1. Children and Young People’s Emotional Wellbeing and Mental Health Conference 10 th October 2012

2. The Importance of the Early Years in Developing Emotional Resilience Jane Barlow Professor of Public Health in the Early Years

3. Structure of paper The impact of the early parent-infant relationship on the child’s later development neurological development attachment security Implications for practice

4. The first year is Foundational Emotional/ social development Intellectual Development Behavioural development InfancyTrust/attachmentAlertness/curiosityImpulse control ToddlerhoodEmpathy Communication/ mastery motivation Coping ChildhoodSocial Relationships Reasoning/problem solving Goal-directed behaviour Adolescence Supportive social network Learning ability/achievement Social responsibility AFFECT REGULATION

5. Why are the early years so important?

6. The Infant Brain Babies born with immature brains Wiring takes place during prenatal period to school-entry – important first two years in response to the environment Most important aspect of the environment is primary caregiver Rapid proliferation and overproduction of synapses followed by loss (pruning) ‘Use it or lose it’ – lost if not functionally confirmed

7. Looks 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 Family’s doting looks help brain to grow Negative looks trigger a different biochemical response (cortisol), stopping these hormones and related growth (Gerhardt, 2004) The Social Baby

8. Babies of depressed mothers: nearly half show reduced brain activity much lower levels of left frontal brain activity (joy; interest; anger) (Dawson et al 2006) 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) The Social Baby

10. Parent-Infant Interaction

11. Nurturance/ Emotional and Behavioural Regulation Key aspects of early parenting that promote ‘secure’ attachment organisation: Sensitivity/attunement (Woolf, van Ijzendoorn 1997) Mid-range contingency (Beebe et al 2010) Reflective Function and Marked Mirroring (Fonagy 2002)/ Mind-Mindedness (Meins et al 2001; 2001)

12. Video Clip One

13. Affect Synchrony

14. By two months the mothers face is the primary source of visuo- affective communication Face-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 The dance – synchrony; rupture; repair Absolutely fundamental to healthy emotional development – prolonged negative states are ‘toxic’ to infants Adults that are incapable of ‘attunement’ i.e. intrusive; depressed, cannot regulate appropriately ‘Affect Synchrony’ – the dance

15. Reflective Function

16. Capacity to understand the infant’s behaviour in terms of internal states/feelings Child’s development of self-organization is dependent on the caregiver's ability to communicate understanding of the child's internal states via ‘marked mirroring’ Reflective function in pregnancy and postnatal period predicts infant attachment security (Fonagy & Target, 2005; Grienenberger, Kelly & Slade, 2005; Slade, Grienenberger, Bernback, Levy & Locker, 2005)

17. Sensitivity or Reflective function A mother who has left her infant to go to another room hears him cry for comfort. She returns to the room and picks him up. Sensitive but ? mind-minded If while comforting the infant she remarks that the baby is crying because he did not want her to leave or felt lonely, this would be classified as ‘appropriate’ mind related comments. If, however, she comments that the baby is crying because she is angry or bored these would be classified as non-attuned’ because they misinterpret the infants likely internal state (Meins, 2010)

18. Attachment and Representations

19. Attachment ‘Attachment’ is an important biobehavioural feedback system that plays a significant role in helping the infant to regulate their emotions particularly when distressed Attachment shapes the child’s adaptive responses, and involves development of ‘internal working models’

21. Internal Working Models Infants begin ‘mapping’ the world from birth; A key aspect of the environment that is mapped is interactions with primary caregivers; Internal maps (IWMs) - enable a person to anticipate and interpret another's behaviour and plan a response Caregiver is experienced as a source of security and support, infant develops a positive self-image and expect positive reactions from others; Infants with non-attuned or abusive caregivers internalise a negative self-image and generalise negative expectations to other relationships

22. Types of attachment Secure (Group B) – able to use caregiver as a secure base in times of stress and to obtain comfort (55-65%) Insecure Anxious/resistant (Group C) – up-regulates in times of stress to maintain closeness (8-10%) Avoidant (Group A) - down-regulates in times of stress to maintain closeness (10-15%) Disorganised (Group D) – unable to establish a regular behavioural strategy (up to 15% in population sample; 80% in abused sample) (Carlson, cicchetti et al 1989)

23. Parenting predicts attachment security Secure (Group B) – predictable, responsive, sensitive/attuned parenting Insecure Anxious/resistant (Group C) – unresponsive, inconsistent Avoidant (Group A) – rejecting, punitive Disorganised (Group D) – Fr-behaviour/Atypical parenting behaviours

24. Fr- and Atypical parenting behaviours Fr-behaviour – frightened AND frightening (Main and Hesse 1990) Atypical/anomalous parenting behaviours (Lyons-Ruth 2003): threatening (looming); dissociative (haunted voice; deferential/timid); disrupted (failure to repair, lack of response), affective communication errors (mother laughing while child distressed) Meta-analysis (12 studies) – strong association between atypical behaviours and disorganised attachment at 12/18months (Madigan et al 2006)

25. Long-term Trajectories

26. Secure Attachment Secure (Group B) – (55-65%) Longitudinal studies show that secure attachment in infancy is associated with optimal later functioning across a range of domains including scholastic, emotional, social and behavioural adjustment, as well as peer-rated social status (e.g. Berlin, Cassidy and Appleyard 2008; Granot, Mayseless 2001; Sroufe 2005).

