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Infant Mental Health Services: Recognising the Importance of Relationships in the Early Years as the Foundation for Practice-Based Evidence.

“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.

2. Introduction: why babies’ emotional needs have been neglected.

4. In the beginning: evolution and early influences on the mind.

6. Neurobiological development: the significance of brain plasticity.

11. Epigenetic effects of excessive stress at the beginning of life.

14. The importance of the attachment relationship: the first

experiences can lead to resilience or disturbances.

20. The effects of trauma, neglect and disconnectedness: the long-term consequences

of maltreatment.

30. The roots of violence: how moral behaviour depends on early parenting.

31. Implications of the research data: a summary to this point.

35. Caregiving in jeopardy: a knowledge of risk factors means help can be offered

before a baby is traumatised, not after the event.

40. Early intervention services, an overview.

43. Economic benefits of very early intervention.

46. The components of an early intervention service: existing models of delivery.

51. Different approaches to infant mental health interventions: evidence-based

practice and practice-based evidence.

78. Conclusion.

82. Appendix. Risk Factors.

83. References.

‘Traumatic events of the earliest years of infancy and childhood are not

lost but, like a child’s footprints in wet cement, are often preserved

lifelong. Time does not heal the wounds that occur in those earliest years;

time conceals them. They are not lost; they are embodied’ (Felitti, 2010:xiii).

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Introduction.

Probablythemostimportantperiodineveryone’slifeisonetheycannot

remember.Thefirsttwoorthreeyears,thetimebeforememorycanbeverbally

taggedforlaterretrieval,settheirstamponallthatcomesafter.These

experiencesbecomethebasisforthehumansoftwareofrelationshipsandthe

futureresponsetothreat,recordedinprocedural,orimplicit(unquestioned,

inaccessibletolanguage)memory.Evolutionhasequippedhumanswithabrain

thatanticipatesnothingandcanfitinwithmost.‘Atbirthaninfantcandevelop

intoaninfinityofselves,anditsbrainisequippedtodealwiththatuncertainty’

(Donald,2001:211).Butthehumanbrainisdesignedtobecomeananticipatory

machine,usingpastexperiencesallthetimetoforecastthenextmoment.

Theearlyyearscanthus,inmostcases,inthebroadestsenseeitherbepositive,

aswhenachildgainstheresourceofbeingresilientinadversitysothatlater

stressfuleventsdonotbecomeatraumaandtheyhavethecapacityfor

emotionalself-repair;or,whenthereisanyformofmaltreatment,negativeas

whenachild’searly(s)caregivinghaslefta‘basicfault’(Balint,1968)because

therewastoogreatadiscrepancybetweentheinfant’sbiologicalneedsandthe

qualityofcaregivingthatwasavailable.Thisdiscrepancyeasilygetslostor

ignored,itmayremaininvisibleforyears,althoughithasbecomeacentralpart

ofthesoftwareforsurvivalhardwiredintotheneurobiologyofthedeveloping

mindreadytooverridebothrationalityandempathyinadversecircumstances.

Karr-MorseandWiley(1997:278)pinpointthreeobstaclesthatseemtoprevent

usfacingtheunpleasantrealityofanincreasingnumberofbabies(whichiswhy

thepredicamentofrefugeechildrengetsside-lined.‘Thefirstofthesemaybe

grief,angerorsadnessfrompersonalchildhoodexperiences.Sometimesthese

aretoopainfultore-awaken.Theremayalsobesadnessandregretforthe

memorieswemayhaveinadvertentlycreatedforourownchildren.Athird

barriertoactingonthisinformationistofeeloverwhelmedbythedepthand

breadthoftheproblem.’Itishardtofeelhelpless,especiallyifwefacetheworld

fromthepointofviewofthesebabies.Emde(2001:23)drawsattentiontowhy

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3

theplightofmanybabiescanbehardtocontemplateandsogetspushedaside.

‘Itisoftenpainfulanddifficulttorecogniseandaddressmentalhealthproblems

ininfantsandyoungchildren.’Takingbabiesseriouslyopensanemotional

Pandora’sBox.Helistsfourkindsofmentalsufferingthatallwouldwantto

avoidandsomightprefernottothinkabout.‘Painanddistressfromtrauma,

abuse,orlossofacaregiver;miseryfromneglect;sufferingfromcumulative

stress;andsufferingfromlackofopportunity(ibid).’Distresscanberelieved,

butrescueorrepairmaybenomorethanmythscreatedbywishfulthinking

unlessthehelpisimmediateandspecialised.Theemotionalenvironmentof

infancy,whichfromthebaby’spointofviewconsistsofrelationshipswiththe

parents,willbepreservedonbothapsychologicalandneurologicallevelfor

goodorforill.Paradoxically,relationshipscaneitherbeadisasterorapathway

tohope,as:‘Theessenceofinfantmentalhealthworklieswithintheparent-child

relationship’(SolchanyandBarnard,2001:46).Relationshipsarethemost

importantfactorinababy’slife,literallyvital,andofcoursethiscontinuesever

after.

Inmanyinstanceswhenanolderchildcomestotheattentionofspecialist

helpingservicesprovidedbyEducation,Health,SocialServicesorthevoluntary

sectoritmayappeardifficulttodifferentiatebetweentheeffectsofearly

experiencesandreactionstocurrentfamilydysfunction,whichoftenpredates

thebirthofthechild.Sometimesasimplechangeinparentalunderstanding,

attitudeandbehaviour,ordirecttreatmentofsomeformwiththechild,will

enabletheproblemtobecomeresolved.However,asignificantpopulationof

children,whoseeffectandcostisoutofallproportiontotheirnumber,cannotbe

helpedinthisway.Itisjusttoolate.Thisiswhy,asdetailedbelow:‘Early

interventionfordisadvantagedchildrenandtheirfamiliescanbeasound

economicinvestment’(Barnett,2000:605).Babiescannotwait;foriftheyhave

beenadaptingtoanemotionallyinimicalsettingforanylengthoftimethenthe

damagecausedbyinappropriatecaregivingwillnotbeundonebyachangeof

circumstances,asisalltooclearwithmanychildrenwhohavebeenfosteredor

adopted,andsomuchmoreintensiveandlong-terminterventionsbecome

necessarywithasubsequentlygreaterdrainonresources.Thesearethechildren

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4

whodonotmakeuseofeducation,whodisrupttheclassroomanddemand

attentionastheybecomeeitherbulliesorvictims,whosometimesharm

themselvesasmuchasothersandwillgoontospreadcollateraldamage

throughouttheirlives.Asteenagerstheyattractdesperatelabelsasan

alternativetoafulfilledlife:conductdisorder,suiciderisk,borderline

personality,disruptivepupil,delinquentordisturbedandmore.Theywillbe

over-representedinthecriminaljusticesystem.Astheymoveintoadulthood

theyareatagreatlyincreasedriskforawiderangeoflife-threateningmental

andphysicalillhealthproblemsthatwilldepletehealthservicebudgetsuntil

theydie(see:http://www.cdc.gov/violenceprevention/acestudy/and

http://www.ajpmonline.org/article/S0749-3797(98)00017-

8/fulltext?refuid=S0266-6138(11)00071-4&refissn=0266-6138).

Inthebeginning.

Babiesareborn‘pre-programmed’toseekoutandadapttotherelationshipthat

theyhavewiththeirparents.Thisisabiologicalgiven,evolution’sanswertothe

prolongedperiodofhelplessnessinchildhoodandtheneedtoadjusttothe

infinitepossibilitiescreatedwithinafamilyininteractionwiththewiderculture.

‘Mostofhumanknowledgecannotbeanticipatedinaspecies-specificgenome…

andthusbraindevelopmentdependsongeneticallybasedavenuesfor

incorporatingexperienceintothedevelopingbrain’(ShonkoffandPhillips,

2000:53).Thehumangeneticpackagetransmitsinitialflexibilityandthe

capacitytoadapttotheenvironment,whicheventhenisincreasedbyepigenetic

processes;evolutionarysuccessforhumansisadaptationtotheimmediate

cultureandunforeseeablesocialdiversityratherthantothephysicalecosystem.

‘Thehumanbrainistheonlybraininthebiospherewhosepotentialcannotbe

realisedonitsown.Itneedstobecomepartofanetworkbeforeitsdesign

featurescanbeexpressed’(Donald,2001:324).

Anisolatedhumancannotexist,wedependonoursocialsurroundingsinorder

tojustbeandbecomewhatweare.‘Havingculturemeanswearetheonly

speciesthatacquirestherulesofitsdailylivingfromtheaccumulatedknowledge

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ofourancestorsratherfromthegenestheypassontous.Ourculturesandnot

ourgenessupplythesolutionsweusetosurviveandprosperinthesocietyof

ourbirth’(Pagel,2012:3),andthefamilyofourbirthistheprototypicalsetting

andconduitforthissurvivalinformation.Thusthegeneticimperativeforthe

babyisfitintowhatyoufind.‘Thechild’sfirstrelationship,theonewiththe

mother,actsasatemplate,asitpermanentlymouldstheindividual’scapacities

toenterintoalllaterrelationships.Theseearlyexperiencesshapethe

developmentofauniquepersonality,itsadaptivecapacitiesaswellas

vulnerabilitiestoandresistancesagainstparticularformsoffuturepathologies’

(Schore,1994:1).Intermsofgenerationalcontinuityoneofthemostimportant

learningexperiencesofinfancyisparenting–thisistheagewhenparenting

classeswouldactuallyhaveaneffectifwecouldmanageit–asparentingisone

ofthosetaken-for-grantedactivitieslearnedinthepre-verbalperiodandlargely

recordedinproceduralmemory.‘Parentalloveispossibleonlybecauseithasits

rootsinformerattachments;empathyandattunementwithanewbornare

enhancedbyrecognitionofwarmstatesorfeelingsfamiliarfromformer

relationships’(BrazeltonandCramer,1991:148).Thuseveryparentwilloneday

besurprisedtoheartheirownparentspeakthroughthem.Thisishardlyanew

observation:‘Asisthemother,soisherdaughter’(Ezekial,16:14).However,in

thecontextofearlyintervention,itisimportanttonotassumethatabackground

ofabusiveparentinginvariablybecomesre-playedinthenextgeneration

(HughesandCosser,2016);thisonlyappliestoaminorityinproportionalterms,

althoughthisisagreatmanyfamiliesintheoverallschemeofthings.

Theminddevelopsthroughoutlifeasthegeneticallyprogrammedconstruction

ofthebrain,intermsofneuro-physiologicalprocesses,anditcontinuesto

respondtosignificantexperienceswithotherpeopleaslongasitexists.

Relationshipschangeminds;andeverythingthought,feltorimaginedhasabasis

inelectrochemicalandneurohormonalprocesseswhosefinalconfiguration

derivesfromtheinteractionbetweenindividualexperience(includinginutero)

andtheparametersofgeneticandepigeneticpotential.Anysystemisatitsmost

adaptablewhileitisbeingbuilt,andhumanbrainsautomaticallyadapttoan

environmentdefinedbythequalityofthecaregivingrelationship.

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Notonlycanbabiesnotwait,butalsotheycannotstandupforthemselveseither.

Inaddition,babieshavenocomparisonsandthequalityofthecaregiving

relationshipisthemajorcomponentoftheirworld.Active,satisfyingand

reciprocalrelationshipswithparentscreatethe‘takenforgranted’basisofa

senseofidentity,self-esteem,appreciationofothersonalllevels,ethical

behaviourandself-control.‘Humanrelationships,andtheeffectsofrelationships

onrelationships,arethebuildingblocksofhealthydevelopment.Fromthe

momentofconceptiontothefinalityofdeath,intimateandcaringrelationships

arethefundamentalmediatorsofsuccessfulhumanadaptation’(Shonkoffand

Phillips,2000:27).Morethanthat,thequalityandcontentofthebaby’s

relationshipwithhisorherparentshasaphysiologicaleffectonthe

neurobiologicalstructureofthegrowingchild’sbrainthatwillbeenduring.

Neurobiologicaldevelopment:thesignificanceofearlyadverse

experiences.

Researchonbraindevelopment,whichhasre-writtenthetextbookssincethe

endofthelastcenturywiththeadventofnewtechniquesforimagingthe

functioningbrain,hasshownthat‘theinfant’stransactionswiththeearly

socioemotionalenvironmentindeliblyinfluencetheevolutionofbrainstructures

responsiblefortheindividual’ssocioemotionalfunctioningfortherestofthe

lifespan’(Schore,1994:540).Karr-MorseandWiley(1997:277),afteranin-

depthreviewofevidencefrommanydifferentdisciplinesonthegenesisof

violentbehaviour,returntothecellularlevel.‘Thestrengthandvulnerabilityof

thehumanbrainlieinitsabilitytoshapeitselftoenableaparticularhuman

beingtosurviveitsenvironment.Ourexperiences,especiallyourearliest

experiences,becomebiologicallyrootedinourbrainstructureandchemistry

fromthetimeofourgestationandmostprofoundlyinthefirstmonthoflife.’

(Forasummaryofresearch,see:Balbernie,2017;BelskyanddeHaan,2011;

Fox,etal.,2010;Gerhardt,2015;Glaser,2000;Hart,2008;Siegel,2012;Teicher

andSamson,2016.)Thebrainisatitsmostadaptable,orplastic,forthefirsttwo

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7

yearsafterbirth,duringwhichtime‘theprimarycaregiveractsasanexternal

psychobiologicalregulatorofthe‘experience-dependent’growthoftheinfant’s

nervoussystem.Theseearlysocialeventsareimprintedintotheneurobiological

structuresthatarematuringduringthebraingrowthspurtofthefirsttwoyears

oflife,andthereforehavefar-reachingeffects’(Schore,2001b:208).Whatwedo

intimesofstressreflectswhatwasdonetouswhenwewerebabies.

Thepostnatalperiodismarkedbyasequentialproliferationandthenpruningof

synapsesoccurringinsequenceasdifferentfunctionalcapacitieswireup;this

hasbeguninuteroandpost-mortemstudiesdemonstratethat‘theelaborationof

dendrites,spines,andsynapsescontinuestogrowatanearlogarithmicpace

thoughthefirst350-400postnataldays’(TauandPeterson,2010:153).The

brainisatitsmostadaptable,orplastic,forthesefirsttwoorthreeyearsafter

birthasthisistheperiodofmostrapidgrowthandchange.Thegenetically

governedhugepotentialnumberofsynapsesmustbeslimmeddowntobemore

efficientandfitthespaceavailable.‘Byinitiallyoverproducingconnectionsthat

havebeenspreadtoavarietyoftargets,andthenselectingfromamongtheseon

thebasisoftheirdifferentfunctionalcharacteristics,highlypredictableand

functionallyadaptivepatternsofconnectivitycanbegeneratedwithminimal

prespecificationofthedetails’(Deacon,1997:202).Experience-expectantbrain

growthtakesplacewhenthebrainisprimedtoreceiveparticularclassesof

externalinformationinordertobuildbasicskillsinthemostflexibleway.The

processofpruningisamatterofrespondingtotheenvironment,whileitseffects

dependontheareaofthebraininwhichitoccurs.Thegreatestover-abundance

ofsynapsesoccursduringsensitive,orevencritical,periods(theformerbeing

lessall-or-nothing)duringwhichafunctionalareaofthecortexreliesoninput

fromtheenvironmentinordertobecomesuitablyorganised.The‘fittest’,or

mostusedanduseful,synapsesareselected;andinneuraldevelopmentthisisa

matterofthelevelofelectricalactivityandneurotransmitterproduction.‘During

earlychildhood,excesssynapsesareremoved(pruning),andmanyneuronsdie.

Certainneuralcircuitsspecialise(parcellation),andneuronsthatdonotget

sufficientusefailtoconnectintocircuits;theydieortheirdendriteslosetheir

branches.Neuronsthatreceivefrequentuseandexercisegrowlarger,andtheir

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dendritesexpand.Apoptosisservestofinetunethesystemandcontinuesfor

manyyearsafterbirth’(Hart,2008:49).Pruninginareasinvolvedwithhigher

cognitivefunctionscontinuesthroughadolescencewhenthereisasecondphase

ofenhancedneuroplasticity.

Thebrainisinlargepartasocialorgan,designedbyevolutiontochangeininthe

contextofsignificantrelationships.Atthebeginningoflife‘Fromabasic

biologicalperspective,thechild’sneuronalsystem–thestructureand

functioningofthedevelopingbrain–isshapedbytheparent’smoremature

brain.Thisoccurswithinemotionalcommunication’(Siegel,1999:278).Toputit

simply,thebaby’sbrainwilladaptandchangetofitthefamilyenvironment,if

thisishostileordeprivingratherthanlovingitmakesnodifferencetothe

mechanism.‘Itisnowacceptedthatearlychildhoodabusespecificallyalters

limbicsystemmaturation,producingneurobiologicalalterationsthatactasa

biologicalsubstrateforavarietyofpsychiatricconsequences.Theseinclude

affectiveinstability,inefficientstresstolerance,memoryimpairment,

psychosomaticdisorders,anddissociativedisturbances’(Schore,2012:81).

Thereisnodoubtthatexposuretotoxicstressinanyformhasanegativeeffect

onthestructureofthedevelopingbrain.‘Maltreatmentisassociatedwith

reliablemorphologicalalterationsinanteriorcingulate,dorsallateralprefrontal

andorbitofrontalcortex,corpuscallosumandadulthippocampus,andwith

enhancedamygdalaresponsestoemotionalfacesanddiminishedstriatal

responsestoanticipatedrewards’(TeicherandSamson,2016:241).Experience

mightnotchangetheprocessofbraindevelopment,butitdoesmakeadifference

tothefinalproduct–andhowitwillbeused.‘Theseearlyimprintscanbe

remarkablylonglastingbecauseveryearlystressfullifeexperienceshaveleft

emotionalsystemssensitizedordesensitized,withpermanent,epigenetically

inducedhigh-stressreactivityandexcessiveprimary-processnegativisticfeeling’

(PankseppandBiven,2012:434).

Maltreatmentthatoccurswithinthefamilyisparticularlyperniciousasthebrain

is‘designed’toadaptitsstructureinresponsetotheenvironmentofimmediate

relationshipssothat‘trauma,neglect,andrelatedexperiencesofmaltreatment

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9

suchasprenatalexposuretodrugsoralcoholandimpairedearlybondingall

influencethedevelopingbrain.Theseadverseexperiencesinterferewithnormal

patternsofexperience-guidedneurodevelopmentbycreatingextremeand

abnormalpatternsofneuralandneurohormonalactivity’(Perry,2009:241).

This,itmustbeemphasised,isanormalprocessofenvironmentaladaptation;it

becomesahugedisadvantagewhentheadultenvironmentisobjectively

relativelybenignbuttheprogrammedobservation,interpretationandresponses

oftheindividualareoperatinginveryhostileterritorystill.‘Stress-induced

developmentalmodifications,triggeredbythenatureofexperienceduring

critical,sensitivestages,aredesignedtoallowtheindividualtoadapttohigh

levelsoflife-longstressordeprivationthatmaybesignaledbyearlystressful

experience.Ifanindividualisbornintoamalevolentandstress-filledworld,the

manifestationsofearlystressfulexperienceonlaterdevelopmentmayservean

adaptivepurpose,enablingtheindividualtomobilizeintensefight-flight

responsesorreactaggressivelytochallenge’(Teicher,etal.(2003:39).Itislessa

matterofearlystressdamagingagrowingbrainasitisthecasethatthegrowing

brainmakesanappropriateadaptationtoastressfulenvironment.

Aninfantwhohasdevelopedinsecureattachmenthas,bytheageofoneyear,

encodedwhatcouldbelifelongexpectationsoftheworldandoftheself,along

withafullsetofpathologicalanddangerousoperatinginstructions.‘Repeated

experiencesofterrorandfearcanbeengrainedwithinthecircuitsofthebrainas

statesofmind.Withchronicoccurrence,thesestatescanbecomemorereadily

activated(retrieved)inthefuture,sothattheybecomecharacteristictraitsofthe

individual’(Siegel,2012:55).Thetraumadoesnothavetobedirect,whatababy

seesandhearswillalsodefinetheirenvironmentofadaptedness.Ithasbeen

shownthatexposuretofamilyviolencecausesthesameadaptationsinthe

amygdalaandanteriorinsulaasoccurinsoldiersonthebattlefield,causing

increasedreactivitytothreateningfaceswhichinturnbringsariskof

vulnerabilitytopsychopathology(McCrory,etal.,2011).

Mostadultmentalillnesshassuchanucleusofoldandunrememberedterror

(Read,etal.,2008).‘Structuralandfunctionalabnormalitiesinitiallyattributedto

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psychiatricillnessmaybeamoredirectconsequenceofabuse’(Teicherand

Samson,2016:241).Earlystressfulexperienceswithinthecaregiving

relationshipmayhavea‘pathogenicimpactbymakingtheself-processing

fronto-tempo-parietalsystemmorevulnerable;and…areassociatedwith

sensoryandcognitiveimpairments…whichcancriticallyimpactself-processing’

(Debbane,etal.,2016:9),andthisinvulnerableindividualscanleadtolater

psychosis.Lessextremebutequallyharmfulforboththeindividualandfor

society,babieshavenochoicebuttoadapttotheirenvironment,andthe

behavioursassociatedwithdisorganisedattachmentarenotsomuch“bad”,

rathertheyarefittingtoabadsituation.Asurvivalstatehasbecomea

personalitytraitandthecapacitytohandleanystrongemotioninapro-social

mannercompromised;andtheharmfulchangesinbrainstructureandfunction

associatedwiththisaresimply‘adaptiveresponsestoanearlyenvironment

characterisedbythreat’(McCrory,etal.,2010:1088).Veryyoungchildrenwho

suffermaltreatmenthavethehiddenfoundationsoftheirmindwrecked

comparedwiththosemorefortunate,leadingtophysiologicalchangeswithin

theirneuroanatomythatmaybeimpossibletoreverse.‘Earlysocial,emotional,

andnutritionaldeprivationinhumanshasbeenshowntoresultinreduced

functioningoftheorbitofrontalcortex,thehippocampus,theamygdala,andthe

lateraltemporalcortex.Italsodisruptsthewhite-matterconnectivityinthe

brain–particularlytheuncinatefasciculus,afan-likewhitemattertractthat

connectsfrontalbrainregionstotheamygdalaandtemporalbrainareastothe

limbicareas.Prolongedandchronicstress,includingdisruptedorpoor

mothering,disruptsthebrain’sstress-responsesystem.Thatresultsinexcessive

glucocorticoidrelease,areductioninglucocorticoidreceptors,andultimately

braindegeneration’(Raine,2013:265).Theolderthechildbecomes,thenthe

harderitcanbeto‘re-wire’manyareasofthebrain;whichmeansthatwithout

interventionachildwhohasexperiencedabuseorneglectasaninfantwill

unwittinglycontinuewithpatternsofresponsesthatareengravedinthemindas

sheersurvivalresponses,evenifcircumstanceschange.Thesechangesare

holistic,beginningatthepsychologicallevelandworkingthroughtothe

molecular.Thecorollaryofthisisthatageandtheenergyneededtochangea

mindincreasetogether.

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Epigeneticeffectsofexcessivestressatthebeginningoflife.

Thequalityofthefirstrelationshipwithcaregiversisalsothoughttoaffecthow

manyofanindividual’sgenesare‘expressed’(switchedonoroff),settingthe

limitsofwhatwillorwillnotbepossibleinthefutureonabasicbiologicallevel.

Whatarecalledepigeneticmechanismsmayalteragene’sfunctionwithout

affectingitssequence(thesequenceisinherited),andthesehavethecapacityto

changegeneexpressioninresponsetoenvironmentalpressures,arapidformof

structuraladaptation,byaddingachemicalsignatureabove(thustheepi)the

genethatcandeterminewhetherornot,orwhen,itisexpressed.Collectively

thesesignatures,ormarkers,areknownastheepigenomeanditstaskisto

programmethegenome.‘Epigeneticpatternsaregeneratedduringcellular

differentiationbyahighlyprogrammedandorganizedprocess.Nevertheless,

theyaredynamicandresponsivetotheenvironmentespeciallyduringthe

criticalperiodsofgestationandearlylifeaswellaslaterinlife.Thissensitivityof

theepigeneticmachinerytotheenvironmentoffersaconduitthroughwhichthe

environmentcansculptthegenomeandhavealong-termimpactonhealth’

(Szyf,2009:879).Pre-birthinfluencesareparticularlysignificant,see

(http://www.beginbeforebirth.org).

Thisisamechanismthatbothpermitsandprohibitsthebiologicalbuilding

blocksbehindcertaincharacteristicsandbehaviours.(SeeBuchan,2010,fora

clearintroductiontothistopic.)‘Epigeneticsreferstochemicalmodificationsto

theDNAortothehistoneproteinsthatarephysicallyassociatedwiththeDNA…’

(Meaney,2013:100).Roughlyspeaking,thegenecontrolstheproductionof

aminoacidsthatcreatethecellularbuildingblocksofappropriateprotein.But:

‘Structuralgenes…arecodesforresourcesneededfordevelopment.Theyare

notthecodesforthecourseandend-pointsofdevelopmentitself’(Richardson,

2008:30).DNAiswrappedaroundahistone-basedproteincalledchromatin

whosestructuremaybeextensivelyamended,mostcommonlybymethylation

butalsobyphosphorylation,acetylationandwhatischarminglyknownas

ubiquitination(whichmustcoverallbets),allformingthebasesofhistone

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modifyingenzymes(Syf,2009).Withinthedevelopingmindneurobiological

signalinginresponsetoextremeenvironmentalchallengessetsoffthe

productionofgeneregulatoryproteins,whichthenattractorrepeltheenzymes

thatinturnaddorremoveepigeneticmarkerstoaltertheformandstructureof

DNA.‘Forthegrowingbrainofayoungchild,thesocialworldsuppliesthemost

importantexperiencesinfluencingtheexpressionandregulationofgenes’

(Siegel,2012:32).Epigeneticmarkersswitchfunctionalcharacteristicofthe

geneonandoffbycontrollinghowmuchproteinismanufactured,sothat‘these

epigeneticmarksontheDNAandthehistoneproteinsofthechromatinregulate

thestructureandoperationofthegenome.Thus,epigeneticsisdefinedasa

functionalmodificationtotheDNAthatdoesnotinvolveanalterationof

sequence’(Meaney,2013:105).Althoughepigeneticmarkingsarelonglasting

theyarealsopotentiallycapableofbeingreversed(Syf,2009)byboth

psychotherapeuticandpharmacologicaltreatments.Animalstudiesshowthat

epigeneticmodificationsmaybeinheritedduringmitosis(andsometimesin

meiosis)andcanbetransmittedtothenextgeneration.Theyalsodemonstrate

that‘abundantmaternalcaresetsinmotionaseriesofepigeneticchangesin

gene-expressionpatternsthatmake‘well-loved’animalsmoreresilientwith

robust,life-longresistanceagainstvariousstressors’(PankseppandBiven,

2012:308).Contrary,onecouldspeculatethatepigenetictransmissionmightbe

whyafewbabiesadoptedatbirthhavelatersevereemotionalstruggles

regardlessofhow‘good’theintermediateparentinghasbeen–theycarry

survivaltraitsappropriatetotheabusivechildhoodenvironmentofaparent.

Lessfar-fetchedmaybe,studieshavenowshownthat‘theepigenomeofa

prenatallydevelopinginfantissensitivetothemother’sexperiences,the

prenatalenvironment,andeventheexperienceofbirth’(RothandSweatt,2011:

404).Insuchinstancessuchthingsasmaternalstressorrestricteddietmay

havecausedepigeneticchangesinutero.So,withacertainelementoftruth,one

couldsaythatearlyinterventionwithinthefieldofinfantmentalhealthinvolves

notonlymicrobrainsurgerybutalsogeneticmodification-nopressure!

Generegulationhasevolvedtoimportcontextonacellularlevel.‘Epigenetic

findingsstronglysuggestthathistory,politics,socialenvironments,racism,and

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discriminationmustbegivenconsiderationequaltoorgreaterthanthatof

immediatefamilycircumstances,thusposingchallengingquestionsforthe

locationofresponsibilityforillhealth’(Lock,2013:1897).Theemotional

environment,especiallyduringpregnancyandinfancy,activatesandsilences

usefulandunhelpfulgenesthatarecrucialformentalwellbeing,affectregulation

andsocialandemotionaldevelopment.Natureissituatedwithinnurtureasthe

genomecannotoperatewithnoconnectiontoitssocialsetting;and:‘Forthe

developinginfantthemotheressentiallyistheenvironment’(Schore,1994:78).

Thisisnotanewobservation,Winnicott(1971:53)observedthatatthestartof

life‘thebehaviouroftheenvironmentispartoftheindividual’sownpersonal

development…’

Alongitudinalstudyhasexaminedepigeneticchangesintheglucocorticoid

receptorgenethatplaysacrucialroleinstressregulationbynegativelyaffecting

theHPAaxis.Childrenexposedtophysicalabusedisplayedaspecificepigenetic

effectwithmoremethylationofseveralkeychromosomalsitesimplicatedina

rangeofbiologicalfunctionsincludinghealthybraindevelopment,oneofwhich

wasreducedglucocorticoidreceptorswhichwouldimpairnegativefeedbackof

theHPAsystemresultinginstressregulationproblems(Romens,etal.,2014).

Wealsonowknowthatadultstestedasinsecureininfancyhavedifferentneural

responsesfromthesecurelyattachedinaselfcontrolparadigmwheretheywere

askedtoup-regulatetheexperienceofpositiveaffect,showinggreateractivation

intheprefrontalregionsinvolvedwithcognitivecontrolandreducedco-

activationofthenucleusaccumbens(asourceofemotionalresponses)withthe

prefrontalcortexsuchaswouldindicatearelativeinefficiencyinregulating

positiveaffect(Moutsiana,etal.,2014).Thesetwosetsofobservedstructural

changesinthebrainwouldleadtoproblemsofselfcontrol,whichhaslongbeen

regardedasvirtuallysynonymouswithqualityofattachment(andwithsuccess

inmanyareasoflife),sothattheflexibleandrelativelyefficientaffectregulation

andcapacitytointroducethoughtbetweenimpulseandaction,thattogether

conferresilienceandsuccesstothesecure,islacking.ThelongitudinalDunedin

Studyhasdemonstratedthatchildhoodself-control,whenseparatedoutfrom

socialclassandintelligence,isaverystrongpredictorforphysicalhealth,

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14

substancedependence,personalfinancesandcriminaloffendinginadulthood

(Moffitt,etal.,2011).Thereisapricetopayforanysocietythatdoesnot

prioritizesupportingtheearlycaregivingrelationship.

Theimportanceoftheattachmentrelationship.

Attachmenttheory,developedbytheBritishPsychiatristandPsychoanalystJohn

Bowlby,hasprovidedaframeworkforstudiesonboththeimmediateandlong-

termeffectsofearlyrelationshipexperiencesonthemindandbehaviourofthe

developingchild.‘Ourmostdistinctiveandimportanthumanabilities–our

capacitiesforlearning,invention,andinnovation;andfortradition,culture,and

morality–arerootedinrelationshipsbetweenparentsandchildren’(Gopnik,

2016:22).Attachmentresearchhasintegratedtheinner,psychological,world

withtheouterworldofbehaviourtodemonstratethat‘thepatterningor

organizationofattachmentrelationshipsduringinfancyisassociatedwith

characteristicprocessesofemotionalregulation,socialrelatedness,accessto

autobiographicalmemory,andthedevelopmentofself-reflectionandnarrative’

(Siegel,1999:67).Attachmenttheoryandalargeandgrowingbodyofresearch

convergetoagreethat‘aninfant’sformationofanattachmenttoacaregiverisa

keydevelopmentaltaskthatinfluencesnotonlythechild’srepresentationsof

selfandother,butalsostrategiesforprocessingattachment-relatedthoughts

andfeelings…(and)mayberelatedtoriskforpsychopathologyorto

psychologicalresilienceinadulthood’(Dozier,etal.,2008:718).However,the

attachmentparadigmcoversonlyapartofhumandevelopmentandany

theorizingorinterventionthatonlyreliesonthisapproachruntheriskof

becomingsomewhatone-dimensional.

