Keeping The Baby In Mind

Infant Mental Health in Practice

Jane Barlow, P.O. Svanberg, Jane Barlow, P.O. Svanberg

• Publisher: Routledge
• Year: 2009
• Print ISBN: 9780415442978
• eBook ISBN: 9781134106998
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Keeping the Baby in Mind builds on the expanding evidence pointing to the crucial importance of parents in facilitating their baby's development, and brings together expert contributors to examine a range of innovative psychological and psychotherapeutic interventions that are currently being used to support parents and their infants. It not only provides an overview of the many projects that are now available but also makes recommendations for future practice and the way in which children's services are organised.

The book brings together interventions and ways of working that can be used both universally to support parents during the transition to parenthood, and with high-risk groups of parents where for example there may be child protection concerns or parents experience severe mental health problems. Each chapter describes the evidence supporting the need for such interventions and the approach being developed, and concludes with a description of its evaluation.

Keeping the Baby in Mind marks a new and exciting phase in the development of interventions to support infant mental health and will be of interest across a wide range of disciplines from primary and community care to early years and Children's Centre settings.

1 Keeping the baby in mind

Jane Barlow and P. O. Svanberg

It is not easy being a baby in the hurried, post-industrial world of twenty-first-century Britain. Although their chances of survival are much higher than in the past, babies are not naturally designed for a noisy, fast and over-stimulating environment. The task of parenting has also been made much harder by the wide-ranging social changes that have taken place in the family, and a falling-off in the level of support that has been available during pregnancy and the postnatal period to date. There is, in addition, a general lack of understanding in the UK about how to intervene effectively to support parenting and the parent–infant relationship during the perinatal period, and a paucity of primary preventive, early intervention and infant mental health services.

The aim of this book is to try to address some of these challenges by bringing together significant early interventions that are being used in the UK, and which have as their focus the aim of improving the social and emotional well-being of infants and toddlers. The interventions that are reviewed in this volume are based on evidence concerning the benefits of intervening early, alongside recent research pointing to the importance of the first two years of life for later development.

This chapter will provide a brief review of the policy context for recent developments in Britain, alongside an examination of the development of the discipline of ‘infant mental health’ internationally. We review recent developments in the field of attachment and beyond, before providing a summary of some of the new methods of working to promote infant mental health.

The policy context

The current UK government has been the first to prioritise the promotion of health and well-being in the early years. The Sure Start initiative in England and Wales (DfES, 1999), partly modelled on Early Head Start in the US, reflected the government’s views expressed in the Consultation Paper Supporting Families (in addition to other documents published since then including Every Child Matters (DfES, 2003), The National Service Framework for Children, Young People and Maternity Services (DH 2004), and the public health White Paper Choosing Health (DH 2004), about the importance of the family environment, and parenting in particular, in determining key outcomes for children.

The emphasis in Sure Start on local autonomy and empowering the local community through the use of a ‘bottom up’ approach to service provision, alongside a reluctance to prescribe models or protocols, gave rise for the first time to the development of a range of innovative parent–infant programmes. However, these pockets of innovation (which tended to have in common a lead from a psychologist or a child psychotherapist, very close multi-disciplinary work with health visitors and family support workers, and a focus on the parent–infant relationship) have on the whole been masked by a continuity in the standard focus of practitioners working within Sure Start (particularly midwives and health visitors) (Barlow et al., 2007). In addition, the move to Children’s Centres has been underpinned by an emphasis on educational outcomes alongside a retreat from prevention and a gradual return of focus to toddlers and young children. Consequently a number of emerging and highly innovative infant mental health programmes and projects across the country have been lost.

Most recently, however, ‘Aiming High for Children: Supporting the Family’ (HM Treasury, 2007) has emphasised the need to increase the resilience of children by supporting parenting through early intervention. The introduction of home visiting programmes in ten demonstration sites across the UK, beginning during pregnancy and continuing until the child is 2 years of age, has thereby introduced a way of working with families that is evidence-based (Olds et al., 1986, 1999, 2007) and underpinned by attachment theory.

There is, however, still a paucity of innovative infant mental health programmes being used as part of standard practice in the UK, and considerable scope for improvement.

