The roots of disease in early development
There are signs that various aspects of the human condition are under severe stress and this is being expressed in an increase in emotional disorders in childhood and adulthood (Schore, 2012). The roots of psychopathology lie in traumatic attachment experiences (Schore, 2012). There is a need to focus psychotherapeutically on the precursors to disorders in childhood not just their manifestations in adulthood. Dysregulated affect (particularly unconscious affect) plays a primary role in not just psychopathogensis but all illness and disease. The beginnings of living systems set the stage for every aspect of an organism’s functioning throughout the lifespan. A scientific consensus is emerging that the origins of adult disease can be found in the developmental and biological disruptions in early childhood. Early relational trauma has been referred to as ‘the hidden epidemic’ (Lanius et al. 2010).
It is only in recent decades that the size of the problem of developmentally damaged people has begun to be recognised (Felitti, in Lanius et al, 2010). It has become evident that traumatic experiences during childhood and adolescence are far more common that is usually recognised. Early traumatic experience is linked with outcomes later in life that are of concern to public health and the social fabric. Early adverse experiences have been shown to have a large impact on neuroregulatory systems mediating illness as well as social behaviour. We often focus our attention on tertiary consequences far downstream while primary causes are protected by time, taboo and social convention. The ‘hidden epidemic’ of early trauma is not just a problem for mental health fields and medicine but for all of society. There is a need to create interventions for primary prevention of many physical and mental illnesses. Parenting skills is likely to be a core feature of primary prevention in the future of medicine and psychiatry. The influence of childhood experience, as outlined by Freud, including often unrecognised traumatic experience, is as powerful as Freud and other early pioneers described it. Chronic life stress in early development is generally underappreciated as an etiological mechanism underlying many biomedical illnesses.
An array of personal, public and social health problems is ‘skyrocketing’ in United states and around the world (Navarez et al, 2013) These include ADHD, autism, anxiety, depression, and psychosomatic conditions like diabetes, hypertension, obesity and autoimmune disorders. Science does not have a complete understanding or reliable remedies, nor preventative strategies for addressing these problems, although considerable progress is being made. The emergence of the social and affective neurosciences means that this is an opportune time to reconsider the early life needs of humans in the context of fostering optimal development.
Most mental illness begins far earlier in life that was previously believed (Insel and Fenton, 2005). A scientific consensus is emerging that the origins of adult disease is found among developmental and biological disruptions occurring in the early years of life (Leckman and March, 2011). In utero and immediate postnatal environments and dyadic relations between child and caregivers in the early years have an enduring impact on brain development and behaviour. The declining mental health of children is playing a prominent role in the emergence of physical problems (Schore, 2012). Psychosomatic and psychosocial disorders have a long-lasting impact on children’s lives and society. There is thus a need to focus more on prevention and early intervention in mental disorders (Merikangas et al., 2010).
Investing in child development is the foundation for improved health, economic and social outcomes (Silver and Singer, 2014). Not getting the early years ‘right’ is linked with violence, depression, transmission of non-communicable diseases, lower wages and negative impact on gross domestic product. Unless early development is addressed effectively countries will be locked into poverty and sustainable development will not be achieved.
Early care makes substantial contributions to later adult psychiatric morbidities (Burea et al, in Pain et al. 2010). ‘Hidden trauma’ refers to risk for behavioural and physiological dysregulation as a result of poor early care in infancy These experiences are likely to have an equal or greater impact on later morbidity than maltreatment which is easily observed. Psychiatric disorders can start at a very young age (Keren and Tyano, 2012). Violence is a big problem in society and the best intervention is to prevent developmental aggression in very early childhood from turning into antisocial personality disorders. Early care-giving qualities is a major contributor to outcomes and the longer a developmental pathway is pursued the harder it is to change.
