Author: Julie Ribaudo, LMSW, IMH-E® and Hayley Beckett, MSW student

  • What’s Going on in There? The Neonate Becomes an Infant

    What’s Going on in There? The Neonate Becomes an Infant

    ‘There is no such thing as an infant’, meaning, of course, that whenever one finds an infant one finds maternal care, and without maternal care there would be no infant.”  (Winnicott, 1960, p. 585)

    Abstract: In the first of a series of articles about early childhood development, the Michigan Association for Infant Mental Health’s (MI-AIMH) esteemed Michael Trout asked us to consider what is happening in the mind of expectant parents, particularly that of the mother. This article ponders the evolution of a neonate through the first year of life. Precisely because each baby is a being with unique biology, temperament, feelings, experiences, and ways of experiencing and learning, much is to be discovered and understood about them.  The question of “what is going on in there?” is especially salient given that the baby’s wordless communication requires adult caregivers to intuit, infer, hypothesize and experiment. As we walk alongside parents who struggle to come to know their infant, we are required to have conceptual knowledge of how a newborn becomes a fully awakened infant. Beginning with the influence of parental perception, eloquently described by Trout,  this chapter of our series will explore the development of attachment and how that influences relational expectations, communication, and social-emotional development. Each of these domains of development is impacted by factors other than attachment, but it is by now clear that babies grow in the context of relationship, and the quality of those relationships affects  the physiological and psychological organization of the baby.

    Isn’t She Lovely: The Birth

    “What a glorious conclusion to the amazing developmental/psychological work of pregnancy: to be able, at the end, to say “Goodbye” in the service of saying “Hello.”  (Trout, 2018)

    Who is this tiny being the parent(s) are greeting? We are accustomed to hearing the search for clues: Who does he resemble? How does she cuddle in? Do they1 cry immediately or are they an “easy” baby? For the parents, the “real” newborn is meeting the “imagined” baby (Stern, 1999) and that encounter introduces the first threads of the unfolding relationship. The way the baby has been perceived throughout pregnancy is not inconsequential. Caregiver representations of their infant exert a powerful influence on the manner in which the baby’s signals and cues are experienced, comprehended and responded to (Rosenblum, Dayton, & Muzik, 2019; Dayton, Levendosky, Davidson, & Bogat, 2010;) and are indicated in the development of attachment (Vreeswijk, Maas, & van Bakel, 2012). If, as in Trout’s  example  on the developmental tasks of pregnancy (2018), the baby represents the mother’s ‘irrational, perhaps, but no less profound’ sense of failure to protect the baby from environmental toxins, then worries of normalcy or loss, and fears of inadequacy are likely to color the initial greeting — saying “hello” to this new being.

    The transactional model (Sameroff, 2010; Sameroff & MacKenzie, 2003) elucidates the process by which parental perception is one pathway to infant outcomes. In a transactional way, first the “infants stimulate their parents, either through their appearance or behavior; second, the parents impose some meaning system on the input; and third, the parents then react with some form of caregiving (Sameroff & MacKenzie, 2003, p. 19). We can imagine a mother, already predisposed to conscious or unconscious worries about the health of her baby, selectively attending to behaviors that confirm her worry that she has irreparably harmed her baby. She may hear his cries as more intense or as signaling excessive fragility, and thus tend to him with a level of anxiety that is transmitted to him, intensifying his cries. Thus the cycle begins.

    It does not have to play out this way, of course. There are a myriad of ways their interactions might unfold. A kindly nurse might normalize his cries, appease the mother’s worries and set the parent-infant relationship on a different course. A grandmother might note “Oh, he sounds just like you when you were a baby,” thus linking the past and the present in a way that affirms health and survival. For the IMH specialist, what is salient is that listening for the meaning of the baby to the parent is worthy of our careful attention as it offers a port of entry when there is a distortion or withdrawal from the baby. With an awareness that the baby may represent an array of past people and experiences, we can intervene to help the caregiver come to know the real baby. 

