Birth to three really does matter: in search of security

This blog reviews some attachment and care related issues I have covered in recent presentations, considering the origins, further development and implications of attachment theory, and how this might inform national policy creation for children under three and their families.

‘Classic’ attachment theory

Attachment theory was created by the British psychologist John Bowlby over the period directly following the Second World War (1939–45). Bowlby had built up the theory from his psychoanalytic work with children who had been evacuated from the cities during the war, separating them from home and family at very young ages. His central proposal was that human mothers and babies have a natural, evolved instinct to form a strong emotional bond, which if never made, or if broken in the first three years, created life-long emotional problems for the child. While this exclusive focus on mothers was later found to be highly problematic, Bowlby’s concept of the ‘Internal Working Model’ is still at the centre of modern attachment theory. He proposed that, based on their earliest relationships, infants construct an Internal Working Model (IWM) of what to expect from other people, and of their own level of ‘lovability’. Bowlby proposed that stable and loving relationships create an ‘other people are nice and I am lovable’ IWM, whereas troubled and fragmented relationships create an ‘other people are unkind and I am not lovable’ IWM. This basic belief, he proposed, was the basis of all subsequent emotional interactions with others, both in childhood and in later life.

Schaffer and Emerson (1964) later found, in a longitudinal study of babies aged 0–2, that several bonds with adults were formed in the first months. The babies tended to have one primary attachment and several secondary attachments, being content to be cared for by any of these ‘bonded’ adults. Only approximately 50 per cent of these babies had the primary attachment to the mother; the other 50 per cent had formed a primary attachment to another member of the family (most commonly the father or grandmother). The primary attachment tended to be the person in the family who showed the most ‘sensitive responsiveness’ to the baby.

The flexible human being

Bowlby had also drawn from ethology to create his ‘maternal deprivation’ theory, basing it partially on the phenomenon of imprinting in birds. What Schaffer and Emerson’s work indicates is that human beings are unsurprisingly rather more flexible than birds in the way in which they construct their early relationships, but that nevertheless, these relationships are have implications for lifelong mental health.  

D W Winnicott (1951) also shed light on this element of human flexibility when he studied what he came to call ‘transitional objects’- familiar toys and everyday objects (e.g., a teddy bear or a blanket) that small children use to bolster feelings of security in stressful situations. This again is unsurprising when we consider the human being as a symbolic primate. People operate via symbols- it is what makes us evolutionarily ‘special’. Words are the most obvious symbols, standing for the object in a sound or in a squiggle on the page. Children explore the more complex elements of symbolism in learning to speak, and later to read, but in very early development, they can create such a symbol subconsciously/ emotionally in a concrete object that can then temporarily stand for an attachment figure in stressful situations; a phenomenon that had been previously intuited in the early 20^th century children’s book The Velveteen Rabbit:

"Real isn't how you are made," said the Skin Horse. “It's a thing that happens to you. When a child loves you for a long, long time, not just to play with, but REALLY loves you, then you become Real”

(Williams 1922, online).

The studies of Mary Ainsworth (e.g., Ainsworth and Bell 1970) indicated that the quality of attachment that an infant had to bonded carers had a lasting effect on the IWM. Ainsworth proposed that where children’s experience was of bonded carers readily available to provide emotional support, they developed confidence to independently explore beyond the vicinity of the carer in an ever-widening arena, in the knowledge that they would be able to access emotional support when required. But where children learned that such support was never available, or that it was only available sporadically, they developed a reluctance to explore. Children who lacked emotional support altogether demonstrated a learned helplessness, developing a defence mechanism of responding dismissively to other people’s attempts to help; those who had learned that emotional support was only sporadically and unpredictably available developed a preoccupied/fearful style, developing a defence mechanism of constantly seeking reassurance from others due to an underlying concern that it might not be forthcoming when needed. In the mid-20^th century, therefore, building strong bonds of attachment in childhood was emphatically proposed by developmental psychologists to be crucial for lifelong individual mental health, and for cohesion and mutual trust in society in general.

