An Infant Mental Health Service: The Importance of the Early Years and
Evidence-Based Practice.
(This document gives detailed evidence for the importance of infant-parent psychotherapy, and related
relationship-based interventions, as a therapeutic and preventative service for at-risk babies and their
parents. Each section can stand alone; but helping small people seems to call for big explanations!)
***
“Train up a child in the way he should go: and when he
is old, he will not depart from it.”
Proverbs, 22:6.
Contents:
Page number.
2.
Introduction: why babies’ emotional needs have been sidelined.
4. In the beginning: evolution and early influences on the mind.
5. Neurobiological development: the significance of brain plasticity.
6. The importance of the attachment relationship: the first experiences can lead to
resilience or disturbances.
11. The effect of trauma and neglect: the long-term consequences of disorganised
attachment.
17. The roots of violence: how moral behaviour depends on early parenting.
18. Implications of the research data: a summary to this point.
19. Caregiving in jeopardy: a knowledge of risk-factors means help can be offered
before a baby is traumatised, not after the event.
23. Early intervention services, an overview.
25. Economic benefits of very early intervention.
27. The components of an early intervention service: existing models of delivery.
32. Different approaches to infant mental health: evidence-based practice.
54. Conclusions.
56. References.
1
Introduction.
Probably the most important period in everyone’s life is one they cannot remember.
The first two or three years, the time before memory can be verbally tagged for later
retrieval, set their stamp on all that comes after. This can be positive, as when a child
gains the resource of being resilient in adversity so that later stressful events do not
become a trauma; or negative, when a child’s early parenting has left a “basic fault”
(Balint, 1968) because there was too great a discrepancy between the infant’s needs
and the quality of caregiving that was available. This discrepancy easily gets lost or
ignored. Karr-Morse and Wiley (1997:278) pinpoint three obstacles that seem to
prevent us facing the unpleasant reality of an increasing number of babies. “The first
of these may be grief, anger, or sadness from personal childhood experiences.
Sometimes these are too painful to re-awaken. There may also be sadness and regret
for the memories we may have inadvertently created for our own children. A third
barrier to acting on this information is to feel overwhelmed by the depth and breadth
of the problem.” It is hard to feel helpless, especially if we face the world from the
point of view of these babies. Emde (2001:23) draws attention to why the plight of
many babies can be hard to contemplate and so gets pushed aside. “It is often painful
and difficult to recognise and address mental health problems in infants and young
children.” Taking babies seriously opens Pandora’s Box. He lists four kinds of
mental suffering that all would want to avoid and so might prefer not to think about.
“Pain and distress from trauma, abuse, or loss of a caregiver; misery from neglect;
suffering from cumulative stress; and suffering from lack of opportunity.” Distress
can be relieved, but rescue or repair may be no more than myths created by wishful
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thinking unless the help is immediate. The emotional environment of infancy, which
from the baby’s point of view, consists of relationships with the parents, will be
preserved on both a psychological and neurological level, for good or for ill. This can
either be a disaster or a pathway to hope, as: “The essence of infant mental health
work lies within the parent-child relationship.” (Solchany & Barnard, 2001:46)
In many instances when an older child comes to the attention of specialist helping
services provided by Education, Health or Social Services, it may appear difficult to
differentiate between the effects of early experiences and reactions to current family
dysfunction, which often predates the birth of the child anyway. Sometimes a simple
change in parental understanding and attitude, or direct treatment of some form with
the child, will enable the problem to become resolved. However, a significant
population of children, whose effect and cost is out of all proportion to their number,
cannot be helped in this way. It is just too late. This is why, as detailed below: “Early
intervention for disadvantaged children and their families can be a sound economic
investment.” (Barnett, 2000:605) Babies cannot wait; for if they have been adapting to
an emotionally inimical setting for any length of time then the damage caused by
inappropriate caregiving will not be undone by a change of circumstances, as is all too
clear with many children who have been fostered or adopted, and so much more
intensive and long-term interventions becomes necessary with a subsequently greater
drain on resources. These are the children who do not make use of education, who
disrupt the classroom and demand attention as they become either bullies or victims,
who sometimes harm themselves as much as others. As teenagers they attract labels as
an alternative to success: - conduct disorder, disruptive pupil, delinquent or disturbed,
and mental health diagnostic categories get dropped around them out of desperation.
3
In the beginning.
Babies are born ‘pre-programmed’ to seek out and adapt to the relationship that they
have with their parents. This is a biological given, evolution’s answer to the
prolonged period of helplessness in childhood and the need to adjust to the infinite
possibilities created within a family in interaction with the wider culture. “Most of
human knowledge cannot be anticipated in a species-specific genome … and thus
brain development depends on genetically based avenues for incorporating experience
into the developing brain.” (Shonkoff & Phillips, 2000:53) The human genetic
package transmits initial flexibility, evolutionary success is adaptation to
unforeseeable social diversity. Thus the genetic imperative for the baby is fit into
what you find. “The child’s first relationship, the one with the mother, acts as a
template, as it permanently moulds the individual’s capacities to enter into all later
relationships. These early experiences shape the development of a unique personality,
its adaptive capacities as well as vulnerabilities to and resistances against particular
forms of future pathologies.” (Schore, 1994:1) Active, satisfying and reciprocal
relationships with parents create the ‘taken for granted’ basis of a sense of identity,
self-esteem, appreciation of others and self-control. “Human relationships, and the
effects of relationships on relationships, are the building blocks of healthy
development. From the moment of conception to the finality of death, intimate and
caring relationships are the fundamental mediators of successful human adaptation.”
(Shonkoff & Phillips, 2000:27) More than that, the quality and content of the baby’s
relationship with his or her parents has a physical effect on the neurobiological
structure of the child’s brain that will be enduring.
4
Neurobiological development.
Research on brain development, which has re-written the textbooks over the last
decade with the advent of new techniques for imaging the functioning brain, has
shown that: “the infant’s transactions with the early socioemotional environment
indelibly influence the evolution of brain structures responsible for the individual’s
socioemotional functioning for the rest of the lifespan.” (Schore, 1994:540) KarrMorse and Wiley (1997:277), after an in-depth review of evidence from many
different disciplines on the genesis of violent behaviour, return to the cellular level.
“The strength and vulnerability of the human brain lie in its ability to shape itself to
enable a particular human being to survive its environment. Our experiences,
especially our earliest experiences, become biologically rooted in our brain structure
and chemistry from the time of our gestation and most profoundly in the first month
of life." (For a summary of recent research, see: Glaser, 2000; Balbernie, 2001.) The
brain is at its most adaptable, or plastic, for the first two years after birth, during
which time: “the primary caregiver acts as an external psychobiological regulator of
the ‘experience-dependent’ growth of the infant’s nervous system. These early social
events are imprinted into the neurobiological structures that are maturing during the
brain growth spurt of the first two years of life, and therefore have far-reaching
effects.” (Schore, 2001b:208). Thus: “From a basic biological perspective, the child’s
neuronal system – the structure and functioning of the developing brain – is shaped by
the parent’s more mature brain. This occurs within emotional communication.”
(Siegal, 1999:278) The older the child becomes, then the harder it can be to ‘re-wire’
certain areas of the brain; which means that without intervention a child who has
5
experienced abuse or neglect as an infant will unwittingly continue with patterns of
responses that are engraved in the mind, even if circumstances change.
The importance of the attachment relationship.
Attachment theory, developed by the British Psychiatrist and Psychoanalyst John
Bowlby, has provided a framework for studies on both the immediate and long-term
effects of early relationship experiences on the developing child. Attachment research
has integrated the inner, psychological, world with the outer world of behaviour to
demonstrate that: “the patterning or organization of attachment relationships during
infancy is associated with characteristic processes of emotional regulation, social
relatedness, access to autobiographical memory, and the development of selfreflection and narrative.” (Siegal, 1999:67) Attachment theory and a large body of
research converge to agree that ‘an infant’s formation of an attachment to a caregiver
is a key developmental task that influences not only the child’s representations of self
and other, but also strategies for processing attachment-related thoughts and
feelings… (and) may be related to risk for psychopathology or to psychological
resilience in adulthood.’ (Dozier, Stovall-McLough and Albus, 2008:718)
Following the creation by Ainsworth and colleagues (1978) of the Strange Situation
Procedure, attachment behaviour was initially split into three observable categories.
The majority of children (about 65%) demonstrate secure attachment, to be contrasted
with anxious-avoidant, anxious-ambivalent and, a later conceptualisation,
disorganised-disoriented (or controlling) patterns of attachment. The organised
patterns of anxious attachment can be thought of as clusters of goal-directed activity
6
whose aim is to maintain the best available emotional and physical connection, as the
child sees it, with the caregiver. ‘Each of the three patterns reflects a strategy for
enlisting the caregiver in the service of alleviating stress. The secure infant explores
freely and seeks contact with the attachment figure as necessary. The avoidant infant
focuses on exploration, and monitors and maintains proximity to the attachment
figure, but does not express attachment needs in order to avoid risking rejection. The
resistant infant is preoccupied with the availability of an inconsistent caregiver,
making repeated high-intensity demands to ensure that at least some of the latter elicit
attention.’ (Goldberg, 2000:23) The different categories of attachment, once in place,
demonstrate the dependant child’s ‘chosen’ method of affect regulation; this will have
a big influence on internal and interpersonal processes. ‘Each attachment pattern
reflects a different ecologically contingent strategy designed to solve adaptive
problems posed by different rearing environments.’ (Simpson, 1999:125) Babies and
toddlers, of course, have no means of making comparisons and so this is just the way
the world of relationships and emotions goes and can be expected to carry on going.
Secure attachment is a protective factor, conferring confidence and adaptability,
although not a total guarantee of future mental health, and without this emotional
resource neither child nor adult will feel free to make the most of their life’s
possibilities. In later life secure children and adults can self-repair. An insecure child
has too many anxieties that get in the way of investigating the world, so horizons stay
safely near. Research makes it clear that: “In general, secure children show more
concentrated exploration of novel stimuli and more focussed attention during tasks.
