Difficult starts of life: Topics
The impact of abuse and neglect Child maltreatment prevalence Risk factors and consequences Neurobiology of abusive parents Prevention and intervention Marian J. Bakermans Kranenburg Leiden University The Netherlands
Keynote at the conference of the Nordic Association for Infant Mental Health September 13, 2017
Definition of child maltreatment US National Incidence Studies (NIS) Any form of threatening or violent behavior towards a minor Mandated by the American Congress of physical, psychological or sexual nature (Keeping Children and Families Safe Act of 2003) that is actively or passively forced upon the minor Periodic — 4 previous cycles: by parents or other persons on whom the minor NIS 1, 1979 is dependent and causes or threatens to cause serious harm in NIS 2, 1986 the form of physical or psychological damage NIS 3, 1993 including neglect (withholding help, medical care NIS 4, 2004 2009 and education)
Wet op de Jeugdzorg, 2005
teachers CPS Sentinels general practitioners police well baby clinics day care centers shelters for battered women
The NIS assumes that abused and neglected children who receive CPS attention are just the tip of the iceberg
CPS = Child Protection Services
1 Prevalence in the Netherlands Prevalence in the Netherlands
119,000 or 34 per 1000 children
were victims of child maltreatment in 2010
Marinus van IJzendoorn Saskia Euser Lenneke Alink
Alink et al., 2011, NPM-2010; Euser, Alink, Pannebakker, Vogels, Bakermans-Kranenburg, Van IJzendoorn, 2013
Prevalence in Denmark Many children experience more than one type of abuse: Comorbidity
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119,000 50
or 40 1 34 per 1000 children 2 30 3 were victims of child maltreatment in 2010 20 >4 10
0 Number of maltreatment types
Alink et al., 2011, NPM-2010
90,000 CPS Risk factors environment 80,000 Sentinels
70,000 Low education 9.3 60,000 Single parenthood 7.3 50,000 Unemployment 6.4 40,000 Psychological 6.0 problems 30,000 New immigrants 4.7 20,000 Traditional 3.3 immigrants 10,000 Large family 2.7
0 Foster family 1.2 Sexual abuse Physical Emotional Physical Emotional Other abuse abuse neglect neglect 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 Risk ratio Euser, Alink, Pannebakker, Vogels, Bakermans-Kranenburg, Van IJzendoorn, 2013
2 How about the rest of the world? A series of meta analyses Sexual abuse (CSA) (Stoltenborgh et al., Child Maltreatment, 2011) Physical abuse (PA) (Stoltenborgh et al., International Journal of Psychology, 2013) Emotional abuse (EA) (Stoltenborgh et al., Journal of Aggression, Maltreatment & Trauma, 2012) Physical & emotional neglect (PN; EN) (Stoltenborgh et al., Social Psychiatry and Psychiatric Epidemiology, 2012) The prevalence of child maltreatment across the globe: Review of a series of meta analyses (Stoltenborgh et al., Child Abuse Review, 2015)
Numbers and types of studies Types of studies over the world
350
300
250
200 Self report Informant
150
100 551 studies 26 studies Number of prevalence rates prevalence of Number 50 Africa Europe Asia North America 0 Australia/New Zealand South America CSA PA EA EN PN self report (k = 551) informant (k = 26)
Combined prevalence rates What did we learn so far?
45 Self-report Informant 40 Child maltreatment is a global problem of considerable extent, in all its forms and all over 35 the world 30 Studies are not evenly spread around the world 25 There is a big prevalence gap between self 20
Prevalence(%) reported child maltreatment and informant 15 reported child maltreatment
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5 Triangulation, world coverage, and regular monitoring
0 of maltreatment prevalence are badly needed CSA f CSA m PA EA EN PN CSA PA EA (k=193) (k=104) (k=157) (k=42) (k=16) (k=13) (k=8) (k=11) (k=4)
3 Attachment theory Topics Evolutionary theory applied to human development
Child maltreatment prevalence Environment of Evolutionary Adaptedness Risk factors and consequences Attachment behavior necessary for survival to reproductive age in Neurobiology of abusive parents contact and proximity orphanages? Prevention and intervention comfort and protection universal across species and cultures
John Bowlby Harry Harlow
Intervention Experiment at Great Ape Nursery Yerkes
29 standard 17 responsive birth care care
Peer +4 hours reared per day Bayley 9mo
Strange 12mo Situation
Van IJzendoorn, Bard, Bakermans Kranenburg, Dev Psychobiology, 2008.