The Cortisol Studies

With the growth of developmental neuro-biology in the early 21^st century, additional neurophysiological evidence emerged to support the importance of secure relationships in infancy. A range of studies discovered abnormally raised levels of the stress hormone cortisol in young children placed in situations where they did not feel secure in the care that they received. This was found in a range of studies of under threes spending full days in collective daycare, while comparison groups cared for in their family home showed normal cortisol levels (e.g., Badanes and Watamura 2012, Dettling, Gunnar and Donzella, 1999; Dettling, Parker, Lane, Sebanc and Gunnar, 2000; Watamura et al., 2003; Watamura, Kryzer, and Robertson, 2009).

However, it would be naïve to propose that every family home is more emotionally supportive than every daycare setting, and Australian researchers Sims, Guilfoyle and Parry (2006) clearly demonstrated this when they compared the cortisol levels of children in daycare settings judged as ‘high quality’ against the cortisol levels of children in daycare settings judged as ‘satisfactory’. Their findings indicated while children in the satisfactory settings typically showed the raised cortisol levels discovered by the previous research, children in the ‘high quality’ daycare typically showed no signs of a cortisol-elevated stress response. Sims et al suggested that the defining features of ‘high quality’ daycare were as follows:

• Protective care: staff provide careful, individualised care for all children at all times, and individual needs for safety, rest and comfort are met. Staffing policies and practices facilitate continuity of care for each child. Children are appropriately dressed for indoor and outdoor play. Toileting and nappy procedures are calm, positive experiences.
• Staff Relationships: happy engaging atmosphere, with staff positively guiding children’s behaviour; Staff communicate effectively and function as a team
• Partnership: Staff and families effectively exchange both verbal and written information about the children, and about the centre’s routines and expectations
• Respect: staff initiate and maintain communication with children, accommodating their individual needs including the recognition of social and cultural difference
• Planning, Learning and Evaluation: the centre programmes reflect a clear centre philosophy and shared goals, which cater for the needs, interests and abilities of all the children, and all the children are helped towards successful learning. The centre programmes encourage and support children to make confident choices and take on new challenges

The indications of Sims et al’s findings were therefore that the children in the high quality settings had fully accepted the daycare workers as into their circle of bonded adults, and felt secure in their care.

How should we care for under threes?

The key point emerging from attachment research carried out over half a century is therefore that children under three need affectionate, trusting relationships with a small group of adults who care for them in a calm, attentive fashion. With respect to home-based care, the chances that secure, bonded relationships will be cemented is greatly optimised by ensuring that parents have sufficient financial and social support, and are not placed under unmanageable stress during their child’s first three years of life. Tharner et al (2011, p.162) explain that ‘parenting stress explained the most variance in child emotional and behaviour problems’ but that ‘in families with high parenting stress, securely attached children had fewer socio-emotional problems than insecurely attached children’.

The role that well-trained professional adults can play in supporting children at risk of insecure family relationships has been further highlighted by Shonkoff et al (2015) who found that supportive adult-child relationships outside the immediate family circle could blunt the impact of insecure family relationships in early childhood, and that emotional resilience could be strengthened to some extent by supportive relationships with non-familial adults at any point in childhood. They list the important factors in such relationships as follows:

• That the relationship is long-standing, stable, caring and supportive
• The adult provides support for the child to believe that s/he can overcome adversity
• The adult supports the child to develop self-regulation skills (the ability to manage one’s own behaviour, emotions and attention focus). This is not an imposition of draconian external discipline, but gentle support for the child to learn how to regulate his/her own responses in situations that are experienced as stressful
• The adult is careful to support and affirm the social and cultural traditions to which the child and his/her family are affiliated

 Daycare is thus not precluded as an option for providing care for under threes, but the emotional support requirements of such young children put very high professional and financial demands upon it. These are principally that children have secure relationships with both the staff in the setting and with those who care for them at home, and that all bonded attachments are supported by both sets of adults, who interact respectfully and proactively. It also requires that adult-child ratios in professional settings are very high, that staff turnover is very low, and that the adults within the settings are properly trained to deal with the needs of very young children. Such staff would necessarily be well paid, to reflect the education and training required, and to be provided with further continuing professional development and a secure career structure to retain a stable staff cohort within the setting.

