Parenting)in)the)Early)Years) ! - - PDF document

Parenting)in)the)Early)Years)

! Presentation!(Word!version)!to!HRH!The!Duchess!of!Cambridge! ! By!Jane!BarlowA!Professor!of!EvidenceABased!Intervention!and! Policy!Evaluation,!University!of!Oxford! ! Argument)of)the)paper) !

• The!early!years!are!key!to!equalising!the!life!chances!of!

children!because!the!brain!is!highly!sensitivity!to!input!at! this!time!including!stress!

• Parents!play!a!key!role!in!moderating!the!stress!that!infants!

experience!via!the!‘attachment’!relationship!!

• Current!approaches!to!equalising!the!life!chances!of!very!

young!children!include!The!Healthy!Child!Programme!(HCP)! and!A!Better!Start!(ABS)! ) Equalising)the)life)chances)of)children) !

• In!order!to!equalise!life!chances!we!need!to!need!to!give!

every!child!the!best)start)in)life)(Marmot!2010)!

• 2!key!periods!–!pregnancy;!first!2!years!of!life!
• The!reason:!‘The!biological!embedding!of!adversities!during!

sensitive!developmental!periods’!(Shonkoff!2009;!2011)! ! Disadvantage)and)stress) ) One!recent!study!showed!that!exposure!to!disadvantaged! environments!as!indicated!by!low!income,!low!maternal! education,!unstable!family!structure,!and!harsh!parenting,!was! associated!with!a!reduced!Telomere!Length!(TL),!a!biological! marker!of!chronic!stress,!by!9!years!of!age!(Mitchell!et!al!2014)! ! Other!studies:!Maternal!depression!(Gotlib!et!al!2014);! Neighbourhood!disorder!(Theall!et!al!2014);!Childhood! adversities!(Kannanen!et!al!2010);!Exposure!to!violence!(Shalev!et! al!2014)!etc! ! DoseAdependent!relationship!with!early!life!stress!(Price!et!al! 2013)!! !

Stress)in)early)childhood) !

• Infant!and!toddler!stress!due!to!internal!(hunger,!discomfort!

etc)!or!external!(fear)!triggers;! ! Types)of)stress)in)early)childhood:!! !

• Positive!stress!–!normative:!brief!and!mild/moderate!in!

magnitude!

• Tolerable!stress!–!nonAnormative:!a!greater!magnitude!of!

adversity!or!threat!

• Toxic!stress!–!strong,!frequent!or!prolonged!activation!of!

stress!response!system!in!absence!of!buffering!of!adult! support!(NSCDC!2014)! ! Consequences)of)excessive/‘toxic’)stress) ) Disrupts)developing)brain)architecture)and)other)organ) systems)and)regulatory)functions;! !

• Physiology!–!hyperAresponsive/chronically!activated!stress!

response!

• Behaviour!–!maladaptive!responses!
• Learning!A!linguistic,!cognitive!and!other!skills!compromised!

! Increased)stressDrelated)chronic)disease,)unhealthy)lifestyles) and)widening)health)disparities)(Shonkoff)et)al)JAMA,)2009;) 2011)) ! Impact)of)early)exposure)to)stress)on)developing)brain) ) Exposure)to)stress) ) exposure!to!stress!during!the!early!postnatal!period!that! was!not!mediated!by!sensitive!parental!caregiving!had!an! impact!on!the!infant's!hypothalamicApituitaryA adrenocorticol!(HPA)!system!(Gunnar1994;!1997)! ! ) ) ) )

Exposure)to)PND) ) nearly!half!show!reduced!brain!activity!(Dawson!1997)! much!lower!levels!of!left!frontal!brain!activity!(joy;!interest;! anger)children!of!postnatally!depressed!mothers!at! substantially!increased!riskfor!depression!A!by!age!16! prevalence!was!more!than!40%,!with!the!average!age!of!first!

• nset!of!depression!at!age!14!(Murray,!2011)!