Secure attachment provides the best-known psychological precondition for tensionfree playful exploration.” (Grossmann, et al., 1999:781)
7
By the time infants enter into their second year of life there are consistent observable
differences in their behaviour that depend upon the level of security they have
experienced in the relationship with their parents. Thompson (1999:274) gives a
summary of decades of research to describe how: “securely attached children show
greater enthusiasm, compliance, and positive affect (and less frustration and
aggression) during shared tasks with their mother, as well as affective sharing and
compliance during free play with their mothers. Securely attached infants tend to
maintain more harmonious relations with parents in the second year.” Attachment
provides the launch-pad, if it is firm and trustworthy then better the take-off and the
more successful is the flight! This can be surprisingly long-lasting; as shown by a
longitudinal study of high-risk infants where infant security was: “associated with the
observed quality of participants’ romantic relationships in young adulthood.”
(Roisman, Collins, Sroufe and Egeland, 2005)
The three different categories of insecure, or anxious, attachment make the child
increasingly vulnerable to life’s events; but apart from the most serious classification,
insecure attachment by itself is not necessarily a disorder, although it can lead to one.
Goldberg (2000:209) summarises how in the relevant research: “A very common
finding is that the history of psychiatric patients is riddled with negative attachmentrelated experiences such as loss, abuse or conflict.” Insecure attachment is a risk
factor that will interact with other risks present in the emotional and physical
environment of the growing child; the level of attachment disturbance is equivalent to
a level of vulnerability that is difficult to change without help. It is worth noting that a
longitudinal study of high risk infants showed “substantial shifting towards insecurity
8
in late adolescence, particularly towards the dismissing classification.” (Weinfield,
Whaley and Egeland, 2004:89) Conversely, early disorganised attachment was
significantly related to late adolescent insecurity. Research shows how in adolescence
insecurity is linked to conduct problems. (Allen, et al., 1997; Rosenstein and
Horowitz, 1996) It is important to bear in mind that initial “good enough” attachment
can be lost in the face of later adverse circumstances, initial secure attachment does
not confer invulnerability.
Children with problems related to insecure attachment begin to soak up statutory
resources from early on when “externalising” behaviour (aggression, non-compliance,
negative and immature behaviours, etc.) demands a response. (Speltz, et al., 1990)
This is probably the largest group of children that Social Services, Special Education
and the Child and Adolescent Mental Health Service are expected to deal with. “The
social and economic costs of these types of disorders are staggering.” (Greenberg, et
al., 1997:197) It has been estimated that: “In England the costs of mental ill-health
are greater than the total costs of crime, and there is every reason to believe that this is
also the case in the UK as a whole.” (Friedli and Parsonage, 2007:16) Studies have
consistently demonstrated: “a high rate of insecure attachments among clinic-referred
boys and their mothers.” (ibid, p. 216); the same applies to children in special
educational provision (E. B. D. schools). A recent study compared emotionally
disturbed children with two control groups from other school settings. Most of these
children had been diagnosed as having attention deficit disorder, the rest as either
conduct disorder or depression, with half the sample having more than one diagnosis.
They were found to be: “strikingly different from their counterparts in regular
classrooms in the extent to which they had experienced major disruptions in their
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relationships with both mothers and fathers.” (Kobak et al., 2001:252) The different
categories of insecure attachment predispose towards specific difficulties in later life.
Avoidant attachment is a strategy often developed by an infant whose parents have
discouraged overt signs of either affection or distress, and who do not readily offer
sympathy or comfort. The conviction that others do not see you as someone worth
loving, or even responding to, can lead to low self-esteem and subsequent aggression.
Close relationships are avoided as the child gets older, and such adults may mask their
insecurity by becoming addicted to work, acquisitions or achievement, or retreat
behind obsessional and ritualistic behaviours. “Avoidant attachment would also seem
to be a component of compulsive personality traits. At its extreme, the compulsive
personality is the nightmare version of the uptight, authoritarian father who is
determined to banish all emotions. He lives in a constricted world, his attentions
narrowed to schedules, rules, and tidiness; and he is obsessed with trivia.” (Karen,
1994:391) The isolated child: “who also has an avoidant attachment history and
perhaps certain genetic leanings, may, if things continue to go poorly, develop into a
schizoid personality.” (ibid)
Ambivalent, or resistant, attachment stems from the infant’s experience of
inconsistent parenting when the child is never quite sure if his or her expressions of
anxiety and distress will be suitably attended to. There is a lack of consistent
nurturing and protection from the parent that makes it hard for the infant to feel that
exploring the world is a safe option. Thus the child has a low threshold for distress,
but no confidence that comfort will be forthcoming. When upset he or she tries to get
close to the caregiver, but only to become angry and resist contact. This pattern can be
10
carried into adulthood and there reveals itself in relationship difficulties where there is
either a withdrawal from others or a compulsion to be dependent. This is the
hysterical personality who: “flees from intimacy, and, like the ambivalent child, she
tends to be demanding or clingy, immature, and easily overwhelmed by her own
emotions.” (Karen, 1994:392) A longitudinal study found that adolescents diagnosed
with anxiety disorders were significantly more likely to have had resistant
attachments with their parents when they were infants. (Warren, et al., 1997)
Avoidant and ambivalent attachments may be anxious, but they have worked within
the family and they are coherent and provide the child (and grown-up) with some sort
of unconscious set of strategies for relating to others. These are internal working
models of what once actually did, and is now expected to, occur in interpersonal
exchanges. At least something is predictable, and a certain amount of meaning and
satisfaction can be gained within mature relationships. This is not true for the most
serious form of insecure attachment, labelled as disorganised and controlling, which is
caused by pathological conditions and gives rise to pathological ways of relating.
The effect of trauma and neglect.
Disorganised attachment occurs when the parent either has so many unresolved
emotional issues from their own past that they have no mental space left over for their
baby or, graver, is a threat. The baby is biologically impelled to seek safety through
closeness to the caregiver. When the parent is the source of fear (and this may be the
result of neglect) the paradox cannot be resolved, there is no predictable solution and
11
the child’s faith in the world of relationships is demolished by their ‘scaregiver’ and
he or she is left with no coherent means of relating to other people. “Abuse and
neglect in the first years of life have a particularly pervasive impact. Pre-natal
development and the first two years of life are the time when the genetic, organic, and
neurochemical foundations for impulse control are being created. It is also the time
when the capacity for rational thinking and sensitivity to other people are being rooted
– or not – in the child’s personality.” (Karr-Morse & Wiley, 1997:45) The impact can
show on a physical level almost immediately, as it has been found that the rate of
disorganised attachment associated with failure to thrive is extremely high (Wood, et
al., 2000). From a life-path perspective it has been clearly demonstrated that children
who have suffered early neglect and abuse are far more likely to suffer from serious
illnesses when they are adults, thus taking up an excessive and disproportional
amount of health service resources, and they are also at a greatly increased risk of
early death. (Felitti, et al., 1998)
Disorganised attachment, frequently the result of maltreatment, becomes in itself a
major risk factor that, in the ‘wrong’ circumstances, can disrupt many different areas
of development. In a summary of research Moss et al. (1999:160) conclude that;
“Disorganized/controlling attachment is predictive of the development of behavioural
problems at preschool and school age in both high-risk and normal samples. Studies
indicate that both externalizing and internalizing symptoms characterize the behaviour
problems of disorganized school-aged children between 5 and 9 years of age.
Although at preschool and early school age, it is primarily an aggressive, disruptive
behaviour pattern that is associated with disorganization, anxieties and fears related to
performance, abilities, and self-worth become more pronounced in middle
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childhood." Disorganised attachment predominates in children referred to CAMHS.
(Green, Stanley and Peters, 2007) Children who have been assessed as having
disorganised attachment at 5-7 years have poorer skills at maths age 8 (Moss, et al.
1998) and show impaired formal operational skills and self-regulation at 17 years of
age (Jacobson, et al. 1994). These two studies suggest that low self-esteem and lack of
confidence in school mediated the poor performance, thus exacerbating the problems
with self-esteem which is known to go with disorganised attachment anyway
(Cassidy, 1988).
A prospective study of a non-clinical population has examined the long-term
consequences of different attachment patterns in children, differentiating between
those with mother and father. (Verschueren and Marcoen, 1999; Verschueren, 2001)
Children who had disorganised attachment with their fathers showed high levels of
internalising behaviours when they were 5; and by 9 years of age (by teacher report)
they had internalising problems, extremely poor social adjustment and low selfesteem. Children with disorganised maternal attachment (not the same ones) were six
times more likely to be rejected by their peer group than average (more than twice the
rate for avoidant children). If the child was unfortunate enough to have disorganised
attachment with both parents they had both sets of difficulties.
The problems associated with poor quality of attachment between child and parents
begin to be visible almost straight away. “Children on trajectories towards serious
externalizing problems are likely to have insecure, particularly disorganized,
attachments in the first year.” (Shaw, et al., 1996:697) In addition, it is now accepted
that: “severely compromised attachment histories are … associated with brain
13
organizations that are inefficient in regulating affective states and coping with stress,
and therefore engender maladaptive infant mental health.” (Schore, 2001a:16) It is
this ‘wired in’ compromised ability for self-control, a lack of coping mechanisms on a
neurological level for dealing with internal and external stresses and frustrations, that
confers a high vulnerability for later emotional, relational and mental health problems.
The Minnasota Study has found that: - All types of abuse in the first years related to
significant emotional problems in adolescence, and predicted the need for treatment.
Out of all the children they had followed since birth 90% of the sample who had been
maltreated qualified for at least 1 psychiatric diagnosis by age 17. It turned out that
every form of abuse was related to delinquency, with a history of psychological
unavailability being the strongest predictor. Neglect also predicted delinquency,
although these children tended not to be angry or defiant. Witnessing parental
violence correlated with externalising problems for boys at age 16 and internalising
problems for girls. This was independent of other predictors such as abuse or neglect.
