Meeting Emotional Needs in Intellectual Disability E-Book

Tanja Sappok

• Herausgeber: Hogrefe Publishing
• Kategorie: Geisteswissenschaft
• Sprache: Englisch
• Veröffentlichungsjahr: 2022

Seitenzahl: 423

Beschreibung

Help adults with intellectual disabilities improve their mental health and quality of life - Introduces a new emotional development, evidence-based model - Details phases and milestones of development for people with ID - Explains challenging behaviour and mental health problems according to the model - Detailed guidance on how to apply the approach in practice - Full of case examplesMore about the book Using a developmental perspective, the authors offer a new, integrated model for supporting people with intellectual disability (ID). This concept builds upon recent advances in attachment-informed approaches, by drawing upon a broader understanding of the social, emotional, and cognitive competencies of people with ID, which is grounded in developmental neuroscience and psychology. The book explores in detail how challenging behaviour and mental health difficulties in people with ID arise when their basic emotional needs are not being met by those in the environment. Using individually tailored interventions, which complement existing models of care, practitioners can help to facilitate maturational processes and reduce behaviour that is challenging to others. As a result, the "fit" of a person within his or her individual environment can be improved. Case examples throughout the book illuminate how this approach works by targeting interventions towards the person's stage of emotional development. This book will be of interest to a wide range of professionals working with people with ID, including: clinical psychologists, psychiatrists, occupational therapists, learning disability nurses, speech and language therapists, and teachers in special education settings, as well as parents and caregivers.

Leseprobe

Meeting Emotional Needs in Intellectual Disability

The Developmental Approach

Tanja Sappok, Sabine Zepperitz, and Mark Hudson

About the Authors

Tanja Sappok, MD, was born and grew up in Heidelberg and studied medicine at the RWTH Aachen, Germany, and at the Louisianna State University, Shreveport, LA, and the East Tennessee State University, Johnson City, TN, USA. As chief physician, she heads the Berlin Treatment Center for Mental Health in Developmental Disabilities at the Ev. Krankenhaus Königin Elisabeth Herzberge. Clinical and scientific fields of work include autism spectrum disorders, emotional development, behavioural disorders, and dementia. As president of the European Association for Mental Health in Intellectual Disability (EAMHID) and vice president of the German Society for Mental Health with Mental Disability (DGSGB), she is organising the EAMHID Congress 2021 in Berlin. She teaches psychiatry at the medical faculty of the Charité and with her work she aims to improve medical care for people with intellectual developmental disabilities.

Email: [email protected]

Sabine Zepperitz, Dipl.-päd., studied educational sciences at the Technical University of Berlin, Germany. She is a systemic therapist and trauma consultant and leads pedagogical staff at the Berlin Treatment Center for Mental Health in Developmental Disorders at the Ev. Krankenhaus Königin Elisabeth Herzberge. She works primarily with people with moderate to severe intellectual disabilities. Her task within the framework of psychiatric treatment is to conceive nondrug treatment methods and to implement them in the patients’ living environments. Mrs Zepperitz trains facilitators for SED-S diagnostics and counselling in a series of workshops. She has been offering advanced training for caregivers and team consultations in the support for people with disabilities for several years.

Email: [email protected]

Dr Mark Hudson, DClinPsy, completed his undergraduate degree in psychology at the University of Leicester, UK, before studying clinical psychology at the University of Birmingham and University of Sheffield, UK. He is a practising clinical psychologist and assistant professor of clinical psychology at the University of Nottingham, UK, where he carries out teaching and research. After qualifying, he initially worked in an inpatient assessment unit for children with moderate-severe intellectual disabilities (ID), before moving to work in both a community child and adolescent mental health service and a specialist community team for children with ID. He has a particular interest in attachment and systemic family therapy, and has published on the use of these approaches in people with autism and ID. He currently co-leads the Elizabeth Newson Centre, providing specialist assessments to families where a child has developmental difficulties.

Email: [email protected]

Library of Congress of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2021942784

Library and Archives Canada Cataloguing in Publication

Title: Meeting emotional needs in intellectual disability : the developmental approach / Tanja

Sappok, Sabine Zepperitz, and Mark Hudson.

Other titles: Alter der Gefühle. English

Names: Sappok, Tanja, author. | Zepperitz, Sabine, author. | Hudson, Mark (Mark P.), author.

Description: Translation of: Das Alter der Gefühle. | Includes bibliographical references and index.

Identifiers: Canadiana (print) 20210266155 | Canadiana (ebook) 20210266570 | ISBN 9780889375895

(softcover) | ISBN 9781616765897 (PDF) | ISBN 9781613345894 (EPUB)

Subjects: LCSH: Intellectual disability. | LCSH: People with mental disabilities—Mental health. |

LCSH: People with mental disabilities—Psychology. | LCSH: Developmental psychology. | LCSH:

Affective neuroscience.

Classification: LCC RC570.2 .S3613 2021 | DDC 616.85/88—dc23

© 2022 by Hogrefe Publishing

www.hogrefe.com

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ISBN 978-0-88937-589-5 (print) • ISBN 978-1-61676-589-7 (PDF) • ISBN 978-1-61334-589-4 (EPUB)

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Dedicated to our patients

|vii|Preface to the English Edition

In this book, Meeting Emotional Needs in Intellectual Disability, we introduce the emotional development approach and offer a variety of tools to help support the challenging behaviours associated with the different stages of development. This is the result of an interdisciplinary collaboration between a medical doctor (Tanja Sappok), a behavioural specialist (Sabine Zepperitz), and for the English edition, a clinical psychologist (Mark Hudson). It draws on the expertise and insights from family members, doctors, behavioural specialists, therapists, psychologists, nurses, and other healthcare professionals, as well as special needs educators and social workers who have lived or worked for years with people with an intellectual disability (ID) and mental health problems or severe challenging behaviours. This scientifically based textbook aims to reduce problem behaviours and to foster well-being and mental health in people with an intellectual disability. The first part of the book (Chapters 1–6) anchors the developmental approach within the theoretical frameworks of developmental neuroscience and developmental psychology. The second part (beginning with Chapter 7) increasingly focuses on the implications of the approach for clinical practice and people’s daily lives. Therefore, if you as the reader are more interested in the practical aspects, then you may wish to start from part 2 or read the short “in a nutshell” summaries in part 1 first.

