Download The Origins, Clinical Innovations and Evidence

The Origins, Clinical Innovations and Evidence-Basis for Infant
and Early Childhood Psychotherapy
Consuelo E. Cavalieri, Ph.D.
Cavalieri, C. E. (2011, May). The origins,
clinical innovations and evidence-basis for
infant and early childhood psychotherapy.
Workshop presented at the meeting of the
Minnesota Association for Children’s Mental
Health, Duluth, Minnesota.
Plan for Today’s Presentation
• Historical Perspectives
• Attachment Theory
• Relationship Intervention
• Evidence-Basis for Child-Parent Psychotherapy
Infant Mental Health Competencies
• Relationship-Based, Therapeutic Practice
• Psychotherapeutic and Behavioral Theories of Change
Institutional Care
Restricted Visiting Hours
“A Two Year Old Goes to
Hospital”
Protest, Despair, & Detachment
Sequence
(Bowlby, 1969/1982; Bretherton, 1992; Karen, 1994; Markel, 2008)
Hospitalism
“...a vitiated condition of the
body due to long confinement in
a hospital, or the morbid
condition of the atmosphere of a
hospital.”
(Spitz, 1945, p. 53)
The Role of Maternal Deprivation on Development
Environment
Parental Home
Institution
(Spitz, 1945)
Cultural and Social
Background
Developmental
Quotient first 4
months
Developmental
Quotient last 4
months
Professional (Urban)
133
131
Village (isolated, fishing)
107
108
Nursery (penal institution for 101.5
delinquent girls)
105
Foundling Home
72
124
Spitz’ Additional Findings
• Extreme friendliness (indiscriminate friendliness)
• Anxious avoidance of inanimate objects
• Generalized anxiety--blood curdling screams
• Bizarre stereotyped motor patterns (disorganized attachment)
• Delays in language acquisition, independent feeding, walking
• Susceptibility to illness
(Spitz, 1945)
Dispelling the Feeding
Hypothesis
Wire vs. Cloth Mother Surrogate
Contact Comfort
(Harlow, 1958)
Attachment Theory
The propensity to be “strongly
disposed to seek proximity to
and contact with a specific figure
and to do so in certain situations,
notably when he is frightened,
tired or ill.”
(Bowlby, 1982, p. 371)
Internal Working Models
• Self & Other
• Expectations
• Misinformation
(Bowlby, 1980; Bretherton, 1987, 1990; Bretherton & Munholland, 2008)
Patterns of Attachment
• Sensitive Responsiveness
• Strange Situation
• Secure
• Anxious Avoidant
• Anxious Ambivalent/Resistant
• Disorganized
(Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1986)
Ghosts in the Nursery
“In every nursery, there are
ghosts...”
(Fraiberg, 1980)
Child-Parent Psychotherapy
(Lieberman & Van Horn, 2008)
Culture & Context
Adaptive Functioning
• Emotions without lasting
collapse
• Trusting relationships
• Development of culturally
competent behavior
(Lieberman & Van Horn, 2008)
Format
• Presence of attachment figures
• Flexible session length
• Location in home, clinic or
other setting
• Range of toys
(Lieberman & Van Horn, 2008)
Domains of Functioning
• Presenting Problem
• Cognitive
• Social
• Emotional
(Lieberman & Van Horn, 2008)
Continuum of Adaptive-Maladaptive
• Perturbations--healthy features of functioning despite strains
• Disturbances--problematic but subclinical distress
• Disorders--meet criteria for diagnosis
(Lieberman & Van Horn, 2008)
Attachment-Caregiving Relationship Problems
• Role Reversal
• Elevated Distress
• Withdrawn
(Lieberman & Van Horn, 2008)
Talking to Children About Therapy
• Link prior distressing/frightening experiences to arrival for therapy
• Work with parent to prepare child prior to first session
(Lieberman & Van Horn, 2008)
Primary Clinical Task:
to serve as translator of the child and parent’s subjective experiences
(Lieberman & Van Horn, 2008)
Therapeutic Strategies
• Developmental Guidance
• Putting Feelings into Words: Trauma Narratives
• Modeling Protective Behavior
(Lieberman & Van Horn, 2008)
Clinical Trials with Child Parent Psychotherapy
• Anxiously attached toddlers who have immigrated to U.S.