Children experiencing continuous stress due to early and ongoing insecure relationships typically have higher resting levels of cortisol and take longer to return to baseline after individual stressful experiences; a process that becomes ‘toxic’. A simplified comparison can be made between a continually stressed brain and a computer constantly running a program that takes up a significant amount of its processing capacity. Implications for such a child as time goes by include:

•        Fight or flight response always on stand-by

•        Quick to anger, to sadness and ‘learned helplessness’

•        Short attention span

•        Problems concentrating at school

•        View the world as a dangerous place

•        Mistrustful of adults and other children

•        Feeling of inadequacy/ lacks confidence

•        Lack of self-belief/ lack of self-motivation

•        May be over-dependent upon opinion/ support of others (preoccupied)

•        May reject support from others (dismissive)

This ongoing ‘fall out’ is emergent from the subconscious IWM they carry of the world within their emotional cognitions, i.e., that other people are not or may not be friendly and helpful, and that they themselves are not, or may not be worthy of affection. Insecurity in this fundamental construction of the self and other people’s responses to the self inevitably compromises mental well-being on a lifelong basis.

So what does this mean for policy?

Where we are constructing a national policy for care for under threes, we therefore have several choices. We may choose to rely on kin and neighbourhood to provide a bonded circle of adults, or we may set up high quality professional daycare facilities to reproduce such relationships. European nations offer models of both patterns of care, for example, the Netherlands principally relies upon kin and neighbourhood in a culture where adequate social welfare provision is made for families, and part-time working is commonplace, while the Scandinavian nations dedicate a significant proportion of their Gross Domestic Product to the provision of very high-quality daycare (Naumann et al 2013). Issues are likely to arise, however, in nations such as the UK where nearly one in three children live in families that are officially designated poor (Child Poverty Action Group 2019); where there is little financial or social support specifically targeted at families with children under three, and where funding mechanisms for daycare have been so badly managed by the government that a significant number of daycare providers closed down over the year following a funding policy change (Morton 2018), while those left are barely managing to meet their staff payroll (Ferguson 2019).

Towards the end of his life, Bowlby accepted that he may have put too much emphasis on the exclusive role of the mother, but further reflected:

Man and woman power devoted to the production of material goods counts a plus in all our economic indices. Man and woman power devoted to the production of happy, healthy and self-reliant children in their own homes does not count at all. We have created a topsy-turvy world’

(Bowlby 1988, p.2).

This point is just as relevant today. The birth to three period of a human life matters intensely in terms of nurturing an emotionally secure individual, but we give this so very little thought in contemporary policy creation. When we piece our society back together after the current Brexit crisis, this consideration must be placed at the very top of the national policy agenda.

References

Ainsworth, M.D.S. and Bell, S.M. (1970) ‘Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation’. Child Development, 41, pp.49–67.

Badanes, L., Dmitrieva, J. and Watamura, S. (2012) ‘Understanding cortisol reactivity across the day at child care: The potential buffering role of secure attachments to caregivers’, Early Childhood Research Quarterly 27, pp.156– 165.

Bowlby, J. (1988) A Secure Base. London: Routledge.

Bowlby, J. (1952) Maternal Care and Mental Health. Geneva: The World Health Organisation. Retrieved from http://whqlibdoc.who.int/publications/9241400021_part1.pdf

Child Poverty Action Group (2019) Child Poverty Facts and Figures. Available at: http://www.cpag.org.uk/content/child-poverty-facts-and-figures

Dettling, A.C., Parker, S.W., Lane, S., Sebanc, A. and Gunnar, M.R. (2000) ‘Quality of care and temperament determine changes in cortisol concentrations over the day for young children in childcare’, Psychoneuroendocrinology 25, pp.819–836.

Dettling, A.C., Gunnar, M.R. and Donzella, B. (1999) ‘Cortisol levels of young children in full-day childcare centers: Relations with age and temperament’, Psychoneuroendocrinology, 24, pp.519–536.

Ferguson, D. (2019) Parents in England face shock rise in childcare costs as government cuts bite. The Observer online. Available at: https://www.theguardian.com/money/2019/mar/31/childcare-fees-rocket-lack-of-early-years-funding-nurseries-close

Morton, K. (2018) Nursery closures rise 66 per cent since 30 hours began. Nursery World Online. Available at: https://www.nurseryworld.co.uk/nursery-world/news/1165551/nursery-closures-rise-66-per-cent-since-30-hours-began

Naumann I., McLean, C., Koslowski, A., Tisdall, K., and Lloyd, E. (2013) Early Childhood Education and Care Provision: International Review of Policy, Delivery and Funding. Edinburgh. Centre for Research on Families and Relationships (University of Edinburgh). Available at: https://www.nls.uk/scotgov/2013/9781782564164.pdf

Schaffer, H.R. and Emerson, P.F. (1964) ‘The development of social attachments in infancy’. Monographs of the Society for Research in Child Development, 29 (Serial No. 94).