Even though we believe that developmental science can substantially improve the living conditions of people with disabilities in modern society, there are certain risks associated with this view. As a result of a decade-long emancipation process – and finally with the adoption of the UN Convention on the Rights of Persons With Disabilities – adults with an intellectual disability are also recognised and treated as adults. The result is a respectful but also distanced form of interaction. The application of developmental neuroscience expands our concept of adulthood in intellectual disability to encompass needs which are typically associated with earlier developmental stages. This, however, creates a new area of tension. We do not mean that adolescents and adults with intellectual disability are child-like, and we respect the fact that they will have had many experiences and gained skills which would not be expected of a young child. Rather, we would like to encourage you to acknowledge all aspects of their personality, including their physical, intellectual, and social–emotional competences and their personal and family goals, in order to help them fulfil their potential in a self-determined way.

Tanja Sappok, Sabine Zepperitz, and Mark Hudson,

Berlin and Nottingham in May 2021

Contents

Preface to the English Edition

1 Emotional Development: An Introduction

1.1 Emotion and Cognition in Dialogue

1.2 Conceptualisation of Emotional Development

1.3 The Development of the Emotional Brain

1.4 The Neuroanatomy of the Emotional Brain

1.5 Developmental Theories and Developmental Tasks

1.6 The Developmental Approach and Adulthood

2 Phases of Emotional Development

2.1 SED-S Phase 1: Adaptation (Reference Age: 0–6 Months) – SYMBIOSIS

2.2 SED-S Phase 2: Socialisation (Reference Age: 7–18 Months) – SAFETY

2.3 SED-S Phase 3: First Individuation (Reference Age: 19–36 Months) – AUTONOMY

2.4 SED-S Phase 4: Identification (Reference Age: 4th–7th Years of Life) – FORMING SELF

2.5 SED-S Phase 5: Reality Awareness (Reference Age: 8th–12th Years of Life) – SELF-DIFFERENTIATING

2.6 SED-S Phase 6: Social Individuation (Reference Age: 13th–17th Years of Life) – IDENTITY

3 The Practical Application of the SED-S

3.1 The Scale of Emotional Development – Short: SED-S

3.2 Assessing Emotional Development With the SED-S

3.3 Analysis of the SED-S

3.4 The SED-S Assessment and the Derivation of Therapeutic Interventions in the Case Study

3.5 Other Methods of Developmental Diagnostics

4 SED-S: The Milestones of Emotional Development

4.1 Domain 1: Relating to Their Own Body

4.2 Domain 2: Relating to Significant Others

4.3 Domain 3: Dealing With Change – Object Permanence

4.4 Domain 4: Differentiating Emotions

4.5 Domain 5: Relating to Peers

4.6 Domain 6: Engaging With the Material World

4.7 Domain 7: Communicating With Others

4.8 Domain 8: Regulating Affect

5 Challenging Behaviour

5.1 The Stage of Emotional Development as the Key to Understanding Challenging Behaviour

5.2 Emotional Development and Challenging Behaviour: A Case Study

5.3 Behavioural Syndromes According to the Level of ED

6 Mental Health Problems

6.1 The Importance of Emotional Development for the Development of Psychological Distress

6.2 Psychiatric Diagnoses as a Function of the Level of Emotional Development

6.3 Mental Disorders Influencing the Stage of Emotional Development

6.4 The Dilemma of Categorisation

7 The Implementation of the Emotional Development Approach in Clinical Practice

7.1 General Aspects

7.2 Special Features in Childhood and Adolescence

8 Characteristic Examples of Care and Treatment Approaches in the Individual SED-S Phases

8.1 Case Study for SED-S Phase 1

8.2 Case Study for SED-S Phase 2

8.3 Case Study for SED-S Phase 3

8.4 Case Study for SED-S Phase 4

8.5 Case Study for SED-S Phase 5

8.6 Case Study for SED-S Phase 6

9 Therapeutic Interventions

10 Opportunities and Possibilities for Development-Based, Multi-Disciplinary Case Conferences

Summary

Concluding Observation

Acknowledgements

Definitions and Abbreviations

References

Subject Index

|1|1 Emotional Development: An Introduction

A 20-year-old woman with a severe intellectual disability scratches and bites herself and walks restlessly between rooms. The restlessness occurs mainly in situations where she must wait or when she is physically uncomfortable, e.g., because of hunger. She needs help to eat and to get dressed. She is often on her own; she rocks back and forth, snuggles in her bed during the day, twirls her hair, or chews on a sensory object. She lives in a residential home with seven other residents and works eight hours a day in a sheltered employment project. However, she is not interested in any of the other residents and only seeks contact with her caregivers.

A 25-year-old man with a moderate intellectual disability cannot stay alone, seems restless, and walks around a lot. He continuously seeks out caregivers and complains when they turn toward another service user. He persistently asserts his own will. Otherwise, he is a friendly, curious person who can understand consequences and has some abstract thinking skills. His restlessness and constant search for affection are so stressful for the carers that he was dismissed from his job. This makes the situation even worse because he is at home all day long.

