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Preventing and Treating Emotional Abuse: Getting it Right from the Start Jane Barlow Professor of Public Health in the Early Years.

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Presentation on theme: "Preventing and Treating Emotional Abuse: Getting it Right from the Start Jane Barlow Professor of Public Health in the Early Years."— Presentation transcript:

1 Preventing and Treating Emotional Abuse: Getting it Right from the Start Jane Barlow Professor of Public Health in the Early Years

2 Structure of paper Emotional Abuse – what is it? Why are the early years so important? What characterises high risk parents? What should we be doing…?

3 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 childrens 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 childrens development and socialisation

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 carers attention/affection - withdrawal of their primary carers attention/affection - antipathy, terrorising or threatening behaviours and proxy attacks - antipathy, terrorising or threatening behaviours and proxy attacks

6 The first three years – why are they SO important?

7 Trauma in infancy: attachment system compromised Sensitised nervous system as brain adapts to emotional environment Stress in child 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 (Robin Balbernie 2011)

8 Aspects of Early Development Emotional/ social development Intellectual Development Behaviouraldevelopment 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 AFFECT REGULATION

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11 The Social Baby In first 15 hours babys distinguish the voice, smell and face of their mother In first 15 hours babys 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 babys brain has developed according to the type of emotions to which they have been exposed By 10-months babys brain has developed according to the type of emotions to which they have been exposed (Beebe and Lachman, 2004)

12 Important aspects of early parenting Sensitivity/attunement and contingent interaction Reflective function

13 Contingent 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 Contingent Interaction

15 Attuned mutual co-ordination between mother and infant occurs when the infants squeal of delight is matched by the mothers 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).

16 Reflective Function

17 Capacity to understand the infants behaviour in terms of internal states/feelings Capacity to understand the infants 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 1

19 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 Insensitive, inconsistent or unresponsive care – insecure/disorganised attachment

20 Who is securely attached? 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)

21 Child abuse and attachment Up to 80% of children who are abused have a disorganised 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) 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 psychopathology Disorganised attachment predicts very poor outcomes including a range of social and cognitive difficulties, and psychopathology Safeguarding practitioners MUST have this developmental model at the core of their practice Safeguarding practitioners MUST have this developmental model at the core of their practice

22 Disorganised/Controlling Attachment 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

23 Arousal in traumatic attachments Hyper-arousal (aggression, impulsive behaviour, children emotional and behavioural problems – Fight or flight response) WindowOfTolerance Hypo-arousal (dissociation, depression, self harm etc)

24 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

25 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. 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) 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)

26 Vulnerable Parents

27 Affect synchrony in the face of parental problems Infants 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)

28 Unresolved/disorganised parents Unresolved loss; abuse; or trauma and in continuing state of fear Unresolved loss; abuse; or trauma and in continuing state of fear Fr-Behaviour - frightened and frightening; hostile and helpless Fr-Behaviour - frightened and frightening; hostile and helpless Atypical Maternal Behaviors – affective communication errors; disorientation; negative- intrusive behaviours; Atypical 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) 53% of parents with unresolved states of mind had infants classified as disorganized (van IJzendoorn, 1995)

29 Videoclip – Severely suboptimal M-I interaction

30 Getting it right first time… Identify high risk families during pregnancy – pre-birth assessments; Identify high risk families during pregnancy – pre-birth assessments; Ideally intervention is offered ante-natally - FNP Ideally intervention is offered ante-natally - FNP Assess parent-infant interaction Assess parent-infant interaction Provide time-limited EB intervention and clear goals to be achieved; re-assess interaction Provide time-limited EB intervention and clear goals to be achieved; re-assess interaction Remove infants where there is insufficient improvement before 6 months ideally, end of first year at worst Remove infants where there is insufficient improvement before 6 months ideally, end of first year at worst

31 Standardised Scales PIR-GAS – Parent Infant Relationship Global Assessment Scale (Zero to Three 1994) PIR-GAS – Parent Infant Relationship Global Assessment Scale (Zero to Three 1994) KIPS – Keys to Interactive Parenting Scale KIPS – Keys to Interactive Parenting Scale NCAST – Nursing Child Assessment Satellite Training (Kelly and Barnard 2000; Barnard 1994) NCAST – Nursing Child Assessment Satellite Training (Kelly and Barnard 2000; Barnard 1994) ADBS - Alarm Distress Baby Scale (Guedeney and Fermanian 2001) ADBS - Alarm Distress Baby Scale (Guedeney and Fermanian 2001) CARE-Index (Crittenden 1984) CARE-Index (Crittenden 1984) PIRAT - Parent-Infant Relational Assessment Tool (Broughton 2010) PIRAT - Parent-Infant Relational Assessment Tool (Broughton 2010) EAS - Emotional Availability Scales (Biringen 2010) EAS - Emotional Availability Scales (Biringen 2010)

