableasthe
interventions(andfacilities)forolderchildrenandtheirfamilies.Thisisnotjust
amatterofsite,access,noise-andintimidation-level,orthelackofsuitably
trainedclinicianswithrelevantbackgrounds.AsBarrows(2000:19)argues,itis:
‘onlywithinthecontextofaservicethatisdedicatedtoInfantMentalHealththat
(the)focusontheparent-infantrelationshipislikelytobesustained,andto
featureastheprimefocusofanytherapy.’Aconsiderationofthewiderangeof
riskfactorsthatmustbeaddressedmakesitclearthatamulti-disciplinaryteam
isessential,sinceseeminglydistalpressureswillinfluencethecaregiver-infant
relationship.
Sometimesbabiesandtoddlersarelivinginsuchadversecircumstancesthat
theyneedtobemovedtoanewsetofcaregiversasquicklyaspossible.The
relationshipwiththeparentmaybedistortedbeyondrepairbyanaccumulation
ofriskfactors.Aswellasatreatmentmodality,theknowledgebaseofinfant
mentalhealthoffersustheunderstandingneededforspeedyassessmentand
recommendationastothecourseofactionthatwillbeinthebaby’sbestinterest.
Themostradicalandeffectivetreatmentforaninfantisanewfamily.Itishas
beenacceptedforyearsthatthelongeraftersixmonthsanadoptionisfinalised
thegreatertheriskoflaterproblemsinrelationships(Singer,etal.,1985).An
InfantmentalHealthteaminBatonRouge,ontheoutskirtsofNewOrleans,isa
pioneeringexampleofhowappliedknowledgeinthisfieldenablesa
comparativelyrapidassessmentofcaregivingtobecarriedoutforveryyoung
childrenreferredtotheChildProtectionService.Thisprojectisfundedbythe
courtsandhasaproventrackrecord.Itusesarangeofspecialisedassessment
methods,onceagainmakingcarefuluseofvideotechnology(Larrieuand
Zeanah,2004).Thepurposeofthisserviceistoprovidethecourtswithan
assessmentthatwillbeusedaspartofthedecision-makingprocessasto
whetherornotachildwillbefreedforadoption.Asimilarchildpopulationis
servedbyanAttachmentClinicinMontrealwhichconsultstotheYouth
ProtectionServiceonissuesrelatedtopermanencyplanningforveryyoung
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childreninfostercare(Gauthier,FortinandJeliu,2004).Theypayspecial
attentiontohowthechildhasbeenaffectedbytheoriginalseparationfrom
biologicalparentsandtheirresponsetothepossibilitythattheymightreturn
afteralongperiodwithfosterparents.
Theinfantmentalhealthspecialist(adiscreteprofessioninAmerica)needsto
calluponawiderangeofskillsandstrategiesthattogether‘contributetothe
parent’sunderstandingoftheinfant,theawakeningorrepairoftheearly
developingattachmentrelationship,andtheparent’scapacitytonurtureand
protectayoungchild’(Weatherston,2000:6).Thismeansstrengthening
relationships,whetherbetweenparentandchild,therapistandparent,orwithin
theboundariesoftheinfantmentalhealthservice.Startingfromthefundamental
premisethatallparentswanttodothebesttheycanfortheirbabies,theinfant
mentalhealthteambuildsonstrengthsinordertoremoveobstaclestoanatural
stateofaffairs.Parents,unsurprisingly,maynotappreciateotherknow-it-alls
thinkingtheyneedtraining,indeed,suchanattitude‘maysendamessageof
presumedincompetence,whichmightundermineamother’sorfather’sself-
confidenceandcontributeinadvertentlytolesseffectiveperformance’(Shonkoff
andPhillips,2000:371).Thepedagogicapproachofparentingclassessimplywill
notcutthemustardwithhigh-riskfamilies,notexactlyanewobservation.
‘Motherswhohaveitinthemtoprovidegoodenoughcarecanbeenabledtodo
thisbetterbybeingcaredforthemselvesinawaythatacknowledgesthe
essentialnatureoftheirtask.Motherswhodonothaveitinthemtoprovide
goodenoughcarecannotbemadegoodenoughbymereinstruction’(Winnicott,
1965:49).Infantmentalhealthspecialistsmaybeexperts,buttheyrelateto
parentsonthebasisofpartnership,notpower,modellingtherelationshipsthey
wishtopromote.
Conclusion.
Thereisagrowingbodyofevidencethatdemonstrateshowearly,targetedand
strength-basedinterventionsfocussingonrelationshipscanbringaboutpositive
.