These examples demonstrate that people with intellectual disabilities often behave in ways that challenge their relatives, caregivers, and healthcare professionals. In order to better understand and deal with these behaviours, emotional development should be considered alongside physical and cognitive development. When supporting people with intellectual disabilities, we often first ascertain their biological age and cognitive abilities, whereas their emotional developmental age is typically not known and is therefore given little consideration (see Figure 1). This can result in overwhelming situations, which can lead to serious behavioural problems or even to mental health difficulties, such as depression.

The young woman presented at the beginning shows an emotional reference age of about 6 months. Her great need for rest, desire for immediate satisfaction of her needs, predominant preoccupation with her own body, and lack of interest in peers are expressions of her emotional stage of development. At this stage, the primary need is for physical and emotional regulation; the development task is integrating sensory information. Therefore, caregivers should take on the role of reliable providers, offer body-oriented and sensory interventions, and ensure she has sufficient rest and recovery periods.

The emotional reference age of the young man is about 3 years; emotionally, he is in the so-called phase of defiance. His primary need is therefore to develop autonomy. The central developmental task is individuation, i.e., separating from his main caregivers and establishing his own sense of self. In this stage, establishing clear structures and rules and |2|identifying areas of life in which he can fulfil his growing need for independence in a gradual and manageable way may be helpful. Caregivers can ensure that they provide a clearly structured daily routine and ascribe responsibilities in certain areas, such as setting the table or sorting laundry. It is crucial that the team work together in a consistent manner and provide direct, immediate praise to reinforce desired behaviours. Through consistent positive regard – independent of behaviour – he will be confirmed in his person and will no longer need to demand attention. As a result, his restlessness is likely to decrease, and he will be able to separate from caregivers for longer periods.

Figure 1: The encounter typically depends on the client’s biological age, followed by their level of cognitive development; the emotional state of development is often the least considered. However, the emotional reference age may be lower, when compared to cognitive development.

By knowing the level of emotional development, caregivers can more easily change their perspective, understand a person’s behaviour, and address their needs. Adapting interventions to the level of emotional development can precipitate the personality growth of clients, increase their opportunities for participation in social life, and lead to a better understanding of problem behaviours (Hart & Lindahl Jacobsen, 2018).

1.1 Emotion and Cognition in Dialogue

In Western culture, which has been shaped by philosophers such as Descartes and Kant, the concept of intelligence is predominantly related to mathematical, logical, and verbal abilities. This is contrasted with socio-emotional processes based on affective experiences and interpersonal relationships. In the 1980s, the importance of emotional competences for decision-making and social life was increasingly emphasised by researchers such as Damasio, which broadened the concept of intelligence (“Descartes’ error;” Damasio, 2012). Emotion and cognition are categorical terms that combine a multitude of different competences. The assignment of various abilities to being either cognitive or emotional is a social construct; the human brain itself does not assign its different functions to one or the other!

In people with an intellectual disability, emotional, social, and physical abilities can also be impaired in addition to pure cognitive skills (APA, 2013; ICD-11, 2018; Frankish, 2016; Lehmkuhl, Sinzig, Sappok, & Diefenbacher, 2011; World Health Organisation, 2001). |3|These abilities are displayed in various neural networks (Kandel, Schwartz, & Jessell, 2000; LeDoux, 2002; Pessoa, 2008; Yeates, Bigler, Dennis, Gerhardt, Rubin, Stancin et al., 2007). The cortical structures, which, for example, are mainly responsible for language, motor, and sensory skills etc., were first described in the 19th/20th century by Brodmann, Broca and Wernicke, among others (Brodmann, 2007; Dronkers, Plaisant, Iba-Zizen, & Cabanis, 2007; Wernicke, 1994). During the last century, it became possible to describe more complex cognitive functions, such as memory, in more detail, and to identify the neuronal centres involved (Kandel, 2001; Kandel, 2006), for which Eric Kandel, among others, was awarded the Nobel Prize for Physiology/Medicine in 2000 (Kandel, 2006). Concise case histories, such as Phineas Gage, who survived a severe head injury caused by an iron rod being driven through his forebrain after a construction accident, clearly demonstrated the importance of this brain region for action planning, impulse control, and the person’s character (Damasio, Grabowski, Frank, Galaburda, & Damasio, 1994; Forbes & Grafman, 2010).

The foundation of the architecture of the social brain, which is located in various parts of the limbic system, develops at certain sensitive periods of prenatal and early life (Brothers, 1990; Byrne & Bates, 2010; Fox et al., 2010). The emergence of the mind and socio-emotional brain functions are linked to the formation of the respective neuronal networks (Roth & Strüber, 2018; Adolphs, 2003, 2010a, 2010b). The developmental changes in structural brain connectivity result from a sequence of (epi-)genetic mechanisms at key developmental stages (Fox et al., 2010). Environmental factors and early life experiences play a crucial role in the coordination and timing of the specific neuronal patterning. The brain architecture is scaffolded prenatally and early in life, followed by an extended period of differentiation of the cytoarchitecture by dendritic growth and formation, pruning and stabilisation of synapses. While short-range connectivity predominates in infancy, there is a shift towards long-range networks in adolescents and adults. Hence, higher order cognitive networks build on circuits that process lower lever information.

