Abuse and Neglect:

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Abuse and Neglect Developmental and
attachment-based interventions
Stavanger 25 April 2008
David Howe University of East Anglia Norwich, UK
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David Howe Child Abuse and Neglect attachment,
development and intervention Palgrave/Macmillan 2
005
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Caregiving Environment and Childrens Adaptive
Behaviour
Internal working model psychological
and behavioural adaptations to survive and
function within caregiving environment
Characteristics of caregiving environment

• Caregivers
• own
• relationship
• history

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Information and analysis of attachments
Carers attachment history
Caregiving environment
Childs internal working model/ adaptive behaviour
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Secure individuals value attachment relationships
and regard attachment-related experiences as
influential. Remain objective and independent
when reflecting on self and others. Little
distortion of behaviour, cognition (thought) and
emotion (feeling). Able to fully access and
process thought, feeling and attachment-related
events (memory systems are integrated) COMPLEX
BRAINS
COGNITION
BEHAVIOUR
EMOTION
ATTACHMENT-RELATED EXPERIENCES AND MEMORIES
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Interventions
1. Primary/prevention 2. Secondary 3.
Tertiary
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Treatment and therapy
Physical, somatic and sensory integration ?
Physical and somatic integration, and integration
of the senses precede emotional integration. By
organising their bodies and their sensations,
children gain control over their emotions.
The kindling and mentalisation of affectivity ?
Mind-mindedness ? Affect regulation ? Emotional
integration
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Sensory integration and self regulation
Children who have suffered early trauma
are aroused physiologically - their bodies signal
danger, which in turn triggers fear and responses
of flight, fight or freeze. Insecurity therefore
may be experienced physiologically as well as
emotionally, neither of which is able to be
regulated or integrated with the cortex -
cognition, reflective appraisal etc. therefore
cannot think your way out of fear, distress and
anxiety.
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ATTACHMENT
None of us in born with the capacity to regulate
our own emotions. The caregiver- child
regulatory system evolves where the infants
signals of changes in state are understood and
responded to by the caregiver, thereby becoming
more regulated.
Peter Fonagy 2000
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Affect Mirroring
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Mentalised Affectivity
The recognition, communication and naming of
emotions.
.
The recognition of the way ones own and other
peoples affective states affect both parties
feelings, thoughts and behaviour.
.
The baby/child/adult gradually come to accept
that feelings can be safely felt and ideas may be
safely thought about
(Fonagy).
.
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Mentalised Affectivity
It is therapeutic to be the subject of reliable,
coherent, rational, congruent and
contingent thinking.
.
The development of a stable internal self is
impossible without a stable external
environment.
(Bateman and Fonagy).
.
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A developmental base for
interventions
Developmental attachment-based therapies aim to
develop parents capacity for empathy,
sensitivity, psychological-mindedness,
and emotional availability ie help carers
develop an understanding of the
psychological complexity of the infant.

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Steps Toward Effective, Enjoyable
Parenting STEEP (Egeland and Erickson
2004) Intervention goals for high risk parents
and children
1. Promote healthy, realistic attitudes,
beliefs and expectations about pregnancy,
childbirth, child rearing, and the
parent-child relationship. 2. Promote
understanding of child development and form
realistic expectations for child behaviour.
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Steps Toward Effective, Enjoyable
Parenting STEEP (Egeland and Erickson
2004) Intervention goals
3. Encourage a sensitive, predictable
response to the babys cues and signals. 4.
Enhance parents ability to see things from
the childs point of view. 5. Facilitate the
creation of a home environment that is safe,
predictable, and conducive to optimal
development.
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Parent-infant interventions
Enhancing parental sensitivity and
responsiveness, including changing the parents
behaviour with their infant (behavioural
change) Changing the parents mental
representation/working model of attachment,
including their mental representation of their
relationship with their infant (cognitive change
by increasing insight and reflective function)
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Video Intervention to Promote Positive Parenting
(VIPP)
To improve parental sensitivity
To increase infant security of attachment
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Video Intervention to Promote Positive Parenting
(VIPP)

• Behavioural interventions
• - video taped while playing or bathing
• - tape analysed back at clinic
• next home visit, tape shown drawing
• particular attention to babys signals,
• facial expressions, body movements
• - this stimulates mothers observational
• skills and interest in her childs state
• of mind, promoting empathy

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Video Intervention to Promote Positive Parenting
(VIPP)

• Behavioural interventions
• negative parental responses
• generally ignored
• - positive reinforcement given to more
• sensitive, mind-minded interactions

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Video Intervention to Promote Positive Parenting
(VIPP)
1. The mother is invited to speak for the
baby eg on the babys contact-seeking
(attachment), exploratory and
intersubjective behaviour 2. The accurate
perception of the babys signals, facial
expressions and body movements.
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Video Intervention to Promote Positive Parenting
(VIPP)
3. The relevance of prompt (contingent) and
adequate (congruent) responding to the
babys signals 4. Affective attunement and
sharing of emotions
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Video Intervention to Promote Positive Parenting
discussions at the representational level
(VIPP-R)

• Discussion of representational and
• attachment issues during home
• visits covers 4 themes
• Separations in the past, including when
• parent was a child, and separations from
• her own baby now that she is a parent.