(Sroufe, Egeland, Carlson and Collins, 2005) In addition, suicidal behaviour in
adolescence is strongly influenced by unresolved-disorganised attachment, with girls
being at highest risk. (Adam, et al. 1996) Child maltreatment does not spring from
nowhere, and older children who come into the child protection system almost always
have a history of grief going back to babyhood. The peak age for being murdered is
under one. Early intervention, where vulnerable and over stressed parents can be
identified and supported before the baby suffers, before their own emotionally barren
and terrifying past becomes entangled in the relationship (and expectations) with their
baby, is an essential preventative service if we want to avoid a steady growth in the
number of referrals to adult mental health services. “Child abuse has a causal role in
most mental health problems, including depression, anxiety disorders, PTSD, eating
14
disorders, substance abuse, personality disorders, and dissociative disorder.
Psychiatric patients subjected to childhood sexual or physical abuse have earlier first
admissions and longer and more frequent hospitalizations, spend longer time in
seclusion, receive more medication, are more likely to self-mutilate, and have higher
symptom severity.” (Read, Fink, Rudegeair, Felitti & Whitfield, 2008: 218)
A recent summary of the research on the connections between early attachment
experiences and adult psychopathology (Dozier, et al., 1999) looks at “attachment
related circumstances” and their effect on later mental health problems. “Loss predicts
multiple disorders, including depression, anxiety, and antisocial personality disorder
… Depression is associated generally with the early loss of the mother. Major
depression in particular … has been found to be related to permanent loss of a
caregiver, whereas depression characterized by anger and other externalizing
symptoms has been found to be related to separation. Anxiety appears to be associated
more closely with threats of loss and instability than with permanent loss. Antisocial
personality disorder is associated with loss through desertion, separation and divorce.”
(p. 513) It appears that the quality of a child’s early parenting can put them on the
pathway to different destinations. “Affective and anxiety disorders tend to be
associated most frequently with parental rejection combined with loss. Antisocial
personality disorders are most frequently associated with parental rejection, harsh
discipline, and inadequate control. Eating disorders are associated with maternal
rejection and overprotection combined with paternal neglect, and borderline
personality disorder is associated most consistently with parental neglect.” (p. 514)
Several longitudinal studies have demonstrated the link between difficult family
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environments and their influence on the baby and the development of dissociative,
borderline and conduct disorders in young adults (Lyons-Ruth, 2008).
The early relationship between caregiver and baby will act as an external system for
the child’s internal regulation of affect. Attachment is, in many ways, a measure of
self-control. The growing infant, who began totally dependent on mother for soothing,
stimulation and emotional regulation, gradually claims the ability to manage alone. In
other words: “early development entails the gradual transition from extreme
dependence on others to manage the world for us to acquiring the competencies
needed to manage the world for oneself.” (Shonkoff & Phillips, 2000:121) Caregivers
maintain the baby within comfortable, or acceptable, feeling states by intuitively
recognising what their child is experiencing and how they can help to restore
equilibrium. The parents’ ability to do this depends on their baby’s grandparents. In
order to achieve such sensitivity the adult’s emotional awareness is a taken for
granted resource that enables an automatic acknowledgement of need and a
subsequent response. “A caretaker with a predisposition to see relationships in terms
of mental contents permits the normal growth of the infant’s mental function. His or
her mental state anticipated and acted on, the infant will be secure in attachment.”
(Fonagy, et al., 1991:214) Comfort is not always an automatic presence; in dire
circumstances it can seem unattainable.
The secure child (and adult) has the psychological, and neurological, capacity to selfmodulate recognised affects. Responses to stressful or exciting circumstances can be
thought about rather than acted out. “As a result of being exposed to the primary
caregiver’s regulatory capacities, the infant’s expanding adaptive ability to evaluate
16
on a moment-to-moment basis stressful changes in the external environment,
especially the social environment, allows him or her to begin to form coherent
responses to cope with stressors.” (Schore, 2001a:14) However, when the infant has
been exposed to relationships likely to engender disorganised, or controlling,
attachment they have no choice about adapting to these emotional conditions, leading
to: “brain organizations that are inefficient in regulating affective states and coping
with stress.” (p. 16) An inability to think about others’ feelings coupled with an equal
inability to control impulses will have serious long-term consequences.
The roots of violence.
Infants who have suffered adverse relationships become teenagers and adults who are
grossly over-represented in the criminal justice system. This is not only a direct drain
on resources, it also signifies a large population who are not in a position to contribute
to the wider society (the same applies to those who never leave their dependency on
mental health provision). Delinquent, antisocial and violent behaviour, frequently
associated with no sense of either empathy or remorse, has been traced back to being
on the receiving end of abuse and neglect during the first two years of life. (de
Zulueta, 1993; Karr-Morse & Wiley, 1997) Even having a conscience cannot be taken
for granted, as it has been demonstrated that this is cultivated by: “caregivers who are
warm and provide clear expectations for child behaviour that are consistently
reinforced.” (Shonkoff & Phillips, 2000:243)
It has been found that attachment problems in adolescence predict later criminal
behaviour (Allen, et al., 1996); and an attachment based study of prisoners with a
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psychiatric disorder confirmed the hypothesis that: “ criminality arises in the context
of weak bonding with individuals and social institutions and the relatively ready
dismissal of attachment objects. Criminal behaviour may be seen as a socially
maladaptive form of resolving trauma and abuse … Violent acts are committed in
place of experienced anger concerning neglect, rejection and maltreatment.
Committing antisocial acts is facilitated by a nonreflective stance regarding the
victim.” (Fonagy, et al., 1997: 255) As de Zulueta (1993:76) puts it, violence: “is the
manifestation of attachment behaviour gone wrong.” The ability to be mindful of
another’s mind, and thus mind how you treat them, is derived from the infant’s
relationship with their caregiver.
Implications of the research data.
If the early relationship between the baby and his or her parents is given the attention
it deserves then this has two major implications. - Firstly, many later emotional and
mental health problems can only be reworked in a similar fire as forged them. Longterm, intensive and (this time) thought-about relationships may be necessary to help
those who carry the mental imprint of early trauma and neglect. For as long as the
brain retains sufficient plasticity in the relevant areas then its neurochemical structure
will continue to adapt to the effect of affect. Evidence suggests that psychotherapy:
“probably initially changes the functional connections among neurones, and then later
converts these functional changes into changes in the actual structure of the cerebral
cortex itself.” (Vaughan, 1997:68) But less effort would have been called for when
the mind was, by design, more readily adaptable. – Secondly, by recognising that the
parent-infant relationship is the crucible for change and development, for good or ill,
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we can look beyond the individuals to the wider conditions that impinge upon this
relationship. Looking for reasons removes blame. Every parent always does the best
they can for their baby within what is possible for them. A broader perspective, trying
to understand rather than passing judgement, points to the importance of a catalogue
of known risk factors. It is feasible to anticipate what sort of situation tends to lead to
insecure attachment, and thus offer treatment or some other form of help before
anything goes drastically wrong. That is, before responses get so ‘hard-wired’ into the
brain that they become increasingly hard to change.
Caregiving in jeopardy.
There is a large body of research on risk factors, with general agreement on what
these are and how they affect parenting. (e.g. Balbernie, 2002; Fonagy & Higgitt,
2000; Karr-Morse & Wiley, 1997; Osofsky & Thompson, 2000; Sameroff, 2000;
Zeanah, et al., 1997) The parent-baby relationship is always located in a wider
context, within which are found both risk and protective factors. These can harm the
baby directly (e.g. pollution, unhealthy housing) but mostly are titrated into the
relationship via their effects on the parents’ functioning, since they dictate the baby’s
immediate experiences.
Nurture and nature can no longer be regarded as discretely separate issues. “Genetic
susceptibilities are activated and displayed in the context of environmental influences.
Brain development is exquisitely tuned to environmental inputs that, in turn, shape its
emerging architecture. The environment provided by the child’s first caregivers has
profound effects on virtually every facet of early development, ranging from the
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health and integrity of the baby at birth to the child’s readiness to start school at age
5.” (Shonkoff & Phillips, 2000:219) Some (but certainly not all) of the risk factors
known to adversely affect the parent-baby relationship are: problems intrinsic to the
baby, such as low birth weight or congenital abnormalities; a parent who lacks the
ability to sensitively attune to the baby’s needs, who does not interact with their infant
or maltreats him or her; one or both parents struggling with a mental health or
addiction problem, or with a background of abuse, neglect or loss in their own
childhood; inadequate income or sub-standard housing, family dysfunction and
(extremely harmful) domestic violence; single teenage mother without support.
(These examples from Landy, 2000:345; and see also Sameroff, 2000:12) So many
factors external to the baby and parent can mess up their relationship that problems
here can be taken as a sign that the child, without intervention, will grow up
struggling with emotional harassment from many different directions.
A working assumption that can direct both early and later intervention is that:
“attachment disruption may be a marker or summary variable for a number of
pathogenic factors in the child’s environment.” (Kobak et al., 2001:254) The baby has
no comparisons, what is met is simply how the whole world is organised. You get
born, you take your chance! “As a source of risk, the home may reflect an atmosphere
of disorganization, neglect, or frank abuse. As a source of resilience and growth–
promotion, it is characterized by regularized daily routines and both a physical and a
psychological milieu that supports healthy child-caregiver interactions and rich
opportunities for learning.” (Shonkoff & Phillips, 2000:345)
20
The research on risk factors means that babies who might be likely to have adverse
developmental pathways through life, because of stresses in their initial relationship
with their parents, can be identified early on. Even the unborn child cannot be
assumed to be safe. The foetus can be directly harmed by a number of toxins
(including the effects of stress on the mother) which can cause disability, regulatory
disorders, attention difficulties or skill deficits; any one of which may make it hard for
the neonate to settle into an attachment relationship. “Children born already impaired
are more likely to be the brunt of destructive parenting behaviours and abuse.” (KarrMorse & Wiley, 1997:55) A major risk, the single biggest cause of cognitive delay in
developed countries, is maternal alcohol consumption during pregnancy. It is now
accepted that: “the teratogenic effects of alcohol are not limited to heavy chronic
exposure, or to exposure during a specific time during the gestation period.”