Infant chimpanzee exploratory behavior in the Strange Situation
4 Yerkes chimp
Attachment in chimpanzee infants Report to the World Health Organization on the post war (Yerkes) status of orphans and abandoned children (1951) B secure A avoidant C ambivalent Conclusion: orphanages D disorganised have a devastating effect on child development
But: about 8 million children grow up in institutions Standard care: 72% Disorganized Responsive care: 41% Disorganized (UNICEF)
How is life in an institution?
Developmental delays in Mumbai orphanage Institutionalized care in Ukraine
SD > 100,000 children in institutionalized care 1 norm Growing number of HIV (social) orphans 0 -1 Sufficient medical care and food -2 Caregiver child ratio 1:3 to 1:7 stunted -3 Many changes in caregivers
-4 After 3 yrs > 50 caregivers weight height head IQ circumference
Juffer, Bakermans Kranenburg, & Van IJzendoorn ( in prep .) Femmie Juffer Natasha Dobrova-Krol
5 Height for Age Institutional Care in Ukraine 2
Family HIV 1
0 Family HIV +
-1 height-for-age Institution HIV -2
-3 Institution HIV + -4 birth 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48
IQ Attachment quality (SSP)
Family HIV % 70 secure avoidant 60 resistant disorganized 50 Family HIV+ 40 30 Institution HIV HIV+ 20 10 64 70 79 99 0 Fam HIV Fam HIV+ Inst HIV Inst HIV+
Dobrova Krol, Van IJzendoorn, Bakermans Kranenburg, & Juffer (2010) Child Development, 81, 237 251 .
Bowlby was right: Bowlby was right: Attachment distributions in institutions and Attachment quality is worse in institutions than in families ‘bad’ families
disorganized disorganized secure secure
insecure insecure insecure insecure disorganized secure disorganized secure
disorganized secure institutions normative institutions normative insecure and under the skin? maltreatment
Institutions from Greece, Romania, Russia, Ukraine, Chile, China Institutions from Greece, Romania, Russia, Ukraine, Chile, China
6 Institutional care in the brain (1) Institutional care in the brain (2)
Children (11 yrs) adopted to US from Russia, Romania (30 mo) Bucharest Early Intervention Project (Romania) Adopted children smaller cerebellum Assignment to foster care 7 33 mo; assessment at 10 yrs Mediated lower performance on memory and planning White matter recovery, grey matter no catch up Deficit or accelerated maturation (life history theory) Bauer et al., 2009 Sheridan, Fox, Zeanah, et al., 2012
Childhood maltreatment associated But also normal variation in with structural changes in the brain parenting matters
AAI with 44 women, MRI hippocampus Meta analysis with 49 studies 2,270 participants In adults or with multiple abuse smaller hippocampus
Riem, Alink, Out, Van IJzendoorn, Bakermans Kranenburg (2015) Dev & Psychopath
What did we learn so far? Maltreatment in the family: 0 3 yrs increased risk Attachment is universal across species and cultures Extreme environments create anxious attachments and numerous deficits Environment is crucial even for ‘heritable’ traits Extreme environments affect brain development Not only institutionalized care
Risk ratio 0 3 yrs: 2.6 (95% CI: 2.58 2.65) Euser, Alink, Pannebakker, Vogels, Bakermans Kranenburg, Van IJzendoorn (2013)
7 Infant crying elicits care and abuse Topics Proximity seeking Information on health Child maltreatment prevalence condition Evolutionary adaptive Risk factors and consequences Neurobiology of abusive parents BUT: Aversion Prevention and intervention
%
Reijneveld et al., Lancet, 2004 2/3
Behavioral, physiological, and neurological Behavioral reaction to cry: reactions to infant crying Handgrip force Maltreating mothers (neglect Non maltreating mothers + abuse) ( N = 44) (learning,attention problems) (N = 42) *More childhood abuse *More depression, anxiety Baseline Laughter Crying In family therapy Children in therapy
4x: “squeeze at maximum strength” “squeeze at half strength”
Marinus van IJzendoorn Lenneke Alink Sophie Reijman
Reactivity to infant cry Physiological reactivity to infant crying
500Hz More often excessive force 700Hz For physical abuse But also for neglect
Compier de Block et al., 2015, Child Abuse and Neglect
8 Salivary α amylase (sAA) Maltreating mothers lower sAA and flat response to infant cry
Salivary glands produce sAA in the mouth
Indirect, non invasive measure for activity sympathetic nervous system (immediate stress response)
Reijman et al., Child Psychiatry and Human Dev., 2015
Maltreating mothers flatter profile Meta Analysis: skin conductance to infant cry Higher baseline, no more reactivity
What did we learn so far? The Role of Emotion Recognition
Pollak et al. Infant crying is a risk for maltreatment 2009 Maltreating parents show dysregulated physiological responses to infant crying Neglecting parents have difficulties recognizing fear
May this have to do with their own attachment Neglecting parents: problems identifying fear (p = .01) experiences or representation? Fear signals the need for protection, and neglecting parents fail in just that: offering protection to their child