    Getting to Know You, Getting to Know All About You: The Early Weeks

    In the first month of life, the neonate becomes increasingly physiologically adjusted to life outside the womb. They1 become familiar with the sights, sounds, smells, touch and movement that begin to shape their experience of the world. The physical and emotional nature of interaction with caregivers begins to develop the attachment relationship. Ainsworth, in her seminal work, spent hundreds of hours, first in Uganda, then in Baltimore, observing the developing relationship between babies and their mothers (Ainsworth, 1967; Ainsworth, Blehar, Waters & Wall, 1978). She identified four phases of the development of infant-mother2 attachment.

    ____________________

    1They is a gender-neutral term for a person and will be occasionally used in this article. In most instances, though, for sake of clarity, the parent will be referred to as she and the baby as he or they.

    2 Though Ainsworth and other early attachment studies focused on mothers, primarily because of the cultural context, “mothering” is non-gendered, and no inference is made that only females can be primary attachment figures.

    In the early weeks of life, the “initial preattachment phase” (Ainsworth, et al., 1978, p. 23), the baby orients to any person who is in proximity, seeming not to differentiate the mother from other people. His inborn care-seeking behaviors include crying, “rooting, sucking, grasping and postural adjustments” (p. 23) that allow him to signal or maintain contact with another. Later research noted that neonates recognize the sound of their mother’s voice (DeCasper & Spence, 1986) and the smell of her breast milk (Marlier, Schaal, & Soussignan, 1998) so even though the baby may settle for a variety of caregivers, the presence of their mother is still sure to be a source of familiarity.

    Once the newborn’s sensory systems begin to consolidate, they become increasingly capable of differentiating their primary caregiver from other people. Through smells, sounds and sight, they discern not only familiar from unfamiliar people, but between familiar people as well. It is in this phase, beginning between eight and 12 weeks and known as the “attachment-in-the-making phase,” that we notice the baby show differential smiles, settle for a few key caregivers more readily than others and more specifically orient and cue particular caregivers than others. A home visitor, asked to hold a baby for a few minutes while the mother attends to a toddler, might notice that they baby shifts his body in order to retain visual contact with the mother. In offering developmental guidance that supports the important emerging relationship with the primary caregiver, we have often been heard to say on a home visit, “Yes, yes, I know! You don’t know me and you want to be able to see your momma!”

    Once an infant is capable of rolling, scooting, and crawling (i.e., approximately six through eight months), he is now capable of taking a more active role in seeking out proximity to his preferred caregiver. He may still occasionally prefer to signal through crying, smiling or reaching, but now, especially as he becomes increasing motorically competent, he is also able to scramble up on the parent, bury his head into a lap when anxious or alarmed, or crawl to a parent for a quick snuggle and emotional recharge. The capacity to locomote signals the onset of the phase of “clear-cut attachment.” The same capacity to seek out the caregiver also allows the child the ability to more actively explore the environment. It is the balance of the capacity to explore the environment and to return to a “safe haven” when alarmed, tired, hungry or ill that differentiates the quality of the attachment relationship. As Bowlby noted,

    “All of us, from the cradle to the grave, are happiest when life is organised as a series of excursions, long or short, from the secure base provided by our attachment figures” (1988, p. 62).

    Mounds and decades of research have described, studied and elaborated the styles of attachment relationships shaped in the first year of life. Through day-to-day interactive exchanges, babies begin to form schemas, or expectancies of their world, including mental maps of the self, the other and the self-in-interaction-with-the-other. Bowlby described these “internal working models” (1988, p. 165) as meaningful and reasonable ways of understanding the world in order to predict others’ behavior and to “plan” accordingly (realizing full well that this is a nonconscious process in the first year of life). In an era where much therapeutic treatment was constructed on the idea that babies were capable of generating and acting upon fantasies about their parents (Abram & Hinshelwood, 2018), Bowlby held fast to the notion that infants were responding to and developing ways of interacting with the actual environment. In other words,

    if parents were accepting of the baby’s strong emotions or bids for interaction, the baby would begin to construct a sense of self as worthy of care and protection.

