Safeguarding infants from Safeguarding infants from emotional maltreatment: emotional maltreatment:

What works?What works?

Professor Jane BarlowProfessor Jane Barlow

Structure of paperStructure of paper What is emotional abuse during the first two years of life;What is emotional abuse during the first two years of life;

Why the first two years matter;Why the first two years matter;

What the evidence tells us about ‘what works’What the evidence tells us about ‘what works’

Emotional AbuseEmotional Abuse

Emotional Abuse – the problemEmotional Abuse – the problem

Referrals for primary emotional abuse rose Referrals for primary emotional abuse rose from 4,700 (13%) to 5,100 (20%) over past from 4,700 (13%) to 5,100 (20%) over past decadedecade

This equates to 4.7 per 10,000 childrenThis equates to 4.7 per 10,000 children

As many as 80% of children registered for As many as 80% of children registered for physical abuse and neglect have also physical abuse and neglect have also experienced emotional abuse experienced emotional abuse

Subjective PerceptionsSubjective Perceptions Large-scale population-based study Large-scale population-based study

(involving 2,869 adults) in the UK(involving 2,869 adults) in the UK 6% reported 6% reported

- frequent and severe - frequent and severe psychological control and psychological control and domination; domination;

- psycho/physical control and domination, - psycho/physical control and domination, humiliation, attacks on self-esteemhumiliation, attacks on self-esteem

- withdrawal of their primary carer’s - withdrawal of their primary carer’s attention/affectionattention/affection

- antipathy, terrorising or threatening behaviours - antipathy, terrorising or threatening behaviours and proxy attacks and proxy attacks

Five categories definedFive categories defined rejecting:rejecting: behaviours which communicate or behaviours which communicate or

constitute abandonment of the child;constitute abandonment of the child; isolating:isolating: preventing the child from participating in preventing the child from participating in

normal social interaction activities;normal social interaction activities; terrorising:terrorising: threatening the child with severe threatening the child with severe

punishment, or deliberately cultivating a climate of punishment, or deliberately cultivating a climate of fear or threat;fear or threat;

ignoringignoring: where the caregiver is psychologically : where the caregiver is psychologically unavailable to the child and fails to respond to the unavailable to the child and fails to respond to the child's behaviour; andchild's behaviour; and

corrupting:corrupting: caregiver behaviour which encourages caregiver behaviour which encourages the child to develop false social values that the child to develop false social values that reinforce antisocial or deviant behavioural reinforce antisocial or deviant behavioural patternspatterns

(Glaser and (Glaser and Prior,2002)Prior,2002)

What is emotional abuse?What is emotional abuse?

A constant, repeated pattern of parental A constant, repeated pattern of parental behaviour, (unaccompanied by physical behaviour, (unaccompanied by physical abuse, sexual abuse or necessarily by abuse, sexual abuse or necessarily by physical neglect) that is likely to be physical neglect) that is likely to be interpreted by a child that she or he is interpreted by a child that she or he is unloved, unwanted, serves only unloved, unwanted, serves only instrumental purposes, and/or which instrumental purposes, and/or which severely undermines children’s severely undermines children’s development and socialisation development and socialisation

(Barlow and Schrader-McMillan 2010)(Barlow and Schrader-McMillan 2010)

DefinitionDefinition Consistent with WHO definition (1999)Consistent with WHO definition (1999)

Includes acts toward the child that have a Includes acts toward the child that have a high probability of causing harm to their high probability of causing harm to their health or to any aspect of their health or to any aspect of their development (physical, emotional or social development (physical, emotional or social etc)etc)

ALSO includes the failure to provide a ALSO includes the failure to provide a developmentally appropriate and developmentally appropriate and supportive environment in which the child supportive environment in which the child can develop the full range of emotional and can develop the full range of emotional and social competencies commensuratesocial competencies commensurate with her with her or his personal potentialor his personal potential

