The Origins, Clinical Innovations and Evidence-Basis for Infant and Early Childhood PsychotherapyConsuelo E. Cavalieri, Ph.D.

Cavalieri, C. E. (2011, May). The origins, clinical innovations and evidence-basis for infant and early childhood psychotherapy. Workshop presented at the meeting of the Minnesota Association for Children’s Mental Health, Duluth, Minnesota.

• Historical Perspectives

• Attachment Theory

• Relationship Intervention

• Evidence-Basis for Child-Parent Psychotherapy

Plan for Today’s Presentation

Infant Mental Health Competencies

• Relationship-Based, Therapeutic Practice

• Psychotherapeutic and Behavioral Theories of Change

Institutional Care

Restricted Visiting Hours

“A Two Year Old Goes to Hospital”

Protest, Despair, & Detachment Sequence

(Bowlby, 1969/1982; Bretherton, 1992; Karen, 1994; Markel, 2008)

Hospitalism

“...a vitiated condition of the body due to long confinement in a hospital, or the morbid condition of the atmosphere of a hospital.”

(Spitz, 1945, p. 53)

The Role of Maternal Deprivation on Development

EnvironmentCultural and Social

Background

Developmental Quotient first 4

months

Developmental Quotient last 4

months

Parental Home Professional (Urban)

Village (isolated, fishing)

133

107

131

108

Institution Nursery (penal institution for delinquent girls)

Foundling Home

101.5

124

105

72

(Spitz, 1945)

Spitz’ Additional Findings

• Extreme friendliness (indiscriminate friendliness)

• Anxious avoidance of inanimate objects

• Generalized anxiety--blood curdling screams

• Bizarre stereotyped motor patterns (disorganized attachment)

• Delays in language acquisition, independent feeding, walking

• Susceptibility to illness

(Spitz, 1945)

Dispelling the Feeding Hypothesis

Wire vs. Cloth Mother Surrogate

Contact Comfort

(Harlow, 1958)

Attachment Theory

The propensity to be “strongly disposed to seek proximity to and contact with a specific figure and to do so in certain situations, notably when he is frightened, tired or ill.”

(Bowlby, 1982, p. 371)

Internal Working Models

• Self & Other

• Expectations

• Misinformation

(Bowlby, 1980; Bretherton, 1987, 1990; Bretherton & Munholland, 2008)

Patterns of Attachment

• Sensitive Responsiveness

• Strange Situation

• Secure

• Anxious Avoidant

• Anxious Ambivalent/Resistant

• Disorganized

(Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1986)

“In every nursery, there are ghosts...”

(Fraiberg, 1980)

Ghosts in the Nursery

Child-Parent Psychotherapy

(Lieberman & Van Horn, 2008)

Culture & Context

• Emotions without lasting collapse

• Trusting relationships

• Development of culturally competent behavior

Adaptive Functioning

(Lieberman & Van Horn, 2008)

Format

• Presence of attachment figures

• Flexible session length

• Location in home, clinic or other setting

• Range of toys

(Lieberman & Van Horn, 2008)

Domains of Functioning

• Presenting Problem

• Cognitive

• Social

• Emotional

(Lieberman & Van Horn, 2008)

Continuum of Adaptive-Maladaptive

• Perturbations--healthy features of functioning despite strains

• Disturbances--problematic but subclinical distress

• Disorders--meet criteria for diagnosis

(Lieberman & Van Horn, 2008)

Attachment-Caregiving Relationship Problems

• Role Reversal

• Elevated Distress

• Withdrawn

(Lieberman & Van Horn, 2008)

Talking to Children About Therapy

• Link prior distressing/frightening experiences to arrival for therapy

• Work with parent to prepare child prior to first session

(Lieberman & Van Horn, 2008)

Primary Clinical Task: to serve as translator of the child and parent’s subjective experiences (Lieberman & Van Horn, 2008)

• Developmental Guidance

• Putting Feelings into Words: Trauma Narratives

• Modeling Protective Behavior

Therapeutic Strategies

(Lieberman & Van Horn, 2008)

Clinical Trials with Child Parent Psychotherapy

• Anxiously attached toddlers who have immigrated to U.S.

