Presentation on theme: "Preventing and Treating Emotional Abuse:"— Presentation transcript:
1Preventing and Treating Emotional Abuse: Getting it Right from the StartJane BarlowProfessor of Public Healthin the Early Years
2Structure of paper Emotional Abuse – what is it? Why are the early years so important?What characterises ‘high risk’ parents?What should we be doing…?
3What 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
4Emotional Abuse – the problem Referrals for primary emotional abuse rose from 4,700 (13%) to 5,100 (20%) over past decadeThis equates to 4.7 per 10,000 childrenAs many as 80% of children registered for physical abuse and neglect have also experienced emotional abuse
5Subjective Perceptions Large-scale population-based study (involving 2,869 adults) in the UK6% reported- frequent and severe psychological control and domination;- psycho/physical control and domination, humiliation, attacks on self-esteem- withdrawal of their primary carer’s attention/affection- antipathy, terrorising or threatening behaviours and proxy attacks
6The first three years – why are they SO important?
7Sensitised nervous system as brain adapts to emotional environment Trauma in infancy:attachment system compromisedSensitised nervous system as brain adapts to emotional environmentStress in childreminders & experiences of trauma,life events, etc.Unbearably painful emotional statesRetreat:isolationdissociationdepressionSelf-destructiveactions:substance abuseeating disordersdeliberate self-harmsuicidal actionsDestructiveactions:aggressionviolencerage(Robin Balbernie 2011)
8Aspects of Early Development Emotional/social developmentIntellectual DevelopmentBehaviouraldevelopmentInfancyTrust/attachmentAlertness/curiosityImpulse controlToddlerhoodEmpathyCommunication/mastery motivationCopingChildhoodSocial RelationshipsReasoning/problem solvingGoal-directed behaviourAdolescenceSupportive social networkLearning ability/achievementSocial responsibilityAFFECT REGULATION
11The Social BabyIn first 15 hours baby’s distinguish the voice, smell and face of their motherThey connect what they do with what happens immediately afterBabies have a sophisticated understanding of facial expressions – distinguish between surprise, fear, sadness, anger and delightBy 10- months babies seek emotional information from others to help them interpret things around themBy 10-months baby’s brain has developed according to the type of emotions to which they have been exposed (Beebe and Lachman, 2004)
12Important aspects of early parenting Sensitivity/attunement and contingent interactionReflective function
14Contingent Interaction By two months the mothers face is the primary source of visuo-affective communicationFace-to-face interactions emerge which are high arousing, affect-laden and expose infants to high levels of cognitive and social information and stimulationTo regulate this infant and mothers regulate the intensity of these interactions – ‘affect synchrony’ and repairs to rupturesAbsolutely fundamental to healthy emotional development – prolonged negative states are ‘toxic’ to infants14
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 mis-coordination: 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).
17Reflective FunctionCapacity to understand the infant’s behaviour in terms of internal states/feelingsA 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’Lack of parental RF plays a key role in pathological functioning
19Attachment What is it:? What is its function?: - 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 attachmentInsensitive, inconsistent or unresponsive care – insecure/disorganised attachment
20Who is securely attached? Secure (Group B) – able to use caregiver as a secure base in times of stress and to obtain comfort (55-65%)InsecureAnxious/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)20
21Child abuse and attachment Up to 80% of children who are abused have a ‘disorganised attachment’In maltreating families parent-child interactions characterised by hostility; low levels of reciprocity, engagement and synchrony, unpredictability (ignoring plus intrusive hostility)Disorganised attachment predicts very poor outcomes including a range of social and cognitive difficulties, and psychopathologySafeguarding practitioners MUST have this developmental model at the core of their practice21
22Disorganised/Controlling Attachment Caregivers – unpredictable and rejecting; source of comfort also source of distressSelf represented as unlovable, unworthy, capable of causing others to become angry, violent and uncaringOthers – frightening, dangerous, unavailablePredominant feelings – fear and angerLittle time for exploration or social learning
23Arousal in traumatic attachments Hyper-arousal (aggression, impulsive behaviour, children emotional and behavioural problems – ‘Fight or flight’ response)WindowOfToleranceHypo-arousal (dissociation, depression, self harm etc)
24Compulsive Strategies Compulsive compliance (where parent is threatening) – watchful; vigilant and compliantCompulsive caregiving (where parent is needy) – role reversal; parentification; children deny own developmental needsCoercive – combination of threatening and placatory behavioursControlling strategies (abusive and neglectful) – self is strong and powerful but also dangerous and bad; avoidance and aggression; completely ‘out of control’ and ‘fearless’
25Compulsive 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).’