(Fitzgerald, et al., 2000:129)
Over and above the effects of the drug on the embryo, a child born to parents with
addiction problems may well develop attachment difficulties as addiction in any form
flags up an attachment-related disorder, insofar as it gives the illusion of a ‘safe’
dependency where the object of desire is controllable. A vulnerable baby does not
have to experience distress and damage that he or she cannot comprehend before help
is offered. The greater the number of risk factors found in a family’s total ecology
then the greater the need for immediate assistance. But sadly, the more a family is
under stress then the harder it becomes to make full use of any help available. Only a
relationship can change a relationship, but if you are ground down by inner and outer
circumstances a new relationship is hard to contemplate.
21
Getting the first, prototypical, important relationship of anyone’s life more or less
right is a necessity, not a luxury. This is the most sensible and economic time to put in
therapeutic resources. And furthermore, unique to this stage of life, one can guarantee
that the child both wants to co-operate and has not got stuck in the trap of gaining
self-esteem from antisocial acts. This is society’s best chance to help itself. “The
interactive process most protective against later violent behaviour begins in the first
year after birth: the formation of a secure attachment relationship with a primary
caregiver. Here in one relationship lies the foundation of three key protective factors
that mitigate against later aggression: the learning of empathy or emotional
attachment to others; the opportunity to learn control and balance feelings, especially
those that can be destructive; and the opportunity to develop capacities for higher
levels of cognitive processing.” (Karr-Morse & Wiley, 1997:184)
The analysis of risk factors, which: “is an exercise in estimating probabilities, not
finding causes” (Sameroff, 2000:28), shows clearly how the relationships within a
family can be distorted by external pressures which need intervention on a social level
as much (if not more) as their emotional consequences need help on a personal level.
For instance, the single most important broad risk factor that predicts later
maladjustment is poverty (Brooks-Gunn, et al., 2000; Halpern, 1993) since this
amplifies and concentrates all the other risks. “Low income creates a particularly
stressful context in which positive interactions with children are threatened, and
punitive or otherwise negative relationships may result. The high prevalence of
depression, attachment difficulties, and posttraumatic stress among mothers living in
poverty serves to undermine their development of empathy, sensitivity, and
responsiveness to their children, which can lead to diminished parenting behaviours
22
and thus decreased learning opportunities and poorer developmental outcomes.”
(Shonkoff & Phillips, 2000:353) The effects of inadequate financial resources can be
partially addressed in many instances, as can other adverse factors, but ultimately it
takes individualised responsive care to change a pattern of caregiving.
Early intervention services: an overview.
The major review by the American National Research Council (part of the National
Academy of Sciences) of many different lines of research carried out on the
development of children, summarises a conservative core of replicated findings over
thirty years of evaluating early intervention programmes. (Shonkoff & Phillips,
2000:342) To paraphrase slightly, and omitting their extensive references, these are as
follows:
 Well-designed and successfully implemented interventions can enhance the shortterm performance of children living in poverty.
 Such interventions can promote significant short-term gains on standardised
cognitive and social measures for young children with developmental delays or
disabilities.
 Short-term impacts on the cognitive development of young children living in highrisk environments are greater when the intervention is goal-directed and childfocussed in comparison to generic family support programs.
 Measured, short-term impacts on the cognitive and social development of young
children with developmental disabilities are greater when the intervention is more
structured and focussed on the child-caregiver relationship.
23
 Short-term I.Q. gains associated with high-quality preschool interventions for
children living in poverty typically fade out during middle childhood, after the
intervention has been completed; however, long-term benefits in higher academic
achievement , lower rates of grade retention (repeating a year), and decreased referral
for special education services have been replicated.
 Extended longitudinal investigations into the adolescent and adult years are
relatively uncommon but provide documentation of differences between the
intervention and control groups for economically disadvantaged children in high
school graduation, income, welfare dependence, and criminal behaviour.
 Analyses of the economic costs and benefits of early childhood intervention for lowincome children have demonstrated medium- and long-term benefits to families as
well as savings in public expenditure for special education, welfare assistance, and
criminal justice.
On the other hand, there appears to be a relative lack of evidence that wide-scale
projects that broadly target a general population have much long-term effect. At the
end of a review of American Federal and State interventions, such as Head Start,
Farran (2000:525) finds it disheartening that: “A great deal of money was spent on
programs that have not been shown to be more effective than doing nothing at all.”
This is a reminder that families do not exist in isolation.
Where a child appears to have a disadvantaged start in life the whole context of the
baby-parent relationship needs to be taken into account. “Competence is the result of
a complex interplay between children with a range of personalities, the variations in
their families, and their economic, social, and community resources.” (Sameroff,
24
2000:9) There are a large number of therapeutic interventions that have been
demonstrated to help the relationship between parent and infant, but results cannot be
sustained in a vacuum. None of the programmes reviewed by Farran (2000:525):
“made any difference to the income, housing conditions, or employment of the
parents involved, despite the fact that the families were often chosen because they had
extremely low incomes.” Exactly the same adverse influences that have impinged on
the adult members of the family will probably continue to exert an effect on the child
throughout his or her development, making specific predictions difficult unless wider
issues (such as standards of education and employment prospects) are also tackled
head on. “That is to say, significant medium- and long-term benefits of early
childhood intervention may be viewed as a continuing developmental pathway that is
contingent on a chain of positive effects that increase the probability of remaining on
track.” (Shonkoff & Phillips, 2000:352) Perhaps it will not be possible to gauge the
most important long-tern effect of early intervention until follow-up studies are
carried out on these infants when they have become parents in turn.
Economic benefits of very early intervention.
There are a number of studies which have demonstrated the long-term cost benefits of
helping vulnerable families provide the sort of emotional environment for their babies
and toddlers that in general leads to secure attachment. Parenting is only meant to be
‘good enough’. For instance, the Perry Pre-school Highscope Programme has data
spanning forty years, showing that for every $1 spent in setting up and running their
pre-school nursery initiative in a high-risk area they find that almost $13 were saved
in terms of later services not accessed when participants were followed up at age 40.
25
(High/Scope Perry Preschool Program, follow-up report in 2005, on line) Another
longitudinal study, described below, known as the Elmira Home Visiting Project has
shown that early specialised support for vulnerable first-time mothers had paid back
its costs by four years. At a 15 year follow up the savings exceeded the costs of the
program by a factor of four. (Olds et al, 1999) The Children’s Trust Fund in
Michigan targets the prevention of maltreatment as: “Research shows that for every
$1 spent on child abuse and neglect prevention, $7 will not be spent on publiclyfunded, crisis-oriented programming such as protective services, foster care, special
education, and counseling with the exception of juvenile delinquency or adult
incarceration” (www.michigan.gov/ctf/0,1607,7-196--232496--,00.html)
The expense of not intervening is in the direct and indirect costs of such later antisocial behaviour as is associated with conduct disorder. It had been calculated that a
young adult who eventually suffers social exclusion due to conduct problem will costs
the country three and a half times more than someone with no problem; while conduct
disorder will incur costs of ten times higher than having no problem. (Scott, Knapp,
Henderson & Maughan, 2001) A conservative estimate (so it will grow year on year)
is that preventing conduct disorders in those children who are most disturbed would
save around £150,000 of lifetime costs for each individual; and promoting positive
mental health in those children with moderate mental health would yield lifetime cost
benefits to each of about £75,000. (Friedli and Parsonage, 2007) This analysis did not
take into account the monetary implications the negative effects these children have
upon others, such as all the disruption they cause in the classroom and the long-term
effects of the violence they may inflict on other – not least future partners and
children. Taking the above figures, the total value of the benefits of prevention in a
26
one-year cohort of children in the UK is £5.25 billion, and the value of promoting
positive mental health comes to £23.625 billion. (Ibid, p. 20) A recent study by the
New Economics Foundation (2009) for Action for Children, ‘Backing the Future’
shows the clear economic benefits of early intervention, clearly differentiating the
different benefits to society, with the long-term savings being several magnitudes
greater than the costs of setting up preventative services.
Early intervention is still well worth the effort and allocation of resources even if the
immediate success rate seems relatively low. “To be worth undertaking, the
intervention thus needs a success rate of only one in 25 for conduct disorder and one
in 55 for conduct problems. In other words, the potential benefits are so large relative
to costs that intervention is worthwhile, even if its effectiveness is very limited.”
(Friedli and Parsonage, 2007) Sinclair, writing for The Work Foundation and coming
from a background in practical economics, is clear. “Dysfunctional parenting and
children at risk represent classic market failure. This is where the government will get
the greatest rate of returns for money invested.” (Sinclair, 2007:54) Simply preventing
the occurrence of early child maltreatment or, if that has been impossible, offering
prompt and appropriate treatment has a long-term benefit that is enormous in terms of
services not called upon to intervene in the child’s future. A host of research from
different disciplines converges to show how early trauma is ‘the frequent cause of
physical and mental illness, school underachievement and failure, substance abuse,
maltreatment, and criminal behavior.’ (Harris, Lieberman and Marans, 2007:393)
The components of an early intervention service.
27
Two reviews examine what appears to be necessary for early intervention services for
high-risk parents and babies if they are to meet the needs of this group (Zero to Three,
1998, 18 (4); Shonkoff & Phillips, 2000:360-367). The guiding principle of early
intervention is that services need to be carefully tailored to their client population,
there is no single answer. For instance, findings from a home visiting service for highrisk mothers and babies indicated: “that higher-risk mothers benefited more from a
mental health curriculum than an educational curriculum whereas lower-risk mothers
benefited more from the educational curriculum than the mental health curriculum.”
