Early Parenting and Prevention of Disorder

Psychoanalytic Research at Interdisciplinary Frontiers

Robert N. Emde

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429913068
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book is devoted to a topic that is fundamental value for psychoanalytic research; namely a quest for the roots of psychopathological impediments and disorders as well as the related question as to what extent these developmental disturbances can be avoided by adequate early parenting.

PART I

PERSPECTIVES

CHAPTER ONE


The prevention sciences of early development and challenging opportunities for psychoanalysis

Robert N. Emde

The sciences of early development, disorder prevention, and health have recently undergone momentous advances (see the reviews in American Academy of Pediatrics, 2012; Beardslee, Chien and Bell, 2011; Emde, 2012; Mercy & Saul, 2009; Rutter, 2011; Shonkoff, 2012). New knowledge and methods have generated new ways of thinking. Correspondingly, a greater awareness of science, suffering and the adverse effects of unattended early risk have all combined to energise preventive interventions. Such work, converting knowledge into practice, is necessarily interdisciplinary and collaborative, and leads both to exciting opportunities and challenges. As the reader of this volume will find, psychoanalysts have much to contribute and have vigorously joined in preventive work. This chapter provides an introduction for the perspectives and programmes of empirical research in the chapters that follow.

After reviewing some basic prevention concepts, including trials and the emerging field of implementation science, I will discuss my perspective on prevention principles that lead to psychoanalytic opportunities. A view of current science will then serve to introduce the chapters of the book that provide overviews of research in some remarkably creative prevention programmes. I believe the reader will be rewarded by experiences of sharing in the accounts of engaged psychoanalysts as they describe their working and their promising early results.

Prevention concepts, trials, and implementation¹

Prevention concepts in widespread use involve two different ways of thinking about intervention levels. Classic public health designations have been as primary, secondary, and tertiary. Primary prevention refers to intervention designed to prevent the onset of a disorder or condition before it occurs, secondary prevention refers to intervention designed to deal with early identification and treatment of a disorder (typically before it is symptomatic) and tertiary prevention to intervention via treatment of the disorder once it is identified as well as to minimising disability. More recently, useful concepts have included another set of intervention levels, with designations of universal, targeted, and indicated. Universal refers to interventions that are population—or community wide, for everyone, such as education about the adverse effects of smoking or alcohol intake during pregnancy or public campaigns about the encouragement of breastfeeding. Targeted refers to interventions that are designed for identified groups at high risk for problems, such as home visitation programmes for those living in extreme poverty and immigrant populations suffering from dislocation and trauma. Indicated refers to interventions that are designed for individuals already identified with problems or disorder, typically after screening procedures.

Aside from abstract concepts, learning by doing is the modus operandi of the prevention sciences, and such doing involves prevention trials. In framing the contributions of this book it is useful to review them, indicating why the sequencing of trials is important for the practice of prevention and why experimental trials (usually referred to as RCTs or randomised controlled trials) are at the centre of the prevention sciences.

A basic scheme or method strategy involves three kinds of preventive-intervention trials (Mrazek & Haggerty, 1994). These can be designated as pilot, experimental, and community. Most readers are probably familiar with experimental trials, often referred to as “the gold standard” for evidence (or not) of an intervention. Experimental trials have a particular method and format. They are considered crucial for the step-by-step establishing of evidence and progress, and as we consider psychoanalytic prevention work, it is essential to use them. One can think of experimental trials as a pure test of intervention. They involve using randomised control groups in order to minimise selection factors and better allow inferences about cause and effect. They also involve a standard intervention with a manualisation of that intervention so that assessments of consistency of application can take place.

Experimental trials, however, are not intended to occur without preparation. It is important to carry out pilot trials within an earlier prevention phase that includes problem identification and forming hypotheses about how to change the problem for the better. Such trials are exploratory, assessing feasibility, and they typically involve simple designs such as before-and-after evaluations and such contrast groups as can be assembled. Ideally, after pilot trials, a “theory of change” (Connell & Kubisch, 1998; Mackenzie & Blamey, 2005) can be constructed, based on evidence on hand, that can lead to the next phase of experimental trials.

Experimental trials, of course, are not intended to occur as an ends-in-themselves, or in isolation. Correspondingly, the next prevention phase is for community trials that have to do with real-world application. Such trials are expected to respond to local community needs and hence to be based on a community needs assessment. They also involve a necessary adaptation of the manualised intervention that has come forward from the phase of experimental trial(s). Community trials may involve randomised control designs (also considered by many the “gold standard” for purposes of evaluation) or they may involve a variety of “quasi-experimental” contrasts. An additional feature for community trials concerns “reach”. This refers to evaluating the extent to which the intervention can be widespread, reaching the people who really need it, as well as understanding the issues involved in uptake.

In the basic scheme the trials are set in sequence and are conceived of as a cycle, wherein the community trials generate new problem identification and hypotheses in pilot work, and in turn this leads to more work with experimental trials and later community application trials (as originally described in Mrazek & Haggerty, 1994). The scheme is, of course, idealised and not strictly linear as multiple phases often occur concurrently within a given project. As important, and as the studies reported in this book illustrate, the realities of funding and of different community needs typically require more and more community participation and engagement in all phases.

This leads us to concepts and strategies in prevention that we can refer to as the emerging field of “implementation science” (Eccles & Mittman, 2006). Two major trends in research and science policy are noteworthy. The first has to do with the translation of knowledge, indicating that more attention be paid (and hence more resources mobilised) for “translational research” that brings knowledge from basic research to human application and then to community practice. Knowledge of “efficacy” (referring to what is gleaned from experimental trials) must be linked with more knowledge of “efficiency” (referring to what is gained from community application). In the United States, increasing priorities in funding are directed at providing incentives for translational research (Woolf, 2008).