FollowingthecreationbyAinsworthandcolleagues(1978)oftheStrange

SituationProcedure,attachmentbehaviourwasinitiallysplitintothree

observablecategories.Themajorityofchildren(about65%)demonstratesecure

attachment,tobecontrastedwithanxious-avoidant,anxious-ambivalentand,a

laterconceptualisation,disorganised-disorientedorcontrollingpatternsof

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15

attachment.Theorganisedpatternsofanxiousattachmentcanbethoughtofas

clustersofgoal-directedactivitywhoseaimistomaintainthebestavailable

emotionalandphysicalconnection,asthechildseesit,withthecaregiver.‘Each

ofthethreepatternsreflectsastrategyforenlistingthecaregiverintheservice

ofalleviatingstress.Thesecureinfantexploresfreelyandseekscontactwiththe

attachmentfigureasnecessary.Theavoidantinfantfocusesonexploration,and

monitorsandmaintainsproximitytotheattachmentfigure,butdoesnotexpress

attachmentneedsinordertoavoidriskingrejection.Theresistantinfantis

preoccupiedwiththeavailabilityofaninconsistentcaregiver,makingrepeated

high-intensitydemandstoensurethatatleastsomeofthelatterelicitattention’

(Goldberg,2000:23).Thedifferentcategoriesofattachment,onceinplace,

demonstratethedependantchild’schosenmethodofaffectregulation;thiswill

haveabiginfluenceoninternalandinterpersonalprocesses.‘Eachattachment

patternreflectsadifferentecologicallycontingentstrategydesignedtosolve

adaptiveproblemsposedbydifferentrearingenvironments’(Simpson,

1999:125).Babiesandtoddlers,ofcourse,havenomeansofmaking

comparisonsandsothisisjustthewaytheworldofrelationshipsandemotions

goesandcanbeexpectedtocarryongoing.Theyhavejustadaptedtothe

situationathand.Theobservedpatternsofattachmentbehaviourarethechild’s

automaticresponsetothefamilyemotionalhabitat;secureattachmentisno

more‘good’thaninsecureattachmentis‘bad’–thinkinginthesetermsisatrap

oflanguagewiththe‘in’prefixacuefornegativevalue.Evolutionarytheory

speaksof‘conditionaladaptation’,anditisworthexplainingthisinratheralong

quoteasremovingvaluejudgementsasfaraspossibleopensspaceinthemind

forempathyandthinking.Thishypothesisalsoreinforcestheimportanceof

lookingtochangethewholeenvironment(preferablybeforethechildisborn)

ratherthansolelyaimingtofixaprobleminthechildorparent(s),theparents

alsoareadaptingtocircumstances.

‘Fromwithinsuchaperspective,thehighlysusceptiblechildwho

respondstoadangerousenvironmentbydevelopinginsecure

attachments,adoptinganopportunisticinterpersonalorientation,and

sustaininganearlysexualdebutisnolessfunctionalthanthecontext-

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16

sensitivechildwhorespondstoawell-resourcedandsupportivesocial

environmentbydevelopingtheopposingcharacteristicsandorientations.

Afurtherimplicationisthateffortstoreducethepainandsufferingof

childrengrowingupunderstressfulconditionsneedtotakeinto

considerationthelocalsenseinwhichriskyandseeminglyself-destructive

behaviorsmaybeadaptive.Childrenhaveevolvedtofunction

competently,thatis,tosurviveandultimatelyreproduce,inavarietyof

contexts.Thedefaultassumptionshouldbethatalternativepatternsof

developmentinresponsetobothstressfulandsupportiveenvironmental

conditions(withintherangeencounteredoverhumanevolution)

constituteadaptivevariation'(Ellis,etal.,2011:10).

Secureattachmentisabroad-bandprotectivefactor,conferringconfidenceand

adaptability,althoughnotatotalguaranteeoffuturementalhealth,andwithout

thisemotionalresourceneitherchildnoradultwillfeelfreetomakethemostof

theirlife’spossibilities.Inlaterlifesecurechildrenandadultscanbothaskfor

helpandself-repair,andaremorelikelytoberesilientinthefaceofadversity.

Theyalsodemonstrateimprovedexecutivefunctionperformance(Bernier,etal.,

2012),anadvantageinallwalksoflife.Aninsecurechild,ontheotherhand,has

toomanyanxietiesthatgetinthewayofinvestigatingtheworld,sohorizons

staysafelynear.Researchmakesitclearthat‘Ingeneral,securechildrenshow

moreconcentratedexplorationofnovelstimuliandmorefocussedattention

duringtasks.Secureattachmentprovidesthebest-knownpsychological

preconditionfortension-freeplayfulexploration’(Grossmann,etal.,1999:781).

Largelyasaconsequenceoftheimpactofallformsofinsecureattachmentonthe

capacitytobeplayful,curious,formpositiverelationshipswithpeersandadults,

theabilitytoexertself-control,co-operationandcognitiveskills,thisisapoor

startinaschoolcareer;andisapredictorforacademicfailureanddropoutin

lateryears(Ramsdal,etal.,2015).

Bythetimeinfantsenterintotheirsecondyearoflifethereareconsistent

observabledifferencesintheirbehaviourthatdependuponthelevelofsecurity

theyhaveexperiencedintherelationshipwiththeirparents.Thompson

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17

(1999:274)givesasummaryofdecadesofresearchtodescribehow‘securely

attachedchildrenshowgreaterenthusiasm,compliance,andpositiveaffect(and

lessfrustrationandaggression)duringsharedtaskswiththeirmother,aswellas

affectivesharingandcomplianceduringfreeplaywiththeirmothers.Securely

attachedinfantstendtomaintainmoreharmoniousrelationswithparentsinthe

secondyear.’Attachmentrelationshipsprovidethelaunchpad,iftheyarefirm

andtrustworthythenbetterthetake-offandthemoresuccessfulistheflight.

Thisinfluencecanbelonglasting;asshownbyalongitudinalstudyofhigh-risk

infantswhereinfantsecuritywasshowntobeassociatedwiththesuccessornot

ofparticipants’romanticrelationshipsinyoungadulthood(Roisman,etal.,

2005).

Thethreedifferentcategoriesofinsecure,oranxious,attachmentmakethechild

increasinglyvulnerabletolife’sevents;butapartfromthemostserious

classification,insecureattachmentbyitselfisnotnecessarilyadisorder,

althoughitcanleadtoone.Goldberg(2000:209)summariseshowintherelevant

researchhere.‘Averycommonfindingisthatthehistoryofpsychiatricpatients

isriddledwithnegativeattachment-relatedexperiencessuchasloss,abuseor

conflict.’Insecureattachmentisariskfactorthatwillinteractwithotherrisks

presentintheemotionalandphysicalenvironmentofthegrowingchild;the

levelofattachmentdisturbanceisequivalenttoalevelofvulnerabilitythatis

difficulttochangewithouthelp.Itisworthnotingthatalongitudinalstudyof

high-riskinfantsshowed‘substantialshiftingtowardsinsecurityinlate

adolescence,particularlytowardsthedismissingclassification’(Weinfield,etal.,

2004:89).Conversely,disorganisedattachmentinveryyoungchildrenwas

significantlyrelatedtolateadolescentinsecurity.Researchshowshowin

adolescenceinsecurityislinkedtoconductproblems(Allen,etal.,1997;

RosensteinandHorowitz,1996).Itisimportanttobearinmindthatinitial‘good

enough’attachmentcanbelostinthefaceoflatersevereadversecircumstances

andsotraumaresponseserviceswillalwaysbenecessary;initialsecure

attachmentdoesnotconfertotalinvulnerability.

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18

Childrenwithproblemsrelatedtoinsecureattachmentbegintosoakup

statutoryresourcesfromearlyonwhenexternalisingbehaviour(aggression,

non-compliance,negativeandimmaturebehaviours,etc.)demandsaresponse

(Speltz,etal.,1990).ThisisprobablythelargestgroupofchildrenthatSocial

Services,SpecialEducationandtheChildandAdolescentMentalHealthService

areexpectedtodealwith.‘Thesocialandeconomiccostsofthesetypesof

disordersarestaggering’(Greenberg,etal.,1997:197).Ithasbeenestimatedthat

‘InEnglandthecostsofmentalill-healtharegreaterthanthetotalcostsofcrime,

andthereiseveryreasontobelievethatthisisalsothecaseintheUKasawhole’

(FriedliandParsonage,2007:16).Studieshaveconsistentlydemonstrated‘ahigh

rateofinsecureattachmentsamongclinic-referredboysandtheirmothers’(ibid,

p.216);thesameappliestochildreninspecialeducationalprovision(E.B.D.

schools).Arecentstudycomparedemotionallydisturbedchildrenwithtwo

controlgroupsfromotherschoolsettings.Mostofthesechildrenhadbeen

diagnosedashavingattentiondeficitdisorder,therestaseitherconduct

disorderordepression,withhalfthesamplehavingmorethanonediagnosis.

Theywerefoundtobe‘strikinglydifferentfromtheircounterpartsinregular

classroomsintheextenttowhichtheyhadexperiencedmajordisruptionsin

theirrelationshipswithbothmothersandfathers’(Kobaketal.,2001:252).The

differentcategoriesofinsecureattachmentareinthemselvesriskfactorsthat

predisposetowardsspecificdifficultiesinlaterlife.

Avoidantattachmentisastrategyoftendevelopedbyaninfantwhoseparents(or

nannies)havediscouragedovertsignsofeitheraffectionordistress,andwhodo

notreadilyoffersympathyorcomfort.Itischaracterisedbyminimalexpressions

ofemotioninthepresenceofacaregiverwhohaspreviouslybeenconsistently

rejectingorignoringof,orinsensitiveto,suchemotions.Theconvictionthat

othersdonotseeyouassomeoneworthloving,orevenrespondingto,canlead

tolowself-esteemandsubsequentaggression.Closerelationshipsareavoidedas

thechildgetsolder,andsuchadultsmaymasktheirinsecuritybybecoming

addictedtowork,acquisitionsorachievement,orretreatbehindobsessionaland

ritualisticbehaviours.‘Avoidantattachmentwouldalsoseemtobeacomponent

ofcompulsivepersonalitytraits.Atitsextreme,thecompulsivepersonalityisthe

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19

nightmareversionoftheuptight,authoritarianfatherwhoisdeterminedto

banishallemotions.Helivesinaconstrictedworld,hisattentionsnarrowedto

schedules,rules,andtidiness;andheisobsessedwithtrivia’(Karen,1994:391).

Theisolatedchild‘whoalsohasanavoidantattachmenthistoryandperhaps

certaingeneticleanings,may,ifthingscontinuetogopoorly,developintoa

schizoidpersonality’(ibid).Avoidantattachment,inthewrongcircumstancesis

aprecursorofdissociativeidentitydisorderandconductdisorder.

Ambivalent,orresistant,attachmentstemsfromtheinfant’sexperienceof

inconsistentparentingwhenthechildisneverquitesureifhisorher

expressionsofanxietyanddistresswillbesuitablyattendedtoattherighttime.

Theywillmaximisetheexpressionofnegativeemotionsanddisplaysof

attachmentbehavioursinanattempttocapturetheattentionoftheir

inconsistentlyresponsiveandattentivecaregiver.Thereisalackofconsistent

nurturingandprotectionfromtheparentthatmakesithardfortheinfanttofeel

thatexploringtheworldisasafeoption.Thusthechildhasalowthresholdfor

distress,butnoconfidencethatcomfortwillbeforthcoming.Thechildhardly

everisreturnedtohomeostasisbytheircaregiver.Whenupsetheorshetriesto

getclosetothecaregiver,butonlytobecomeangryandresistcontact.This

patterncanbecarriedintoadulthoodandthererevealsitselfinrelationship

difficultieswherethereiseitherawithdrawalfromothersoracompulsiontobe

dependent.Thisisthehystericalpersonalitywho‘fleesfromintimacy,and,like

theambivalentchild,shetendstobedemandingorclingy,immature,andeasily

overwhelmedbyherownemotions’(Karen,1994:392).Alongitudinalstudy

foundthatadolescentsdiagnosedwithanxietydisordersweresignificantlymore

likelytohavehadresistantattachmentswiththeirparentswhentheywere

infants(Warren,etal.,1997).

Avoidantandambivalentattachmentsmaybeanxious,buttheyhaveworked

withinthefamilyandtheyarecoherentandprovidethechild(andgrown-up)

withsomesortofunconscioussetofstrategiesforrelatingtoothers.Anxiously

insecurechildrenhaveadaptedintheirownwaytoboththebehaviourandthe

zonesofemotionalcomfortoftheirparents.Theseareinternalworkingmodels

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20

ofwhatonceactuallydid,andisnowexpectedto,occurininterpersonal

exchanges.Atleastsomethingispredictableandthesearenotunkindcaregivers,

andacertainamountofmeaningandsatisfactioncanbegainedwithinmature

relationships.Thisisnottrueforthemostseriousformofinsecureattachment,

labelledasdisorganisedandcontrolling,whichiscausedbypathological

conditionsandgivesrisetopathologicalwaysofrelating.

Theeffectoftrauma,neglectanddisconnectednessontheattachment

responseandlong-termdevelopment.

Maltreatmentandtraumawithinthefamilywillshattertheprotectiveshieldthat

allyoungchildrenexpecttheirparentstoprovide.Inmany,notall,casesthe

behaviourpatternassociatedwithdisorganisedattachmentisamarkerfor

maltreatmentwithinthefamily.Whatisknowninattachmentresearchas

disorganisedattachmentfrequentlyoccurswhentheparenteitherhassomany

unresolvedemotionalissuesfromtheirownpastthattheyhavenomentalspace

leftoverfortheirbabyor,graver,posessomeformofthreat.Thetwoconditions

mayco-occur.Ineithercasethecaregiverisunabletosoothe,comfortand

containtheirdistressedoranxiouschildandsotheattachmentsystemremains

inoverdrive,thereisnoreturntorest.Thechildmay,intheworstinstances,be

driventotakepsychologicalrefugeindissociation,splittingtheurgesofthe

biologicallybasedattachmentsystemforproximityawayfromtheawareness

thatthecaregiverhasamindthatholdshostile,abusiveorneglectfulthoughts

directedtowardstheircharge.Herethechildstruggleswithalackofcoherent

andorganisedstrategiestodealwithstressandemotionalregulation,andshows

behavioursthatappearcontradictory,misdirected,dissociatedorfearfulinthe

presenceofthecaregiver.Fearhascometobeassociatedwithparental

behaviourandattitudessincetheattachmentsystemcannotbede-activatedby

thepresenceoftheputativecaregiver–whoisfrequentlyexperiencedasa

scaregiver.Againthismaynotbeamatterofobviousmaltreatment,butmay

occurwhen‘disruptedparentalresponsestoinfantattachmentbehaviorare

extremeenough,andcontradictoryenough,thatavoidantorambivalent

.

21

strategiescannotbeorganizedinrelationtothecaregiver;thatis,suchstrategies

donotworkwellenoughtomaintainamodicumofproximityandprotection.

Thesedisruptedandcontradictoryparentalresponses,inturn,generate

complementarypatternsofdisorganizedhelplessandcontradictoryresponses

fromtheinfantaroundtheneedforclosenessandcomfort’(Lyons-Ruthand

Jacobvitz,2008:675).Suchapatternofinteractioncanbeequallydifficultto

recogniseandtreatasfirstlytheparentsmaygenuinelyfeeltheyaredoingthe

besttheycanandsecondlynoimmediatetraumamaybevisible;andifthe

problemderivesfromconflictualrelationshipsinthecaregiver’sownchildhood

thatnowunintentionallyinformpatternsofcaretheninfantparent

psychotherapy,overanextendedperiodoftime,maybenecessarytoaddress

suchunconsciousdynamicsthathavebecomeprojectedontotheinfant.

Babiesareborntoseekaconnectionwithacaregiver,andwhenthisinherited

behaviouralmotivationsystemisnotadequatelyrespondedtothenthe

subsequentanxietykicksintheattachmentsystem.Thebabyortoddleris

biologicallyimpelledtoseeksafetythroughphysicalandemotionalclosenessto

thecaregiverwhenworried.Whentheparentisoutoftouchorthesourceoffear

(andthismaybetheresultofneglect)theparadoxcannotberesolved;evena

caregiverwhoappearstobedoingalltherightthingsbutwhoharbourshostile

orresentfulthoughtsagainstthebaby(andthesemaybeunconscious)will

createthesameclashbetweenbiologyandpsychology.Whenthereisno

predictablesolutiontoresolvetheoppositepullsofapproachandavoidanceand

thechild’sfaithintheworldofrelationshipsisdemolishedbytheir‘scaregiver’,

thenheorsheisleftwithnocoherentmeansofrelatingtootherpeople.There

canbeatragicsymmetryhere,withsomemothersbecomingfearfuloreven

aversiveofthebabywhensignalsofdistressarousestrongconflictualfeelings

derivedfromtheirownbabyhoodthattheyareunabletomanage.A‘ghostinthe

nursery.’‘TheghostsrepresenttheunconsciousrepetitionofthepastIthe

presentthroughpunitiveorneglectfulcaregivingpractices,whichthenow-

parentinternalizedasachildinaneffortatself-protectionbybecominglikethe

abusiveparent’(Lieberman,IppenandVanHorn,2015:167).Allformsofmisery

arebadforbabiesandsmallchildren;butwhereasitmaytakeaseveretrauma

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22

tocreatedisorganisedattachmentwhenachildstartsoffwithsecurity,fora

childwhoseparenthasconsistentlyfoundithardtoattuneandrespond

appropriatelyarelativelymildmisfortunemaycementdisorganizationintothe

foundationsoftheirpersonality.Achildclosetoacliffwillfalloffwithonlya

smallnudge,whereasonestandingbackwouldnotevenregisteradanger.

Secureattachmentconfersthemosthardinessandemotionalroomto

manoeuvre;disorganisedattachmentmeansyoumightstumbleatanymoment.

Themainaimofallformsofearlyinterventionistopreventthemanydifferent

parentingconditionsthatmayleadtodisorganizedattachmentintheshortterm,

withmaltreatmentbeingthemostobvious,butnottheonly,cause.Aninfant

mentalhealthinterventionfocusesonthepresentwhileholdingthecaregiver’s

pastinmind;itisamatterofinterveningpre-emptively,withalwaysaneye

towardsthefuture.‘Abuseandneglectinthefirstyearsoflifehaveaparticularly

pervasiveimpact.Pre-nataldevelopmentandthefirsttwoyearsoflifearethe

timewhenthegenetic,organic,andneurochemicalfoundationsforimpulse

controlarebeingcreated.Itisalsothetimewhenthecapacityforrational

thinkingandsensitivitytootherpeoplearebeingrooted–ornot–inthechild’s

personality’(Karr-Morse&Wiley,1997:45).Fromanevolutionaryperspective

thisiswhatwewouldexpect,thecaregivingenvironmentispreparingthechild

withtheskillsandtraitsthatwillhelphimorhersurvivetoreproductiveage.

Evolutiontakesnonoticeofpersonalhappiness,justgeneticsurvival.‘Stress-

induceddevelopmentalmodifications,triggeredbythenatureofexperience

duringcritical,sensitivestages,aredesignedtoallowtheindividualtoadaptto

highlevelsoflife-longstressordeprivationthatmaybesignaledbyearly

stressfulexperience.Ifanindividualisbornintoamalevolentandstress-filled

world,themanifestationsofearlystressfulexperienceonlaterdevelopmentmay

serveanadaptivepurpose,enablingtheindividualtomobilizeintensefight-flight

responsesorreactaggressivelytochallenge’(Teicher,etal.2003:39).Anyearly

interventionservicethatreducesthepossibilityofmaltreatmentor‘out-of-

touchness’duringinfancyhasthepotentialtoreducethelong-termcosttoboth

theindividualandsociety.Butatthesametimeitisimportanttokeepinmind

thatthereareother,lessvisiblepathstodisorganizedattachmentthatwillhave

.

23

asimilareffectonthedevelopingchild’sbehaviorinthelongterm.(Itis

importanttobearinmindthatmeasuringattachmentstatus,eitherbythe

StrangeSituationorobservation,isnotinfallibleandthechild’sbehaviourmay

beinfluencedonthedaybymanyotherunknownfactors;thusmaltreatment

doesnotalwaysleadtodisorganizedattachmentanddisorganisedattachment

doesnotinvariablyindicateabackgroundofmaltreatment.)Thebehaviours

associatedwithdisorganizedattachmentarenotinvariablytobetakenas

symptomsofabuseorasareasonfortraumatizingachildbyremovingthem

fromtheirfamily.Itisprimarilytheaccumulatedexperienceoftoxicstressfrom

severeadverseexperiencesthatcausesthelong-termnegativedevelopmental

outcomes.

Theswatheofinterpersonalexperiencewithintheboundariesofattachment

relationshipsinthefirsttwoyearsoflifethatcancreatedisorganized

attachmentmayresultinstructurallimitationsoftheinfant’searlydeveloping

rightbrainanditisthesethatliebehindtheobservedbehaviours.Thisisthe

hemispherethatlargelyholdstheattachmentsoftwareandisdominantforthe

unconsciousprocessingofsocialandemotionalinformation,theregulationof

bodilystates,thecapacitytocopewithemotionalstress,theabilityto

understandtheemotionalstatesofothers(empathy)andthesenseofabodily

andemotionalself.‘Itisnowacceptedthatearlychildhoodabusespecifically

alterslimbicsystemmaturation,producingneurobiologicalalterationsthatact

asabiologicalsubstrateforavarietyofpsychiatricconsequences.Theseinclude

affectiveinstability,inefficientstresstolerance,memoryimpairment,

psychosomaticdisorders,anddissociativedisturbances’(Schore,2012:81).

Thesechildrenfromvulnerablefamiliesbecomevulnerableadults.

Theenduringfunctionalcopingdeficitsofthedisorganisedattachmentpattern

associatedwiththespectrumofinsensitivityandinappropriateresponsesthat

rangesfromjustbeingoutoftouchtomaltreatmentreflectastructuraldefectof

therightorbitofrontalcortex.Dysfunctioninthisbrainareamayresultin

personalityandemotionaldeficitsthatparallelcriminalpsychopathicbehaviour,

forexamplealackofemotionalcomprehensionandaffectregulationcoupled

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24

withahair-triggerstressresponse.Atthesametime,experiencesofprolonged

andfrequentepisodesofunregulatedstressinbabieswhoseemotionsare

uncontainedorpredominantlyfearfulcanbedeemedtoxic.Theyhave

devastatingeffectsontheestablishmentofpsycho-physiologicalregulationand

theestablishmentofstableandtrustingrelationshipsinthefirstyearoflife.The

impactofmaltreatmentatthisearlystageofbraindevelopment,ofmaximum

neuroplasticity,canleadtoanincreaseinthelikelihoodofthedevelopmentof

seriousmentalillnessatadolescence.‘Byunderminingtheneuralintegrityof

brainregionssustainingflexibleandrobustemotionregulation,aswellasself-

referentialandmetacognitiveprocessing,theearlydisruptionofthestress

regulatorysystemmay…makeanimportantcontributiontopsychosisrisk’

(Debbane,etal.,2016:5).Thedifferentcategoriesofattachmentaremerelya

measureofthechild’sability–ornot–toselfregulateandself-protect.

Disorganizedattachmentisanadaptationtorelationshiprisksinthefirstyears

oflifeanditscharacteristicsareappropriatesurvivalresponsesinthat

environment,thesearestrategiesformanagingtheunmanageable.

Theimpactofearlyabuseandneglectcanshowonaphysicallevelalmost

immediately,asithasbeenfoundthattherateofdisorganisedattachment

associatedwithfailuretothriveisextremelyhigh(Wood,etal.,2000).Froma

life-pathperspectiveithasbeenclearlydemonstratedthatchildrenwhohave

sufferedearlyneglectandabusearefarmorelikelytosufferfromserious

illnesseswhentheyareadults,thustakingupanexcessiveanddisproportional

amountofhealthserviceresources,andtheyarealsoatagreatlyincreasedrisk

ofearlydeathfrombothphysicaldiseasesandsuicide(Felitti,etal.,1998;

http://www.cdc.gov/violenceprevention/acestudy/).Humanbabies(and

children)havenoinheritedbiologicalresponsetothreatfromwithinthefamily

beyondthestressresponses,itwasnotaproblemevolutionhadto‘solve’,andso

thelong-termeffectsofsuchabnormalbehaviourcanlastalifetime.The

AdverseChildhoodExperiencesStudyhasmatchedthelifetime(ashortone)of

negativephysicalandmentalhealthdifficultiesthatstemfrommaltreatment

withtheresearchonthecumulativeeffectsoftraumaonthestressresponsein

thedevelopingbrainaswellastheresultingimpairmentinmultiplebrain

.

25

structuresandfunctionsthataccumulatewithincreasingexposuretodifferent

formsofnegativeandtraumaticexperiences(Anda,etal.,2006),andthe

youngerthechildiswhenthisbeginsthenthemoresevereistheoutcome.‘Child

maltreatmentposessevererisksforlong-termmaladjustmentandthe

developmentofpsychopathology.Childmaltreatmentexemplifiesapathogenic

environmentthatisfarbeyondtherangeofwhatisnormativelyencountered

andengenderssubstantialriskformaladaptationacrossdiversedomainsof

biologicalandpsychologicaldevelopment.Boththeproximalenvironmentofthe

immediatefamilyandthemoredistalfactorsassociatedwiththecultureand

community,aswellasthetransactionsthatoccuramongtheseecological

contexts,conspiretounderminenormalbiologicalandpsychological

developmentalprocessesinmaltreatedchildren’(Cicchetti,etal.,2006:624),

withseriousnegativeconsequencesfortheindividual.

‘Exposuretochildhoodadversityleadstotheearlyinitiationofdrug,

alcohol,andnicotineuseandriskysexualbehaviorsandaccountsfor

50-70%ofthepopulationattributableriskforalcoholism,drug

abuse,depressionandsuicide.Italsosubstantiallyincreasesrisk

factorsforischemicheartdisease,liverdiseaseandobesity.This

powerfuladverserelationshipisbestunderstoodasacascade.

Exposuretoearlyadversityalterstrajectoriesofbraindevelopment,

whichinturn,leadstosocial,emotionalandcognitiveimpairment,

followedbytheadoptionofhealthriskbehaviors’(Teicher,etal.,

2010:112).

Disorganizedattachment,frequentlyamarkerformaltreatment(butagainit

mustnotbeassumedthatmaltreatmentinevitablyliesbehinddisorganized

attachment),isamajorriskfactorthat,inthe‘wrong’circumstances,candisrupt

manydifferentareasofdevelopment.Itisalsoamarkerforotherrisks.Ina

summaryofresearchMossetal.(1999:160)concludethat‘Disorganized/

controllingattachmentispredictiveofthedevelopmentofbehaviouralproblems

atpreschoolandschoolageinbothhigh-riskandnormalsamples.Studies

indicatethatbothexternalizingandinternalizingsymptomscharacterizethe

.

26

behaviourproblemsofdisorganizedschool-agedchildrenbetween5and9years

ofage.Althoughatpreschoolandearlyschoolage,itisprimarilyanaggressive,

disruptivebehaviourpatternthatisassociatedwithdisorganization,anxieties

andfearsrelatedtoperformance,abilities,andself-worthbecomemore

pronouncedinmiddlechildhood.’Disorganizedattachmentpredominatesin

childrenreferredtoCAMHS(Green,etal.,2007).Childrenwhohavebeen

assessedashavingdisorganizedattachmentat5-7yearsmessuptheir

education;theyhavepoorerskillsatmathsage8(Moss,etal.1998)andshow

impairedformaloperationalskillsandself-regulationat17yearsofage

(Jacobson,etal.1994).Thesetwostudiessuggestthatlowself-esteemandlack

ofconfidenceinschoolmediatedthepoorperformance,thusexacerbatingthe

problemswithself-esteemthatisknowntogowithdisorganizedattachment

anyway(Cassidy,1988).Playandcuriosityareimpossiblewhentheattachment

systemisonsuchahighalert,solearninganythingbutsurvivalskillsgoesoutof

thewindow;theybecomeemotionallyandscholasticallyilliterateversionsof

BearGrylls–scary-andafatlotofuseintermsofcontributingintosociety.

Aprospectivestudyofanon-clinicalpopulationhasexaminedthelong-term

consequencesofdifferentattachmentpatternsinchildren,differentiating

betweenthosewithmotherandfather(VerschuerenandMarcoen,1999;

Verschueren,2001).Childrenwhohaddisorganisedattachmentwiththeir

fathersshowedhighlevelsofinternalisingbehaviourswhentheywere5;andby

9yearsofage(byteacherreport)theyhadinternalisingproblems,extremely

poorsocialadjustmentandlowself-esteem.Childrenwithdisorganisedmaternal

attachment(notthesameones)weresixtimesmorelikelytoberejectedbytheir

peergroupthanaverage(morethantwicetherateforavoidantchildren).Ifthe

childwasunfortunateenoughtohavedisorganisedattachmentwithboth

parentstheyhadbothsetsofdifficulties.Suchfrightenedandunhappychildren

oftenupsetandalienatetheirpeers,creatinganegativefeedbackcyclethat

increasestheirdefences.

Theproblemsassociatedwithpoorqualityofattachmentbetweenchildand

parentsbegintobevisiblealmoststraightaway.‘Childrenontrajectories

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27

towardsseriousexternalizingproblemsarelikelytohaveinsecure,particularly

disorganized,attachmentsinthefirstyear’(Shaw,etal.,1996:697).Inaddition,

itisnowacceptedthat‘severelycompromisedattachmenthistoriesare…

associatedwithbrainorganizationsthatareinefficientinregulatingaffective

statesandcopingwithstress,andthereforeengendermaladaptiveinfantmental

health’(Schore,2001:16).Itisthiswired-incompromisedabilityforself-control,

alackofcopingmechanismsonaneurologicallevelfordealingwithinternaland

externalstressesandfrustrations,whichconfersahighvulnerabilityforlater

emotional,relationalandmentalhealthproblems.TheMinnesotaStudy,

followinghighriskchildrenfrombeforebirthforaboutthirtyyearsnow,has

foundthatalltypesofabuseinthefirstyearsrelatedtosignificantemotional

problemsinadolescence,andpredictedtheneedfortreatment.Outofallthe

childrentheyhadfollowedsincebirth90%ofthesamplewhohadbeen

maltreatedqualifiedforatleastonepsychiatricdiagnosisbyage17.Itturnedout

thateveryformofabusewasrelatedtodelinquency,withahistoryof

psychologicalunavailabilitybeingthestrongestpredictor.Neglectalsopredicted

delinquency,althoughthesechildrentendednottobeangryordefiant.

Witnessingparentalviolencecorrelatedwithexternalisingproblemsforboysat

age16andinternalisingproblemsforgirls.Thiswasindependentofother

predictorssuchasabuseorneglect(Sroufe,etal.,2005).Inaddition,suicidal

behaviourinadolescenceisstronglyinfluencedbyunresolved-disorganised

attachment,withgirlsbeingathighestrisk(Adam,etal.1996).

Childmaltreatmentdoesnotspringfromnowhere,andolderchildrenwhocome

intothechildprotectionsystemalmostalwayshaveahistoryofgriefgoingback

tobabyhood.Thepeakageforbeingmurderedisunderone.Theriskpretty

muchdoublesifthereisanon-biologicallyrelatedadultinthehousehold(Daly

andWilson,1998).Earlyintervention,wherevulnerableandoverstressed

parentscanbeidentifiedandsupportedbeforethebabysuffers,beforetheir

ownemotionallybarrenandterrifyingpastbecomesentangledinthe

relationship(andexpectations)withtheirbaby,isanessentialpreventative

serviceifwewanttoavoidasteadygrowthinthenumberofreferralstoadult

mentalhealthservices.‘Childabusehasacausalroleinmostmentalhealth

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problems,includingdepression,anxietydisorders,PTSD,eatingdisorders,

substanceabuse,personalitydisorders,anddissociativedisorder.Psychiatric

patientssubjectedtochildhoodsexualorphysicalabusehaveearlierfirst

admissionsandlongerandmorefrequenthospitalizations,spendlongertimein

seclusion,receivemoremedication,aremorelikelytoself-mutilate,andhave

highersymptomseverity’(Read,etal.,2008:218).Takingdisorganized

attachmentasamarkerforchildabuse(butnotassumingflagrantabusealways

liesbehindit),oritsprecursorsasahighrisk,makesitanimportanttargetfor

preventativeservices,whichcanbeginatconception,offeringhelponthebasis

ofriskbeforethechildsuffers.