27Affect 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)Interaction becomes characterized by:- withdrawal, distancing or neglect (i.e. omission)- intrusion in the form of blaming, shaming, punishing and attacking (i.e. commission)
28Unresolved/disorganised parents Unresolved loss; abuse; or trauma and in ‘continuing state of fear’Fr-Behaviour - frightened and frightening; hostile and helplessAtypical Maternal Behaviors – affective communication errors; disorientation; negative-intrusive behaviours;53% of parents with unresolved states of mind had infants classified as disorganized (van IJzendoorn, 1995).
30Getting it right first time… Identify high risk families during pregnancy – pre-birth assessments;Ideally intervention is offered ante-natally - FNPAssess parent-infant interactionProvide time-limited EB intervention and clear goals to be achieved; re-assess interactionRemove infants where there is insufficient improvement before 6 months ideally, end of first year at worst
31Standardised ScalesPIR-GAS – Parent Infant Relationship Global Assessment Scale (Zero to Three 1994)KIPS – Keys to Interactive Parenting ScaleNCAST – Nursing Child Assessment Satellite Training (Kelly and Barnard 2000; Barnard 1994)ADBS - Alarm Distress Baby Scale (Guedeney and Fermanian 2001)CARE-Index (Crittenden 1984)PIRAT - Parent-Infant Relational Assessment Tool (Broughton 2010)EAS - Emotional Availability Scales (Biringen 2010)
32Evidence-Based Interventions Sensitivity/attachment-based: Interaction Guidance; FNPPsychotherapeutic: Parent-infant psychotherapyParenting programmes – Parents under Pressure; Parent-Child Interaction TherapyMentalisation: Minding the Baby
33Commonalities‘Dyadic’ - focus on parent-child interaction with emphasis on the child’s attachment; parental sensitivity; parental reflective function etcUnderpinned by a clear mechanism for changeEmphasis on relationship between therapist/provider and parent
34Video-Interaction Guidance Practitioners videotapes parent-infant interactions and sharesVideo jointly reviewed by practitioner and parent using micro-moments of successful contact with the aim of reflecting on strengths in the parent’s ability to attuneReflective discussion involves support and information about how to enhance their relationship with their child as well as activating the parent to reflect on their child and themselves and their relationship.
35EvidenceVideo feedback interventions effective improving parenting behaviour; parenting attitudes; and children’s behaviour (Fukkink 2008)Includes children of all agesVIG effective in reducing disorganised attachment in abused children (Moss et al 2011)
36Parent-Infant Psychotherapy Watch, Wait and Wonder (Cohen et al 2001)Infant led parent-infant psychotherapyMother observes her infant’s self-initiated activity whilst being physically accessible to infantDiscussion of these experiences with therapist as a way of examining the mother’s internal working models of herself in relation to her infant
37Evidence of Effectiveness Evidence from rigorous studies highlighting the benefits of parent-child psychotherapy for:- children exposed to severely compromised or traumatising (e.g. DV) environments (Lieberman et al 2008; 2004;- parents who are emotionally abusive (Cicchetti et al 2006) or who have major depressive disorder (Toth et al 2006);- preliminary clinical studies have also examined the value of this approach with parents with Borderline Personality Disorder (Newman & Stevenson 2008)
38PUP ProgrammePUP 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 hoursPUP 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;
39PUP evaluation Parents Under Pressure RCT with substance abusing parents of children aged 2-8 years (Dawe and Harnett 2007)Compared PUP with standard parenting programmeSignificant 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
40Parent-Child Interaction Therapy PCIT is a short-term, parent training programmeBased on both attachment and social learning theoryIt is directed at families with 2- to 6-yr-old children experiencing behavioral, emotional, or family problemsRigorous research evidence about its effectiveness with physically abusive parents (Hakman et al 2009; Chaffin et al2004)
41Manualised programme; assessment driven (i. e Manualised programme; assessment driven (i.e. parents have mastered the skills) not time-limited;Two phases – Child Directed Interaction (CDI); Parent Directed Interaction (PDI)Emphasis throughout on interaction between parent and child;CDI concentrates on strengthening parent-child attachment as a foundation for PDI, which emphasizes a structured and consistent approach to discipline
42Mentalisation-based approaches Emerging model of intervention that builds on both parent-infant psychotherapy and recent advances in advances in attachment theoryMinding the Baby is an interdisciplinary, relationship based home visiting program for young, at-risk new mothersDelivered 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 capacitiesIt aims at addressing relationship disruptions that stem from mothers' early trauma and derailed attachment historyOnly case-study evidence available (Slade et al., 2005)
43SummaryImportance of identifying high risk families and conducting pre-birth assessmentIntervention should begin ante-natally if possible;Post-natal assessment should include parent-infant interactionTime-limited intervention with clear goalsA range of evidence-based universal and targeted interventions to support parent-child interaction;
44PublicationsBarlow J, Scott J (2010). Safeguarding in the 21st Century: Where to Now? Dartington: Research in Practice.www.rip.org.ukBarlow J, Schrader-McMillan A (2010). Safeguarding Children from Emotional Abuse: What Works? London: Jessica Kingsley.