Counseling at the Beginning

Interventions and Issues in Infancy and Early Childhood

Catherine Tucker

• Publisher: Routledge
• Year: 2019
• Print ISBN:
  9781138960664
• eBook ISBN:
  9781317311522
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Counseling at the Beginning is a thorough, practice-based guide for counselors who serve the mental health needs of very young children and their families. Chapters based on current developmental psychology research prepare mental health, school, and addictions counselors to work with pregnant women and children under the age of 5. Discussion of topics such as brain development, self-regulation, trauma, prenatal alcohol and drug exposure, and toxic stress prepares providers to meet the needs of this growing area of practice. Concrete information about how and when to intervene, written by experts working in the field, is accompanied by lists of resources for further learning at the end of each chapter.

1 Attachment

The Foundation of Mental Health

Catherine Tucker

As scientists studying the human brain uncover more of the mysteries of our inner workings, the ideas underpinning attachment theory have largely moved from the theoretical realm to that of fact. There is surely still much to learn about the mechanics of the processes involved in the bonds between humans: how they form, what parts of the brain and body are involved most in which stages, and how best to intervene when problems arise. Nonetheless, we now have a large body of evidence from the fields of biology and neuroscience to be confident in the assertion that early primary relationships set the stage for all future relationships and coping behaviors, for better or for worse.

History and Development of Attachment Theory

This solid evidence for the role of early relationships in later life outcomes is a relatively new development in the fields related to human services. In 1930 for example, behaviorist John Watson famously declared,

Men are built, not born. Give me the baby, and I’ll make it climb and use its hands in constructing buildings of stone or wood. I’ll make it a thief, a gunman or a dope fiend. The possibilities of shaping in any direction are almost endless.

Watson and other behaviorists, such as B.F. Skinner, published books and articles encouraging parents to provide a very ordered and scheduled environment for young children, while taking care not to overindulge them or worry much about a baby’s emotional needs. This approach was quite popular, and in spite of being written by well-educated psychologists, was not built on any scientific examination of its outcomes.

The behaviorist ideals of high levels of structure and low levels of nurture in early childhood stand in almost direct opposition to the ideas of the early attachment theorists. Among them, John Bowlby is generally regarded as the first author of a systematic theory of attachment, although his work has been enlarged and refined by many other researchers. Bowlby’s interest in attachment sprang from his work with juvenile delinquents (Bowlby, 1944). As he got to know the life stories of boys who had been involved with the justice system, he noticed that most of them had very disruptive early lives. Some had been orphaned; others had abusive and/or neglectful parents. Very few of the boys had intact families and stable homes (Bretherton, 1992). His first important paper, written in 1944, “Forty-four juvenile thieves: Their character and home lives,” shows the early threads of Bowlby’s theory about the importance of early relationships. In this article, Bowlby produces statistical analysis and case histories demonstrating the overarching theme of lack of strong familial bonds among this group of young criminals.

Bowlby spent the rest of his career researching how the relationships an infant has to its caregivers in early life impact later outcomes. His theory is based around the relationship between an infant and its primary caregivers, usually, but not always, the parents. Beginning at around the age of 9 or 10 months, babies begin to recognize individual caregivers and develop specific relationships to them. Prior to this time, infants do learn to respond to the general quality of care and react accordingly but do not yet have the ability to form distinct relationships. Infants can recognize individual people by about 2–3 months but don’t develop preferences quite yet (Zeanah & Smyke, 2009). If an infant’s needs are generally met in a timely and sensitive manner, he or she will usually develop a relationship to the caregivers that allows the infant a sense of safety when in the presence of the caregiver. Caregiver proximity, sensitivity, and responsiveness are continually monitored by the young child. If the child senses that the caregiver is present and is able to respond appropriately to his or her needs, a secure attachment will form between them (Bowlby, 1973). Secure attachment is created when caregivers: (1) provide a secure base for exploration; (2) are available and flexible; (3) are sensitive and responsive to distress; and (4) intervene appropriately when needed. Secure attachment allows individuals to develop a positive self-image, effectively manage their emotions, and feel comfort with autonomy and in forming relationships (Bowlby, 1973).