Asummaryoftheresearchontheconnectionsbetweenearlyattachment

experiencesandadultpsychopathology(Dozier,etal.,1999)lookedat

‘attachmentrelatedcircumstances’andtheireffectonlatermentalhealth

problems.‘Losspredictsmultipledisorders,includingdepression,anxiety,and

antisocialpersonalitydisorder…Depressionisassociatedgenerallywiththe

earlylossofthemother.Majordepressioninparticular…hasbeenfoundtobe

relatedtopermanentlossofacaregiver,whereasdepressioncharacterizedby

angerandotherexternalizingsymptomshasbeenfoundtoberelatedto

separation.Anxietyappearstobeassociatedmorecloselywiththreatsofloss

andinstabilitythanwithpermanentloss.Antisocialpersonalitydisorderis

associatedwithlossthroughdesertion,separationanddivorce’(ibid,513).It

appearsthatthequalityofachild’searlyparentingcanputthemonthepathway

todifferentdestinations.‘Affectiveandanxietydisorderstendtobeassociated

mostfrequentlywithparentalrejectioncombinedwithloss.Antisocial

personalitydisordersaremostfrequentlyassociatedwithparentalrejection,

harshdiscipline,andinadequatecontrol.Eatingdisordersareassociatedwith

maternalrejectionandoverprotectioncombinedwithpaternalneglect,and

borderlinepersonalitydisorderisassociatedmostconsistentlywithparental

neglect’(ibid,514)Severallongitudinalstudieshavedemonstratedthelink

betweendifficultfamilyenvironmentsandtheirinfluenceonthebabyandthe

developmentofdissociative,borderlineandconductdisordersinyoungadults

(Lyons-Ruth,2008).

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Theearlyrelationshipbetweencaregiverandbabywillactasanexternalsystem

forthechild’sinternalregulationofaffect.Attachmentis,inmanyways,a

measureofself-controlandemotionalregulation.Thegrowinginfant,whobegan

totallydependentonmotherforsoothing,stimulationandemotionalregulation,

graduallyclaimstheabilitytomanagealone.Theircortexlearnstodowhatthe

caregiver’scortexhadtodoforthem.Inotherwords‘earlydevelopmententails

thegradualtransitionfromextremedependenceonotherstomanagetheworld

forustoacquiringthecompetenciesneededtomanagetheworldforoneself’

(ShonkoffandPhillips,2000:121).Caregiversmaintainthebabywithin

comfortable,oracceptable,feelingstatesbyintuitivelyrecognisingwhattheir

childisexperiencingandhowtheycanhelptorestoreequilibrium.Theparents’

abilitytodothisdependsontheirbaby’sgrandparents.Inordertoachievesuch

sensitivitytheadult’semotionalawarenessisatakenforgrantedresourcethat

enablesanautomaticacknowledgementofneedandasubsequentresponse.‘A

caretakerwithapredispositiontoseerelationshipsintermsofmentalcontents

permitsthenormalgrowthoftheinfant’smentalfunction.Hisorhermental

stateanticipatedandactedon,theinfantwillbesecureinattachment’(Fonagy,

etal.,1991:214).Comfortisnotalwaysanautomaticpresence;indire

circumstancesitcanseemunattainableandinternalpeaceisimpossible.

Thesecurechild(andadult)hasthepsychologicalandneurologicalcapacityto

self-modulaterecognisedaffects.Thecapacityforself-controlandthecategoryof

attachmentarefairlysynonymous.Responsestostressfulorexciting

circumstancescanbethoughtaboutratherthanactedout.‘Asaresultofbeing

exposedtotheprimarycaregiver’sregulatorycapacities,theinfant’sexpanding

adaptiveabilitytoevaluateonamoment-to-momentbasisstressfulchangesin

theexternalenvironment,especiallythesocialenvironment,allowshimorherto

begintoformcoherentresponsestocopewithstressors’(Schore,2001:14).

However,whentheinfanthasbeenexposedtorelationshipslikelytoengender

disorganised,orcontrolling,attachmenttheyhavenochoiceaboutadaptingto

theseemotionalconditions,leadingto‘brainorganizationsthatareinefficientin

regulatingaffectivestatesandcopingwithstress’(ibid:16).Aninabilitytothink

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30

aboutothers’feelingscoupledwithanequalinabilitytocontrolimpulseswill

haveseriouslong-termconsequencesthatwillrippleoutwardsfromthechild.

‘Widespreadtraumatodevelopingnervoussystemsispotentiallyascatastrophic

tohumansocietyasthegreenhousegasesaretotheplanet’(Karr-Morseand

Wiley,2012:249).Politiciansseemkeenonpromotingandsubsidising‘clean’

energytopreventglobalwarming;afractionofthatinvestmentinparent-baby

relationshipswouldequallyprotectoutfutureemotionalenvironment.

Therootsofviolence.

Infantswhohavesufferedadverserelationshipsgoontobecometeenagersand

adultswhoaregrosslyover-representedinthecriminaljusticesystem.Thisis

notonlyadirectdrainonresources;italsosignifiesalargepopulationwhoare

notinapositiontocontributetothewidersociety(thesameappliestothose

whoneverleavetheirdependencyonmentalhealthprovision).Delinquent,

antisocialandviolentbehaviour,frequentlyassociatedwithnosenseofeither

empathyorremorse,hasbeentracedbacktobeingonthereceivingendofabuse

andneglectduringthefirsttwoyearsoflife(deZulueta,1993;Karr-Morse&

Wiley,1997;TheWaveReport,2005,fromhttp://www.wavetrust.org/key-

publications/reports/all).Evenhavingaconsciencecannotbetakenforgranted,

asithasbeendemonstratedthatthisiscultivatedby‘caregiverswhoarewarm

andprovideclearexpectationsforchildbehaviourthatareconsistently

reinforced’(ShonkoffandPhillips,2000:243).Thecapacityforemotional

regulationandself-controlisvirtuallysynonymouswiththequalityof

attachmentinearlychildhood.Thisisthetimewhentheneurologicaland

hormonalfoundationsformentalandemotionalhealtharebeinglaiddown;and

ahard-wireshair-triggerfightandflightresponsewilldonobodyanyfavours.

Ithasbeenfoundthatattachmentproblemsinadolescencepredictlatercriminal

behaviour(Allen,etal.,1996);andanattachmentbasedstudyofprisonerswith

apsychiatricdisorderconfirmedthehypothesisthat‘criminalityarisesinthe

contextofweakbondingwithindividualsandsocialinstitutionsandthe

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31

relativelyreadydismissalofattachmentobjects.Criminalbehaviourmaybeseen

asasociallymaladaptiveformofresolvingtraumaandabuse…Violentactsare

committedinplaceofexperiencedangerconcerningneglect,rejectionand

maltreatment.Committingantisocialactsisfacilitatedbyanonreflectivestance

regardingthevictim’(Fonagy,etal.,1997:255).AsdeZulueta(1993:76)putsit,

violence‘isthemanifestationofattachmentbehaviourgonewrong.’Theability

tobemindfulofanother’smind,andthusmindhowyoutreatthem,isderived

fromtheinfant’srelationshipwiththeircaregiver.

Implicationsoftheresearchdata.

Iftheearlyrelationshipbetweenthebabyandhisorherparentsisgiventhe

attentionitdeservesthenthishastwomajorimplications.-Firstly,manylater

emotionalandmentalhealthproblemscanonlybereworkedinasimilarfireas

forgedthem.Long-term,intensiveand(thistime)thought-aboutrelationships

maybenecessarytohelpthosewhocarrythementalimprintofearlytrauma

andneglect.Foraslongasthebrainretainssufficientplasticityintherelevant

areasthenitsneurochemicalstructurewillcontinuetoadapttotheeffectof

affect.Evidencesuggeststhatpsychotherapy‘probablyinitiallychangesthe

functionalconnectionsamongneurones,andthenlaterconvertsthesefunctional

changesintochangesintheactualstructureofthecerebralcortexitself’

(Vaughan,1997:68).Butlesseffortwouldhavebeencalledforwhenthemind

was,bydesign,morereadilyadaptable.–Secondly,byrecognisingthatthe

parent-infantrelationshipisthecrucibleforchangeanddevelopment,forgood

orill,wecanlookbeyondtheindividualstothewiderconditionsthatimpinge

uponthisrelationship.Lookingforreasonsremovesblame.Everyparentalways

doesthebesttheycanfortheirbabywithinwhatispossibleforthem.Abroader

perspective,tryingtounderstandratherthanpassingjudgement,pointstothe

importanceofacatalogueofknownriskfactors.Itisfeasibletoanticipatewhat

sortofsituationtendstoleadtoinsecureattachment,andthusoffertreatmentor

someotherformofhelpbeforeanythinggoesdrasticallywrong.Thatis,before

responsesgetso‘hard-wired’intothebrainthattheybecomeincreasinglyhard

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32

tochange.Itishardtoholdinmindthenumberofriskssomefamilieshaveto

contendwithandnotfeelhumbledbyhowwelltheycope.Butbeingawareof

theriskfactorsmeansinterventionhasabetterchanceofbeingatthe

preventativeendofthespectrumratherthanthereactive.Thesecanbeapplied

beforethebabyisborn,andaninfantmentalhealthteamwillworkwithfamilies

duringpregnancy,especiallyiftheparent-fetalattachmentisnotaswewould

wantittobe-anunhappystateofaffairsthathasasmanynegativeconsequences

asithascauses(Cataudella,etal.,2016).

Theideaofprovidingspecializedservicesthattargettherelationshipbetween

caregiver(usuallybutnotinvariablyabiologicalparent)andbabyortoddleris

onethathasbecomeincreasinglymainstreamoverthelasttwodecades,and

clinicalprovisioninthestatutoryandvoluntarysectorshasbeguntobuildup.

Suchearlyinterventionisproactiveratherthanwaitingforaproblemtoarise.

Theprimeaimistopreventmaltreatment.Itisimportanttohaveathandthe

rationalebehindsuchprovision;andsuchinitiativesasthe‘1001CriticalDays’

campaignandtherecentAPPGReport‘BuildingGreaterBritons’(2015),aswell

asabroadrangeofgoodbriefingpapersfromtheNSPCC,haveencourageda

widesurgeofinterest(www.1001criticaldays.co.uk)thathasthepotentialto

openupalotofopportunitiesacrosstheUK.

Infantmentalhealthinterventionisahighlyskilledspecialitybutmanydifferent

professionsneedtobeinvolved.Thenumberofqualifiedpractitionersininfant-

parentpsychotherapyissteadilygrowingwithcoursesavailablethroughthe

AnnaFreudCentre,OXPIP,TheTavistockCentreandTheSchoolofInfantMental

Health.Thesearepost-professionalqualificationtrainings,psychodynamically

based,andaproperlytrainedclinicianmeritsahighpayband,anathemainthe

currentclimateoffrugalitywhereCAMHSmanagersarereducingthegradeand

payofthemostqualifiedandexperiencedclinicianswherevertheycan.Butyou

donothavetobeapsychotherapisttobeaninfantmentalhealthspecialist;and

thereareotherequallyusefulinterventionssuchasInteractionGuidanceand

therapeuticgroupsalongthelinesofMellowParentingandCircleofSecurity.

Midwivesandhealthvisitors(thebestearlywarningsystemforadultproblems

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33

thatwehave)arecentralastheyareuniversalandnotstigmatising,andbothare

nowspecialisinginearlydetectionandinterventionwithvulnerablefamilies.An

infantmentalhealthteamshouldbebothmultidisciplinaryandarelationship-

basedorganisation(Bertacci,1996),againquitecontrarytothefranticpressure

ofareducedCAMHSfacedwithmorereferralsthantheycanhopetoofferan

adequateserviceto;andinthesamespirit,treatmentmustfollowthecaregiving

relationshipsratherthanaritualistictime-limitingformulaandso,insome

cases,mightneedtobeopen-ended;suchacavalierattitudetotheethosof

meetingtargetsmaycauseorganisationalstressandbadfeeling.

Anobviousproblemforthestatutorysectoristhatinearlyintervention,which

ideallycanbeginduringpregnancyandthencontinueupuntilatleastthesecond

birthday,isthatthereisstrictlyspeakingnoindividuallyidentifiedpatient.The

‘patient’isthecaregivingrelationship,whichhopefullyincludesbothmotherand

fatherandallthattheirbackgroundandtheindividualbabytogethercontribute.

Butparents/carersmustchoosetobeengaged;soanyfileneedstobeopenedin

theirnamenotthechild’s,bothforclearethicalreasonsandalsoforanychild

protectionconcerns(theremaybechildrenwithdifferentsurnamesinthesame

family)and,especiallyimportant,foreaseofcommunicationwithadultservices

whentheyareinvolved.Andwhointheirrightmindwouldknowinglywant

theirbaby,oranybodyelse’s,tocollectamentalhealthrecord?Thisthen

deprivesanyCAMHSofnumbers,somayberesistedpurelytomeettargets.

ThereisalsoatendencyforCAMHSservicestobelargelyclinic-based.They

generallydolesshomevisitingthanadultteamsorcommunityworkersfroma

children’scentre.Thisishardlythebestplacetoworkwithavulnerablefamily

wherethenormalheightenedstressandanxietycausedbyanewbabyis

amplifiedbythesenseofbeingjudged,letalonetheanxietiesthatcanariseina

noisywaitingroom;andCAMHSmighthavenegativeassociationsfortheparent.

Betterforthecliniciantocontaintheanxietyofahomevisit(unlessunsafe),

wheremorecanbelearnedfromasingleobservationthanastringofclinic

sessions,thantheparentshavingthehassleoftransportinganinfant,plusallthe

attendantclobberandpossiblyasibling.Anotherreasontokeepinfantmental

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34

healthservicesdistantfromCAMHSisthatalmostinvariablythefamilyhasnot

requestedhelp,ithasbeensuggestedbysomeprofessionalsuchasamidwife,

healthvisitororchildrencentreworker.EveryreferraltoCAMHShasmotivated

parentsaskingfortheirchildtobe‘fixed’;ininfantmentalhealththereisusually

nochildwithasymptom(thoughbabiescanhaveemotionalandmentalhealth

difficulties)astheprimeaimistomaintainhealthysocialandemotional

developmentasfaraspossible.Atthisagemost‘problems’beginasanintangible

withinthecaregivingrelationship,andthat,asariskanalysisshows,canhavea

multitudeofsources.Thisiswhyanearlyinterventionteamneedstobothbe

highlyskilled,close,creativeandmultidisciplinary;andthenatureofthe

personalcommitmenttothiswork,withmorestressandlesswaitingtimes,

demandsanorganisationallyunrulyteam-ifnotthereisaproblem.Insome

regionssuchateammaybemoreefficientandcreativeinthevoluntarysector

(seewww.pipuk.org.uk)andfeelmoresupportedandcontainedwithinthe

focussedandskilledbustleofachildren’scentrethana‘formal’mentalhealth

setting.

Thereisabreadthofevidence-basedpracticeinthefieldofearlyintervention,as

detailedbelow;although,basedonthe‘goldstandard‘ofRCTs,someofthe

populationleveleffectsareprettysmall.(Forexamplessee:www.aimh.org.uk).

Onereasonforthisisthatpoverty,whichamplifiesandconcentratesallthe

otherrisks,remainsthesourceofmajorstressonparentsandallthe

psychologicalinterventionsintheworldwillnotaffectthat.Thisdiversityshows

thenecessityforsettingupappropriatelytrainedteamshousingmultipleskills

ratherthanstickingtoasinglemethodofoffering‘therapeutic’helpto

vulnerablefamilies.

Inaveryroughandreadywaytherapeuticinterventionscoveringthefirst1001

criticaldayscanbecategorisedaseithergroups,whereparentsareheldby

relationshipsasopposedtotaught,orindividualworkwiththeprimecaregiver

tochangebehavioureitherdirectlyorthroughanalterationinthewayinwhich

bothparentingandthebabyareviewed.Thesearedetailedbelow.Butinthe

realandmessyworldtherearenotsuchclear-cutdifferencesandaflexible

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35

approachisthemostrealistic.Theexamplesinthispaperarenotexhaustive,I

amsureIhavenotreadeverythingbyalongchalk,butarebackedupby

practice-basedevidence.Thesearebestdeliveredfromachildren’scentre

offeringuniversalservicesasthat,coupledwithanattitudeofhelpingall

vulnerablefamilies(whocomefromeverystrataofsociety)lowersthe

reluctanceofparentstobecomeinvolvedasfarasispossible.

Caregivinginjeopardy.

Wheneveranewbabyarrivesonthesceneitisstressfulforfamily.Thatisjust

thewaynaturehassetusup;wehavethemostextendedperiodofjuvenile

dependencyofanyspeciesandworriesabouttheyoungshouldactivatethe

caregivingsystem,sountiladulthood(andbeyond)childrenaredesignedtotax

theirparents.Hardluck.Thisisbothnormalandcanbethoughtofasa

spectrum;atoneendallconcernedarefairlycoolandhaveconfidencethat

althoughtherewillinevitablybeupsetsanddramasthesewillbeabletobe

overcome,whileattheredendtheadditionalresponsibilityofababycan

actuallybeastresstoofar.Ofcourseveryfewparentsanticipatethelatter,

althoughwedomeetparents-to-bewhoresentordreadhavingababy,

sometimestothepointoffear.Thisiswherethesensitivemidwifeiscrucialin

enlistingspecialisthelpinthepre-natalperiod.

Aparentwhocarriesaburdenofanxietyfrommultiplesourceswillnotbeable

togreetthebabywithanopenmind.Caregiverswhocanholdtheirchildin

mindatalltimescreatesecureattachment,thebestfoundationforbuildingall

thelaterskillsthatnormaldevelopmentwillmakepossible.Amindfullof

stressorshaslessspaceforthechild.Thereisalargebodyofresearchonrisk

factors,withgeneralagreementonwhattheseareandhowtheyaffectparenting.

(E.g.Balbernie,2002;FonagyandHiggitt,2000;Karr-MorseandWiley,1997&

2012,2000;Sameroff,2000;Zeanah,etal.,1997.)TheAdverseChildhood

ExperiencesStudy,wherethesampleismiddleclassandaffluent,hasclearly

shownhowabuildupofrisksinthefamilyenvironmentisapredictorfor,

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36

amongotherthings,seriousphysicalandmentalillheath,beingbotha

perpetratorandvictimofdomesticviolenceandforsubstanceabuse(Felittiet

al.,1998).Theserisksareeasilyspotted(seeappendix),again,inthepre-natal

periodthemidwifeisinthebestpositiontodothis,andthenthehealthvisitor

takesovertheroleofearlywarningsystemforthementalhealthofthenext

generation.

Theparent-babyrelationshipisalwayslocatedinamuchwiderecological

context,withinwhicharefoundbothriskandprotectivefactors(Osofskyand

Thompson,2000).Whathasbeencalled‘familywell-being’,withoutwhich

developmentallyappropriateparentingwillbestressfulanddifficult,isa

compositeofmanydifferentcomponents(Newland,2015),whichiswhyearly

interventionisbuiltuponaknowledgeofrisks(seeappendix1).Thesecanharm

thebabydirectly(e.g.pollution,unhealthyhousing)butmostlyaretitratedinto

therelationshipviatheireffectsontheparents’functioning,sincetheydictate

thebaby’simmediateexperiences.TheMillenniumCohortStudyhasconfirmed

that:‘Thegreaterthenumberofrisksexperiencedbythechild,thegreaterthe

problemsthatthechildwillfaceduringthelifecourse’(SabatesandDex,2012:

22).

Nurtureandnaturecannolongerberegardedasdiscretelyseparateissues.

‘Geneticsusceptibilitiesareactivatedanddisplayedinthecontextof

environmentalinfluences.Braindevelopmentisexquisitelytunedto

environmentalinputsthat,inturn,shapeitsemergingarchitecture.The

environmentprovidedbythechild’sfirstcaregivershasprofoundeffectson

virtuallyeveryfacetofearlydevelopment,rangingfromthehealthandintegrity

ofthebabyatbirthtothechild’sreadinesstostartschoolatage5’(Shonkoffand

Phillips,2000:219).Thisevengoesdowntothegeneticlevel,asthrough

epigeneticchangescaregivingcancause‘long-lastingdifferencesingenescritical

forbehavior,stressresponsivity,metaboliccontrolandautoimmunityleadingto

emergenceofdiseaselaterinlife’(Syf,2009:879).Someparentsareover-

burdenedbynegativefactors,pastandpresent,whicharebeyondtheircontrol.

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37

Theyneednon-judgementalassistanceassoonaspossibleifwewanttobreak

thecycleofemotionaldeprivation.

Some(butcertainlynotall)oftheriskfactorsknowntoadverselyaffectthe

parent-babyrelationshipare:problemsintrinsictothebaby,suchaslowbirth

weightorcongenitalabnormalities;aparentwholackstheabilitytosensitively

attunetothebaby’sneeds,whodoesnotinteractwiththeirinfantormaltreats

himorher;oneorbothparentsstrugglingwithamentalhealthoraddiction

problem,orwithabackgroundofabuse,neglectorlossintheirownchildhood;

inadequateincomeorsub-standardhousing,familydysfunctionand(extremely

harmful)domesticviolence(Brigg-Gowan,etal.,2010);singleteenagemother

withoutsupport.(TheseexamplesfromLandy,2000:345;andseealsoSameroff,

2000:12.)Somanyfactorsexternaltothebabyandparentcanmessuptheir

relationshipthatproblemsherecanbetakenasasignthatthechild,without

intervention,willgrowupstrugglingwithemotionalharassmentfrommany

differentdirections.Interventionmayhavetobeonmultiplelevelsassuggested

byLisaNewland(2015)whohasbuiltatheoryofchangeonherfamilyWell-

BeingModel,wherethestrongestinterventionswouldaddressfamilyself-

sufficiency,developmentalparentingandchildwell-beingsimultaneously.She

pointstotheimportanceofappropriateclinicalservicesandtheuseofhome-

basedinterventions,backedupbyparentingeducationandfamilysupport

programmes(ibid:10).

Aworkingassumptionthatcandirectbothearlyandlaterinterventionisthat

‘attachmentdisruptionmaybeamarkerorsummaryvariableforanumberof

pathogenicfactorsinthechild’senvironment’(Kobaketal.,2001:254).Thebaby

hasnocomparisons,whatismetissimplyhowthewholeworldisorganised

(andwhyshoulditchange?)andthisiswhatwillbeautomaticallyadaptedto.

Theimmediaterelationshipbasedenvironmentprogrammesinemotional

softwarefairlyrapidly.‘Asasourceofrisk,thehomemayreflectanatmosphere

ofdisorganization,neglect,orfrankabuse.Asasourceofresilienceandgrowth–

promotion,itischaracterizedbyregularizeddailyroutinesandbothaphysical

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38

andapsychologicalmilieuthatsupportshealthychild-caregiverinteractionsand

richopportunitiesforlearning’(ShonkoffandPhillips,2000:345).

Theresearchonriskfactorsmeansthatbabieswhomightbelikelytohave

adversedevelopmentalpathwaysthroughlife,becauseofstressesintheirinitial

relationshipwiththeirparents,canbeidentifiedearlyon.Eventheunbornchild

cannotbeassumedtobesafe.Thefoetuscanbedirectlyharmedbyanumberof

toxins(includingtheeffectsofstressonthemother)whichcancausedisability,

regulatorydisorders,attentiondifficultiesorskilldeficits;anyoneofwhichmay

makeithardfortheneonatetosettleintoanattachmentrelationship.‘Children

bornalreadyimpairedaremorelikelytobethebruntofdestructiveparenting

behavioursandabuse’(Karr-Morse&Wiley,1997:55).Amajorrisk,thesingle

biggestcauseofcognitivedelayindevelopedcountries,ismaternalalcohol

consumptionduringpregnancy.Itisnowacceptedthat:‘theteratogeniceffects

ofalcoholarenotlimitedtoheavychronicexposure,ortoexposureduringa

specifictimeduringthegestationperiod(Fitzgerald,etal.,2000:129).Foran

excellentworkingsummaryonfoetalalcoholspectrumdiagnosis,childoutcomes

andparentalhelpseeShah,etal.,2015.

Overandabovetheeffectsofthedrugontheembryo,achildborntoparents

withaddictionproblemsmaywelldevelopattachmentdifficultiesasaddictionin

anyformflagsupanattachment-relateddisorder,insofarasitgivestheillusion

ofa‘safe’dependencywheretheobjectofdesireiscontrollable.Avulnerable

babydoesnothavetoexperiencedistressanddamagethatheorshecannot

comprehendbeforehelpisoffered.Thegreaterthenumberofriskfactorsfound

inafamily’stotalecologythenthegreatertheneedforimmediateassistance.But

sadly,themoreafamilyisunderstressthentheharderitbecomestomakefull

useofanyhelpavailable.Onlyarelationshipcanchangearelationship,butifyou

aregrounddownbyinnerandoutercircumstancesanewrelationshipishardto

contemplate.

However,alongwithpressuresonthecaregivingrelationshiptherewillalways

bestrengthsthatcanbebuiltupon.Improvingparentingcapability,ifitistobe

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39

positiveforthefamily,mustalsobuildupontheprotectivefactorswithinand

aroundtheparents.Topromoteinfantwellbeingitisnecessarytopromotethe

proficiencyoftheparents.Ifafamilyistargetedforservicessolelyonthebasisof

theknownriskfactorswhichareknowntocorrelatewithchildmaltreatment

thismayindeedemployscarceresourcesforthosemostinneed,butontheother

handitmightalienatefamilieswho(justifiably)donotwanttobelabelledas

potential‘bad’parentsorabusers.Avisiblytargetedservicewillinevitably

discouragethemostvulnerableasthefearofhavingachildremovedwill

overwhelmrationalthought.

Risksidentifysusceptibility;theyarenotaninfallibleforecastofdisaster.And

maltreatmentmayoccurinhigh-incomefamilieswithalltheadvantagesoflife.

Thismeansthatinterventionsmusthaveastrength-basedorientation(notsolely

adeficitmodel)whichhasthepotentialtobemoreinclusive,withabetter

capacitytoengagewithotherpartneragenciesinthecommunityarounda

resilienceframeworkwhichcanhelpeveryoneinvolvedseehowtheirworkcan

contributetopreventingmaltreatment.Themostimportantprotectivefactors

foranyfamilyareasfollows(Browne,2014:4).(1)Parentalresilience:Managing

stressandfunctioningwellwhenfacedwithchallengesandadversities.(2)Social

connections:Havingasenseofconnectednesswithconstructive,supportive

people,networksandinstitutions.(3)Knowledgeofparentingandchild

development:Understandingparentingbestpracticesanddevelopmentally

appropriatechildskillsandbehaviours.(4)Concretesupportintimesofneed:

Identifying,accessingandreceivingneededadult,childandfamilyservices.(5)

Socialandemotionalcompetenceofchildren:Formingsecureadultandpeer

relationships;experiencingregulatingandexpressingemotions.(6)Nurturing

attachment:Providingparent-childexperiencesthatlaythefoundationfora

warmsecurebond.Lookingatthislist(alsoseeOsofskyandThompson,2000)it

isclearthatchildren’scentresarecentraltoprevention,althoughthiscannotbe

adequatelydoneunlesstheyhavealargewell-qualifiedmulti-disciplinaryteam;

whichinthecurrentclimateoflocalauthoritiesfarmingthemouttoprofit-

makingcharitieswhoparebackonstaffassoonastheycantosavemoneyis

unlikelytohappen.

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Gettingthefirst,prototypical,importantrelationshipofanyone’slifemoreor

lessrightisanecessity,notaluxury.Thisisthemostsensibleandeconomictime

toputintherapeuticresources.Andfurthermore,uniquetothisstageoflife,one

canguaranteethatthechildbothwantstoco-operateandhasnotgotstuckin

thetrapofgainingself-esteemfromantisocialacts.Thisissociety’sbestchance

tohelpitself.‘Theinteractiveprocessmostprotectiveagainstlaterviolent

behaviourbeginsinthefirstyearafterbirth:theformationofasecure

attachmentrelationshipwithaprimarycaregiver.Hereinonerelationshiplies

thefoundationofthreekeyprotectivefactorsthatmitigateagainstlater

aggression:thelearningofempathyoremotionalattachmenttoothers;the

opportunitytolearncontrolandbalancefeelings,especiallythosethatcanbe

destructive;andtheopportunitytodevelopcapacitiesforhigherlevelsof

cognitiveprocessing’(Karr-Morse&Wiley,1997:184).

Theanalysisofriskfactors,which:‘isanexerciseinestimatingprobabilities,not

findingcauses’(Sameroff,2000:28),showsclearlyhowtherelationshipswithina

familycanbedistortedbyexternalpressureswhichneedinterventiononasocial

levelasmuch(ifnotmore)astheiremotionalconsequencesneedhelpona

personallevel.Forinstance,thesinglemostimportantbroadriskfactorthat

predictslatermaladjustmentispoverty(Brooks-Gunn,etal.,2000;Halpern,

1993),sincethisamplifiesandconcentratesalltheotherrisks.‘Lowincome

createsaparticularlystressfulcontextinwhichpositiveinteractionswith

childrenarethreatened,andpunitiveorotherwisenegativerelationshipsmay

result.Thehighprevalenceofdepression,attachmentdifficulties,and

posttraumaticstressamongmotherslivinginpovertyservestounderminetheir

developmentofempathy,sensitivity,andresponsivenesstotheirchildren,which

canleadtodiminishedparentingbehavioursandthusdecreasedlearning

opportunitiesandpoorerdevelopmentaloutcomes’(ShonkoffandPhillips,

2000:353).Thislineofinfluenceiscomplicated;beingpoordoesnotmake

anyoneapoorparent,butpovertyisassociatedwitharaftofstressorsthat

impactthecaregivingrelationshipthroughmanydifferentroutes,andimplies

diminishedresourcestobuyoneselfoutoftrouble.Also,manyrecent

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41

neuroimagingresearchprojectshaveshownthatachildrearedinpovertyhas

fairlysevereneurologicalshortcomingsthroughnofaultoftheirown.

‘(E)xposuretopovertyduringearlychildhoodisassociatedwithsmallerwhite

matter,corticalgraymatter,andhippocampalandamygdalavolumesmeasured

atschoolage/earlyadolescence’(Luby,etal.,2013:7).Theeffectsofinadequate

financialresourcescanbepartiallyaddressedinmanyinstances,andmustbeas

anurgencyinmanycases,ascanotheradversefactors,butultimatelyittakes

individualisedresponsivecareandatherapeuticrelationshiptochangeapattern

ofcaregivingthatisbasedonanunconsciousfrombabyhood.

EarlyInterventionServices:anoverview.

ThemajorreviewbytheAmericanNationalResearchCouncil(partofthe

NationalAcademyofSciences)ofmanydifferentlinesofresearchcarriedouton

thedevelopmentofchildren,summarisesaconservativecoreofreplicated

findingsoverthirtyyearsofevaluatingearlyinterventionprogrammes.

(Shonkoff&Phillips,2000:342)Toparaphraseslightly,andomittingtheir

extensivereferences,theseareasfollows:

•Well-designedandsuccessfullyimplementedinterventionscanenhancethe

short-termperformanceofchildrenlivinginpoverty.

•Suchinterventionscanpromotesignificantshort-termgainsonstandardised

cognitiveandsocialmeasuresforyoungchildrenwithdevelopmentaldelaysor

disabilities.

•Short-termimpactsonthecognitivedevelopmentofyoungchildrenlivingin

high-riskenvironmentsaregreaterwhentheinterventionisgoal-directedand

child-focussedincomparisontogenericfamilysupportprograms.

•Measured,short-termimpactsonthecognitiveandsocialdevelopmentof

youngchildrenwithdevelopmentaldisabilitiesaregreaterwhenthe

interventionismorestructuredandfocussedonthechild-caregiverrelationship.

•Short-termI.Q.gainsassociatedwithhigh-qualitypreschoolinterventionsfor

childrenlivinginpovertytypicallyfadeoutduringmiddlechildhood,afterthe

interventionhasbeencompleted;however,long-termbenefitsinhigher

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academicachievement,lowerratesofgraderetention(repeatingayear),and

decreasedreferralforspecialeducationserviceshavebeenreplicated.

•Extendedlongitudinalinvestigationsintotheadolescentandadultyearsare

relativelyuncommonbutprovidedocumentationofdifferencesbetweenthe

interventionandcontrolgroupsforeconomicallydisadvantagedchildreninhigh

schoolgraduation,income,welfaredependence,andcriminalbehaviour.

•Analysesoftheeconomiccostsandbenefitsofearlychildhoodinterventionfor

low-incomechildrenhavedemonstratedmedium-andlong-termbenefitsto

familiesaswellassavingsinpublicexpenditureforspecialeducation,welfare

assistance,andcriminaljustice.

