1. Child Abuse and Neglect: Attachment and development
ESTD Belfast
9 April 2010
David Howe
University of East Anglia, Norwich

2. John Bowlby

3. Behavioural systems
Attachment system  attachment behaviour
Exploratory/
prosocial system  exploratory behaviour
Caregiving system  caregiving behaviour

4. SURVIVAL
REGULATION
physiological,
emotional, cognitive
Attachment
system
Intersubjectivity

5. cortex
limbic
system
brain stem
cerebellum

6. Bruce Perry: The ChildTrauma Academy, 5161 San Felipe,  Suite 320 Houston, Texas 77056
(also see B. Perry 2008, The Boy Who Was Raised as a Dog Basic Books)

7. Affect regulation
How young minds form in the
context of close relationships
(Allan Schore)

8. None of us in born with the capacity to regulate our own emotions.
ATTACHMENT
None of us in born with the capacity
to regulate our own emotions.
The caregiver- child regulatory system
evolves where the infant’s signals
of changes in state are understood
and responded to by the caregiver,
thereby becoming more regulated
- co-regulation of affect.
Peter Fonagy 2000

9. Psychological availability
mind-mindedness
'Mentalisation'
attunement
sensitivity

10. The parents’ capacity to observe the child’s
Sensitivity and mentalisation
The parents’ capacity to observe the child’s
mind seems to facilitate the child’s
general understanding of minds, and
hence his/her self-organisation through
the medium of a secure attachment.
Peter Fonagy

11. The child has the opportunity to ‘find
Mentalisation: Peter Fonagy and Patrick Luyten 2009
The child has the opportunity to ‘find
himself/herself in the other’ as someone
with thoughts and feelings - with a mind.
The child recognises themselves and others
as intentional beings. Mentalisation is
the imaginative mental activity that enables
us to perceive and interpret human
behaviour in terms of intentional mental
states.
Impairments in mentalisation play a role in
a variety of psychopathologies of the self.

12. Internal working model: cognition
self
others
relationship
nb Kenneth Craik (1943) and
J. Z. Young A Model for the Brain 1964.

13. Patterns of attachment
SECURE
INSECURE
organised
INSECURE
organised
AVOIDANT
AMBIVALENT
INSECURE
DISORGANISED

14. Helpless/hostile caregiving
The helpless stance involves failing to provide protection and regulation for the child
Helpless states of mind - without strategies - a state in which the parent abdicates care and protection for the child, failing to terminate the child’s attachment system.
Mentalisation goes ‘off-line’

15. Helpless/hostile caregiving
Feelings of fear, helplessness and hostility which result in frightening/ frightened behaviour might be the result of parents being unable to control frightening memories or emotions associated with their own childhood loss/traumas.

16. Helpless/hostile caregiving
Helpless states of mind - infant’s pain and fear evokes carer’s own past unresolved losses and fears + helplessness to know how to find comfort and safety.
Carers find it difficult to hear, respond to and help modulate fear and distress in their child.
Carers therefore both evoke fear in their children AND fail to recognise it.

17. Disorganised/disorientated attachments: infancy
Disorganised attachments arise when the attached infant has been alarmed by the parent rather than the external situation.
The parent is experienced as:
Frightening physically alarming/hostile
dangerous parental behaviour
Frightened psychologically alarming
parental behaviour/helpless

18. DISORGANISED ATTACHMENTS
Simultaneous activation of two
incompatible behavioural responses:
FEAR and ATTACHMENT
(avoidance) (approach)
fear without escape; fright without solution.
E. Hesse and M. Main

19. Abandonment
Aloneness
Rejection
Danger

20. Relational trauma

21. Caregiving and disorganised attachments
Physical, emotional and/or sexual abuse, including rejection
Severe neglect and deprivation
Misuse/abuse of alcohol/drugs
Serious affective disorder eg
depression
Unresolved losses/childhood traumas
Domestic violence
Multiple placements

