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Safeguarding infants from emotional maltreatment: What works? Professor Jane Barlow.

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Presentation on theme: "Safeguarding infants from emotional maltreatment: What works? Professor Jane Barlow."— Presentation transcript:

1 Safeguarding infants from emotional maltreatment: What works? Professor Jane Barlow

2 Structure 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’

3 Emotional Abuse

4 Emotional Abuse – the problem Referrals for primary emotional abuse rose from 4,700 (13%) to 5,100 (20%) over past decade Referrals for primary emotional abuse rose from 4,700 (13%) to 5,100 (20%) over past decade This equates to 4.7 per 10,000 children This equates to 4.7 per 10,000 children As many as 80% of children registered for physical abuse and neglect have also experienced emotional abuse As many as 80% of children registered for physical abuse and neglect have also experienced emotional abuse

5 Subjective Perceptions Large-scale population-based study (involving 2,869 adults) in the UK Large-scale population-based study (involving 2,869 adults) in the UK 6% reported 6% reported - frequent and severe psychological control and domination; - frequent and severe psychological control and domination; - psycho/physical control and domination, humiliation, attacks on self-esteem - psycho/physical control and domination, humiliation, attacks on self-esteem - withdrawal of their primary carer’s attention/affection - withdrawal of their primary carer’s attention/affection - antipathy, terrorising or threatening behaviours and proxy attacks - antipathy, terrorising or threatening behaviours and proxy attacks

6 Five categories defined rejecting: behaviours which communicate or constitute abandonment of the child; rejecting: behaviours which communicate or constitute abandonment of the child; isolating: preventing the child from participating in normal social interaction activities; 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; 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; and ignoring: where the caregiver is psychologically unavailable to the child and fails to respond to the child's behaviour; and corrupting: caregiver behaviour which encourages the child to develop false social values that reinforce antisocial or deviant behavioural patterns corrupting: caregiver behaviour which encourages the child to develop false social values that reinforce antisocial or deviant behavioural patterns (Glaser and Prior,2002) (Glaser and Prior,2002)

7 What 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 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) (Barlow and Schrader-McMillan 2010)

8 Definition Consistent with WHO definition (1999) Consistent 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) 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 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

9 Early Development and Later Wellbeing Infants’ CNS Self-esteem Behaviour Mentalising Relationships Emotional regulation via attachment Empathy Smoking/drugs Promiscuity School failure Delinquency Obesity ETC…Learning Parenting CORE of incipient self

10 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 abuse eating disorders deliberate self-harm suicidal actions Destructive actions: aggression violence rage Retreat: isolation dissociation depression

11 Aspects of Early Development Emotional competence Cognitive Development SocialCompetence InfancyTrust/attachmentAlertness/curiosity Impulse control ToddlerhoodEmpathyCommunication/ mastery motivation Coping Childhood Social Relationships Reasoning/problem solving Goal-directed behaviour Adolescence Supportive social network Learning ability/achievement Social responsibility

12 The Social Baby In first 15 hours baby’s distinguish the voice, smell and face of their mother In first 15 hours baby’s distinguish the voice, smell and face of their mother They connect what they do with what happens immediately after They connect what they do with what happens immediately after Babies have a sophisticated understanding of facial expressions – distinguish between surprise, fear, sadness, anger and delight Babies have a sophisticated understanding of facial expressions – distinguish between surprise, fear, sadness, anger and delight By 10- months babies seek emotional information from others to help them interpret things around them By 10- months babies seek emotional information from others to help them interpret things around them By 10-months baby’s brain has developed according to the type of emotions to which they have been exposed By 10-months baby’s brain has developed according to the type of emotions to which they have been exposed (Beebe and Lachman, 2004) (Beebe and Lachman, 2004)

13 Infant secure Attachment Affect synchrony Containment Mirroring Reflective function i. Attachment behaviours ii. Internal Working Model Sense of ‘self’ Parent-Child Interaction

14 By two months the mothers face is the primary source of visuo-affective communication 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 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 – ‘affect synchrony’ and repairs to ruptures To regulate this infant and mothers regulate the intensity of these interactions – ‘affect synchrony’ and repairs to ruptures Absolutely fundamental to healthy emotional development – prolonged negative states are ‘toxic’ to infants 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 Adults that are incapable of ‘attunement’ i.e. intrusive; depressed, cannot regulate appropriately ‘Affect Synchrony’ – the dance

15 ‘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). ‘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).