Relationship-basedinterventionstargetthecreationofsupportiveandnurturing

parent-infantinteractionsbecausetheseareassociatedwithawiderangeof

healthydevelopmentaloutcomes.Findingsfromameta-analysisindicatethat

‘supportiveparent-childinteractionsweremaximisedwhenstudieswerenon-

random,directlytargetedtheparent-childdyad,orwereshorterinduration(in

months).Furthermore…interventionsthatusedaprofessionalintervenorand

freeplay-tasksduringassessmentwerethemosteffective’(Mortensenand

Mastergeorge,2014:348).Ontheotherhand,thereappearstobearelativelack

ofevidencethatwide-scaleprojectsthatbroadlytargetageneralpopulation

havemuchlong-termeffect.AttheendofareviewofAmericanFederalandState

interventions,suchasHeadStart,Farran(2000:525)findsitdishearteningthat:

‘Agreatdealofmoneywasspentonprogramsthathavenotbeenshowntobe

moreeffectivethandoingnothingatall.’Thisisareminderthatfamiliesdonot

existinisolation.

Whereachildappearstohaveadisadvantagedstartinlifethewholecontextof

thebaby-parentrelationshipneedstobetakenintoaccount.‘Competenceisthe

resultofacomplexinterplaybetweenchildrenwitharangeofpersonalities,the

variationsintheirfamilies,andtheireconomic,social,andcommunityresources’

(Sameroff,2000:9).Therearealargenumberoftherapeuticinterventionsthat

havebeendemonstratedtohelptherelationshipbetweenparentandinfant,but

resultscannotbesustainedinavacuum.Noneoftheprogrammesreviewedby

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43

Farran(2000:525)‘madeanydifferencetotheincome,housingconditions,or

employmentoftheparentsinvolved,despitethefactthatthefamilieswereoften

chosenbecausetheyhadextremelylowincomes.’Exactlythesameadverse

influencesthathaveimpingedontheadultmembersofthefamilywillprobably

continuetoexertaneffectonthechildthroughouthisorherdevelopment,

makingspecificpredictionsdifficultunlesswiderissues(suchasstandardsof

educationandemploymentprospects)arealsotackledheadon.‘Thatistosay,

significantmedium-andlong-termbenefitsofearlychildhoodinterventionmay

beviewedasacontinuingdevelopmentalpathwaythatiscontingentonachain

ofpositiveeffectsthatincreasetheprobabilityofremainingontrack’(Shonkoff

andPhillips,2000:352).Perhapsitwillnotbepossibletogaugethemost

importantlong-terneffectofearlyinterventionuntilfollow-upstudiesare

carriedoutontheseinfantswhentheyhavebecomeparentsinturn.

Someoftheeconomicbenefitsofveryearlyintervention.

Thereareanumberofstudiesthathavedemonstratedthelong-termcost

benefitsofhelpingvulnerablefamiliesprovidethesortofemotional

environmentfortheirbabiesandtoddlersthatingeneralleadstosecure

attachment.Parentingneedonlybe‘goodenough’.Forinstance,thePerryPre-

schoolHighscopeProgrammehasdataspanningfortyyears,showingthatfor

every$1spentinsettingupandrunningtheirpre-schoolnurseryinitiativeina

high-riskareatheyfindthatalmost$13weresavedintermsoflaterservicesnot

accessedwhenparticipantswerefollowedupatage40.(High/ScopePerry

PreschoolProgram,follow-upreportin2005,online.)Anotherlongitudinal

study,knownastheElmiraHomeVisitingProject,hasshownthatspecialised

earlysupportforvulnerablefirst-timemothershadpaidbackitscostsbyfour

years.Ata15-yearfollowupthesavingsexceededthecostsoftheprogrambya

factoroffour(Oldsetal,1999).Caldwellin1992analyzedthecostsrelatedto

childmaltreatmentanditsconsequencesinMichigan.Thesecostswere

comparedwiththecostsofprovidingpreventionservicestoallfirsttime

parents.Thecomparisonyieldeda19to1advantagetopreventioni.e.forevery

dollarspentonprevention19dollarsweresaved.Consideringthecollateral

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44

damagethatabusedchildrenspreadaroundthem,thisisgoodvalue.

(https://www.msu.edu/user/bob/cost.html)TheChildren’sTrustFundin

Michigancontinuestotargetthepreventionofmaltreatmentas‘Researchshows

thatforevery$1spentonchildabuseandneglectprevention,$7willnotbe

spentonpublicly-funded,crisis-orientedprogrammingsuchasprotective

services,fostercare,specialeducation,andcounselingwiththeexceptionof

juveniledelinquencyoradultincarceration’

(http://www.michigan.gov/ctf/0,1607,7-196--232496--,00.html).

Karolyetal(1998)inalargestudybytheRandCorporationsummarisethecosts

benefitsofinvestinginearlychildhoodinterventionasfollows:-

• Programsthattargetchildrenandfamilieswhowillbenefitmostfromthe

servicesofferedhavethehighestchanceofrepayingtheircosts.

• Thelongerthefollow-upthemorelikelythatsavingsgeneratedbythe

programmewilloutweighthecosts.

• Manyoftheprogrammesalsoinfluencetheoutcomeforthemotherand

notonlythechild.

Generalinterventionassumptions:-

• Bettertotreatthefamilythanthechildalone.

• Earlierthebetter,interventionsininfancypreferredtotoddlerhoodetc.

• Higherintensityofinterventionbetter.

• Training,background,supervisionandpersonalityoftheservice

providingpersonnelmatters.

• Tailormadeinterventionspreferred.

Theexpenseofnotinterveningisinthedirectandindirectcostsofsuchlater

anti-socialbehaviour,suchasthoseassociatedwithconductdisorder.Ithasbeen

calculatedthatayoungadultwhoeventuallysufferssocialexclusiondueto

conductproblemwillcoststhecountrythreeandahalftimesmorethan

someonewithnoproblem;whileconductdisorderwillincurcostsoftentimes

higherthanhavingnoproblem(Scott,Knapp,HendersonandMaughan,2001).A

conservativeestimate(soitwillgrowyearonyear)isthatpreventingconduct

disordersinthosechildrenwhoaremostdisturbedwouldsavearound£150,000

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45

oflifetimecostsforeachindividual;andpromotingpositivementalhealthin

thosechildrenwithmoderatementalhealthwouldyieldlifetimecostbenefitsto

eachofabout£75,000(FriedliandParsonage,2007).Thisanalysisdidnottake

intoaccountthemonetaryimplicationsofthenegativeinfluencethesechildren

haveuponothers,suchasallthedisruptiontheycauseintheclassroomandthe

long-termeffectsoftheviolencetheymayinflictonother–notleastfuture

partnersandchildren.Takingtheabovefigures,thetotalvalueofthebenefitsof

preventioninaone-yearcohortofchildrenintheUKis£5.25billion,andthe

valueofpromotingpositivementalhealthcomesto£23.625billion(ibid,p.20).

Itisestimatedthatthecostoftreatingcommonmentalhealthproblemssuchas

anxiety,depressionandpersonalitydisorderswillincreasefrom£24.3billionto

£38.7billioninthenext20years.Thecostoftreatingchildandadolescent

mentalhealthproblemsisestimatedtodouble(McCrone,etal.2008).IntheUK

theoverallcostofmentalhealthproblemswas£115billionin2006/07.In2002

wefindthat20%ofthetotalburdenofdiseaseintheUKwasattributableto

mentalillness,comparedwith17.2%forcardiovasculardiseaseand15.5%for

cancer(Friedli&Parsonage,2007).Mentalillnesscontributessignificantlyto

crimesofviolence(Arseneault,etal.,2000).ArecentstudybytheNew

EconomicsFoundation(2009)forActionforChildren,‘BackingtheFuture’

showstheeconomicbenefitsofearlyintervention,clearlydifferentiatingthe

differentbenefitstosociety,withthelong-termsavingsbeingseveral

magnitudesgreaterthanthecostsofsettinguppreventativeservices.

Earlyinterventionisstillwellworththeeffortandallocationofresourcesevenif

theimmediatesuccessrateseemsrelativelylow.‘Tobeworthundertaking,the

interventionthusneedsasuccessrateofonlyonein25forconductdisorderand

onein55forconductproblems.Inotherwords,thepotentialbenefitsareso

largerelativetocoststhatinterventionisworthwhile,evenifitseffectivenessis

verylimited’(FriedliandParsonage,2007).Sinclair,writingforTheWork

Foundationandcomingfromabackgroundinpracticaleconomics,isclear.

‘Dysfunctionalparentingandchildrenatriskrepresentclassicmarketfailure.

Thisiswherethegovernmentwillgetthegreatestrateofreturnsformoney

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46

invested’(Sinclair,2007:54).Simplypreventingtheoccurrenceofearlychild

maltreatmentor,ifthathasbeenimpossible,offeringpromptandappropriate

treatmenthasalong-termbenefitthatisenormousintermsofservicesnot

calledupontointerveneinthechild’sfuture.‘Childmaltreatmentposessevere

risksforlong-termmaladjustmentandthedevelopmentofpsychopathology.

Childmaltreatmentexemplifiesapathogenicenvironmentthatisfarbeyondthe

rangeofwhatisnormativelyencounteredandengenderssubstantialriskfor

maladaptationacrossdiversedomainsofbiologicalandpsychological

development’(Cicchetti,RogoschandToth,2006:624).Ahostofresearchfrom

differentdisciplinesconvergestoshowhowtraumainthefirstfewyearsoflifeis

‘thefrequentcauseofphysicalandmentalillness,schoolunderachievementand

failure,substanceabuse,maltreatment,andcriminalbehavior’(Harris,

LiebermanandMarans,2007:393).

ThecomponentsofanEarlyInterventionservice.

Tworeviewsexaminewhatappearstobenecessaryforearlyintervention

servicesforhigh-riskparentsandbabiesiftheyaretomeetthemanydifferent

needsofthisgroup(ZerotoThree,1998,18(4);Shonkoff&Phillips,2000:360-

367).Theguidingprincipleofearlyinterventionisthatservicesneedtobe

carefullytailoredtotheirdifferentclientpopulations;thereisnosingleanswer.

Forinstance,findingsfromahomevisitingserviceforhigh-riskmothersand

babiesindicated‘thathigher-riskmothersbenefitedmorefromamentalhealth

curriculumthananeducationalcurriculumwhereaslower-riskmothers

benefitedmorefromtheeducationalcurriculumthanthementalhealth

curriculum’(Berlin,et.al.,1998:13).Thereisasecondandequallyimportant

principlethatisattheheartofpracticalservicedelivery.Anyintervention,

regardlessoftechniqueortheory,isonlyaseffectiveasthequalityofthe

relationshipsthatinfantmentalhealthpractitionerscanbuildupwiththe

familiestheybecomeinvolvedwith.‘Newrelationalexperiencesintherapyare

thecoreofthehealingprocess.Thepresenceofanauthentic,empathic,and

responsiveconnectionbetweenclientandtherapistcanfosterhealingandthe

subsequentdevelopmentofasenseofrelationalcompetencefortheclient,which

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47

entailstheabilitytobringaboutchange,andtheexperienceoffeelingeffectivein

connection.Inmother-infanttherapy,thissenseofefficacyistransposedtothe

mothermovingoutofisolationandintoamorereciprocalandsatisfying

relationshipwithherbaby’(Paris,SpielmanandBolton,2009:305).

Relationshipsandtheeffectofrelationshipsuponrelationshipsareagaincentral.

Anoverviewofearlyinterventionprogrammesargues‘thattheparent’s

relationshipwiththeintervenerservesastheengineoftherapeuticchange’

(Berlin,etal.,2008:747).Thusitisagiven(oftenignored)thatanyprogramme

thataimstoimprovetherelationshipbetweenparentandbabycanonlydeliver

ifitisembeddedwithina‘relationship-basedorganization’wherethequalityof

therelationshipswithintheteammatchthequalityoftherelationshipstheyaim

tofosterwithinthefamiliesbeingsupported.‘Thereisadefiniteparallel

betweentherelationshipsthatlinestaffformwithfamiliesandtheirchildren

andtherelationshipthatstaffformwithadministratorsandsupportstaffofthe

organization’(Bertacchi,1996:3).Twokeycomponentshereareexternal

consultationandfluidreflectivesupervisionforallstaff.‘Arelationship-based

organizationwillcometoacceptthatstaffareitsprizedpossession’(ibid:7).

Creatingandmaintainingarelationship-basedservicehasbecomeavery

difficulttaskwithinapublicsectordominatedbytargetswithamanagerial

culturebasedonsuchmistrustthateverymovemustbecontrolledbyapolicy

andmanagersbecomedemotedtomeremonitors.

Servicescanberoughlydividedbetweenthosethatarecentre-basedandthose

thataredeliveredinthehome.‘Center-basedservicesaremorelikelythan

home-basedprogramstotargetchildrendirectly–especiallyintermsoftheir

cognitiveandlanguagedevelopment’(Berlin,et.al.,1998:7).Whereas‘Home-

basedservices,whichvirtuallyalwaysincludethechild’sprinciplecaregiver,

maybeespeciallywell-suitedtoenhancingparents’well-beingandthechild-

parentrelationship’(ibid,p.6).Earlyinterventionservicesaremosteffective

whenthetwoapproachesareoneandthesamesothat,forinstance,the

Children’sCentrecanreferimmediatelytoamorespecialised,tierthree,infant

mentalhealthserviceforimmediatework;andatthesametimethecentrecan

takeupandsupportisolatedfamiliesreferredtotheinfantmentalhealthteam

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fromanothersource.Bothteamsarethenabletoworkinatotallyintegrated,

andminimallystigmatisingmannerthatcanlead,forexample,tomutuallyrun

therapeuticgroupssuchasMellowBabies(http://www.mellowparenting.org).

However,earlyinterventionhasalwaystobetailoredtothesettingandneedsof

thefamiliesinvolvedsothat,forinstance,successfulhelpcanequallybegivento

high-riskmothersandtheirbabieswithinaprison(Baradon,etal.,2008)orina

residentialsettingforsubstanceabusingmothersandtheirbabies(Pajulo,etal.

2012).Whateverthesetting,itisimportantthatservicesaretargeted

appropriately,theaimofeveryprovisionshouldbeclear.‘Foryoungchildren

wheredevelopmentmaybecompromisedbyanimpoverished,disorganized,or

abusiveenvironment…interventionsthataretailoredtospecificneedshave

beenshowntobemoreeffectiveinproducingdesiredchildandfamilyoutcomes

thanservicesthatprovidegenericadviceandsupport’(ShonkoffandPhillips,

2000:360).

Preventativeinterventionsalsoneedtobecarefullytailoredtomeettherapidly

progressiveorganisationofdevelopmentalcompetencies(andoccasional

incompetencies)associatedwithearlychilddevelopment,somethingthatcalls

forspecialistknowledge.‘Toeffectchangeinthecourseofpsychological

developmentandavertpsychopathologicaloutcomes,preventativeinterventions

informedbyanorganizationalperspectiveshouldfocusonpromoting

competenciesandreducingineffectiveresolutionofthestage-salient

developmentalissuesthatemergeatdifferentperiodsinontogenesis’(Cicchetti,

RogoschandToth,2006:623).Evidencealsosupportstheprinciplethat

proactiveprogrammes,thosethataretrulypreventative,beginningeitherpre-

natallyoratbirth,havethegreatestandmostsustainedeffect.‘Thereisastrong

indicationthatwhilegainsmadethroughproactiveinterventionsaresustained,

andevenincreased,overtimethosemadethroughreactiveinterventionstendto

fade’(MacLeodandNelson,2000:1141).Suchservicescanbeeitheruniversalor

targetedonanindividualbasis.Thispointsuptheimportanceofanintegrated

approachacrossallprofessionsconcernedwithbabies,sothatchildren’scentre,

midwives,obstetriciansandgeneralpractitionersallseethemselvesasavery

earlywarningsystem.Theearlierweintervenethebetter.Babiescan’twait.The

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bestresultsareattainedwithstrength-basedapproachesthatfocusonparental

empowermentandinvolvement.Thisishighlyskilledworkwhichdemandswell

skilled,welltrainedandwellpaidstaffwhohavethecompetenciesneededto

gaugewhenandhowtointervene;andthisincludestherecognitionthat

continuedprofessionaldevelopmentisessential,notaluxurythatcanbecutto

savemoney.‘Harnessingthepowerofrelationshipstoinfluencerelationships

andhoningcapacityforreflection-in-actionarefundamentaltohigh-quality

professionaldevelopmentforthoseservingveryyoungchildrenandtheir

families’(Seibal,2011:49).

TheUKSureStartinitiativehasevolvedintoanearlyinterventionthatcombines

centrebasedprovisionwithoutreachworkdeliveredtothesurrounding

community.AlthoughtheinitialevaluationofthemyriadofdifferentSureStart

schemeswasdisappointing,thishaschangedwithtime.Onereasonisthatthe

servicedeliveryisnowbasedinChildren’sCentresandthefirstwaveoffamilies

accessingtheseearlyinterventionshasbeenworkedthroughandnowhelpcan

beconsistentlyonofferfromconceptiontopre-schoolage.Children’sCentres

areperfectlyplacedtodeliver‘wraparound’servicesrangingfromspecialist

infantmentalhealthteamstothefullgamutofdifferentparentinggroups

available.Suchservicesbecomeacceptedsimplybyvirtueofbeingthere.Studies

comparingoutcomesforchildreninSecureStartareaswiththoselackingthis

inputhavefoundthattheformer‘showedbettersocialdevelopment,exhibiting

morepositivesocialbehaviourandgreaterindependence/selfregulationthan

theircounterpartsinnon-SureStartareas…Also,familiesinSureStartareas

reportedusingmorechildandfamily-relatedservicesthanfamiliesinnon-Sure

Startareas’(Melhuish,BelskyandBarnes,2010:160).

Evenifaninterventionseemstofitthebill,thereisnoguaranteeitwilldeliver

resultsunlesstheservicecreatedisappropriatelyfundedandstaffed.Therecan

bean‘implementationgap’setupby‘thediscrepancybetweentheintervention

thatprogramdesignersplanandtheinterventionthatfamiliesreceive’(Barnard,

1998:23).Thiscanleadtoalowerthanexpectedtake-upofservices.‘Theimpact

ofqualityhasbeenshowntobeparticularlyimportantforchildrenfromfamilies

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50

whobeartheburdenofmultiplerisk-factors’(ShonkoffandPhillips,2000:362).

Everyonewantsthebestfortheirbaby,nobodysetsouttobea‘bad’parent,but

manyhavenochoiceaboutwhatisonofferandnobodyatallhashadachoice

abouthowtheywereparented.

Theintensityanddurationofanyinterventionareobviouslyimportant,butas

aspectsofqualitytheyarehardtomeasure.Fewresearchershaveaddressed

thesevariables,astherearefrequentlyethicalimplicationstoconducting

randomisedexperimentalstudiesonavulnerable,clinical,population.However,

therearesomesuggestivedata.IthasbeenfoundthatI.Q.scoresmeasuredat36

monthsincreasedwiththeamountoftimesachildattendedadaycentre,the

numberofhomevisitsandthefrequencywithwhichparentsattendedrelevant

meetings(Ramey,etal.,1992).Greaterinvolvementwithhelpingservices,

whetherinthehomeoracentre,wasalsoassociatedwithhigherratingsofthe

familyhomeenvironmentwhenthechildwasoneyearold,andhigherI.Q.scores

atagethree.Forproactivepreventativeinterventions‘whichmeasuredchild

maltreatmentasanoutcome;effectsizesincreasedasthelengthofthe

interventionincreased’(MacLeodandNelson,2000:1143).Motherswhoactively

participatedinthePrenatal/EarlyInfancyProjectfortwoyearswerelesslikely

toabusetheirchildrenthanthosemotherswhohadonlybeenengagedfornine

months.Andafifteenyearslaterfollow-upshowedaninverserelationbetween

theamountofservicereceivedandanumberofnegativematernaloutcomes,

includingchildmaltreatment,repeatpregnancy,welfaredependence,substance

abuseandbrusheswiththelaw(Olds,etal.,1997;Olds,2006).Twostudiesofa

homevisitingserviceforinfantsinfamilieslivinginpoverty,whereoneused

randomassignmenttosetupatreatmentandcontrolgroup,foundthatweekly

visitsresultedinhigherchilddevelopmenttestscoresthanfortnightlyvisits,

whichinturnobtainedhigherscoresthanmonthlyvisits(PowellandGrantham-

McGregor,1989).Theonlymeta-analysisofhomevisitingprogrammesthathas

beendoneconfirmstheobvious,thatefficiencyincreaseswithfrequencyof

visits.Ingeneralitisclearthatintensive‘homevisitingforlow-incomeorat-risk

familiesimprovesmaternalbehavior’(Nievar,VanEgerenandPollard,

2010:511).

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Itseemsatruismtostressthatqualityofserviceprovisionisentirelydependent

onthecalibreofthestaff.‘Earlyinterventionserviceproviderscarryout

intensiveandemotionallydemandingwork.Theirpersonalcharacteristics–

especiallytheirabilitytobeemotionallyavailableandempathic–andtheir

trainingandworkexperienceinfluencethewaysinwhichtheydeliverservices’

(Berlin,etal.,1998:8).Infantmentalhealthservicesdemandacoreofspecialised

knowledgeandskillscongruentwiththewiderangeofriskfactorsand

developmentalissuesthatneedtobeconsidered.Goodreflectivesupervisionis

essentialtoavoidtheriskofdefensiveavoidance,vicarioustraumatisation,

counter-transferencecollusionandburnout.Inmanywaysonlyadedicated,

specialised,well-functioningteamcanhopetomovebetweensuchmattersas

discordantattachmentrelationships,adultmentalhealthandsubstanceabuse,

andtheproblemsforceduponafamilybypoverty.‘Inthiscontext,theultimate

impactofanyinterventionisdependentuponbothstaffexpertiseandthequality

andcontinuityofthepersonalrelationshipestablishedbetweentheservice

providerandthefamilythatisbeingserved’(ShonkoffandPhillips,2000:365).

Differentapproachestoinfantmentalhealthinterventions.

Itappears,then,thatwell-plannedandwell-fundedservicesforbabiesand

parentsatriskcanredirectalikelydevelopmentalpathwayalonganew,

healthierdirection.‘Programsthatcombinechild-focussededucationalactivities

withexplicitattentiontoparent-childinteractionpatternsandrelationship

buildingappeartohavethegreatestimpacts’(ShonkoffandPhillips,2000:379).

Whereas‘servicesthataresupportedbymoremodestbudgetsandarebasedon

genericsupport,oftenwithoutacleardelineationofinterventionstrategies

matcheddirectlytomeasurableobjectives,appeartobelesseffectiveforfamilies

facingsignificantrisk’(ibid).Earlyinterventioncanhaveadifferingemphasison

twoapproaches:thefirstisprevention(targetingapopulation,orafamily,

identifiedbyriskfactoranalysis),andthesecondistreatment(workingwith

referredcaseswheresomethinghasalreadygoneamiss).Thisisarather

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artificialdivide,sinceinpracticebothgoalsarecompatiblewitheachother

withinasingleprogramme;e.g.workingwithfamiliesatriskwillinevitably

reveal‘hidden’disturbancesthatneedtobereferredontoamorespecialised

therapeuticservice.However,conceptualisingearlyinterventionservicesinthis

waydoesprovideaframeworkforexaminingtheresultsofprojectsthatwere

setupwithdifferentaimsandmethods.Whateverthemodeofintervention,

though,thereareunlikelytobetheclear,measurableandrapidresultsbeloved

bycommissionersandmanagers.Ittakestimetobuildarelationship,andifyour

backgroundhasgivenyouanassociationbetweencloseand‘caring’

relationshipsandmaltreatmenttheninterestandkindnesscanbeterrifying–

‘Wecannotinterruptcyclesofdisorganisedattachmentunlessweprovidea

havenofsafetyformothers’(SladeandSadler,2013:34).Thislastquoteleadsto

anobviouscaveat;thegreatermajority,ifnotall,theinterventionsmentioned

belowhavebeentargetedatmothers,andasawholeissueofZerotoThree(May

2015Vol.35,No.5)hasfocussedon,fathersareconspicuousbytheirabsence

whichhardlymatchesreality.

Preventativeserviceswillusuallybeeithercentre-orhome-based,justasmost

treatmentoptionsareeitherclinic-orhome-basedaswell.(Andmanyfamilies

willbeabletomakeuseofeithersitefordifferentservices.)Anexampleofa

centre-basedearlyintervention/preventativeserviceistheCarolina

AbecedarianProjectwherehigh-riskchildrenreceivedintensiveearlyeducation

fivedaysaweek,beginningatsixweeksandendingatfiveyears.Twogroupsof

similarbabieswereselected,allwithmotherswhohadeducationaldifficulties.

Thecontrolgroup,whoonlyreceivedfreemilkandnappies,wereall(except

one)eventuallyassessedasbeingretardedorofborderlineintelligence.Inthe

interventiongroupallthechildrentestedwithinthenormalrangeofintelligence

byagethree;byage15theyscoredsignificantlyhigheringeneralknowledge,

readingandmathematics,andonly24%(48%inthecontrolgroup)needed

specialeducationservices(CampbellandRamey,1994&1995).Furthermore,

(accordingtotheproject’swebsite,http://abc.fpg.unc.edu)whenthechildren

reached21yearsofage35%oftheinterventiongroupwereatcollege,compared

to14%inthecontrolgroup;and65%wereinemploymentcomparedto50%in

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theothergroup.ThechildrenwhosemothershadthelowestI.Q.appearedto

gainthemostfromthisintervention,andthosewhohadafollow-upprogramme

intoelementaryschoolbenefitedfurtherstill.Ananalysisthatcomparedthe

PerryPre-Schoolproject,mentionedearlier,withtheAbecedarianintervention

notesthatbothhavehas‘statisticallysignificanteffectsonthehealthybehavior

andhealthoftheirparticipants’(Conti,etal.,2015:29).

Anexceptiontothehomeorcentrequandarymightbeservicesforteenage

motherswhichcanbeestablishedwithinaschoolsettingwheretheadditional

provisionofgoodqualitychildcarewouldensurethattheyoungwomencould

finishtheireducationaswell.The‘ChancesforChildren’TeenParent-Infant

ProjectinNewYorkhassuccessfullyimplementedand,usingacontrolgroup,

evaluatedsuchaprogramme.Theyprovideindividual,dyadicandplaytherapies

alongwithparentinggroupsandsupportforthenurserystaff.Theyhavefound

thattheyoungmotherstheyhadworkedwithimprovedtheirinteractionswith

theirinfants‘intheareasofresponsiveness,affectiveavailability,and

directiveness.Inaddition,infantsinthetreatmentgroupwerefoundtoincrease

theirinterestinmother,respondmorepositivelytophysicalcontact,and

improvetheirgeneralemotionaltone,whichthecomparisoninfantsdidnot’

(Mayers,Hagar-BudnyandBuckner,2008:332).Thesamepositiveresultswere

foundinasubsetofyoungmotherswhoremaineddepressed,showingthateven

thenitisstillpossibletoimprovemother-infantinteractions.

Earlyinterventionwithhighrisk,veryvulnerable,familiesneedstobeamulti-

agencyconcern;andthebetterdifferentagenciesworktogetherthenthemore

long-lastingandpositivearetheresultsfortheinfantsinthesefamilies.Agood

example,whichhasbeenevaluatedanumberofdifferenttimes(includingfocus

groupswiththemothersinvolved),istheCanadianinitiativeforhelpingfamilies

wherethereismaternalsubstanceabuse.Thisiscalled‘BreakingtheCycle’

(BTC),andwaslaunchedbysevenpartnerorganisationsin1995.‘Positive

resultsoftheBTCapproachinclude(a)enhancedbirthandperinataloutcomes

forinfantsofsubstance-involvedmotherswhoareengagedearlierinpregnancy,

(b)enhanceddevelopmentaloutcomesofchildrenwhoareinvolved,(c)

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enhancedparentingconfidenceandcompetence,(d)enhancedtreatment

outcomes,and(e)decreasedratesofseparationofmothersandchildren’(Motz,

LeslieandDeMarchi,2007:20).Theinterventionfocusisonthemother-infant

relationshipandinvolvesarangeofdifferentprogrammesbasedonasingle-

accessmodelthatincludesstreetaccessandhomevisiting.

Mostgroup-basedparentingprogrammes(orclasses)willofnecessitybebased

inaChildren’sCentreofsomesort.TheMellowParenting,andespeciallyMellow

Babiesfortheunder-ones,approachisdesignedspecificallyforfamilieswhere

thereisarelationshipproblemwithasmallchild,andhasbeenparticularly

successfulinhelpingmothersandinfantsimprovethequalityoftheir

relationshipandinteractions,withmaternalmoodimprovementandpositive

feedbackfromparentswhoattendedwhencomparedwithawaitinglistcontrol

group(Puckering,2004;Puckeringetal.,2010).Itistheonlyprogramme

specificallydesignedforunderthreesandbasedcompletelyonattachment

theory.–ThereisevenaMellowBumps.Andthishasbeenshowntoincrease

pre-natalattachmentandreducefeelingsofisolationandstigmainvulnerable

women,allofwhoenjoyedtheexperience(BirtwellandPuckering,2013).The

greatermajorityofparentingskillsclassesaregearedto,andaremoreusefulfor,

thosewitholderchildren;anditcouldbearguedthatthereisaninherent

differenceofattitudeandoutlookbetweenagroupandaclass,withtheformer

beinglessintrinsicallyhumiliatingfortheparents.MellowParentingisan

intensiveandcontainingday-longgroupexperienceextendingovermanyweeks

thatengageswithahighriskgroupoffamilieswherechildprotectionissuesare

paramount,domesticviolenceispresent,wherethemotherhasconflictual

relationshipswithherfamilyoforigin,isexperiencingbehaviouralproblems

withherchildandmaybestrugglingwithpsychologicaldifficultiesofherown.

Thisprogrammehasconsistentlyengagedhard-to-reachfamiliesandhas

demonstratedpositivechangesinmother-childinteractions,children’s

behaviouralproblemsandtheirintellectualdevelopment.Apilotstudythat

appliedaslightlymodifiedversionofMellowParentingtoagroupofmothers

sufferingfrompost-nataldepressionhashadencouragingresults.Thedepressed

moodofthemotherschangedsignificantly,observedpositiveinteractions

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55

increasedandnegativereactionswentdown.‘TheMellowBabiesgroup

interventioncanimproveboththementalhealthofwomenwithpostnatal

depressionandtheirinteractionwiththeirbabies’(Puckering,2009:161).The

immediateadvantageofthisgroupapproachisthateachmotherwhoattends

immediatelyfeelslessisolatedandguiltythatshealonefindsparentinga

challenge.Inasimilarspiritedattachment-basedgroupinterventionsetupin

newYorkthatwasevaluatedindetail(butnoRCT,-strictlyspeakingonecould

regardanyRCTasunethicalifatreatmentthatisexpectedtohavepositive

effectsisdenied)theyfoundfoundpositivechangesinthemother-toddler

attachmentrelationshipalthoughithadlessimpactonthemother’soverallstate

ofmindregardingattachment(Steele,Murphy,andSteele,2010).

Another,perhapsmoretechnophile,groupapproachthathasbeenconsistently

abletoimprovethequalityoftherelationshipbetweenparentsandtheirsmall

childrenistheCircleofSecurityintervention,deliveredaspartofanEarlyHead

Startproject.Thismethodcarefullyreviewswithparentsthevideorecordingsof

theStrangeSituationproceduredonebyeachmemberwiththeirchildaspartof

thisgroup-basedprogramme.Oneaimofthisistoemphasisthesophisticated

capabilitiesofyoungchildrenandtodrawtheircaregiver’sattentiontothe

meaningofquitesubtleandsometimeshardtonoticebehaviours.Oneofthe

goalsofthismethodistoteachauser-friendlyversionofattachmenttheoryto

theparents,andthiscanbebaseduponwhatallhaveobservedinthereplaysof

theStrangeSituationprocedures.Thisclinicalservicehasbeenbasedfirmlyona

combinationofattachmentandobjectrelationstheory.‘Theunderlyingstructure

oftheCOSprotocolconsistsofprovidingasecurebasefromwhichcaregivers

canbothlearnabouttheattachmentneedsoftheirchildrenandexploretheir

owninternalobstaclestomeetingthoseneeds’(Cooper,etal.2005:146).Initial

outcomesappeartobepromising;andthisprogrammeiscurrentlyunder

evaluationinanumberofdifferentsites.Alongitudinalstudy(withoutacontrol

group)showedasignificantpositiveimpactontheattachment-caregiving

patternsofhigh-risktoddlers,pre-schoolersandtheirprimarycaregivers

(Hoffman,etal.,2006).AnAustralianclinicalstudyofthismethod,inthiscase

withanagerangeofonetosevenyears,showedsignificantimprovementsfor

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parentratingsofchildprotectivefactors,behaviouralconcerns,internalizingand

externalizingsymptomswithaconsistentfindingthatthosechildrenwhobegan

withthemostsevereproblemsshowedthebestimprovement(Huber,etal.,

2015a).Thesameinterventionalsoproducedanimprovementinparental

reflectivefunction,caregivingrepresentationandattachmentsecurityinthe

child,andtherewasasignificantdecreaseinchildrenassessedwith

disorganizedattachment(Huber,etal.,2015b).