• Preschoolers exposed to Marital Violence

• Toddler’s of Depressed Mothers

• Maltreated Preschoolers

(Cicchetti, Rogosch, & Toth, 2000; Lieberman, Ippen, & Van Horn, 2006; Lieberman, Van Horn, & Ippen, 2005; Lieberman, Weston, & Pawl, 1991; Toth, Maughan, Manly, Spagnola, & Cicchetti, 2002)

Toddlers Who Were Anxiously Attached to Mothers

Reduced Toddler’s Angry BehaviorDecreased AvoidanceDecreased ResistancePromoted Goal-Corrected Partnership

(Lieberman, et al., 1991)

Preschoolers’ Exposed to Marital Violence

Treatment End

•Reduced child’s traumatic symptoms and diagnoses of PTSD

•Reduced child’s behavior problems

•Mothers showed less avoidance symptoms of PTSD

6-month follow-up

• Children had fewer behavioral problems compared to control

• Mothers reported less psychological distress

(Lieberman, et al., 2006; Lieberman, et al., 2005)

Toddlers of Depressed Mothers

Prevented cognitive decreases that occurred with children of depressed mothers

(Cicchetti, et al., 2000)

Maltreated Preschoolers

•Increase in adaptive representations of mothers•Decrease in maladaptive representations of mothers•Increase in positive self-representations•Decrease in negative self-representations

(Toth, et al., 2002)

Summary of Evidence

Children

• Restoration of safety

• Decreased negative self-representations

• Increased positive self-representations

• Prevention of cognitive declines assoc. with maternal depression

• Reduced problematic behaviors

Mothers

• Increase in empathic understanding

• Reduced psychological distress

• Reduced PTSD symptoms

Recommendations for Practice

1.The Relationship is the client, not the individuals

2.Good developmental knowledge is essential

3.Sometimes observing rather than actively intervening is best

4.Need supervisor who is your secure base with whom you reflect upon your “ghosts” and the feelings associated with this work

(Lieberman & Van Horn, 2008)

References

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.Bowlby, J. (1969/1982). Attachment and loss (Vol. I). New York: Basic Books.Bowlby, J. (1980). Attachment and loss (Vol. III). New York: Basic Books.Bretherton, I. (1987). New perspectives on attachment relations: Security, communication, and internal working models. In J. D. Osofsky (Ed.), Handbook of infant

development (pp. 1061-1100). New York: Wiley.Bretherton, I. (1990). Open communication and internal working models: Their role in the development of attachment relationships. In R. A. Thompson (Ed.), Nebraska

Symposium on Motivation: Vol. 36. Socioemotional development (pp. 59-113). Lincoln: University of Nebraska Press.Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28, 759-775. Bretherton, I., & Munholland, K. A. (2008). Internal working models in attachment relationships: Elaborating a central construct in attachment theory. In J. Cassidy & P. R.

Shaver (Eds.), Handbook of Attachment: Theory, research, and clinical applications (2nd ed.). New York: Guilford Press.Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2000). The efficacy of toddler-parent psychotherapy for fostering cognitive development in offspring of depressed mothers. Journal

of Abnormal Child Psychology, 28, 135-148. doi: 10.1023/A:1005118713814Fraiberg, S. (1980). Clinical Studeies in Infant Mental Health. New York: Basic Books.Karen, R. (1994). Becoming Attached. New York: Oxford University Press.Lieberman, A. F., Ippen, C. G., & Van Horn, P. (2006). Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial. Journal of the American Academy of

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the American Academy of Child and Adolescent Psychiatry, 44, 1241-1248. Lieberman, A. F., Weston, D. R., & Pawl, J. H. (1991). Preventative intervention and outcome with anxiously attached dyads. Child Development, 62, 199-209. doi:

10.2307/1130715Main, M., & Solomon, J. (1986). Discovery of a new, insecure-disorganized/disoriented attachment pattern. In T. B. Brazelton & M. W. Yogman (Eds.), Affective Development in

Infancy (pp. 95-124). Norwood: Ablex.Markel, H. (2008, January 1). When hospitals kept children from parents, The New York Times. Retrieved from http://www.nytimes.comToth, S. L., Maughan, A., Manly, J. T., Spagnola, M., & Cicchetti, D. (2002). The relative efficacy of two interventions in altering maltreated preschool children's representational

models: Implications for attachment theory. Development and Psychopathology, 14, 877-908. doi: 10.1017/S095457940200411X