In people with an intellectual disability, impairments of these areas/systems are associated with basically the same deficits as are observed in people without any intellectual impairment (Barnard, Muldoon, Hasan, O’Brien, & Stewart, 2008; Happé, 1994; Harris, Best, Moffat, Spencer, Philip, Power et al., 2008; Sappok, Bergmann, Kaiser, & Diefenbacher, 2010; van Lang, Bouma, Sytema, Kraijer, & Minderaa, 2006). Since various brain regions or systems are involved in different cognitive or emotional functions, these can also be disrupted or may function to different degrees (Baron-Cohen, Ring, Wheelwright, Bullmore, Brammer, Simmons et al., 1999; Kennedy & Adolphs, 2012; Izard, Youngstrom, Fine, Mostow, Trentacosta, 2006). Developmental delay in social cognition becomes more and more apparent during the course of development and as differences in physical development increase (Beck, Kumschick, Eid, & Klann-Delius, 2012; Rosenqvist, Lahti-Nuuttila, Laasonen, & Korkman, 2014). Depending on the cause and timing of the brain damage, brain development may be impaired differently in the various parts of the brain (Dennis, Barnes, Wilkinson, & Humphreys, 1998; Yeates et al., 2007). Therefore, it is not possible to deduce the level of emotional development from the intelligence quotient (Baurain, Nader-Grosbois, & Dionne, 2013). The cognitive, social, emotional, and physical aspects of development together form the personality (see Figure 2; Harris, 1998; Rutter, 1980).

|4|

Figure 2: The bio-psycho-social disease model is extended to include the emotional development perspective.

In a nutshell

Cognitive and emotional brain functions are located in different brain regions.

In people with an intellectual impairment, social brain networks may also have delayed or incomplete development.

The stage of emotional development may differ from the cognitive reference age.

1.2 Conceptualisation of Emotional Development

Emotional competencies develop over the course of childhood. Newborns are already emotionally competent beings who can express, perceive, and react to various basic emotions (Bowlby, 1969; Piaget, 1954; Stern, 1985). During the first year of life, the emotional reactions of the child become increasingly modulated by the behaviour of the caregiver (Bertin & Striano, 2006; Stern, 1985; Winberg, 2005). In the second year, the experience of divided attention with a close caregiver evokes joy in the child (Kasari, Sigman, Mundy, & Yirmiya, 1990; Trevarthen, 1980). The emotional responses and regulation possibilities gradually become more complex, e.g., children are able to influence the emotional states of others (Jackson & Tisak, 2001). Pre-school children can increasingly understand the causes and consequences of emotions and regulate their affective states themselves (Rieffe, Terwogt, & Cowan, 2005). At school age, further advances in empathy and increasingly pro-social behaviour become apparent (Rieffe et al., 2005). These age-appropriate changes in the emotional system are the basis for our self-concept and the formation of our personality structure (Došen, 1997).

We consider the concept of emotional development in the sense of the developmental approach described above, i.e., the acquisition of emotional competencies according to the typical maturational processes during childhood. Therefore, the concept of emotional development contains predominantly affective but also social, sensorimotor, and cognitive |5|functions that are relevant to developmental psychology (see Figure 3; Došen, 2005a; Greenspan, 1985; Sappok, Schade, Kaiser, Došen, & Diefenbacher, 2011; Sroufe, 2009). These different components interact with and stimulate each other and thus lead to further maturation and adaptation of the young person to the environment (Izard et al., 2006; Mayer, Roberts, & Barsade, 2008). This ability to adapt to the demands of everyday life, i.e., adaptive behaviour, is crucial in order to use and live out one’s own potential productively and to lead a fulfilled life. Therefore, the assessment of brain functions should be extended to include not only logical, mathematical, and verbal abilities, i.e., purely academic competences, but also socio-emotional brain functions, such as perceiving, recognising, and consciously influencing feelings, being able to regulate one’s own emotions, or mentalisation abilities.

Figure 3: Conceptualisation of emotional development. Adapted from Sappok et al., 2013.

In a nutshell

The typical development of emotional competencies in children and adolescents serves as a model for the emotional development approach.

The emotional development approach includes affective, cognitive, sensorimotor, and social aspects relevant to development.

|6|1.3 The Development of the Emotional Brain

So far, there are only a few studies on how social networks develop in the brain. It is currently assumed that this is an interplay between automated, genetically determined brain maturation processes on the one hand, and environmental adaptation processes on the other (Johnson et al., 2005; Johnson, 2011). Phylogenetically, old brain areas and networks (see. 1.4, the lower limbic level) develop partly due to a congenital predisposition, i.e., the aspects of the social brain are created at a very early stage (Happé & Frith, 2014). On the other hand, these automatic processes can be influenced by external factors, such as learning experiences, stress, deprivation, or maltreatment in early childhood (Hanson, Chung, Avants, Shirtcliff, Gee, Davidson et al., 2010; Karmiloff-Smith, 2010; McCrory & Viding, 2010). By pruning or sprouting synaptic connections between nerve cells, existing neural networks can be specified or reinforced (Workman, Charvet, Clancy, Darlington, & Finlay, 2013).

The development of emotional competencies is closely interwoven with cognitive maturation processes (Damasio, 2012; Martínez-Castilla, Burt, Borgatti, & Gagliardi, 2015). Object permanence, i.e., the inner, representational model of the external environment, is, for example, an important prerequisite for the development of a secure attachment style, since the child is then able to internalise a multi-modal representation of the mother’s affective responses (Piaget, 1954, Schore, 2016). This promotes the development of autonomy and allows delayed gratification of the child’s needs (i.e., during separation). Interaction processes characterised by sensitivity and empathy, in which caregivers mirror the inner emotional states of their infants, thereby also promote emotional development and secure attachment (Ainsworth, Bell, & Stayton, 1974; Bowlby, 1969; Choi-Kain & Gunderson, 2008; Kernberg, 2012). Finally, the situational context can also influence emotional regulation mechanisms and emotional reactivity (Aldao & Nolen-Hoeksema, 2012; Wieser & Brosch, 2012). For example, the father’s increasing role in arousal modulation and stimulation in the middle of the second year influences the experience-dependent growth of cortical areas and helps to resolve the child’s emotional ambivalence towards their mother during this period (Schore, 2016).