(Berlin, et. al., 1998:13) There is a second and equally important principle that is at
the heart of practical service delivery. Any intervention, regardless of technique or
theory, is only as effective as the quality of the relationships that the infant mental
health practitioners can build up with the families they become involved with. “New
relational experiences in therapy are the core of the healing process. The presence of
an authentic, empathic, and responsive connection between client and therapist can
foster healing and the subsequent development of a sense of relational competence for
the client, which entails the ability to bring about change, and the experience of
feeling effective in connection. In mother-infant therapy, this sense of efficacy is
transposed to the mother moving out of isolation and into a more reciprocal and
satisfying relationship with her baby.” (Paris, Spielman and Bolton, 2009:305)
Services can be roughly divided between those that are centre-based and those that are
delivered in the home. “Center-based services are more likely than home-based
programs to target children directly – especially in terms of their cognitive and
language development.” (Berlin, et. al., 1998:7) Whereas: “Home-based services,
which virtually always include the child’s principle caregiver, may be especially well-
28
suited to enhancing parents’ well-being and the child-parent relationship.” (ibid, p. 6)
However, infant mental health work has to always be tailored to the setting and needs
of the families involved so that, for instance, successful help can equally be given to
high risk mothers and their babies within a prison (Baradon, et al., 2008). Whatever
the setting, it is important that services are targeted appropriately, the aim of every
provision should be clear. “For young children where development may be
compromised by an impoverished, disorganized, or abusive environment …
interventions that are tailored to specific needs have been shown to be more effective
in producing desired child and family outcomes than services that provide generic
advice and support.” (Shonkoff & Phillipps, 2000:360) Evidence also supports the
principle that proactive programmes, those which are truly preventative, beginning
either pre-natally or at birth, have the greatest and most sustained effect, “There is a
strong indication that while gains made through proactive interventions are sustained,
and even increased, over time those made through reactive interventions tend to fade”
(MacLeod and Nelson, 2000:1141). Such services can be either universal or targeted
on an individual basis. The earlier we intervene the better. The best results are
attained with strength-based approaches that focus on parental empowerment and
involvement.
The UK Sure Start initiative has evolved into an early intervention that combines
centre based provision with outreach work delivered to the surrounding community.
Although the initial evaluation of the myriad of different Sure Start schemes was
disappointing, this has changed with time. One reason is that the service delivery is
now based in Children’s Centres and the first wave of families accessing these early
interventions has been worked through and now help can be consistently on offer
29
from conception to pre-school age. Children’s Centres are perfectly placed to deliver
‘wrap around’ services ranging from specialist infant mental health teams to the full
gamut of different parenting groups available. Studies comparing outcomes for
children in Secure Start areas with those lacking this input have found that the former
‘showed better social development, exhibiting more positive social behaviour and
greater independence/self regulation than their counterparts in non-Sure Start
areas….Also, families in Sure Start areas reported using more child and familyrelated services than families in non-Sure Start areas.’ (Melhuish, Belsky and Barnes,
2010:160)
Even if an intervention seems to fit the bill, there is no guarantee it will deliver results
unless the service created is appropriately funded and staffed. There can be an
“implementation gap” set up by: “the discrepancy between the intervention that
program designers plan and the intervention that families receive.” (Barnard, 1998:23)
This can lead to a lower than expected take-up of services. “The impact of quality has
been shown to be particularly important for children from families who bear the
burden of multiple risk-factors” (Shonkoff & Phillips, 2000:362). Everyone wants the
best for their baby, but many have no choice about what is on offer.
The intensity and duration of any intervention are obviously important, but as aspects
of quality they are hard to measure. Few researchers have addressed these variables,
as there are frequently ethical implications to conducting randomised experimental
studies on a vulnerable, clinical, population. However, there are some suggestive data.
It has been found that I.Q. scores measured at 36 months increased with the amount of
times a child attended a day centre, the number of home visits and the frequency with
30
which parents attended relevant meetings. (Ramey, et al., 1992) Greater involvement
with helping services, whether in the home or a centre, was also associated with
higher ratings of the family home environment when the child was one year old, and
higher I.Q. scores at age three. For proactive preventative interventions, “which
measured child maltreatment as an outcome; effect sizes increased as the length of the
intervention increased” (MacLeod and Nelson, 2000:1143). Mothers who actively
participated in the Prenatal / Early Infancy Project for two years were less likely to
abuse their children than those mothers who had only been engaged for nine months.
And a fifteen years later follow-up showed an inverse relation between the amount of
service received and a number of negative maternal outcomes, including child
maltreatment, repeat pregnancy, welfare dependence, substance abuse and brushes
with the law. (Olds, et al., 1997, Olds, 2006) Two studies of a home visiting service
for infants in families living in poverty, where one used random assignment to set up
a treatment and control group, found that weekly visits resulted in higher child
development test scores than fortnightly visits, which in turn obtained higher scores
than monthly visits. (Powell & Grantham-McGregor, 1989)
It seems a truism to stress that quality of service provision is entirely dependent on the
calibre of the staff. “Early intervention service providers carry out intensive and
emotionally demanding work. Their personal characteristics – especially their ability
to be emotionally available and empathic – and their training and work experience
influence the ways in which they deliver services” (Berlin, et al., 1998:8). Infant
mental health services demand a core of specialised knowledge and skills congruent
with the wide range of risk factors and developmental issues that need to be
considered. Good reflective supervision is essential to avoid the risk of defensive
31
avoidance, vicarious traumatisation and burnout. In many ways only a dedicated,
specialised, well-functioning team can hope to move between such matters as
discordant attachment relationships, adult mental health and substance abuse, and the
problems forced upon a family by poverty. “In this context, the ultimate impact of any
intervention is dependent upon both staff expertise and the quality and continuity of
the personal relationship established between the service provider and the family that
is being served” (Shonkoff & Phillips, 2000:365).
Different approaches to infant mental health.
It appears, then, that well-planned and well-funded services for babies and parents at
risk can redirect a likely developmental pathway along a new, healthier direction.
“Programs that combine child-focussed educational activities with explicit attention to
parent-child interaction patterns and relationship building appear to have the greatest
impacts” (Shonkoff & Phillips, 2000:379). Whereas: “services that are supported by
more modest budgets and are based on generic support, often without a clear
delineation of intervention strategies matched directly to measurable objectives,
appear to be less effective for families facing significant risk.” (ibid) Early
intervention can have a differing emphasis on two approaches: the first is prevention
32
(targeting a population, or a family, identified by risk factor analysis), and the second
is treatment (working with referred cases where something has already gone amiss).
This is a rather artificial divide, since in practice both goals are compatible with each
other within a single programme; e.g. working with families at risk will inevitably
reveal ‘hidden’ disturbances that need to be referred on to a more specialised
therapeutic service. However, conceptualising early intervention services in this way
does provide a framework for examining the results of projects that were set up with
different aims and methods.
Preventative services will usually be either centre- or home-based, just as most
treatment options are either clinic- or home-based as well. (And many families will be
able to make use of either site for different services.) An example of a centre-based
early intervention/preventative service is the Carolina Abecedarian Project where
high-risk children received intensive early education five days a week, beginning at
six weeks and ending at five years. Two groups of similar babies were selected, all
with mothers who had educational difficulties. The control group, who only received
free milk and nappies, were all (except one) eventually assessed as being retarded or
of borderline intelligence. In the intervention group all the children tested within the
normal range of intelligence by age three; by age 15 they scored significantly higher
in general knowledge, reading and mathematics, and only 24% (48% in the control
group) needed special education services. (Campbell & Ramey, 1994 & 1995)
Furthermore, (according to the project’s website) when the children reached 21 years
of age 35% of the intervention group were at college, compared to 14% in the control
group; and 65% were in employment compared to 50% in the other group. The
children whose mothers had the lowest I.Q. appeared to gain the most from this
33
intervention, and those who had a follow-up programme into elementary school
benefited further still. An exception to the home or centre quandary might be services
for teenage mothers which can be established within a school setting where the
additional provision of good quality childcare would ensure that the young women
could finish their education as well. The ‘Chances for Children’ Teen Parent-Infant
Project in New York has successfully implemented and, using a control group,
evaluated such a programme. They provide individual, dyadic and play therapies
along with parenting groups and support for the nursery staff. They have found that
the young mothers they had worked with improved their interactions with their infants
‘in the areas of responsiveness, affective availability, and directiveness. In addition,
infants in the treatment group were found to increase their interest in mother, respond
more positively to physical contact, and improve their general emotional tone, which
the comparison infants did not’ (Mayers, Hagar-Budny and Buckner, 2008:332). The
same positive results were found in a subset of young mothers who remained
depressed, showing that even then it is still possible to improve mother-infant
interactions.
Early intervention with high risk, very vulnerable, families needs to be a multi-agency
concern; and the better different agencies work together then the more long-lasting
and positive are the results for the infants in these families. A good example, which
has been evaluated a number of different times (including focus groups with the
mothers involved), is the Canadian initiative for helping families where there is
maternal substance abuse. This is called ‘Breaking the Cycle’ (BTC), and was
launched by seven partner organisations in 1995. “Positive results of the BTC
approach include (a) enhanced birth and perinatal outcomes for infants of substance-
34
involved mothers who are engaged earlier in pregnancy, (b) enhanced developmental
outcomes of children who are involved, (c) enhanced parenting confidence and
competence, (d) enhanced treatment outcomes, and (e) decreased rates of separation
of mothers and children” (Motz, Leslie and DeMarchi, 2007:20). The intervention
focus is on the mother-infant relationship and involves a range of different
programmes based on a single-access model which includes street access and home
visiting.
Most group-based parenting programmes (or classes) will of necessity be based in a
Children’s Centre of some sort. The Mellow Parenting, and especially Mellow Babies
for the under-ones, approach is designed specifically for families where there is a
relationship problem with a small child, and has been particularly successful in
helping mothers and infants improve the quality of their relationship. (Puckering,
2004) The greater majority of parenting skills classes are geared to, and are more
useful for, those with older children; and it could be argued that there is an inherent
difference of attitude and outlook between a group and a class, with the former being
less intrinsically humiliating for the parents. Mellow Parenting and Babies is an
intensive and containing day-long group experience extending over many weeks that
engages with a high risk group of families where child protection issues are
paramount, domestic violence is present, where the mother has conflictual
relationships with her family of origin, is experiencing behavioural problems with her
child and may be struggling with psychological difficulties of her own. This
programme has consistently engaged hard-to-reach families and has demonstrated
positive changes in mother-child interactions, children’s behavioural problems and
their intellectual development. A pilot study that applied a slightly modified version
35
of Mellow Parenting to a group of mothers suffering from post-natal depression has
had encouraging results. The depressed mood of the mothers changed significantly,
observed positive interactions increased and negative reactions went down. ‘The
Mellow babies group intervention can improve both the mental health of women with
postnatal depression and their interaction with their babies. (Puckering, 2009:161)
The immediate advantage of this group approach is that each mother who attends
immediately feels less isolated and guilty that she alone finds parenting a challenge.