Early Development and Later Early Development and Later WellbeingWellbeing

Infants’ CNS

Self-esteem

Behaviour

Mentalising

Relationships

Emotional regulationvia attachment Empathy

Smoking/drugs

Promiscuity

School failure

Delinquency

Obesity

ETC…Learning

Parenting

CORE of incipient selfCORE of incipient self

Trauma 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 abuseeating disordersdeliberate self-harmsuicidal actions

Destructiveactions:aggressionviolencerage

Retreat:isolationdissociationdepression

Aspects of Early Aspects of Early DevelopmentDevelopment

Emotional Emotional competencecompetence

Cognitive Cognitive DevelopmentDevelopment

SocialSocial

CompetencCompetencee

InfancyInfancy Trust/Trust/attachmentattachment

Alertness/Alertness/curiositycuriosity

Impulse Impulse controlcontrol

ToddlerhooToddlerhoodd

EmpathyEmpathy Communication/Communication/

mastery mastery motivationmotivation

CopingCoping

ChildhoodChildhood Social Social RelationshipsRelationships

Reasoning/Reasoning/problem solvingproblem solving

Goal-directed Goal-directed behaviourbehaviour

AdolescencAdolescencee

Supportive Supportive social networksocial network

Learning Learning ability/achievemeability/achievementnt

Social Social responsibilityresponsibility

The Social Baby In first 15 hours baby’s distinguish the voice, In first 15 hours baby’s distinguish the voice,

smell and face of their mothersmell and face of their mother They connect what they do with what happens They connect what they do with what happens

immediately afterimmediately after Babies have a sophisticated understanding of Babies have a sophisticated understanding of

facial expressions – distinguish between surprise, facial expressions – distinguish between surprise, fear, sadness, anger and delightfear, sadness, anger and delight

By 10- months babies seek emotional information By 10- months babies seek emotional information from others to help them interpret things around from others to help them interpret things around themthem

By 10-months baby’s brain has developed By 10-months baby’s brain has developed according to the type of emotions to which they according to the type of emotions to which they have been exposedhave been exposed

(Beebe and Lachman, (Beebe and Lachman, 2004)2004)

Infant secure Attachment

Affect synchrony

Containment

Mirroring

Reflective function

i. Attachment behaviours

ii. Internal Working Model

Sense of ‘self’

Parent-Child Interaction

By two months the mothers face is the primary By two months the mothers face is the primary source of visuo-affective communicationsource of visuo-affective communication

Face-to-face interactions emerge which are high Face-to-face interactions emerge which are high arousing, affect-laden and expose infants to high arousing, affect-laden and expose infants to high levels of cognitive and social information and levels of cognitive and social information and stimulationstimulation

To regulate this infant and mothers regulate the To regulate this infant and mothers regulate the intensity of these interactions – ‘affect synchrony’ intensity of these interactions – ‘affect synchrony’ and repairs to rupturesand repairs to ruptures

Absolutely fundamental to healthy emotional Absolutely fundamental to healthy emotional development – prolonged negative states are ‘toxic’ development – prolonged negative states are ‘toxic’ to infantsto infants

Adults that are incapable of ‘attunement’ i.e. Adults that are incapable of ‘attunement’ i.e. intrusive; depressed, cannot regulate appropriatelyintrusive; depressed, cannot regulate appropriately

‘‘Affect Synchrony’ – the Affect Synchrony’ – the dancedance

‘ ‘Attuned mutual co-ordination between mother and Attuned mutual co-ordination between mother and infant occurs when the infant’s squeal of delight is infant occurs when the infant’s squeal of delight is matched by the mother’s excited clapping and matched by the mother’s excited clapping and sparkling eyes. The baby then becomes sparkling eyes. The baby then becomes overstimulated, arches its back and looks away overstimulated, arches its back and looks away from the mother. A disruption has occurred and from the mother. A disruption has occurred and there is a misco-ordination: the mother, still there is a misco-ordination: the mother, still excited, is leaning forward, while the baby, now excited, is leaning forward, while the baby, now serious, pulls away. However, the mother then serious, pulls away. However, the mother then picks up the cue and begins the repair: she stops picks up the cue and begins the repair: she stops laughing and, with a little sigh, quietens down. laughing and, with a little sigh, quietens down. The baby comes back and makes eye contact The baby comes back and makes eye contact again. Mother and baby gently smile. They are again. Mother and baby gently smile. They are back in sync again, in attunement with each other back in sync again, in attunement with each other (Fosha, 2003 in Walker 2008, p. 6). (Fosha, 2003 in Walker 2008, p. 6).

