Preventing and Treating Emotional Abuse:

Getting it Right from the Start

Jane BarlowProfessor of Public Health

in the Early Years

Structure of paperStructure of paper

Emotional Abuse – what is it?

Why are the early years so important?

What characterises ‘high risk’ parents?

What should we be doing…?

What is emotional abuse?What is emotional abuse?

A constant, repeated pattern of parental A constant, repeated pattern of parental behaviour, (unaccompanied by physical behaviour, (unaccompanied by physical abuse, sexual abuse or necessarily by abuse, sexual abuse or necessarily by physical neglect) that is likely to be physical neglect) that is likely to be interpreted by a child that she or he is interpreted by a child that she or he is unloved, unwanted, serves only unloved, unwanted, serves only instrumental purposes, and/or which instrumental purposes, and/or which severely undermines children’s severely undermines children’s development and socialisationdevelopment and socialisation

Emotional Abuse – the problemEmotional Abuse – the problem

Referrals for primary emotional abuse rose Referrals for primary emotional abuse rose from 4,700 (13%) to 5,100 (20%) over past from 4,700 (13%) to 5,100 (20%) over past decadedecade

This equates to 4.7 per 10,000 childrenThis equates to 4.7 per 10,000 children

As many as 80% of children registered for As many as 80% of children registered for physical abuse and neglect have also physical abuse and neglect have also experienced emotional abuse experienced emotional abuse

Subjective PerceptionsSubjective Perceptions Large-scale population-based study Large-scale population-based study

(involving 2,869 adults) in the UK(involving 2,869 adults) in the UK 6% reported 6% reported

- frequent and severe - frequent and severe psychological control and psychological control and domination; domination;

- psycho/physical control and domination, - psycho/physical control and domination, humiliation, attacks on self-esteemhumiliation, attacks on self-esteem

- withdrawal of their primary carer’s - withdrawal of their primary carer’s attention/affectionattention/affection

- antipathy, terrorising or threatening behaviours - antipathy, terrorising or threatening behaviours and proxy attacks and proxy attacks

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

Trauma in infancy:attachment system compromised

Sensitised nervous system as brain adapts to emotional environment

Stress in childreminders & experiences of trauma,

life events, etc.

Unbearably painful emotional states

Self-destructive actions:substance abuseeating disordersdeliberate self-harmsuicidal actions

Destructiveactions:aggressionviolencerage

Retreat:isolationdissociationdepression

(Robin Balbernie 2011)

Aspects of Early Aspects of Early DevelopmentDevelopment

Emotional/Emotional/

social social developmentdevelopment

Intellectual Intellectual DevelopmentDevelopment

BehaviouralBehavioural

developmendevelopmentt

InfancyInfancy Trust/Trust/attachmentattachment

Alertness/Alertness/curiositycuriosity

Impulse Impulse controlcontrol

ToddlerhooToddlerhoodd

EmpathyEmpathy Communication/Communication/

mastery mastery motivationmotivation

CopingCoping

ChildhoodChildhood Social Social RelationshipsRelationships

Reasoning/Reasoning/problem solvingproblem solving

Goal-directed Goal-directed behaviourbehaviour

AdolescencAdolescencee

Supportive Supportive social networksocial network

Learning Learning ability/achievemeability/achievementnt

Social Social responsibilityresponsibility

AFFECT REGULATION

The Social Baby In first 15 hours baby’s distinguish the In first 15 hours baby’s distinguish the

voice, smell and face of their mothervoice, smell and face of their mother They connect what they do with what They connect what they do with what

happens immediately afterhappens immediately after Babies have a sophisticated understanding Babies have a sophisticated understanding

of facial expressions – distinguish between of facial expressions – distinguish between surprise, fear, sadness, anger and delightsurprise, fear, sadness, anger and delight

By 10- months babies seek emotional By 10- months babies seek emotional information from others to help them information from others to help them interpret things around theminterpret things around them

By 10-months baby’s brain has developed By 10-months baby’s brain has developed according to the type of emotions to which according to the type of emotions to which they have been exposedthey have been exposed (Beebe and Lachman, 2004)

Important aspects of early parenting

Sensitivity/attunement and contingent interaction

Reflective function

Contingent Interaction

By two months the mothers face is the By two months the mothers face is the primary source of visuo-affective primary source of visuo-affective communicationcommunication

Face-to-face interactions emerge which are Face-to-face interactions emerge which are high arousing, affect-laden and expose high arousing, affect-laden and expose infants to high levels of cognitive and social infants to high levels of cognitive and social information and stimulationinformation and stimulation