Another, perhaps more technophile, group approach that has been consistently able to
improve the quality of the relationship between parents and their small children is the
“Circle of Security” intervention, delivered as part of an Early Head Start project.
This method carefully reviews with parents the video recordings of the Strange
Situation procedure which each member has done with their child as part of this
group-based programme. One of the goals of this method is to teach a user friendly
version of attachment theory to the parents, and this can be based upon what all have
observed in the replays of the Strange Situation procedures. This clinical service has
been based firmly on a combination of attachment and object relations theory. “The
underlying structure of the COS protocol consists of providing a secure base from
which caregivers can both learn about the attachment needs of their children and
explore their own internal obstacles to meeting those needs” (Cooper, et al.
2005:146). Initial outcomes appear to be promising; and this programme is currently
under evaluation in a number of different sites.
Away from a centre and into the home, a 20 year research project following the
outcome of the Nurse Home Visitation Program is a good example of a preventative
36
intervention targeting an at risk population in the community. However, the families
chosen were very limited, and the help was only offered to low income unmarried
first time mothers; this would be ethically inappropriate within the context of the
universal system of NHS provision, and so generalising the exact model to the UK
setting is not entirely valid. However, as the NHS is being dismantled and becoming a
collection of isolated franchises, this objection does not hold much water. The Nurse
Home Visitation Program involved two randomised trials (in Elmira, New York, and
Memphis, Tennessee), plus one other which is still in progress (in Denver). The
investigators (Olds, et al., 1999:44) have concluded that: “The program benefits the
neediest families (low income unmarried mothers) but provides little benefit to the
wider population. Among low-income unmarried women, the program helps reduce
rates of childhood injuries and ingestions that may be associated with child abuse and
neglect, and helps mothers defer subsequent pregnancies and move into the
workforce. Long-term follow-up of families in Elmira indicates that nurse-visited
mothers were less likely to abuse or neglect their children or to have rapid successive
pregnancies. Having fewer children enabled women to find work, become
economically self-sufficient, and eventually avoid substance abuse and criminal
behaviour. The children benefited too. By the time the children were 15 years of age,
compared with the control group, they had fewer arrests and convictions, smoked and
drank less, and had fewer sexual partners.” The home visiting began before birth and:
“Compared with counterparts randomly assigned to receive comparison services,
women who were nurse-visited experienced greater informal and formal social
support, smoked fewer cigarettes, had better diets, and exhibited fewer kidney
infections by the end of pregnancy.” (p.45) Four years after their children had been
born the cost of the programme was less than the savings that had been made. This
37
manualised intervention: “explicitly promoted sensitive, responsive, and engaged
caregiving in the early years of a child’s life.” (p.48) It was found that the biggest
obstacle to benefiting from the service was the presence of domestic violence, with
treatment effect diminishing as the level of violence increased. (Eckenrode, et al.,
2000) This strength-based programme of intervention has been re-named the NurseFamily Partnership and rolled out in the U. K. where it is already showing positive
gains for some vulnerable families struggling with a gamut of adverse experiences.
(Rowe, 2009)
Another home-based programme that worked with high risk adolescent and nonadolescent mothers evaluated results after six months of teaching parenting skills and
the basics of child development while also making a link with local community
resources. (Culp, et al. 1998) It was shown that these mothers significantly improved
their knowledge of the taught subjects and their empathic responsiveness, also there
was more involvement with the community and home safety was enhanced as well.
The same approach (and curriculum) was applied again to an intervention group of
204 and a control group of 150 first-time mothers. (Culp, et al., 2004) Compared to
the control group the intervention mothers showed the same gains as before, and also
demonstrated a better understanding of non-corporal punishment along with
behaviours that were more accepting and respectful of their infants.
The equivalent professionals in the UK are Health Visitors, who have the enormous
advantage over home visitors in America as they are universal, ‘invisible’ and nonstigmatising. It is literally vital that this invaluable service remains taken for granted.
Once Health Visitors chuck some of the check lists they become the most important
38
adult mental health resource we have, the only problem being that the results of their
work take a couple of decades to show up! The Solihull Approach has shown that
Health Visitors who are trained in this form of reflective practice are able to work
more effectively with children with less complex sleeping, feeding, toileting and
behavioural difficulties and so prevent the need to refer them to CAMHS. (Douglas
and Ginty, 2001) Health visitors and others trained in this approach consider that it
improves perception and practice; and for the families involved there is a significant
reduction in the severity of presenting difficulties, a reduction inparental anxiety and
improvements in child behaviour. (summarised in Douglas and Rheeston, 2009.) It is
also a methodology that appears to improve the ability to identify and help resolve
minor problems in young children. (Milford, Kleve, Lea and Greenwood, 2006) A
study based on a different but compatible approach where high risk families study
were given an 18 month programme of weekly health visitor contact, using the Family
Partnership Model (Davis, Day and Bidmead, 2002), suggests that “this intensive
home-visiting programme may improve parenting in vulnerable families and increase
identification of abuse and neglect in infancy.” (Barlow, et al., 2007:232) This model
stresses the interpersonal skills and personal characteristics needed in order to work in
a relationship based way with vulnerable families, since ‘the process of helping,
including the development of the working relationship, is determined by what both
the helper and parents bring to the interaction.’(Davis, 2009:69)
A bridge to a purely treatment-based programme is provided by the relationship-based
intervention for very high risk mothers set up in Los Angeles. This involved a
randomised trial to create a similar comparison group who were only given paediatric
appointments. These were all mothers who almost invariably would have come to the
39
attention of an infant mental health service, had one been available. The project
workers were all mental health professionals with experience in child development
and the family systems approach. The primary goal of the intervention was: “to offer
the mother the experience of a stable trustworthy relationship that conveys
understanding of her situation, and that promotes her sense of self-efficacy through a
variety of specific interventions.” (Heinicke, et al., 1999:356) When compared with
the control group: “The mothers became more responsive to the needs of their infants
and more effectively encouraged their autonomy and task involvement. Moreover, the
children in the intervention as opposed to non-intervention group were more secure,
autonomous, and task involved on a variety of indices at 12 months.” (p. 371) The
two groups were compared again when the children were two years old, by which
time: “the mothers experiencing the intervention, in comparison with those that did
not, also used more appropriate forms of control, and their children responded more
positively to these controls. Mothers who did not experience the help of the
intervention had significantly more difficulty controlling their child if it was a boy as
opposed to a girl. They used the least appropriate methods of control and the boys
responded more negatively to these controls.” (Heinicke, et al., 2001:458)
A similar clinical-type intervention was carried out in Holland, the difference being
that the risk factor resided in the infant, not in the surrounding family. The aim of the
programme was to help mothers with infants who demonstrated an irritable
temperament, since there is evidence that negative emotionality in babies leads on to
later behavioural problems. Mothers were helped to respond more to both positive and
negative emotions in their child, and at the same time encouraged to show less
intrusive behaviour and detached lack of involvement. The quality of attachment
40
between parent and child appears to be enhanced by the parent’s ability and
willingness to be sensitively responsive to their child. This was confirmed by the
finding that: “more toddlers whose mothers participated in the intervention were
securely attached than there were securely attached control group dyads.” (van den
Boom, 1995:1809) At age two years, the mothers in the intervention group still
demonstrated a greater responsiveness and involvement with their toddlers. And at
three years both parents were more attuned to their child than those in the control
group. “Intervention children continued to be more secure in their relationship with
their mother, exhibited less behaviour problems, and were better able to maintain a
positive relationship with the peer than the control group children.” (p. 1811) Helping
parents respond in a more sensitive, or thoughtful, way to their infants promotes
secure attachment.
Depressed mothers are another high-risk group, as when the condition is severe it will
interfere with the ability to tune into their baby’s signals and provide a sensitive and
emotionally nurturing caregiving environment. Post-natal depression is linked to an
increase in insecure attachment in toddlers, behavioural disturbance at home, less
creative play and greater levels of disturbed or disruptive behaviour at primary school,
poor peer relationships, and a decrease in self-control with an increase in aggression.
(Cummings & Davies, 1994; Murray, 1997; Sinclair & Murray, 1998; Murray et al.,
1999; Zeanah et al., 1997) Direct psychotherapy with depressed mothers has been
shown to increase their capacity to recognise emotional expressions, including
negative ones, and be more accurate in affective language communication. (Free, et
al., 1996) Although this could be expected to improve the quality of attachment, this
was not measured. However, another study that compared the effect of toddler-parent
41
psychotherapy between two, randomly assigned, groups of mothers with a major
depressive disorder found that attachment was improved by the end of treatment. The
two groups were further compared with another where the mothers had no mental
health problems. “Toddlers of depressed mothers who received TPP evidenced rates
of secure attachment that were no different from those of the non-depressed control
group following the conclusion of this intervention.” (Cicchetti, et al., 1999:58) These
were mothers with a relatively high level of income, education and family support
who may well have been: “better able to utilize an insight-oriented mode of therapy
than women confronted with a multitude of daily living challenges.” (p. 59). The
authors of the study go on to speculate that: “as mothers become freed from the
‘ghosts from their pasts’ their internal working models became more positive and they
were increasingly able to focus on the present, including their relationship with their
child.”
As a contrast, another approach to infant mental health intervention is provided by
Interaction Guidance, which does not rely on insight to bring about change in the
parent-baby relationship. This technique uses video feedback in order to encourage
positive aspects of caregiver-infant interaction, helping parents: “in gaining
enjoyment from their child and in developing an understanding of their child’s
behaviour and development through interactive play experience.” (McDonough,
1993:414) This form of treatment was specifically tailored to reach families overburdened with multiple risks, and probably exemplifies the strength-based philosophy
intrinsic to all infant mental health therapy more than any other approach.