Disorders of brain development, such as genetic syndromes or other brain injuries, can affect the development of the emotional brain (Kok, Post, Tucha, de Bont, Kamps, & Kingma, 2014). For example, autism, a pervasive developmental disorder associated with a range of cognitive differences, appears to also affect the social brain network (Sappok, Budczies, Bölte, Dziobek, Došen,, & Diefenbacher, 2013). Adults with intellectual disability but without autism have been shown to reach an emotional reference age of 3 to 7 years of age. By contrast, people with an additional autism spectrum disorder had an emotional developmental stage corresponding to a reference age of 1.5 to 3 years of age. This lower level of emotional development was independent of the severity of the intellectual disability (Sappok et al., 2013). Not only autism spectrum disorders but also other cerebral impairments, such as meningoencephalitis (Sappok et al., 2012), or genetic syndromes, such as Down’s syndrome (Cicchetti & Ganiban, 1990; Kasari & Sigman, 1996), can delay emotional development or make it incomplete (Kok et al., 2014). In addition, environmental factors can also impair the formation of the social brain circuits, for example, traumatisation (Hanson et al., 2010; McCrory & Viding, 2010; Vela, 2014), insufficient emotional support in |7|institutionalised environments (Nelson, Bloom, Cameron, Amaral, Dahl, & Pine, 2002), emotional neglect (Hughes, Power, O’Connor, & Orlet Fisher, 2015), or crises, acute illness, and permanent stress. Different causes can thus lead to short- or long-term emotional developmental delays or regressions.

In a nutshell

The emergence of the mind and the developmental periods of emotional brain functions are closely linked with the formation of the respective neural circuits within the limbic ­system.

Hence, higher-level neural circuits that carry out sophisticated mental functions build on lower-level networks.

Consequently, the basic needs, developmental tasks, and ways to perceive the world and to respond depend on the maturation of the different components of the limbic system.

1.4 The Neuroanatomy of the Emotional Brain

Neuroanatomically, the functions of the emotional brain are located in the limbic system (Roth & Strüber, 2018, LeDoux, 2000, 2002; Kennedy & Adolphs, 2012). Figure 4 graphically depicts the functions of the different levels and their origin.

Figure 4: The neuroanatomy of the emotional brain: functions of the different levels of the limbic system (arrows on the left) and time of origin (right). Note: The functions of the lower and middle limbic levels operate unconsciously.

|8|The lower limbic level consists of the diencephalon (hypothalamus, brain stem centres, and periventricular grey) and the central amygdala. Most of these structures develop before birth. Here, basic survival functions, such as eating, sex drive, and the flight-flight-freeze response, are controlled. The stress regulation system and mechanisms underpinning autonomous bodily functions, such as sweating or heart rate, are also located here. The processes localised in this part of the limbic system are predominantly unconscious and are genetically or epigenetically determined. Fundamental brain functions of the newborn phase are regulated in these brain structures. The functions of the emotional brain described here can be influenced only minimally by education or life events.

In the mesolimbic system, basic emotions, such as fear, sadness, disgust, joy, and anger, are determined. These emotions are conditioned by early childhood attachment experiences, i.e., the infant learns to perceive, differentiate, and understand their own emotions, as well as those of others, in interactive contact with caregivers (Kernberg, 2012). This part of the limbic system consists predominantly of subcortical brain regions, such as the basolateral amygdala, the ventral segmentum, and the nucleus accumbens or ventral striatum. These brain structures develop prenatally or during the first months and years of life. Here, the control circuits for non-verbal communication are localised, i.e., emotional-communicative signals are recognised and processed. In addition, the internal reward system (endogenous opioids and dopamine) forms the basis for behavioural motivation. These brain functions are predominantly unconscious. The milestones of emotional development observed in infants and toddlers are particularly regulated in these brain regions.

The upper limbic level is localised in the associative neocortex, especially in the orbitofrontal, ventromedial prefontal, anterior cingulate and insular cortex. This is where conscious emotional perception and social motivation take place. Skills such as impulse control, delayed gratification, frustration tolerance, empathy, and weighing up the consequences of one’s own actions are controlled in this area. In this way, risks can be realistically assessed and actions consciously controlled. Moral thinking is also anchored here. These competences are developed in contact with the broader social environment, i.e., friends, schoolmates, other family members, etc. Environmental factors and sensory perception of the environment influence emotional reactivity and the available emotion-regulation strategies (Aldao & Nolen-Hoeksema, 2012). The various basal, sensory, motor, and cognitive functions, in interaction with environmental factors, have an influence on the development of the so-called emotional brain and thus on an individual’s instinctive survival reactions and temperament, their regulation and control of emotions, as well as their social adaptation. The upper limbic system develops in later childhood and adolescence.

In summary, various brain structures and their connections form the architectural components of the so-called emotional brain. This forms the neuroanatomical basis for observable social and emotional abilities that are biologically closely linked to cognitive competencies (Damasio, 2012; Pessoa, 2014; see Figure 5). The state of emotional development depends not only on various internal and external aspects, such as genetic factors or acquired brain damage, but also on learning and social interaction processes; cognitive, sensory, and abilities; and environmental and psychological stress factors. People with intellectual disabilities generally go through the same stages of development as people without disabilities, their development may be delayed and |9|possibly incomplete (Cicchetti & Ganiban, 1990; Greenspan, 1997; Hodapp & Zigler, 1995; Martínez-Castilla et al., 2015; Webster, 1963).

Figure 5: Relationship between neuroanatomical development of the brain, the associated neuropsychological control loops, and mentalisation ability (see also Figure 9). Depending on the maturation of the different networks, different parts of the limbic system are instrumental for the behaviours that can be observed. These active parts are a kind of compass for the expressed behaviour.

The neuroanatomical knowledge of brain development presented here requires scientific methods, such as functional imaging, which have only been available for the last few decades. The first developmental psychological investigations and findings were therefore initially conducted on the basis of behaviour (Nelson et al., 2002). The following section summarises the related aspects of child development described by well-known developmental theorists.