Trauma is pervasive throughout the world and has negative impact on individuals, communities and society (Magrueder et al, 2016). In the social-ecological model, by targeting risk factors at various levels there are number of opportunities for prevention and intervention. Community and society trauma-informed interventions are greatly influenced by the values, beliefs, laws and customs of the wider culture (Waite and Ryan, 2020). Trauma does not take place in a vacuum but is influenced by family, peers, community and socio-political forces. This is a multilevel phenomenon – macrosystem philosophies have a great influence on micro-system functioning. Interventions to address Adverse childhood experiences (ACE’s) must use an ecological systems perspective along with a strengths-based approach rather than a deficit and problem-based approach that emphasises pathology. This must be supported by policy that addresses structural difficulties that contribute to the child, family and community’s difficulty. Structural and cultural support must be offered to the child, as well as those who immediately effect the child’s well-being. Families and neighbourhoods reciprocally enforce positive development. A system of shared support and unity supports the idea that ‘all children are our children’ – which stems from the macrosystem of ideas and philosophies.
Converging evidence shed new light on the potential for primary prevention in mental health for young people (Colizzi et al, 2020). Prevention in mental health should not be the responsibility of mental health professionals alone. Integrated and multidisciplinary services are needed to implement the range of interventions required to improve long-term outcomes. However, mental health professionals have responsibility for giving direction to social, political and other healthcare groups involved in meeting mental health care needs in young people. Promotion, prevention and early intervention strategies may produce the greatest impact on people’s well-being.
There has been a call to ‘reboot’ mental health treatment in order to address the population level burden of mental health (Kazdin and Blaze, 2011). Rather than seeking to deliver only efficacious, the public health approach seeks to balance efficacy with ‘reach’ – getting at higher proportion of the target population. Research and practice is guided by how far an intervention goes in reaching the population level burden of child trauma. A public health approach is helpful in going beyond the individual to the vast population impact of trauma and identifying a range of potential models to address this impact that go beyond individual interventions. Mental health issues are largely ignored in the global public health agenda.
There is a need to act at the individual, family and culture levels to provide an optimal context for mental and physical health (Schore, 2012). In addition to fostering cognitive development there is a need to support social-emotional development via right-brain functions of intersubjectivity, empathy, affect process and interactive regulation of stress. Research on the critical survival functions of the right brain can be applied to cultures as well as individuals. There is converging evidence that we can maximise the impact of interventions by focusing on the early critical period of the brain growth spurt during, roughly, the first two years of life.
It appears we are failing to adequately care for the most vulnerable members of our society – children. Perhaps there is a collective denial at play which may be serving as a defense mechanism to protect us from acknowledging this painful reality and the sense of overwhelm that can come with it. Given the detrimental long-term health implications of poor early care we are morally obliged to take greater action on this issue. The challenge is the realisation of how pervasive it is and the fact that much of the harm done can take the form of ‘hidden trauma’ which is not as overt as abuse and extreme neglect. Dealing with this problem is likely therefore to require a cultural shift in how we support young people’s development (i.e. how we parent and how we educate). Investing in protecting the developing child is likely to not just reduce disease but holds the promise of increasing health and well-being – for individual’s, communities and the culture as a whole.
Development
In order to prevent the development of pathology we must protect the developing person, particularly in the early years. How the person be protected as they develop through the lifespan to reduce the risk of the development of disease and disorder? You do not need to know the cause of a problem to prevent it – it is enough to know about the mechanisms through which the problem is sustained or transmitted (Kloos et al, 2021). What is the mechanism through which pathology is transmitted?
In order to know when, where and how to intervene we must first examine the developmental process and develop an understanding of psychopathogenesis. This means understanding risk and protective factors so that interventions can reduce the former while boosting the latter. Essentially, the question we are exploring is how do problems in development arise and how can we act to prevent these initially and treat them thereafter?