79
changesintheemotionalenvironmentofvulnerablebabies(Barlow,etal.,
2010).AssummarisedbyProfessorFonagyattheendofthelastcentury
(1998:132)inanoverviewofthefield‘earlypreventativeinterventionshavethe
potentialtoimproveintheshorttermthechild’shealthandwelfare(including
betternutrition,physicalhealth,fewerfeedingproblems,low-birth-weight
babies,accidentandemergencyroomvisits,andreducedpotentialfor
maltreatment),whiletheparentscanalsoexpecttobenefitinsignificantways
(includingeducationalandworkopportunities,betteruseofservices,improved
socialsupport,enhancedself-efficacyasparentsandimprovedrelationships
withtheirchildandpartner).Inthelongterm,childrenmayfurtherbenefitin
criticalwaysbehaviourally(lessaggression,distractibility,delinquency),
educationally(betterattitudestoschool,higherachievement)andintermsof
socialfunctioningandattitudes(increasedprosocialattitudes),whiletheparents
canbenefitintermsofemployment,educationandmentalwell-being.’Soone
hastowonderwhysolittleresourcesgointotheearlyyearsinthiscountry;the
costofkillingafewforeignerswouldhelpagreatmanybabiesoutoftrouble.
Asdemonstratedabove,thereareagreatmanyexamplesofevidence-based
practice–andevenmoreofpractice-basedevidence–showingthepositive
resultsofaninfantmentalhealthapproachtowardsearlyinterventionthat
beginsandendswiththeimportanceofrelationships.However,toomuch
insistenceonevidence-basedinterventioncaneasilybeusedtodisguiseasimple
reluctancetoinvestfunds;albeittheamountsinvolvedwouldbeatiny
percentageofthebudgetsforadultmentalhealthandthecriminaljustice
system.Anecologicalperspectivemakesclearthatwhatmayworkbrilliantlyin
aspecificlocationmighthavenoeffectsomewhereelse,since‘evidencebased
practicesinpreventionsciencewhichmayhavebeentriedandshowntobe
effectiveinonelocationunderonesetofhistoricalandcontextualconditions
cannotbeassumedtobeeffectiveinanother’(Schensul,2009:243).Onesize
doesnotfitall.‘Listsofevidence-basedpracticesarebasedonstudiesof
unrepresentativesamplesthatdonotrepresentthediversityoftheindividuals
thatmostpractitionersencounterinthefield’(Shean,2014:503).Inearly
interventionrelationshipshaveamoresignificanteffectthantechniques–a
.
80
nightmareforthosewhocommissionsincethepersonwillbemoreimportant
thantheprocedureandthepeoplegoodatmakingtherapeuticrelationshipswill
beuselessatfollowingprocedures!
Tocomplementtheevidenceofclinicalimpact,longitudinalresearch,both
psychologicalandneurological,hasconfirmedthevitalimportanceoftheearly
attachmentrelationshipforfuturedevelopment.‘Foryoungchildren,infant-
caregiverrelationshipsarethemostimportantexperience-nearcontextfor
infantdevelopmentandarethedistinctivefocusoftheinfantmentalhealthfield’
(ZeanahandZeanah,2009:8).Thecradleofthefirstrelationshipsetsupparallel
flexiblesystemsinanewlyformingfamilyandanewlyformingbrain.‘Thetime
ofgreatestinfluence,forgoodorill,iswhenthebrainisnew.Ifwewanttohelp
thenextgenerationweshouldbeworkingwiththeirparentswhiletheyare
babiesnow’(Balbernie,2001:253).Thisissimplyatechnicalconfirmationof
whateveryparenthasalwaysknown,althoughtheymaynothavetimetothink
aboutituntiltheyaregrandparents.Itissomethingthatsomehowgetsavoided
whentheimplicationshavetobeturnedintopolicyorcommandresources.Who
reallydoubtsthat:‘(T)hechildhoodshowstheman,asmorningshowstheday’
(Milton,1671/1992:492).
Ifthefirsttwoyearsoflifearecradledwithinsecureattachmentthenthe
growingchildfeelsgoodabouthimorherself,canappreciatethefeelingsof
othersandseetheirpointofview,isabletotakefulladvantageofeducationand
hasinherentpsychologicalresiliencytofallbackuponintimesofstress.Nobody
canavoidtrippingoverthepitfallsoflife;butthosewithabeginningofsecure
attachmentstandabetterchanceofbeingabletoself-repair.Attheotherendof
thespectrum,theinfantwithdisorganisedattachment,whohasoftensuffered
abuseorneglect,willbecomethechildwhocannottrustrelationships,whohas
noempathyforpeopleorrespectforsocialrules,whodisrupts,attacksandtries
todominatewhatmaybeonofferinboththefamilyandschool,andwhomight
wellbeseriouslyvulnerabletolatermentalhealthproblems.Andfurthermore,
mostimportantly,thesepatternsofbehaviourstandagoodchanceofbeing
passedontothenextgenerationastheattachmentexperiencesofinfancycutthe
.