Videoclip OneVideoclip One

Reflective FunctionReflective Function Capacity to understand the infant’s behaviour in Capacity to understand the infant’s behaviour in

terms of internal states/feelingsterms of internal states/feelings A key determinant of self-organization which is A key determinant of self-organization which is

acquired in the context of the child's early social acquired in the context of the child's early social relationships (Fonagy, 1997)relationships (Fonagy, 1997)

Development of self-organization is dependent on Development of self-organization is dependent on the caregiver's ability to communicate the caregiver's ability to communicate understanding of the child's intentional stance via understanding of the child's intentional stance via ‘marked mirroring’‘marked mirroring’

Lack of parental RF plays a key role in pathological Lack of parental RF plays a key role in pathological functioningfunctioning

Videoclip twoVideoclip two

Affect synchrony in the face of parental problems

Infant’s emotional states can trigger Infant’s emotional states can trigger profound discomfort in the parent profound discomfort in the parent (e.g. (e.g. where there is unresolved loss/trauma, mental where there is unresolved loss/trauma, mental health problems, drug/alcohol abuse, or where health problems, drug/alcohol abuse, or where there is domestic violence etc)there is domestic violence etc)

Interaction becomes characterized by Interaction becomes characterized by withdrawal, distancing or neglect (i.e. withdrawal, distancing or neglect (i.e. omission) or intrusion in the form of omission) or intrusion in the form of blaming, shaming, punishing and blaming, shaming, punishing and attacking (i.e. commission) (ibid).attacking (i.e. commission) (ibid).

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The Impact on the Developing Neurosystem

The Infant’s Brain – The Infant’s Brain – SoftwiringSoftwiring

Unique wiring of individual brain Unique wiring of individual brain determines how we behave; think; feel; determines how we behave; think; feel; memories etc and our sense of ‘self’memories etc and our sense of ‘self’

Wiring takes place during Wiring takes place during prenatal period to prenatal period to school-entryschool-entry – important first two years – important first two years

Rapid proliferation and overproduction of Rapid proliferation and overproduction of synapses followed by loss (pruning)synapses followed by loss (pruning)

‘‘Use it or lose it’ – lost if not functionally Use it or lose it’ – lost if not functionally confirmedconfirmed

Influenced by genes and environmentInfluenced by genes and environment Most important aspect of the environment Most important aspect of the environment

is primary care-takeris primary care-taker

Looks and smilesLooks and smiles help the help the brain to growbrain to grow

Baby looks at mother; sees dilated pupils (evidence Baby looks at mother; sees dilated pupils (evidence that sympathetic nervous system aroused and that sympathetic nervous system aroused and happy); own nervous system is aroused - heart happy); own nervous system is aroused - heart rate increases rate increases

Lead to a biochemical response - pleasure Lead to a biochemical response - pleasure neuropeptides (betaendorphin and dopamine) neuropeptides (betaendorphin and dopamine) released into brain and helps neurons grow released into brain and helps neurons grow

Families doting looks help brain to growFamilies doting looks help brain to grow

Negative looksNegative looks trigger a different biochemical trigger a different biochemical response response (cortisol)(cortisol) stops these hormones and stops these hormones and related growthrelated growth

(Gerhardt, 2004)(Gerhardt, 2004)

For example…For example…

Babies of Babies of depresseddepressed mothers: mothers: - nearly half show reduced brain activity- nearly half show reduced brain activity

- much lower levels of left frontal brain - much lower levels of left frontal brain activity (joy; interest; anger)activity (joy; interest; anger)