Pathology is a process that is considered to be a disorder or impairment of normal functioning (Morsunbul et al, 2019). Psychopathology takes place in the developing organism – therefore, a developmental perspective is needed to understand and treat it. The basic science of human development creates knowledge that can inform efforts to promote physical and mental health, prevent the development of problems and treat problems that have already emerged (Belsky et al, 2020). This science is based on the same logic as other scientific disciplines. If you understand how something works you are in a good position to maintain that thing in good working order and you are well prepared for problems that might arise. The discipline of human development can be compared to meteorology in that there are a variety of forces and factors to consider that interact over time and space in complex ways. Like meteorology, human development is probabilistic rather than deterministic. Risk is increased under certain circumstances but it is also possible to identify forces that mitigate against these risks which opens up possibilities for intervention to reduce the likelihood that the risk will be realised. This science gives insight into how to prevent problems from developing, treat those problems that do develop and promote well-being generally. A risk factor is anything that increases the probability of a negative outcome in development (Sroufe et al, 2005). Protective factors are resources that promote resilience in the face of risk. These protective factors can help guide prevention and early interventions.
Developmental theorists
John Bowlby (2010) described how, at the time of writing, the favoured model of personality development was one where the person moved through different stages on a single track to maturity. Disturbances or problems occur, according to this line of thought, when there is an arrest at one of these stages. Under stress the personality then regresses to that point in development where the arrest took place. There are a set of ‘developmental lines’ along which all personalities develop. Problems arise when there is a fixation at some point along one of these lines.
An alternative model is one in which personality development is viewed as a process that develops “unceasingly along one or another of an array of possible developmental pathways” (Bowlby, 2010, p.412). All of these pathways start close together so that at the start the individual has access to a broad range of pathways along which they may potentially travel. The pathway chose turns at an interaction between the organism as it has developed up to that point and the environment in which it finds itself at each stage of the journey. At conception, for example, development arises out of the interaction between the genome and the intra-uterine environment. At birth it is an interaction between the neonate and the family etc. At conception the total array of pathways available is determined by the genome. As development proceeds the number of potential pathways diminish.
The two models presented here can be compared to two railway systems. The first model is like a single mainline on which there are a number of different stations. At each station the train can be halted, either temporarily or permanently. The longer it gets stuck there the more it is prone to return there when it meets with resistance further down the line. The second model is like a system that starts as a single main route which leaves a city going in a particular direction but soon forks into a number of different, diverse routes. While these routes branch off to a degree, initially they generally head in the same direction as the main route. The further each route travels however, the more it branches off in different directions and slowly a greater degree of diversity in direction occurs. While these sub-branches diverge further, there are other branches that take a course that converges with the original one so that this route may come to run close to or parallel with the original. In this model the critical times are at these junctions where the lines fork because as the train moves along one line the pressure to stay on it increases. However as long as the divergence does not become too great there is an opportunity for convergence at the next junction.
Many theorists have conceptualised development as a series of changing issues that act as the focus for adaptation at different ages (Sroufe et al, 2009). The dynamic systems approach to development offers an alternative to seeing the causes of development as being inherent in the organism or as being determined by the environment, or later developments being caused in a linear way by some previous event. Non-obvious forms that are increasingly complex emerge from the interaction of different parts of the system, in the face of new demands from the environment. Early experience is important from the systems perspective because it is an ‘initiating condition’ that sets the stage for all subsequent transactions and provides a foundational form of organisation. But systems are nonlinear in that outcomes depend not just on initiating conditions but also on their interaction with conditions that arise later. The impact of an early condition depends on the environment that is encountered and responses to later experiences depend on prior history.
