Attachment and Parenting

1. Attachment and Parenting Kings Hill Conference Centre Kent March 26th 2009 Angela Underdown Associate Professor of Public Health

2. Start by depicting the importance of early relationships as a major factors in long-term outcomes Identify some key aspects of early development and a main thread flowing through my presentation revolves around how we can help parents to perceive their child as a unique individual with their own strengths and sensitivities. The early seeds of attachment are sown in pregnancy and we will review how the new CHPP (healthy child programme reflects this early support. Start by depicting the importance of early relationships as a major factors in long-term outcomes Identify some key aspects of early development and a main thread flowing through my presentation revolves around how we can help parents to perceive their child as a unique individual with their own strengths and sensitivities. The early seeds of attachment are sown in pregnancy and we will review how the new CHPP (healthy child programme reflects this early support.

3. Parenting and later outcomes Educational achievement; School drop-out (Desforges, 2003) Behaviour problems, delinquency, criminality, violence (Farrington, 2003) Mental and physical health in adulthood (Stewart-brown and Shaw, 2004) Promiscuous sex and teenage pregnancy (Scaramella et al., 1998) Healthy eating (Kremers et al., 2003) Smoking (Cohen et al., 1994) Alcohol misuse (Garnier et al., 1998; Egland et al., 1997) Parenting is a protective and risk factor at the heart of a range of public health issues and there is an increasing body of research which links attachments difficulties as a factor within a whole range of outcomes such as educational success or failure; delinquency; mental and physical health; promiscuity eating disorders, and addictive behaviours. Parenting involvement takes many forms such as providing a secure and stable environment, intellectual stimulus, discussion contact an dparticipation in school but foundations are laid in early infancyParenting is a protective and risk factor at the heart of a range of public health issues and there is an increasing body of research which links attachments difficulties as a factor within a whole range of outcomes such as educational success or failure; delinquency; mental and physical health; promiscuity eating disorders, and addictive behaviours. Parenting involvement takes many forms such as providing a secure and stable environment, intellectual stimulus, discussion contact an dparticipation in school but foundations are laid in early infancy

4. This is a process model depicting the importance of parenting in infancy � the early environment the everyday care and interactions the baby has impact on the development of the brain and will help him or her regulate their emotions and behaviour in conjunction with interaction with the main carer. If an infant�s efforts to seek comfort and security from caregivers in times of distress are habitually rebuffed or if they elicit an unpredictable mixture of acceptance and rejection, insecure attachment patterns (avoidant-resistant or anxious-resistant) typically develop This is a process model depicting the importance of parenting in infancy � the early environment the everyday care and interactions the baby has impact on the development of the brain and will help him or her regulate their emotions and behaviour in conjunction with interaction with the main carer. If an infant�s efforts to seek comfort and security from caregivers in times of distress are habitually rebuffed or if they elicit an unpredictable mixture of acceptance and rejection, insecure attachment patterns (avoidant-resistant or anxious-resistant) typically develop

5. Process model of the determinants of parenting Important to remember that parenting takes place within an ecological framework 1.As parents we all bring our own developmental history of parents and their person psychological resources 2. Characteristics of the child - a transactional model - child actively affects parent and vice versa 3. Contextual sources of stress and support such as work and social support network PARENTAL DEVELOPMENTAL HISTORY MORE INFLUENCIAL THAN CHILD CHARACTERISTICS Foundations for healthy relationships are laid down right from the start - yet it is only fairly recently that the importance of relationships in pregnancy are recognisedImportant to remember that parenting takes place within an ecological framework 1.As parents we all bring our own developmental history of parents and their person psychological resources 2. Characteristics of the child - a transactional model - child actively affects parent and vice versa 3. Contextual sources of stress and support such as work and social support network PARENTAL DEVELOPMENTAL HISTORY MORE INFLUENCIAL THAN CHILD CHARACTERISTICS Foundations for healthy relationships are laid down right from the start - yet it is only fairly recently that the importance of relationships in pregnancy are recognised

6. What matters during pregnancy�.? Mother�s internal world and external environment Fathers involvement Foetal environment

7. Pregnancy Matters� time of enormous psychological and physiological change���mental representations of the infant are important for the emerging parent-infant relationship

8. Influences on prenatal perceptions: �Pregnancy revives old psychological conflicts, reorganises a woman�s relationship with her own mother and causes her to develop attitudes towards and representations of her developing child� (Huth-Bocks). women who had experienced D/V had significantly more negative representations of their infants and themselves � more likely to be insecurely attached (Huth-Bocks) mother already has 2-3 children under 7 years and pregnancy unplanned (Pajulo et al 2006)

9. Maternal anxiety during pregnancy �In a prospective, longitudinal study of over 7,000 pregnant women and their offspring, findings indicated that maternal anxiety during pregnancy doubled the risk for hyperactivity in 4-year-old boys, independent of obstetric and sociodemographic risks as well as mothers� postnatal anxiety levels� (O�Connor, Heron, Golding, Beveridge and Glover, 2002).

10. Impact of birth on relationships what was the birth experience like � for the father as well as the mother parents begin to get know and accept the real baby rather than the imagined one adjustments greater if baby is the undesired sex, pre-term or with a disability�.

