Bonding agents

When a child comes to the attention of specialist services it
often seems as if it is just too late to help. For many of these
children – those who cannot use education, who disrupt the
classroom and demand attention – the difficulties began in
babyhood. They become either bullies or victims, sometimes harming
themselves as much as others. They grow up collecting labels:
conduct disorder, ADHD, disruptive pupil, delinquent, depressed, or
disturbed. And as adults they are at greatly increased risk of
developing mental health problems such as borderline and
dissociative personality disorders.

The most disturbed, difficult and unhappy children frequently
had as infants the sort of problematic relationship with one or
both parents that is classified as “disorganised attachment”. This
tends to develop when the parent either is some sort of threat, or
is burdened by unresolved emotional issues of loss or dependency.
The baby is biologically impelled to seek safety through closeness
to the caregiver; all development is a matter of reaching out from
this “secure base”. When the parent generates insecurity (and this
may be the result of neglect as well as maltreatment) the
contradiction cannot be resolved, and the child’s faith in
the world of relationships is demolished by their “scaregiver”.

We now know that babies are born “pre-programmed” to seek out
and adapt to the relationship that they have with their parents.
Pre-verbal interpersonal experiences form the basis of a
lifetime’s expectations. Active, satisfying and reciprocal
relationships with parents create the “taken for granted” basis of
a sense of identity, self-esteem, appreciation of others,
self-control and interactions with others. This has received
recognition in the first Sure Start objective which emphasises
“supporting early bonding between parents and their children”. In a
few projects this has translated into the formation of specific
services. Sure Start, with its potential to create a network of
locally responsive, relationship-based, support for vulnerable
families provides an ideal opportunity to engage with the challenge
of infant mental health.

Research over the past 10 years emphasises the importance of the
first few years of life. The quality of the baby’s
significant relationships with her parents causes alterations to
the neurobiological structure of the
brain.¹ The older the child becomes,
the harder it can be to “rewire” certain areas of the brain,
especially those parts concerned with emotional regulation and
attachment. This means that without intervention a child who has
experienced maltreatment or neglect as an infant may continue with
responses that are engraved in the biological structure of the
mind, even if circumstances change. These relationship-based
reactions compose the unconscious “internal working models” of
attachment. Such patterns of interaction stand a good chance of
being passed on to the next generation, as the attachment
experiences of infancy cut the template for the caregiving of
adulthood.

Secure attachment is a protective factor, conferring confidence
and adaptability, although not a total guarantee of future mental
health. An insecure child has too many anxieties that get in the
way of investigating all aspects of the world, so horizons stay
safely near. Early intervention with parents and babies aims to
increase the sensitivity and awareness of the caregiver so that
secure attachment is more likely to develop.

As well as the relationship between individuals we should also
look to the wider conditions that impinge upon this relationship.
Looking for reasons removes blame. Every parent always does the
best they can for their baby within what is possible for them. A
broader perspective, trying to understand rather than passing
judgement, points to the importance of a catalogue of known risk
factors.

Research makes it feasible to anticipate what sort of situation
tends to lead to insecure attachment, and thus to offer
intervention before responses get so “hard-wired” into the brain
that they become increasingly hard to change. Vulnerable babies do
not have to experience distress and damage. But sadly, the more a
family is under stress then the harder it becomes to take advantage
of any help available. Only a relationship can change a
relationship, but if you are ground down by inner and outer
circumstances a new relationship is hard to contemplate or
trust.

Sure Start workers observed that when Claire played with Doreen
there was no eye contact between them at all. Claire gradually
accepted more support from the whole team. It became clear that
this was a high-risk situation. She was a single parent with
learning difficulties living in poor housing on a low income. She
had postnatal depression, her mother had abandoned the family when
she was a toddler, she had been sexually abused and then spent the
bulk of her life in care. Rather than an insight-oriented approach,
Claire found using video-feedback useful. This technique aims to
pick out, examine and then reinforce examples of sensitive
parenting.

This is the most cost-effective stage for society to put in
therapeutic resources to help these children and protect itself
from their future antisocial behaviour. Furthermore, unique to this
stage of life, the child “wants” to co-operate.

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 militate 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.²

With this in mind it is clear that an infant mental health
service needs to call upon a wide range of skills and strategies
that concentrate on a network of relationships. Sure Start provides
the ideal framework. Surely it is best to start from the premise
that all parents want to do the best they can for their babies,
building on strengths in order to remove obstacles. It is a service
that should be available to all families by right, not chance.

¹ R Balbernie, Circuits and
circumstances: the neurobiological consequences of early
relationship experiences, Journal of Child Psychotherapy, 27 (3)
237-255, 2001

² R Karr-Morse, MS
Wiley, Ghosts From the Nursery: Tracing the Roots of Violence, The
Atlantic Monthly Press, 1997

• Robin Balbernie is a child
psychotherapist

“A ghost in the nursery”

Amy’s health visitor was concerned at the hostile thoughts
Amy was having towards Bella, who was only three weeks old. Amy had
refused to touch Bella for the first two weeks after birth, and was
saying that she had fantasies of harming her to the extent that she
had to force herself to go into another room sometimes. Amy was
offered infant-parent psychotherapy, to try to unravel what “ghost
in the nursery” was present. There were a number of reasons behind
her tendency to change any challenge into conflict, which turned
out to be a long-standing tendency. It was a surprise to Amy when
it was discovered that her own mother had also been unable to hold
her for the first two weeks of her life; before this she had
interpreted the situation along familiar lines. On follow-up at one
and two years Bella and Amy were thriving together, the latter
showing the signs of secure attachment.