81
templateforthecaregivingbehavioursofadulthood.‘Byfailingtounderstand
thecumulativeeffectsofthepoisonsassaultingourbabiesintheformofabuse,
neglect,andtoxicsubstances,weareparticipatinginourowndestruction’(Karr-
MorseandWiley,1997:12).
Earlyinterventionwithintheremitofaninfantmentalhealthserviceisan
effectivewayofbeginningtobreakthecycleofinsecureattachmentasittakes
advantageofboththeneurologicalplasticityofthebabyandthefluiddynamics
ofafamilyintheprocessofadaptingtoanewmember.Leaveittoolateandboth
thestructureofthebrainandfamilyinteractionsbecomeincreasingly
establishedandconsequentlyhardertochange.
RobinBalbernie
ConsultantChildPsychotherapist.
ClinicalDirectorPIPUK.
(22/06/2016).
Theappendixonthefollowingpagesisariskfactorchecklistthatmaybeusedtoassesswhenthecaregivingrelationshipispotentiallyatrisk.Byusingsuchascreeningtoolitispossibletoofferhelpbeforeharmhasoccurred.Thisiskinder,lessstigmatisingandmorecosteffective.Pleasefeelfreetocopy,useandmodify,inanywaythatyoulike.
.
82
Manyknownriskfactorsputastrainonthebaby-parentrelationship.Ananalysisoftheseallowsinterventiontobeconsideredatapreventivelevel,beforetheinfant’squalityofattachmenthasbeencompromised.Thepresenceoffourtosixmoderateriskfactorsissignificantalthoughsomecombinationsofalessernumbermeritattention.However,therearecertainseriousconditionsthatmaycallforinterventionsontheirown.Thesehavebeenitalicised(inred)inthelistbelow.1. BiologicalVulnerabilityintheInfant: Mothersubstanceabused/onmethadoneduringpregnancy. Verylowbirthweight/extremelypremature. Failuretothrive/feedingdifficulties/malnutrition. …… Motherdrankalcoholduringpregnancy. …… Congenitalabnormalities/illness/seriousdevelopmentaldelay. …… Verydifficulttemperament/extremecrying. …… Verylethargic/non-responsive. …… Resistsholding/hypersensitivetotouch. …… Chronicmaternalanxiety/stressduringpregnancy. …… Mothersmokedheavilyduringpregnancy. …… Regulatory/sensoryintegrationdisorder. ……2. ParentalHistoryandCurrentFunctioning: Mentalillness,includingdepressionandeatingdisorder. Seriousmedicalcondition/physicaldisability. Ownmothermentallyill/substanceabused. Alcoholand/ordrugabuse(currentorpast). Historyofphysicalorsexualabuse,witnessingviolence,neglectorloss. Parentsseemincoherentorconfused. …… Parentwasincare(lookedafter)/adopted.
Lackofpreparationduringpregnancy.…………
Learningdisability/loweducationalachievement. …… Criminaloryoungoffender’srecord/hasbeenimprisoned. …… Previouschildhasbeenplacedinfostercareoradopted. …… Motherhasexperiencedthedeathofachild. …… Previouschildhasbehaviourproblems. …… Presenceofanacutefamilycrisis. ……3. InteractionalorParentingVariables: Lackofsensitivitytoinfant’scriesorsignals. …… Lackofconsistentprimecaregiverforinfant. …… Physicallypunitiveorharshtowardschild. …… Lackofvocalisationtoinfant,few‘conversations’. …… Lackofeye-to-eyecontact. …… Negativeattributionsmadetowardschild,evenif‘jokey’. …… Lacksknowledgeofparentingandchilddevelopment. …… Infanthaspoorcare(e.g.dirtyandunkempt),physicalneglect. …… Doesnotanticipateorencouragechild’sdevelopment. …… Qualityofpartnerrelationship;maybeunderminedorunsupported. …… Infantavictimofmaltreatment,emotionalabuseorneglect. Anyviolencereportedinthefamily,especiallyifwitnessedbychild. Negativeaffect(includingfear)/verbalabuseopenlyshowntowardschild. 4. Socio-demographicFactors: Chronicunemployment. …… Inadequateincome/housing/hygiene. …… Overcrowdinginhousehold. …… Singleteenagemotherwithoutfamilysupport.
Absentparentorstepparentinfamily(i.e.notbiologicallyrelated).…………
Poorquality/morethan20hoursperweekday-care. …… Severefamilydysfunction,currentandinbackground. …… Lackofsupport/isolation. …… Recentlifestress(e.g.bereavement,birthtrauma,immigration). ……
.
83
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