16 Videoclip One

17 Reflective Function Capacity to understand the infant’s behaviour in terms of internal states/feelings Capacity to understand the infant’s behaviour in terms of internal states/feelings A key determinant of self-organization which is acquired in the context of the child's early social relationships (Fonagy, 1997) A 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’ 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 Lack of parental RF plays a key role in pathological functioning

18 Videoclip two

19 Affect synchrony in the face of parental problems Infant’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) Infant’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). 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).

20 Videoclip two

21 The Impact on the Developing Neurosystem

22 The Infant’s Brain – Softwiring Unique wiring of individual brain determines how we behave; think; feel; memories etc and our sense of ‘self’ Unique 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 years Wiring takes place during prenatal period to school-entry – important first two years Rapid proliferation and overproduction of synapses followed by loss (pruning) Rapid proliferation and overproduction of synapses followed by loss (pruning) ‘Use it or lose it’ – lost if not functionally confirmed ‘Use it or lose it’ – lost if not functionally confirmed Influenced by genes and environment Influenced by genes and environment Most important aspect of the environment is primary care-taker Most important aspect of the environment is primary care-taker

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25 Looks and smiles help the brain to grow 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 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 Lead to a biochemical response - pleasure neuropeptides (betaendorphin and dopamine) released into brain and helps neurons grow Families doting looks help brain to grow Families doting looks help brain to grow Negative looks trigger a different biochemical response (cortisol) stops these hormones and related growth Negative looks trigger a different biochemical response (cortisol) stops these hormones and related growth (Gerhardt, 2004) (Gerhardt, 2004) For example…

26 Babies of depressed mothers: Babies of depressed mothers: - nearly half show reduced brain activity - nearly half show reduced brain activity - much lower levels of left frontal brain activity (joy; interest; anger) - much lower levels of left frontal brain activity (joy; interest; anger) Early experiences of persistent neglect and trauma: Early experiences of persistent neglect and trauma: - overdevelopment of neurophysiology of brainstem and midbrain (anxiety; impulsivity; poor affect regulation, hyperactivity) - overdevelopment of neurophysiology of brainstem and midbrain (anxiety; impulsivity; poor affect regulation, hyperactivity) - deficits in cortical functions (problem-solving) and limbic function (empathy) - deficits in cortical functions (problem-solving) and limbic function (empathy)

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29 Attachment 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 attachment Sensitive, emotionally responsive care during first year – secure attachment Insensitive, inconsistent or unresponsive care – insecure attachment Insensitive, inconsistent or unresponsive care – insecure attachment

30 The Importance of Attachment Secure base – to explore the world Secure base – to explore the world Prototype for later relations – internal working model is a ‘representational model’ of self and self with other Prototype for later relations – internal working model is a ‘representational model’ of self and self with other Provide child with expectations in relation to self and others Provide child with expectations in relation to self and others

31 Attachment Majority of children (two thirds) who have sensitive care will form secure attachments – 67% Majority of children (two thirds) who have sensitive care will form secure attachments – 67% Remaining children will be: Remaining children will be: - Insecure attachment (i.e. unable to use caregiver to - Insecure attachment (i.e. unable to use caregiver to modulate their aroused state) Avoidant – over-regulate; modulate their aroused state) Avoidant – over-regulate; Resistant – under-regulate Resistant – under-regulate - Disorganised attachment – no consistent patterns of - Disorganised attachment – no consistent patterns of behaviour - conflicting emotions behaviour - conflicting emotions E.g. 82% of abused cf 19% of non-abused children had E.g. 82% of abused cf 19% of non-abused children had disorganised attachment (Carlson, Cicchetti et al., 1989) disorganised attachment (Carlson, Cicchetti et al., 1989)