! ParentDinfant)interaction)–)a)central)) deDtoxifier)of)stress…) ! Looks)and)smiles!help!the!brain)to)grow! Baby!looks!at!mother;!sees!dilated!pupils!(evidence!that! sympathetic!nervous!system!aroused!and!happy);!own!nervous! system!is!aroused!A!heart!rate!increases;!this!lead!to!a!biochemical! response!in!which!‘pleasure!neuropeptides’!(betaendorphin!and! dopamine)!released!into!brain!and!helps!neurons!grow.!! ! Negative)looks!trigger!a!different!biochemical!response! (cortisol)!stops!these!hormones!and!related!growth!!(Gerhardt,! 2004)! ! Maltreatment)(toxic)stress)) ) Childhood!maltreatment!is!the!most)important)preventable) cause)of)psychopathology)accounting!for!about!45%!of!the! population!attributable!risk!for!childhood!onset!psychiatric! disorders!(Green!et!al!2010)! ! Childhood!maltreatment!is!associated!with!consistent!alterations! structure,)function)and)connectivity)of)brain) )! Maltreatment!is!associated!with!reliable!morphological!alterations! in!anterior!cingulate,!dorsal!lateral!prefrontal!and!orbitofrontal! cortex,!corpus!callosum!and!adult!hippocampus,!and!with! enhanced!amygdala!response!to!emotional!faces!and!diminished! striatal!response!to!anticipated!rewards.! !! Brain!regions!and!pathways!reported!to!differ!in!maltreated! individuals!are!predominantly!part!of!circuits)regulating)threat) detection)and)reward)anticipation.!!

Evidence!is!emerging!that!these!regions!and!interconnecting! pathways!have!sensitive!exposure!periods!when!they!are!most! vulnerable.(summarised!in!Teicher!and!Samson!2016)! ! ! ! Early!interaction!and!attachment! The!early!years!are!foundational…! ! Early)interaction)–)what)does)this)involve?) ! Early!parenting/interaction!with!infants/toddlers!promotes! ‘secure’!attachment!organisation!and!development!of!‘self’! ! The!following!factors!have!been!identified!as!being!important:!! !

• Sensitivity/attunement!(Woolf,!van!Ijzendoorn!1997)!
• MidArange!contingency!(Beebe!et!al!2010)!
• Reflective!function!(Fonagy!2002)!

! Attachment)outcomes) ) Secure)attachment!–!more!optimal!functioning!across!all! domains!scholastic,!emotional,!social!and!behavioural!adjustment,! peerArated!social!status!etc!(e.g.!Sroufe!2005)!! ! Insecure)attachment!–!less!optimal!functioning!across!all! domains!(Lecce!2008)! !

Sensitivity)and)Attunement) ! Parent!responds!gently!and!in!a!timely!way!to!infant!using!voice!

• r!touch!

!!! Sensitivity!accounts!for!around!oneAthird!of!the!variance!in!terms!

• f!attachment!security!(Woolf,!van!Ijzenddorn!1996)!

! Midrange)balance) )

• Interactions!between!parents!and!infants!prior!to!

acquisition!of!language!are!characterised!by!a!dance!A! ‘protoconversational!turntaking’!

• Moment!of!synchrony,!followed!by!rupture!(baby!breaks!

aways)!and!parents!who!is!sufficiently!attuned!picks!up!the! rupture!and!waits!for!the!infant!to!reAestablish!contact.!

• The!cycle!of!dance!then!repeats!itself,!synchrony,!rupture,!

repair! ! Midrange!Balance!Model!(Beebe!and!Lachmann!2005)! ! ) ) Parental)Reflective)Function)(PRF)) !

• Capacity!to!understand!the!infant’s!behaviour!in!terms!of!

internal!states/feelings.! !

• ‘The%capacity%of%the%parents%to%experience%the%baby%as%an%

‘intentional’%being%rather%than%simply%viewing%them%in%terms%

• f%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)! !

• Development!of!selfAorganization!is!dependent!on!the!

caregiver's!ability!to!communicate!understanding!of!the! child's!internal!states!via!‘marked!mirroring’! ! Studies)of)PRF) ! PRF!strongly!associated!with!maternal!parenting!behaviours!(e.g.! flexibility!and!responsiveness)!and!use!of!mothers!as!secure!base;! low!RF!associated!with!emotionally!unresponsive!maternal! behaviours!(withdrawal,!hositility,!intrusiveness)!!(Slade!et!al! 2001;!Grienenberger!et!al!2001)! ! Improvement!in!PRF!using!mentalisation!parenting!programme!A! improved!maternal!caregiving!and!infant!regulation!24;!36!!(e.g.! Suchman!et!al!2009;!2008)! ! …and)its)not)just)about)mums…) …dads)are)just)as)important) !