To regulate this infant and mothers To regulate this infant and mothers regulate the intensity of these interactions regulate the intensity of these interactions – ‘affect synchrony’ and repairs to ruptures– ‘affect synchrony’ and repairs to ruptures

Absolutely fundamental to healthy Absolutely fundamental to healthy emotional development – prolonged emotional development – prolonged negative states are ‘toxic’ to infantsnegative states are ‘toxic’ to infants

Contingent InteractionContingent Interaction

‘Attuned mutual co-ordination between mother and infant occurs when the infant’s squeal of delight is matched by the mother’s excited clapping and sparkling eyes. The baby then becomes overstimulated, arches its back and looks away from the mother. A disruption has occurred and there is a mis-coordination: the mother, still excited, is leaning forward, while the baby, now serious, pulls away. However, the mother then picks up the cue and begins the repair: she stops laughing and, with a little sigh, quietens down. The baby comes back and makes eye contact again. Mother and baby gently smile. They are back in sync again, in attunement with each other (Fosha, 2003 in Walker 2008, p. 6).

Reflective Function

Reflective FunctionReflective Function Capacity to understand the infant’s behaviour in Capacity to understand the infant’s behaviour in

terms of internal states/feelingsterms of internal states/feelings A key determinant of self-organization which is A key determinant of self-organization which is

acquired in the context of the child's early social acquired in the context of the child's early social relationships (Fonagy, 1997)relationships (Fonagy, 1997)

Development of self-organization is dependent on Development of self-organization is dependent on the caregiver's ability to communicate the caregiver's ability to communicate understanding of the child's intentional stance via understanding of the child's intentional stance via ‘marked mirroring’‘marked mirroring’

Lack of parental RF plays a key role in pathological Lack of parental RF plays a key role in pathological functioningfunctioning

Videoclip 1Videoclip 1

Attachment What is it:?- Affective bond between infant and caregiver

(Bowlby, 1969)

What is its function?: - Dyadic regulation of infant emotion and

arousal (Sroufe, 1996)

Antecedants of attachment: Sensitive, emotionally responsive care during

first year – secure attachment Insensitive, inconsistent or unresponsive care

– insecure/disorganised attachment

Who is securely attached?Who is securely attached?Secure (Group B) – able to use caregiver as a secure base in times of stress and to obtain comfort (55-65%)

InsecureAnxious/resistant (Group C) – up-regulates in times of stress to maintain closeness (8-10%)Avoidant (Group A) - down-regulates in times of stress to maintain closeness (10-15%)

Disorganised (Group D) – unable to establish a regular behavioural strategy (up to 15% in population sample; 80% in abused sample) (Carlson, Cicchetti et al 1989)

Child abuse and attachmentChild abuse and attachment Up to 80% of children who are abused have a Up to 80% of children who are abused have a

‘disorganised attachment’ ‘disorganised attachment’ In maltreating families parent-child interactions In maltreating families parent-child interactions

characterised by hostility; low levels of reciprocity, characterised by hostility; low levels of reciprocity, engagement and synchrony, unpredictability engagement and synchrony, unpredictability (ignoring plus intrusive hostility)(ignoring plus intrusive hostility)

Disorganised attachment predicts very poor Disorganised attachment predicts very poor outcomes including a range of social and cognitive outcomes including a range of social and cognitive difficulties, and psychopathologydifficulties, and psychopathology

Safeguarding practitioners MUST have this Safeguarding practitioners MUST have this developmental model at the core of their practicedevelopmental model at the core of their practice

Disorganised/ControllingDisorganised/Controlling Attachment Attachment

Caregivers – unpredictable and rejecting; Caregivers – unpredictable and rejecting; source of comfort also source of distresssource of comfort also source of distress

Self represented as unlovable, unworthy, Self represented as unlovable, unworthy, capable of causing others to become angry, capable of causing others to become angry, violent and uncaringviolent and uncaring

Others – frightening, dangerous, Others – frightening, dangerous, unavailableunavailable

Predominant feelings – fear and angerPredominant feelings – fear and anger Little time for exploration or social learningLittle time for exploration or social learning

Arousal in traumatic Arousal in traumatic attachmentsattachments

Hyper-arousal (aggression, impulsive behaviour, Hyper-arousal (aggression, impulsive behaviour, children emotional and behavioural problems – children emotional and behavioural problems – ‘Fight or flight’ response)‘Fight or flight’ response)

