Professor Jane Barlow Structure of paper What is emotional abuse during the first two years of life Why the first two years matter What the evidence tells us about what works ID: 913991
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Slide1
Safeguarding infants from emotional maltreatment: What works?
Professor Jane Barlow
Slide2Structure of paper
What is emotional abuse during the first two years of life;Why the first two years matter;What the evidence tells us about ‘what works’
Slide3Emotional Abuse
Slide4Emotional Abuse – the problemReferrals for primary emotional abuse rose from 4,700 (13%) to 5,100 (20%) over past
decadeThis equates to 4.7 per 10,000 childrenAs many as 80% of children registered for physical abuse and neglect have also experienced emotional abuse
Slide5Subjective PerceptionsLarge-scale population-based study (involving 2,869 adults) in the UK6% reported
- frequent and severe psychological control and domination; - psycho/physical control and domination, humiliation, attacks on self-esteem - withdrawal of their primary carer’s attention/affection - antipathy, terrorising or threatening behaviours and proxy attacks
Slide6Five categories definedrejecting: behaviours which communicate or constitute abandonment of the child;
isolating: preventing the child from participating in normal social interaction activities;terrorising: threatening the child with severe punishment, or deliberately cultivating a climate of fear or threat;ignoring: where the caregiver is psychologically unavailable to the child and fails to respond to the child's behaviour; andcorrupting: caregiver behaviour which encourages the child to develop false social values that reinforce antisocial or deviant behavioural patterns (Glaser and Prior,2002)
Slide7What is emotional abuse?
A constant, repeated pattern of parental behaviour, (unaccompanied by physical abuse, sexual abuse or necessarily by physical neglect) that is likely to be interpreted by a child that she or he is unloved, unwanted, serves only instrumental purposes, and/or which severely undermines children’s development and socialisation (Barlow and Schrader-McMillan 2010)
Slide8DefinitionConsistent with WHO definition (1999)Includes acts toward the child that have a high probability of causing harm to their health or to any aspect of their development (physical, emotional or social etc)
ALSO includes the failure to provide a developmentally appropriate and supportive environment in which the child can develop the full range of emotional and social competencies commensurate with her or his personal potential
Slide9Early Development and Later Wellbeing
Infants’ CNSSelf-esteemBehaviourMentalising
Relationships
Emotional regulation
via attachment
Empathy
Smoking/drugs
Promiscuity
School failure
Delinquency
Obesity
ETC…
Learning
Parenting
CORE of incipient self
Slide10Trauma in infancy:attachment system compromised.
Sensitised nervous system as brain adapts to emotional environment.Stress in adult:reminders & experiences of trauma, life events, etc. Unbearably painful emotional states.
Self-destructive
actions:
substance abuse
eating disorders
deliberate self-harm
suicidal actions
Destructive
actions:
aggression
violence
rage
Retreat:
isolation
dissociation
depression
Slide11Aspects of Early Development
Emotional competence
Cognitive Development
Social
Competence
Infancy
Trust/attachment
Alertness/curiosity
Impulse control
Toddlerhood
Empathy
Communication/
mastery motivation
Coping
Childhood
Social Relationships
Reasoning/problem solving
Goal-directed behaviour
Adolescence
Supportive social network
Learning ability/achievement
Social responsibility
Slide12The Social BabyIn first 15 hours baby
’s distinguish the voice, smell and face of their motherThey connect what they do with what happens immediately afterBabies have a sophisticated understanding of facial expressions – distinguish between surprise, fear, sadness, anger and delightBy 10- months babies seek emotional information from others to help them interpret things around themBy 10-months baby’s brain has developed according to the type of emotions to which they have been exposed (Beebe and Lachman, 2004)
Slide13Infant
secure Attachment
Affect synchrony
Containment
Mirroring
Reflective function
i. Attachment behaviours
ii. Internal Working Model
Sense of
‘
self
’
Parent-Child Interaction
Slide14By two months the mothers face is the primary source of visuo-affective communicationFace-to-face interactions emerge which are high arousing, affect-laden and expose infants to high levels of cognitive and social information and stimulation
To regulate this infant and mothers regulate the intensity of these interactions – ‘affect synchrony’ and repairs to rupturesAbsolutely fundamental to healthy emotional development – prolonged negative states are ‘toxic’ to infantsAdults that are incapable of ‘attunement’ i.e. intrusive; depressed, cannot regulate appropriately‘Affect Synchrony’ – the dance
Slide15‘Attuned mutual co-ordination between mother and infant occurs when the infant’s squeal of delight is matched by the mother’s excited clapping and sparkling eyes. The baby then becomes overstimulated, arches its back and looks away from the mother. A disruption has occurred and there is a misco-ordination: the mother, still excited, is leaning forward, while the baby, now serious, pulls away. However, the mother then picks up the cue and begins the repair: she stops laughing and, with a little sigh, quietens down. The baby comes back and makes eye contact again. Mother and baby gently smile. They are back in sync again, in attunement with each other (Fosha, 2003 in Walker 2008, p. 6).