11. Infants are born socially interactivethey are: ready to engage in social communications with others receptive to feeling states in others and emotional tones in speech engaged by parent�s face. (Gazing leads to smiling and cooing and eventual turn taking. Baby can initiate and end interaction by averting gaze) (Trevarthen,C. and Aitkin, K. (2001) Infant intersubjectivty: research theory and clinical applications. Journal of Child Psychology and Psychiatry, 42 (1) 3-48. Myths about babies - that they are too young to relate or passive recipients have been exploded and we know that babies are born ready to socially interact Myths about babies - that they are too young to relate or passive recipients have been exploded and we know that babies are born ready to socially interact

12. Interactions are reciprocal:  initiated by both the baby and the carer uses sensory modalities � so touch, gazing, smell, vocalisations often intense short interactions followed by pauses when the infant assimilates what is going on (Brazelton 1974)

13. Attunement an empathic responsiveness between two individuals which subtly conveys a shared emotion attuned adults will be able to acknowledge the infant�s current emotional state and symbolise it in verbal and non-verbal interaction Attuned interactions help infant develop emotional regulation �rupture� and �repair� essential part (Stern 1985)

14. Mirroring the infant experiences that the emotion he or she is feeling is closely reflected (but not replicated) in the carer�s mind. (Fonagy et al 2004)

15. Containment the way in which one person can take on board the powerful feelings of another and, by communicating with touch, gesture and speech, make them more manageable Bion 1962

16. Reciprocity �the sophisticated interaction between a baby and an adult where both are involved in the initiation, regulation and termination of an interaction (Douglas 2004)�

17. Holding the baby in mind Winnicott (1960) described how parents �hold in mind� the needs of the baby so the infant experiences a sense of security with someone who understands his needs, responds to his distress signals and �contains� his difficult feelings more research emphasis on early cognitive development than on socio-emotional development

18. Reflective Function the capacity of the parents to experience the baby as an �intentional� being rather than simply viewing them in terms of physical characteristics or behaviour, is what helps the child to develop an understanding of mental states in other people and to regulate their own internal experiences (Fonagy 2004).

19. Why are early interactions important? Brain development and hardwiring Co-regulation of stress Affect regulation Regulation of physical states

20. The Infant�s Brain - wiring Unique wiring of individual brain determines how we behave, think, feel and our sense of �self� Wiring takes place during prenatal period to school-entry � important first two years Rapid proliferation and overproduction of synapses followed by loss (pruning) �use it or lose it� � lost if not functionally confirmed Brain is a �self organising system�, and brain development occurs in the context of a relationship with another self�another brain (Schore 2003)

21. Regulation one of key tasks of infancy is learning to co-regulate and self-regulate bodily and emotional states Infants learn to manage their impulses and affect in conjunction with main carers who holds them in mind, reflect on their intentions accurately � picking up on cues and do not overwhelm them�� (Shonkoff and Phillips 2000).

22. Key aspects of infant development Developing sensitive attuned interactions with main attachment figures Co-regulating and gradually self-regulating emotional behaviours, feeding, sleeping etc. Developing an emerging sense of identity and self-esteem Developing secure attachments

24. Secure Attachment Lewis et al 1984 found that secure attachment at 18 months correlated with: The quality and the sensitivity of mother - child interaction at 6 -15 weeks Curiosity and problem solving aged two Social confidence at nursery aged three Lack of behaviour problems (boys) age six (Lewis M. Feiring C. McGuffoy C. and Jaskir J. (1984) Predicting psychopathology in six year olds from early social relations. Child Development 55, 123 -36.)

25. What can be done to support early sensitive care, reflection and attachment

26. Ante-natally �Child Health Promotion Programme Work with fathers-to-be as well as mothers Using promotional interviews to explore with parents their feelings, attitudes and expectations about the new baby Listening and supporting problem solving techniques Family-nurse partnership

27. Progressive universalism Universal services � early identification CHPP team to contribute to care packages led by specialist services parents with addictions, mental health problems or where there is D/V specialist multi-agency support to provide group-based ante-natal and parent education classes for parents with learning difficulties

28. Supporting Bonding Promoting closeness and sensitive, attuned parenting: Skin-to-skin care Use of soft baby carriers Infant massage

29. Introducing the Social Baby Both parents should be introduced to information about their baby�s sensory and perceptual capabilities The Social Baby book/video Baby Express newsletters) Validated tools e.g. Brazelton NBAS

30. Observing and supportingthe Parent-Infant Relationship Using key opportunities to observe and support the developing parent-infant relationship - Optimal parent-infant relationship; - Sub-optimal: in need of support by the CHPP team; - Sub-optimal: in need of referral to specialist support including child protection services This should be the core task of every visit/consultation

31. Supporting the Parent-Infant Relationship Individualised coaching (by a skilled professional) aimed at stimulating attuned interactions � videotape feedback Invitation to group-based parenting programmes (e.g. Mellow Parenting; an infant massage group) Father�infant groups that promote opportunities for play and guided observation Referral to attachment-oriented or parent� infant psychotherapy interventions

32. Anticipating Problems Temperament-based anticipatory guidance: - practical guidance on managing crying and healthy sleep practices e.g. bath, book, bed routines, and activities - encouragement of parent�infant interaction using a range of media-based interventions Can lead to significant improvements in parents� routines with children

33. Supporting Fathers Need to work with both parents from pregnancy onwards Methods of supporting mothers also work with fathers!! (e.g. infant massage; NBAS) Most effective methods of support involve: - Active participation with, or observation of, their baby - Repeated opportunities for practice of new skills - Responsive to individual concerns Important to address parental conflict

34. Promoting Child Development Parenting and early environment are a significant influence on the infants developing brain Should start from the first weeks and months Encouragement to use books, music and interactive activities to promote parent�baby relationship and thereby development Disadvantaged families: Group-based interactive support (e.g. PEEP) Encouragement to use good quality early intervention

35. Key messages�� Pre-natal as well as post-natal support Parental capacity to perceive infant as individual with own personality and character traits foundation for sensitive attuned secure attachments Using the CHPP to help to get it right for babies and their families What works for mothers often works with fathers!