Window Window

OfOf

ToleranceTolerance

Hypo-arousal (dissociation, depression, self harm Hypo-arousal (dissociation, depression, self harm etc)etc)

Compulsive StrategiesCompulsive Strategies

Compulsive compliance (where parent is Compulsive compliance (where parent is threatening) – watchful; vigilant and compliant threatening) – watchful; vigilant and compliant

Compulsive caregiving (where parent is needy) Compulsive caregiving (where parent is needy) – role reversal; parentification; children deny – role reversal; parentification; children deny own developmental needsown developmental needs

Coercive – combination of threatening and Coercive – combination of threatening and placatory behavioursplacatory behaviours

Controlling strategies (abusive and neglectful) – Controlling strategies (abusive and neglectful) – self is strong and powerful but also dangerous self is strong and powerful but also dangerous and bad; avoidance and aggression; completely and bad; avoidance and aggression; completely ‘out of control’ and ‘fearless’‘out of control’ and ‘fearless’

Compulsive caregiving ‘ ‘Caroline is 18 months old. She lives with her Caroline is 18 months old. She lives with her

mother, who is chronically depressed. The mother, who is chronically depressed. The mother describes the household as ‘noxious to mother describes the household as ‘noxious to the soul’. She cannot tolerate the idea that her the soul’. She cannot tolerate the idea that her depression is affecting Caroline. She says: depression is affecting Caroline. She says: “Caroline is the only one who makes me laugh.” “Caroline is the only one who makes me laugh.”

It is observed that Caroline silently enacts the It is observed that Caroline silently enacts the role of a clown. She disappears into her room and role of a clown. She disappears into her room and comes out wearing increasingly more comes out wearing increasingly more preposterous costumes. Caroline makes her preposterous costumes. Caroline makes her mother laugh, but she herself never laughs…’ mother laugh, but she herself never laughs…’ (Howe, 1999)(Howe, 1999)

Vulnerable ParentsVulnerable Parents

Affect synchrony in the face of parental problems

Infant’s emotional states can trigger profound discomfort in the parent (e.g. where there is unresolved loss/trauma, mental health problems, drug/alcohol abuse, or where there is domestic violence etc)

Interaction becomes characterized by: - withdrawal, distancing or neglect (i.e. omission) - intrusion in the form of blaming, shaming,

punishing and attacking (i.e. commission)

Unresolved/disorganised Unresolved/disorganised parentsparents

Unresolved loss; abuse; or trauma and in Unresolved loss; abuse; or trauma and in ‘continuing state of fear’‘continuing state of fear’

Fr-Behaviour - frightened and frightening; hostile Fr-Behaviour - frightened and frightening; hostile and helplessand helpless

Atypical Maternal Behaviors – affective Atypical Maternal Behaviors – affective communication errors; disorientation; negative-communication errors; disorientation; negative-intrusive behaviours;intrusive behaviours;

53% of 53% of parentsparents with with unresolvedunresolved states of mind states of mind had infants classified as had infants classified as disorganizeddisorganized (van (van IJzendoorn, 1995)IJzendoorn, 1995)

Videoclip –Videoclip –Severely suboptimal Severely suboptimal

M-I interactionM-I interaction

Getting it right first time…Getting it right first time… Identify high risk families during pregnancy – Identify high risk families during pregnancy –

pre-birth assessments;pre-birth assessments; Ideally intervention is offered ante-natally - FNPIdeally intervention is offered ante-natally - FNP Assess parent-infant interactionAssess parent-infant interaction Provide time-limited EB intervention and clear Provide time-limited EB intervention and clear

goals to be achieved; re-assess interactiongoals to be achieved; re-assess interaction Remove infants where there is insufficient Remove infants where there is insufficient

improvement before 6 months ideally, end of improvement before 6 months ideally, end of first year at worstfirst year at worst

Standardised ScalesStandardised Scales PIR-GAS – Parent Infant Relationship Global Assessment PIR-GAS – Parent Infant Relationship Global Assessment

Scale (Zero to Three 1994)Scale (Zero to Three 1994) KIPS – Keys to Interactive Parenting Scale KIPS – Keys to Interactive Parenting Scale NCAST – Nursing Child Assessment Satellite Training NCAST – Nursing Child Assessment Satellite Training

(Kelly and Barnard 2000; Barnard 1994) (Kelly and Barnard 2000; Barnard 1994) ADBS - Alarm Distress Baby Scale (Guedeney and ADBS - Alarm Distress Baby Scale (Guedeney and