Compier de Block et al. (in prep)
9 What about Adult Attachment The Adult Attachment Interview Representations in Maltreating parents? George, Kaplan & Main
“Set of conscious and/or unconscious rules for Semistructured the organization of information [about attachment experiences] and for obtaining or General descriptors of childhood attachmentCoherence limiting access to that information” relationships (mother and father) Concrete evidence from attachment related (Main, Kaplan, & Cassidy, 1985) experience Evaluation of effects on current personality Adult Attachment Interview Traumatic events: loss and maltreatment Attachment representation Current relationship with parents
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Adult Attachment Representations (AAI) in Adult attachment representations maltreating and non maltreating mothers
U U Secure autonomous (F) E Value attachment relationships F Ds F Insecure dismissing (Ds) E Ds Idealize or minimize importance of attachment Insecure preoccupied (E) non abuse abuse Anger and maximize impact of attachment Unresolved loss and trauma (U)
Hesse, 2008, 2016
Adult Attachments in Typical and Abused AAI and Neural response to crying % 80 Women without children Ds F E U AAI: attachment representation 60 Cry sounds 500, 700, 900 Hz Control sounds 40 500, 700, 900 Hz Matched on acoustic characteristics 20
0 Typical Mothers Abused/trauma The First 10,000 Adult Attachment Interviews Bakermans Kranenburg & Van IJzendoorn, Attachment & Human Development , 2009
10 AAI and neural response to crying Higher activation of the amygdala in Ds, E, & U
1.6 Insecure: more amygdala activation 1.4
1.2
1 Anxiety Aversion 0.8 Arousal 0.6
0.4
Mean Mean amygdalaZ activation 0.2
0 F Ds E U Riem, Bakermans Kranenburg, Van IJzendoorn, Out, & Rombouts (2012) F Ds E U Attachment & Human Development, 14, 533 551
Irritation and handgrip force in Handgrip force response to crying
Insecure attachment representation: More irritation More excessive force Baseline Crying
5 4 p < .10 p < .01 4 3 3 4x: 2 2 “squeeze at maximum strength” 1 1 “squeeze at half strength” 0 0 Secure Insecure Secure Insecure Irritation Excessive force
What did we learn so far? Topics
Maltreating parents are more often Child maltreatment prevalence Unresolved Risk factors and consequences Insecure parents show more activation of Neurobiology of abusive parents the amygdala in response to crying, indicating more aversion Prevention and Intervention Insecure parents experience more irritation during infant crying, and use excessive force more often
11 Maltreatment Possibilities for prevention and “runs in the family” ? intervention Extended family design (3 G study)
Marian J. Bakermans Kranenburg Leiden University The Netherlands
Keynote at the conference of the Nordic Association for Infant Mental Health September 13, 2017 3 G Parenting study
Extended family design: Heritability variation in genetic relatedness
Part of the phenotypic variance that is explained by genetic relatedness e.g. parent child 0.5, cousins 0.125 Polygenetic model Comparing log likelihoods Shared and non shared environment
Heritability estimates Heritability estimates
100% 100%
80% 80%
60% 60%
40% 40%
20% 20%
0% 0% Maltreatment Abuse emotional (very) severe Neglect Maltreatment Abuse emotional (very) severe Neglect abuse physical abuse physical abuse abuse
non shared environment shared environment genetics non shared environment shared environment genetics
Pittner et al., in prep Pittner et al., in prep
12 Bivariate association between Shared-environmental risk factors abuse and neglect Note: Intervention not only Low education 9.3 useful in case of environmental Single parenthood 7.3 influences ! (e.g., PKU) Phenotypic covariance r(393) = .56, p < .01 Unemployment 6.4 Psychological 6.0 Shared causal pathways? problems Genetic correlation: 53% New immigrants 4.7 genetic overlap Traditional 3.3 immigrants Complete overlap in shared environment Large family 2.7 No overlap in influence of Foster family 1.2
unique environment 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 What should Risk ratio we think of? Euser, Alink, Pannebakker, Vogels, Bakermans-Kranenburg, Van IJzendoorn, 2013
Can we prevent or stop maltreatment? Problem
Large group with these characteristics but no maltreatment
Screening: many false positives
Saskia Euser
Intervention effects on maltreatment Which interventions are most
0.45 ** effective? Effect size d ** 0.4 ** 0.35 0.3 0.25 0.2 0.15 ** 0.1 0.05 0 Combined Trim and At risk Abusive Support Parent Parent effect size fill samples samples training training and support
13 Features of the VIPP method Video feedback