22. Disorganised attachments in young childhood
ecological transactions
mediators
Adult psychopathology

23. Maltreated Children
Many abused and neglected children find mentalisation hard, particularly in interpersonal and intimate relationships because mentalising interactively is one of the most complex tasks.
It is at these times that we are all vulnerable to hyperarousal and we need a buffer to protect us against overwhelming affect – it is mentalisation that acts as a cushion.
Bateman and Fonagy 2004

24. response: makes children aggressive, impulsive, needy, frightened.
Maltreated Children
For maltreated children, hyperarousal throws mentalisation ‘off-line’ – the result is panic, impulsive behaviour, fight-flight
response: makes children aggressive, impulsive, needy,
frightened.
Under extreme trauma, a freeze-
dissociative response is more likely.
Bateman and Fonagy 2004

25. Fearful and preoccupied attachments, emotionally
For example, Borderline Personality Disorder:
Fearful and preoccupied attachments, emotionally
needy, feelings of being unloved and vulnerable,
painful intolerance of aloneness, hypersensitivity
to social environment, expectation of hostility from
others, elevated rates of co-morbidity with
dissociation, disturbed sense of identity, poor
mentalization, poor self-regulation, poor sense
of self agency. Relationship chaos.
Strong links with emotional neglect and
emotional maltreatment in early childhood –
child’s internal experiences not adequately
recognised, mirrored, enjoyed.

26. executive (mentalising) to automatic (flight or fight) responding.
Low arousal/stress threshold in the context of close relationships sees a switch from
executive (mentalising) to automatic (flight or fight) responding.
Therefore low threshold of attachment system activation + simultaneous
switch to low mentalisation, both of which further intensify the relationship with the other.
P. Fonagy and P. Luyten 2009: A developmental, mentalization-based
approach…to BPD, Development and Psychopathology, 21, pp

27. representations of another person’s
We hypothesize that that the failure to think and reflect about self, others and feelings might leave the individual with difficulties in decoupling their
representations of another person’s
experience from their own self-representations (reflected in terms of brain structures subserving the processes of knowing self and others).
P. Fonagy and P. Luyten 2009: A developmental, mentalization-based
approach…to BPD, Development and Psychopathology, 21, pp

28. When mentalization fails, any sense of
loss, rejection, abandonment or disinterest
in the context of a close relationship feels
catastrophic. There is the constant danger
of being overwhelmed by the other’s
mental state. Psychic equivalence –
subjective experience feels intensively real.
Fight-flight responses.
Emotional neglect + abuse/trauma:
freeze, dissociative response (pretend mode
losing connection with reality).

29. Controlling Children
Controlling strategies empower the child, allowing them to disown representations of the self as helpless, vulnerable and needing comfort - with this some degree of mental and behavioural coherence is achieved.
However, when the child’s attachment system is strongly activated, this coherence is quickly destroyed:  irrational, catastrophic, self-destructive ideation
Under such stresses, the fragile unitary representation of the self as ‘controlling’ is underpinned by a disorganised, dissociated iwm of self.

30. compulsive caregiving/parentification compulsive compliance
Controlling behaviours
compulsive caregiving/parentification
compulsive compliance
compulsive self-reliance
aggressive/punitive behaviours

31. Bowlby (1980) proposed 2 major defensive strategies:
defensive exclusion, and
‘segregation of principal systems.’
Both have the effect of shutting available, but potentially anxiety-provoking, information out of awareness.

32. Segregated mental systems is the more severe
defence – it occurs when 2 or more selves are segregated from each other – walled off - each having access to its own sectionalised memory store or internal working model = dissociative processes, including DID.
The selves can alternate in consciousness, but generally only one is dominant at any one time.

33. Liotti, G. (2004). Trauma, dissociation, and disorganized attachment: three strands of a single braid. Psychotherapy: theory, research, practice and training, 41:

34. fearful – out-of-control unresolved caregiving
helpless – hostile
fearful – out-of-control
unresolved caregiving
parent-caregiver
Hostile
persecutor
controlling
punitive
aggressive
self-reliant
frightening
bad/evil
Helpless
victim
frightened
compliant
sad
Protective
controlling
caregiving
rescuer
comforting
child
disorganised/rage/out-of-control/dissociation

35. Liotti also found that 62% of adults diagnosed with dissociative disorders had mothers who had lost a close relative within 2 years of their children’s birth. Similar risk also found if mother also suffered a traumatic experience within 2 years of child’s birth.