Fermanian 2001)Fermanian 2001) CARE-Index (Crittenden 1984) CARE-Index (Crittenden 1984) PIRAT - Parent-Infant Relational Assessment Tool PIRAT - Parent-Infant Relational Assessment Tool

(Broughton 2010)(Broughton 2010) EAS - Emotional Availability Scales (Biringen 2010)EAS - Emotional Availability Scales (Biringen 2010)

Evidence-Based InterventionsEvidence-Based Interventions

Sensitivity/attachment-based: Sensitivity/attachment-based: Interaction Guidance; FNPInteraction Guidance; FNP

Psychotherapeutic: Psychotherapeutic: Parent-infant Parent-infant psychotherapypsychotherapy

Parenting programmes Parenting programmes – Parents under – Parents under Pressure; Parent-Child Interaction TherapyPressure; Parent-Child Interaction Therapy

Mentalisation: Minding the BabyMentalisation: Minding the Baby

CommonalitiesCommonalities ‘‘Dyadic’ - focus on parent-child Dyadic’ - focus on parent-child

interaction with emphasis on the child’s interaction with emphasis on the child’s attachment; parental sensitivity; attachment; parental sensitivity; parental reflective function etcparental reflective function etc

Underpinned by a clear Underpinned by a clear mechanism for mechanism for changechange

Emphasis on relationship between Emphasis on relationship between therapist/provider and parenttherapist/provider and parent

Video-Interaction GuidanceVideo-Interaction Guidance Practitioners videotapes parent-infant interactions Practitioners videotapes parent-infant interactions

and shares and shares Video jointly reviewed by practitioner and parent Video jointly reviewed by practitioner and parent

using micro-moments of successful contact with using micro-moments of successful contact with the aim of reflecting on strengths in the parent’s the aim of reflecting on strengths in the parent’s ability to attuneability to attune

Reflective discussion involves support and Reflective discussion involves support and information about how to enhance their information about how to enhance their relationship with their child as well as activating relationship with their child as well as activating the parent to reflect on their child and themselves the parent to reflect on their child and themselves and their relationship.and their relationship.

EvidenceEvidence Video feedback interventions Video feedback interventions

effective improving parenting effective improving parenting behaviour; parenting attitudes; and behaviour; parenting attitudes; and children’s behaviour (Fukkink 2008)children’s behaviour (Fukkink 2008)

Includes children of all agesIncludes children of all ages VIG effective in reducing VIG effective in reducing

disorganised attachment in abused disorganised attachment in abused children (Moss et al 2011)children (Moss et al 2011)

Parent-Infant PsychotherapyParent-Infant Psychotherapy Watch, Wait and Wonder (Cohen et al 2001)Watch, Wait and Wonder (Cohen et al 2001)

Infant led parent-infant psychotherapyInfant led parent-infant psychotherapy

Mother observes her infant’s self-initiated Mother observes her infant’s self-initiated activity whilst being physically accessible activity whilst being physically accessible to infantto infant

Discussion of these experiences with Discussion of these experiences with therapist as a way of examining the therapist as a way of examining the mother’s internal working models of herself mother’s internal working models of herself in relation to her infantin relation to her infant

Evidence of EffectivenessEvidence of Effectiveness Evidence from rigorous studies highlighting the Evidence from rigorous studies highlighting the

benefits of parent-child psychotherapy for:benefits of parent-child psychotherapy for: - children exposed to severely compromised or - children exposed to severely compromised or

traumatising (e.g. DV) environments (Lieberman et al traumatising (e.g. DV) environments (Lieberman et al 2008; 2004;2008; 2004;

- parents who are emotionally abusive (Cicchetti et al 2006) - parents who are emotionally abusive (Cicchetti et al 2006) or who have major depressive disorder (Toth et al 2006);or who have major depressive disorder (Toth et al 2006);

- preliminary clinical studies have also examined the value - preliminary clinical studies have also examined the value of this approach with parents with Borderline Personality of this approach with parents with Borderline Personality Disorder (Newman & Stevenson 2008)Disorder (Newman & Stevenson 2008)

PUP ProgrammePUP Programme PUP comprises an intensive, manualized, home-PUP comprises an intensive, manualized, home-

based intervention of ten modules conducted in based intervention of ten modules conducted in the family home over 10 to 12 weeks, each the family home over 10 to 12 weeks, each session lasting between one and two hours session lasting between one and two hours

PUP is underpinned by an ecological model of PUP is underpinned by an ecological model of child development and targets multiple domains child development and targets multiple domains of family functioning, including the psychological of family functioning, including the psychological functioning of individuals in the family, parent–functioning of individuals in the family, parent–child relationships, and social contextual factors. child relationships, and social contextual factors.