32 Disorganised/Controlling Attachment 82% of abused cf 19% of non-abused children had disorganised attachment (Carlson, Cicchetti et al., 1989) 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 distress 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 Self represented as unlovable, unworthy, capable of causing others to become angry, violent and uncaring Others – frightening, dangerous, unavailable Others – frightening, dangerous, unavailable Predominant feelings – fear and anger Predominant feelings – fear and anger Little time for exploration or social learning Little time for exploration or social learning

33 Arousal following trauma Hyper-arousal (aggression, impulsive behaviour, children emotional and behavioural problems – ‘Fight or flight’ response) WindowOfTolerance Hypo-arousal (dissociation, depression, self harm etc)

34 Compulsive Strategies Compulsive compliance (where parent is threatening) – watchful; vigilant and compliant Compulsive compliance (where parent is threatening) – watchful; vigilant and compliant Compulsive caregiving (where parent is needy) – role reversal; parentification; children deny own developmental needs Compulsive caregiving (where parent is needy) – role reversal; parentification; children deny own developmental needs Coercive – combination of threatening and placatory behaviours Coercive – combination of threatening and placatory behaviours Controlling strategies (abusive and neglectful) – self is strong and powerful but also dangerous and bad; avoidance and aggression; completely ‘out of control’ and ‘fearless’ Controlling strategies (abusive and neglectful) – self is strong and powerful but also dangerous and bad; avoidance and aggression; completely ‘out of control’ and ‘fearless’

35 Compulsive 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)

36 Disorganised attachment stems from disruption in the emotional communication, or lack of attunement, between parent and baby. Lack of effective regulation of 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.

37 Framework Physical abuse Sexual abuse Emotional abuse Neglect Witnessing IPV Long-term outcomes Prevention before occurrence Prevention of recurrence Prevention of impairment UniversalTargeted

38 Prevention before occurrence

39 Nurse Family Partnership Intensive home visits during pregnancy and first two years Intensive home visits during pregnancy and first two years Goal based; ecological; attachment; self-efficacy etc Goal based; ecological; attachment; self-efficacy etc Reduced child physical abuse and neglect, as measured by official child protection reports Reduced 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 Reduced associated outcomes such as injuries in children of first-time, disadvantaged mothers Level of evidence: RCTs Level of evidence: RCTs

40 Triple P Dissemination of Triple P professional training to the existing workforce alongside universal media and communication strategies, across 18 randomly assigned counties in the US Dissemination 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 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 groups Rates of maltreatment rose in both groups Analysis is not clear, and further evaluation and replication is recommended Analysis is not clear, and further evaluation and replication is recommended Level of evidence: one RCT Level of evidence: one RCT

41 Healthy Child Programme Preparation for parenthood Supporting bonding Supporting attachment and addressing early problems Supporting parenting Identifying and supporting high-risk families – teenage parents; domestic violence; parental mental health problems

42 Preventing re-exposure and impairment

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

44 Nurse Family Partnership Intensive home visits during pregnancy and first two years Intensive home visits during pregnancy and first two years Goal based; ecological; attachment; self-efficacy etc Goal based; ecological; attachment; self-efficacy etc Reduced child physical abuse and neglect, as measured by official child protection reports Reduced 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 Reduced associated outcomes such as injuries in children of first-time, disadvantaged mothers Level of evidence: RCTs Level of evidence: RCTs

45 Interaction guidance Weekly for 10 weeks Weekly for 10 weeks - reinforcement of adequate maternal behaviours; modification of inappropriate patterns; Video based recordings and coaching of actual interactions - 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) 22 FTT mothers and babies - significant reduction decreasing atypical behaviours and disrupted communication (Benoit et al 2001) [Tissot et al., 1999]

46 PUP Programme PUP 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. PUP 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; 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, each PUP comprises an intensive, manualized, home-based intervention of ten modules conducted in the family home over 10 to 12 weeks, each session lasting between one and two hours session lasting between one and two hours