Early experiences of persistent Early experiences of persistent neglect and trauma:neglect and trauma:

- overdevelopment of neurophysiology of - overdevelopment of neurophysiology of brainstem and midbrain (anxiety; brainstem and midbrain (anxiety; impulsivity; poor affect regulation, impulsivity; poor affect regulation, hyperactivity)hyperactivity)

- deficits in cortical functions (problem-- deficits in cortical functions (problem-solving) and limbic function (empathy)solving) and limbic function (empathy)

Attachment What is it:?What is it:?- Affective bond between infant and caregiver - Affective bond between infant and caregiver

(Bowlby, 1969)(Bowlby, 1969)

What is its function?: What is its function?: - Dyadic regulation of infant emotion and arousal - Dyadic regulation of infant emotion and arousal

(Sroufe, 1996)(Sroufe, 1996)

Antecedants of attachment: Antecedants of attachment: Sensitive, emotionally responsive care during first Sensitive, emotionally responsive care during first

year – secure attachmentyear – secure attachment Insensitive, inconsistent or unresponsive care – Insensitive, inconsistent or unresponsive care –

insecure attachmentinsecure attachment

The Importance of The Importance of AttachmentAttachment

Secure base – to explore the worldSecure base – to explore the world Prototype for later relations – internal Prototype for later relations – internal

working model is a ‘representational working model is a ‘representational model’ of self and self with othermodel’ of self and self with other

Provide child with expectations in Provide child with expectations in relation to self and othersrelation to self and others

AttachmentAttachment Majority of children (two thirds) who have Majority of children (two thirds) who have

sensitive care will form secure attachments – 67%sensitive care will form secure attachments – 67%

Remaining children will be: Remaining children will be:

- - Insecure attachmentInsecure attachment (i.e. unable to use (i.e. unable to use caregiver tocaregiver to

modulate their aroused state) Avoidant – over-modulate their aroused state) Avoidant – over-regulate; regulate;

Resistant – under-regulateResistant – under-regulate

- Disorganised- Disorganised attachment – no consistent attachment – no consistent patterns ofpatterns of

behaviour - conflicting emotionsbehaviour - conflicting emotions

E.g. 82% of abused cf 19% of non-abused E.g. 82% of abused cf 19% of non-abused children hadchildren had

disorganised attachment (Carlson, Cicchetti et disorganised attachment (Carlson, Cicchetti et al., 1989)al., 1989)

Disorganised/ControllingDisorganised/Controlling Attachment Attachment

82% of abused cf 19% of non-abused children 82% of abused cf 19% of non-abused children had disorganised attachment (Carlson, had disorganised attachment (Carlson, Cicchetti et al., 1989)Cicchetti et al., 1989)

Caregivers – unpredictable and rejecting; Caregivers – unpredictable and rejecting; source of comfort also source of distresssource of comfort also source of distress

Self represented as unlovable, unworthy, Self represented as unlovable, unworthy, capable of causing others to become angry, capable of causing others to become angry, violent and uncaringviolent and uncaring

Others – frightening, dangerous, unavailableOthers – frightening, dangerous, unavailable Predominant feelings – fear and angerPredominant feelings – fear and anger Little time for exploration or social learningLittle time for exploration or social learning

Arousal following traumaArousal following trauma

Hyper-arousal (aggression, impulsive behaviour, Hyper-arousal (aggression, impulsive behaviour, children emotional and behavioural problems – children emotional and behavioural problems – ‘Fight or flight’ response)‘Fight or flight’ response)

Window Window

OfOf

ToleranceTolerance

Hypo-arousal (dissociation, depression, self harm Hypo-arousal (dissociation, depression, self harm etc)etc)

Compulsive StrategiesCompulsive Strategies Compulsive compliance (where parent is Compulsive compliance (where parent is

threatening) – watchful; vigilant and compliant threatening) – watchful; vigilant and compliant