Slide16Videoclip One
Slide17Reflective FunctionCapacity to understand the infant’s behaviour in terms of internal states/feelingsA key determinant of self-organization which is acquired in the context of the child's early social relationships (Fonagy, 1997)
Development of self-organization is dependent on the caregiver's ability to communicate understanding of the child's intentional stance via ‘marked mirroring’Lack of parental RF plays a key role in pathological functioning
Slide18Videoclip two
Slide19Affect synchrony in the face of parental problemsInfant’s emotional states can trigger profound discomfort in the parent
(e.g. where there is unresolved loss/trauma, mental health problems, drug/alcohol abuse, or where there is domestic violence etc)Interaction becomes characterized by withdrawal, distancing or neglect (i.e. omission) or intrusion in the form of blaming, shaming, punishing and attacking (i.e. commission) (ibid).
Slide20Videoclip two
Slide21The Impact on the Developing Neurosystem
Slide22The Infant’s Brain – SoftwiringUnique wiring of individual brain determines how we behave; think; feel; memories etc and our sense of
‘self’Wiring takes place during prenatal period to school-entry – important first two yearsRapid proliferation and overproduction of synapses followed by loss (pruning)‘Use it or lose it’ – lost if not functionally confirmedInfluenced by genes and environmentMost important aspect of the environment is primary care-taker
Slide23Slide24Slide25Looks and smiles help the brain to grow
Baby looks at mother; sees dilated pupils (evidence that sympathetic nervous system aroused and happy); own nervous system is aroused - heart rate increases Lead to a biochemical response - pleasure neuropeptides (betaendorphin and dopamine) released into brain and helps neurons grow Families doting looks help brain to growNegative looks trigger a different biochemical response (cortisol) stops these hormones and related growth (Gerhardt, 2004)For example…
Slide26Babies of depressed mothers: - nearly half show reduced brain activity
- much lower levels of left frontal brain activity (joy; interest; anger)Early experiences of persistent neglect and trauma: - overdevelopment of neurophysiology of brainstem and midbrain (anxiety; impulsivity; poor affect regulation, hyperactivity) - deficits in cortical functions (problem-solving) and limbic function (empathy)
Slide27Slide28Slide29Attachment
What is it:?- Affective bond between infant and caregiver (Bowlby, 1969)What is its function?: - Dyadic regulation of infant emotion and arousal (Sroufe, 1996)Antecedants of attachment: Sensitive, emotionally responsive care during first year – secure attachmentInsensitive, inconsistent or unresponsive care – insecure attachment
Slide30The Importance of AttachmentSecure base – to explore the worldPrototype for later relations – internal working model is a
‘representational model’ of self and self with otherProvide child with expectations in relation to self and others
Slide31Attachment
Majority of children (two thirds) who have sensitive care will form secure attachments – 67%Remaining children will be: - Insecure attachment (i.e. unable to use caregiver to modulate their aroused state) Avoidant – over-regulate; Resistant – under-regulate
- Disorganised
attachment – no consistent patterns of
behaviour - conflicting emotions
E.g. 82% of abused cf 19% of non-abused children had
disorganised attachment (Carlson, Cicchetti et al., 1989)
Slide32Disorganised/Controlling Attachment
82% of abused cf 19% of non-abused children had disorganised attachment (Carlson, Cicchetti et al., 1989)Caregivers – unpredictable and rejecting; source of comfort also source of distressSelf represented as unlovable, unworthy, capable of causing others to become angry, violent and uncaringOthers – frightening, dangerous, unavailablePredominant feelings – fear and angerLittle time for exploration or social learning
Slide33Arousal following traumaHyper-arousal (aggression, impulsive behaviour, children emotional and behavioural problems –
‘Fight or flight’ response)Window OfToleranceHypo-arousal (dissociation, depression, self harm etc)
Slide34Compulsive StrategiesCompulsive compliance (where parent is threatening) – watchful; vigilant and compliant
Compulsive caregiving (where parent is needy) – role reversal; parentification; children deny own developmental needsCoercive – combination of threatening and placatory behavioursControlling strategies (abusive and neglectful) – self is strong and powerful but also dangerous and bad; avoidance and aggression; completely ‘out of control’ and ‘fearless’
Slide35Compulsive caregiving
‘Caroline is 18 months old. She lives with her mother, who is chronically depressed. The mother describes the household as ‘noxious to the soul’. She cannot tolerate the idea that her depression is affecting Caroline. She says: “Caroline is the only one who makes me laugh.” It is observed that Caroline silently enacts the role of a clown. She disappears into her room and comes out wearing increasingly more preposterous costumes. Caroline makes her mother laugh, but she herself never laughs…’ (Howe, 1999)
Slide36Disorganised attachment stems from disruption in the emotional communication, or lack of attunement, between parent and baby.