    More current research has also confirmed his hypothesis that responsive caregiving during the first year of life plays a critical, though by no means sole, role in  healthy development (Schore, 2005; Sroufe, Coffino & Carson, 2010 ).

    Baby Mine: Patterns of Attachment

    Books and papers abound that describe the typical patterns of attachment. Briefly, attachment theory describes four basic styles of attachment: three “organized” styles (Ainsworth et al., 1978) and one “disorganized” style (Hesse & Main, 1999).  In the organized patterns, the caregiver, during the first year of life, has responded in ways that are relatively consistent or predictable, allowing the baby to develop a mental map of what can be expected from their caregiver. Babies who by the end of the first year are coded as “secure” in standardized assessment procedures, most typically the Strange Situation Procedure (Ainsworth, et al., 1978; Sroufe, et al., 2010), have experienced reliable, predictable and sensitive responsivity from their caregivers (Bowlby, 1988). Their tender needs and their needs for exploration have been, on balance, accepted. They are confident in the knowledge that their parent is a source of safety, both psychic and physical, and thus they are free to explore their environment. These babies develop “positive expectations concerning relationships with others, beginning capacities for emotion regulation and object mastery skills because of how secure attachment promotes exploration” (Sroufe, et al. 2010, p. 46). For these babies and caregivers, relationships are a source of pleasure and joy. Home visitors may find themselves relieved to visit these families, noticing the sense of attunement and comfort in the parent-infant relationship. In the context of visiting families where poverty of resources, and sometimes poverty of hope, prevail, seeing babies who are secure is a welcome salve.

    Infants who develop insecure patterns of attachment lack confidence in the responsivity or availability of their caregivers. In one direction, babies who develop an avoidant attachment have experienced repeated rejection or rebuffing in times of heightened distress or fear. Their mothers, in home observations conducted by Ainsworth (Ainsworth, et al., 1978), were observed to experience irritability and anger in interaction with their baby far more often than mothers of secure babies. They showed a restricted range of affect and often did not enjoy physical contact with their baby. These babies, by the end of the first year of life, learn to minimize their displays of need by turning their attention away from caregivers, often toward toys or other inanimate objects.  In addition to having to hide their need for comfort in order to avoid rejection, they also must mask their anger, lest it provoke more parental anger and rejection. As Bowlby described, “When in marked degree such an individual attempts to live his life without the support of others, he tries to become emotionally self-sufficient…” (1988, p. 124).

    Infants who develop a resistant, aka ambivalent, attachment to their mothers are uncertain about their caregiver’s emotional availability. In the Minnesota longitudinal study (Sroufe, Egeland, Carlson, & Collins, 2005), mothers of future ambivalent children were the “least psychologically aware” of any mothers in the study. Ainsworth et al. (1978) found the mothers of ambivalent babies to be less rejecting of their babies than mothers of avoidant babies, but less sensitive to their babies’ signals than mothers of secure babies. While not averse to physical contact with their infants, they also were “inept” (p. 300) and awkward in their ministrations. These mothers appear to have difficulty consistently seeing and knowing “what is going on in there,” and the baby experiences a confusing array of unpredictable caregiving responses.  By the end of the first year, ambivalent infants appear preoccupied with their mother’s whereabouts and, uncertain that their mother will be able to assist in times of discomfort, alarm or fear, are unable to use soothing, even when the mother offers it. They are less likely to explore their world and seem to say “It is hard to let go when I do not know if you will be there when I need you” (Ribaudo, 2016).