(McDonough, 2004). It does not explicitly focus on exploring the caregiver’s internal
representational world of feelings and memories, although such material will be
42
addressed if it arises during the course of work. “This nonintrusive method of family
treatment has proven to be especially successful for infants with failure to thrive,
regulation disorders, and organic problems. Parents who are either resistant to
participating in other forms of psychotherapy, or young, inexperienced, or cognitively
limited respond positively to this treatment approach.” (McDonough, 1993:414)
Interaction Guidance has also been successfully used to improve sensitivity and
decrease the amount of disrupted communication between mothers and babies with
feeding problems (Benoit et al., 2001); and a slightly modified version has been
shown to help mothers with postnatal depression re-connect with their babies (Vik
and Braten, 2009). This technique has been shown to bring about surprisingly rapid
positive changes in disruptive caregiving behaviour, and this was measurable after the
first session. (Madigan, Hawkins, Goldberg and Benoit, 2006) Video feedback of
mothers and infants using a split screen technique, so that both faces can be viewed
simultaneously while they play together, has also been shown to be effective in a brief
treatment intervention that combines a psychoanalytic approach with an in-depth
analysis of immediate interactions. (Beebe, 2003) Microanalysis of the recorded intercommunication within the excerpt of play reveals patterns of affect regulation that can
inform a psychodynamic weaving together of the presenting difficulties, the observed
behaviour of the dyad and the parent’s own early history.
The technique of Interaction Guidance, with its use of video recordings to emphasise
responsive and pleasurable mother-infant interactions, can be either clinic- or homebased; and it is sometimes used in conjunction with, rather than as an alternative to,
more psychodynamic methods of treatment. A meta-analysis of early, attachmentbased, interventions suggests that disorganised attachment is most successfully
43
addressed by using sensitivity-focussed feedback. (Bakermans-Kranenburg, van
Ijzendoorn and Juffer, 2005) Attachment-based video feedback was the intervention
of choice in a study that used a randomised control group and targeted high risk
families in order to prevent externalising problems in pre-school children. The
children were aged 7 to 10 months when the treatment took place, and video was
used, in their words, to promote positive parenting. There were two post-intervention
tests at one month after, and then at age 40 months; and compared with the control
group those in the trial had less preschool clinical externalising and total behavioural
problems. (Velderman, et al., 2006) The evidence-based clinical work of this group
along with its background in research (at Leiden University) has led to a successful
programme to enhance parental sensitivity called ‘Video-feedback Intervention to
Promote Positive Parenting’, or VIPP. (Juffer, Bakermans-Kranenburg and van
IJzendoorn, 2007) This is a focussed and relatively short-term intervention with a
number of slight variations, and it has been applied to adopted infants as well as
babies of mothers with an eating disorder and mothers coping with a baby suffering
from skin disorders. This strategy has been subject to more RCTs than you can shake
a stick at! Video feedback, in combination with infant-parent psychotherapy, has
also been used successfully to treat mothers suffering from PTSD following a history
of violence-related trauma. (Schechter, 2004; Schechter, et al., 2006) It was found that
the baby’s felt-to-be-intolerable distress, or current domestic violence, would trigger
past traumatic memories for the mother, which then became confused with her current
perception of the child. This intervention, over only thee visits, was able to
significantly reduce the degree of negativity and of distortion of maternal attributions.
44
An example of how different strategies and methods can be applied is a childguidance clinic in Stockholm that uses both Interaction Guidance and infant-parent
psychotherapy to help mothers and babies, with the additional provision of three long
group sessions each week. They have carried out an in-depth follow-up evaluation of
their work. Out of ten randomly chosen mother-infant pairs that were looked at only
one had not made considerable progress during treatment. (Karlsson & Skagerberg,
1999) A combination of intervention methods appeared to achieve the most gains.
Similarly, in the U.K the Sunderland Project, where Health Visitors were trained in
the use of Patricia Crittenden’s “Care Index” and how to apply this to brief video
recordings of mother-baby play, a multi-disciplinary mixed intervention strategy has
clearly been shown to achieve measurable improvements in a high-risk population.
Svanberg, (2005) concludes that: “The process of video-feedback and the support of
the health visitor, who in his/her turn was supported and supervise by the parentinfant psychologists, enabled these parents to increase their own sensitivity
sufficiently to support their child’s development towards a secure attachment and a
more resilient future.” This approach roughly doubled the proportion of secure
attachment in the intervention group where the mothers’ sensitivity and the infants’
cooperativeness increased significantly compared with a control group receiving
routine care. (summarised in Svanberg, 2009) Unfortunately, in spite of the fact that a
careful evaluation of the Sunderland Infant Programme has demonstrated clear and
considerable long-term savings to health and social services (more than the costs), it
has been closed down.
A research project in Geneva has compared the results achieved by brief insight
oriented, infant-parent psychotherapy with those attained by the more behaviourist
45
method of video feedback using Interaction Guidance. In the process, both forms of
intervention were demonstrated to bring about appreciable, positive, changes in the
mother-infant relationship. Since the study was carried out on families who had been
referred to a child guidance clinic it was felt to be unethical to have a control group,
although comparisons could be made with a non-clinical but otherwise matched
sample. The results of both forms of treatment were evaluated, and: “marked
symptom relief was observed in several areas, with the greatest improvements in
sleeping, feeding and digestion (i.e. symptoms affecting physiological functions).”
(Robert-Tissot, et al., 1996:105) In general, mothers became less intrusive and infants
more co-operative, with maternal sensitivity to the baby’s signals increasing after
treatment. “The results of the study indicate that brief mother-infant psychotherapies
were effective in treating cases consulting for early functional disorders.” (p. 108) The
only differences between the two approaches were that Interaction Guidance brought
about more change in mothers’ sensitivity, while psychodynamic therapy had a
greater impact on maternal self-esteem.
It could be argued that the two different approaches of Interaction Guidance and
infant-parent psychotherapy were in fact identical in task, and each improved parental
‘reflective function’. “A caretaker with a predisposition to see relationships in terms
of mental content permits the normal growth of the infant’s mental function. His or
her mental state anticipated and acted on, the infant will be secure in attachment.”
(Fonagy, Steele, Steele, Moran and Higgitt, 1991:214). Recent research demonstrates
that: “negative maternal caregiving behaviour is inversely correlated with maternal
reflective functioning. (Grienenberger, Kelly and Slade, 2005:304) A gain in
reflective function may lie behind all successful interventions that aim to improve the
46
sensitive responsiveness that is seen to be the basis of secure attachment. It has been
demonstrated that: “maternal reflective function, measured at 10 months, is likewise
linked to infant attachment security measured at 14 months using the Strange
Situation.” (Slade, et al. 2005:293) A study examining reflectivity, mind-mindedness
and behaviour in parents concluded that ‘directing attention towards supporting the
mother’s capacity to effectively mentalize is likely to hold positive consequences for
both her mental experiences of the child and the relationship as well as for her
parenting behaviour during interaction.’ (Rosenblum, McDonough, Sameroff and
Muzic, 2008:374) A research project showed that mothers of pre-school children
with behavioural and emotional difficulties who participated in a clinical intervention
that increased their insightfulness had children whose problems decreased; whereas
mothers who did not gain from this had children whose behaviour problems
increased. (Oppenheim, Goldsmith and Koren-Karie, 2004) A service for vulnerable
families in New Haven, Connecticutt, is based on the principle of enhancing reflective
functioning. This is a weekly home-visiting intervention called the Minding the Baby
Program, and is focussed on the mother-infant dyad. A preliminary evaluation (Slade,
Sadler and Mayes, 2005) indicates a marked gain in maternal reflective function in
relation to the spectrum of their child’s developmental domains, and (using the
Strange Situation) no children with disorganised attachment. For the mothers, the
trend is towards lower levels of depression and post-traumatic stress symptoms along
with higher levels of self-efficacy.
In psychodynamic infant-parent psychotherapy the ‘patient’ is the relationship
between baby and caregiver. It is to be expected that this approach would directly
affect maternal self-esteem, since emotional difficulties from past relationships are
47
addressed within the context of a new relationship which is secure enough to both
withstand and encourage exploration. “The quality of the relationship between
therapist and parent is perhaps the more crucial in infant-parent psychotherapy than in
any other form of treatment, because it is intended to be a mutative factor in the
parent’s relationship with his or her child. “ (Lieberman & Pawl, 1993:430) In a study
designed to evaluate the effectiveness of infant-parent psychotherapy, which
compared an intervention group of mothers and infants with a similar control group, it
was found that: “Mothers who formed a strong positive relationship with the
intervener tended to be more empathic to their infants at outcome, and their children
in turn tended to show less avoidance on reunion.” (p.434) However, the most
important treatment variable turned out to be the mother’s ability: “to use infantparent psychotherapy to explore her feelings towards herself and toward her child.”
(ibid) The two randomly assigned groups of mother-infant dyads where the child had
been assessed as demonstrating insecure attachment were further compared with a
second control group of securely attached infants and their mothers in order to
examine outcomes. Evaluation took place when the child was two years old, after one
year of treatment. “The intervention group performed significantly better than the
anxious controls in the outcome measures and was essentially indistinguishable from
the control group.” (p. 440) Those mothers who became most engaged in the
therapeutic process became more actively attuned to their children, who in turn:
“showed less anger and avoidance, more security of attachment, and more reciprocal
partnership in the negotiation of mother-child conflict.” (p. 441) Again, it is
relationships that change relationships. This intervention evolved into an intervention
for three to five year olds traumatised by domestic abuse; and in a randomised clinical
trial these children ‘improved significantly more than children receiving case
48
management plus treatment as usual in the community, both in decreased total
behavioural problems and decreased PTSD symptoms.’ (Lieberman, Van Horn and
Ippen, 2005:1246) These ‘improvements in children’s behavior problems and
maternal symptoms as the result of treatment with child parent psychotherapy
continue to be evident 6 months after the termination of treatment when compared to
the control group.’ (Lieberman, Ippen and Van Horn, 2006:916) The methodology of
this approach has been covered in detail in a recent book (Lieberman and Van Horn,
2008), and it has been successfully applied to situations of domestic violence in the
perinatal period (Lieberman, Diaz and Van Horn, 2009).