Shonkoff, J., Levitt, P., Bunge, S., Cameron, J., Duncan, G., Fisher, P., Fox, N., Gunnar, M., Hensch, T., Martinez, F., Mayes, L., McEwen, B. and Nelson, C. (2015) Supportive relationships and active skill building strengthen the foundations of resilience. National Scientific Council on the Developing Child. Harvard: Center for the Developing Child, Harvard University. Available at: https://developingchild.harvard.edu/wp-content/uploads/2015/05/The-Science-of-Resilience.pdf

Sims, M., Guilfoyle, A. and Parry, T. (2006) ‘Child care for infants and toddlers: where in the world are we going? The First Years – Nga Tau Tuatahi’. New Zealand Journal of Infant and Toddler Education, 8(1), pp.12–19.

Tharner, A. (2011) Parents and Infants: determinants of attachment in a longitudinal population-based study. Amsterdam: Erasmus Medical Centre​

Watamura, S.E., Donzella, B., Alwin, J. and Gunnar, M.R. (2003) ‘Morning-to-afternoon increases in cortisol concentrations for infants and toddlers at child care: Age differences and behavioral correlates’, Child Development 74, pp.1006–1020.

Watamura, S.E., Kryzer, E.M. and Robertson, S.S. (2009) Cortisol patterns at homeand child care: Afternoon differences and evening recovery in children attending very high quality full-day center-based child care. Journal of Applied Developmental Psychology 30, pp.475–485.

Williams, M. (1922) The Velveteen Rabbit. Available at: https://digital.library.upenn.edu/women/williams/rabbit/rabbit.html

Winnicott, D.W. (1951) ‘Transitional objects and transitional phenomena. A study of the first not-me possession’. International Journal of Psycho-Analysis, 34, pp.89–97.

ACEs too High? Educating Yorkshire in ACEs awareness

The concept of ACEs- Adverse Childhood Experiences and their effects upon later adult life- is becoming a much discussed meme across the western world. It is therefore now time to reflect upon these ideas and to consider their validity, particularly within practice environments. This blog will consider ACEs in this spotlight, arguing that the concept has a clear relevance and application for practice with children and families going forward into the twenty first century, although there are clear pitfalls which must be carefully avoided when putting the ideas into practice. The basic ACEs theory is demonstrated in the following diagram:

 

The original study to explore the concept of ACEs was that of Felitti et al in 1998. The researchers carried out a large-scale analysis of the effects of a range of childhood stressors upon both mental and physical health in later life and found a number of statistically significant effects. Film maker James Redford, son of actor Robert Redford, came across an article disseminating the research findings and thought these ideas should be raised more prominently within the public eye (Cocozza 2017) In order to achieve this he made a film entitled Resilience: the biology of stress and the science of hope which has now been widely distributed across the western world.

Redford compares the constant stress that some children live under as comparable to arriving home every night to find a bear in the living room; that the mentally ill or abusive parent and/or the effects of ongoing poverty upon the family are likely to have long term adverse effects: ‘day after day, those chemicals – the adrenaline, cortisol, the process of high sugar, that whole response, changes the way your brain processes information. It affects the development of the organs on a cellular level. This continual exposure to stress wears the body down’ (Cocozza 2017, online).

ACEs research has continued across the world, making very similar findings to Felliti et al (1998). Recent large-scale studies in Wales (Bellis et al 2015) and Scotland (Couper and Mackie 2016) have linked poor mental and physical health in adulthood to childhood ACEs, while clear links have been drawn between ACEs, poverty and parenting stress (Steele et al 2016). Of course, human beings are the sum of all their experiences, which makes isolating cause and effect extremely difficult. A recent development has been the suggestion of a 'pair of ACEs', encompassing the environmental aspect. This was recently explored by NHS (Highland) in their Annual Report of 2018.