Compulsive caregiving (where parent is needy) – Compulsive caregiving (where parent is needy) – role reversal; parentification; children deny own role reversal; parentification; children deny own developmental needsdevelopmental needs

Coercive – combination of threatening and Coercive – combination of threatening and placatory behavioursplacatory behaviours

Controlling strategies (abusive and neglectful) – Controlling strategies (abusive and neglectful) – self is strong and powerful but also dangerous and self is strong and powerful but also dangerous and bad; avoidance and aggression; completely ‘out of bad; avoidance and aggression; completely ‘out of control’ and ‘fearlesscontrol’ and ‘fearless’’

Compulsive caregiving ‘‘Caroline is 18 months old. She lives with her Caroline is 18 months old. She lives with her

mother, who is chronically depressed. The mother, who is chronically depressed. The mother describes the household as ‘noxious mother describes the household as ‘noxious to the soul’. She cannot tolerate the idea to the soul’. She cannot tolerate the idea that her depression is affecting Caroline. She that her depression is affecting Caroline. She says: “Caroline is the only one who makes says: “Caroline is the only one who makes me laugh.” It is observed that Caroline me laugh.” It is observed that Caroline silently enacts the role of a clown. She silently enacts the role of a clown. She disappears into her room and comes out disappears into her room and comes out wearing increasingly more preposterous wearing increasingly more preposterous costumes. Caroline makes her mother laugh, costumes. Caroline makes her mother laugh, but she herself never laughs…’ (Howe, but she herself never laughs…’ (Howe, 1999)1999)

Disorganised attachment stems from Disorganised attachment stems from disruption in the emotional communication, disruption in the emotional communication, or lack of attunement, between parent and or lack of attunement, between parent and

baby. 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.

Borderlinesymptoms in lateadolescence.

Strongest predictor

Dissociativesymptoms in lateadolescence.

Hostile / frightening response.

FrameworkFramework

Physical abuseSexual abuseEmotional abuseNeglectWitnessing IPV

Long-term outcomes

Preventionbeforeoccurrence

Preventionofrecurrence

Preventionofimpairment

Universal

Targeted

Prevention before Prevention before occurrenceoccurrence

Nurse Family PartnershipNurse Family Partnership Intensive home visits during pregnancy and Intensive home visits during pregnancy and

first two yearsfirst two years Goal based; ecological; attachment; self-Goal based; ecological; attachment; self-

efficacy etcefficacy etc Reduced child physical abuse and neglect, as Reduced child physical abuse and neglect, as

measured by official child protection reportsmeasured by official child protection reports Reduced associated outcomes such as injuries Reduced associated outcomes such as injuries

in children of first-time, disadvantaged mothers in children of first-time, disadvantaged mothers Level of evidence: RCTsLevel of evidence: RCTs

Triple PTriple P Dissemination of Triple P professional Dissemination of Triple P professional

training to the existing workforce alongside training to the existing workforce alongside universal media and communication universal media and communication strategies, across 18 randomly assigned strategies, across 18 randomly assigned counties in the UScounties in the US

Showed positive effects on substantiated Showed positive effects on substantiated child protection services reports, out-of-child protection services reports, out-of-home placements, and hospital and home placements, and hospital and emergency reports of injuries emergency reports of injuries

Rates of maltreatment rose in both groupsRates of maltreatment rose in both groups Analysis is not clear, and further evaluation Analysis is not clear, and further evaluation

and replication is recommendedand replication is recommended Level of evidence: one RCTLevel of evidence: one RCT

Healthy Child ProgrammeHealthy Child Programme

Preparation for parenthoodPreparation for parenthood

Supporting bondingSupporting bonding

Supporting attachment and addressing early problemsSupporting attachment and addressing early problems

Supporting parentingSupporting parenting

Identifying and supporting high-risk families – teenage Identifying and supporting high-risk families – teenage parents; domestic violence; parental mental health parents; domestic violence; parental mental health problemsproblems

Preventing re-exposure Preventing re-exposure and impairmentand impairment

Key Intervention ApproachesKey Intervention Approaches Sensitivity/attachment-based: Sensitivity/attachment-based: Interaction Interaction