Parent infant psychotherapy was the main therapeutic modality applied to improve the
relationship between mother and child in high risk families in the Florida Infant
Mental Health Pilot Programme. This intervention targeted families with infants at
risk of abuse and neglect who were likely to be removed from their parents or where
this had actually occurred. There was no control group; and given that the project was
funded by the legislature this would not have been ethical. Fifty nine percent of the
programmes participants were court-ordered to participate, and many had already a
record of maltreating their children. The results are impressive because of the wide
range of family arrangements that fell within the scheme, which was thus less
“choosy” and far more clinically realistic than many other research projects. At the
end of this pilot study ‘there were no further reports of abuse or neglect during the
treatment period and up to post-assessment for participants. There was a major
reduction in reports of child abuse and neglect…from 97% of children prior to
treatment to none of the children completing treatment during the first three years of
the pilot project… (Also), the health and developmental status of children improved.’
49
(Osofsky, et al. 2007:273) In addition there was a reduction of depressive symptoms
in the caregivers along with a measured and reported improvement in the parent-child
relationship. But a lot of effort went into these achievements, as should be expected
for high risk families, and it was estimated that behind every hour of treatment were
another ten spent on efforts to engage the family.
The Parent Infant Psychotherapy (PIP) clinic at the Anna Freud Centre has a
therapeutic focus on the parent-infant relationship as observed in the mutually
influencing interactions in the sessions. (Baradon, et al. 2005) Here too, video
feedback is an essential part of the process. One aim of parent-infant psychotherapy is
to interrupt the generational continuity of unhelpful patterns of parenting and, ay the
same time, to encourage the establishment of a secure attachment relationship for the
child. A research project at the Anna Freud Centre, in a pilot study, evaluated
outcomes using a range of psychometric tools. The majority of parents felt that their
child’s development had been better than expected. Little more than 10-15% had
significant concerns about the child at follow up. Less than one in twenty experienced
a worsening. On both intellectual and motor development, as measured with the
Bayley assessment of development, referred families had infants seven points behind
the average. By six months they were indistinguishable from the average, and this
improvement had increased slightly at follow-up.
Another, final, example of a well-researched, intervention for parents and infants is
the technique of “Watch, Wait and Wonder” used in the Toronto Infant-Parent
Program. In this form of infant-parent psychotherapy the parent is encouraged to be
50
more directly involved with their child by engaging in playful interaction that follows
the lead of the child. The parent is then invited to explore the feelings and thoughts
that were evoked by what he or she observed and experienced in the preceding play
session. This mode of treatment also appears to be a positive experience with good
outcomes for mothers struggling with borderline personality disorder (Newman and
Stevenson, 2008). Allowing the child to be spontaneous can be hard for a parent
haunted by “ghosts in the nursery”, especially when these are revenants of past abuse;
and a defensive infant, who is more used to complying to the pattern of available
caregiving in order to extract the maximum available sense of felt-security, can be
equally stumped. The research project set out to compare the effects of traditional
infant-parent psychotherapy (PPT) with Wait, Watch and Wonder. A broad range of
outcome measures was applied before and after treatment, and again on follow-up six
months later. The majority of children referred to this service were insecurely
attached. Both forms of treatment were delivered by highly trained clinicians. It was
found that by the end of the intervention the Wait, Watch and Wonder method was
associated with a more pronounced move towards secure attachment. The infants in
this group also: “exhibited a greater capacity to regulate their emotions with a
concomitant increase in cognitive ability.” (Cohen, et al., 1999:445) Their mothers:
“reported more satisfaction with parenting than mothers in the PPT group and lower
levels of depression at the end of treatment.” (ibid) Both forms of treatment showed
similar positive gains. “They were associated with a reduction of presenting problems,
improvement in the quality of the mother-child relationship, and reduction in
parenting stress.” (ibid) However, at the six-month follow-up the two groups were
similar on all measures. The Wait, Watch and Wonder group had retained its positive
gains while the group receiving parent-infant psychotherapy had ‘caught up’. It was
51
concluded that both approaches are helpful, but the effects of Wait, Watch and
Wonder came about more quickly.
Wait, Watch and Wonder, with its dual emphasis on positive interaction and insight,
is a hybrid of behavioural (i.e. interaction guidance) and psychodynamic approaches.
Although not made explicit, this procedure too plainly targets and enhances parental
reflective function with an emotionally containing setting. As with the other treatment
modalities that have been mentioned, this technique could easily be offered in any
CAMHS setting provided there were suitably qualified staff, since, again
theoretically, the age–range for clients begins at zero. But there is an important caveat
to be considered, since may would argue that infant mental health work does not
naturally belong in the same stable as the interventions (and facilities) for older
children and their families. This is not just a matter of site, access, noise- and
intimidation-level, or the lack of suitably trained clinicians with relevant backgrounds.
As Barrows (2000:19) argues, it is: “only within the context of a service that is
dedicated to Infant Mental Health that (the) focus on the parent-infant relationship is
likely to be sustained, and to feature as the prime focus of any therapy.” A
consideration of the wide range of risk-factors that must be addressed makes it clear
that a multi-disciplinary team is essential, since the caregiver-infant relationship will
be influenced by seemingly distal pressures.
Sometimes babies and toddlers are living in such adverse circumstances that they
need to be moved to a new set of caregivers as quickly as possible. The relationship
with the parent may be distorted beyond repair by an accumulation of risk factors.
(Balbernie, 2002) As well as a treatment modality, the knowledge-base of infant
52
mental health offers us the understanding needed for speedy assessment and
recommendation as to the course of action that will be in the baby’s best interest. The
most radical and effective treatment for an infant is a new family. It is has been
accepted for years that the longer after six months an adoption is finalised the greater
the risk of later problems in relationships. (Singer, Brodzinsky, Ramsay, Steer and
Waters, 1985) An Infant mental Health team in Baton Rouge, on the outskirts of New
Orleans, is a pioneering example of how applied knowledge in this field enables a
comparatively rapid assessment of caregiving to be carried out for very young
children referred to the Child Protection Service. This project is funded by the courts
and has a proven track record. It uses a range of specialised assessment methods, once
again making careful use of video technology. (Larrieu and Zeanah, 2004) The
purpose of this service is to provide the courts with an assessment that will be used as
part of the decision-making process as to whether or not a child will be freed for
adoption. A similar child population is served by an Attachment Clinic in Montreal
which consults to the Youth Protection Service on issues related to permanency
planning for very young children in foster care. (Gauthier, Fortin and Jeliu, 2004)
They pay special attention to how the child has been affected by the original
separation from biological parents and their response to the possibility that they might
return after a long period with foster parents.
The infant mental health specialist (a discrete profession in America) needs to call
upon a wide range of skills and strategies that together: “contribute to the parent’s
understanding of the infant, the awakening or repair of the early developing
attachment relationship, and the parent’s capacity to nurture and protect a young
child.” (Weatherston, 2000:6) This means strengthening relationships, whether
53
between parent and child, therapist and parent, or within the boundaries of the infant
mental health service. Starting from the fundamental premise that all parents want to
do the best they can for their babies, the infant mental health team builds on strengths
in order to remove obstacles to a natural state of affairs. Parents, unsurprisingly, may
not appreciate other know-it-alls thinking they need “training”, indeed, such an
attitude: “may send a message of presumed incompetence, which might undermine a
mother’s or father’s self-confidence and contribute inadvertently to less effective
performance.” (Shonkoff & Phillips, 2000:371) Infant mental health specialists may
be experts, but they relate to parents on the basis of partnership, not power, modelling
the relationships they wish to promote.
Conclusion.
There is a growing body of evidence that demonstrates how early, targeted and
strength-based interventions focussing on relationships can bring about positive
changes in the emotional environment of vulnerable babies. As summarised by
Professor Fonagy (1998:132) in an overview of the field: “early preventative
interventions have the potential to improve in the short term the child’s health and
welfare (including better nutrition, physical health, fewer feeding problems, lowbirth-weight babies, accident and emergency room visits, and reduced potential for
maltreatment), while the parents can also expect to benefit in significant ways
(including educational and work opportunities, better use of services, improved social
support, enhanced self-efficacy as parents and improved relationships with their child
54
and partner). In the long term, children may further benefit in critical ways
behaviourally (less aggression, distractibility, delinquency), educationally (better
attitudes to school, higher achievement) and in terms of social functioning and
attitudes (increased prosocial attitudes), while the parents can benefit in terms of
employment, education and mental well-being.”
To complement the evidence of clinical impact, longitudinal research, both
psychological and neurological, has confirmed the vital importance of the early
attachment relationship for future development. “The time of greatest influence, for
good or ill, is when the brain is new. If we want to help the next generation we should
be working with their parents while they are babies now” (Balbernie, 2001:253). This
is simply a technical confirmation of what every parent has always known, although
they may not have time to think about it until they are grandparents. It is something
that somehow gets avoided when the implications have to be turned into policy or
command resources. Who really doubts that: “The childhood shows the man, as
morning shows the day.”? (Milton, 1671:Paradise Regained)
If the first two years of life are cradled within secure attachment then the growing
child feels good about him or herself, can appreciate the feelings of others and see
their point of view, is able to take full advantage of education and has inherent
psychological resiliency to fall back upon in times of stress. At the other end of the
spectrum, the infant with disorganised attachment, who has often suffered abuse or
neglect, will become the child who cannot trust relationships, who has no empathy for
people or respect for social rules, who disrupts, attacks and tries to dominate what
may be on offer in both the family and school, and who might well be seriously
55
vulnerable to later mental health problems. And furthermore, most importantly, these
patterns of behaviour stand a good chance of being passed on to the next generation as
the attachment experiences of infancy cut the template for the caregiving behaviours
of adulthood. “By failing to understand the cumulative effects of the poisons
assaulting our babies in the form of abuse, neglect, and toxic substances, we are
participating in our own destruction.” (Karr-Morse & Wiley, 1997:12) Early
intervention within the remit of an infant mental health service is an effective way of
beginning to break the cycle of insecure attachment as it takes advantage of both the
neurological plasticity of the baby and the fluid dynamics of a family in the process of
adapting to a new member. Leave it too late and both the structure of the brain and
family interactions become increasingly established and consequently harder to
change.
*****
Robin Balbernie.
Child Psychotherapist.
(robin.balbernie@glos.nhs.uk)
(09/05/09).
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