Attachment and Biobehavioral Catch up Focus on parent child interaction ABC, Mary Dozier Standardized (protocol) and individualized ten 1 hour sessions Video feedback video and ‘in the moment’ comments by parent coach Practice observational skills * ‘Speaking for the child’ * Video feedback Intervention to promote Positive Parenting (VIPP SD) Reinforce parental sensitive behaviors * six 1.5 hour sessions personalized video feedback * Ainsworth’s definition of sensitivity Juffer, Van IJzendoorn & Bakermans Kranenburg, 2017 Current Opinion in Psychology 80
VIPP-SD themes Why video? Sensitivity Discipline Harlow, Robertson A Two year old goes to Hospital Attachment & Distraction & Session 1 John, 17 months, in a Residential Nursery Exploration Understanding What words cannot say Session 2 ‘Speaking for the child’ Positive reinforcement have a second look (at a quieter time) promote reflection and perspective taking Session 3 ‘Sensitivity chain’ Sensitive time out opportunity for empathy expand positive moments Induction & Session 4 Sharing of emotions Understanding
Sessions 5 and 6 are ‘booster sessions’ (repeating all themes) Juffer & Steele, 2014 Attachment and Human Development
Meta analysis VIPP SD (N = 1,116) Features of VIPP Home based Short term Moss et al., Parent is her own model 2011 ‘Here and now’ approach Focus on strenghts, positive moments Active involvement of parent (‘expert’) Supportive relationship with the parent
Juffer, Bakermans Kranenburg, & Van IJzendoorn, 2017 84
14 Video feedback structure VIPP SD procedure Filming interaction Session 1 and 2 Focusing on child behavior Preparing a script at the institute Session 3 and 4 Next visit: video feedback Focusing on child and parent behavior Show the videotape Later sessions (5 and 6) Using the manual for themes and messages Booster sessions (repeating all) Using the video of the dyad to connect messages to specific moments or episodes Inviting the parent to also comment on the video
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“Speaking for the child” – exploration “Speaking for the child” –attachment
“Sarah looks up to you, putting the spoon in her mouth. She shares this with you, “Sarah is really focused here. She is looking at the piece of bread and because you are so important to her. It’s nice for her that you are playing with her cutting with the knife. She has a very concentrated look on her face!” and following her play. Playing together is more fun than playing alone! ”
Child development messages Attunement & sharing emotions
“Children of this age need more time to discover new toys than “This is a really nice moment : the two of you are sharing the excitement adults. Adults know what to do with a piece of the puzzle right away, together. Tom pushes the blocks with his hand and clearly enjoys this. It’s really nice for him that you are smiling at him and sharing the joy with him!” but children look at it longer and discover by looking and touching”
15 Fragment 1 What has struck you?
Preparation of feedback: Profile of the interaction what does the parent well ? what should be worked on as opportunities for change? basis for video feedback
Profile Adaptations VIPP Foster Care Noticing of child signals Understanding of what moves the child (interpretation child signal) Reacting to positive signals of the child Address disturbed attachment behavior Reacting to negative signals of the child sensitivity E.g., child hurts himself but does not cry Using different reactions to negative signals Not interfering when the child is exploring or playing E.g., controlling behavior Adjusting the pace to that of the child Recognize children’s subtle behaviors introduce breaks, “wait and see” Giving directions to the child in a sensitive way Small steps in the right direction Giving explanations to the child in a sensitive way Stress regulation in foster parent and child Showing empathy and understanding discipline Encouraging eye contact Promoting playful physical/eye contact Encouraging physical contact Open communication, playful interaction and sharing of feelings Warmth in the parent’s voice and facial expression affect attunement “Following” of the child
What did we learn so far? Food for thought Few successful intervention programs to stop or prevent maltreatment Childhood adversity shapes social and Support not enough, parent training cognitive abilities (e.g., anger recognition) necessary Enhanced capacities Video feedback promising results shifting ability empathic accuracy More randomized trials Individuals who may perform best under necessary ! stressful, changing conditions
Ellis et al., 2017
16 VIPP Research and implementation in more than 20 countries
currently testing VIPP Foster Care But: Better chances for development in the context of a supportive (therapeutic, parental, peer)
relationship! Femmie Juffer Marinus van IJzendoorn thanks! http://www.vippleiden.com/ 98
Thank you!
Supported by the Netherlands Organization for Scientific Research (NWO), ZON, ERC, Jacobs foundation, the Dutch Ministry of Education, Culture, and Science, and Leiden University
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