Lack of effective regulationof fearful arousal in infant.(Disorganised attachment.)A withdrawing response..Negative-intrusive responses..A role-confused response.
Disoriented/confused responses.
Emotional communication errors,
e.g. giving conflicting cues to baby,
failure to respond to infant
’
s signals.
Borderline
symptoms in late
adolescence.
Strongest predictor
Dissociative
symptoms in late
adolescence.
Hostile / frightening response.
Slide37Framework
Physical abuseSexual abuseEmotional abuseNeglectWitnessing IPV
Long-term outcomes
Prevention
before
occurrence
Prevention
of
recurrence
Prevention
of
impairment
Universal
Targeted
Slide38Prevention before occurrence
Slide39Nurse Family PartnershipIntensive home visits during pregnancy and first two yearsGoal based; ecological; attachment; self-efficacy etcReduced child physical abuse and neglect, as measured by official child protection reports
Reduced associated outcomes such as injuries in children of first-time, disadvantaged mothers Level of evidence: RCTs
Slide40Triple PDissemination of Triple P professional training to the existing workforce alongside universal media and communication strategies, across 18 randomly assigned counties in the US
Showed positive effects on substantiated child protection services reports, out-of-home placements, and hospital and emergency reports of injuries Rates of maltreatment rose in both groupsAnalysis is not clear, and further evaluation and replication is recommendedLevel of evidence: one RCT
Slide41Healthy Child Programme
Preparation for parenthoodSupporting bondingSupporting attachment and addressing early problemsSupporting parentingIdentifying and supporting high-risk families – teenage parents; domestic violence; parental mental health problems
Slide42Preventing re-exposure and impairment
Slide43Key Intervention ApproachesSensitivity/attachment-based: Interaction Guidance; FNPPsychotherapeutic:
Parent-infant psychotherapyMentalisation: Minding the BabyParenting programmes – Parents under PressureParenting Programmes – Circle of Security; Baby Triple P
Slide44Nurse Family PartnershipIntensive home visits during pregnancy and first two yearsGoal based; ecological; attachment; self-efficacy etc
Reduced child physical abuse and neglect, as measured by official child protection reportsReduced associated outcomes such as injuries in children of first-time, disadvantaged mothers Level of evidence: RCTs
Slide45Interaction guidance
Weekly for 10 weeks - reinforcement of adequate maternal behaviours; modification of inappropriate patterns; Video based recordings and coaching of actual interactions 22 FTT mothers and babies - significant reduction decreasing atypical behaviours and disrupted communication (Benoit et al 2001)
[Tissot et al., 1999]
Slide46PUP ProgrammePUP is underpinned by an ecological model of child development and targets multiple domains of family functioning, including the psychological functioning of individuals in the family, parent–child relationships, and social contextual factors.