Guidance; FNPGuidance; FNP Psychotherapeutic: Psychotherapeutic: Parent-infant Parent-infant

psychotherapypsychotherapy Mentalisation: Mentalisation: Minding the BabyMinding the Baby Parenting programmes Parenting programmes – Parents under – Parents under

PressurePressure Parenting Programmes Parenting Programmes – Circle of Security; – Circle of Security;

Baby Triple PBaby Triple P

Nurse Family PartnershipNurse Family Partnership

Intensive home visits during pregnancy and Intensive home visits during pregnancy and first two yearsfirst two years

Goal based; ecological; attachment; self-Goal based; ecological; attachment; self-efficacy etcefficacy etc

Reduced child physical abuse and neglect, as Reduced child physical abuse and neglect, as measured by official child protection reportsmeasured by official child protection reports

Reduced associated outcomes such as injuries Reduced associated outcomes such as injuries in children of first-time, disadvantaged mothers in children of first-time, disadvantaged mothers

Level of evidence: RCTsLevel of evidence: RCTs

Interaction guidanceInteraction guidance Weekly for 10 weeksWeekly for 10 weeks - reinforcement of adequate maternal - reinforcement of adequate maternal

behaviours; modification of behaviours; modification of inappropriate patterns; Video based inappropriate patterns; Video based recordings and coaching of actual recordings and coaching of actual interactionsinteractions

22 FTT mothers and babies - significant 22 FTT mothers and babies - significant reduction decreasing atypical reduction decreasing atypical behaviours and disrupted behaviours and disrupted communication (Benoit et al 2001)communication (Benoit et al 2001)

[Tissot et al., 1999]

PUP ProgrammePUP Programme PUP is underpinned by an ecological model of child PUP is underpinned by an ecological model of child

development and targets multiple domains of development and targets multiple domains of family functioning, including the psychological family functioning, including the psychological functioning of individuals in the family, parent–functioning of individuals in the family, parent–child relationships, and social contextual factors. child relationships, and social contextual factors.

Incorporates ‘mindfulness’ skills that are aimed at Incorporates ‘mindfulness’ skills that are aimed at improving parental affect regulation;improving parental affect regulation;

PUP comprises an intensive, manualized, home-PUP comprises an intensive, manualized, home-based intervention of ten modules conducted in based intervention of ten modules conducted in the family home over 10 to 12 weeks, eachthe family home over 10 to 12 weeks, each

session lasting between one and two hours session lasting between one and two hours

PUP evaluationPUP evaluation Parents Under PressureParents Under Pressure RCT with substance abusing parents of children RCT with substance abusing parents of children

aged 2-8 years (Dawe and Harnett 2007) aged 2-8 years (Dawe and Harnett 2007) Compared PUP with standard parenting Compared PUP with standard parenting

programmeprogramme Significant reductions in parental stress; Significant reductions in parental stress;

methadone dose and child abuse potential methadone dose and child abuse potential (significant worsening in the child abuse (significant worsening in the child abuse potential of parents receiving standard care); potential of parents receiving standard care); improved child behaviour problemsimproved child behaviour problems

Mentalisation-based Mentalisation-based approachesapproaches

Emerging model of intervention that builds on both parent-Emerging model of intervention that builds on both parent-infant psychotherapy and recent advances in advances in infant psychotherapy and recent advances in advances in attachment theoryattachment theory

Minding the Baby is an interdisciplinary, relationship based Minding the Baby is an interdisciplinary, relationship based home visiting program for young, at-risk new mothershome visiting program for young, at-risk new mothers

Delivered by a team that includes a nurse practitioner and Delivered by a team that includes a nurse practitioner and clinical social worker- uses a mentalisation-based approach clinical social worker- uses a mentalisation-based approach that involves working with mothers and babies in a variety that involves working with mothers and babies in a variety of ways to develop mothers' reflective capacitiesof ways to develop mothers' reflective capacities