Such a vast number of variables in individual experience have been raised by those criticising the ACEs concept, who propose that, by over-simplification, there may be the creation of a deficiency model and a subsequent self-fulfilling prophecy, depicting individuals simplistically as victims of circumstance. The implication emergent from such a construction may be that people have little ability to control their own destinies, leading to stereotyping and stigma (Edwards et al., 2017). These researchers also express concerns about the problem of simplistic tick box screening being developed by amateurs, which may subsequently be used to promote shallow concepts of building resilience through counselling, rather than exploring solutions to the root causes.

These are of course highly valid concerns, but at the level of how we as a society respond to the concept of ACEs, rather than whether the effects actually exist or not. It is however useful to note that the practice of simplistic screening leading to self fulfilling prophecies must certainly be stringently avoided as a more ACEs aware society develops.

Edwards et al.’s more far reaching criticism- that ACEs is a retrospective model based on adults’ recall of childhood events, and may therefore lack reliability and validity (2017) is partially countered by the findings of Barboza Solis et al (2015) who found evidence of ACEs effects in the 1958 British birth cohort study, and by Horowitz et al (2001) who created a sample of participants from records of those who had experienced childhood adversity, and thence exploring whether ACEs were a factor in their adult lives. Both studies found evidence of ACEs effects, and additionally that later life events and gender were also significant influencing factors. Dube et al (2003) found evidence of ACEs effects in a US study dating back to participants born in the early 1900s. They concluded that although ‘ACEs rarely occur in isolation...it has been shown that the limbic system, which is responsible for emotional response, is adversely affected’ (p.274).

People with significant ACE loads, having experienced toxic stress in childhood, enter adulthood with a stress ‘thermostat’ that is chronically set at too high a level, in the same manner as a central heating system that has been set at maximum heat, which puts constant pressure on the boiler, so that when the thermostat is advanced even further by stressors in the day-to-day environment, the system becomes increasingly likely to ‘blow’, see diagram below.

The effect of the stress in early childhood through disruption of the human attachment process has also been extensively studied. Neurobiologists have investigated potential dysfunctions in the limbic system created by the modern practice of placing young infants in mass daycare settings for very long hours. I have carried out a literature review on this area of research, which is currently under peer review. In this I propose on the basis of my findings that as a society we should urgently explore more creative care initiatives for under 3s. In an earlier blog, I reflected that there is much for nations such as the UK to address, for example, the fact that ‘nearly one in three children live in families that are officially designated poor [and] where there is little financial or social support specifically targeted at families with children under three.’ I also consider the problems with memory and learning by cortisol disturbance, such as a short attention span and problems with concentration.

Links have additionally been drawn between adult attachment anxiety and cortisol dysfunction (Quirin et al 2008) and between ‘toxic stress’ and cortisol dysfunction (Oral et al 2015). Burke Harris (2018 p.187) reflects that it is a far more challenging prospect to build healthy attachment relationships and carry out calm, focused nurturing in families who are coping with poverty. It is becoming increasingly clear that categories of ACEs will continue to be refined as the effects are more widely studied, and that we will become more intricately aware of some of the more insidious effects of everyday stressors such as poverty and infant attachment disturbances

Some of these more subtle and transactional effects are already emerging from ACEs research, particularly with respect to attachment. Tharner (2011, p.162) found that ‘parenting stress explained the most variance in child emotional and behaviour problems’ but that ‘in families with high parenting stress securely attached children had fewer socio-emotional problems than insecurely attached children’. Shonkoff et al (2015) found that even just one supportive adult-child relationship in early childhood could blunt the impact of ACEs. These researchers propose that ‘resilience requires relationships’ (p.7) and that it can be strengthened by relationships at any point in childhood. Their checklist of important protective factors is illustrated in the following diagram.

Finally, it is important to remember that ACEs tend to be passed from generation to generation if parents do not receive support to reflect upon childhood stressors, and to explore how these may feed into current problematic behaviours and ongoing health issues. The aim of working with adults with high ACE scores should therefore be to help them to understand how their body and brain have been primed by their childhood environment. Just as we must guard against shallow screening exercises that label and ‘victimise’ children, so we must guard against doing the same thing to their parents. As Burke Harris (2018, p.219) points out, ‘how adversity affects you is not a referendum on your character. We don’t need to play the shame game.’ Support for parents with high ACE scores is currently being trialled.

