Hazards and hopes in the early years

Whenever a new baby arrives on the scene, it is stressful for the family. 

Robin Balbernie
Clinical Director of PIP (Parent Infant Partnership) UK

A parent who carries a burden of anxiety from multiple sources will not be able to greet the baby with an open mind. Caregivers who can hold their child in mind at all times create secure attachment, the best foundation on which to build all the later skills that normal development will make possible. A mind full of stressors cannot always embrace a child. There is a large body of research (e.g. Karr-Morse & Wiley, 1997 & 2012; Osofsky & Thompson, 2000; Sameroff, 2000) on all the negative influences that can impact the caregiving relationship, with general agreement on what these are and how they affect the capacity to parent - perhaps largely because they fill the parents’ minds with so many conscious and unconscious issues that there is less space for the child. The Adverse Childhood Experiences Study (Felitti et al., 1998), where the sample is sufficiently affluent to afford good quality private health care, has clearly shown how a build-up of traumatising events in the family environment is a predictor for, among other things, serious physical and mental ill health, being both a perpetrator and a victim of domestic violence, and for substance abuse and suicide (see Figure 1). These risks are easily spotted. In the UK context during the pre-natal period the midwife is in the best position to do this, and then the health visitor takes over the role of early warning system for the mental and emotional health of the next generation once the baby is born.Whenever a new baby arrives on the scene, it is stressful for the family. We have the most extended period of juvenile dependency of any species and worries about the young child activate the caregiving system, so until adulthood (and beyond) children are designed to tax their parents. This is both normal and can be thought of as a spectrum. At one end, those caring for the baby have confidence that although there will inevitably be upsets and dramas, it will be possible to overcome these, while at the red end, the additional responsibility of a baby can be a stress too far for another family. Of course, very few parents anticipate the latter, although there are parents-to-be who resent or dread having a baby, sometimes to the point of fear. This is where the sensitive midwife, educator or family worker is crucial in enlisting specialist help in the pre-natal period.

We need to be continually aware of how the parent-baby relationship is always located in a much wider ecological context, within which are found both risk and protective factors. These can harm the baby directly (e.g. pollution, abuse, poor diet, unhealthy housing) but mostly are titrated into the relationship via their effects on the parents’ functioning, since the parents dictate the baby’s immediate experiences. The Millennium Cohort Study (Sabates & Dex, 2012:22) has confirmed that, ‘the greater the number of risks experienced by the child, the greater the problems that the child will face during the life course’.

The caregiving relationship synthesises nature and nurture

Nurture and nature can no longer be regarded as discretely separate issues, and the caregiving relationship synthesises the two. ‘Genetic susceptibilities are activated and displayed in the context of environmental influences. Brain development is exquisitely tuned to environmental inputs that, in turn, shape its emerging architecture. The environment provided by the child’s first caregivers has profound effects on virtually every facet of early development, ranging from the health and integrity of the baby at birth to the child’s readiness to start school at age 5’ (Shonkoff & Phillips, 2000:219). This even goes down to the genetic level, as through epigenetic changes caregiving can cause ‘long-lasting differences in genes critical for behaviour, stress responsivity, metabolic control and auto-immunity leading to emergence of disease later in life’ (Syf, 2009:879). Some parents are overburdened by negative factors, past and present, which are beyond their control. They need non-judgemental assistance as soon as possible if we want to break the cycle of emotional deprivation.

Some (but certainly not all) of the risk factors known to adversely affect the parent-baby relationship are as follows:

• Low birth weight baby or congenital abnormalities; 
• A parent who lacks the ability to sensitively attune to the baby’s needs and who does not interact with the infant or maltreats him or her; 
• One or both parents struggling with a mental health or addiction problem;
• Or with a background of abuse, neglect or loss in their own childhood; 
• Inadequate income or sub-standard housing; 
• Family dysfunction including (extremely harmful) domestic violence; 
• A single teenage mother without support.

So many factors external to the baby and parent can disrupt their relationship; and multiple problems impacting an infant in the first two years of life pretty well predict that the child, without intervention, will grow up struggling with emotional and cognitive adversity that will be a disadvantage in all areas of life. Intervention may have to be on several levels, taking into account multiple causality.

A working assumption that can direct both early and later intervention is that ‘attachment disruption may be a marker or summary variable for a number of pathogenic factors in the child’s environment’ (Kobak et al., 2001:254). The baby can have no comparisons; what the baby meets is simply how the whole world is organised (and why should it change?) and this is what he or she will automatically adapt to. The immediate relationship-based environment and all that affects it will programme the child’s emotional and cognitive software one way or another fairly rapidly. ‘As a source of risk, the home may reflect an atmosphere of disorganization, neglect, or frank abuse. As a source of resilience and growth-promotion, it is characterized by regularized routines and both a physical and a psychological milieu that supports healthy child-caregiver interactions and rich opportunities for learning’ (Shonkoff & Phillips, 2000:345).