27. Outcomes of Disorganised attachment Follow-up of children disorganised at 1-year at age 6 (Lieberman and Amaya-Jackson 2005); – controlling behaviours toward parent; – avoidance of the parent; – dissociative symptoms; – behavioural/oppositional problems; – emotional disconnection; – aggression toward peers; – low social competence in preschool Associated with significant psychopathology in childhood and later (Green and Goldwyn 2002)

28. Disorganised/Controlling Attachment Caregivers – unpredictable and rejecting; source of comfort also source of distress Self represented as unlovable, unworthy, capable of causing others to become angry, violent and uncaring Others – frightening, dangerous, unavailable Predominant feelings – fear and anger Little time for exploration or social learning Range of ‘coercive’ strategies developed by child e.g. Controlling strategies and compulsive caregiving

29. Arousal in traumatic/disorganised attachments Hyper-arousal (aggression, impulsive behaviour, children emotional and behavioural problems – ‘Fight or flight’ response) Window of Tolerance Hypo-arousal (dissociation, depression, self harm etc)

30. Parent-infant Interaction Disorganised Attachment - Inability to regulate emotions Normal stresses of childhood 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 (Modified Robin Balbernie 2011)

31. Vulnerable Parents

32. Parent-infant relationship in the face of parental problems Key factors – Domestic violence; mental health problems; substance/alcohol misuse; unresolved trauma Infant’s emotional states trigger profound discomfort in these parents Interaction becomes characterized by: - withdrawal, distancing or neglect (i.e. omission) - intrusion in the form of blaming, shaming, punishing and attacking (i.e. commission)

33. Parental attachment predicts child’s attachment Studies show that parental attachment status predicts child attachment security (Hesse, 2008; van IJzendoorn, Schuengel & Bakermans, 1999) Mothers classified as ‘unresolved’ more likely to develop disorganised attachment relationships with their children (e.g. Lyons-Ruth and Jacobvitz, 1999; van Ijzendoorn et al 1999).

34. Supporting Early Parenting

35. Key Points for Intervening to support attachment Early infancy (4-6 weeks) – Regulation of emotional states - PROMOTING SENSITIVE/ATTUNED INTERACTION AND MIND- MINDEDNESS 7 – 14 months – Safety and Exploration - PROMOTING SECURE ATTACHMENT 15-24 months (toddlerhood) – Developing independence – emerging behaviour problems - PROMOTING POSITIVE PARENTING STRATEGIES

36. Evidence-based programme of interventions

37. Introducing parents to their ‘Social Baby’ Promote closeness and sensitive, attuned parenting (e.g. Skin-to-skin care and the use of soft baby carriers; infant massage etc) Provide parents with information about the sensory and perceptual capabilities of their baby (e.g. The Social Baby book/video or Baby Express newsletters) or validated tools (e.g. Brazelton or NCAST) Underdown A, Barlow J (2011) 'Interventions to support early relationships: mechanisms identified within infant massage programmes.', Community Practitioner, 84 (4),

38. Supporting the Parent-Infant/toddler Relationship Invitation to group-based parenting programmes (e.g. Solihull; Triple P; Mellow Babies; Circle of Security) Father–infant groups that promote opportunities for play and guided observation Individualised coaching (by a skilled professional) aimed at stimulating attuned interactions – videotape feedback Referral to attachment-oriented or parent– infant psychotherapy interventions

39. Anticipating Problems Anticipatory guidance: - practical guidance on managing crying and healthy sleep practices e.g. bath, book, bed routines, and activities - encouragement of parent–infant interaction using a range of media-based interventions Can lead to significant improvements in parents’ routines with children

40. Promoting Early Development Encouragement to use books, music and interactive activities to promote parent–baby relationship and thereby development Disadvantaged families: Group-based interactive support (e.g. PEEP) Encouragement to use good quality early intervention

41. Key Intervention Approaches Sensitivity/attachment-based: Interaction Guidance; FNP Psychotherapeutic: Parent-infant psychotherapy Mentalisation: Minding the Baby Parenting programmes – Parents under Pressure Parenting Programmes – Circle of Security; Baby Triple P

42. Further reading Barlow, J. and Underdown, A. (2008) 'Supporting parenting during infancy', in Child and adolescent mental health today: a handbook, Editors: Jackson, C., Hill, K. and Lavis, P. Brighton: Pavilion Publishing/Mental Health Foundation; Barlow, J. and Underdown, A. (2008) 'Attachment and infant development‘ as above.