    A fourth attachment pattern is labeled disorganized/disoriented. Identified later in attachment research by Main & Solomon (Main & Solomon, 1990), these babies show a collapse of their typical organized strategy (secure, avoidant or ambivalent) when faced with significant distress. Disorganized/disoriented infants are thought to have experienced frightened and/or frightening parental behavior (Lyons-Ruth, 2008) that is sporadic and unpredictable, or parental affective communication that is “disrupted and contradictory” (Lyons-Ruth, 2008, p. 675) such as mocking or teasing when the baby is distressed. When faced with distress, a disorganized baby tends to show contradictory behavior such as approaching a parent with averted head, or walking toward a parent as if to seek comfort but then walking past him or her. Parental withdrawal (directing the infant toward a toy when the baby seeks comfort) and disinterest in the baby (e.g., silent caregiving during daily routines) is a significant risk factor for the development of a disorganized attachment and later psychopathology (Lyons-Ruth et al., 2013). Disorganized attachment ranges from 13 percent in nonclinical samples to 90 percent in samples of maltreated children (Cicchetti, Rogosch, & Toth, 2006; Lyons-Ruth & Jacobvitz, 2008).  Highlighting the intergenerational nature of patterns of relating, disorganized attachment is more prominent in dyads in which the parent has a history of unresolved loss or trauma in his or her own childhood (Hesse & Main, 1999). Duschinsky (2018) recently clarified the range of experience of fear or alarm in the presence of the caregiver, elaborating, for instance, that the caregiver may not be the direct source of harm but may be associated with fear due to being a cue for danger, as in the case of being exposed to parental interpersonal violence.  In instances where the parent is a direct source of fear or threat to the baby, as in maltreatment, the home visitor is likely to experience moments of confusion, despair and helplessness as they watch dyads where the source of comfort (i.e., the parent) is at the same time the source of fear.

    Talk to Me Baby: Communication

    What is an infant trying to communicate through babbling sounds and coos? What does an infant’s extended eye contact with a caregiver reveal about their developing attachment? Infant communication starts at birth, and the ways in which infants and caregivers communicate in the first few months help build the attachment relationship.

    Infants are born with the biological hard wiring for connection and begin to attend to their caregivers at birth. The quiet, alert state of a healthy newborn, who quiets to the voice and touch of the parent, is already engaging in and contributing to communication by virtue of this initial awake state. At two weeks, infants are able to follow their mothers’ gaze to external objects. By weeks seven and eight, infants exhibit social smiling in interactions, sustained eye contact, vocalizations and cooing, lip and tongue movements preparing their mouths for speech, and the ability to explore a communication partner’s face and start to gather and mirror back emotional cues (Lavelli & Fogel, 2013). As infants interact with their mothers in this second month, there is growth in what is sometimes referred to as “mother-infant coregulation processes”: Infants start to engage in short “turn-like dialogues” involving vocalizations and facial expressions like eyebrow raising (Lavelli & Fogel, 2013, p. 2266). These face-to-face interactions can be sustained longer by three to four months when infants develop the ability to engage in ongoing back-and-forth communicative patterns and to smile with full open mouths to display positive emotionality (Beebe & Steele, 2013). Between seven and 11 months, infants start to mimic sounds and behaviors of others, especially their mothers. They can respond to directing and pointing during one-on-one interactions, engage in ongoing babbling, and visually focus on objects or interactions with increased acuity (Dave, Mastergeorge, & Olswang, 2018, citing Albrecht & Miller, 2001).

    Infants have an early ability to both pick up on and reciprocate physical and vocal cues from their mothers, and whether a mother is able to read and respond back to these signals is important for healthy language development and predictive of secure or insecure attachment. Mothers’ positive feedback to infants’ vocal sounds and expressions is largely responsible for developmentally appropriate communicative growth within secure attachments (Lavelli & Fogel, 2013). By two months, infants are less responsive to strangers’ vocalizations and smiles when they differ in affect from those of their mothers, suggesting that infants’ interactions with their mothers shape communication patterns with others (Lavelli & Fogel, 2013, citing Stern, 1974). Infants start to provide more vocal and expressive signals of their emotions at three months through smiles and coos, providing more attuned mothers with increased opportunities to mirror back their cues by smiling back or repeating their sounds. Infants whose mothers can provide this immediate vocal and facial feedback are shown to smile, gaze and coo at their mothers more than infants with less attuned mothers, who may disengage or become distressed when their communication is not reciprocated (Legerstee & Varghese, 2001). Thus, the home visitor or early interventionist is wise to carefully watch for the amount of reciprocity and vocalizations, especially in the fourth month, when we would expect to see increasing vocalizations.

