Therapeutic Approaches with Babies and Young Children in Care

Observation and Attention

Jenifer Wakelyn

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781000020229
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Therapeutic Approachesfor Babies and Young Children in Care: Observation and Attention is about the value of observation and close attention for babies and young children who may be vulnerable to psychological and attachment difficulties. Case studies explore the potential for observation-based therapeutic approaches to support caregivers, social workers, and professional networks. A third theme in the book is the roots of observation-based approaches in psychoanalytic infant observation and the contribution of these ways of working to professional training and continuing development.

Using case examples, Jenifer Wakelyn illustrates observational ways of working that can be practised by professionals and family members to help children express themselves and feel understood. The interventions focus on the early stages of life in care and on the "golden thread" of relationships with caregivers. The book explores contemporary neuroscience and child development research alongside psychoanalytic theory to explore the role of attention in helping children to develop the internal continuity that sustains the personality and protects against the fragmenting impact of trauma.

Therapeutic Approaches forBabies and Young Children in Care is written for social workers, teachers, medical staff, and other professionals whose work brings them in contact with the youngest children in care; it will also be relevant for commissioners, managers, and trainers as well as mental health clinicians who are starting to work with children in care. It will provide a valuable insight into the lives of infants and young children in the care system and the applications of psychoanalytic infant observation.

CHAPTER ONE

Being seen

Interaction with a responsive adult is intimately connected with a baby’s development from the first moments of life. As parents think about their baby and try to understand what he or she might be feeling, they are providing something very important for their baby’s development. When a parent is able to be attentive to a baby who is crying, powerful feelings such as fear, hunger, or discomfort can be made sense of, and the baby has the experience of being attended to and thought about. Repeated interactions of this kind allow the baby to develop the expectation of being responded to, taken seriously, cared for, and helped. The psychoanalyst Wilfred Bion (1962) called this emotional linking between baby and parent “containment”. For Winnicott, the receptivity and responsiveness to the baby’s moods and needs that a mother intuitively provides is a form of “holding” that allows the baby to have a feeling of “going-on-being” (1962). A parent’s heightened preoccupation with the baby’s needs seems to be nature’s way of reinforcing the parent–child bond.

Containment provides the basis for emotional growth: the infant’s raw and powerful feelings are taken in, while also a change is brought about in them. When the feelings are understood, put into words, or simply accepted by the caregiving adult, they become more digestible, less overwhelming. The child psychotherapist Shirley Hoxter puts it like this:

The mother who is not too immersed in her own difficulties replies to the infant’s behaviour, his varied cries, his kicks and screams, his inertia or limpness, his smiles and gurgles, as though she believes that such behaviour is a meaningful communication which requires to be understood and responded to. Her response is probably an essential prerequisite enabling the baby gradually to build up some form of realization of his own that behaviour is meaningful and communicative. Such experience accumulates from innumerable little incidents.

[1977, p. 215]

Psychoanalytic writers and child development researchers who come to the study of childhood from different perspectives agree that the earliest experiences with caregivers are formative. The Harvard Center for the Developing Child (2018) uses the metaphor of “serve and return” to describe cycles of attuned interaction between child and caregiver. The baby “serves”, sending a signal as he slightly opens his mouth, moves his tongue, or lifts his eyebrows. The parent or caregiver, watching closely, “returns” by echoing the infant’s facial expression, perhaps slightly amplifying it, introducing a slight variation, or accompanying the return signal with a matching sound. The infant watches the face of the adult with equally rapt attention, and further sequences of “serve and return” bring a glow to the face of baby and adult alike, until the baby turns away for a rest. During these interactive sequences, pleasurable hormones are released that motivate baby and parent to come back for more, reinforcing the bond between child and caregiver (Ungar, 2017).

[A]n enormous amount of the activity of the child during the first year and a half of life is extraordinarily social and communicative. . . . When the child’s attachment to the mother (or caretaker) is initially assured by a variety of innate response patterns, there very quickly develops a reciprocity that the infant comes to anticipate and count on.