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Video Intervention to Promote Positive Parenting
discussions at the representational level
(VIPP-R)
2. Parenting in the past, experienced as a
child, and parenting in the present
experienced as a mother. 3. The process of
breaking away during adolescence, defining
adult relationships with parents, and
expectations of future relationships with her
child.
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Video Intervention to Promote Positive Parenting
discussions at the representational level
(VIPP-R)
4. The explicit link between being the child
of my parents and being the parent of my
child, focussing on which childhood
experiences the mother wants to pass or not
pass on to her child.
nb VIPP more effective for dismissing mothers
VIPP-R more effective for preoccupied mothers
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Circle of Security
High risk toddlers and pre-school children
(age 1 4 years) and their carers Caregivers
meet as a group and with a psychotherapist for
75 minutes each week for 20 weeks. Caregivers
are introduced to the idea of a Secure Base
and a Haven of Safety from which children can
explore and return at times of anxiety and need
ie when their attachment system is activated.
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CIRCLE OF SECURITY parent attending to the
childs needs
Cooper et al 2000
I need you to...

• Watch over me
• Help me
• Enjoy with me

Support my exploration
Secure base
I need you to...
Safe haven

• Protect me
• Comfort me
• Delight in me
• Organise/regulate
• my feelings

Welcome my coming to you
Always be stronger, wiser and kind Whenever
possible follow my childs need Whenever
necessary take charge
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Circle of Security
Aim to help carers become more aware, perceptive,
available, responsive and skilful in reading
childrens attachment signals. Much use of video
material by group (lets figure out whats
happening) as children move from exploration to
attachment. Carers also helped to recognise how
their anxieties and defences (attachment
pattern) affect childs attachment-exploratory bal
ance, and how insecure children miscue their
feelings and needs.
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Watch, Wait, Wonder
The carer is encouraged To follow the infants
spontaneous and undirected play activity
(watch) See what happens (wait) Reflect on what
the child might be thinking, feeling and doing
(wonder).
Cohen et al 1999
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A developmental base for
interventions
When intervening with children, it is important
to assess their developmental age rather
than their chronological age.
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A developmental base for
interventions
Early stage developmental experiences have to be
introduced or re-worked. The regulation of
emotional arousal is key to success and
therefore affect regulation must be the
primary target of all interventions.
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Interventions with pre-school and school-age
children
Many traumatised children need to establish a
close, mind-engaging relationship with
a sensitive caregiver but they have learned to
stay safe by not getting close, preferring to
remain compulsively self-reliant.
Need to introduce a range of developmentally infor
med techniques using all the senses.
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Mentalised Affectivity
Normally, the dysregulating feelings generated by
old unresolved loss/abuse/trauma cascade
uncontrollably through the mind leading to highly
dysregulated and out-of-control behaviour.
Individuals with unresolved losses and traumas
need emotionally to re-experience the event
without feeling helpless (cf babies).
.
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Mentalised Affectivity
The key intervention principle requires the carer
(or therapist) to observe, recognise and become
attuned to the childs subjective experiences and
affective states, and contingently reflect them
back to the child.
.
Carer (or therapist) is playful, loving,
accepting, curious, and empathic p.l.a.c.e
(Daniel Hughes)
.
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Bruce Perry therapeutic work with maltreated
and traumatised children

• Do not be afraid to talk about the traumatic
  event if the child brings it up on his or her
  own.

• Provide a consistent, predictable pattern for the
  day and make sure the child knows and can expect
  this pattern. If the day is likely to include
  doing something different or out of the ordinary,
  this will need to be carefully explained.
  Traumatised children feel anxious about change
  and the unexpected. They also like to feel that
  caring, safe adults are in control of events.

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Perry cont

• Be nurturing, comforting and affectionate in the
  appropriate context. Intimacy, particularly for
  sexually abused children, can be frightening and
  confusing. Provide cuddles, hugs and kisses when
  the child seeks them. Never demand a kiss or a
  hug. Abused children associate commands with
  power in others and helplessness (and therefore
  danger).

• Discuss your expectations of behaviour and your
  style of discipline with the child. Make sure
  rules and expectations are clear, and what the
  consequences will be if they are broken. Be
  consistent.

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Perry cont
Talk with the child, giving them age-appropriate
information so that they have as much knowledge
about present and future situations as possible.
Dont be afraid of repetition. Traumatised
children need clear and full explanations. It is
uncertainty which distresses them. Honesty and
openness help children develop trust.

• Protect the child. Cut short activities which are
  upsetting or re-traumatising for the child.

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Perry cont
Give the child choices and some sense of
control. It is lack of control which makes
traumatised children feel that the situation is
dangerous, and may cause them to behave in a
wild, frightened and uncontrolled way. Giving the
child choices (chosen by the parent) makes them
feel safer (You can either choose to do what I
have asked or you can carry on being noisy and
miss out on watching your favourite video. You
can choose.)
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Perry cont
Having established a safe and sensitive
relationship, cognitive restructuring of the self
and others can begin to take place. This is
achieved by building positive and accurate
emotional understanding and affect regulation.