Safeguarding infants from
emotional maltreatment:
What works?
Professor Jane Barlow
Structure of paper
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What is emotional abuse during the first
two years of life;
Why the first two years matter;
What the evidence tells us about ‘what
works’
Emotional Abuse
Emotional Abuse – the problem

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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
As many as 80% of children registered for
physical abuse and neglect have also
experienced emotional abuse
Subjective Perceptions

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Large-scale population-based study (involving
2,869 adults) in the UK
6% 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
Five categories defined
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rejecting: behaviours which communicate or constitute
abandonment of the child;
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;
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
(Glaser and Prior,2002)
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
(Barlow and Schrader-McMillan 2010)
Definition

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
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)
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
Early Development and Later
Wellbeing
Parenting
Self-esteem
Smoking/drugs
Promiscuity
Behaviour
Infants’
CNS
School failure
Mentalising
Delinquency
Relationships
Emotional regulation
via attachment
Empathy
CORE of incipient self
Learning
Obesity
ETC…
Trauma in infancy:
attachment system compromised.
Sensitised nervous system as brain adapts to emotional environme
Stress in adult:
reminders & experiences of trauma,
life events, etc.
Unbearably painful emotional states.
Retreat:
isolation
dissociation
depression
Self-destructive
actions:
substance abuse
eating disorders
deliberate self-harm
suicidal actions
Destructive
actions:
aggression
violence
rage
Aspects of Early
Development
Emotional
competence
Cognitive
Development
Social
Competence
Trust/attachment
Alertness/curiosity
Impulse
control
Toddlerhood Empathy
Communication/
mastery motivation
Coping
Childhood
Social
Relationships
Reasoning/problem
solving
Goal-directed
behaviour
Adolescence
Supportive social
network
Learning
ability/achievement
Social
responsibility
Infancy
The Social Baby
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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
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 baby’s brain has developed according to
the type of emotions to which they have been exposed
(Beebe and Lachman, 2004)
Affect synchrony
Mirroring
Parent-Child Interaction
Containment
Reflective function
Infant
secure Attachment
i. Attachment behaviours
ii. Internal Working Model
Sense of ‘self’
‘Affect Synchrony’ – the
dance
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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 – ‘affect synchrony’ and repairs to
ruptures
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
‘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).
Videoclip One
Reflective Function
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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)
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
Videoclip two
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)

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).
Videoclip two
The Impact on the
Developing Neurosystem
The Infant’s Brain –
Softwiring

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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
Rapid proliferation and overproduction of
synapses followed by loss (pruning)
‘Use it or lose it’ – lost if not functionally
confirmed
Influenced by genes and environment
Most important aspect of the environment is
primary care-taker
For example…
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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
Families doting looks help brain to grow
Negative looks trigger a different biochemical response
(cortisol) stops these hormones and related growth
(Gerhardt, 2004)

Babies of depressed mothers:
- nearly half show reduced brain activity
- much lower levels of left frontal brain activity
(joy; interest; anger)

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)
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:
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Sensitive, emotionally responsive care during first year –
secure attachment
Insensitive, inconsistent or unresponsive care – insecure
attachment
The Importance of
Attachment
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Secure base – to explore the world
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
Attachment


Majority of children (two thirds) who have sensitive care
will form secure attachments – 67%
Remaining children will be:
- Insecure attachment (i.e. unable to use caregiver to
modulate their aroused state) Avoidant – over-regulate;
Resistant – under-regulate
- Disorganised attachment – no consistent patterns of
behaviour - conflicting emotions
E.g. 82% of abused cf 19% of non-abused children had
disorganised attachment (Carlson, Cicchetti et al., 1989)
Disorganised/Controlling
Attachment
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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
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
Arousal following trauma
Hyper-arousal (aggression, impulsive behaviour, children
emotional and behavioural problems – ‘Fight or flight’
response)
Window
Of
Tolerance
Hypo-arousal (dissociation, depression, self harm etc)
Compulsive Strategies
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Compulsive compliance (where parent is
threatening) – watchful; vigilant and compliant
Compulsive caregiving (where parent is needy) –
role reversal; parentification; children deny own
developmental needs
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’
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)
Disorganised attachment stems from
disruption in the emotional
communication, or lack of attunement,
between parent and baby.
Borderline
A withdrawing response..
Strongest predictor
symptoms in late
adolescence.
Negative-intrusive responses..
Hostile / frightening response.
A role-confused response.
Lack of effective regulation
of fearful arousal in infant.
(Disorganised attachment.)
Disoriented/confused responses.
Emotional communication errors,
e.g. giving conflicting cues to baby,
failure to respond to infant’s signals.
Dissociative
symptoms in late
adolescence.
Framework
Prevention
before
occurrence
Prevention
of
recurrence
Physical abuse
Sexual abuse
Emotional abuse
Neglect
Witnessing IPV
Universal
Targeted
Prevention
of
impairment
Long-term
outcomes
Prevention before
occurrence
Nurse Family Partnership
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Intensive home visits during pregnancy and first
two years
Goal based; ecological; attachment; self-efficacy
etc
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
Level of evidence: RCTs
Triple P
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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
Rates of maltreatment rose in both groups
Analysis is not clear, and further evaluation and
replication is recommended
Level of evidence: one RCT
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
Preventing re-exposure
and impairment
Key Intervention
Approaches

Sensitivity/attachment-based: Interaction
Guidance; FNP

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Psychotherapeutic: Parent-infant psychotherapy
Mentalisation: Minding the Baby
Parenting programmes – Parents under
Pressure

Parenting Programmes – Circle of Security;
Baby Triple P
Nurse Family Partnership





Intensive home visits during pregnancy and first
two years
Goal based; ecological; attachment; self-efficacy
etc
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
Level of evidence: RCTs
Interaction guidance
Weekly for 10 weeks
- 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)
[Tissot et al., 1999]
PUP Programme
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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;
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 evaluation


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Parents Under Pressure
RCT with substance abusing parents of children
aged 2-8 years (Dawe and Harnett 2007)
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
Mentalisation-based
approaches



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
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

Only case-study evidence available (Slade et al., 2005)
Parent-Infant
Psychotherapy
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

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’
Linking of ghosts with mother’s
own history facilitates changes
to her representational world
and new paths for growth of
both mother and infant
Combined Approaches
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Watch, Wait and Wonder
Infant led parent-infant
psychotherapy
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

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


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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
COS - Findings

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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;
is a promising intervention for the reduction of
disorganized and insecure attachment in highrisk toddlers and preschoolers (Hoffman, Irvine and
Powell,2006)
Interaction Guidance

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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 playfocused 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
Results showed that a modified version of Interaction
Guidance was effective in decreasing atypical
behaviours and disrupted communication
Parenting Programmes




Parents Under Pressure
RCT with substance abusing parents of children
aged 2-8 years (Dawe and Harnett 2007)
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
Mentalisation-based
approaches



Emerging model of intervention that builds on both parentinfant 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
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

Only case-study evidence available (Slade et al., 2005)
Parent-infant psychotherapy



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
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)
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)
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).
Summary



Emotional neglect and abuse during first two
years are ‘traumatising’
Evidence base about ‘what works’ is developing
Interventions that may be effective include:
- CBT/affect regulating parenting programmes
- Interaction Guidance
- Psychotherapeutic approaches including parent
psychotherapy, parent infant psychotherapy
- Mentalisation programmes
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