[Bruner, 1983, p. 72]

In her book, Why Love Matters, Sue Gerhardt (2015) provides an engrossing account of neuroscientific discoveries that have confirmed the suppositions of the first psychoanalysts about the formative nature of early experience. Another readable account is provided by Lynne Murray and Liz Andrews in their book The Social Baby: Understanding Babies’ Communication from Birth (2005), which is illustrated with photographs.

During moments of close reciprocal attention, the infant’s physiological systems are fully activated (Music, 2016). New connections being made in the infant’s brain—and even, to a lesser degree, in the brain of the responding adult—promote the capacities for recognizing emotions and for thinking. A baby whose parent or caregiver attends closely to his signals experiences a range of emotions in response to the expressive face and voice of his partner in this interactive “dance”. In Finding Your Way with Your Baby: The Emotional Life of Parents and Babies (2015), Dilys Daws and Alex de Rementeria describe how, in gaining the fundamental security of experiencing his or her feelings being understood and known by another person, the baby also comes to know about the range of human feelings. In ordinary parenting, the to and fro of responsive interaction is repeated innumerable times. Following the misunderstandings and interruptions that are part of the fabric of daily life, efforts to work out what went wrong, and to repair, help the infant–parent couple to get back on track. Being seen and attended to, and becoming re-attuned after an interruption or a mismatch, are fundamental experiences of relating to another that enable infants, over time, to come to know their own feelings (Stern, 2004; Trevarthen, 2001). Infants who regularly experience these everyday but highly complex interactions gradually develop the ability to regulate their feelings for themselves.

Adversity in infancy

Trauma and the response to trauma

The fundamental early experiences of being seen and responded to in safe, nurturing, and stimulating ways are interrupted, or may never have become established, for children who cannot be looked after by their parents. Babies who lack these experiences of attunement, or have significantly less of them, are more likely to struggle in their development. In the absence of an understanding or comforting response, the feelings of an infant who is totally dependent on adult caregivers intensify; if this goes on longer than the infant can bear, the feelings are likely to be experienced as overwhelmingly bad, just needing to be got rid of. Neuroscientists have discovered pathways through which the resulting “toxic stress” can become entrenched in the infant’s brain (Perry, Pollard, Blakley, Baker, & Vigilante, 1995; Schore, 2001). Survival modes that protect the self from immediate danger bypass the parts of the brain that recognize and regulate emotion. When these areas of the brain fail to develop, defensive responses such as hypervigilance, dysregulation, and dissociation continue to interfere with play, social interaction, and learning long after the danger has passed.

Traumatic events remain encoded in body and mind in the form of sensory memories or flashbacks that can be instantly triggered by later stimuli. Patterns of brain activity in children who have been exposed to family violence have been found to be similar to those of soldiers exposed to combat (McCrory, De Brito, & Viding, 2011). The physiological systems for responding to threat are fully activated, while the systems in the brain that store, recognize, and respond to positive, loving, and affectionate experiences are less well developed, meaning that these aspects of experience are less available as a resource for the individual.

Mental health problems and transgenerational family difficulties are often the context in which abuse and neglect lead to children entering care. Maltreatment, in the forms of physical, sexual or emotional abuse, neglect, and severe family dysfunction are the most common reasons for children being taken into care (DfE, 2017). These adversities, cumulative in their impact, are likely to be compounded by a lack of the attuned interactions that are fundamental for early development, as parents who harm their children are more likely to have difficulty in responding to their child’s cues (Brandon et al., 2014). In their report, Missed Opportunities: Indicators of Neglect—What Is Ignored, Why, and What Can Be Done? (2014), Marian Brandon and colleagues highlight neglect as the most common form of maltreatment, as harmful, or more harmful, in the long term than physical or sexual abuse. Children who are severely neglected grow up in chaotic conditions and squalor, with no regular routines for feeding, sleeping, or toileting; they may be exposed to accidental injury and to unknown adults. Some children receive little or no affection, attention, or stimulation. Failures of supervision that result in children being exposed to violence and conflict between adults and to unboundaried sexual activity also come under the heading of neglect.