Asacontrast,workingmorefromtheconceptofintersubjectivity,afiveweek

therapeuticmusicgroupinaresidentialsettingformotherswithseverepost-

nataldepressionandtheirbabiessignificantlyincreasedtheamountof

intersubjectivesharingbetweeneachmotherandherinfant,andbythefifth

sessionmothershadbecomemoreplayfulontheirowninitiative.‘(M)usicwas

usedasatooltocreatemomentsofrepairandvitality’(VanPuyvelde,etal.,

2014:230).DanielSterndescribedintersubjectivecontactasoccurringwhen:

‘Twopeopleseeandfeelroughlythesamementallandscapeforamomentat

least.’(Stern,2004:75)Hepointsoutthatthisisaprimarymotivationalforce

separatefromattachment,buttogethertheyformamutuallycontributing

system.‘Attachmentkeepspeopleclosesothatintersubjectivitycandevelopor

deepen,andintersubjectivitycreatesconditionsthatareconducivetoforming

attachments’(Stern,2004:102).Attachmentrelatedbehaviourisusuallyan

indicatorofanemergency;itkicksinwhenneededandshouldnotbeinevidence

formostofthetime;whereasintersubjectiveprocessesareoccurringwithinall

interpersonalcontactsandformthebasisofthejoyofparenthoodandthe

satisfactionofallrelationships.Thusinterventionsthatbuildupthe

intersubjectiveresonancebetweenmotherandinfant,suchasprovidedbythis

creative(andfun)useofmusic,createtheconditionswheresecureattachment

canflourish.Thisisalsotheaimofparent-infantpsychotherapy(Balbernie,

2007),asdescribedlater.

Awayfromacentreandintothehome,a20yearresearchprojectfollowingthe

outcomeoftheNurseHomeVisitationProgramisagoodexampleofa

preventativeinterventiontargetinganatriskpopulationinthecommunity.

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However,thefamilieschosenwereverylimited,andthehelpwasonlyofferedto

lowincomeunmarriedfirsttimemothers.TheNurseHomeVisitationProgram

involvedtworandomisedtrials(inElmira,NewYork,andMemphis,Tennessee),

plusoneotherwhichisstillinprogress(inDenver).Theinvestigators(Olds,et

al.,1999:44)haveconcludedthat:‘Theprogrambenefitstheneediestfamilies

(lowincomeunmarriedmothers)butprovideslittlebenefittothewider

population.Amonglow-incomeunmarriedwomen,theprogramhelpsreduce

ratesofchildhoodinjuriesandingestionsthatmaybeassociatedwithchild

abuseandneglect,andhelpsmothersdefersubsequentpregnanciesandmove

intotheworkforce.Long-termfollow-upoffamiliesinElmiraindicatesthat

nurse-visitedmotherswerelesslikelytoabuseorneglecttheirchildrenorto

haverapidsuccessivepregnancies.Havingfewerchildrenenabledwomentofind

work,becomeeconomicallyself-sufficient,andeventuallyavoidsubstanceabuse

andcriminalbehaviour.Thechildrenbenefitedtoo.Bythetimethechildren

were15yearsofage,comparedwiththecontrolgroup,theyhadfewerarrests

andconvictions,smokedanddrankless,andhadfewersexualpartners.’The

homevisitingbeganbeforebirthand‘Comparedwithcounterpartsrandomly

assignedtoreceivecomparisonservices,womenwhowerenurse-visited

experiencedgreaterinformalandformalsocialsupport,smokedfewer

cigarettes,hadbetterdiets,andexhibitedfewerkidneyinfectionsbytheendof

pregnancy’(p.45).Fouryearsaftertheirchildrenhadbeenbornthecostofthe

programmewaslessthanthesavingsthathadbeenmade.Thismanualised

intervention‘explicitlypromotedsensitive,responsive,andengagedcaregiving

intheearlyyearsofachild’slife’(p.48).Itwasfoundthatthebiggestobstacleto

benefitingfromtheservicewasthepresenceofdomesticviolence,with

treatmenteffectdiminishingasthelevelofviolenceincreased(Eckenrode,etal.,

2000).Thisstrength-basedprogrammeofinterventionhasbeenre-namedthe

Nurse-FamilyPartnershipandrolledoutintheU.K.whereitisalreadyshowing

positivegainsforsomevulnerablefamiliesstrugglingwithagamutofadverse

experiences(Rowe,2009).However,thisprogrammeonlyhasalongterm

impactonfemalechildren,whobyagenineteenhadfewerarrestsand

convictions;butintermsofhighschoolgraduation,economicproductivity,

numberofsexualpartners,useofbirthcontrol,ratesofpregnancyandchildbirth

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anduseofwelfareprogrammestherewerenooveralllong-termtreatment

effects(Eckenrode,etal.,2010).Butthisisexpectableifnoneoftheothersocial

andeconomicrisksandpressureswerealtered.

Asimilarbutmorerelationship-focussedhomevisitingmethodologythanFNP,

withalessnarrowremit,isTheGettingReadyInterventionwhichhasbeen

evaluatedindetailwithfamiliesenrolledintheEarlyHeadStartprogrammein

Americausingarandomisedcontrolstudy.Itwasfoundthat‘theGettingReady

interventionsoffersvalueaddedinthedimensionsofwarmthandsensitivity,

encouragementofautonomy,supportforlearning,andtheappropriatenessof

guidanceanddirectivesofferedbyparents’(Knoche,etal.,2012:453).Another

semi-structuredparentingprogrammeinterventiongroundedinattachment

theorydevelopedbyMaryDozier,AttachmentandBiobehavioralCatch-up,has

beensubjecttoRCTandshowntopromotesecurityofattachmentinhigh-risk

youngfosterchildren(Bernard,etal.,2012;Dozier,etal.,2008).Thisapproach

focusesonspecificparentingbehaviours:nurturance,followingthechild’slead

andreducingfrighteningcaregivingbehaviour.ApilotRCTaimedathelping

substanceabusingmotherswhowerealsoinresidentialtreatmentalsoshowed

thatthecomparativelyshortABCinterventionimprovedtheparentingqualityin

thehomeenvironment(Berlin,etal.,2014).AlaterRCThasdemonstratedthat

thisrelativelyshorttermintervention(tensessions)greatlyimprovesparental

sensitivityanddecreasesintrusiveness,withthegreaterrateofimprovement

beingquiteearlyoninthework(Yarger,etal.,2016).

Anotherhome-basedprogrammethatworkedwithhighriskadolescentand

non-adolescentmothersevaluatedresultsaftersixmonthsofteachingparenting

skillsandthebasicsofchilddevelopmentwhilealsomakingalinkwithlocal

communityresources(Culp,etal.1998).Itwasshownthatthesemothers

significantlyimprovedtheirknowledgeofthetaughtsubjectsandtheirempathic

responsiveness,alsotherewasmoreinvolvementwiththecommunityandhome

safetywasenhancedaswell.Thesameapproach(andcurriculum)wasapplied

againtoaninterventiongroupof204andacontrolgroupof150first-time

mothers(Culp,etal.,2004).Comparedtothecontrolgrouptheintervention

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mothersshowedthesamegainsasbefore,andalsodemonstratedabetter

understandingofnon-corporalpunishmentalongwithbehavioursthatwere

moreacceptingandrespectfuloftheirinfants.Againwithvulnerableadolescent

mothersapilotintervention(withacontrolgroup)inItalysensiblymixedthree

interventionstrategies:videofeedback,developmentalguidanceandparent-

infantcounselling.Thiswasevaluatedatthreeandsixmonths,andfromthestart

improvedthequalityofinteractionandplaybetweenmotherandinfant,withthe

formerbecominglesscontrolling.Boththemothersandthebabiesshoweda

bettercapacityformutualregulation,withanincreaseinmaternalsensitivity

andinfantcooperation(Crugnola,etal.,2016).

TheequivalentprofessionalsintheUKareHealthVisitors,whohavethe

enormousadvantageoverhomevisitorsinAmericaastheyareuniversal,

‘invisible’andnon-stigmatising.(Thishasunfortunatelychangedinrecentyears

astheprofessionhasbeenhijackedtobecomeabranchofchildprotection.)Itis

literallyvitalthatthisinvaluableserviceremainstakenforgranted.OnceHealth

Visitorschucksomeofthecheckliststheycanreturntobeingthemost

importantadultmentalhealthresourcewehave,theonlyproblembeingthatthe

resultsoftheirworktakeacoupleofdecadestoshowup.TheSolihullApproach

hasshownthatHealthVisitorswhoaretrainedinthisformofreflectivepractice

areabletoworkmoreeffectivelywithchildrenwithlesscomplexsleeping,

feeding,toiletingandbehaviouraldifficultiesandsopreventtheneedtorefer

themtoCAMHS(DouglasandGinty,2001).Healthvisitorsandotherstrainedin

thisapproachconsiderthatitimprovesperceptionandpractice;andforthe

familiesinvolvedthereisasignificantreductionintheseverityofpresenting

difficulties,areductioninparentalanxietyandimprovementsinchildbehaviour

(summarisedinDouglasandRheeston,2009).Itisalsoamethodologythat

appearstoimprovetheabilitytoidentifyandhelpresolveminorproblemsin

youngchildren(Milford,Kleve,LeaandGreenwood,2006).Astudybasedona

differentbutcompatibleapproachwherehighriskfamiliesstudyweregivenan

18monthprogrammeofweeklyhealthvisitorcontact,usingtheFamily

PartnershipModel(Davis,DayandBidmead,2002),suggeststhat‘thisintensive

home-visitingprogrammemayimproveparentinginvulnerablefamiliesand

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increaseidentificationofabuseandneglectininfancy’(Barlow,etal.,2007:232).

Thismodelstressestheinterpersonalskillsandpersonalcharacteristicsneeded

inordertoworkinarelationshipbasedwaywithvulnerablefamilies,since‘the

processofhelping,includingthedevelopmentoftheworkingrelationship,is

determinedbywhatboththehelperandparentsbringtotheinteraction’(Davis,

2009:69).

Abridgetoapurelytreatment-basedprogrammeisprovidedbythe

relationship-basedinterventionforveryhigh-riskmotherssetupinLosAngeles.

Thisinvolvedarandomisedtrialtocreateasimilarcomparisongroupwhowere

onlygivenpaediatricappointments.Thesewereallmotherswhoalmost

invariablywouldhavecometotheattentionofaninfantmentalhealthservice,

hadonebeenavailable.Theprojectworkerswereallmentalhealthprofessionals

withexperienceinchilddevelopmentandthefamilysystemsapproach.The

primarygoaloftheinterventionwas‘toofferthemothertheexperienceofa

stabletrustworthyrelationshipthatconveysunderstandingofhersituation,and

thatpromoteshersenseofself-efficacythroughavarietyofspecific

interventions’(Heinicke,etal.,1999:356).Whencomparedwiththecontrol

group‘Themothersbecamemoreresponsivetotheneedsoftheirinfantsand

moreeffectivelyencouragedtheirautonomyandtaskinvolvement.Moreover,

thechildrenintheinterventionasopposedtonon-interventiongroupwere

moresecure,autonomous,andtaskinvolvedonavarietyofindicesat12

months’(p.371).Thetwogroupswerecomparedagainwhenthechildrenwere

twoyearsold,bywhichtime‘themothersexperiencingtheintervention,in

comparisonwiththosethatdidnot,alsousedmoreappropriateformsofcontrol,

andtheirchildrenrespondedmorepositivelytothesecontrols.Motherswhodid

notexperiencethehelpoftheinterventionhadsignificantlymoredifficulty

controllingtheirchildifitwasaboyasopposedtoagirl.Theyusedtheleast

appropriatemethodsofcontrolandtheboysrespondedmorenegativelytothese

controls’(Heinicke,etal.,2001:458).

Asimilarclinical-typeinterventionwascarriedoutinHolland,thedifference

beingthattheriskfactorresidedintheinfant,notinthesurroundingfamily.The

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aimoftheprogrammewastohelpmotherswithinfantswhodemonstratedan

irritabletemperament,sincethereisevidencethatnegativeemotionalityin

babiesleadsontolaterbehaviouralproblems.Motherswerehelpedtorespond

moretobothpositiveandnegativeemotionsintheirchild,andatthesametime

encouragedtoshowlessintrusivebehaviouranddetachedlackofinvolvement.

Thequalityofattachmentbetweenparentandchildappearstobeenhancedby

theparent’sabilityandwillingnesstobesensitivelyresponsivetotheirchild.

Thiswasconfirmedbythefindingthat‘moretoddlerswhosemothers

participatedintheinterventionweresecurelyattachedthanthereweresecurely

attachedcontrolgroupdyads’(vandenBoom,1995:1809).Atagetwoyears,the

mothersintheinterventiongroupstilldemonstratedagreaterresponsiveness

andinvolvementwiththeirtoddlers.Andatthreeyearsbothparentsweremore

attunedtotheirchildthanthoseinthecontrolgroup.‘Interventionchildren

continuedtobemoresecureintheirrelationshipwiththeirmother,exhibited

lessbehaviourproblems,andwerebetterabletomaintainapositiverelationship

withthepeerthanthecontrolgroupchildren’(ibid,p.1811).Helpingparents

respondinamoresensitive,orthoughtful,waytotheirinfantspromotessecure

attachment.Amorerecentattachmentbasedinterventionthatalsotargeted

irritableinfantsinfamiliesstrugglingwithseveresocioeconomicstressisknown

asTheCircleofHomeHealthVisiting.Thethreeonehourhomevisitsaimedto

helpmothersbecomemoreawareoftheirinfants’attachmentbehavioursin

termsoftheiralternatingneedforproximityandthenexploration,andthegoal

wastoincreasematernalresponsivenessanddecreaseintrusiveness.Ina

randomisedcontrolstudytheinterventiongroupshowedsignificantgainsin

thesepositiveattributes(Cassidy,etal.2011).

Depressedmothersareanotherhigh-riskgroup,aswhentheconditionissevere

itwillinterferewiththeabilitytotuneintotheirbaby’ssignalsandprovidea

sensitiveandemotionallynurturingcaregivingenvironment.Post-natal

depressionislinkedtoanincreaseininsecureattachmentintoddlers,

behaviouraldisturbanceathome,lesscreativeplayandgreaterlevelsof

disturbedordisruptivebehaviouratprimaryschool,poorpeerrelationships,

andadecreaseinself-controlwithanincreaseinaggression(Cummingsand

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Davies,1994;Murray,1997;SinclairandMurray,1998;Murrayetal.,1999;

Zeanahetal.,1997).Directmassagewithdepressedmothershasbeenshownto

increasetheircapacitytorecogniseemotionalexpressions,includingnegative

ones,andbemoreaccurateinaffectivelanguagecommunication(Free,etal.,

1996).Althoughthiscouldbeexpectedtoimprovethequalityofattachment,this

wasnotmeasured.However,anotherstudythatcomparedtheeffectoftoddler-

parentpsychotherapybetweentwo,randomlyassigned,groupsofmotherswith

amajordepressivedisorderfoundthatattachmentwasimprovedbytheendof

treatment.Thetwogroupswerefurthercomparedwithanotherwherethe

mothershadnomentalhealthproblems.‘Toddlersofdepressedmotherswho

receivedTPPevidencedratesofsecureattachmentthatwerenodifferentfrom

thoseofthenon-depressedcontrolgroupfollowingtheconclusionofthis

intervention”’(Cicchetti,etal.,1999:58).Theseweremotherswitharelatively

highlevelofincome,educationandfamilysupportwhomaywellhavebeen:

‘betterabletoutilizeaninsight-orientedmodeoftherapythanwomen

confrontedwithamultitudeofdailylivingchallenges’(p.59).Theauthorsofthe

studygoontospeculatethat:‘asmothersbecomefreedfromthe‘ghostsfrom

theirpasts’theirinternalworkingmodelsbecamemorepositiveandtheywere

increasinglyabletofocusonthepresent,includingtheirrelationshipwiththeir

child.’AninterventioninBostonthatoffereddyadictherapywiththeexpress

aimofengagingthemothertoworkwithherdepressionwhileatthesametime

neverloosingsightofboththerelationshipandtheinteractionsbetweenmother

andinfantshowedpromisingresults.Thisdemonstratedimprovementsinthe

mothers’perceptionofparentingwithselfesteemgoingupandparentingstress

goingdown,whichinturnwereassociatedwithbettermother-childinteractions.

Themothers’depressiondistressalsolessened,althoughthisbyitselfdidnot

leadtoanimprovementinparentinginteractions(Paris,BoltonandSpielman,

2011).Interventiontohelpimprovetherelationshipbetweenadepressed

motherandhersmallchilddoesnothavetobecomplicatedorhightec.Ameta-

analysisofapproachesrevealedthat‘Themosteffectiveandrobusttechniqueto

improvematernalsensitivity…wastheuseofbabymassage’(Kersten-Alvarez,et

al.,2011:372);andthisstudy,whichhadstrictinclusioncriteria,infactfoundno

evidencethatindividualinterpersonaltherapyfordepressedmothershadany

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effectonsensitivity.However,theevidencesuggeststhatbabymassagehasthe

mosteffectwhenappliedtomediumriskmothers,thereislittleornopositive

resultsforloworhighriskfamilies(Underdown,etal.,2013).

Asacontrast,anotherapproachtoinfantmentalhealthinterventionisprovided

byInteractionGuidance,whichdoesnotrelyoninsighttobringaboutchangein

theparent-babyrelationship.Thistechniqueusesvideofeedbackinorderto

encouragepositiveaspectsofcaregiver-infantinteraction,helpingparents‘in

gainingenjoymentfromtheirchildandindevelopinganunderstandingoftheir

child’sbehaviouranddevelopmentthroughinteractiveplayexperience’

(McDonough,1993:414).Thisformoftreatmentwasspecificallytailoredto

reachfamiliesover-burdenedwithmultiplerisks,andprobablyexemplifiesthe

strength-basedphilosophyintrinsictoallinfantmentalhealththerapymore

thananyotherapproach(McDonough,2004).Itdoesnotexplicitlyfocuson

exploringthecaregiver’sinternalrepresentationalworldoffeelingsand

memories,althoughsuchmaterialwillbeaddressedifitarisesduringthecourse

ofwork.‘Thisnonintrusivemethodoffamilytreatmenthasproventobe

especiallysuccessfulforinfantswithfailuretothrive,regulationdisorders,and

organicproblems.Parentswhoareeitherresistanttoparticipatinginother

formsofpsychotherapy,oryoung,inexperienced,orcognitivelylimited,respond

positivelytothistreatmentapproach’(McDonough,1993:414).Interaction

Guidancehasalsobeensuccessfullyusedtoimprovesensitivityanddecreasethe

amountofdisruptedcommunicationbetweenmothersandbabieswithfeeding

problems(Benoitetal.,2001);andaslightlymodifiedversionhasbeenshownto

helpmotherswithpostnataldepressionre-connectwiththeirbabies(Vikand

Braten,2009).Thistechniquehasbeenshowntobringaboutfairlyrapid

positivechangesindisruptivecaregivingbehaviour,andthiswasmeasurable

afterthefirstsession(Madigan,Hawkins,GoldbergandBenoit,2006).Video

feedbackofmothersandinfantsusingasplitscreentechnique,sothatbothfaces

canbeviewedsimultaneouslywhiletheyplaytogether,hasalsobeenshownto

beeffectiveinabrieftreatmentinterventionthatcombinesapsychoanalytic

approachwithanin-depthanalysisofimmediateinteractions(Beebe,2003).

Microanalysisoftherecordedinter-communicationwithintheexcerptofplay

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64

revealspatternsofaffectregulationthatcaninformapsychodynamicweaving

togetherofthepresentingdifficulties,theobservedbehaviourofthedyadand

theparent’sownearlyhistory.

ThetechniqueofInteractionGuidance,withitsuseofvideorecordingsto

emphasiseresponsive,positiveandpleasurablemother-infantinteractions,can

beeitherclinic-orhome-based;anditissometimesusedinconjunctionwith,

ratherthanasanalternativeto,morepsychodynamicmethodsoftreatment.The

advantagesofusingvideoaremanifold,allrevolvingaroundthewayinwhich

carefullylookingatafilmedpieceifinteractioncanallowselfreflectionwhilethe

actionis‘cold’,whichinturncanpromoteinsightintowhatisgoingoninthis

particularcaregivingrelationship.Thecarefuluseofvideofeedback‘servesto

activatepowerfulfeelings,basedonearlyattachmentrepresentations,inthe

therapeuticsessionswheretheparentcanbehelpedtobecomeawareofthese

thoughtsandfeelingsthatunderlietheirbehaviorwiththeirchildren,thereby

openingupnewwaysofbeingwiththeirchildren’(Steele,etal.,2014:407).Ifthe

programmeproviderusesastructuredmeansofanalysingthevideoclipthen

thisgivesawaytobothidentifyspecificstrengthsandskillstobeworkedon

whileatthesametimeallowingtheservicetoquantifyandcompareinorderto

collectthedatathatcaninformtheintervention.Aparticularlyusefulmethodfor

analysingfilmedplayisprovidedbytheKeystoInteractiveParentingScale

whichaddstoanyvideo-basedtreatmentbythewayitisabletostandardiseand

codedifferentaspectsofparentingbehaviourwhichinturncanpinpoint,track

andevaluatetheintervention.InaoneyearstudyinKentuckywhereKIPSwas

usedtotrackprogressandparentingoutcomesit‘detectedsignificantchangesin

parentingforagroupoffirst-time,at-riskparents.Theparents’scoresonthe

qualityofparentingstartedatalow-qualitylevelbutroseasparents

participatedinfamilyservices’(Comfort,etal.,2010:37).

Ameta-analysisofearly,attachment-based,interventionssuggeststhat

disorganisedattachmentismostsuccessfullyaddressedbyusingsensitivity-

focussedfeedback(Bakermans-Kranenburg,vanIjzendoornandJuffer,2005).

Attachment-basedvideofeedbackwastheinterventionofchoiceinastudythat

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usedarandomisedcontrolgroupandtargetedhigh-riskfamiliesinorderto

preventexternalisingproblemsinpre-schoolchildren.Thechildrenwereaged7

to10monthswhenthetreatmenttookplace,andvideowasused,intheirwords,

topromotepositiveparenting.Thereweretwopost-interventiontestsatone

monthafter,andthenatage40months;andcomparedwiththecontrolgroup

thoseinthetrialhadlesspreschoolclinicalexternalisingandtotalbehavioural

problems(Velderman,etal.,2006).Theevidence-basedclinicalworkofthis

groupalongwithitsbackgroundinresearch(atLeidenUniversity)hasledtoa

successfulprogrammetoenhanceparentalsensitivitycalledVideo-Feedback

InterventiontoPromotePositiveParenting,orVIPP(Juffer,Bakermans-

KranenburgandvanIJzendoorn,2007).Thisstrategyisafocussedandrelatively

short-terminterventionwithanumberofslightvariations,andithasbeen

appliedtoadoptedinfantsaswellasbabiesofmotherswithaneatingdisorder

andmotherscopingwithababysufferingfromskindisorders.Ithasbeen

showntobeeffectivewhenworkingwithmultiplydisadvantagedfamilieswhere,

comparedtoamatchedcontrolgroup,itimprovedmaternalnon-intrusiveness,

childresponsivenessandinvolvementalthoughithadlittleimpactonmaternal

sensitivity(Negrao,etal.,2014).AninterventionbasedonVIPPhasbeenshown

tobeeffectiveinreducingmothers’useofharshdisciplinemostlywhenthe

mothersarehighlystressed(Pereira,etal.,2014).Ithasbeeneffectivein

enhancingsensitivityandinfantattachmentinfirsttimemotherswhohad

insecureattachmentthemselves(Cassibba,etal.,2015).Thisstrategyhasbeen

subjecttomoreRCTsthanyoucanshakeastickat.However,althoughVIPP

generally(butnotalways)promotesanincreaseinmaternalsensitivitythiscan

sometimeshavenoeffectatalloninfantsecurity(Kalinauskiene,etal.,2009),so

intermsofinfantmentalhealthinterventionthistechniqueprobablyneedstobe

alwayscombinedwithsomethingelsesuchasparent-infantpsychotherapy.‘The

successofvideo-feedbackinterventionsintargetingparentalbehaviorandofPIP

inchangingmaternalmoodandrepresentationsofthechildsuggeststhata

mixedmethodmaybemoreeffectiveinaddressingbehavioraland

representationallevelsintandem’(Fonagy,etal.,2016:109).Intherealworld,

awayfromprojectspoweredbyresearch,itisunlikelythatrelyingonasingle

mechanismofchangewillproducepositiveresults;perhapsbecausefidelityto

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theprocessisbeingplacedabovethetherapeuticrelationship.AsDanielStern

emphasises,inclinicalworkdifferent‘portsofentry’areneededtohelpafamily,

andwhicheverpartofthesystemisworkedwiththerestwillchangeaswell

(Stern,1995).

Videofeedback,incombinationwithinfant-parentpsychotherapy,hasalsobeen

usedsuccessfullytotreatmotherssufferingfromPTSDfollowingahistoryof

violence-relatedtrauma(Schechter,2004;Schechter,etal.,2006).Itwasfound

thatthebaby’sfelt-to-be-intolerabledistress,orcurrentdomesticviolence,

wouldtriggerpasttraumaticmemoriesforthemother,whichthenbecame

confusedwithhercurrentperceptionofthechild.Thisintervention,overonly

threevisits,wasabletosignificantlyreducethedegreeofnegativityandof

distortionofmaternalattributions.Anothershort-termattachment-based

interventionsetouttotargetmaltreatingfamilieswithchildrenbetweenthe

agesofoneandfiveyearsold.ThisinvolvedaRCTbasedonrandomassignment

toeitheratreatmentorcontrolgroup.Theytoousedusingvideofeedbackalong

withfocusseddiscussionaroundattachmentandemotionalregulationwithin

eighthomevisitsofaboutanhourandahalfeach.Comparisonsbetweenpre-

andpost-testscoresrevealedsignificantimprovementsintheinterventiongroup

inparentalsensitivityandchildattachmentsecurity,alongwithareductionin

children’sdisorganizedattachment.Theolderchildreninthetreatmentgroup

alsoshowedlowerlevelsofbothexternalizingandinternalizingbehaviour

(Moss,etal.,2011;Mossetal.,2014).

Anexampleofhowdifferentstrategiesandmethodscanbeappliedisachild-

guidanceclinicinStockholmthatusesbothInteractionGuidanceandinfant-

parentpsychotherapytohelpmothersandbabies,withtheadditionalprovision

ofthreelonggroupsessionseachweek.Theyhavecarriedoutanin-depth

follow-upevaluationoftheirwork.Outoftenrandomlychosenmother-infant

pairsthatwerelookedatonlyonehadnotmadeconsiderableprogressduring

treatment(KarlssonandSkagerberg,1999).Acombinationofintervention

methodsappearedtoachievethemostgains.Similarly,intheU.KtheSunderland

Project,whereHealthVisitorsweretrainedintheuseofPatriciaCrittenden’s

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CareIndexandhowtoapplythistobriefvideorecordingsofmother-babyplay,a

multi-disciplinarymixedinterventionstrategyhasclearlybeenshowntoachieve

measurableimprovementsinahigh-riskpopulation.Svanberg(2005)concludes

that‘Theprocessofvideo-feedbackandthesupportofthehealthvisitor,whoin

his/herturnwassupportedandsupervisebytheparent-infantpsychologists,

enabledtheseparentstoincreasetheirownsensitivitysufficientlytosupport

theirchild’sdevelopmenttowardsasecureattachmentandamoreresilient

future.’Thisapproachroughlydoubledtheproportionofsecureattachmentin

theinterventiongroupwherethemothers’sensitivityandtheinfants’

cooperativenessincreasedsignificantlycomparedwithacontrolgroupreceiving

routinecare(summarisedinSvanberg,2009;alsoSvanberg,etal.2010).

Unfortunately,inspiteofthefactthatacarefulevaluationoftheSunderland

InfantProgrammehasdemonstratedclearandconsiderablelong-termsavingsto

healthandsocialservices(morethanthecosts),ithasbeencloseddown.

AresearchprojectinGenevahascomparedtheresultsachievedbybriefinsight

oriented,infant-parentpsychotherapywiththoseattainedbythemore

behaviouristmethodofvideofeedbackusingInteractionGuidance.Inthe

process,bothformsofinterventionweredemonstratedtobringabout

appreciable,positive,changesinthemother-infantrelationship.Sincethestudy

wascarriedoutonfamilieswhohadbeenreferredtoachildguidanceclinicit

wasfelttobeunethicaltohaveacontrolgroup,althoughcomparisonscouldbe

madewithanon-clinicalbutotherwisematchedsample.Theresultsofboth

formsoftreatmentwereevaluated,and‘markedsymptomreliefwasobservedin

severalareas,withthegreatestimprovementsinsleeping,feedinganddigestion

(i.e.symptomsaffectingphysiologicalfunctions)’(Robert-Tissot,etal.,

1996:105).Ingeneral,mothersbecamelessintrusiveandinfantsmoreco-

operative,withmaternalsensitivitytothebaby’ssignalsincreasingafter

treatment.‘Theresultsofthestudyindicatethatbriefmother-infant

psychotherapieswereeffectiveintreatingcasesconsultingforearlyfunctional

disorders’(p.108).Theonlydifferencesbetweenthetwoapproacheswerethat

InteractionGuidancebroughtaboutmorechangeinmothers’sensitivity,while

psychodynamictherapyhadagreaterimpactonmaternalself-esteem.

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ItcouldbearguedthatthetwodifferentapproachesofInteractionGuidanceand

infant-parentpsychotherapywereinfactidenticalintaskwhilebeingdifferent

inmethod,andeachimprovedreflectivefunction,aparentalcapacitythat

promotesandfuseswithsecureattachment.‘Secureattachmentandreflective

functionareoverlappingconstructs,andthevulnerabilityassociatedwith

insecureattachmentliesprimarilyinthechild’sdiffidenceinconceivingofthe

worldintermsofpsychicratherthanphysicalreality’(Fonagy,Gergely,Jurist

andTarget,2002:351).Toalargeextenttheparent’scapacityforreflectingon

theirownsignificantrelationshipsandthefactthatmentalstatesliebehindall

behaviour(aswellastheabilitytopresenttheseinacoherentnarrative-asin

theAdultAttachmentInterview),isasignifierforthelevelofsecurityof

attachmentthattheirchildrenhavewiththem.Asummaryofresearchreaches

theconclusionthat‘thecapacitytomentalizeintheattachmentrelationshipis

partandparcelofsecureattachment’(Allen,FonagyandBateman,2008:101).It

hasbeenfoundthatmotherscomingfromabackgroundofmaltreatmentyet

whohaveachievedgoodreflectivefunctiongenerallyhavesecurechildren,

whichmaystemfromtheir‘abilitytofilternegativebehavioursanddevelopand

promoterelationshipsthatfosterattachmentsecurityandorganization(Ensink,

etal.,2016:16).Thismaywellbeaskillthancanbedevelopedandhonedinthe

holdingenvironmentofinfant-parentpsychotherapy.