    Mothers’ abilities to follow their infants’ lead and engage in these positive back and forth communicative interactions are a key indicator of maternal sensitivity and the burgeoning stability or instability of the mother-infant attachment (Beebe, et al., 2010). Maternal ability to “stimulate” infants during periods of shared gaze with touch, vocalizations, and expressions and to hold back on stimulation when their babies looked away was positively correlated with secure attachment at 12 months (Beebe & Steele, 2013, p. 590). Likewise, a mother’s tendency to increase stimulation following “negative infant cues” such as breaking eye contact or showing signs of distress, and to withhold interaction when infants gaze and vocalize to them was positively correlated with insecure attachment at 12 months (Beebe & Steele, 2013, p. 590-591). Disorganized attachment at 12 months is, in part, predicted by maternal discordant affect, seen in mothers who display surprise or a smile when their baby shows distress (Beebe & Steele, 2013).

    This reciprocity of vocal and facial expressions between mothers and infants extends beyond the ability to recognize and mirror back the infants’ communicative cues. During moments of mutual gaze, vocalizations, and play, infants and mothers derive a shared sense of each other’s emotions, mental states, and intent. Mothers with secure attachments shape their language and expectations based upon accurate understanding of infants’ abilities to comprehend their words and meaning (Dave, Mastergeorge, & Olswang, 2018). To illustrate this ability to provide responsive and appropriate communication, Dave, Mastergeorge and Olswang provide an example of a mother instructing her infant to “Give me the ball” at seven or 11 months, and the distinction in the appropriateness of this request based upon the infant’s developmental level.

    By the same token, when mothers within insecure attachments are not attuned to their infants’ behaviors and vocalizations and unable to build reciprocity within the relationship, those patterns repeat themselves and limit prelinguistic development through 12 months and beyond. In insecure attachments, inconsistencies and rigidity in exchanges reverse the pattern of communication, with mothers, rather than infants, dictating vocalizations. Again, the infant’s sense of agency and verbal exploration is limited, often leading to the infant’s withdrawal (Lavelli & Fogel, 2013). Additional strain to communicative and linguistic growth can occur when mothers are depressed. Because caregiver communication consists in part of emotional affect and expression, social-emotional engagement is critical to infant-mother interactions. Even as early as the neonatal period, infants with depressed mothers tend to be less responsive to voices and faces (Dave, Mastergeorge, & Olswang, 2018; Field, Diego, & Hernandez-Reif, 2009; Lavelli & Fogel, 2013). Further, four-month-old infants of mothers with lowered responsiveness and emotional affect showed reduced self-contingency (Beebe et al., 2007; Lavelli & Fogel, 2013). Reciprocity between infants and mothers during the first year of life is an important contributor to prelinguistic development, attachment, and emotional development.

    Do You Feel Like I Feel? Emotional Development

    Throughout all the developments in cognitive systems and language, emotions hold the self together … Trevarthen, 2001, p. 114

    How do babies experience emotions? What is present at birth and what is noticed later in infancy? How do parents observe and respond to their babies’ emotions? Does a cry represent a need for comfort or an attempt at manipulation? Is a smile perceived as an invitation to play or a smug taunt? Which emotions get attended to, elaborated, contained or rejected are influenced by parental perception and the budding attachment relationship.

    Babies are born “wired” to experience and express emotions. Recent research has worked to elaborate what is seen on the outside, i.e. expressions, and what is experienced on the inside, i.e. which emotional displays correspond with which regions of the brain (Panksepp & Watt, 2011). It is beyond the scope of this article to review the scientific debate regarding what is universal vs. culture and experience in the development and display of emotions.

    There is general consensus that newborns tend to display three discrete emotions: distress, positive/joy and interest (Rosenblum, Dayton & Muzik, 2019).