When the basic needs for loving nurture and responsive attention remain unmet, a profound lack of self-worth and self-agency can ensue, leading to withdrawal and, in extreme situations, failure to thrive. Children can be exposed to severe neglect for years unless or until physical injuries alert professional attention. Many foster carers are profoundly shocked by the states in which neglected child come to their care. When neglect has been severe and long-standing, children may be undernourished and may steal and hoard food, while others may be grossly obese. Some toddlers and young children are unable to stand or walk, having been kept strapped into buggies for many hours of the day. Some children are startlingly indiscriminate in approaching strangers. Others withdraw and barely react to the presence of others, neither showing distress nor seeking comfort. Some children who have been deprived of loving affection engage in comfort-seeking sensory activity, which may follow exposure to adult sexuality or sexual abuse or may be a substitute for physical affection and comfort. Many neglected children have delayed speech and language, and their medical and dental needs have often not been addressed.

The ordinarily thriving baby is a magnet for adult attention, but some babies may respond to extreme stress by developing defensive ways of relating that deflect adult attention. It is harder to notice and respond to infants when their cues and signals are fleeting, muted, or shockingly different from what we expect. Studies by Selma Fraiberg and colleagues in the US recorded the reactions of babies from age three months towards their mothers who had severe mental health difficulties (1982). The babies, who received treatment together with their parents, had been so frightened by their mothers that they did not look at them or seek to be close to them. Some babies showed no sign whatsoever of recognition when looking in their mother’s direction, or when their mother spoke, and seemed frozen and cut off from feeling. These babies were unable to turn to their mothers for help, and when fear, distress, or discomfort broke through the barrier of dissociation, the storm of feeling was so extreme that they could not be consoled either by their parents or by the clinicians:

The same babies who avoid their mothers present another part of the story in states of distress. Hunger, solitude, state transitions, a sudden noise, or a stimulus that cannot even be identified can trigger states of helplessness and disorganization in these babies, together with screaming and flailing about—a frenzy that gathers momentum to a climax which ends in exhaustion.

[Fraiberg, 1982, p. 619]

Fraiberg’s work led to the development of an extensive programme of early interventions in the US and to the establishment of the World Association for Infant Mental Health. Esther Bick, the psychoanalyst who first introduced infant observation into child psychotherapy training in the UK, described similar survival mechanisms in early infancy which she called “second-skin” defences (1968). The idea is that when there is containment and continuity in an infant’s care, the infant develops a “psychic skin”, equivalent to the physical skin surrounding the body.

When containment is faulty or lacking, for whatever reason, the baby may resort to substitute, “second-skin” defences that rely on muscular tension in order to hold together parts of the self, in the absence of a psychic skin. These ways of protecting the self against primitive terrors can take the form of continuous restless movement, withdrawal inside a shell of muscular rigidity, or holding tight to something hard and solid. Bick saw the constant movement that drives some children who have been exposed to trauma as a defence against primitive fears of falling and falling apart, on the unconscious premise that “if you do not stop, you cannot fall”.

Trauma and the responses that trauma sets going have the potential to significantly impact on long-term development and the capacities for self-regulation, attachment, and psychological well-being.

