Symposium: social paediatrics
Child maltreatment during infancy: atypical parent–infant relationships

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Abstract

Infants under one account for up to 13% of child protection registrations in the UK with neglect (55%) and emotional abuse (17%) accounting for nearly two-thirds of these. Infants are highly dependent on their caregivers to enable them to optimise their rapidly developing nervous system, and also to promote their ability for affect regulation via the attachment relationship. As a result, maltreatment that occurs during this period has a disproportionate effect on the child's development.

This paper examines the importance of the parent–infant relationship for later infant development, and the impact of ‘atypical’ or anomalous parent–infant interaction occurring during this period. A number of innovative and evidence-based methods of assessing and supporting parents, who are experiencing a range of problems that place them at high risk of poor parent–infant interaction during this period, are examined. The research strongly points to the need for prevention through assessment and intervention that begins in pregnancy and continues throughout the first postnatal year.

Introduction

A number of recent high profile cases have drawn attention to the need for paediatricians to be alert to the possibility of the maltreatment of infants. This age-group are over-represented in terms of the overall numbers of maltreated children, and have a higher than average risk of being the victims of homicide. Recent research suggests that infants identified as being at significant risk of maltreatment, are not given adequate protection within a timeframe that is consistent with their developmental needs.

The focus of this paper is on maltreatment that occurs during the first two years of a child's life. The evidence suggests that this is a significant period in terms of the child's developing nervous system and their emotional development, and that parent–infant interaction plays a key role in facilitating these aspects of development. It will be argued that particular types of severely compromised or ‘atypical’ parent–infant interaction comprise maltreatment during the first year of life.

The first part of this paper examines the specific aspects of the parent–infant interaction that facilitate normal infant development, and the factors that characterize severely compromised interaction referred to here as ‘atypical’ or ‘anomalous’. It highlights the problems that interfere with a parent's ability to provide sensitive, attuned interaction, and the long-term impact on the child of severely compromised parent–infant interaction. The second part of the paper examines the role of the paediatrician in assessing and identifying such parent–infant interaction, alongside the evidence regarding the most appropriate management and treatment approaches.

Section snippets

Definition

The WHO (1999) definition of maltreatment refers not only to acts toward the child that ‘have a high probability of causing harm to their health or to any aspect of their development (physical, emotional or social)’, but also ‘the failure to provide a developmentally appropriate and supportive environment in which the child can develop the full range of emotional and social competencies commensurate with her or his personal potential’.

The failure to provide a developmentally appropriate and

The prevalence early abuse

Recent estimates show that severely suboptimal parenting of infants is a major public health problem. Infants under one account for up to 10% of child protection registrations in the UK. Neglect (54%) and emotional abuse (18%) account for nearly two-thirds of these, but infants also face four times the average risk of child homicide, the risk being greatest in the first three months and the perpetrators being the parents in most cases. Non-accidental head injuries are also high in this age

The impact of the environment

The first two years of a child's life are now recognised as being particularly important for later development, primarily because of the impact of the early environment on the infant's developing neurological system. Research from a range of disciplines (e.g. neuroscience, physiology, developmental psychology, infant mental health, and genetics) has converged in terms of a recognition that the child's neurodevelopment is highly dependent on and influenced by the child's environment, and that

Consequences of child maltreatment during the first two years of life

Recent reviews of the evidence about the impact of early abuse on the child's developing psychobiological system has highlighted the impact on the stress response including dysregulation of the hypothalamic-pituitary-adrenal axis, and parasympathetic and catecholamine responses. The most recent of these reviews found a number of structural (e.g. changes in the corpus callosum, left neocortex, hippocampus, and amygdala) in addition to these functional (e.g. electrical activity in limbic

Factors influencing parent–infant interaction

The research on early parenting that has been characterised as ‘Fr-behaviour’ has identified the importance of unresolved trauma and losses on the part of the parent, and suggests that parent–infant interaction may play a significant role in the intergenerational transmission of abuse and trauma. A number of other factors have also been shown to be associated with suboptimal parent–infant interactions including parental mental health problems, substance dependency and domestic abuse.

A range of

The role of the paediatrician

Paediatricians both in hospital and community settings work with the most vulnerable children in society, and as such they have a key role to play in a) promoting optimal parenting of infants and young children; b) assessing not only the functioning and health of infants and very young children who may be at risk of abuse, but in making assessments about the extent to which the parenting is sufficiently compromised to be classified as emotional maltreatment or neglect; and c) ensuring that

Conclusion

Research from a range of disciplines has highlighted the first year of life as being a critical period in terms of a number of significant aspects of development, and as such the consequences of maltreatment that occurs during this period are both severe and protracted. Recent UK research that followed a group of high-risk infants found severe developmental and behavioural difficulties occurred in infants who experienced long delays because of protracted assessments, prior to being removed.

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