    Each of these early primary emotions then evolve into more distinct and elaborated emotions such as anger, sadness, and more robust displays of joy, including laughter. By four months, infants can show anger at having a goal blocked (Izard, 2007) and perhaps even jealousy by six months (Rosenblum, Dayton & Muzik, 2019). It is important to note that emotions connected to self-awareness, such a guilt, shame or pride, are not observed until the second year of life. Awareness of the normative onset of emotions can assist the home visitor to attend to attributions made by the parent that are more likely to be a projection of the parent’s own disavowed emotion than an actual emotion experienced by the infant.

    Rosenblum, Dayton and Muzik (2019) describe children who are well regulated in behavior and emotion as “better able to adapt to contextual and situational changes in the environment in a flexible and spontaneous manner (p. 103).” In infancy, the primary strategies available to babies include avoidance (gaze aversion, postural adjustments), displays of distress (crying), and self-comforting (touching, sucking) (Rosenblum, et al., 2019; Beebe, et al., 2010). Schore (2003) has noted that the caregiver’s capacity to modulate their own emotions, and thus more sensitively respond to their baby, influences the infant’s capacity to share pleasurable states and to find comfort and support that minimizes negative affects.

    There are many pathways by which parental reactions to infant emotions begin to shape the emotional world of the baby, as well as their relationships. One important area we can observe and support is the parental capacity to accurately appraise and mirror back, in a slightly exaggerated fashion, their infant’s emotion (Gergely & Watson, 1996). This “marking” (Gergely & Watson, 1996), even of negative emotions, helps contain the infant’s emotions and assists in the process of an infant beginning to know that their internal state can be “felt” by others. For example, the parent who responds with a “woe face” (Beebe, et al., 2010) to a baby’s distress, saying “Aww, you don’t like that; that made you sad” is communicating to the infant that their internal experience can be shared and comprehended by another, that the internal feeling “looks” like what they see on their parent’s face (i.e., they see a “mirror” of what they are feeling), and that there are words that accompany the experience. This process of marking and containing, done repeatedly in the first years of life, lays the foundation for a child to know their own internal state, find words for them, and thus be able to share them with others, as well as empathize with the internal states of others. In other words,

    a baby whose emotional world has been, for the most part, accurately interpreted and responded to through parental affect, tone of voice and words, is well on their way to being the toddler in the child care center who offers his binkie to a distressed peer or pats a crying baby.

    They are also well on their way to gleefully shouting “Me did it!” and sharing their delight at success with the caregiver, having full confidence in the admiration of the caring adult. Having been seen, known, understood, and accepted, they are on their way to doing so for others.

    The Ants Go Marching: The Journey into Toddlerhood

    By the end of the first year, the neonate has evolved into a fully-fledged human, capable of expressing strong emotions such as love, sadness, fear, jealousy, and anger, and full of their own ideas, thoughts, intentions, wishes and desires. The scientist in the crib (Gopnick, Meltzoff & Kuhl, 1999) has become the scientist in the high chair. Returning to our example, what has become of the neonate whose mother feared she has irreparably harmed him in utero? Has his robustness registered and allowed her to feel reassured? Has her partner or a family member buffered or appeased her worry or have comments only heightened her anxiety? Has she found  the words to share her worry and begun to see him in a different light? Has she developed confidence in her own capacity to help him with any struggles, real or perceived, despite her worries about the toxic exposure? Her resolution to the prenatal anxiety will have shaped his experiences in the first year. What nascent sense of self will accompany him into the journey into toddlerhood?

    References

    Abram, J., & Hinshelwood, R. (2018). The Clinical Paradigms of Melanie Klein and Donald Winnicott. London: Routledge.

    Ainsworth, M.D.S. (1967). Infancy in Uganda: Infant Care and the Growth of Love. Baltimore, MD: The Johns Hopkins Press.

    Ainsworth, M.D.S., Blehar, M.C., Waters, E., Wall, S. (1978). Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum Associates.