It aims at addressing relationship disruptions that stem It aims at addressing relationship disruptions that stem from mothers' early trauma and derailed attachment from mothers' early trauma and derailed attachment historyhistory

Only case-study evidence available (Slade et al., 2005)Only case-study evidence available (Slade et al., 2005)

Parent-Infant Parent-Infant PsychotherapyPsychotherapy

Focus on mother’s Focus on mother’s representational world e.g. representational world e.g. the way in which the mother’s the way in which the mother’s current view of her infant is current view of her infant is affected by representations affected by representations from her own historyfrom her own history

Fraiberg ‘Ghosts in the Fraiberg ‘Ghosts in the Nursery’Nursery’

Linking of ghosts with Linking of ghosts with mother’s own history mother’s own history facilitates changes to her facilitates changes to her representational world and representational world and new paths for growth of both new paths for growth of both mother and infantmother and infant

Combined ApproachesCombined Approaches Watch, Wait and WonderWatch, Wait and Wonder

Infant led parent-infant Infant led parent-infant psychotherapypsychotherapy

Mother observes her infant’s Mother observes her infant’s self-initiated activity whilst self-initiated activity whilst being physically accessible being physically accessible to infantto infant

Discussion of these Discussion of these experiences with therapist experiences with therapist as a way of examining the as a way of examining the mother’s internal working mother’s internal working models of herself in relation models of herself in relation to her infantto her infant

RCT of 67 anxiously attached dyads (less than 30 months)

Post Intervention Both WWW and PPT were successful in reducing infant

presenting problems, decreasing parenting stress, reducing maternal intrusiveness and mother-infant conflict

WWW 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 depression

6-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

COS - FindingsCOS - Findings Participants – 65 toddler/preschooler– caregiver Participants – 65 toddler/preschooler– caregiver

dyads recruited from Head Start and Early Head dyads recruited from Head Start and Early Head Start programs;Start programs;

Significant within-subject changes from Significant within-subject changes from disorganized to organized attachment disorganized to organized attachment classifications, with a majority changing to the classifications, with a majority changing to the secure classification;secure classification;

is a promising intervention for the reduction of is a promising intervention for the reduction of disorganized and insecure attachment in high-risk disorganized and insecure attachment in high-risk toddlers and preschoolers toddlers and preschoolers (Hoffman, Irvine and (Hoffman, Irvine and Powell,2006)Powell,2006)

Interaction GuidanceInteraction Guidance Interaction Guidance aims at increasing Interaction Guidance aims at increasing

maternal sensitivity & is a brief (6-7 week) maternal sensitivity & is a brief (6-7 week) intervention designed specifically for families intervention designed specifically for families who have been hard to engage and who have a who have been hard to engage and who have a limited capacity for introspectionlimited capacity for introspection

Benoit et al (2001) compared the effect of a Benoit et al (2001) compared the effect of a play-focused intervention (Interaction Guidance) play-focused intervention (Interaction Guidance) combined with training on feeding, and training combined with training on feeding, and training on feeding alone for parents of babies with FGon feeding alone for parents of babies with FG

28 FTT infants and their mothers – controlled 28 FTT infants and their mothers – controlled studystudy

Results showed that a modified version of Results showed that a modified version of Interaction Guidance was effective in decreasing Interaction Guidance was effective in decreasing atypical behaviours and disrupted atypical behaviours and disrupted communicationcommunication

Parenting ProgrammesParenting Programmes Parents Under PressureParents Under Pressure RCT with substance abusing parents of RCT with substance abusing parents of

children aged 2-8 years (Dawe and Harnett children aged 2-8 years (Dawe and Harnett 2007) 2007)

Compared PUP with standard parenting progCompared PUP with standard parenting prog Significant reductions in parental stress and Significant reductions in parental stress and

methadone dose and child abuse potential methadone dose and child abuse potential (significant worsening in the child abuse (significant worsening in the child abuse potential of parents receiving standard care); potential of parents receiving standard care); improved child behaviour problemsimproved child behaviour problems