Incorporates ‘mindfulness’ skills that are aimed at Incorporates ‘mindfulness’ skills that are aimed at improving parental affect regulation;improving parental affect regulation;

PUP evaluationPUP evaluation Parents Under PressureParents Under Pressure RCT with substance abusing parents of children RCT with substance abusing parents of children

aged 2-8 years (Dawe and Harnett 2007) aged 2-8 years (Dawe and Harnett 2007) Compared PUP with standard parenting Compared PUP with standard parenting

programmeprogramme Significant reductions in parental stress; Significant reductions in parental stress;

methadone dose and child abuse potential methadone dose and child abuse potential (significant worsening in the child abuse (significant worsening in the child abuse potential of parents receiving standard care); potential of parents receiving standard care); improved child behaviour problemsimproved child behaviour problems

Parent-Child Interaction Parent-Child Interaction TherapyTherapy

PCIT is a short-term, parent training programmePCIT is a short-term, parent training programme Based on both attachment and social learning Based on both attachment and social learning

theorytheory It is directed at families with 2- to 6-yr-old It is directed at families with 2- to 6-yr-old

children experiencing behavioral, emotional, or children experiencing behavioral, emotional, or family problems family problems

Rigorous research evidence about its Rigorous research evidence about its effectiveness with physically abusive parents effectiveness with physically abusive parents (Hakman et al 2009; Chaffin et al2004)(Hakman et al 2009; Chaffin et al2004)

Manualised programme; assessment driven Manualised programme; assessment driven (i.e. parents have mastered the skills) not (i.e. parents have mastered the skills) not time-limited;time-limited;

Two phases – Child Directed Interaction Two phases – Child Directed Interaction (CDI); Parent Directed Interaction (PDI)(CDI); Parent Directed Interaction (PDI)

Emphasis throughout on interaction Emphasis throughout on interaction between parent and child; between parent and child;

CDI concentrates on strengthening parent-child CDI concentrates on strengthening parent-child attachment as a foundation for PDI, which attachment as a foundation for PDI, which emphasizes a structured and consistent approach emphasizes a structured and consistent approach to disciplineto discipline

Mentalisation-based Mentalisation-based approachesapproaches

Emerging model of intervention that builds on both Emerging model of intervention that builds on both parent-infant psychotherapy and recent advances in parent-infant psychotherapy and recent advances in advances in attachment theoryadvances in attachment theory

Minding the Baby is an interdisciplinary, relationship Minding the Baby is an interdisciplinary, relationship based home visiting program for young, at-risk new based home visiting program for young, at-risk new mothersmothers

Delivered by a team that includes a nurse practitioner Delivered by a team that includes a nurse practitioner and clinical social worker- uses a mentalisation-based and clinical social worker- uses a mentalisation-based approach that involves working with mothers and babies approach that involves working with mothers and babies in a variety of ways to develop mothers' reflective in a variety of ways to develop mothers' reflective capacitiescapacities

It aims at addressing relationship disruptions that stem It aims at addressing relationship disruptions that stem from mothers' early trauma and derailed attachment from mothers' early trauma and derailed attachment historyhistory

Only case-study evidence available (Slade et al., 2005)Only case-study evidence available (Slade et al., 2005)

SummarySummary Importance of identifying high risk families and Importance of identifying high risk families and

conducting pre-birth assessmentconducting pre-birth assessment Intervention should begin ante-natally if Intervention should begin ante-natally if

possible;possible; Post-natal assessment should include parent-Post-natal assessment should include parent-

infant interactioninfant interaction Time-limited intervention with clear goalsTime-limited intervention with clear goals A range of evidence-based universal and A range of evidence-based universal and

targeted interventions to support parent-child targeted interventions to support parent-child interaction;interaction;

PublicationsPublications Barlow J, Scott J (2010). Barlow J, Scott J (2010). Safeguarding in Safeguarding in

the 21the 21stst Century: Where to Now Century: Where to Now? ? Dartington: Research in Practice.Dartington: Research in Practice.www.rip.org.uk

Barlow J, Schrader-McMillan A (2010). Barlow J, Schrader-McMillan A (2010). Safeguarding Children from Emotional Safeguarding Children from Emotional Abuse: What Works? Abuse: What Works? London: Jessica London: Jessica Kingsley.Kingsley.