In general, sensitive care is an umbrella term used to indicate that several aspects of communication are taking place between caregiver and infant. Current literature on the subject implies that sensitive care consists of a combination of appropriate physical responses to the baby, such as gentle touch when baby cries (holding, rocking, etc.); feeding in a timely manner; being sure baby is dry, clean, and dressed for the weather; giving appropriate facial expressions in response to baby’s coos or cries; and an array of cognitive responses. The underlying cognitive responses are variously identified in the literature, but in this text will be referred to as Parental Reflective Functioning (PRF). PRF is defined by Midgley and Vrouva (2012) as the adult’s ability to consider both his/her own internal mental state and that of the child, and to understand how those mental states create behavior. Although no one can truly know what an infant is thinking, adults with strong PRF are aware that considering the infant as an individual person capable of thought, and wondering what those thoughts and feelings might be, is important to the care of the infant. Most often, skills related to PRF are learned from one’s own parents. However, according to Pajulo et al., “Mothers who have experienced considerable deprivation and trauma in their lifetimes but are nonetheless highly reflective are more likely to have securely attached children whereas their counterparts who have limited reflective capacities almost invariably have insecurely attached children” (2012, p. 72). Many of the interventions discussed in this text have a component of developing PRF in relation to building more secure parent–child relationships. Some interventions, notably Child–Parent Psychotherapy, are built almost entirely on working with PRF to improve attachment quality. Fortunately, PRF does appear to be amenable to change through group or individual intervention, even when the mother is struggling with Substance Use Disorder or other issues (Pajulo et al., 2012).

Another key concept relative to attachment quality is the regulation of emotion. When the baby senses danger or becomes upset, he or she will seek out an adult caregiver for safety and soothing. Caregivers then provide comfort and thus, help the infant to regulate his or her emotional states and arousal. Because the caregiver is a regular part of this arousal-comfort cycle, the child incorporates the caregiver and the usual response into his or her cognitive and biological schema of how emotions are handled. Babies learn quickly to seek out comfort in ways that do as little as possible to disrupt the normal cycle of events. Over time, the daily drama of care-seeking becomes a pattern of expected actions and responses that form a lasting attachment style (Slade, 2007). How this relational push-and-pull is established has implications for brain development, learning, emotional regulation, and mood throughout the lifespan (Bowlby, 1973; Cassidy, 1999; Zeanah & Smyke, 2009).

These very early experiences and relationships allow the child to develop what Bowlby called a secure base from which to explore the world. This secure base is the person to whom the child turns when he or she is frightened, hungry, tired, or otherwise in need of comfort or protection (Cassidy, 1999). When the secure base is present, the child feels more comfortable exploring the world around him- or herself more readily (Bowlby, 1969/1982). This preferential attachment to one or two primary caregivers becomes clear around 9 to 10 months and appears to be less clear once the child develops enough verbal skill to ask adults to meet specific needs (Zeanah, Berlin, & Boris, 2011). The balance between returning to the secure base for comfort and leaving to explore the world constitutes the observable behaviors of early attachment. This then leads to a cascade of later developmental shifts that create a cognitive template for how an individual approaches all relationships and how he or she views the world (Bowlby, 1969/1982; Cassidy, 1999). This template is often referred to as the inner working model, a key concept in Bowlby’s work and in later attachment research and therapies.

Infants who develop an inner working model of the world as safe and interesting, and of people as generally trustworthy and caring, generally go on to develop personality traits that match these cognitive models (Cassidy, 1999). In preschool children, secure attachments and healthy inner working models propel youngsters to engage with teachers and peers with excitement and joy. Behavioral problems in these children can be corrected by using cognitive behavioral strategies with relative ease and success. On the other hand, children who develop inner working models of the world as being dangerous and unpredictable, and of adults as frightening and dangerous, develop behavioral strategies based on survival. These survival strategies may help the child endure chaotic and violent homes but are not well received at school. In school, children who believe the world to be scary and chaotic often engage with peers violently in order to establish dominance or withdraw from social contact. With teachers and other adults, these children may be overly clingy and compliant in order to feel protected or may avoid contact with adults with violence or defiance (DeKlyen & Greenberg, 2016). Children with insecure or disorganized attachment also display increased levels of the stress hormone cortisol and more heart rate irregularity, both of which can have long-term deleterious health affects (Buckwalter & Reed, 2018).

Once a child’s inner working model is established, it can be difficult, but not impossible, to shift. Depending on how long the child has been exposed to fear-inducing environments and how the adults in those environments responded to the child’s concerns, counseling and other interventions can, over time, help the child believe he or she is safe and that other people can be trusted. This is also true of adults who have insecure attachments and fear-based inner working models. However, in order for counselors to be effective in helping clients to achieve changes in these deeply held, hardwired ways of seeing the world, expertise in how attachments form, are maintained, and can be changed is required (Buckwalter & Reed, 2018).