Bothparent-infantpsychotherapyandallthedifferentbrandsofvideofeedback

aredifferentportsofentryintotheparent’sinternal(unconscious)

representationsoftheirinfant,providingtheopportunitytofreeupandimprove

theobservationalskillsandempathythatareusuallysotakenforgrantedasto

gounnoticed.‘Acaretakerwithapredispositiontoseerelationshipsintermsof

mentalcontentpermitsthenormalgrowthoftheinfant’smentalfunction.Hisor

hermentalstateanticipatedandactedon,theinfantwillbesecurein

attachment’(Fonagy,Steele,Steele,MoranandHiggitt,1991:214).Again,thisis

anexampleofhowapositiveintersubjectiveoverlapleadstopositivechildsocial

andemotionaldevelopment.Researchhasdemonstratedthat‘negativematernal

caregivingbehaviourisinverselycorrelatedwithmaternalreflectivefunctioning’

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(Grienenberger,KellyandSlade,2005:304).Againinreflectivefunctionmaylie

behindallsuccessfulinterventionsthataimtoimprovethesensitive

responsivenessthatisseentobethebasisofsecureattachment.Ameta-analysis

ofteninterventionstargetingmaternalreflectivefunctionandsensitivitywith

theaimofimprovingthequalityofinfantattachmentfoundthat‘comparedto

infantswhodidnotreceivetheattachmentintervention,infantswhoreceived

theinterventionwerenearlythreetimesaslikelytobesecurelyattached’

(Letourneau,etal.,2015:383),andwhenthelowestqualitytrialwasfactoredout

thiseffectsizeincreasedevenmore.Interventionsthatfocussedonboth

reflectivefunctionandsensitivityproducedthemostbeneficialeffect;and

programmestargetingthemosthigh-riskpopulationshowedthemostbenefit–

‘effectsweregreatestformaltreatedandhighlyirritablechildren’(ibid).

Ithasbeendemonstratedthat‘maternalreflectivefunction,measuredat10

months,islikewiselinkedtoinfantattachmentsecuritymeasuredat14months

usingtheStrangeSituation’(Slade,etal.2005:293).Aninterventioncalled

‘MotheringfromtheInsideOut’basedonthisaspectofattachmenttheoryhas

beenshowntotoimproveparentinginsubstanceabusingmothersand,in

anotherpilotstudy,mothersreceivingtreatmentinanoutpatientmentalhealth

treatmentclinic.Thefocuswasonimprovingthesehigh-riskmothers’capacity

forreflectivefunctioningintheirparentingrole.Therewasarandomisedcontrol

groupreceivingparentingclasses.Itwasfoundthatatpost-treatmentthe

mothersdemonstratedimprovementsinreflectivefunctioning,sensitivityand

parentingbehaviour(Suchman,etal.,2010;Suchman,2016,Suchman,etal.,

2016).Thetherapeutictargethereisthemother’scapacityforemotional

regulationandmentalization,specificallymodulatingnegativeaffectduring

stressfulparentingsituations;andtheprogrammeisdeliveredinacommunity

setting.Anotherstudyexaminingreflectivity,mind-mindednessandbehaviourin

parentsconcludedthat‘directingattentiontowardssupportingthemother’s

capacitytoeffectivelymentalizeislikelytoholdpositiveconsequencesforboth

hermentalexperiencesofthechildandtherelationshipaswellasforher

parentingbehaviourduringinteraction’(Rosenblum,McDonough,Sameroffand

Muzic,2008:374).Aresearchprojectshowedthatmothersofpre-school

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childrenwithbehaviouralandemotionaldifficultieswhoparticipatedina

clinicalinterventionthatincreasedtheirinsightfulnesshadchildrenwhose

problemsdecreased;whereasmotherswhodidnotgainfromthishadchildren

whosebehaviourproblemsincreased(Oppenheim,GoldsmithandKoren-Karie,

2004).

AserviceforvulnerablefamiliesinNewHaven,Connecticut,isbasedonthe

principleofenhancingreflectivefunctioning.Thisisaweeklyhome-visiting

interventioncalledtheMindingtheBabyProgram,andisfocussedonthe

mother-infantrelationshipwiththerelationshipthemothercanslowlyform

withtheworkersbeingthevehicleofchange,recognisingthatinmanyinstances

highriskparents‘mayrebufftheclinicians,forgetappointments,leavehomejust

beforecliniciansareduetoarrive,ordropoutofsightforweeksatatime

(requiringcreativeandpersistenttracking)’(SladeandSadler,2013:34).

(Incidentally,thisdescriptionoftheclientgroupclearlydemonstrateshowinfant

mentalhealthservicesneedtobesitedoutsideofCAMHSwiththelatter’s

philosophyofdefensivegatekeeping,facilequickfixesandquickerthroughputto

massagetargetstatistics.)MindingtheBabyisadynamichybridoftheNurse

FamilyPartnershipandinfant-parentpsychotherapy,basedontheideathat‘an

approachthatwouldencouragemotherstotakenoteofthebaby’sexperiencein

arangeofwayswoulddiminishthelikelihoodofherrespondinginafrightening

orfrightenedwayandpotentiallymaltreatingherchild’(Sadler,etal,2013:393).

Thisformofearlypreventativeinterventioniscurrentlybeingintroducedtothe

UKundertheauspicesoftheNSPCC(Phillips,2013).Apreliminaryevaluation

(Slade,SadlerandMayes,2005)indicatesamarkedgaininmaternalreflective

functioninrelationtothespectrumoftheirchild’sdevelopmentaldomains,and

(usingtheStrangeSituation)nochildrenwithdisorganisedattachment.Forthe

mothers,thetrendwastowardslowerlevelsofdepressionandpost-traumatic

stresssymptomsalongwithhigherlevelsofself-efficacy.AlaterRCTwith

randomassignmentofpre-natalcaregroupsshowed‘amovetowardless

disruptedinteractionsat4months,higherratesofsecureattachmentandlower

ratesofdisorganizedattachmentat12months,andastrongtrendtowardlower

ratesofchildprotectionservicereferralsat24months…(Themothers)alsoare

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attendingtotheirchildren’spediatrichealthvisitsanddelayingsubsequent

childbearing…’(Sadler,etal.,2013:401).

Inpsychodynamicinfant-parentpsychotherapythe‘patient’istherelationship

betweenbabyandcaregiver.Child-parentpsychotherapyhasbeenshowntobe

effectiveinhigh-riskfamilysituationswherethereispresentmaternal

depression,poverty,domesticviolence,motherswithatraumaticchildhoodand

childrenalreadyknowntohavesufferedmaltreatment(Cicchetiietal.1999,

2000,2006;Lieberman,etal.1991,2005,2009).Thisapproachdoesnotsee

currentdifficultiesintheparentchildrelationshipasstemmingjustfromalack

ofparentingskillsorknowledge;rathertheparent’sproblemsinrelating

sensitivelytotheirinfantarelargelycausedbytheconflictualnatureofthe

parent’sinternal,unconscious,representationalmodelsstemmingfromtheir

ownexperiencesinchildhood–theghostsinthenursery.Itistobeexpected

thatthisapproachwoulddirectlyaffectmaternalself-esteem,sinceemotional

difficultiesfrompastrelationshipsareaddressedwithinthecontextofanew

relationshipthatissecureenoughtobothwithstandandencourageexploration.

‘Thequalityoftherelationshipbetweentherapistandparentisperhapsthe

morecrucialininfant-parentpsychotherapythaninanyotherformoftreatment,

becauseitisintendedtobeamutativefactorintheparent’srelationshipwithhis

orherchild’(Lieberman&Pawl,1993:430).

Inastudydesignedtoevaluatetheeffectivenessofinfant-parentpsychotherapy,

whichcomparedaninterventiongroupofmothersandinfantswithasimilar

controlgroup,itwasfoundthat‘Motherswhoformedastrongpositive

relationshipwiththeintervenertendedtobemoreempathictotheirinfantsat

outcome,andtheirchildreninturntendedtoshowlessavoidanceonreunion’

(LiebermanandPaul,1993:434).However,themostimportanttreatment

variableturnedouttobethemother’sability‘touseinfant-parent

psychotherapytoexploreherfeelingstowardsherselfandtowardherchild’

(ibid).Thetworandomlyassignedgroupsofmother-infantdyadswherethe

childhadbeenassessedasdemonstratinginsecureattachmentwerefurther

comparedwithasecondcontrolgroupofsecurelyattachedinfantsandtheir

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mothersinordertoexamineoutcomes.Evaluationtookplacewhenthechildwas

twoyearsold,afteroneyearoftreatment.‘Theinterventiongroupperformed

significantlybetterthantheanxiouscontrolsintheoutcomemeasuresandwas

essentiallyindistinguishablefromthecontrolgroup’(p.440).Thosemothers

whobecamemostengagedinthetherapeuticprocessbecamemoreactively

attunedtotheirchildren,whointurn‘showedlessangerandavoidance,more

securityofattachment,andmorereciprocalpartnershipinthenegotiationof

mother-childconflict’(p.441).Again,itisrelationshipsthatchange

relationships.Thisinterventionevolvedintoaninterventionforthreetofive

yearoldstraumatisedbydomesticabuse;andinarandomisedclinicaltrialthese

children‘improvedsignificantlymorethanchildrenreceivingcasemanagement

plustreatmentasusualinthecommunity,bothindecreasedtotalbehavioural

problemsanddecreasedPTSDsymptoms’(Lieberman,VanHornandIppen,

2005:1246).These‘improvementsinchildren’sbehaviorproblemsandmaternal

symptomsastheresultoftreatmentwithchildparentpsychotherapycontinue

tobeevident6monthsaftertheterminationoftreatmentwhencomparedtothe

controlgroup’(Lieberman,IppenandVanHorn,2006:916).Themethodologyof

thisapproachhasbeencoveredindetail(LiebermanandVanHorn,2008;

Lieberman,IppenandVanHorn,2016),andithasbeensuccessfullyappliedto

situationsofdomesticviolenceintheperinatalperiod(Lieberman,DiazandVan

Horn,2009).Agoodprécisofallstudiesprovingtheefficacyofthisformofchild-

parentpsychotherapycanbefoundonpages49to54inLieberman,Ippenand

VanHorn,2016.CurrentlyaRCTisinplacetoseetheresultsofapplyingthis

approachintheperinatalperiod.

Inanotherwell-controlledstudy,oneyearoldinfantsandtheirmaltreating

familieswererandomlyassignedtoeitherastandardcommunitycontrolgroup,

anotherthatreceivedapsycho-educationalparentingintervention(Nurse

FamilyPartnership)or,thirdly,infant-parentpsychotherapy;andinaddition

therewasamatchednormativesampleofnon-maltreatingfamilies.Atpost-

interventionfollowupatage26monthschildreninthetwotreatmentgroups

demonstratedsubstantialincreasesinsecureattachment,whilethiswasnot

foundinthetwocontrolgroups(Cicchetti,RogoschandToth,2006),withthe

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lowestrateofdisorganizedattachmentintheinfant-parentpsychotherapy

group.Usingavariantofparentinfantpsychotherapywhichfocusesonthe

analyst’sabilityto‘contain’theinfant’sdistressbyinteractingand

communicatingwiththeinfantduringthesessionarandomisedcontroltrialin

Stockholmshowedthatthisformoftreatmentimprovedmotherinfant

relationships,aswellasmaternalsensitivityanddepression(Salomonssonand

Sandell,2011).Whenthesechildrenwerefollowedupatagefourandahalf,and

comparedtothecontrolgroup,theywerefoundtoshowbetterresultsonglobal

functioningandtobelesstroubled(Salomonsson,etal.,2015a).Theirmothers

appearedtohavebeenhelpedwithasenseofpersonalwellbeing,tobecome

moresensitivetotheirbaby’ssufferingandtobettersupportandappreciate

theirchildrenthroughoutinfancyandtoddlerhood(Salomonsson,etal,2015b).

However,infantparentpsychotherapyisnotasstandardisedandstructuredas

someofthemoretechniqueorinstructionalorientedapproachesusedwith

vulnerablefamilies.Thismakesthecontrolledandmanualiseddeliveryof

treatmentthatiscalledforinaRCTmoredifficulttodeliver.Inthereal

therapeuticsituationcliniciansmixandmatchinresponsetotheneedsofboth

caregiverandinfant;andalsointherealworlditisacceptedthatthevehicleof

changeistherelationshipbetweentherapistandthemother-babycouple,hard

toreducetoasetformula.‘Wethinklessofwhatgoesonintrapsychically,and

moreaboutwhatgoesoninterpersonallyandintersubjectively…Thesubject

matteroftherapeuticinterestnolongerresideswithinthepatient-client’smind

norwithinthehomevisitor-therapist’smindbutratherintheproductsoftheir

interaction…Thelargelyunpredictableproductsoftheirinteractionbecomethe

subjectmatterthatbringsaboutchange…Theprocessofinterrelating,itself,

bringsaboutchange.Itbringsaboutnewexperiences,feelings,insights,and

interactionalskills’(Stern,2006:3).Thedynamicsofinfantparent

psychotherapyhavetoincludebeingopenandquickwittedenoughtoplucka

‘momentofmeeting’(TheBostonChangeProcessStudyGroup,2010)outof

chaos.Thismeanstrustingone’sownunconsciousandbeingpreparedto

abandontechniquewhennecessary,somethingmanymightfindhardtodo.One

sizewillneverfitallandeverytechniqueisnomorethanatoolinthebox,tobe

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effectiveinbuildingorrepairinganythingyouneedarangeoftools.The

psychodynamicoutlookgivesdepthtoanyintervention(attachmentisabranch

ofpsychoanalytictheory),butasaninterventionitmaybemoresuccessfulwhen

combinedwithothermodalitiesandasacomponentofamultidisciplinary

relationship-basedteam.

Parentinfantpsychotherapywasthemaintherapeuticmodalityappliedto

improvetherelationshipbetweenmotherandchildinvulnerableandhigh-risk

familiesintheFloridaInfantMentalHealthPilotProgramme.Thisintervention

targetedfamilieswithinfantsatriskofabuseandneglectwhowerelikelytobe

removedfromtheirparentsorwherethishadactuallyoccurred.Therewasno

controlgroup;andgiventhattheprojectwasfundedbythelegislaturethis

wouldnothavebeenethical.Fiftyninepercentoftheprogrammesparticipants

werecourt-orderedtoparticipate,andmanyhadalreadyarecordofmaltreating

theirchildren.Theresultsareimpressivebecauseofthewiderangeoffamily

arrangementsthatfellwithinthescheme,whichwasthuslesschoosyandfar

moreclinicallyrealisticthanmanyotherresearchprojects.Attheendofthis

pilotstudy‘therewerenofurtherreportsofabuseorneglectduringthe

treatmentperiodanduptopost-assessmentforparticipants.Therewasamajor

reductioninreportsofchildabuseandneglect…from97%ofchildrenpriorto

treatmenttononeofthechildrencompletingtreatmentduringthefirstthree

yearsofthepilotproject…(Also),thehealthanddevelopmentalstatusof

childrenimproved’(Osofsky,etal.2007:273).Inadditiontherewasareduction

ofdepressivesymptomsinthecaregiversalongwithameasuredandreported

improvementintheparent-childrelationship.Butalotofeffortwentintothese

achievements,asshouldbeexpectedforhighriskfamilies,anditwasestimated

thatbehindeveryhouroftreatmentwereanothertenspentoneffortstoengage

thefamily.

TheParentInfantPsychotherapy(PIP)clinicattheAnnaFreudCentrehasa

therapeuticfocusontheparent-infantrelationshipasobservedinthemutually

influencinginteractionsinthesessions(Baradon,etal.2005).Heretoo,video

feedbackisanessentialpartoftheprocess.Oneaimofparent-infant

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psychotherapyistointerruptthegenerationalcontinuityofunhelpfulpatternsof

parentingand,atthesametime,toencouragetheestablishmentofasecure

attachmentrelationshipforthechild.AresearchprojectattheAnnaFreud

Centre,inapilotstudy,evaluatedoutcomesusingarangeofpsychometrictools.

Themajorityofparentsfeltthattheirchild’sdevelopmenthadbeenbetterthan

expected.Littlemorethan10-15%hadsignificantconcernsaboutthechildat

followup.Lessthanoneintwentyexperiencedaworsening.Onbothintellectual

andmotordevelopment,asmeasuredwiththeBayleyassessmentof

development,referredfamilieshadinfantssevenpointsbehindtheaverage.By

sixmonthstheywereindistinguishablefromtheaverage,andthisimprovement

hadincreasedslightlyatfollow-up(Fonagy,etal.,2002).However,alater

controlledRCTfromtheAnnaFreudcentrethatlookedatparent-infant

psychotherapyforparentswithmentalhealthproblemsfoundnodifferencein

outcomebetweentreatmentandcontrolgroupsinmeasuresofdevelopment,

caregivinginteraction,maternalreflectivefunctionand(ona12monthfollow

up)infant’sattachmentstatus.Theonlypositiveoutcomeslimitedtothe

treatmentgroupwereareductionofstress,improvedparentalmentalhealth

andmorepositiveparentalrepresentationsoftheirchild(whichmightbe

expectedtohavealongerterm‘sleeper’effect).Overall‘MothersreceivingPIP

feltlesshelpless,lessintrudedupon,moreincontrol,andgenerallylessstressed

bytheirchildcareresponsibilities’(Fonagy,etal.,2016:110).

Another,final,exampleofawell-researched,interventionforparentsandinfants

isthetechniqueofWatch,WaitandWonderusedintheTorontoInfant-Parent

Program.Inthisformofinfant-parentpsychotherapytheparentisencouraged

tobemoredirectlyinvolvedwiththeirchildbyengaginginplayfulinteraction

thatfollowstheleadofthechild.Theparentistheninvitedtoexplorethe

feelingsandthoughtsthatwereevokedbywhatheorsheobservedand

experiencedintheprecedingplaysession.Thismodeoftreatmentalsoappears

tobeapositiveexperiencewithgoodoutcomesformothersstrugglingwith

borderlinepersonalitydisorder(NewmanandStevenson,2008).Allowingthe

childtobespontaneouscanbehardforaparenthauntedby‘ghostsinthe

nursery’,especiallywhenthesearerevenantsofpastabuse;andadefensive

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infant,whoismoreusedtocomplyingtothepatternofavailablecaregivingin

ordertoextractthemaximumavailablesenseoffelt-security,canbeequally

stumped.WhenWatch,WaitandWonderiscombinedwithbothimaginationand

Interactionguidanceitformsthebasisofaproductivegroupapproach,Baby

Watching,whichhasapparentlysuccessfullyengagedhardtoreachmothers

(Celebi,2014).

Aresearchprojectsetouttocomparetheeffectsoftraditionalinfant-parent

psychotherapy(PPT)withWait,WatchandWonder.Abroadrangeofoutcome

measureswasappliedbeforeandaftertreatment,andagainonfollow-upsix

monthslater.Themajorityofchildrenreferredtothisservicewereinsecurely

attached.Highlytrainedcliniciansdeliveredbothformsoftreatment.Itwas

foundthatbytheendoftheinterventiontheWait,WatchandWondermethod

wasassociatedwithamorepronouncedmovetowardssecureattachment.The

infantsinthisgroupalso‘exhibitedagreatercapacitytoregulatetheiremotions

withaconcomitantincreaseincognitiveability’(Cohen,etal.,1999:445).Their

mothers‘reportedmoresatisfactionwithparentingthanmothersinthePPT

groupandlowerlevelsofdepressionattheendoftreatment’(ibid).Bothforms

oftreatmentshowedsimilarpositivegains.‘Theywereassociatedwitha

reductionofpresentingproblems,improvementinthequalityofthemother-

childrelationship,andreductioninparentingstress’(ibid).However,atthesix-

monthfollow-upthetwogroupsweresimilaronallmeasures.TheWait,Watch

andWondergrouphadretaineditspositivegainswhilethegroupreceiving

parent-infantpsychotherapyhadcaughtup.Itwasconcludedthatboth

approachesarehelpful,buttheeffectsofWait,WatchandWondercameabout

morequickly.

Wait,WatchandWonder,withitsdualemphasisonpositiveinteractionand

insight,isahybridofbehavioural(i.e.interactionguidance)andpsychodynamic

approaches.Althoughnotmadeexplicit,thisproceduretooplainlytargetsand

enhancesparentalreflectivefunctionwithanemotionallycontainingsetting.As

withtheothertreatmentmodalitiesthathavebeenmentioned,thistechnique

couldeasilybeofferedinanyCAMHSsettingprovidedthereweresuitably

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qualifiedstaff,since,againtheoretically,theage–rangeforclientsbeginsatzero.

Butthereisanimportantcaveattobeconsidered,sincemaywouldarguethat

infantmentalhealthworkdoesnotnaturallybelonginthesamestableasthe

interventions(andfacilities)forolderchildrenandtheirfamilies.Thisisnotjust

amatterofsite,access,noise-andintimidation-level,orthelackofsuitably

trainedclinicianswithrelevantbackgrounds.AsBarrows(2000:19)argues,itis:

‘onlywithinthecontextofaservicethatisdedicatedtoInfantMentalHealththat

(the)focusontheparent-infantrelationshipislikelytobesustained,andto

featureastheprimefocusofanytherapy.’Aconsiderationofthewiderangeof

riskfactorsthatmustbeaddressedmakesitclearthatamulti-disciplinaryteam

isessential,sinceseeminglydistalpressureswillinfluencethecaregiver-infant

relationship.

Sometimesbabiesandtoddlersarelivinginsuchadversecircumstancesthat

theyneedtobemovedtoanewsetofcaregiversasquicklyaspossible.The

relationshipwiththeparentmaybedistortedbeyondrepairbyanaccumulation

ofriskfactors.Aswellasatreatmentmodality,theknowledgebaseofinfant

mentalhealthoffersustheunderstandingneededforspeedyassessmentand

recommendationastothecourseofactionthatwillbeinthebaby’sbestinterest.

Themostradicalandeffectivetreatmentforaninfantisanewfamily.Itishas

beenacceptedforyearsthatthelongeraftersixmonthsanadoptionisfinalised

thegreatertheriskoflaterproblemsinrelationships(Singer,etal.,1985).An

InfantmentalHealthteaminBatonRouge,ontheoutskirtsofNewOrleans,isa

pioneeringexampleofhowappliedknowledgeinthisfieldenablesa

comparativelyrapidassessmentofcaregivingtobecarriedoutforveryyoung

childrenreferredtotheChildProtectionService.Thisprojectisfundedbythe

courtsandhasaproventrackrecord.Itusesarangeofspecialisedassessment

methods,onceagainmakingcarefuluseofvideotechnology(Larrieuand

Zeanah,2004).Thepurposeofthisserviceistoprovidethecourtswithan

assessmentthatwillbeusedaspartofthedecision-makingprocessasto

whetherornotachildwillbefreedforadoption.Asimilarchildpopulationis

servedbyanAttachmentClinicinMontrealwhichconsultstotheYouth

ProtectionServiceonissuesrelatedtopermanencyplanningforveryyoung

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childreninfostercare(Gauthier,FortinandJeliu,2004).Theypayspecial

attentiontohowthechildhasbeenaffectedbytheoriginalseparationfrom

biologicalparentsandtheirresponsetothepossibilitythattheymightreturn

afteralongperiodwithfosterparents.

Theinfantmentalhealthspecialist(adiscreteprofessioninAmerica)needsto

calluponawiderangeofskillsandstrategiesthattogether‘contributetothe

parent’sunderstandingoftheinfant,theawakeningorrepairoftheearly

developingattachmentrelationship,andtheparent’scapacitytonurtureand

protectayoungchild’(Weatherston,2000:6).Thismeansstrengthening

relationships,whetherbetweenparentandchild,therapistandparent,orwithin

theboundariesoftheinfantmentalhealthservice.Startingfromthefundamental

premisethatallparentswanttodothebesttheycanfortheirbabies,theinfant

mentalhealthteambuildsonstrengthsinordertoremoveobstaclestoanatural

stateofaffairs.Parents,unsurprisingly,maynotappreciateotherknow-it-alls

thinkingtheyneedtraining,indeed,suchanattitude‘maysendamessageof

presumedincompetence,whichmightundermineamother’sorfather’sself-

confidenceandcontributeinadvertentlytolesseffectiveperformance’(Shonkoff

andPhillips,2000:371).Thepedagogicapproachofparentingclassessimplywill

notcutthemustardwithhigh-riskfamilies,notexactlyanewobservation.

‘Motherswhohaveitinthemtoprovidegoodenoughcarecanbeenabledtodo

thisbetterbybeingcaredforthemselvesinawaythatacknowledgesthe

essentialnatureoftheirtask.Motherswhodonothaveitinthemtoprovide

goodenoughcarecannotbemadegoodenoughbymereinstruction’(Winnicott,

1965:49).Infantmentalhealthspecialistsmaybeexperts,buttheyrelateto

parentsonthebasisofpartnership,notpower,modellingtherelationshipsthey

wishtopromote.

Conclusion.

Thereisagrowingbodyofevidencethatdemonstrateshowearly,targetedand

strength-basedinterventionsfocussingonrelationshipscanbringaboutpositive

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79

changesintheemotionalenvironmentofvulnerablebabies(Barlow,etal.,

2010).AssummarisedbyProfessorFonagyattheendofthelastcentury

(1998:132)inanoverviewofthefield‘earlypreventativeinterventionshavethe

potentialtoimproveintheshorttermthechild’shealthandwelfare(including

betternutrition,physicalhealth,fewerfeedingproblems,low-birth-weight

babies,accidentandemergencyroomvisits,andreducedpotentialfor

maltreatment),whiletheparentscanalsoexpecttobenefitinsignificantways

(includingeducationalandworkopportunities,betteruseofservices,improved

socialsupport,enhancedself-efficacyasparentsandimprovedrelationships

withtheirchildandpartner).Inthelongterm,childrenmayfurtherbenefitin

criticalwaysbehaviourally(lessaggression,distractibility,delinquency),

educationally(betterattitudestoschool,higherachievement)andintermsof

socialfunctioningandattitudes(increasedprosocialattitudes),whiletheparents

canbenefitintermsofemployment,educationandmentalwell-being.’Soone

hastowonderwhysolittleresourcesgointotheearlyyearsinthiscountry;the

costofkillingafewforeignerswouldhelpagreatmanybabiesoutoftrouble.

Asdemonstratedabove,thereareagreatmanyexamplesofevidence-based

practice–andevenmoreofpractice-basedevidence–showingthepositive

resultsofaninfantmentalhealthapproachtowardsearlyinterventionthat

beginsandendswiththeimportanceofrelationships.However,toomuch

insistenceonevidence-basedinterventioncaneasilybeusedtodisguiseasimple

reluctancetoinvestfunds;albeittheamountsinvolvedwouldbeatiny

percentageofthebudgetsforadultmentalhealthandthecriminaljustice

system.Anecologicalperspectivemakesclearthatwhatmayworkbrilliantlyin

aspecificlocationmighthavenoeffectsomewhereelse,since‘evidencebased

practicesinpreventionsciencewhichmayhavebeentriedandshowntobe

effectiveinonelocationunderonesetofhistoricalandcontextualconditions

cannotbeassumedtobeeffectiveinanother’(Schensul,2009:243).Onesize

doesnotfitall.‘Listsofevidence-basedpracticesarebasedonstudiesof

unrepresentativesamplesthatdonotrepresentthediversityoftheindividuals

thatmostpractitionersencounterinthefield’(Shean,2014:503).Inearly

interventionrelationshipshaveamoresignificanteffectthantechniques–a

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80

nightmareforthosewhocommissionsincethepersonwillbemoreimportant

thantheprocedureandthepeoplegoodatmakingtherapeuticrelationshipswill

beuselessatfollowingprocedures!

Tocomplementtheevidenceofclinicalimpact,longitudinalresearch,both

psychologicalandneurological,hasconfirmedthevitalimportanceoftheearly

attachmentrelationshipforfuturedevelopment.‘Foryoungchildren,infant-

caregiverrelationshipsarethemostimportantexperience-nearcontextfor

infantdevelopmentandarethedistinctivefocusoftheinfantmentalhealthfield’

(ZeanahandZeanah,2009:8).Thecradleofthefirstrelationshipsetsupparallel

flexiblesystemsinanewlyformingfamilyandanewlyformingbrain.‘Thetime

ofgreatestinfluence,forgoodorill,iswhenthebrainisnew.Ifwewanttohelp

thenextgenerationweshouldbeworkingwiththeirparentswhiletheyare

babiesnow’(Balbernie,2001:253).Thisissimplyatechnicalconfirmationof

whateveryparenthasalwaysknown,althoughtheymaynothavetimetothink

aboutituntiltheyaregrandparents.Itissomethingthatsomehowgetsavoided

whentheimplicationshavetobeturnedintopolicyorcommandresources.Who

reallydoubtsthat:‘(T)hechildhoodshowstheman,asmorningshowstheday’

(Milton,1671/1992:492).

Ifthefirsttwoyearsoflifearecradledwithinsecureattachmentthenthe

growingchildfeelsgoodabouthimorherself,canappreciatethefeelingsof

othersandseetheirpointofview,isabletotakefulladvantageofeducationand

hasinherentpsychologicalresiliencytofallbackuponintimesofstress.Nobody

canavoidtrippingoverthepitfallsoflife;butthosewithabeginningofsecure

attachmentstandabetterchanceofbeingabletoself-repair.Attheotherendof

thespectrum,theinfantwithdisorganisedattachment,whohasoftensuffered

abuseorneglect,willbecomethechildwhocannottrustrelationships,whohas

noempathyforpeopleorrespectforsocialrules,whodisrupts,attacksandtries

todominatewhatmaybeonofferinboththefamilyandschool,andwhomight

wellbeseriouslyvulnerabletolatermentalhealthproblems.Andfurthermore,

mostimportantly,thesepatternsofbehaviourstandagoodchanceofbeing

passedontothenextgenerationastheattachmentexperiencesofinfancycutthe

.

81

templateforthecaregivingbehavioursofadulthood.‘Byfailingtounderstand

thecumulativeeffectsofthepoisonsassaultingourbabiesintheformofabuse,

neglect,andtoxicsubstances,weareparticipatinginourowndestruction’(Karr-

MorseandWiley,1997:12).

Earlyinterventionwithintheremitofaninfantmentalhealthserviceisan

effectivewayofbeginningtobreakthecycleofinsecureattachmentasittakes

advantageofboththeneurologicalplasticityofthebabyandthefluiddynamics

ofafamilyintheprocessofadaptingtoanewmember.Leaveittoolateandboth

thestructureofthebrainandfamilyinteractionsbecomeincreasingly

establishedandconsequentlyhardertochange.

RobinBalbernie

ConsultantChildPsychotherapist.

ClinicalDirectorPIPUK.

robin.balbernie@gmail.com

orrobin.balbernie@pipuk.org.uk

(22/06/2016).

Theappendixonthefollowingpagesisariskfactorchecklistthatmaybeusedtoassesswhenthecaregivingrelationshipispotentiallyatrisk.Byusingsuchascreeningtoolitispossibletoofferhelpbeforeharmhasoccurred.Thisiskinder,lessstigmatisingandmorecosteffective.Pleasefeelfreetocopy,useandmodify,inanywaythatyoulike.

.

82

Manyknownriskfactorsputastrainonthebaby-parentrelationship.Ananalysisoftheseallowsinterventiontobeconsideredatapreventivelevel,beforetheinfant’squalityofattachmenthasbeencompromised.Thepresenceoffourtosixmoderateriskfactorsissignificantalthoughsomecombinationsofalessernumbermeritattention.However,therearecertainseriousconditionsthatmaycallforinterventionsontheirown.Thesehavebeenitalicised(inred)inthelistbelow.1. BiologicalVulnerabilityintheInfant: Mothersubstanceabused/onmethadoneduringpregnancy. Verylowbirthweight/extremelypremature. Failuretothrive/feedingdifficulties/malnutrition. …… Motherdrankalcoholduringpregnancy. …… Congenitalabnormalities/illness/seriousdevelopmentaldelay. …… Verydifficulttemperament/extremecrying. …… Verylethargic/non-responsive. …… Resistsholding/hypersensitivetotouch. …… Chronicmaternalanxiety/stressduringpregnancy. …… Mothersmokedheavilyduringpregnancy. …… Regulatory/sensoryintegrationdisorder. ……2. ParentalHistoryandCurrentFunctioning: Mentalillness,includingdepressionandeatingdisorder. Seriousmedicalcondition/physicaldisability. Ownmothermentallyill/substanceabused. Alcoholand/ordrugabuse(currentorpast). Historyofphysicalorsexualabuse,witnessingviolence,neglectorloss. Parentsseemincoherentorconfused. …… Parentwasincare(lookedafter)/adopted.