Mentalisation-based Mentalisation-based approachesapproaches

Emerging model of intervention that builds on both Emerging model of intervention that builds on both parent-infant psychotherapy and recent advances in parent-infant psychotherapy and recent advances in advances in attachment theoryadvances in attachment theory

Minding the Baby is an interdisciplinary, relationship Minding the Baby is an interdisciplinary, relationship based home visiting program for young, at-risk new based home visiting program for young, at-risk new mothersmothers

Delivered by a team that includes a nurse Delivered by a team that includes a nurse practitioner and clinical social worker- uses a practitioner and clinical social worker- uses a mentalisation-based approach that involves working mentalisation-based approach that involves working with mothers and babies in a variety of ways to with mothers and babies in a variety of ways to develop mothers' reflective capacitiesdevelop mothers' reflective capacities

It aims at addressing relationship disruptions that It aims at addressing relationship disruptions that stem from mothers' early trauma and derailed stem from mothers' early trauma and derailed attachment historyattachment history

Only case-study evidence available (Slade et al., Only case-study evidence available (Slade et al., 2005)2005)

Parent-infant psychotherapyParent-infant psychotherapy Mother and infant meet weekly with a therapist for one Mother and infant meet weekly with a therapist for one

yearyear Joint observation of the infant, and the therapist aims Joint observation of the infant, and the therapist aims

to ‘allow distorted emotional reactions and perceptions to ‘allow distorted emotional reactions and perceptions of the infant as they are enacted during mother–infant of the infant as they are enacted during mother–infant interaction to be associated with memories and affects interaction to be associated with memories and affects from the mother’s prior childhood experiences. the from the mother’s prior childhood experiences. the therapeutic relationship provides the mothertherapeutic relationship provides the mother

with a corrective emotional experience, through which with a corrective emotional experience, through which the mother is able to differentiate current from past the mother is able to differentiate current from past relationships, form positive internal representations relationships, form positive internal representations (Cicchetti et al 2006)(Cicchetti et al 2006)

Parent-infant/child Parent-infant/child psychotherapypsychotherapy

Recent research suggests that parent-infant/child Recent research suggests that parent-infant/child psychotherapy may be an effective means of psychotherapy may be an effective means of improving parent-child interaction (e.g. Cicchetti et improving parent-child interaction (e.g. Cicchetti et al 2006; Toth et al 2002; Cohen et al., 1999)al 2006; Toth et al 2002; Cohen et al., 1999)

There is a range of different types of There is a range of different types of parent-infant/child psychotherapy available - parent-infant/child psychotherapy available - standard representational models of psychotherapy standard representational models of psychotherapy some incorporating behavioural components (e.g. some incorporating behavioural components (e.g. Watch, Wait and Wonder - see Muir (1992) and Watch, Wait and Wonder - see Muir (1992) and Cohen et al. (1999)Cohen et al. (1999)

Research suggests that parents with avoidant Research suggests that parents with avoidant attachment disorder are better suited to more attachment disorder are better suited to more behavioural than representational models of behavioural than representational models of psychotherapy as a result of their inability to psychotherapy as a result of their inability to introspect about the role of earlier experiences on introspect about the role of earlier experiences on current parenting (Bakermans-Kranenburg et al., current parenting (Bakermans-Kranenburg et al., 2003).2003).

SummarySummary Emotional neglect and abuse during first two Emotional neglect and abuse during first two

years are ‘traumatising’years are ‘traumatising’ Evidence base about ‘what works’ is Evidence base about ‘what works’ is

developingdeveloping Interventions that may be effective include: Interventions that may be effective include:

- CBT/affect regulating parenting programmes- CBT/affect regulating parenting programmes

- Interaction Guidance- Interaction Guidance

- Psychotherapeutic approaches including - Psychotherapeutic approaches including parent psychotherapy, parent infant parent psychotherapy, parent infant psychotherapy psychotherapy

- Mentalisation programmes- Mentalisation programmes