• Preschoolers exposed to Marital Violence
• Toddler’s of Depressed Mothers
• Maltreated Preschoolers
(Cicchetti, Rogosch, & Toth, 2000; Lieberman, Ippen, & Van Horn, 2006; Lieberman, Van Horn, & Ippen, 2005; Lieberman, Weston, & Pawl, 1991; Toth, Maughan, Manly,
Spagnola, & Cicchetti, 2002)
Toddlers Who Were Anxiously Attached to Mothers
Reduced Toddler’s Angry Behavior
Decreased Avoidance
Decreased Resistance
Promoted Goal-Corrected Partnership
(Lieberman, et al., 1991)
Preschoolers’ Exposed to Marital Violence
Treatment End
•Reduced child’s traumatic symptoms
and diagnoses of PTSD
•Reduced child’s behavior problems
•Mothers showed less avoidance
symptoms of PTSD
(Lieberman, et al., 2006; Lieberman, et al., 2005)
6-month follow-up
• Children had fewer
behavioral problems
compared to control
• Mothers reported less
psychological distress
Toddlers of Depressed Mothers
Prevented cognitive decreases that occurred with children of depressed
mothers
(Cicchetti, et al., 2000)
Maltreated Preschoolers
•Increase in adaptive representations of mothers
•Decrease in maladaptive representations of mothers
•Increase in positive self-representations
•Decrease in negative self-representations
(Toth, et al., 2002)
Summary of Evidence
Children
Mothers
• Restoration of safety
• Increase in empathic understanding
• Decreased negative selfrepresentations
• Reduced psychological distress
• Reduced PTSD symptoms
• Increased positive self-representations
• Prevention of cognitive declines assoc.
with maternal depression
• Reduced problematic behaviors
Recommendations
for Practice
1.The Relationship is the client,
not the individuals
2.Good developmental
knowledge is essential
3.Sometimes observing rather
than actively intervening is best
4.Need supervisor who is your
secure base with whom you
reflect upon your “ghosts” and
the feelings associated with this
work
(Lieberman & Van Horn, 2008)
References
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.
Bowlby, J. (1969/1982). Attachment and loss (Vol. I). New York: Basic Books.
Bowlby, J. (1980). Attachment and loss (Vol. III). New York: Basic Books.
Bretherton, I. (1987). New perspectives on attachment relations: Security, communication, and internal working models. In J. D. Osofsky (Ed.), Handbook of infant
development (pp. 1061-1100). New York: Wiley.
Bretherton, I. (1990). Open communication and internal working models: Their role in the development of attachment relationships. In R. A. Thompson (Ed.), Nebraska
Symposium on Motivation: Vol. 36. Socioemotional development (pp. 59-113). Lincoln: University of Nebraska Press.
Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28, 759-775.
Bretherton, I., & Munholland, K. A. (2008). Internal working models in attachment relationships: Elaborating a central construct in attachment theory. In J. Cassidy & P. R.
Shaver (Eds.), Handbook of Attachment: Theory, research, and clinical applications (2nd ed.). New York: Guilford Press.
Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2000). The efficacy of toddler-parent psychotherapy for fostering cognitive development in offspring of depressed mothers. Journal
of Abnormal Child Psychology, 28, 135-148. doi: 10.1023/A:1005118713814
Fraiberg, S. (1980). Clinical Studeies in Infant Mental Health. New York: Basic Books.
Karen, R. (1994). Becoming Attached. New York: Oxford University Press.
Lieberman, A. F., Ippen, C. G., & Van Horn, P. (2006). Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial. Journal of the American Academy of
Child and Adolescent Psychiatry, 45, 913-918.
Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York: Guilford.
Lieberman, A. F., Van Horn, P., & Ippen, C. G. (2005). Toward evidence-based treatment: child-parent psychotherapy with preschoolers exposed to marital violence. Journal of
the American Academy of Child and Adolescent Psychiatry, 44, 1241-1248.
Lieberman, A. F., Weston, D. R., & Pawl, J. H. (1991). Preventative intervention and outcome with anxiously attached dyads. Child Development, 62, 199-209. doi:
10.2307/1130715
Main, M., & Solomon, J. (1986). Discovery of a new, insecure-disorganized/disoriented attachment pattern. In T. B. Brazelton & M. W. Yogman (Eds.), Affective Development in
Infancy (pp. 95-124). Norwood: Ablex.
Markel, H. (2008, January 1). When hospitals kept children from parents, The New York Times. Retrieved from http://www.nytimes.com
Toth, S. L., Maughan, A., Manly, J. T., Spagnola, M., & Cicchetti, D. (2002). The relative efficacy of two interventions in altering maltreated preschool children's representational
models: Implications for attachment theory. Development and Psychopathology, 14, 877-908. doi: 10.1017/S095457940200411X