36. PAST TRAUMA: afraid and alone
Trauma and stress pile-up: Allen 2001
PAST TRAUMA: afraid and alone
Sensitised nervous system
CURRENT STRESS: reminders of trauma
Unbearably painful emotional states
RETREAT
isolation
dissociation
depression
SELF-DESTRUCTIVE
ACTIONS
substance abuse
eating disorders
self-harm
suicidal ideation
DESTRUCTIVE
ACTS
aggression
violence
rages

37. Bruce Perry: The ChildTrauma Academy, 5161 San Felipe,  Suite 320 Houston, Texas 77056
(also see B. Perry 2008, The Boy Who Was Raised as a Dog Basic Books)

38. behavioural and cognitive development social support and relationships
Bottom-up, inside to outside
Respond to developmental age and not chronological age
Relationships as the most powerful of therapeutic experiences
behavioural and cognitive development
social support and relationships
peer relationships
social cognition, understanding, empathy
mentalisation, play, attunement,
affect regulation
predictability, repetition, routines, structure
safe and in control
music, movement and dance
sensory integration treatments
rocking, touch, massage

39. The aim when working with parents is to
help them develop their capacity for
reflective functioning; to help them
mentalise their own and their children’s
experience.
It is difficult for children to change without
their environment also changing.

40. When I work with a parent, I am trying to
create a context in which he or she can
slowly shift from a physical to a reflective
or mentalizing stance. That is, I hold the
child in mind for the parent as a mentalizing
being, as a person whose feelings and
behaviors are inextricably interrelated,
and whose feelings and behaviors are
inextricably intertwined with theirs as a
parent. Most importantly, I see the child’s
behavior as meaningful.
A. Slade (2008)

41. Creation of space where the parent feels
Working with parents
Creation of space where the parent feels
it is safe to mentalise, explore, name,
and play with mental states – a playspace.
2. Holding the parent in mind so that the
parent can begin to hold the child in mind.
3. Establish a working alliance in which the
worker models the reflective stance in
which the links between behaviour and
mental states is constantly underscored.
A. Slade (2008)

42. The aim is to help parents enter their
child’s experience as a means of
understanding them.
Abusive parents tend to distort their
child’s internal life and intentions –
mis-attributions.
Neglectful parents tend to block out,
ignore and disconnect from their child’s
internal world resulting in a vacuous
relationship between parent and child.

43. In order to understand parents’ intent, we will
need to get ‘inside’ their adaptive strategies.
That is, understanding how they develop over
childhood… we will need to think and feel like
someone using their strategy if we are to
understand parents who harm their children.
Once we can do that, we may be able to join
parents meaningfully and guide them safely to a
less dangerous reality. Without understanding
them as they understand themselves, we may
not be able to help.
P. Crittenden 2008: Raising Parents, p 120

44. Treatment needs to involve psychological and
Transitional attachment figure
Once the parent sees or feels that the practitioner understands, the worker can act as a transitional attachment figure in the parent’s zone of proximal development.
Treatment needs to involve psychological and
behavioural reorganisation, as opposed to
symptom reduction.

45. Mentalization-Based Treatment (MBT)
Focuses on the patient’s capacity to
mentalize in the context of an attachment
relationship.

46. Clinical evidence suggests that as the
MBT
Clinical evidence suggests that as the
attachment bond between therapist and
patient intensifies, the quality of BPD
patient’s mentalization deteriorates.
With BPD patients, beware treatments that
focus on gaining insights into the traumatic
past  high stress, hyperactivation of
(fearfully preoccupied) attachment
system, non-mentalising stance,
fight-flight-freeze responses.

47. Child Abuse and Neglect attachment, development
David Howe
Child Abuse and Neglect
attachment, development
and intervention
Palgrave/Macmillan
2005