Infant mental health in the twenty-first century

The emergence of innovative infant mental health programmes in some Sure Start centres, and across the UK more generally, was due in part to the rise of a group of practitioners who believed that ‘infant mental health’ was formative in the later health of children and adults. The discipline of infant mental health began in the US in the immediate post-war years of the last century when Fraiberg (1977) was using her work with congenitally blind babies to understand the needs of ‘normal’ infants, and the types of developmental deviations and delays that can occur. The ‘ghosts in the nursery’ (Fraiberg et al., 1980) referred to ‘the visitors from the unremembered pasts of the parents’ and emphasised the ways in which aspects of the mother’s internal world continued to influence the way in which she interacted with and cared for her own baby, and in particular the way in which this could condemn her to ‘repeat the tragedy of [her] own childhood with [her] own baby in terrible and exacting detail’ (ibid.: 101). The model of intervention developed by Fraiberg involved intensive psychoanalytically informed work with extremely deprived parents and infants, and was eventually to become what we now call parent–infant psychotherapy.

At around the same time in the UK, Esther Bick, a physician and psychoanalyst who had moved to London in 1938, developed a method of infant observation that encouraged observers to watch and listen to babies during the first and second years of life in order to chart the changes taking place. Bick focused attention on the earliest stages of mental development in the infant, and this model of infant observation became the basis for child and infant psychotherapy training in the UK, and eventually served as the basis for early therapeutic intervention.

Alongside Bick at the Tavistock Clinic, John Bowlby was beginning his seminal work on infant attachment. Bowlby was the first person to identify the infant’s need for a trusted attachment figure. Attachment theory (Bowlby, 1969), which was developed in the post-war atmosphere of loss and bereavement, emphasised that it was real lived experiences, in terms of the way that parents actually treat their children and the sense that children make of these experiences, that are of key importance in children’s development. Following Bick and Bowlby in the 1970s the Tavistock Clinic set up the first ‘Under-Fives Counselling Service’ in the country, using the skills learned from infant observation (Miller, 1992), and Dilys Daws pioneered child psychotherapy in the baby clinic at the James Wigg General Practice in London (Daws, 1985, 2006).

Two further seminal thinkers emerged in the field of infant mental health – Daniel Stern and Edward Tronick. Building on the work of Trevarthen (1980), these developmental psychologists began to explore the ‘protoconversational turn taking’ occurring between mother and infant, which is now recognised to be characterised by a ‘rhythmical pattern of looking and withdrawal’ (Stern, 1985; Tronick and Cohn, 1989). This gave rise to a series of research studies based on videotape films of micro-interactions showing that mother and baby engage in a synchronous dance made up of brief periods of attunement followed by brief periods of disruption. These researchers showed that the baby is able to ‘control’ this input by looking away, and that ‘attuned’ mothers are able to engage in this ‘dance’ by regulating their interaction to meet the baby’s needs, and by repairing disruptions. Not all mothers are able to engage in attuned interaction of this nature, however, and women experiencing depression or unresolved loss, for example, can overwhelm the baby with their intrusiveness. As a result, such infants experience extended periods of disruption rather than attunement. Where this disruption is sufficiently chronic, it may eventually be systematised into a defensive ‘avoidant’ stance, which has been documented as early as 3 months of age. The importance of these findings is that later research has shown that such early disturbances in mother–child interactions are implicated in a range of longer-term adverse child cognitive (Meins, 1997) and emotional outcomes (Caplan et al., 1989; Cogill et al., 1986) including behavioural problems (Murray and Cooper, 1997).

More recently the development of new techniques within the field of neuro-developmental science has facilitated the conduct of research which points to a significant impact of the early caregiving environment (i.e. interactions with key people in the baby’s environment) on the developing brain.¹ In conjunction with research from a range of other disciplines, these findings suggest that babies not only build their brains as a result of this early interaction, but that they also build their minds and construct a sense of themselves that will last them a lifetime (for an overview see Schore, 2001 or Gerhardt, 2004).