In a nutshell

The emotional brain initially develops prenatally and in the first few years after birth.

Disturbances in brain development, e.g., as a result of a genetic condition or brain injury, can also impair the maturation of the emotional brain.

People with intellectual disabilities go through the same stages of development as people without disabilities, but development is delayed or incomplete.

|10|1.5 Developmental Theories and Developmental Tasks

by Tanja Sappok and Thomas Bergmann

The emotional development approach used in this book (Došen, 2005a, 2005b) was synthesised from neuropsychological findings, such as those presented above, together with several stage-based psychosocial models of personality development, including the work of Freud, Erikson, Mahler, Bowlby, Piaget, and Stern (see below). The reader will notice broad areas of convergence, for example, the overlap of Mahler’s practising stage (10–14 months) with the period in which attachment patterns can be reliably measured, which also overlaps with a critical period for the maturation of the prefrontal cortex, which is essential for emotional regulation (Schore, 2016).

Sigmund Freud

“A child is absolutely egoistical; it feels its wants acutely, and strives remorselessly to satisfy them.” (Freud, 1913, p. 244)

Freud (1913; 1966) developed a phase model of psychosexual development from the 1st to the 12th year of life:

1st year of life: Oral phase

2nd to 3rd year of life: Anal phase

3rd to 5th year of life: Phallic phase

6th to 7th year of life: Latency phase

8th to 12th year of life: Genital phase.

Freud related psychological disorders, such as neurosis, hysteria, or personality disorder, in adult clients to restrictions in early childhood development. He hypothesised that the infant already has a sex drive (libido), leading them to seek satisfaction (sexual infantilism). If the child experiences failure due to parental and societal disapproval, Freud assumed that the child will become fixated according to themes linked to the erogenous zones dominant in each phase of psychosexual development. This model is limited by the fact that Freud’s clinical work was undertaken with upper class Viennese clients in the sexually restrictive society of the late 19th century.

Eric Erikson

“In the social jungle of human existence, there is no feeling of being alive without a sense of identity.” (Erikson, 1968, p. 130)

In his epigenetic stages, Erikson (1959) developed a step-by-step model of psychosocial development, based on Freud’s phase model:

0–1 years: Trust versus mistrust – Hope

1–2 years: Autonomy versus shame and doubt – Will

3–5 years: Initiative versus guilt – Purpose

6–puberty: Industry versus inferiority – Competence

12–18 years: Adolescence: Identity versus role confusion – Fidelity

|11|Erikson adapted Freud’s theory of psychosexual development by focusing more on the Ego than on the Id. According to Erikson, the Ego (self) develops as it successfully responds to the crises initiated in each phase of life, as the psychological needs of the individual conflict with the needs of society, across the entire life span. This first starts in establishing a sense of trust in others in the mother-child relationship, which will determine the subsequent bonds and social interactions the individual will have. Failure to successfully resolve each phase-specific crisis can result in a reduced ability to complete further stages and therefore lead to a less adaptive personality and sense of self.

Margaret Mahler

“The biological birth of the human infant and the psychological birth of the individual are not coincident in time.” (Mahler, 1975, p. 3)

Margaret Mahler’s (1975) psychoanalytic model describes important milestones in the ability to interact socially:

First month: Normal autism

2–4 months: Symbiosis

5–9 months: Differentiation

10–14 months: Practicing

15–24 months: Rapprochement

2–3 years: Consolidation of Individuality

By working with real children, Mahler was able to add some evidence to support psychoanalytic theories of personality development based on clinical reconstructions. Mahler proposed that maladjustment in children has its origins in their failure to develop a normal symbiotic relationship with their mothers, from which a sense of individual identity could emerge. In the separation-individuation phase starting around the age of 5 months, the child begins to distinguish themselves from the mother, thus developing an individual identity and ego in parallel with cognitive skills and the ability to communicate with others. In order to achieve this psychological birth, a child’s inherent strivings towards autonomy must be supported without overwhelming their capacity to tolerate being alone. According to Mahler, holding positive internal images of one’s primary carer is crucial to feel security and support throughout adulthood. Mahler’s model formed the basis of a related developmental approach to understanding people with intellectual disabilities, which was pioneered in the UK by Pat Frankish (Frankish, 1989, 1992, 2013).

John Bowlby

“A young child’s experience of an encouraging, supportive and co-operative mother, and a little later father, gives him [her] a sense of worth, a belief in the helpfulness of others, and a favourable model on which to build future relationships.” (Bowlby, 1969, p. 378)

In his 1969 work, Bowlby derived his attachment theory from an analysis of the mother-child relationship:

0–6 weeks: Pre-attachment

6 weeks to 6–8 months: Attachment in the making

6–8 months to 18–24 months: Clear-cut attachment

24 months onwards: Goal-corrected partnership

|12|Bowlby was convinced that attachment is innate and therefore has a survival value from an ethological point of view. He hypothesised that both infants and mothers have evolved a biological need to stay in contact with each other and that attachment behaviours are instinctive. As a result, babies are born with the tendency to display certain innate social releaser behaviours, such as crying and smiling, that stimulate caregiving from one main attachment figure (i.e., monotropy). In his maternal deprivation hypothesis, he stated that continual disruption of the attachment to the primary caregiver could have a negative impact on cognitive, social, and emotional development and may result in increased aggression, depression, and psychopathy. Subsequent work has criticised the initial focus on mothers and has expanded attachment theory to include the relationship with fathers and other significant people in a child’s life, such as teachers, for example. Bowlby’s theory was also later developed by Mary Ainsworth, who created the strange situation paradigm, which showed that attachment patterns could be reliably measured from the end of the first year of life (Ainsworth, Blehar, Waters, & Wall, 1978)

Jean Piaget

“The essential functions of the mind consist in understanding and in inventing, in other words, in building up structures by structuring reality.” (Piaget, 1971, p. 27)

Piaget (1954) described the essential stages of cognitive development:

0–2 years: Sensorimotor stage

2–7 years: Pre-operational stage

7–11 years: Concrete operational stage

11 years and older: Formal operational stage

Piaget regarded cognitive development as a process that occurs due to biological maturation and interaction with the environment. According to Piaget, children are born with a very basic mental structure (genetically inherited and evolved) on which all subsequent learning and knowledge are based. Children construct an understanding of the world around them, then experience discrepancies between what they already know and what they discover in their environment. He showed that young children are not less competent thinkers compared to adults but think in strikingly different ways.