Lackofpreparationduringpregnancy.…………

Learningdisability/loweducationalachievement. …… Criminaloryoungoffender’srecord/hasbeenimprisoned. …… Previouschildhasbeenplacedinfostercareoradopted. …… Motherhasexperiencedthedeathofachild. …… Previouschildhasbehaviourproblems. …… Presenceofanacutefamilycrisis. ……3. InteractionalorParentingVariables: Lackofsensitivitytoinfant’scriesorsignals. …… Lackofconsistentprimecaregiverforinfant. …… Physicallypunitiveorharshtowardschild. …… Lackofvocalisationtoinfant,few‘conversations’. …… Lackofeye-to-eyecontact. …… Negativeattributionsmadetowardschild,evenif‘jokey’. …… Lacksknowledgeofparentingandchilddevelopment. …… Infanthaspoorcare(e.g.dirtyandunkempt),physicalneglect. …… Doesnotanticipateorencouragechild’sdevelopment. …… Qualityofpartnerrelationship;maybeunderminedorunsupported. …… Infantavictimofmaltreatment,emotionalabuseorneglect. Anyviolencereportedinthefamily,especiallyifwitnessedbychild. Negativeaffect(includingfear)/verbalabuseopenlyshowntowardschild. 4. Socio-demographicFactors: Chronicunemployment. …… Inadequateincome/housing/hygiene. …… Overcrowdinginhousehold. …… Singleteenagemotherwithoutfamilysupport.

Absentparentorstepparentinfamily(i.e.notbiologicallyrelated).…………

Poorquality/morethan20hoursperweekday-care. …… Severefamilydysfunction,currentandinbackground. …… Lackofsupport/isolation. …… Recentlifestress(e.g.bereavement,birthtrauma,immigration). ……

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83

References.

Adam,K.S.,Sheldon-Keller,A.E.,&West,M.(1996)Attachmentorganizationand

historyofsuicidalbehaviorinclinicaladolescents.

JournalofConsultingPsychology,64,(2),264-272.

Ainsworth,M.D.,Blehar,M.C.,Waters,E.&Walls,S.(1978)Patternsof

attachment:ApsychologicalstudyoftheStrangeSituation.

Hillsdale,N.J.:Erlbaum.

Allen,J.G.,Fonagy,P.&Bateman,A.W.(2008)MentalizinginClinicalPractice.

AmericanPsychiatricPublishing,Inc.:WashingtonDC.

Allen,J.P.,Houser,S.T.,&Barman-Spurrell,E.(1996)Attachmenttheoryasa

frameworkforunderstandingsequelaeofsevereadolescentpsychopathology:

An11-yearfollow-upstudy.

JournalofClinicalandConsultingPsychology,64,254-263.

Allen,J.P.,Moore,C.M.&Kupermine,G.P.(1997)Developmentalapproachesto

understandingadolescentdeviance.pp548-567in:Luthar,S.S.&Burack,J.A.

(Eds)(1997)DevelopmentalPsychopathology:PerspectivesonAdjustment,Risk

andDisorder.

NewYork:CambridgeUniversityPress.

Anda,R.F.,Felitti,V.J.,Bremner,J.D.,Walker,J.D.,Whitfield,C.,Perry,B.D.,

Dube,S.R.&Giles,W.H.(2006)Theenduringeffectsofabuseandrelated

adverseexperiencesinchildhood:Aconvergenceofevidencefromneurobiology

andepidemiology.

EuropeanArchivesofPsychiatryandClinicalNeuroscience,256,(3),174-186.

Arseneault,L.,Moffitt,T.E.,Caspi,A.,Taylor,P.J.&Silva,P.A.(2000)Mental

disordersandviolenceinatotalbirthcohort.

Arch.Gen.Psychiatry,57,979-986.

.

84

(Downloadedfromhttp://archpsyc.jamanetwork.com/)

Bakermans-Kranenburg,M.J.,vanIjzendoorn,M.H.&andJuffer,F.(2005)

Disorganizedinfantattachmentandpreventativeinterventions:Areviewand

meta-analysis.

InfantMentalHealthJournal,Vol.26,(3),191-216.

Balbernie,R.(2017)Circuitsandcircumstances:importanceofearliest

relationshipsandtheircontext.pp.19-27in:Leach,P.(Ed.)TransformingInfant

Wellbeing.(2017)London:Routledge.

Balbernie,R.(2002)Aninfantincontext:Multiplerisksandarelationship.

InfantMentalHealthJournal,23,(3),329-341.

Balbernie,R.(2007)Themovetointersubjectivity:aclinicalandconceptualshift

ofperspective.

JournalofChildPsychotherapy,33,(3),308-324.

Balint,M.(1968)TheBasicFault.

London:TavistockPublications.

Baradon,T.,Broughton,C.,Gibbs,I.,James,J.,Joyce,A.&Woodhead,J.(2005)The

PracticeofPsychoanalyticParentInfantPsychotherapy:ClaimingtheBaby.

London:Routledge.

Baradon,T.,Fonagy,P.,Bland,K.,Lenard,K.&Sleed,M.(2008)NewBeginnings–

anexperiencebasedprogrammeaddressingtheattachmentrelationships

betweenmothersandtheirbabiesinprisons.

JournalofChildPsychotherapy.34,(2),240-258.

Barlow,J.,Davis,H.,McIntosh,E.,Jarrett,P.,Mockford,C.&Stewart-Brown,S.

(2007)Roleofhomevisitinginimprovingparentingandhealthinfamiliesatrisk

.

85

ofabuseandneglect:resultsofamulticentrerandomisedcontroltrialand

economicevaluation.

ArchivesofDiseaseinChildhood,92,229-233.

Barlow,J.,McMillan,A.S.,Kirkpatrick,S.,Ghate,D.,Barnes,J.&Smith.M.(2010)

health-ledinterventionsintheearlyyearstoenhanceinfantandmaternal

mentalhealth:Areviewofreviews.

ChildandAdolescentMentalHealth,15(4),178-185.

Barnard,K.E.(1998)Developing,implementing,anddocumentinginterventions

withparentsandyoungchildren.

ZerotoThree,18,(4),23-29.

Barnett,W.S.(2000)Economicsofearlychildhoodintervention.pp589-610in:

Shonkoff,J.P.&Meisals,S.J.(Eds)(2000)HandbookofEarlyChildhood

Intervention.

Cambridge:CambridgeUniversityPress.

Barrows,P.(2000)Makingthecasefordedicatedinfantmentalhealthservices.

PsychoanalyticPsychotherapy,14,(2),111-128.

Beebe,B.(2003)Briefmother-infanttreatment:psychoanalyticallyinformed

videofeedback.

InfantMentalHealthJournal,Vol.24,(1),24-52.

Belsky,J&deHaan,M(2011)Annualresearchreview:Parentingandchildren’s

braindevelopment:theendofthebeginning.

JournalofChildPsychologyandPsychiatry,52(4),409-428.

Benoit,D.,Madigan,S.,Lecce,S.,Shea,B.,&Goldberg,S.(2001)Atypicalmaternal

behaviourtowardfeeding-disorderedinfantsbeforeandafterintervention.

InfantMentalHealthJournal,22,(6),611-626.

.

86

Berlin,L.J.,O’Neil,C.R.,&Brooks-Gunn,J.(1998)Whatmakesearlyintervention

programswork?Theprogram,itsparticipants,andtheirinteraction.

ZerotoThree,18,(4),4-15.

Berlin,L.J.,Shanahan,M.&Carmody,K.A.(2014)promotingsupportive

parentinginnewmotherswithsubstance-useproblems:apilottrialof

residentialtreatmentplusanattachment-basedparentingprogram.

InfantMentalHealthJournal,35,(1),81-85.

Berlin,L.J.,Zeanah,C.H.&Lieberman,A.F.(2008)Preventionandintervention

programsforsupportingearlyattachmentsecurity.pp.745-761in:Cassidy,J.&

Shaver,P.(Eds)(2008)HandbookofAttachment.

TheGuilfordPress:NewYork.

Bernard,K.,Dozier,M.,Biuck,J.,Lewis-Morrarty,E.,Lindhiem,O.&Carlson,E.

(2012)Enhancingattachmentorganizationamongmaltreatedchildren:Results

ofarandomizedclinicaltrial.

ChildDevelopment,83,(2),623-636.

Bernier,A.,Carlson,S.,Deschenes,M.&matte-Gagne,C.(2010)Socialfactorsin

thedevelopmentofearlyexecutivefunctioning:Acloserlookatthecaregiving

environment.

DevelopmentalScience,15,(1),12-24.

Bertacci,J.(1996)Relationship-basedorganizations.

ZerotoThree,17(2),1-7.

Birtwell,B.,Hammond,L.&Puckering,C.(2013)‘Meandmybump’:An

interpretativephenomenologicalanalysisoftheexperiencesofpregnancyfor

vulnerablewomen.

ClinicalChildPsychologyandPsychiatry,publishedonline23October,2013.

.

87

vandenBoom,D.(1995)Dofirst-yearinterventioneffectsendure?Follow-up

studyduringtoddlerhoodofasampleofDutchirritableinfants.

ChildDevelopment,66,1789-1816.

Bertacchi,J.(1996)Relationship-basedorganizations.

ZerotoThree,17(2),1-7.

Birtwell,B.&Puckering,C.(2013)‘MeandmyBump’:Aninterpretative

phenomenologicalanalysisoftheexperiencesofpregnancyforvulnerable

women.

ClinicalChildPsychologyandPsychiatry,publishedonline23October,2013.

Brazelton,T.B.&Cramer,B.G.(1991)TheEarliestRelationship.

London:KarnacBooks.

Briggs-Gowan,M.J.,Carter,A.S.,Clark,R.,Augustyn,M.,McCarthy,K.J.&Ford,J.

D.(2010)Exposuretopotentiallytraumaticeventsinearlychildhood:

differentiallinkstoemergentpsychopathology.

JournalofChildPsychologyandPsychiatry,51(10)1132-1140.

Brooks-Gunn,J.,Leventhal,T.,&Duncan,G.J.(2000)Whypovertymattersfor

youngchildren:Implicationsforpolicy.pp89-131in:Osofsky,J.D.&Fitzgerald,

H.E.(Eds)(2000)WAIMHHandbookofInfantMentalHealth.Vol.3:Parenting

andChildCare.

NewYork:JohnWiley&Sons.

Browne,C.H.(2014)NationalQualityImprovementCenteronEarlychildhood.

ZerotoThree,(35),1,2-9.

Buchan,L.(2010)Intheirnurture.

Nature,467,(9),146-148.

.

88

(Cataudella,S.,Lampis,J.,Busonera,A.,Marino,L.&Zavattini,G.C.(2016)From

parent-fetalattachmenttoparent-infantrelationship:asystematicreviewabout

prenatalprotectiveandriskfactors.

LifeSpanandDisabilityXIX,2,185-219.)

Caldwell,R.A.(1992).Thecostofchildabusevs.thecostofprevention:

Michigan'sexperience.https://www.msu.edu/user/bob/cost.html

Campbell,F.A.,&Ramey,C.T.(1994)Effectsofearlyinterventiononintellectual

andacademicachievement:Afollow-upstudyofchildrenfromlow-income

families.

ChildDevelopment,65,684-698.

Campbell,F.A.,&Ramey,C.T.(1995)Cognitiveandhigh-schooloutcomesfor

high-riskAfrican-Americanstudentsatmiddleadolescence:Positiveeffectsof

earlyintervention.

AmericanEducationalResearchJournal,32,(4),743-772.

Carlson,E.A.(1998)Aprospectivelongitudinalstudyofattachment

disorganization/disorientation.

ChildDevelopment,69,1107-1129.

Cassiba,R.,Castoro,G.,Constantino,E.,Sette,G.&VanIjzendoorn,M.(2015)

Enhancingmaternalsensitivityandinfantattachmentsecuritywithvideo

feedback:AnexploratorystudyinItaly.

InfantMentalHealthJournal,36,(1),53-61.

Cassidy,J.(1988)Childmotherattachmentandtheselfinsixyearolds.

ChildDevelopment,59,124-134.

Cassidy,J.,Woodhouse,S.S.,Sherman,L.J.,Stupica,B&Lejuez,C.W.(2011)

Enhancinginfantattachmentsecurity:Anexaminationoftreatmentefficacyand

differentialsusceptibility.

.

89

DevelopmentandPsychopathology,23:132-148.

Celebi,M.(2014)BabyWatching:Facilitatingparent-infantinteractiongroups.

JournalofHealthVisiting,2,(7),362-367.

Cicchetti,D.,Rogosch,F.A.&Toth,S.L.(2000)Theefficacyoftoddler-parent

psychotherapyforfosteringcognitivedevelopmentinoffspringofdepressed

mothers.

JournalofAbnormalChildPsychology,28,135-148.

Cicchetti,D.,Rogosch,F.A.&Toth,S.L.(2006)Fosteringsecureattachmentin

infantsinmaltreatingfamiliesthroughpreventativeintervention.

DevelopmentalPsychopathology,18,623-649.

Cicchetti,D.,Toth,S.L.,&Rogosch,F.A.(1999)Theefficacyoftoddler-parent

psychotherapytoincreaseattachmentsecurityinoffspringofdepressed

mothers.

Attachment&HumanDevelopment,1,(1),34-66.

Cohen,N.J.,Muir,E.,Parker,C.J.,Brown,M.,Lojkasek,M.,Muir,R.,&Barwick,M.

(1999)Watch,WaitandWonder:Testingtheeffectivenessofanewapproachto

mother-infantpsychotherapy.

InfantMentalHealthJournal,20,(4),429-451.

Comfort,M.,Gordon,P.R.,English,B.,Hacker,K.,Hembree,R.,Knight,C.R.&

Miller,C.K.(2010)TheKeystoInteractiveParentingScale:KIPSShowsHow

ParentsGrow.

ZerotoThree,30,(4),33-39.

Conti,G.,Heckman,J.J.&Pinto,R.(2015)Theeffectsoftwoinfluentialearly

childhoodinterventionsonhealthandhealthybehaviors.

NationalBureauofEconomicResearchWorkingPaperNo.21454,August2015.

.

90

Cooper,G.,Hoffman,K.,Powell,B.&Marvin,R.(2005)Thecircleofsecurity

intervention:Differentialdiagnosisanddifferentialtreatment.pp.127-151in:

Berlin,L.J.,Ziv,Y.,Amaya-Jackson,L.&Greenberg,M.T.(Eds)(2005)Enhancing

EarlyAttachments.

NewYork:TheGuilfordPress.

Crugnola,C.R.,Lierdi,E.,Albizzati,A.&Downing,G.(2016)Effectivenessofan

attachment-basedinterventionprograminpromotingemotionregulationand

attachmentinadolescentmothersandtheirinfants:Apilotstudy.

FrontiersinPsychology,February,7,article195.

Downloadedon05/05/2015from:

http://journal.frontiersin.org/article/10.3389/fpsyg.2016.00195/full

Culp,A.M.,Culp,R.E.,Blankemeyer,M.&Passmark,L.(1998)Parenteducation

homevisitationprogram:adolescentandnonadolescentmothercomparison

aftersixmonthsofintervention.

InfantMentalHealthJournal,19,(2),111-123.

Culp,A.M.,Culp,R.E.,Hechtner-Galvin,T.,Howell,C.S.,Saathoff-Wells,T.&Marr,

P.(2004)First-timemothersinhomevisitationservicesutilizingchild

developmentspecialists.

InfantMentalHealthJournal,25,(1),1-15.

Cummings,E.M.,&Davies,P.T.(1994)Maternaldepressionandchild

development.

JournalofChildPsychologyandPsychiatry,35,(1),73-112.

Daly,M.&Wilson,M.(1998)TheTruthAboutCinderella:ADarwinianViewof

ParentalLove.

London:Weidenfield&Nicolson.

.

91

Davis,H.(2009)TheFamilyPartnershipModel.)pp63-76in:Barlow,J.&

Svanberg,P.O.(Eds.)(2009)KeepingTheBabyInMind:InfantMentalHealthin

Practice.

London:Routledge.

Davis,H.,Day,C.&Bidmead,C.(2002)TheParentAdviserTrainingManual.

London:HarcourtAssessment.

Deacon,T.(1997)TheSymbolicSpecies.

London:PenguinBooks.

Debbane,M.,Salaminios,G.,Luyten,P.,Badoud,D.,Armando,M.,Tozzi,A.S.,Fonagy,P.&

Brent,B.K.(2016)Attachment,neurobiology,andmentalizingalongthepsychosis

continuum.

FrontiersinHumanNeuroscience.Vol.10,article406,1-22.

Donald,M.(2001)AMindSoRare.

NewYork:W.W.Norton&Co.

Douglas,H.&Ginty,M.(2001)TheSolihullApproach:changesinhealthvisiting

practice.

CommunityPractitioner,74,(6),222-224.

Douglas,H.&Rheeston,M.(2009)TheSolihullApproach:Anintegrativemodel

acrossagencies.pp29-38in:Barlow,J.&Svanberg,P.O.(Eds.)(2009)Keeping

TheBabyInMind:InfantMentalHealthinPractice.

London:Routledge.

Dozier,M.,Peleso,E.,Lewis,E.,Laurenceau,J.P.&Levine,S.(2008)Effectsfan

attachment-basedinterventiononthecortisolproductionofinfantsandtoddlers

infostercare.

DevelopmentandPsychopathology,20,845-859.

.

92

Dozier,M.,Stovell,K.C.&Jacobvitz,D.(1999)Attachmentandpsychopathology

inadulthood.pp.497-519in:Cassidy,J.&Shaver,P.R.(Eds)(1999)Handbookof

Attachment.

NewYork:TheGuilfordPress.

Dozier,M.,Stovell-McClough,K.C.,&Albus,K.E.(2008)Attachmentand

psychopathologyinadulthood.pp.718-744in:Cassidy,J.&Shaver,P.R.(Eds)

(2008)HandbookofAttachment.

NewYork:TheGuilfordpress.

Eckenrode,J.,Ganzel,B.,Henderson,C.R.,Smith,E.,Olds,D.L.,Powers,J.,Cole,R.,

&Sidora,K.(2000)Preventingchildabuseandneglectwithaprogramofnurse

homevisitation.

JournaloftheAmericanMedicalAssociation,284,(11),1385-1391.

Eckenrode,J.,Campa,M.,Luckey,D.W.,Henderson,C.R.,Cole,R.,Kitzman,H,

Anson,E.,Sidora-Arcoleo,K.,Powers,J.&Olds,D.(2010)Long-termeffectsof

prenatalandinfancyhomevisitationonthelifecourseofyouths:nineteen-year

followupofarandomisedtrial.

ArchivesofPediatricandAdolescentMedicine,164,(5),9-15.

Ellis,B.J.,Boyce,W.T.,Belsky,J.,Bakermans-Kranenburg,J.&VanIjzendoorn,M.

H.(2011)Differentialsusceptibilitytotheenvironment:Anevolutionary-

neurodevelopmentaltheory.

DevelopmentalPsychopathology,23,7-28.

Emde,R.N.(2001)InfantmentalhealthchallengesforEarlyHeadStart:

Understandingcontextandovercomingavoidance.

ZerotoThree,22,(1),21-24.

Ensink,K.,Normandin,L.,Plamondon,A.,Berthelot,N.&Fonagy,P.

Intergenerationalpathwaysfromreflectivefunctioningtoinfantattachment

throughparenting.

.

93

CanadianJournalofBehavioralScience,48,(1),9-18.

Farren,D.C.(2000)Anotherdecadeofinterventionforchildrenwhoarelow

incomeordisabled:Whatdoweknownow?pp.510-548in:Shonkoff,J.P.&

Meisals,S.J.(Eds)(2000)HandbookofEarlyChildhoodIntervention.

Cambridge:CambridgeUniversityPress.

Felitti,V.J.(2010)Forewardfor:Lanius,R.A.,Vermetten,E.&Pain,C.(2010)The

ImpactofEarlyLifeTraumasonHealthandDisease.

Cambridge:CambridgeUniversityPress.

Felitti,V.S.,Anda,R.F.,Nordenburg,D.,Williamson,D.F.,Spitz,A.M.,Edwards,

V.,KossM.P.,&Marks,J.S.(1998)Relationshipofchildhoodabuseand

householddysfunctiontomanyoftheleadingcausesofdeathinadults.

AmericanJournalofPreventiveMedicine,14,(4),245-247.

Fitzgerald,H.E.,Puttler,L.I.,Mun,E.Y.,&Zucker,R.A.(2000)Prenataland

postnatalexposuretoparentalalcoholuseandabuse.pp.123-159in:Osofsky,J.

D.&Fitzgerald,H.E.(Eds)(2000)WAIMHHandbookofInfantMentalHealth.

Vol.4.InfantMentalHealthinGroupsatHighRisk.

NewYork:JohnWiley&Sons.

Fonagy,P.(1998)Prevention,theappropriatetargetofinfantpsychotherapy.

InfantMentalHealthJournal,19,(2),124-150.

Fonagy,P.,Sadie,C.&Allison,L.(2002)TheParent-Infantproject(PIP)outcome

study.

AnnaFreudCentre,London(unpublishedmanuscript).

Fonagy,P.,Sleed,M.&Baradon,T.(2016)Randomizedcontrolledtrialofparent-

infantpsychotherapyforparentswithmentalhealthproblemsandyoung

infants.

InfantMentalHealthJournal,37(2)97-114.

.

94

Fonagy,P.,Gergely,G.,Jurist,E.L.&Target,M.(2002)AffectRegulation,

Mentalization,andtheDevelopmentoftheSelf.

NewYork:OtherPress.

Fonagy,P.&Higgitt,A.(2000)Anattachmenttheoryperspectiveonearly

influencesondevelopmentandsocialinequalitiesinhealth.pp.521-578in:

Osofsky,J.D.&Fitzgerald,H.E.(Eds)(2000)WAIMHHandbookofInfantMental

Health,Vol.4:InfantMentalHealthinGroupsatHighRisk.

NewYork:JohnWiley&Sons.

Fonagy,P.,Steele,H.,Steele,M.,Moran,G.S.andHiggitt,A.C.(1991)TheCapacity

forUnderstandingMentalStates:TheReflectiveSelfinParentandChildandits

SignificanceforSecurityofAttachment.

InfantMentalHealthJournal,12,(3),201-218.

Fonagy,P.,Target,M.,Steele,M.,Steele,H.,Leigh,T.,Levinson,A.,&Kennedy,R.

(1997)Morality,disruptivebehaviour,borderlinepersonalitydisorder,crime,

andtheirrelationtosecurityofattachment.pp.223-274in:Atkinson,L.&

Zucker,K.J.(Eds)(1997)AttachmentandPsychopathology.

NewYork:TheGuilfordPress.

Fonagy,P.,Steele,M.,Steele,H.,Leigh,T.,Kennedy,R.,Mattoon,G.,&Target,M.

(1995)Attachment,thereflectiveself,andborderlinestates.pp.233-278in:

Goldberg,S.,Muir,R.,&Kerr,J.(Eds)(1995)AttachmentTheory:Social,

Developmental,andClinicalPerspectives.

Hillsdale,N.J.:TheAnalyticPress.

Fox,S.E.,Levitt,P.&Nelson,C.A.(2010)Howthetimingandqualityofearly

experiencesinfluencesthedevelopmentofbrainarchitecture.

ChildDevelopment,8(1),28-40.

.

95

Free,F.,Alechina,I.,&Zahn-Waxler,C.(1996)Affectivelanguagebetween

depressedmothersandtheirchildren:Thepotentialimpactofpsychotherapy.

JournaloftheAmericanAcademyofChild&AdolescentPsychiatry,35,(6),783-

790.

Friedli,L.&Parsonage,M.(2007)Buildinganeconomiccaseformentalhealth

promotion:part1.

JournalofPublicHealth,6,(3),14-23.

Gauthier,Y.,Fortin,G.&Jeliu,G.(2004)Clinicalapplicationofattachmenttheory

inpermanencyplanningforchildreninfostercare:Theimportanceofcontinuity

ofcare.

InfantMentalHealthJournal,25,(4),379-396.

Gerhardt,S.(2015)WhyLoveMatters.

London:Routledge.

Glaser,D.(2000)Childabuseandneglectandthebrain–areview.

JournalofChildPsychologyandPsychiatry,41,(1),97-116.

Goldberg,S.(2000)AttachmentandDevelopment.

London:Arnold.

Gopnik,A.(2016)TheGardenerandtheCarpenter.

London:TheBodleyHead.

Green,J.,Stanley,C.andPeters,S.(2007)Disorganizedattachment

representationsandatypicalparentinginyoungschoolagechildrenwith

externalisingdisorder.

Attachment&HumanDevelopment,9,(3),207-222.

Greenberg,M.T.,DeKlyer,M.,Speltz,M.L.&Endriga,M.C.(1997)Theroleof

attachmentprocessesinexternalizingpsychopathologyinyoungchildren.pp.

.

96

196-222in:Atkinson,L.&Zucker,K.J.(Eds)(1997)Attachmentand

Psychopathology.

NewYork:TheGuilfordPress.

Grienenberger,J.,Kelly,K.,andSlade,A.(2005)Maternalreflectivefunctioning,

mother-infantaffectivecommunication,andinfantattachment:Exploringthe

linkbetweenmentalstatesandobservedcaregivingbehaviourinthe

intergenerationaltransmissionofattachment.

Attachment&HumanDevelopment,7,(3),299-311.

Grossmann,K.E.,Grossmann,K.,&Zimmermann,P.(1999)Awiderviewof

attachmentandexploration:Stabilityandchangeduringtheyearsofimmaturity.

pp.760-786in:Cassidy,J.&Shaver,P.R.(Eds)(1999)HandbookofAttachment:

Theory,Research,andClinicalApplications.

NewYork:TheGuilfordPress.

Halpern,R.(1993)Povertyininfantdevelopment.pp.73-86in:Zeanah,C.H.

(Ed)(1993)HandbookofInfantMentalHealth.

NewYork:TheGuilfordPress.

Harris,W.M.,Lieberman,A.F.,&Marans,S.(2007)Inthebestinterestsof

society.JournalofChildPsychologyandPsychiatry,48,3/4,392-411.

Hart,S.(2008)Brain,Attachment,Personality:AnIntroductiontoNeuroaffective

Development.

London:KarnacBooksLtd.

Heinicke,C.M.,Fineman,N.R.,Ruth,G.,Recchia,S.L.,Guthrie,D.,&Rodning,C.

(1999)Relationship-basedinterventionwithat-riskmothers:Outcomeinthe

firstyearoflife.

InfantMentalHealthJournal,20,(4),349-374.

.

97

Heinicke,C.M.,Fineman,N.R.,Ponce,V.A.,&Guthrie,D.(2001)Relationship-

basedinterventionwithat-riskmothers:Outcomeinthesecondyearoflife.

InfantMentalHealthJournal,22,(4),431-462.

Hoffman,K.T.,Marvin,R.S.,Cooper,G.&Powell,B.(2006)Changingtoddlers’

andpreschoolers’attachmentclassifications:TheCircleofSecurityintervention.

JournalofConsultingandClinicalPsychology,74,1017-1026.

Huber,H.,McMahon,C.&Sweller,N.(2015a)Improvedchildbehaviouraland

emotionalfunctioningafterCircleofSecurity20-weekintervention.

AttachmentandHumanDevelopment,17,(6),547-569.

Huber,H.,McMahon,C.&Sweller,N.(2015b)Efficacyofthe20-weekCircleof

Securityintervention:Changesincaregiverreflectivefunctioning,

representations,andchildattachmentinanAustralianclinicalsample.

Infant Mental Health Journal, 36, (6), 556-574.

Hughes,M. & Cossar, J. (2016) The relationship between maternal childhood

emotional abuse/neglect and parenting outcomes: A systematic review.

Child Abuse Review, 25, 31-45.

Jacobsen,T.,Edelstein,W.,&Hofmann,V.(1994)Alongitudinalstudyofthe

relationbetweenrepresentationsofattachmentinchildhoodandcognitive

functioninginchildhoodandadolescence.

DevelopmentalPsychology,30,112-124.

Juffer,F.,Bakermans-Kranenburg,M.J.&vanIJzendoorn,M.H.(Eds)(2007)

PromotingPositiveParenting:AnAttachment-BasedIntervention.

London:LawrenceErlbaumAssociates.

Kalinauskiene,L.,Cekuoliene,D.,VanIJzendoorn,M.H.,Bakermans-Kranenburg,

M.J.,Juffer,F.,&Kusakovskaja,I.(2009)Supportinginsensitivemothers:the

.

98

Vilniusrandomizedcontroltrialofvideo-feedbackinterventiontopromote

maternalsensitivityandinfantattachmentsecurity.

Child:Care,HealthandDevelopment,35,(5),613-623.

Karen,R.(1994)BecomingAttached:FirstRelationshipsandHowTheyShape

OurCapacitytoLove.

Oxford:OxfordUniversityPress.

Karlsson,K.&Skagerberg,A.(1999)Experiencefromthefloorofattachmentand

relationshipbuilding.

TheSignal,7,(2),1-7.

Karoly,L.A.etal(1998)Investinginourchildren:Whatweknowanddon'tknow

aboutthecostsandbenefitsofearlychildhoodinterventions.

SantaMonica,CA,RandCorporation.

Karr-Morse,R.&Wiley,M.S.(1997)GhostsFromtheNursery:TracingtheRoots

ofViolence.

NewYork:TheAtlanticMonthlyPress.

Karr-Morse,R.&Wiley,M.S.(2012)ScaredSick:TheRoleofChildhoodTrauma

inAdultDisease.

NewYork:BasicBooks.

Kerstan-Alvarez,L.E.,Hosman,C.M.H.,Riksen-Walraven,J.M.,VanDoesum,K.

T.M.&Hoefnagels,C.(2011)Whichpreventativeinterventionseffectively

enhancedepressedmothers’sensitivity?Ameta-analysis.

InfantMentalHealthJournal,32,(3),362-376.

Knoche,L.L.,Sheridan,S.M.,Clarke,B.L.,Edwards,C.P.,Marvin,C.A.,Cline,K.D.

&Kupzyk,K.A.(2012)gettingready:resultsofarandomisedtrialofa

relationship-focusedinterventionontheparent-infantrelationshipinruralEarly

headStart.

.

99

InfantMentalHealthJournal,33,(5),439-458.

Kobak,R.,Little,M.,Race,E.,&Acosta,M.C.(2001)Attachmentdisruptionsin

seriouslyemotionallydisturbedchildren:Implicationsfortreatment.

Attachment&HumanDevelopment,3,(2),243-258.

Landy,S.(2000)Assessingtherisksandstrengthsofinfantsandfamiliesin

community-basedprograms.pp335-375in:Osofsky,J.D.&Fitzgerald,H.E.

(Eds)(2000)WAIMHHandbookofInfantMentalHealth.Vol.2:Early

Intervention,Evaluation,andAssessment.

NewYork:JohnWiley&Sons.

Larrieu,J.A.andZeanah,C.H.(2004)Treatingparent-infantrelationshipsinthe

contextofmaltreatment:Anintegratedsystemsapproach.pp.243-264in:

Sameroff,A.J.,McDonough,S.C.&Rosenblum,K.L.(Eds)(2004)Treating

Parent-InfantRelationshipProblems:StrategiesforIntervention.

NewYork:TheGuilfordPress.

Letourneau,N.,Tryphonopoulos,P.,Giesbrecht,G.,Dennis,C.L.,Bhogal,S.&

Watson,B.(2015)Narrativeandmeta-analyticreviewofinterventionsaimingto

improvematernal-childattachment.

InfantMentalHealthJournal,36(4)366-387.

Lieberman,A.F.,Diaz,M.A.&VanHorn,P(2009)Saferbeginnings:Perinatal

child-parentpsychotherapyfornewbornsandmothersexposedtodomestic

violence.

ZerotoThree,29,(5),17-22.

Lieberman,A.F.,Ippen,C.G.&VanHorn,P.(2006)Child-parentpsychotherapy:

6-monthfollow-upofarandomisedcontrolledtrial.

JournaloftheAmericanAcademyofChildandAdolescentPsychiatry,45,(8),

913-918.

.

100

Lieberman,A.F.&Pawl,J.H.(1993)Infant-parentpsychotherapy.pp427-442in:

Zeanah,C.H.(Ed)(1993)HandbookofInfantMentalHealth.

NewYork:TheGuilfordPress.

Lieberman,A.F.,VanHorn,P.&Ippen,C.G.(2005)Towardsevidence-based

treatment:Child-parentpsychotherapywithpreschoolersexposedtomarital

violence.

JournaloftheAmericanAcademyofChildandAdolescentPsychiatry,44,(12),

1241-1248)

Lieberman,A.F.&VanHorn,P.(2008)PsychotherapyWithInfantsandYoung

Children.

NewYork:TheGuildfordPress.

Lieberman,A.F.,Ippen,C.G.&VanHorn,P.(2015)Don’tHitMyMommy:A

ManualforChild-ParentpsychotherapyWithYoungChildrenExposedto

ViolenceandOtherTrauma.