According to Vygotsky many capacities are first mastered in social relationships and only later become capacities of the individual (Sroufe at al 2009). Vygotsky also claimed that rather than the environment stamping experiences into the child, the child actively appropriates what is provided by the environment. Louise Sander claimed that the organisation of the caregiver-infant system became the basis for the organisation of the personality. Self-organisation is a reflection of the prior organisation of the relationship. Out of Rene Spitz’s ‘genetic field theory’ came the idea of a ‘sensitive period’ in development. This asserts that the individual has a special openness to, or a need for, certain kinds of experience during a specific development period. A child may be less responsive to an experience at a different time. In Spitz’ view if infants are deprived of care their capacity for relationship may be fundamentally compromised. Sroufe at al (2009) identify another idea of Spitz’ as ‘seminal’: the developmental prototype. This is “a root form, the progenitor of later forms but related to them in a complex, nonlinear way” (p.33). Later forms emerge from former ones and the later embodies the former in its core, but without being a replica. The later form is the prototype transformed. Early adaptations are prototypes that are reflected in core features of later adaptations, even though the later ones are more complex in structure. One reason infancy may have special importance in development is that it cannot be verbally recalled or directly analysed.
A lot of disturbance in development is caused by caregivers’ failure to respond to young children’s healthy needs for closeness and fears of separation (Sroufe et al, 2009). Most psychopathology involves emotional dysregulation or distorted personal relationships. According to Bowlby, the root of such problems are caregivers failure to help children regulated their emotions. Development can be defined as change in the organisation of behaviour over time and the central aspects of an individual’s organisation have their origins in how early primary relationships are organised. Attachment is an integrative construct that sits at the intersection of all social, emotional and cognitive development in the first year. Effective attachment means the child can stay organised in the face of novel experiences. Later development is clearly served by effectively organised attachment. Attachment formation is a ‘prototypical salient issue’ when we consider its centrality to all infant functioning and subsequent development.
The thinking outlined above emphasises the complex and unpredictable nature of human development. Early experience is highlighted as being of foundational importance for it sets the stage for everything that comes after that. However, it is not deterministic, and outcomes depend on how these early experiences interact with later influences. Given the complexity of this process of development there emerges an appreciation of the inherent uncertainty of such a process which in many ways poses a significant challenge and gives pause for thought when considering how best to intervene in prevention work. John Bowlby’s railway model offers comfort and hope that, even if the early years are not ideal, there may be junctions further down the track where effective interventions can provide remedies. However, it is not clear to what extent suboptimal early environments and the experiences they create can be rectified later. The idea of ‘sensitive periods’ indicate that there may be limitations to this. Also, the further down the track you travel, it would appear the harder it is to change.
Developmental psychopathology
The mission of developmental psychopathology is to prevent or ameliorate problems and disorders and promote positive development (Venta et al, 2021). An important concept in this field is the idea of ‘pathways’ or how people change and adapt over time and reach different outcomes and pathologies. Multifinality refers to how similar early risk factors can lead to different outcomes. Early maltreatment may lead to the development of psychopathology or it may not, depending on lots of other factors. Some children may display problems in early childhood, while for other problems only emerge in adolescence. There are different pathways and patterns that develop differently over time. Developmental psychopathology seeks to understand these patterns to see how we can predict these different trajectories. Brofenbrenner’s ecological model, Sameroff’s gene and environment interaction model and other models all demonstrate that we should study processes and systems at multiple levels and how these levels interact to better understand risks for disorders. In the ‘transactional model’ the child’s outcomes are the result of ‘continuous dynamic, reciprocal interactions’ of the child and the environment. The transactional model contrasts with linear models in which A is seen as causing B. Developmental psychopathology is a frame work that can be applied that can leverage support to improve detection, diagnosis, prevention and treatment.
Protective factors ‘buffer’ against risk, decrease the likelihood of negative outcomes and promote successful outcomes (Venta et al, 2021). Risk factors can be acute stressful events but these are not deterministic. Resilience refers to the ability to avoid adverse outcomes and adapt successfully despite being at risk or experiencing adversity. Studying protective factors is important for understanding child and family strengths that can reduce risk. Understanding and identifying at risk individuals and what factors mitigate risk can help improve prevention and intervention efforts.