Incorporates ‘mindfulness’ skills that are aimed at improving parental affect regulation;PUP comprises an intensive, manualized, home-based intervention of ten modules conducted in the family home over 10 to 12 weeks, eachsession lasting between one and two hours
Slide47PUP evaluationParents Under PressureRCT with substance abusing parents of children aged 2-8 years (Dawe and Harnett 2007) Compared PUP with standard parenting programme
Significant reductions in parental stress; methadone dose and child abuse potential (significant worsening in the child abuse potential of parents receiving standard care); improved child behaviour problems
Slide48Mentalisation-based approaches
Emerging model of intervention that builds on both parent-infant psychotherapy and recent advances in advances in attachment theoryMinding the Baby is an interdisciplinary, relationship based home visiting program for young, at-risk new mothersDelivered by a team that includes a nurse practitioner and clinical social worker- uses a mentalisation-based approach that involves working with mothers and babies in a variety of ways to develop mothers' reflective capacitiesIt aims at addressing relationship disruptions that stem from mothers' early trauma and derailed attachment historyOnly case-study evidence available (Slade et al., 2005)
Slide49Parent-Infant PsychotherapyFocus on mother’
s representational world e.g. the way in which the mother’s current view of her infant is affected by representations from her own historyFraiberg ‘Ghosts in the Nursery’Linking of ghosts with mother’s own history facilitates changes to her representational world and new paths for growth of both mother and infant
Slide50Combined ApproachesWatch, Wait and Wonder
Infant led parent-infant psychotherapyMother observes her infant’s self-initiated activity whilst being physically accessible to infantDiscussion of these experiences with therapist as a way of examining the mother’s internal working models of herself in relation to her infant
Slide51RCT of 67 anxiously attached dyads (less than 30 months)
Post InterventionBoth WWW and PPT were successful in reducing infant presenting problems, decreasing parenting stress, reducing maternal intrusiveness and mother-infant conflictWWW group showed greater shift toward more organised or secure attachment and greater improvement in cognitive development and emotion regulation than PPT group.WWW mothers reported greater increase in parenting satisfaction and competence and greater decrease in depression6-month follow-up
The above differences between the groups had disappeared – the PPT group also showed the above gains
Advantage persisted for WWW in mothers comfort in dealing with infant behaviours and parenting stress
Slide52Slide53COS - FindingsParticipants – 65 toddler/preschooler– caregiver dyads recruited from Head Start and Early Head Start programs;Significant within-subject changes from disorganized to organized attachment classifications, with a majority changing to the secure classification;
is a promising intervention for the reduction of disorganized and insecure attachment in high-risk toddlers and preschoolers (Hoffman, Irvine and Powell,2006)
Slide54Interaction GuidanceInteraction Guidance aims at increasing maternal sensitivity & is a brief (6-7 week) intervention designed specifically for families who have been hard to engage and who have a limited capacity for introspection
Benoit et al (2001) compared the effect of a play-focused intervention (Interaction Guidance) combined with training on feeding, and training on feeding alone for parents of babies with FG28 FTT infants and their mothers – controlled studyResults showed that a modified version of Interaction Guidance was effective in decreasing atypical behaviours and disrupted communication
Slide55Parenting ProgrammesParents Under PressureRCT with substance abusing parents of children aged 2-8 years (Dawe and Harnett 2007) Compared PUP with standard parenting prog
Significant reductions in parental stress and methadone dose and child abuse potential (significant worsening in the child abuse potential of parents receiving standard care); improved child behaviour problems
Slide56Mentalisation-based approaches
Emerging model of intervention that builds on both parent-infant psychotherapy and recent advances in advances in attachment theoryMinding the Baby is an interdisciplinary, relationship based home visiting program for young, at-risk new mothersDelivered by a team that includes a nurse practitioner and clinical social worker- uses a mentalisation-based approach that involves working with mothers and babies in a variety of ways to develop mothers' reflective capacitiesIt aims at addressing relationship disruptions that stem from mothers' early trauma and derailed attachment historyOnly case-study evidence available (Slade et al., 2005)
Slide57Parent-infant psychotherapyMother and infant meet weekly with a therapist for one yearJoint observation of the infant, and the therapist aims to ‘allow distorted emotional reactions and perceptions of the infant as they are enacted during mother–infant interaction to be associated with memories and affects from the mother’s prior childhood experiences. the therapeutic relationship provides the mother
with a corrective emotional experience, through which the mother is able to differentiate current from past relationships, form positive internal representations (Cicchetti et al 2006)
Slide58Parent-infant/child psychotherapy
Recent research suggests that parent-infant/child psychotherapy may be an effective means of improving parent-child interaction (e.g. Cicchetti et al 2006; Toth et al 2002; Cohen et al., 1999)There is a range of different types of parent-infant/child psychotherapy available - standard representational models of psychotherapy some incorporating behavioural components (e.g. Watch, Wait and Wonder - see Muir (1992) and Cohen et al. (1999)Research suggests that parents with avoidant attachment disorder are better suited to more behavioural than representational models of psychotherapy as a result of their inability to introspect about the role of earlier experiences on current parenting (Bakermans-Kranenburg et al., 2003).
Slide59SummaryEmotional neglect and abuse during first two years are ‘traumatising
’Evidence base about ‘what works’ is developingInterventions that may be effective include: - CBT/affect regulating parenting programmes - Interaction Guidance - Psychotherapeutic approaches including parent psychotherapy, parent infant psychotherapy - Mentalisation programmes