For example, Blair et al.,(2019) studied the effects of ‘Parent-Child Interaction Therapy (PCIT)’ which compared families where parents were carrying a range of emotional stressors from their own childhoods to those who were not, indicated by scores on the Adverse Childhood Experiences Questionnaire (Felitti et al., 1998). They found that parents with a high ‘ACEs’ score (4 or over) reported significant improvements in the child’s behaviour following PCIT. Thomas et al., (2018) investigated whether pre-natal social support offered to mothers reduced their biological stress reactions and whether any positive effect was then transmitted to the child. They found that this practice reduced biological stress markers in both mother and child.

Of course, the ultimate aim for ACEs informed practice is to create a society in which ACEs occur far less frequently, and where they do, the child and the family are offered support at the earliest opportunity. Will this be very expensive for the nation? Most certainly. But in the end in such a society, taxpayers will not be required to contribute so much to adult health, social care and criminal justice systems, spending less on average on each individual over a ‘whole life’ basis. And of course, far more of the population will have an experience of life that is far more pleasant than they do at the moment. The answer to those who propose that we cannot afford to address ACEs on a national scale is that what we actually cannot afford is to continue to sleepwalk into a society that is incrementally losing connection to human emotional needs.

In April 2018, I worked with three other Leeds-based early years professionals to host a showing of Resilience at the Leeds Vue Cinema, in The Light. Initially we were concerned that we would not manage to secure the 30 ticket purchases we needed to fund the film showing. We advertised the event on social media and through our personal contacts, and the ticket sales quickly took off. The cinema kept moving the viewing to bigger and bigger screening rooms, and by the week before the viewing, we had sold all 175 tickets available.

The film was screened to a packed cinema of children’s workforce professionals. We asked people to fill in an anonymous feedback slip on the film, and to state their professional role. When we collated the information from the slips we found that we had attendees from the fields of teaching (primary secondary and university), social work, educational psychology, child and adolescent mental health services, students on child and family related programmes and early years education and care professionals working across the statutory and voluntary/independent sector. The feedback from the attendees made the following overall points:

We can collectively make a change'

'Everybody can play a part'

'It's not hopeless'

'ACEs affect everyone'

‘The world needs to change'

'Spread the word'

'Parent power'

The future for ACE aware practice would seem to be optimistic, although as detailed above, care must be taken to navigate the inherent problems that arise in the use of ACEs in services for children and families. This primarily centres around well-meaning but poorly informed applications of the ACEs questionnaire by people with insufficient training in the relevant area, which, in the worst scenarios, can increase distress rather than alleviating it. The goal should always be to nurture strong attachment relationships between parents and children rather than engaging in ‘parent blaming’, and to support the development of restorative, ACEs aware practices in education, youth work and youth justice.


References

Barboza Solis, B., Kelly-Irving, M., Fantin, R., Darnaudery, M. Torriusani, J., Lang, T. And Delpierre, C. (2015) Adverse Childhood Experiences and physiological wear-and-tear in midlife: findings from the 1958 British birth cohort. Proceedings of the National Academy of Sciences (USA). Available at: http://www.pnas.org/content/early/2015/01/27/1417325112 Accessed 25th April 2018.

Bellis, M., Ashton, K., Hughes, K., Ford, K., Bishop, J. and Paranjothy, P. (2015) Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population. Cardiff: Public Health Wales. Available at: http://www2.nphs.wales.nhs.uk:8080/PRIDDocs.nsf/7c21215d6d0c613e80256f490030c05a/d488a3852491bc1d80257f370038919e/$FILE/ACE%20Report%20FINAL%20(E).pdf Accessed on 25th April 2018.

Blair, K. Topitzes, J. and Mersky, J. (2019) Do Parents’ Adverse Childhood Experiences Influence Treatment Responses to Parent-Child Interaction Therapy? An exploratory Study with a Child Welfare Sample, Child & Family Behavior Therapy, 41:2, 73-83, DOI:10.1080/07317107.2019.1599255

Bloom, S. (1995) Creating sanctuary in the school. Journal for a Just and Caring Education Vol 1(4): pp.403-433. Available at: http://www.sanctuaryweb.com/Portals/0/Bloom%20Pubs/1995%20Bloom%20Sanctuary%20in%20the%20Classroom.pdf Accessed on 25th April 2018.