The second trend has to do with what has become an active subfield in itself known variously by the designations of community based participatory research (or CBPR), action research and partnered participatory research (Minkler & Wallerstein, 2008; Israel, Eng, Schultz & Parker, 2005). This sub-field provides an orientation and methods that emphasise partnering with communities during all phases of prevention as well as in related research that is community-driven, flexible, and action-oriented. Much of its strategies are aimed at reducing health, education, and socio-economic disparities (Wallerstein & Duran, 2006) and there is a journal devoted to it (Progress in Community Health Partnerships: Research Education and Action).

The reader will see that the psychoanalytically inspired projects described in this book are in varying degrees participatory, action-oriented, and mixed in terms of prevention phases. The language, concepts, and methods of the prevention sciences, reviewed above, will be referenced. Moreover, as appropriate, vivid descriptions will be portrayed involving context and process as well as outcomes. This leads me to put forth some principles of preventive interventions that are not only central, but link to psychoanalytic areas of future opportunity.

Principles of prevention and psychoanalytic opportunities

I choose to highlight five. First is that prevention deals with health as well as illness, and that health is more than the absence of illness. Thus health promotion needs to be considered alongside of disease or disorder prevention. A scheme portrayed in Table 1 illustrates how we used this principle in setting long-term goals for our earlier birth-to-age-three collaborative intervention known in the United States as Early Head Start (EHS in Table 1). Note that competency dimensions of learning and social development are specified for age periods, both for promotion goals as well as for prevention goals (Emde & Robinson, 2000).

Table 1. A scheme for age of assessment using a parenting-to-parenting perspective for outcomes following early head start intervention at 0–3 years (Table modified form figure in Emde & Robinson, 2000).

Developmental period	Age of assessment	Competency dimension	Promoting	Preventing
Pre-school	3 years	Learning	Exploration; persistence in tasks	Lack of motivation for exploration
		Social	Communication skils	Social isolation; disruptive behaviours
Primary school	7 Years	Learning	Learning readiness for school	Lack of engagement in learning
		Social	Social competencies for relationships	Disruptive behaviour disorders
Middle childhood	10 Years	Learning	School engagement	Detention, referral to special education
		Social	Positive peer relations	Disruptive behaviours and disorders
Adolescence	17 Years	Learning	Grade completion	School drop-out
		Social	Positive peer relations	Anti-social behaviour, gang membership
Adulthood	25 Years	Learning	Employment/education beyond H.S.	Unemployment
		Social	Intimate relationships	Social isolation

A second principle is that prevention deals with regulation, which is a central process for living activity and health. It is important to be mindful of the inverted U curve that can represent the relation of activation (on the vertical axis) to performance (on the horizontal axis). I find it worth remembering that this simple function, paradoxically, is one of the most profound and pervasive in biology. Adaptive regulation occurs between “enough” and “too much”—the “golden mean”—in systems at all levels, from cell, to psyche, to human interactions. Those concerned with health and prevention have emphasised the central significance of this aspect of regulation for metabolic functions and for fitness, for example, with enough exercise and other health adequate behaviours needed to promote health and longevity as well as to prevent disease (Bortz, 2011).

A third principle is that all preventive interventions deal with context, taking place within particular cultures, circumstances, and relationships. For meaning and effectiveness, such contexts with their associated values must be understood and taken into account (Sameroff, 2010; Spoth, Kavanagh & Dishion, 2002; Emde & Spicer, 2000).

The principles of health, regulation, and context conjoin in a fourth principle, namely that all prevention deals with development. The goal is to promote healthy development and prevent disruptions in development within individuals over time. Prevention is lifespan in its scope. Adverse human behaviour and decision-making, much of it automatic and non-conscious, is a major cause of morbidity and mortality (Kessler, Ormel & Petukhova, 2011; Kahnemann, 2011; Martineau, Hollands & Fletcher, 2012). As a consequence, more attention is being given in prevention—for both children and parents—to ways of engaging personal knowledge and responsibility with a goal of changing unhealthy behaviours. More poignantly, from the perspective of this book, parenting occurs at different times in development and furthermore, as Table 1 illustrates, our preventive interventions have a goal that our infants and children eventually become healthy and effective parents. The special importance of early experience, recognised in the prevention sciences, is reflected in the contributions of this book, as well as the fact that there is an increasing principled appreciation of individual pathways, related to biology and context.

A final principle I highlight is an appreciation of the complexity of disorders. Individual developmental pathways are not linear in any simple way and there are many pathways to disorder. A striking finding since the human genome has been mapped is that most disorders and developmental outcomes are caused by many genes, not few, and that genetic influences vary and interact. Furthermore, genetic expression is strongly influenced by an individual’s internal regulatory interactions and environmental conditions—and these change as a function of development and circumstance (Mattick, 2011; Meaney, 2010; Roth & Sweatt, 2011; Rutter, 2011). Thus the basic function represented by an inverted U curve is interacting within a complex network. What this means in terms of prevention is that many interventions, applied early, may work and that in addition to specific interventions (for example as in avoidance of alcohol and toxins during pregnancy, reduction of exposure to trauma, treatment of parental depression) there is likely to be a role for non-specific interventions (e.g., minimisation of stress, social support, adequate diet, and exercise). Complexity also means that early preventive interventions are not permanent immunisations against disorder; they need to be followed by adequate environments and opportunities for later development.

How does this discussion link to psychoanalytic opportunities? Table 1 indicates how each of these princ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• About the Editors and Contributors
• Preface
• Foreword and Acknowledgements
• Part I: Perspectives
• Part II: Early Prevention Programmes
• Part III: Interdisciplinary Research in Frankfurt
• Part IV: Clinical Applications
• Index