• Recent!research!shows!that!paternal!postnatal!depression!

can!have!an!effect!that!is!similar!in!magnitude!to!that!of! maternal!depression! !

• One!study!showed!that!boys!of!fathers!who!were!depressed!

during!the!postnatal!period!had!an!increased!risk!of!conduct! problems!at!age!3.5!years,!and!that!boys!of!fathers!who! were!depressed!during!both!the!prenatal!and!postnatal! periods!had!the!highest!risks!of!subsequent! psychopathology!at!3.5!years!and!psychiatric!diagnosis!at! seven!years!of!age!(Ramchandani!2008).! ! Vulnerable)parents) ParentDinfant)relationship)in)the)face)of)parental)problems) !

• Key!factors!–!Domestic!violence;!mental!health!problems;!

substance/alcohol!misuse;!unresolved!trauma!

• Infant’s!emotional!states!can!trigger!profound!discomfort!in!

parents!facing!these!problems!!

• Interaction!becomes!characterized!by:!!!

A!withdrawal,!distancing!or!neglect!(i.e.!omission)! A!intrusion!in!the!form!of!blaming,!shaming,!punishing!and!A! A!attacking!(i.e.!commission)!! ! FrD)and)atypical)parenting)behaviours) )

• FrAbehaviour!–!frightened!and!frightening!(Grienenberg!et!

al!1998);!hostile!and!helpless!(LyonsARuth!2005)!

• Atypical/anomalous!parenting!behaviours:!threatening!

(looming);!dissociative!(haunted!voice;!deferential/timid);! disrupted!(failure!to!repair,!lack!of!response,! insensitive/communication!error!(ibid)!

• MetaAanalysis!of!12!studies!showed!strong!association!

between!atypical!parenting!and!disorganised!attachment! (Madigan!2006)!

• Disorganised!attachment!–!significant!dysfunction!and!later!

psychopathology!(e.g.!Fearon!et!al!2010)!! ! ! Impact)on)prenatal)representations)on)attachment) !

• Maternal!representations!of!the!unborn!baby!(i.e.!conscious!

and!unconscious!mental!images)!change!during!the!course!

• f!pregnancy!
• Studies!that!measured!impact!of!prenatal!maternal!

representations!of!the!unborn!baby!showed!that!they!were! strongly!associated!with!postnatal!parentAinfant!interaction! and!with!infant!attachment!security!at!1!year!(Barlow!et!al,! forthcoming)! ! Equalising!the!lifeAchances!of!all!children! Promoting!sensitive!parenting!and!secure!attachments! !

) ) A)systems)approach)D)A)Better)Start)(ABS)) ! Moving!beyond!individual!interventions!to!considering!the!system! !

• The!Big!Lottery!Fund!invested!£215m!over!10!years!five!

local!area!partnerships!in!target!wards!within!Blackpool,!! Bradford,!Lambeth,!Nottingham!and!Southend!on!Sea.! !

• Aims!to!improve!the!life!chances!of!babies!and!very!young!

children!by!delivering!a!significant!increase!in!the!use!of! preventative!approaches!in!pregnancy!and!the!first!three! years!of!life.! !

• Providing!enhanced!pathways!of!support!based!on!local!

need!through!which!all!pregnant!women,!babies!and! children!aged!up!to!their!fourth!birthday!living!in!the!target! wards!can!benefit.! ! Summary) !

• The!early!years!are!foundational!for!later!development!

!

• Interaction!with!the!parent!is!key!to!all!aspects!of!a!child’s!

early!development! !

• Support!for!parents!who!need!additional!support!should!begin!

in!pregnancy!! !

• A!range!of!early!interventions!have!been!identified!as!being!

effective!in!improving!outcomes!for!vulnerable!dyads! !