The development of interventions to help people with insecure attachment was always Bowlby’s primary interest in early relationship research (Zeanah et al., 2011). He went to work for the prestigious Tavistock Institute in London around the start of World War II, practicing as a child psychiatrist. Although most psychiatric practice at that time was psychoanalytic and focused on the competing inner impulses within the child and discounted the need to include parents in a child’s treatment, Bowlby worked with both the parents and the child in therapy. This practice was controversial in the 1940s and 1950s, causing Bowlby to feel a great pressure to produce positive results and research from his approach (Bretherton, 1992).

He found that when he talked with the parents about their own early experiences of care in front of the child, often important therapeutic breakthroughs occurred leading him to consider that attachment styles are intergenerational and below the conscious notice of most people. Much of Bowlby’s theory of attachment is set out in the seminal paper from 1958, “The nature of a child’s ties to his mother.” Essentially, Bowlby found that infants who have warm, caring, and competent care in early life tend to grow into securely attached children and adults. Meanwhile, infants whose early care is insufficient, inconsistent, or even purposefully frightening, tend to develop what Bowlby framed as an insecure attachment style.

While Bowlby became very interested in how these attachments form or fail to do so, his colleague Mary Ainsworth worked to learn more about the different ways in which a child might relate to his or her caregivers. Ainsworth, a developmental psychologist, joined the Tavistock Institute in 1950 (Bretherton, 1992). She left to go with her husband to Uganda in 1953, where she did some of her most important work regarding attachment theory. While in Uganda, Ainsworth closely observed mother–infant interactions. She learned the local language in order to be able to speak privately with mothers about child-rearing practices. The resulting book, Infancy in Uganda (1967), is widely considered to be a classic reading in ethnography and in infant attachment studies. In it, Ainsworth describes patterns of relating between mothers and babies in the African nation. Later comparison studies show that much of this behavior is very consistent from place to place, a key finding.

When Ainsworth returned to the United States, she began working on ways to tease apart healthy and unhealthy patterns of relating. She had witnessed differing levels of bonding between mothers and babies in her fieldwork, and wanted to learn more about how these patterns might be identified. Over the next few years, Ainsworth remained in close contact with Bowlby, giving him notes on his work, and continuing her observational work in Baltimore (Bretherton, 1992). In 1969, Ainsworth and Wittig published their findings and introduced the idea of the Strange Situation, which has since become the gold standard for attachment research.

Although not universally well received at the time, particularly by behaviorists, the method and findings of the Strange Situation Procedure (SSP) studies are now considered to be foundational classics in the field of child development (Cassidy & Shaver, 1999/2016). In the Strange Situation, a 1-year old and his or her mother enter a room where a research assistant sits. At first, the assistant ignores the dyad and sits quietly. Then, after a few minutes, the mother leaves the infant in the room with the stranger. The varying reactions of the children were recorded and categorized. Some infants barely seemed to notice their mother’s departure, while others cried inconsolably even after her return (Ainsworth, Blehar, Waters, & Wall, 1978).

Over the next decade, Ainsworth and her colleagues collected and analyzed dozens of mother–child interactions. Out of this work, they published another ground-breaking text, in 1978, Patterns of Attachment: A Psychological Study of the Strange Situation. In that text, a very detailed account of the interactions between mothers and infants in the Baltimore study are discussed. Behaviors such as crying, responsiveness to soothing, and avoidance of contact are counted by frequency and analyzed. This work laid the foundation for developing a clinically useful framework for identifying attachment problems (Zeanah & Smyke, 2009). It is important to note that although understanding attachment is important when working with the 0- to 5-year-old population, attachment styles do not directly ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• About the Contributors
• Introduction to Early Childhood Mental Health
• 1 Attachment: The Foundation of Mental Health
• 2 Prenatal Brain Development: A Foundation for All Brain Development
• 3 Beginning at the Beginning
• 4 Counseling Infants and Families
• 5 Counseling Toddlers (13–47 Months) and Their Families
• 6 Preschool to School-Aged (48–72 Months) Children
• 7 Getting Creative: Using Play and Expressive Arts
• 8 Working Across Systems of Care
• Index