Clinical commentary by Paddy Martin, a child psychotherapist working at the Anna Freud Centre's Court Assessment Service and as a specialist child psychotherapist at the North Middlesex Hospital, Paediatric Liaison Service

Background

This is a complex case in terms of constitutional and environmental factors. Lewis was born heroin addicted and there are considerations about both the early impact in utero of heroin upon his brain development and functioning as well as the impact of his environment during these first eight months. Then there is the impact of separation and placement at eight months, developmentally coinciding with the period of stranger anxiety and a crucial stage of separation-individuation. Consequently, there are immediate questions about how Lewis presents now and

how this can be understood in the early history. Not only has his environment been difficult and presented considerable challenges to smooth emotional development but there are questions about the impact of physiological changes early in Lewis's life. A baby born with addiction to heroin will likely be more dysregulated, active or irritable and distressed to an extent that would challenge above-average parenting. Thus environment and constitutional factors may well have been mutually destructive, leading to a downward spiral of reciprocal relational behaviour and possibly considerable cumulative trauma. The impact upon his attachment is undoubtedly a big question.

There is also, however, the question of the intergenerational aspects of this family and what Lewis's mother's own experiences have been, given her drug addiction in adult life. Lewis is now placed with the maternal grandparents, but it is worrying that he was removed for five months due to concerns that he suffered injury at the hands of maternal uncle. Mother's own level of dysfunction, personally and as a parent, may in itself be related to inadequate early care from her parents.

Then there is the question about the frequency of contact Lewis has with his mother, and the impact this has in terms of allowing Lewis to form a more solid attachment and settle into care, or at least build up some mitigating ‘internal working models’ to overlay an a