During the past two decades there has been an increase in evidence across a range of disciplines (e.g. genetics, neuroscience, developmental psychology, infant mental health, psychotherapy) to suggest that the early parent–child relationship has a significant role in the origins of childhood psychiatric disorder. This chapter will present research which suggests that the pathway linking the two is the child’s attachment organisation, and the impact of this on the child’s capacity for emotion regulation and on their rapidly developing nervous system. The chapter will focus specifically on the evidence in relation to disorganised and traumatic attachment relationships, which are now recognised to be significant precursors of a range of clinical phenomena including borderline personality disorder. Psychiatric disorder in adults is strongly associated with childhood psychiatric disorder, and this evidence therefore has significant implications in terms of the development of mental health problems across the lifespan.

The first part of the chapter examines the relationship between a range of child psychiatric problems and the emerging evidence in terms of the aetiological processes involved. The specific focus is on recent theories and evidence about the origins of such problems in terms of early maladaptive intersubjective experiences between the parent and infant. The second part of the chapter examines a number of innovative interventions that involve working ‘dyadically’ to address a range of childhood disorders whose origins, it will be argued, lay in such early relationship experiences. We focus in particular on evidence-based approaches that target both the parent and the child with a view to changing parent–child interaction, and/or parental and child representational systems, in order to target child attachment security. It will be argued that the evidence strongly points to the need for a range of secondary/tertiary level services for children presenting with problems that have their origins in the early parent–child relationship.

Young children experience a range of problems during childhood and these begin early with functional (eating and sleeping) and behavioural disorders being the primary reason for referral of children under the age of 3 years to child mental health clinics [1]. Recent studies have found a prevalence rate of around 10% for behavioural disorders in preschool children [2] with some estimates being as high as 30% [3, 4]. Many of these problems show evidence of comorbidity, and one study found that 45% of referred children between the ages of 18–47 months had signs of both internalising and externalising problems [5]. The research also suggests considerable continuity between early problems and later psychiatric disorder. Emotional and behavioural problems in children aged 3 and 4 years are highly stable, approximately 50% of children still having problems in adolescence [6], and are also strongly associated with later psychopathology [7] including antisocial behaviour and conduct disorder [8].

Genetic and environmental risk factors have long been implicated in the development of childhood psychiatric disorder, but recent evidence has also suggested a role for epigenetic mechanisms, in relation, for example to conditions such as autism [9] and ADHD [10]. Knowledge about the genetic and the epigenetic contribution to disorder is important in terms of our understanding about resilience (i.e. why it is that some children exposed to high risk environments do not go on to develop problems later) and the environmental factors that can be targeted to prevent problems occurring in the case of epigenetic processes. The concerns of this paper, however, are with identifying recent research about the direct influence of early environmental factors and in particular the parent–infant/toddler relationship, which can be targeted as part of secondary and tertiary service/provision.

Although abusive parenting has long been recognized to be strongly associated with a wide range of mental-health problems in children (including anxiety, depression, post-traumatic stress, dissociation, oppositional behaviour, suicidal and self-injurious behaviour, substance misuse, anger and aggression, and sexual symptoms and age-inappropriate sexual behaviour) [11], over the past decade, increasing attention has been given to the influence of wider parenting practices on child development. Developmental research during the 1980s showed a strong association between parenting practices characterised by harsh and inconsistent discipline, little positive parental involvement with the child, poor monitoring and supervision, and behaviour and conduct problems in early childhood [12]. More recently, research in the fields of developmental psychology, infant mental health and neuropsychology has begun to highlight the importance of early parent–child interaction in terms of its impact on a child’s capacity for emotion regulation, and it has been postulated that the key task of very early childhood and in particular, infancy, is the regulation of emotional states [13]. Research on attachment has developed significantly since Bowlby (1982) [14] first identified its role in promoting a sense of safety and security in the child. Perhaps most importantly attachment is now recognized to be a significant bio-behavioural feedback mechanism with a key role in the dyadic regulation of emotion. Research in the field of infant mental health suggests that this dyadic regulation takes place in repeated moments of ‘affect synchrony’ in which the parent and baby are emotionally attuned, and is facilitated by parents who are able to repair ruptures that occur following dyadic misattunement [15]. Neuroscientific research shows that these moments of synchrony impact on the limbic and cortical areas of the developing right cerebral brain [16]. Perhaps most importantly, by the end of the first year of life these early interactions have significantly shaped the right cortical–subcortical circuits via implicit-procedural memory [16], the main consequence being the development of unconscious strategies of affect regulation that have considerable stability over time [17].

Optimal parent–infant interaction thus enables the child ‘to develop an internal system that can adaptively regulate arousal and an array of psychobiological states (and thereby affect, cognition and behavior)’ [18]. Schore (2010) [16] writes the following regarding suboptimal parenting:

‘In contexts of relational trauma this caregiver is emotionally inaccessible, given to inappropriate and/or rejecting responses to her infant’s expressions of emotions and stress and provides minimal or unpredictable regulation of the infant’s states of over-arousal. Instead she induces extreme levels of stimulation and arousal (i.e. the very high stimulation of abuse and/or the very low stimulation of neglect). And finally, because she provides no interactive repair, she leaves the infant to endure extremely stressful intense negative states for long periods of time’ [16].

The discovery of a ‘disorganised’ category of attachment [18] gave rise to a body of research which showed that it was a significant risk factor for later psychopathology across childhood [19]. Disorganised attachment refers to behaviours that appear to be contradictory in terms of the child’s approach to the attachment figure and examples include where the child approaches but with the head averted or with fearful expressions, oblique approaches or disoriented behaviours such as dazed or trance-like expressions or freezing of all movement [18].

Disorganized attachment is found in around 80% of children who experience abusive parenting [20]. However, it is also found in 15% of population samples [21] and as such occurs outside the context of abuse [22]. Although there appears to be a genetic basis (i.e. a polymorphism of the DRD4 gene) for disorganized attachment [23], disorganisation has also been found to be associated with parenting behaviours that have been characterized as frightened and frightening (Fr-behaviour) [24] or hostile and helpless [22], and recent research suggests that it is the maternal behavior that ‘amplifies or offsets the risk conferred by the genotype’ [25]. Such parenting behaviours include affective communication errors (e.g. mother positive while infant distressed); disorientation (frightened expression or sudden complete loss of affect); and negative-intrusive behaviours (mocking or pulling infants wrist) [23]. A recent meta-analysis of 12 studies confirmed the strength of the association between such atypical or ‘anomalous’ parenting at 12/18 months and disorganised attachment [26].

There is a high stability between disorganisation in infancy and wide-ranging problems in later childhood including compulsive coercive/caregiving behaviours [21], social and cognitive difficulties, and psychopathology [27]. A recent study of older children (aged 8–12 years) also found that a disorganised attachment was associated with symptoms that met clinical criteria [28].

Research examining developmental pathways suggests that disorganised attachment maybe a significant factor (often alongside metacognitive deficits such as mentalisation) linking early traumatic interpersonal experiences with dissociative problems [29, 30], personality disorder [31, 32] and schizophrenia [33].

The above research suggests the importance of understanding the early parenting experiences of children presenting with psychopathology, and points to the need for a comprehensive assessment of the extent to which a child’s capacity for affect regulation and the defensive relational structures associated with insecure or disorganised attachment, are impinging on their broader functioning. This body of research also suggests that for interventions to be optimally effective, they need to address these issues, alongside the needs and parenting abilities of the primary caregiver.

The next section examines a number of innovative approaches to treatment that are aimed directly or indirectly at improving the infant’s attachment security. We examine briefly what each approach comprises alongside the evidence base to support their use.