WashingtonD.D.:ZerotoThree.

Lieberman,A.,Weston,D.&Pawl,J.(1991)Preventiveinterventionandoutcome

inanxiouslyattacheddyads.

ChildDevelopment,62,199-209.

Liotti,G.(1999)Disorganizationofattachmentasamodelforunderstanding

dissociativepsychopathology.pp291-317in:Solomon,J.&George,C.(Eds)

(1999)AttachmentDisorganization.

NewYork:TheGuilfordPress.

Lock,M.(2013)Theartofmedicine:Thelureoftheepigenome.

TheLancet,381,1896-1897.

Luby,J.,etal.(2013)Theeffectsofpovertyonchildhoodbraindevelopment:The

Mediatingeffectofcaregivingandstressfullifeevents.

.

101

JamaPediatrics.PublishedonlineOctober28,2013.Downloadedfrom

http://archpedi.jamanetwork.com

Lyons-Ruth,K.(2008)Contributionsofthemother-infantrelationshipto

dissociative,borderline,andconductsymptomsinyoungadulthood.

InfantMentalHealthJournal,29,(3),203-218.

Lyons-Ruth,K.&Jacobvitz,D.(1999)Attachmentdisorganization:Unresolved

loss,relationalviolence,andlapsesinbehaviouralandattentionalstrategies.pp

520-554in:Cassidy,J.&Shaver,P.R.(Eds)(1999)HandbookofAttachment:

Theory,Research,andClinicalApplications.

NewYork:TheGuilfordPress.

Lyons-Ruth,K.&Jacobvitz,D.(2008)Attachmentdisorganization:Genetic

factors,parentingcontexts,anddevelopmentaltransformationfrominfancyto

adulthood.pp.666-697in:Cassidy,J.&Shaver,P.R.(Eds)(2008)Handbookof

Attachment:Theory,Research,andClinicalApplications.2ndEdition.

NewYork:TheGuilfordPress.

MacLeod,J.&Nelson,C.(2000)Programsforthepromotionoffamilywellness

andthepreventionofchildmaltreatment:Ameta-analyticreview.

ChildAbuseandNeglect,24,(9),1127-1149.

Madigan,S.,Hawkins,E.,Goldberg,S.&Benoit,D.(2006)Reductionofdisrupted

caregiverbehaviourusingmodifiedinteractionguidance.

InfantMentalHealthJournal,27,(5),509-527.

Mayers,H.A.,Hagar-Budny,M.andBuckner,E.B.(2008)TheChancesfor

Childrenteenparent-infantproject:resultsofapilotinterventionforteen

mothersandtheirinfantsininnercityhigh-schools.

InfantMentalHealthJournal,29,(4),320-342,

McCrone,Dhanasiri,Patel,Knapp,Lawton-Smith.(2008)PayingThePrice.

.

102

London:King’sFund.

McCrory,E.J.,DeBrito,S,&Viding,E.(2010)Researchreview:Theneurobiology

andgeneticsofmaltreatmentandadversity.

TheJournalofChildPsychologyandPsychiatry,51(10),1079-1095.

McCrory,E.J.,DeBrito,S,A.,Sebastian,C.L.,Mechelli,A.,Bird,G,Kelly,P.A.&

Viding,E.(2011)Heightenedneuralreactivitytothreatinchildvictimsoffamily

violence.

CurrentBiology,21(23)947-948.

McDonough,S.(1993)Interactionguidance:Understandingandtreatingearly

infant-caregiverrelationshipdisturbances.pp.414-426in:Zeanah,C.H.(Ed)

(1993)HandbookofInfantMentalHealth.

NewYork:TheGuilfordPress.

McDonough,S.(2004)Interactionguidance:promotingandnurturingthe

caregivingrelationship.pp.79-96in:Sameroff,A.J.,McDonough,S.C.&

Rosenblum,K.L.(Eds)(2004)TreatingParent–InfantRelationshipProblems:

StrategiesforIntervention.

NewYork:TheGuilfordPress.

Meaney,M.J.(2013)EpigeneticsandtheEnvironmentalRegulationofthe

GenomeanditsFunction.pp.99-128in:Narvaez,D.,Panksepp,J.,Schore,A.N.&

Gleason,T.R.(Eds)(2013)Evolution,EarlyExperienceandHuman

Development.

Oxford:OxfordUniversityPress.

Melhuish,E.,Belsky,J.&Barnes,J.(2010)EvaluationandvalueofSureStart.

ArchivesofDiseaseinChildhood,95,159-161.(availablefromadc.bmj.com)

Milford,R.,Kleve,l.,Lea,J.andGreenwood,R.(2006)APilotEvaluationofthe

SolihullApproach.

.

103

CommunityPractitioner,79,(11),358-362.

Milton,J.(1671)ParadiseRegained.pp.443-504in:Everyman’sLibrary(1992)

TheCompleteEnglishPoems.

DavidCampbellPublishersLtd.:London.

Moffitt,T.E.,Arseneault,L.,Belsky,D.,Dickson,N.,Hancox,R.J.,Harrington,H.,

Houts,R.,Poulton,R.,Roberts,B.W.,Ross,S.,Sears,M.R.,Thomson,W.M.&

Caspi,A.(2011)Agradientofchildhoodself-controlpredictshealth,wealth,and

publicsafety.

ProceedingsoftheNationalAcadamyofScience,108,(7),2693-2698.

Mortensen,J.A.&Mastergeorge,A.M.(2014)Ameta-analyticreviewof

relationship-basedinterventionsforlow-incomefamilieswithinfantsand

toddlers:facilitatingsupportiveparent-childinteractions.

InfantMentalHealthJournal,35(4),336-353.

Moss,E.,Rousseau,D.,Parent,S.,St-Laurent,D.,&Saintonge,J.(1998)Correlates

ofattachmentatschoolage:Maternalreportedstress,mother-childinteraction

andbehaviourproblems.

ChildDevelopment,69,1390-1405.

Moss,E.,St-Laurent,D.,&Parent,S.(1999)Disorganizedattachmentand

developmentalriskatschoolage.pp.160-186in:Solomon,J.&George,C.(Eds)

(1999)AttachmentDisorganization.

NewYork:TheGuilfordPress.

Moss,E.,Dubois-Comtois,K.,Cyr,C.,Tarabulsy,G.M.,St-Laurent,D.&Bernier,A.

(2011)Efficacyofahome-visitinginterventionaimedatimprovingmaternal

sensitivity,childattachment,andbehaviouraloutcomesformaltreatedchildren:

Arandomisedcontroltrial.

DevelopmentandPsychopathology,23,195-210.

.

104

Moss,E.,Tarabulsy,G.M.,St-Georges,R.,Dubois-Comtois,K.,Cyr,C.,Bernier,A.,

St-Laurent,D.,Pascuzzo,K.&Lecompte,V.(2014)Video-feedbackintervention

withmaltreatingparentsandtheirchildren:programimplementationandcase

study.

Attachment&HumanDevelopment,16,(4),329-342.

Motz,M.,Leslie,M.&DeMarchi,G.(2007)BreakingtheCycle:UsingaRelational

ApproachtoAddresstheImpactofMaternalSubstanceAbuseonRegulationand

AttachmentinChildren.

ZerotoThree,27,(4),19-25.

Moutsiana,C.,Fearon,P.,Murray,L.,Cooper,P.,Goodyer,I.,Johnstone,T.&

Haligan,S.(2014)Makinganefforttofeelpositive:insecureattachmentin

infancypredictstheneuralunderpinningsofemotionalregulationinadulthood.

TheJournalofChildPsychologyandPsychiatry,publishedonline,8Jan2014.

http://onlinelibrary.wiley.com/store/10.1111/jcpp.12198/asset/jcpp12198.pdf

?v=1&t=i4pj35z7&s=3b069ad0c5e857302688096bb38a2e6f270db3d8

Murray,L.(1997)Postpartumdepressionandchilddevelopment.

PsychologicalMedicine,27,253-260.

Murray,L.,Sinclair,D.,Cooper,P.,Ducournau,P.,&Turner,P.(1999)The

socioemotionaldevelopmentof5-yearoldchildrenofpostnatallydepressed

mothers.

JournalofChildPsychologyandPsychiatry,40,(8),1259-1271.

Negrao,M.,Pereira,M.,Soares,I.&Mesman,J.(2014)Enhancingpositiveparent-

childinteractionsandfamilyfunctioninginapovertysample:arandomised

controltrial.

Attachment&HumanDevelopment,16,(4),315-328.

NewEconomicsFoundation.(2009)BackingtheFuture.

.

105

Downloaded03/05/2010from:

http://www.neweconomics.org/publications/backing-future

Newland,L.A.(2015)Familywell-being,parenting,andchildwell-being:

pathwaystohealthyadjustment.

ClinicalPsychologist,19,3-14.

Newman,L.&Stevenson,C.(2008)Issuesininfant-parentpsychotherapyfor

motherswithborderlinepersonalitydisorder.

ClinicalChildPsychologyandPsychiatry,13,(4),505-514.

Nievar,M.A.,VanEgeren,L.A.&Pollard,S.(2010)Ameta-analysisofhome-

visitingprograms:Moderatorsofimprovementinmaternalbehavior.

InfantMentalHealthJournal,31(5),499-520.

Olds,D.L.(2006)Thenurse-familypartnership:anevidence-basedpreventive

intervention.

InfantMentalHealthJournal,Vol.27,(1),5-25.

Olds,D.L.,Eckenrode,J.J.,Henderson,C.R.,Kitzman,H.,Powers,J.,Cole,R.,

Sidora,P.,Morris,L.M.,Pettitt,L.M.,&Luckey,D.(1997)Long-termeffectsof

homevisitationonmaternallifecourseandchildabuseandneglect:Fiveteen

yearfollow-upofarandomizedtrial.

JournaloftheAmericanMedicalAssociation,278,(8),637-643.

Olds,D.L.,Henderson,C.R.,Kitzman,H.J.,Eckenrode,J.J.,Cole,R.E.,&

Tatelbaum,R.C.(1999)Prenatalandinfancyhomevisitationbynurses:Recent

findings.

TheFutureofChildren,9,(1),44-65.

Oppenheim,D.Goldsmith,D.&Koren-Karie,N.(2004)Maternalinsightfulness

andpreschoolers’emotionandbehaviourproblems:Reciprocalinfluencesina

therapeuticpreschoolprogram.

.

106

InfantMentalHealthJournal,25,(4),352-367.

Osofsky,J.D.,Kronenberg,M.,Hammer,J.H.,Lederman,C.,Katz,L.,Adams,S.,

Graham,M.&Hogan,A.(2007)Thedevelopmentandevaluationofthe

interventionmodelfortheFloridaInfantMentalHealthPilotProgram.

InfantMentalHealthJournal,28,(3),258-280.

Osofsky,J.D.&Thompson,M.D.(2000)Adaptiveandmaladaptiveparenting:

Perspectivesonriskandprotectivefactors.pp54-75in:Shonkoff,J.P.&Meisals,

S.J.(Eds)(2000)HandbookofEarlyChildhoodIntervention.

Cambridge:CambridgeUniversityPress.

Pagel,M.(2012)WiredforCulture.

London:PenguinGroup.

Panksepp,J.&Biven,L.(2012)TheArchaeologyofMind:Neuroevolutionary

OriginsofHumanEmotions.

NewYork:W.W.Norton&Company.

Pajulo,M.,Pyykkonen,N.,Kalland,M.,Sinkkonen,J.,Helenus,H.,Punamaki,R-L.&

Suchman,N.(2012)Substance-abusingmothersinaresidentialtreatmentwith

theirbabies:importanceofpre-andpost-natalmaternalreflectivefunctioning.

InfantMentalHealthJournal,33(1),70-81.

Paris,R.,Spielman,E.&Bolton,R.E.(2009)Mother-infantpsychotherapy:

Examiningthetherapeuticprocessofchange.

InfantMentalHealthJournal.30,(3),301-319.

Paris,R.,Bolton,R.E.&Spielman,E.(2011)Evaluatingahome-baseddyadic

intervention:Changesinpostpartumdepression,maternalperceptions,and

mother-infantinteractions.

InfantMentalHealthJournal.32,(3),319-338.

.

107

Pereira,M.,Negrao,M.,Soares.&Mesman,J.(2014)Decreasingharshdiscipline

inmothersatriskformaltreatment:Arandomisedcontroltrial.

InfantMentalHealthJournal,35,(6),604-613.

Perry,B.D.(2009)Examiningchildmaltreatmentthroughaneurodevelopmental

lens:Clinicalapplicationsoftheneurosequentialmodeloftherapeutics.

JournalofLossandTrauma,14,240-255.

Phillips,M.(2013)Mindingthebaby:Implementingtheprogramme.

InternationalJournalofBirth&ParentingEducation,1(1),36-37.

Powell,C.&Grantham-McGregor,S.(1998)Homevisitingofvaryingfrequency

andchilddevelopment.

Pediatrics,84,157-164.

Puckering,C.(2004)MellowParenting:Anintensiveinterventiontochange

relationships.

TheSignal,12,(1),1-5.

Puckering,C.(2009)MellowBabies:MellowParentingwithparentsofinfants.pp

155-163in:Barlow,J.&Svanberg,P.O.(Eds.)(2009)KeepingTheBabyInMind:

InfantMentalHealthinPractice.

London:Routledge.

Puckering,C.,McIntosh,E.,Hickey,A.&Longford,J.(2010)MellowBabies:A

groupinterventionforinfantsandmothersexperiencingpostnataldepression.

CounsellingPsychologyReview,25(1),28-40.

Raine,R.(2013)TheAnatomyofViolence.

London:AllenLane.

Ramey,C.T.,Bryant,D.M.,Wasik,B.H.,Sparling,J.J.,Fendt,K.H.,&LaVange,L.

M.(1992)Infanthealthanddevelopmentprogramforlowbirthweight,

.

108

prematureinfants:Programelements,familyparticipation,andchild

intelligence.

Pediatrics,89,454-465.

Ramsdal,G.,Bergvik,S.&Wynn,R.(2015)Parent-childattachment,academic

performanceandtheprocessofhigh-schooldropout:anarrativereview.

Attachment&HumanDevelopment,17,(5),522-545.

Read,J.,Fink,P.J.,Rudegeair,T.,Felitti,V.&Whitfield,C.L.(2008)Child

maltreatmentandpsychosis:Areturntoagenuinelyintegratedbio-socialmodel.

ClinicalSchizophrenia&RelatedPsychosis,2,(3),217-225.

Richardson,K.(2008)Howdynamicsystemshavechangedourminds.pp.25-40

in:Fogel,King&Shanker(Eds.)HumanDevelopmentintheTwenty-First

Century.

Cambridge:CambridgeUniversityPress.

Robert-Tissot,C.,Cramer,B.,Stern,D.S.,Serpa,S.R.,Bachmann,J.P.,Palacio-

Espasa,F.,Knauer,D.,DeMuralt,M.,Bernay,C.,&Mendiguren,G.(1996)

Outcomeevaluationinbriefmother-infantpsychotherapies:Reporton75cases.

InfantMentalHealthJournal.17,(2),97-114.

Roisman,G.I.,Collins,W.A.,Sroufe,L.A.,&Egeland,B.(2005)Predictorsof

youngadults’representationsofandbehaviourintheircurrentromantic

relationship:Prospectivetestsoftheprototypehypothesis.

Attachment&HumanDevelopment.7,(2),105-121.

Romens,S.E.,McDonald,J.,Svaren,J.&Pollak,S.D.(2014)Associationsbetween

earlylifestressandgenemethylationinchildren.

ChildDevelopment,publishedonline24July2014.

http://onlinelibrary.wiley.com/store/10.1111/cdev.12270/asset/cdev12270.pd

f?v=1&t=i4phu3ep&s=fbf2ba19a6f4c6eaa6c91cac718d2afea54f51e2

.

109

Rosenblum,K.L.,McDonough,S.C.,Sameroff,A.J.andMuzic,M.(2008)

Reflectioninthoughtandaction:Maternalparentingreflectivitypredictsmind-

mindedcommentsandinteractivebehavior.

InfantMentalHealthJournal,29,(4),362-376.

Rosenstein,D.S.&Horowitz,H.A.(1996)Adolescentattachmentand

psychopathology.

JournalofConsultingandClinicalPsychology,64,244-253.

Roth,T.L.&Sweatt,J.D.(2011)AnnualResearchreview:Epigeneticmechanisms

andenvironmentalshapingofthebrainduringsensitiveperiodsofdevelopment.

TheJournalofChildPsychologyandPsychiatry,52(4),398-408.

Rowe,A.(2009)Perinatalhomevisiting:ImplementingtheNurse-Family

PartnershipinEngland.pp114-127in:Barlow,J.&Svanberg,P.O.(Eds.)(2009)

KeepingTheBabyInMind:InfantMentalHealthinPractice.

London:Routledge.

Sabates,R.&Dex,S.(2012)Multipleriskfactorsinyoungchildren’s

development.

CLSCohortStudies.Workingpaper2012/1

Downloadedfromhttp://www.cls.ioe.ac.uk/

Sadler,L.S.,Slade,A.,Close,N.,Webb,D.L.,Simpson,T.,Fennie.,&Mayes,L.C.

(2013)Mindingthebaby:Enhancingreflectivenesstoimproveearlyhealthand

relationshipoutcomesinaninterdisciplinaryhome-visitingprogram.

InfantMentalHealthJournal,34(5),391-405.

Salomonsson,B.&Sandell,R.(2011)Arandomizescontrolledtrialofmother-

infantpsychoanalytictreatment:1.Outcomesonself-reportquestionnairesand

externalratings.

InfantMentalHealthJournal,32,(2),207-231.

.

110

Salomonsson,M.W.,Sorjonen,K.&Salomonsson,B.(2015a)Along-termfollow

upofarandomisedcontrolledtrialofmother-infantpsychoanalytictreatment:

Outcomesonthechildren.

InfantMentalHealthJournal,36,(1),12-29.

Salomonsson,M.W.,Sorjonen,K.&Salomonsson,B.(2015b)Along-termfollow-

upstudyofarandomizedcontrolledtrialofmother-infantpsychoanalytic

treatment:Outcomesonmothersandinteractions.

InfantMentalHealthJournal,36,(6),542-555.

Sameroff,A.(2000)Ecologicalperspectivesondevelopmentalrisk.pp.1-33in:

Osofsky,J.D.&Fitzgerald,H.E.(Eds)(2000)WAIMHHandbookofInfantMental

Health,Vol.4:InfantMentalHealthinGroupsatHighRisk.

NewYork:JohnWiley&Sons.

Schechter,D.S.(2004)Howpost-traumaticstressaffectsmothers’perceptionsof

theirbabies:Abriefvideofeedbackinterventionmakesadifference.

ZerotoThree,24,(3),43-49.

Schechter,D.S.,Myers,M.M.,Brunelli,S.A.,Coates,S.W.,Zeanah,C.H.,Davies,

M.,Grienenberger,J.F.,Marshall,R.D.,McCaw,J.E.,Trabka,K.A.&Liebowitz,M.

R.(2006)Traumatizedmotherscanchangetheirmindsabouttheirtoddlers:

understandinghowanoveluseofvideofeedbacksupportspositivechangeof

maternalattributions.

InfantMentalHealthJournal,27,(5),429-447.

Schensul,J.J.(2009)Community,cultureandsustainabilityinmultilevel

dynamicsystemsinterventionscience.(Publishedonline:22April2009.)

AmericanJournalofCommunityPsychology,43,214-256.

Schore,A.N.(1994)AffectRegulationandtheOriginoftheSelf:The

NeurobiologyofEmotionalDevelopment.

NewJersey:Erlbaum.

.

111

Schore,A.N.(2001a)Effectsofasecureattachmentrelationshiponrightbrain

development,affectregulation,andinfantmentalhealth.

InfantMentalHealthJournal,22,(1-2),7-66.

Schore,A.N.(2001b)Theeffectsofearlyrelationaltraumaonrightbrain

development,affectregulation,andinfantmentalhealth.

InfantMentalHealthJournal.22,(1-2),201-269.

Schore,A.N.(2003)Earlyrelationaltrauma,disorganizedattachment,andthe

developmentofapredispositiontoviolence.pp.107-167in:Solomon,M.F.&

Siegel,D.J.(Eds)(2003)HealingTrauma.

NewYork:W.W.Norton&Co.

Schore,A.(2012)TheScienceoftheArtofPsychotherapy.

NewYork:W.W.Norton&Co.

Scott,Knapp,Henderson&Maughan(2001)Financialcostsofsocialexclusion:

Followupstudyofantisocialchildrenintoadulthood.BMJ,323,7306:191.

Seibal,N.L.(2011)Professionaldevelopmentfortheinfant-familyworkforce.

ZerotoThree,32,(1),46-49.

Shah,P.,Milgrom,T.,Munzer,T.&Hoyme,H.E.(2015)Identifyingriskand

promotingresilienceininfantsandtoddlerswithfetalalcoholspectrum

disorders.

ZerotoThree,36,(2),37-44.

Shaw,D.S.,Owens,E.B.,Vondra,J.I.,Keenan,K.,&Winslow,E.B.(1996)Early

riskfactorsandpathwaysinthedevelopmentofearlydisruptivebehaviour

problems.

DevelopmentandPsychopathology,8,679-699.

.

112

Shean,G.D.(2014)Somemethodologicalandepistemiclimitationsofevidence-

basedtherapies.

PsychoanalyticPsychology,32,(3),500-516.

Shonkoff,J.P.,&Phillips,D.A.(Eds.)(2000)FromNeuronstoNeighbourhoods:

TheScienceofEarlyChildhoodDevelopment.

NationalResearchCouncilandInstituteofMedicineCommitteeonIntegrating

theScienceofEarlyChildhoodDevelopment.BoardonChildren,Youthand

Families,CommissiononBehavioralandSocialSciencesandEducation.

WashingtonD.C.:NationalAcademyPress.

Siegel,D.J.(1999)TheDevelopingMind:TowardsaNeurobiologyof

InterpersonalExperience.

NewYork:TheGuilfordPress.

Siegel,D.J.(2012)TheDevelopingMind(SecondEdition).

NewYork:TheGuilfordPress.

Simpson,J.A.(1999)Attachmenttheoryinmodernevolutionaryperspective.pp

115-140in:Cassidy,J.&Shaver,P.R.(Eds)(1999)HandbookofAttachment:

Theory,Research,andClinicalApplications.

Sinclair,A.(2007)0-5:HowSmallChildrenMakeaBigDifference.

ProvocationSeries,Vol.3,(1)www.theworkfoundation.com

London:TheWorkFoundation.

Sinclair,D.&Murray,L.(1998)Theeffectofpostnataldepressiononchildren’s

adjustmenttoschool.

BritishJournalofPsychiatry.172,58-63.

Singer,L.M.,Brodzinsky,D.M.,Ramsay,D.,Steer,M.&Waters,E.(1985)Mother-

infantattachmentinadoptivefamilies.

ChildDevelopment,56,1543-1551.

.

113

Slade,A.,Grienenberger,J.,Bernbach,E.,Levy,D.&Locker,A.(2005)Maternal

reflectivefunctioning,attachment,andthetransmissiongap:Apreliminary

study.

Attachment&HumanDevelopment.7,(3),283-298.

Slade,A.&Sadler,L.(2013)Mindingthebaby:Complextraumaandhome

visiting.

InternationalJournalofBirth&ParentEducation,1(1),32-35.

Slade,A.,Sandler,L.S.,&Mayes,L.C.(2005)Mindingthebaby:Enhancing

parentalreflectivefunctioninginanursing/mentalhealthhomevisiting

program.pp.152-177in:Berlin,L.J.,Ziv,Y.,Amaya-Jackson,L.&Greenberg,M.T.

(Eds)(2005)EnhancingEarlyAttachments.

NewYork:TheGuilfordPress.

Solchany,J.E.&Barnard,K.E.(2001)Ismom’smindonherbaby?Infantmental

healthinEarlyHeadStart.

ZerotoThree.22,(1),39-47.

Speltz,M.L.,Greenberg,M.T.,&DeKlyen,M.(1990)Attachmentinpreschoolers

withdisruptivebehaviour:Acomparisonofclinic-referredandnonproblem

children.

DevelopmentandPsychopathology.2,31-46.

Sroufe,L.A.,Egeland,B.,Carlson,E.A.,&Collins,W.A.(2005)TheDevelopment

ofthePerson:TheMinnesotaStudyofRiskandAdaptationFromBirthto

Adulthood.

NewYork:TheGuilfordPress.

Steele,M.,Murphy,M.&Steele,H.(2010)Identifyingtherapeuticactioninan

attachment-centredinterventionwithhighriskfamilies.

ClinicalSocialWorkJournal.38,61-72.

.

114

Steele,M.,Steele,H.,Bate,J.,Knafo,H.,Kinsey,M.,Bonuck,K.,mísner,P.&

Murphy,A.(2014)Lookingfromtheoutsidein:theuseofvideoinattachment-

basedinterventions.

Attachment&humandevelopment,16,(4),402-415.

Stern,D.(1995)TheMotherhoodConstellation:AUnifiedViewofParent-Infant

Psychotherapy.

NewYork:BasicBooks.

Stern, D. N. (2004) The Present Moment in Psychotherapy and Everyday Life.

New York: W. W. Norton and Company.

Stern, D. (2006) Introduction to the special issue on early intervention and home

visiting.

Infant Mental Health Journal, 27 (1), 1-4.

Suchman,N. E. (2016) Mothering from the Inside Out: A mentalization-based therapy

for mothers in treatment for drug addiction.

International Journal of Birth and Parenting Education, 3 (4), 19-24.

Suchman, N. E., Ordway, M. R., de la Heras, L. & McMahon, T. J. (2016). Mothering

from the Inside Out: results of a pilot study testing a mentalization-based therapy for

mothers enrolled in mental health services.

Attachment & Human Development, 18, (6), 596-617.

Suchman,N.E.,DeCoste,C.,Castiglioni,N.,McMahon,T.J.,Rounsaville,B.&

Mayes,L.(2010)TheMotherandToddlerprogramme,anattachment-based

parentinginterventionforsubstanceusingwomen:Post-treatmentresultsfrom

arandomizedclinicalpilot.

Attachment&HumanDevelopment,12,(5),433-504.

.

115

Svanberg,P.O.G.(2005)Promotingattachmentsecurityinprimaryprevention

usingvideo-feedback:TheSunderlandInfantProgramme.(Personal

communication.)

InfantMentalHealthJournal.Submitted.

Svanberg,P.O.(2009)Promotingasecureattachmentthroughearlyscreening

andinterventions.pp100-114in:Barlow,J.&Svanberg,P.O.(Eds.)(2009)

KeepingTheBabyInMind:InfantMentalHealthinPractice.

London:Routledge.

Svanberg,P.O.,Mennet,L.&Spieker,S.(2010)Promotingasecureattachment:A

primarypreventionpracticemodel.

ClinicalChildPsychologyandPsychiatry.15,(3),363-378.

Szyf,M.(2009)Theearlyenvironmentandtheepigenome.

BiochimicaetBiophysicaActa,1790,(9),877-885.

Tau,G.Z.&Peterson,B.S.(2010)Normaldevelopmentofbraincircuits.

Neuropsychopharmacology.Reviews.35,147-68.

Teicher,M.H.,Rabi,K.,Sheu,Y.,Seraphin,S.B.,Anderson,S.L.,Anderson,C.M.,

Choi,J.&Tomoda,A.(2010)neurobiologyofchildhoodtraumaandadversity.pp.

112-122in:Lanius,R.A.,Vermetten,E.&Pain,C.(2010)TheImpactofEarlyLife

TraumasonHealthandDisease.

Cambridge:CambridgeUniversityPress.

Teicher,M.H.,Andersen,S.L.,Polcari,A.,Anderson,C.M.,Navalta,C.P.&Kim,D.

M.(2003)Theneurobiologicalconsequencesofearlystressandchildhood

maltreatment.

NeuroscienceandBiobehavioralreviews27,33-44.

Teicher,M.H.&Samson,J.A.(2016)AnnualResearchReview:Enduring

neurobiologicaleffectsofchildhoodabuseandneglect.

.

116

JournalofChildPsychologyandPsychiatry,57(3),241-266.

TheBostonChangeStudyGroup,(2010)ChangeinPsychotherapy.

NewYork:W.W.Norton&Company,Inc.

Thompson,R.A.(1999)Earlyattachmentandlaterdevelopment.pp265-286in:

Cassidy,J.&Shaver,P.R.(Eds)(1999)HandbookofAttachment:Theory,

Research,andClinicalApplications.

NewYork:TheGuilfordPress.

Underdown,A.,Norwood,R.&Barlow,J.(2013)Arealistevaluationofthe

processesandoutcomesofinfantmassageprograms.

InfantMentalHealthJournal,34,(6),483-495.

VanPuyvelde,M.,Rodrigues,H.,Loots,G.,DeCoster,L.,DuVill.,K.,Matthijs,L.,

Simcock,D.&Pattyn,N.(2014)Shallwedance?Musicasaportofentranceto

maternal-infantintersubjectivityinacontextofpostnataldepression.

InfantMentalHealthJournal,35,(3),220-232.

Vaughan,S.C.(1997)TheTalkingCure:TheScienceBehindPsychotherapy.

NewYork:C.P.Putnam’sSons.

Velderman,M.K.,Bakermans-Kranenburg,M.J.,Juffer,F.&VanIjzendoorn,M.H.

(2006)Preventingpreschoolexternalizingbehaviorproblemsthroughvideo-

feedbackinterventionininfancy.

InfantMentalHealthJournal,27,(5),466-493.

Velderman,M.K.,Bakermans-Kranenburg,M.J.,Juffer,F.,VanIjzendoorn,M.H.,

Mangelsdorf,S.C.&Zevalkink,J.(2006)Preventingpreschoolexternalizing

problemsthroughvideo-feedbackinterventionininfancy.

InfantMentalHealthJournal,27,(5),466-493.

Verschueren,K.(2001)Narrativesinattachmentresearch.

.

117

BiennialmeetingoftheEuropeanSocietyofDevelopmentalPsychology;Uppsala.

Verschueren,K.&Marcoen,A.(1999)Representationofselfandsocioemotional

competenceinkindergartners:Differentialandcombinedeffectsofattachment

tomotherandtofather.

ChildDevelopment.70,183-201.

Vik,K.&Braten,S.(2009)Videointeractionguidanceinvitingtranscendenceof

postpartumdepressedmothers’self-centredstateandholdingbehavior.

InfantMentalHealthJournal,30,(3),287-300.

Warren,S.L.,Huston,L.,Egeland,B.,&Sroufe,L.A.(1997)Childandadolescent

anxietydisordersandearlyattachment.

JournaloftheAmericanAcademyofChildandAdolescentPsychiatry.36,637-

644.

Weatherston,D.J.(2000)Theinfantmentalhealthspecialist.

ZerotoThree.21,(2),3-10.

Weinfield,N.S.,Whaley,G.J.J.,&Egeland,B.(2004)Continuity,discontinuity,

andcoherenceinattachmentfrominfancytolateadolescence:Sequelaeof

organizationanddisorganization.

Attachment&HumanDevelopment.Vol.6,(1),73-97.

Winnicott,D.W.(1965)TheMaturationalProcessesAndTheFacilitating

Environment.London:TheHogarthpressandTheInstituteofPsychoanalysis.

Winnicott,D.W.(1971)Playingandreality.

London:TavistockPublications.

Wood,M.J.,Lee,S.S.,&Lipper,E.G.(2000)Failure-tothriveisassociatedwith

disorganizedinfant-motherattachmentandunresolvedmaternalattachment.

InfantMentalHealthJournal.21,(6),428-442.

.

118

Yarger,H.A.,Hoye,J.R.&Dozier,M.(2016)Trajectoriesofchangeinattachment

andbiobehavioralcatch-upamonghigh-riskmothers:Arandomizedcontrol

trial.

InfantMentalHealthJournal,37(5),525-536.

Zeanah,C.H.,Boris,N.W.,&Larrieu,J.A.(1997)Infantdevelopmentand

developmentalrisk:Areviewofthepasttenyears.

JournaloftheAmericanAcademyofChildandAdolescentPsychiatry.32,165-

178.

Zeanah,C.H.&Zeanah,P.D.(2009)Thescopeofinfantmentalhealth.pp.5-21

in:Zeanah,C.H.(Ed.)HandbookofInfantMentalHealth(3rdEdition).

NewYork:TheGuilfordPress.

deZulueta,F.(1993)FromPaintoViolence:TheTraumaticRootsof

Destructiveness.

London:WhurrPublications.