Burke Harris, N. (2018) The Deepest Well: healing the long-term effects of childhood adversity. London: Bluebird.

Cocozza, P. (2017) How childhood stress can knock 20 Years off your life. The Guardian Online. Available at: https://www.theguardian.com/lifeandstyle/2017/apr/29/how-bad-parenting-can-knock-20-years-off-your-life Accessed 25th April 2018.

Coupar, S. and Mackie, P. (2016) Polishing the diamonds: addressing Adverse Childhood Experiences in Scotland. Glasgow: Public Health Scotland. Available at: https://www.scotphn.net/wp-content/uploads/2016/06/2016_05_26-ACE-Report-Final-AF.pdf Accessed 25th April 2018.

Dube, S., Felitti, V., Dong, M., Giles, W. and Anda, R. (2003) The impact of Adverse Childhood Experiences on health problems: evidence from four birth cohorts dating back to 1900. Preventative Medicine Vol 37, pp.268-277.

Edwards, R., Gillies, V., Lee, E., Macvarish, J. White, S. and Walsall, D. (2017) The problem with ACEs. Submission to the House of Commons Science and Technology Committee Enquiry into the evidence base for early years intervention (EY100039). Available at: https://blogs.kent.ac.uk/parentingculturestudies/files/2018/01/Discussing-the-Problem-with-ACEs.pdf Accessed on 25th April 2018.

Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M. and Marks, J. (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults (The Adverse Childhood Experiences (ACE) study. American Journal of Preventative Medicine Vol 14 (4), pp.245-258.

Horowitz, A,. Spatz Widom, C.,McLaughlin, J. and Raskin White, H. (2001) The impact of childhood abuse and neglect on adult mental health: a prospective study. Journal of Health and Social Behaviour. Vol 42(2), pp.184-201.

Jarvis, P. (2014) Some reflections upon infancy in the 21st Century. Mothers at Home Matter. Available at: http://mothersathomematter.co.uk/archives/1512 Accessed 25th April 2018.

Jarvis, P. (2016) Mum’s the word for Theresa, Jeremy and Owen. The Huffington Post. Available at: https://www.huffingtonpost.co.uk/pam-jarvis/mums-the-word-for-theresa_b_11674502.html Accessed 25th April 2018.

Jarvis, P. (2017) Banish Baseline, beat poverty instead. Leeds Trinity University Blog. Available at: http://www.leedstrinity.ac.uk/blogs/Banish-Baseline-Beat-Poverty-instead Accessed 25th April 2018.

Oral, R., Ramirez, M. Coohey, C., Nakada, S. Walz, A., Kuntz, A., Benoit, J. and Peek-Asa, C. (2015) Adverse Childhood Experiences and trauma informed care: the future of health care. Pediatric Research. Vol 79 (1) pp.227-233.

Quirin, M., Prusessner., J. and Kuhl, J. (2008) HPA system regulation and adult attachment anxiety: individual differences in reactive and awakening cortisol. Psychoneurology. Vol 33, pp.581-590.

Shonkoff, J., Levitt, P., Bunge, S., Cameron, J., Duncan, G., Fisher, P., Fox, N., Gunnar, M., Hensch, T., Martinez, F., Mayes, L., McEwen, B. and Nelson, C. Supportive relationships and active skill building strengthen the foundations of resilience. National Scientific Council on the Developing Child. Harvard: Center for the Developing Child, Harvard University. Available at: https://developingchild.harvard.edu/wp-content/uploads/2015/05/The-Science-of-Resilience.pdf Accessed on 25th April 2018.

Steele, M., Knafo, H., Meissner, P. and Murphy, A. (2016) Adverse Childhood Experiences, poverty and parenting stress. Canadian Journal of Behavioural Science. Vol 48(1), pp.32-38.

Tharner, A. (2011) Parents and Infants: determinants of attachment in a longitudinal population-based study. Amsterdam: Erasmus Medical Centre.

Thomas, J, Letourneau, N. Campbell, T. and Giesbrecht, G. 2018. Social buffering of the maternal and infant HPA axes: Mediation and moderation in the intergenerational transmission of adverse childhood experiences. Development and Psychopathology 30, 921–939

Pictures 1-5 supplied by  70/30 Campaign http://www.70-30.org.uk/infographics/
Picture 6, Author's own.