Daniel Stern

“Because we cannot know the subjective world that infants inhabit, we must invent it, so as to have a starting place for hypothesis-making.” (Stern 1985, p. 4)

Stern (1985) has developed a layered model based on intensive infant observation for the progressive development of self-awareness, socio-affective abilities and forms of being together with others:

already applied before birth: Emerging self

around 2 months: Core self followed by core self-with-another

from 7 months onwards: Subjective self

from 15 months onwards: Verbal self

around 3 years: Narrative self

|13|Stern assumed that these senses of self develop and persist over the entire lifespan but make significant developmental strides during sensitive periods in the first two years of life. This is in contrast to going through phases in conflict-based models. In focusing on preverbal development, he attributed to the infant the ability to feel like an independent being from the very beginning. However, Stern highlighted the importance of intersubjective emotional relatedness with the primary caregiver and the crucial role of these now moments in psychotherapy.

Based on this historical foundation, which is predominantly based upon theories or on individual case observations, various developmental tasks supported by empirical data are described in more detail in the following section.

In a nutshell

Emotional functions are processed in the emotional brain, which is located in different parts of the limbic system.

The different levels of the limbic system develop in the course of childhood and adolescence, i.e., partly already prenatally (lower level) up to adolescence (upper limbic level).

The emotional brain functions unconsciously to a large extent.

Psychosocial models from a range of personality theorists have also contributed to our understanding of the different stages in emotional development.

1.5.1 Emotional Referencing

by Thomas Bergmann

People strive to induce or increase pleasant emotional states and to eliminate or avoid unpleasant sensations. The goal and developmental task is to be able to keep the extent of arousal within an individually perceived pleasant range. These processes are referred to as affect regulation, which involves various strategies for moderating emotional states. The ability to self-regulate is based on the experience of regulation by another. Affect is used here as a generic term to describe the general weather situation of emotions. Distinguishing between good and bad affects in this interactive process must be viewed critically, since high affective tension – independent of the emotional quality – requires regulating and the beneficial effects of successfully regulating all emotions should be appreciated (Cole, Martin, & Dennis, 2004). Adults who cannot regulate their emotions alone according to their stage of emotional development sometimes show significantly challenging behaviours or a pronounced retreat behaviour. In order to be able to accompany and support those affected in such crises sensitively, caregivers and practitioners should know their basic emotional needs and the behavioural options available to them.

The primary emotions of the infant are rather unrelated reactions to stimuli and nonconscious automatisms (Fonagy et al., 2002) or uncategorised vitality affects associated more with the quality of arousal (Stern, 1985). What is still missing is the ability to differentiate between oneself and the environment, to grasp cause-effect relationships, and to classify the triggered sensations in an inner scheme. Sroufe proceeded from the three basic emotion systems of joy, fear, and anger within which precursor emotions mature into increasingly cognitively processed emotions with meaning in terms of content in the first year of |14|life (Sroufe, 1995). Fear and anger initially express themselves as indistinguishable negative emotional expressions (distress) as a global reaction to a broad spectrum of unpleasant stimulations and not as a precise and immediate reaction to specific, significant moments. At this stage of development, affects are essentially regulated by modulating the interventions of the caregiver, who perceives the infant’s affect situation and reacts appropriately. That being said, the newborn already has a basic homeostatic principle of self-stabilisation (Brazelton & Nugent, 1995) with which it is capable of self-regulation via four basal adaptive behaviour systems (see Figure 6).

Figure 6: Dynamic model of behavioural organisation (Als, 1982).

If the physiological system (e.g., breathing, pulse) finds inner peace, the motor system (arm, leg, stretching movements) finds outer peace, and if the sleep and waking stages find a rhythm, the system of attention and interaction can become active. This developmental model (up arrow) is the basis for further emotional, social, and cognitive development. This means that only regulated affect is the basis for contact with the world and different forms of learning. If the system becomes unbalanced due to internal or external influences (arrow pointing downwards), it is important for the caregiver to recognise signs of stress in order to be able to intervene accordingly. In addition to eliminating external stressors, this requires sensitivity, i.e., attentive perception of the infant’s signals, correct interpretation, and prompt and appropriate reaction. In this reciprocal process, the infant signals necessary pauses in interaction, e.g., through their gaze or by physical turning away. Failure to take these into account or interpreting them as rejection can lead to uncertainty, over-stimulation, and an increase in stress levels. In the case of significant and persistent inadequate actions, which consist not only of an inappropriate intensity and duration but also possibly of an unpredictability and subjectively experienced uncontrollability, the system may be shut down. Here, the child freezes in an emergency reaction controlled by deeper, |15|subcortical areas. The associated flooding of the brain with the stress hormone cortisol destabilises already formed circuits, can favour regression, and endangers further cognitive development (Sapolsky, 1996). During the first year of life, the threshold at which the child becomes dysregulated rises, so they can process a higher degree of stimulation and become increasingly independent of regulation by their caregivers.