Child abuse may lead to different kinds of psychopathology in adulthood (Lieberman, 2020). Or it may lead to successful adaptation depending on other variables such as constitutional factors, the presence of protective adults and other positive influences. Different risk factors can lead to the same outcome. Aggressive behaviour in childhood can result from injury to the frontal lobes, harsh parenting, abuse, or the interplay of several different factors such as genetic predisposition and parental rejection. Pregnancy and the perinatal period may be a maturational stage that is receptive to positive influences to restore a trajectory of healthy development (Lieberman, 2020). Risk factors during pregnancy include poverty, community violence, racism, marginalisation and discrimination which raise the risk for psychiatric conditions like anxiety, depression and PTSD. Other risk factors include a history of psychopathology, substance abuse, past or current trauma exposure like childhood maltreatment, IPV, an unwanted pregnancy and prior pregnancy loss.
The idea that child abuse, even when the experience is buffered by protective factors, may lead to ‘successful adaptation’ is quite counter-intuitive. Can anyone really be expected to adapt successfully when such a trauma is inflicted upon them at vulnerable period in their development when the architecture of the brain is being formed? This seems unlikely, particularly if the abuse takes place within the attachment relationship when those who are supposed to protect you are in fact a source of threat. What is successful adaptation and who decides? Even if one is not ‘pathological’ it does not necessarily mean that one is fully healthy. Also, as the ACE’s literature illustrates, we need to be cautious when conferring ‘resilience’ on people (Felitti, in Lanius et al, 2010). A person may not develop a psychiatric disorder but could instead develop a physical disease in mid-life that may have links to that early stress.
A single cause is unlikely to be necessary or sufficient cause of most pathology (DeKlen and Greenberg in Cassidy and Shaver, 2018). Even disorders with established biological mechanisms are buffered or potentiated by other factors in the environment and biology. Therefore, it is unlikely that attachment insecurity alone will lead to a disorder – although it does increase the likelihood of such an occurrence. Few childhood disorders are likely to be dealt with by only treating the causes that lie within a child. Even when there is a strong biological influence, the parent-child relationship is often the recommended focus for treatment. A variable the confers risk for one disorder may reduce risk for others. The influence of a risk factor can be moderate by other factors (gender, genes, ethinicity) – this is called differential susceptibility. Risk factors occur at multiple levels from individual to family to culture. The association between risk and outcome is often nonlinear. One risk factor may not predict poor outcomes but the likelihood of disorder can increase rapidly with more risk factors. It is not clear whether certain risk factors or combinations matter more than other ones. Risk factors may influence outcomes differently at different periods in development. Attachment may have the greatest impact early on which cognitive development, peer relationships and parental monitoring are more important later. Protective factors might directly decrease dysfunction, prevent risk factors from occurring, buffer the effects of these risk factors or disrupt the mediational chain through which risk leads to disorder.
Developmental psychopathology emphasises the importance of understanding the multilevel nature of contexts that contribute toward the development of psychopathology (Lieberman, 2020). Psychopathology emerges from the interaction between risk and protective factors. Affective bonds between mother and infant is a key aspect of development but it is important to include a broader examination of caregiver influences in understanding individual and group outcomes starting in infancy.
Biological and interpersonal processes are involved in the intergenerational transmission of risk (Lieberman, 2020). ‘Fetal programming’ links prenatal stress to changes in fetal development and an increase in risk of developing psychiatric conditions later in life. Distress to pregnant women may influence fetal functioning by changes in placental gene DNA methylation. Parent’s childhoods and epigenetics are the first exposure in the intergenerational transmission of disadvantage. Maternal adversity, both before and during pregnancy affect the respiratory sinus arrythmia of the fetus – a marker of infant self-regulation which is linked to mental and physical health outcomes throughout life. Higher ACE scores were linked with lower RSA. Maternal prenatal stress was found to be associated with the failure of the infant to recover following the stressor of the still-face experiment.