Under-recognition of infant mental health needs

In a seminal review of child maltreatment in the UK published in The Lancet, Ruth Gilbert and colleagues (2009) emphasize that the incidence of child abuse and neglect is much higher than is commonly thought. Unconscious defences that can be elicited against awareness of the mental and physical pain of the most vulnerable children can distort the mind’s capacity to function (Britton, 1983; Rustin, 2005; Steiner, 1985, 1993). The powerful emotions evoked by child maltreatment may result in the experiences of pre-verbal children being overlooked (Emanuel, 2006). A study of social work practice in child protection carried out by Harry Ferguson shows how this can happen. Practitioners who felt unsupported and isolated in intimidating situations became more likely to “defend themselves from unbearable feelings by detaching physically and emotionally and even completely dissociating from those they are seeking to help” (Ferguson, 2017, p. 1011). This study highlights that robust structures of co-working and reflective supervision are essential in order to equip child protection professionals to carry out their tasks, particularly when family members are felt to be intimidating.

Unrecognized distress can become a further aspect of adversity for babies and young children in care. When children have been injured, or are at risk of significant harm, the necessary focus on their physical safety can, inadvertently, result in the psychological dimensions of their experience becoming overlooked. The idea that infants are too young to have feelings retains a powerful hold; indeed, it seems to be re-invented in each generation. In 1982, Fraiberg alluded to pioneering research by René Spitz (1945) on the impact of trauma in infancy and claimed that, “Since 1945, it has not been possible to say that an infant does not experience love and loss and grief” (1982, p. 612). Nevertheless, over thirty years later, a study of minority ethnic children in the care system found “a prevailing view that infants do not have needs, other than basic physical ones” (Selwyn et al., 2008). Responses from social workers, clinicians, adoptive parents, and foster carers across the UK confirmed this finding in the study summarized in chapter 7, in which one participant commented, “They are this kind of forgotten” (cf. Wakelyn, 2018). Many participants also reported on a lack of services and a lack of attention to the psychological needs of the youngest children in care.

Under-recognition of infant mental health difficulties may be compounded by defensive patterns of interaction that lead even very young infants to shut down. Children who lack experiences of bringing joy and delight into their parents’ lives may have a sense of themselves as empty and without value or identity. The sense of shame that can follow rejection and unmet need creates the impulse to hide. Busy foster homes can also create routines where children’s physical needs are met but the fundamental needs for individual attention and intimacy are overlooked (Meakings & Selwyn, 2016). A study by Carol Hardy and colleagues (2013) of children who experienced severe stress showed that their withdrawal could lead to attention being deflected away from them and the ordinary response of adults to help a child in need being muted.

Many young toddlers and 3–5-year-olds presented with behaviours that did not convey their needs or distress directly to the carer and therefore did not elicit nurturing responses . . . some children would communicate distress or frustration but then reject their carers’ attempts to help or comfort them. Carers tended to feel that they should wait for the child to signal readiness for closer contact, but as avoidant responses were so clearly ingrained in many children . . . a pattern of distant relating between carer and child could become an established norm.

[Hardy et al., 2013, p. 271]

Under-referral

Pre-school children in care constitute a high-risk group for mental health and developmental disorders. Without age-appropriate assessments, their needs go undetected, and opportunities for early intervention are being missed.

[Hillen, Gafson, Drage, & Conlan, 2012, p. 411]

Studies in the UK and in the US report prevalences between 45% and 60% of mental health difficulties in children in care under the age of five years (Dimigen, Del Priore, & Butler, 1999; Klee, Kronstadt, & Zlotnick, 1997; McAuley & Young, 2006; McCann, James, Wilson, & Dunn, 1996; Meltzer, Corbin, Gatward, Goodman, & Ford, 2003; Stahmer et al., 2005; Urquiza, ...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• SERIES EDITORS’ PREFACE
• ACKNOWLEDGEMENTS
• FOREWORD
• Introduction
• 1. Being seen
• 2. Therapeutic observation
• 3. Clinical research: therapeutic observation with an infant in foster care
• 4. Learning from the research
• 5. Therapeutic observation in clinical practice
• 6. Briefer interventions: Watch Me Play!
• 7. Practice considerations for the Watch Me Play! approach
• Afterword
• GLOSSARY
• FURTHER READING AND RESOURCES
• REFERENCES
• INDEX