47 PUP evaluation Parents Under Pressure Parents Under Pressure RCT with substance abusing parents of children aged 2-8 years (Dawe and Harnett 2007) RCT with substance abusing parents of children aged 2-8 years (Dawe and Harnett 2007) Compared PUP with standard parenting programme 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 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

48 Mentalisation-based approaches Emerging model of intervention that builds on both parent-infant psychotherapy and recent advances in advances in attachment theory Emerging model of intervention that builds on both parent-infant psychotherapy and recent advances in advances in attachment theory Minding the Baby is an interdisciplinary, relationship based home visiting program for young, at-risk new mothers Minding the Baby is an interdisciplinary, relationship based home visiting program for young, at-risk new mothers Delivered 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 capacities Delivered 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 capacities It aims at addressing relationship disruptions that stem from mothers' early trauma and derailed attachment history It aims at addressing relationship disruptions that stem from mothers' early trauma and derailed attachment history Only case-study evidence available (Slade et al., 2005) Only case-study evidence available (Slade et al., 2005)

49 Parent-Infant Psychotherapy Focus 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 history Focus 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 history Fraiberg ‘Ghosts in the Nursery’ Fraiberg ‘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 Linking of ghosts with mother’s own history facilitates changes to her representational world and new paths for growth of both mother and infant

50 Combined Approaches Watch, Wait and Wonder Watch, Wait and Wonder Infant led parent-infant psychotherapy Infant led parent-infant psychotherapy Mother observes her infant’s self-initiated activity whilst being physically accessible to infant Mother observes her infant’s self-initiated activity whilst being physically accessible to infant Discussion of these experiences with therapist as a way of examining the mother’s internal working models of herself in relation to her infant Discussion of these experiences with therapist as a way of examining the mother’s internal working models of herself in relation to her infant

51  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

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53 COS - Findings Participants – 65 toddler/preschooler– caregiver dyads recruited from Head Start and Early Head Start programs; Participants – 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; 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) is a promising intervention for the reduction of disorganized and insecure attachment in high- risk toddlers and preschoolers (Hoffman, Irvine and Powell,2006)

54 Interaction Guidance Interaction 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 Interaction 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 FG 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 FG 28 FTT infants and their mothers – controlled study 28 FTT infants and their mothers – controlled study Results showed that a modified version of Interaction Guidance was effective in decreasing atypical behaviours and disrupted communication Results showed that a modified version of Interaction Guidance was effective in decreasing atypical behaviours and disrupted communication

55 Parenting Programmes Parents Under Pressure Parents Under Pressure RCT with substance abusing parents of children aged 2-8 years (Dawe and Harnett 2007) RCT with substance abusing parents of children aged 2-8 years (Dawe and Harnett 2007) Compared PUP with standard parenting prog 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 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

56 Mentalisation-based approaches Emerging model of intervention that builds on both parent- infant psychotherapy and recent advances in advances in attachment theory Emerging model of intervention that builds on both parent- infant psychotherapy and recent advances in advances in attachment theory Minding the Baby is an interdisciplinary, relationship based home visiting program for young, at-risk new mothers Minding the Baby is an interdisciplinary, relationship based home visiting program for young, at-risk new mothers Delivered 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 capacities Delivered 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 capacities It aims at addressing relationship disruptions that stem from mothers' early trauma and derailed attachment history It aims at addressing relationship disruptions that stem from mothers' early trauma and derailed attachment history Only case-study evidence available (Slade et al., 2005) Only case-study evidence available (Slade et al., 2005)

57 Parent-infant psychotherapy Mother and infant meet weekly with a therapist for one year Mother and infant meet weekly with a therapist for one year Joint 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 Joint 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) 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)

58 Parent-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) 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) 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). 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).

59 Summary Emotional neglect and abuse during first two years are ‘traumatising’ Emotional neglect and abuse during first two years are ‘traumatising’ Evidence base about ‘what works’ is developing Evidence base about ‘what works’ is developing 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 parent psychotherapy, parent infant psychotherapy - Psychotherapeutic approaches including parent psychotherapy, parent infant psychotherapy - Mentalisation programmes - Mentalisation programmes


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