Together, these early theorists facilitated a new way of viewing babies by drawing attention for the first time to the importance of the baby’s ‘emotional’ well-being, particularly their capacity for emotional regulation, and to the way in which the primary caretaker influences this. This was to become part of a rapidly expanding infant mental health movement, underpinned by a recognition of the ‘social baby’ (i.e. the way in which babies are born primed to be sociable (Murray and Andrews, 2000)), their sensitivity to the quality of their interactions with other people (Murray and Cooper, 1997), and more recently a recognition that the process of regulation between mother and baby is dynamic and bi-directional – that is, there is considerable co-regulation taking place between them (Beebe et al., 1997) – and of the importance of primary caregivers being able to ‘keep the baby in mind’ (Fonagy et al., 1991a).

Attachment and beyond

Bowlby (1969) described how attachment in evolutionary terms increases the likelihood of the infant’s survival. More recently, researchers have begun to recognise that attachment has more far-reaching functions in terms of the way in which the proximity of the mother helps the infant to modulate or regulate an aroused emotional state, until they are able to do this for themselves.² Securely attached infants³ seek comfort when distressed and recover from an aroused, disorganised state to a calm, organised state when comforted. Insecurely attached infants, however, are unable to use the caregiver to modulate their aroused state. They may over-regulate,⁴ under-regulate,⁵ or show evidence of both, reflecting conflicting emotions.⁶

Ainsworth and her colleagues (1978) showed that these insecure attachment behaviours are help-seeking strategies that have been ‘moulded’ by the caregiver’s inability to provide ‘sensitive-enough’ caregiving. Avoidant (Type A) infants learn to ‘down-regulate’, to inhibit expression of affect - in particular distress – whilst Ambivalent (Type C) infants are unable to predict or anticipate continuity and proximity of the caregiver and consequently become highly vigilant, guarding against anticipated abandonment/separation, usually with great displays of affect, i.e. they learn to ‘up-regulate’. Main and her colleagues have argued that there is an additional category of Disorganised/Disorientated (Type D) infants (Main and Solomon, 1986, 1990) who have experienced caregiving from mothers who were either frightened or frightening and who as a consequence are unable to sustain a coherent attachment strategy, i.e. they are disorganised. However, Crittenden (2000b, 2002) has argued that these attachment behaviours are in fact highly organised in response to threatening or dangerous environments, which can be highly contingent and/or highly unpredictable. She has identified a number of Compulsive (Type A+) infants, Coy/Coercive (Type C+) infants, and a group of infants who show a combination of strategies (Type A/C).

Attachment is important because it provides the infant with a ‘secure base’ from which to begin to explore the world, and because it acts as a prototype for later relations (Bowlby, 1988). Thus, infants’ early attachment interactions are eventually internalised, becoming an ‘internal working model’ that enables them to know what to expect in terms of their interactions with other people (Bowlby, 1969, 1989). This ‘representational model’ provides children with a very early set of expectations in relation to ‘self’ and ‘self with others’ that will continue with them throughout their life (see, for example, Prior and Glaser, 2006). While internal working models may be modified through experience, they mainly function outside of awareness and are therefore resistant to change (Crittenden, 1990). Insecurely attached children range from expecting others to be unresponsive, unavailable and unwilling to meet their needs, to being threatening, abusive and/or endangering.

The availability of the Strange Situation and additional methods of assessing the attachment of older children led to a formidable explosion of research which has not yet abated (Belsky, 1999). A number of longitudinal studies following children for up to twenty years (e.g. Sroufe et al., 2005) have also attested to the great vulnerability of insecurely attached children in terms of their high risk of developing psychological and psychiatric disorders.

Researchers have also begun to disentangle the intergenerational continuities in attachment patterns and have identified a significant association between a parent’s security of attachment (internal working model) and the likelihood that their baby will be securely attached (Fonagy et al., 1991b). This suggests that insecurely attached adults are more likely to have insecurely attached babies.

The most crucial indication of a parent’s attachment status is the way in which a parent thinks about the early care that they received, which can be measured using the Adult Attachment Intervi...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contributors
• Foreword
• 1 Keeping the baby in mind
• PART I Universal approaches
• PART II Targeted approaches
• PART III Indicated approaches
• PART IV Postscript