Social approximation and withdrawal behaviour can be observed at the latest from the 6th month onwards, which is when the infant is able to move actively towards or away from somebody. Affect regulation is supported by maintaining an optimal relational distance, well-calibrated stimulation, and the mediation of security. Infants as young as two months of age show positive reactions to external stimuli, such as smiles or vocalisation, although there are large individual differences. The early childhood temperament influences, on the one hand, individual stimulus thresholds and sensitivities to over- and under-stimulation but also, on the other hand, curiosity and exploratory behaviour. Children with a high tendency to approach others make themselves more familiar with their environment, while reserved children are irritated more quickly by unknown objects or stimuli. This has a direct influence on the balance between the joy of discovering the new vs. the fear of the unknown and shapes further patterns of action (Thomas & Chess, 1977). Context variables, such as the speed at which strangers approach each other or the timing of interaction, continue to play a major role. These complex processes show that affect regulation is not a one-sided process: affect itself regulates the level of activity on the one hand but also the reaction of the other, who in turn, modulates affect in the interactional dance.

The attention system is a further basal self-regulation mechanism that develops from approximately 6 months of age until preschool age. It is located in the anterior cingulate gyrus, in the front part of the brain. It is the deliberate control of attention and action that is linked to the ability to postpone rewards and moral development (Derryberry & Rothbart, 1997). This is shown by the ability to switch attention to less interesting things in situations that are both stimulating and overwhelming at the same time. This includes the ability to perform unpleasant tasks (e.g., personal care) before more pleasant ones (e.g., drinking hot chocolate) and the ability to wait and see. Thus, this ability is closely connected with the control of fear and stress or inner tension. A person who is not able to delay gratification needs a low demand environment, short waiting times, and attractive, alternative stimuli, especially in overtaxing situations.

Fonagy et al. (2002) considered the development of affect regulation and emotion differentiation in interaction with the primary caregivers against the background of recent psychoanalytical theories. The starting point is that, in addition to a rudimentary form of physiological self-regulation, the infant is equipped with basic physical knowledge (Gibson, 1988). This concerns a feeling for the coherence of form and movement as well as for the structure of time and intensity. In addition, there is the ability to imitate and the ability to perceive sensory information across different modalities (hearing, seeing, feeling etc.). As a result of these abilities, the infant strives to maximise contingency, i.e., he prefers synchronous contexts such as soft sounds, small movements, and tender touch to inappropriate and non-synchronous contexts. In addition to these infant skills, the regulation of sometimes violent emotional arousal also requires intuitive parental skills (Papousek & Papousek, 1987), i.e., sensitivity in recognising and reacting to the child’s signals. The regulation of non-verbal affective exchange is divided into primary and secondary affect regulation.

|16|Primary affect regulation takes place on a purely neurophysiological level. First of all, this involves physical regulation, i.e., the infant needs physical comfort from the caregiver through carrying, rocking, stroking etc., in connection with a calming tone of voice, in order to develop a bodily sense of self. After six to eight weeks, the social smile develops, i.e., the ability to react to the immediate environment – particularly to faces. The tendency to imitate the affectively charged facial expression of the primary caregiver, e.g., by smiling back, also assumes a change in the emotion-specific parameters of the autonomous nervous system (Ekman, 1993). Figuratively speaking, one’s own smile not only radiates outwards but also – with corresponding physical-emotional reactions – inwards. This happens in a comprehensive way through affective contagion. In infants of depressed mothers, the same reduced EEG activity in the frontal left hemispheric area of the mother could be observed in the child during interaction (Field, Fox, Pickens, & Nawrocki, 1995), i.e., cerebral dysfunctions typical for depression transferred from the mother to the infant. However, the formation of affective representations is essential for the further empowerment of affective self-regulation as a basis for socio-emotional development.

This takes place in the context of secondary affect regulation through the modulated affect reflection by primary caregivers. The infant links the perceived inner states with the caregiver’s expression and understands this as an expression of their own state of mind. This is equivalent to a reflection and is made possible by baby language, increased prosody, and exaggerated facial expressions and gestures. Timing also plays a role, whereby the mirroring ideally takes place with a slight lag, and so the caregiver is not completely attuned all of the time, as the image of a mirror suggests. Through the markedness of the mirrored affect, the infant can infer that the affect is not real, i.e., does not represent the mood of the caregiver. This referential decoupling enables them to relate the expression of affect to themself – a referential anchoring occurs (Gergely & Watson, 1996).

This regulatory mechanism naturally also refers to negative affects. If the infant shows agitation, it is also helpful for the caregiver to mirror this arousal whilst allowing for breaks in the attunement. This shows the infant that they are not alone with their unpleasant sensation but, at the same time, prevents them from becoming dysregulated. By mixing in contrasted, calming, and safety-inducing emotions, the sensation that may have been experienced as threatening can be partially defused. Since the infant enjoys matching arousal and strives for this fit (contingency maximisation), its arousal curve is interrupted through coordination with the caregiver’s attuned response. At the same time, the infant will also imitate the expression of soothing and thus further reduce its own tension. The experience of successful dyadic regulation will additionally create positive excitement, which will further weaken the infant’s original restlessness. If they can feel themself to have created and been in control of this process of successful affect regulation, the path to self-regulation is prepared.

In a nutshell

Successful affect regulation primarily takes place in the interaction with caregivers. It is dependent on:

the child’s individual temperament

neurophysiological structures (individual thresholds)

the ability to control attention, and

the sensitivity of the interaction partner

|17|1.5.2 Attachment

The first signs of an attachment bond being formed appear from 7 to 9 months of age, when the infant will show apprehension towards strangers and anxiety during separation from familiar caregivers (Happé & Frith, 2014; Zeanah, Berlin, & Boris, 2011). Between the 9th and 18th months of age, toddlers develop a hierarchy of their