The research on risk factors means that babies who might be likely to have adverse developmental pathways through life, because of stresses in their initial relationship with their parents, can be identified early on. Even the unborn child cannot be assumed to be safe. The foetus can be directly harmed by a number of toxins (including the effects of stress on the mother) which can cause disability, regulatory disorders, attention difficulties or skill deficits, any one of which may make it both hard for the neonate to settle into an attachment relationship and make them vulnerable to stressed parenting. ‘Children born already impaired are more likely to bear the brunt of destructive parenting behaviours and abuse’ (Karr-Morse & Wiley, 1997:55). A major hazard, the single biggest cause of cognitive delay in developed countries, is maternal alcohol consumption during pregnancy. However, all forms of substance abuse are potent risks in addition to the teratogenic effect, both from the associated life-style and the psychology of those parents who are still struggling with unmet dependency needs.

Over and above the effects of drugs on the embryo, a child born to parents with addiction problems may well develop attachment difficulties as addiction in any form flags up an attachment-related disorder, insofar as it gives the illusion of a ‘safe’ dependency where the object of desire is controllable. A vulnerable baby does not have to experience distress and damage that he or she cannot comprehend before help is offered. The greater the number of risk factors found in a family’s total ecology, then the greater the need for immediate assistance. The infant mental health teams established by the Parent Infant Partnership UK (www.pipuk.org.uk) use a risk analysis in their Request for Service form. But sadly, the more a family is under stress, the harder it becomes to make full use of any help being made available. Only a relationship can change a relationship, but if a parent is feeling ground down by inner and outer circumstances then a new relationship is hard to contemplate.

However, along with pressures on the caregiving relationship, there will almost always be strengths that can be built upon. Improving parenting capability, if it is to be positive for the family, must build upon the protective factors within and around the parents. To promote infant wellbeing it is necessary to promote the proficiency and resilience of the parents. This is why in the UK, children’s centres which are accessed by all parents, are the bedrock of early intervention, from the universal to the very specialist. If a family is targeted for services solely on the basis of the known risk factors that correlate with child maltreatment this may indeed employ scarce resources for those most in need, but will alienate families who (justifiably) do not want to be labelled ‘bad’ parents or abusers. A visibly targeted service will inevitably not be trusted by the most vulnerable as the fear of having a child removed will overwhelm rational thought. Forcing children’s centres (where they still survive) to target their help is a very unwise move that, should the day arrive when services for the most vulnerable are not being cut in the name of austerity, will make it hard for them to recover the foundation of community trust that was once their main strength.

Interventions must have a strengths-based orientation

Risks identify susceptibility; they are not an infallible forecast of disaster. And maltreatment may equally occur in high-income families who seem to have all the advantages of life – including the ability to conceal. This means that interventions, to be acceptable on a broad front, must have a strength-based orientation (not solely a deficit model). This has the potential to be more inclusive, and offers a greater capacity to engage with other partner agencies in the community around a resilience framework that can help everyone involved see how their work can contribute to preventing maltreatment. Resources are as important as risks. Some of the most important protective factors for any family are as follows:

1. Parental resilience: Managing stress and functioning well when faced with challenges and adversities, being able to conceive of alternative futures.
2. Social connections: Having a sense of connectedness with constructive, supportive people and institutions where trust can be built upon.
3. Knowledge of parenting and child development: Understanding parenting best practices and developmentally appropriate child skills and behaviours and how these change.
4. Concrete support in times of need: Identifying, accessing and receiving adult, child and family services and appropriate and adequate benefits.
5. Nurturing social and emotional competence of children: Forming secure adult and peer relationships; experiencing, regulating and expressing emotions in a healthy manner.
6. Nurturing attachment: providing parent-child experiences that lay the foundation for the warm secure bond that is the bedrock of future development. (Browne, 2014:4)

Getting the first, prototypical, important relationship of anyone’s life more or less right is a necessity not a luxury. This is the most sensible and economic time to put in therapeutic resources when needed. And furthermore, unique to this stage of life, one can guarantee that the child both wants to cooperate and has not got stuck in the trap of gaining self-esteem from antisocial acts. This is society’s best chance to help itself. ‘The interactive process most protective against later violent behaviour begins in the first year after birth: the formation of a secure attachment relationship with a primary caregiver. Here in one relationship lies the foundation of three key protective factors that mitigate against later aggression: the learning of empathy or emotional attachment to others; the opportunity to learn control and balance feelings, especially those that can be destructive; and the opportunity to develop capacities for higher levels of cognitive processing’ (Karr-Morse & Wiley, 1997:184).

The most important risk factor for maladjustment is poverty

The analysis of risk factors, which ‘is an exercise in estimating probabilities, not finding causes’ (Sameroff, 2000:28), along with a balancing of strengths, clearly shows how the relationships within a family can be distorted by external pressures which may need intervention on a social level as much (if not more) as their emotional consequences need help on a personal level. For instance, the single most important broad risk factor that predicts later maladjustment is poverty (Brooks-Gunn et al., 2000; Halpern, 1993), since this amplifies and concentrates all the other risks. ‘Low income creates a particularly stressful context in which positive interactions with children are threatened, and punitive or otherwise negative relationships may result. The high prevalence of depression, attachment difficulties and posttraumatic stress among mothers living in poverty serves to undermine their development of empathy, sensitivity, and responsiveness to their children, which can lead to diminished parenting behaviours and learning opportunities and poorer developmental outcomes’ (Shonkoff & Phillips, 2000:353). The effects of inadequate financial resources can be partially addressed in many instances, as can other adverse factors, but ultimately it takes individualised responsive care and a therapeutic relationship to change a pattern of caregiving.

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