In recent times, researchers in the field of developmental psychopathology have focused on developmental cascades (Morsunbul et al, 2019). Developmental cascades express the connection between different areas that influence steps in development and the consequences of development over time. These link biological, social and cognitive processes encompassing family as well as the larger culture. These cascades may directly or indirectly influence the course of development. These cascades explain why some problems in childhood predict later problems while others do not. This approach provides direction on the prevention and treatment of mental health disorders.
Interpersonal violence, especially violence experienced by children is the largest single, preventable cause of mental illness (Sharfstein, 2006). Early childhood violence is the equivalent for mental health to smoking for physical health. This indicates that it is important to make it a key focus of therapeutic intervention (Lieberman, 2020). There is a large amount of evidence that show the success of interventions that start in pregnancy and continue after birth.
The cumulative-risk hypothesis is the theory that multiple risk factors during childhood, when taken together, exponentially raise the likelihood of negative health outcomes (Kloos et al, 2021). Resiliency refers to the ability of people to overcome adverse conditions and achieve healthy development. Individuals who are resilient have a positive outlook on life and good self-regulation skills; have good healthy relationships with adults and peers, including good parenting; at the community level they are supported by good schools and neighbourhoods, have connections to prosocial organisations, and have access to social services and health care. Many children who do not display resiliency in childhood (they had significant mental and behavioural problems by 18) but go on to do well in middle age, researchers have found that these troubled teens experienced ‘openings of opportunities’ in early adulthood that led to significant increase in their functioning. These include education, a good marriage, geographical relocation, experiences in the military and conversion to a religion that provided them with a community of faith. Professional intervention was found to play a small role in this conversion and most of it occurred through the relationships and resources found in ordinary community life. A rich field has developed exploring ways not just to decrease risk factors but also to increase protective factors that promote resilience and thriving. This is becoming the goal of many intervention programmes. Identifying risk factors provides multiple points at which you can intervene to transform these risks into protective factors.
Sroufe et al (2009) describe the key findings of the Minnesota study of risk and adaptation. That nothing is more important to the development of the child than the care they received, including that in the early years; individuals are impacted by their entire history and that early experience is not erase even after dramatic change; that personal characteristics like resilience and different forms of psychopathology are developmental constructions and are not inborn characteristics; that the individual can only be understood within a model of continuing transactions between the developing person and the supports and challenges in their environment.
The parent-child relationship has been considered central to personality development for a long time (DeKlen and Greenberg in Casidy and Shaver, 2018). Object relations theorists and ego psychologists hypothesised that the earliest relationships in life have a great impact on the development of mental health. Attachment theory provides a crucial developmental frame for understanding how caregiving relationships influence processes involved in psychopathology as it emerges – the creation of cognitive-affective expectancies, the capacity for emotional and behavioural regulation. Regulation of emotion has a critical role to play in many forms of psychopathology. Meta-analyses show that attachment predicts later problems but it generally exerts this influence in the context of other risk factors.
The field of developmental psychopathology offers a useful framework for understanding the development of problems and how to intervene to prevent these. But as already stated this is a very complex process and there do not appear to be easy answers. Do we seek to reduce risk factors, increase protective factors or do both? What are the most important ones to target and at what stage in development? The ecological model offers many points of entry for intervention but in a world of limited resources what level is likely to hold the greatest potential for impact? Eradicating poverty would likely have a huge impact but is such a goal likely or achievable? A recurring theme is the importance of interpersonal relationships and attachment in reducing risk and increasing protective factors. In line with the ‘initiating condition’ principle, programmes that target the early attachment relationship are likely to have a deep impact as they can provide an early protective factor that can buffer against later adversity. The earlier an intervention is initiated the more likely it is to prevent problems from arising. It is likely to set a person on a healthier trajectory (influencing all later development) and also the earlier a measure is enacted means it has more lifespan upon which to continue to exert its influence.
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