32 Evidence-Based Interventions Sensitivity/attachment-based: Interaction Guidance; FNP Sensitivity/attachment-based: Interaction Guidance; FNP Psychotherapeutic: Parent-infant psychotherapy Psychotherapeutic: Parent-infant psychotherapy Parenting programmes – Parents under Pressure; Parent-Child Interaction Therapy Parenting programmes – Parents under Pressure; Parent-Child Interaction Therapy Mentalisation: Minding the Baby Mentalisation: Minding the Baby

33 Commonalities Dyadic - focus on parent-child interaction with emphasis on the childs attachment; parental sensitivity; parental reflective function etc Dyadic - focus on parent-child interaction with emphasis on the childs attachment; parental sensitivity; parental reflective function etc Underpinned by a clear mechanism for change Underpinned by a clear mechanism for change Emphasis on relationship between therapist/provider and parent Emphasis on relationship between therapist/provider and parent

34 Video-Interaction Guidance Practitioners videotapes parent-infant interactions and shares Practitioners videotapes parent-infant interactions and shares Video jointly reviewed by practitioner and parent using micro-moments of successful contact with the aim of reflecting on strengths in the parents ability to attune Video jointly reviewed by practitioner and parent using micro-moments of successful contact with the aim of reflecting on strengths in the parents ability to attune Reflective 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. Reflective 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.

35 Evidence Video feedback interventions effective improving parenting behaviour; parenting attitudes; and childrens behaviour (Fukkink 2008) Video feedback interventions effective improving parenting behaviour; parenting attitudes; and childrens behaviour (Fukkink 2008) Includes children of all ages Includes children of all ages VIG effective in reducing disorganised attachment in abused children (Moss et al 2011) VIG effective in reducing disorganised attachment in abused children (Moss et al 2011)

36 Parent-Infant Psychotherapy Watch, Wait and Wonder (Cohen et al 2001) Watch, Wait and Wonder (Cohen et al 2001) Infant led parent-infant psychotherapy Infant led parent-infant psychotherapy Mother observes her infants self-initiated activity whilst being physically accessible to infant Mother observes her infants self-initiated activity whilst being physically accessible to infant Discussion of these experiences with therapist as a way of examining the mothers internal working models of herself in relation to her infant Discussion of these experiences with therapist as a way of examining the mothers internal working models of herself in relation to her infant

37 Evidence of Effectiveness Evidence from rigorous studies highlighting the benefits of parent-child psychotherapy for: 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; - 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); - 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) - preliminary clinical studies have also examined the value of this approach with parents with Borderline Personality Disorder (Newman & Stevenson 2008)

38 PUP Programme 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 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 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;

39 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

40 Parent-Child Interaction Therapy PCIT is a short-term, parent training programme PCIT is a short-term, parent training programme Based on both attachment and social learning theory Based on both attachment and social learning theory It is directed at families with 2- to 6-yr-old children experiencing behavioral, emotional, or family problems It is directed at families with 2- to 6-yr-old children experiencing behavioral, emotional, or family problems Rigorous research evidence about its effectiveness with physically abusive parents (Hakman et al 2009; Chaffin et al2004) Rigorous research evidence about its effectiveness with physically abusive parents (Hakman et al 2009; Chaffin et al2004)

41 Manualised programme; assessment driven (i.e. parents have mastered the skills) not time- limited; Manualised programme; assessment driven (i.e. parents have mastered the skills) not time- limited; Two phases – Child Directed Interaction (CDI); Parent Directed Interaction (PDI) Two phases – Child Directed Interaction (CDI); Parent Directed Interaction (PDI) Emphasis throughout on interaction between parent and child; 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 CDI concentrates on strengthening parent-child attachment as a foundation for PDI, which emphasizes a structured and consistent approach to discipline

42 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)

43 Summary Importance of identifying high risk families and conducting pre-birth assessment Importance of identifying high risk families and conducting pre-birth assessment Intervention should begin ante-natally if possible; Intervention should begin ante-natally if possible; Post-natal assessment should include parent- infant interaction Post-natal assessment should include parent- infant interaction Time-limited intervention with clear goals Time-limited intervention with clear goals A range of evidence-based universal and targeted interventions to support parent-child interaction; A range of evidence-based universal and targeted interventions to support parent-child interaction;

44 Publications Barlow J, Scott J (2010). Safeguarding in the 21 st Century: Where to Now? Dartington: Research in Practice.www.rip.org.uk Barlow J, Scott J (2010). Safeguarding in the 21 st Century: Where to Now? Dartington: Research in Practice.www.rip.org.ukwww.rip.org.uk Barlow J, Schrader-McMillan A (2010). Safeguarding Children from Emotional Abuse: What Works? London: Jessica Kingsley. Barlow J, Schrader-McMillan A (2010). Safeguarding Children from Emotional Abuse: What Works? London: Jessica Kingsley.


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