    Beebe, B., Jaffe, J., Markese, S.,  Buck, K.,  Chen, H., Cohen, P.,…Feldstein, S. (2010). The origins of 12-month attachment: A microanalysis of 4-month mother–infant interaction. Attachment & Human Development, 12, 3-141.

    Beebe, B., Jaffe, J., Buck, K., Chen, H., Cohen, P. Blatt, S.,…Andrews, H. (2007). Six-week postpartum maternal self-criticism and dependency and 4-Month mother–infant self- and interactive contingencies. Developmental Psychology, 43: 1360–1376 .

    Beebe, B., & Steele, M. (2013). How does microanalysis of mother–infant communication inform maternal sensitivity and infant attachment? Attachment & Human Development, 15, 583–602.

    Bowlby, J. (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. New York, NY: Basic Books.

    Cicchetti, D., Rogosch, F., & Toth, S. (2006). Fostering secure attachment in infants in maltreating families through preventative interventions. Development and Psychopathology, 18, 623-649.

    Dave, S., Mastergeorge, A. M., & Olswang, L. B. (2018). Motherese, affect, and vocabulary development: dyadic communicative interactions in infants and toddlers. Journal of  Child Language, 45, 917–938.

    Dayton, C.J., Levendosky, A.A., Davidson, W.S., & Bogat, G.A. (2010). The child as held in the mind of the mother: The influence of prenatal maternal representations on parenting behaviors. Infant Mental Health Journal, 31, 220–241.

    DeCasper, A.J., & Spence M.J. (1986). Prenatal maternal speech influences newborns’ perception of speech sounds. Infant Behaviour and Development, 9: 133–150.

    Duschinsky, R. (2018). Disorganization, Fear and Attachment: Working Towards Clarification.

    Infant Mental Health Journal, 39, 17–29.

    Field, T., Diego, M., Hernandez-Reif, M. (2009). Infants of depressed mothers are less responsive to faces and voices: A review. Infant Behavior and Development, 32: 239–244

    Gergely, G & Watson, J. S., (1996). The social biofeedback model of parental affect-mirroring. The International Journal of Psychoanalysis, 76, 1181-1212.

    Gopnik, A., Meltzoff, A. N., & Kuhl, P. K. (1999). The scientist in the crib: Minds, brains, and how children learn. New York: William Morrow & Co.

    Hesse, E., & Main, M. (1999). Second‐generation effects of unresolved trauma in  nonmaltreating parents: Dissociated, frightened, and threatening parental behavior. Psychoanalytic Inquiry, 19, 481–540.

    Izard, C. E., (2007). Basic emotions, natural kinds, emotion schemas, and a new paradigm. Perspectives on Psychological Science, 2, pp. 260-280.

    Izard, C. E. (2009). Emotion theory and research: Highlights, unanswered questions, and emerging issues. Annual Review of Psychology, 60, 1–25.

    Lavelli, M., & Fogel, A. (2013). Interdyad differences in early mother–infant face-to-face communication: Real-time dynamics and developmental pathways. Developmental Psychology, 49, 2257–2271.

    Legerstee, M., & Varghese, J. (2001). The Role of Maternal Affect Mirroring on Social Expectancies in Three-Month-Old Infants. Child Development, 72, 1301–1313.

    Lyons-Ruth, K., & Jacobvitz, D. (2008). Attachment disorganization: Genetic factors, parenting contexts, and developmental transformation from infancy to adulthood. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 666-697). New York, NY: Guilford Press.

    Lyons-Ruth, K., Bureau, J.F., Easterbrooks, M.A., Obsuth, I., Hennighausen, K., & Vulliez-Coady, L. (2013). Parsing the construct of maternal insensitivity: Distinct longitudinal pathways associated with early maternal withdrawal. Attachment & Human Development, 15, 562-582.

    Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M.T. Greenberg, D. Cicchetti, & E.M. Cummings (Eds.), The John D. and Catherine T. MacArthur Foundation series on mental health and development. Attachment in the preschool years: Theory, research, and intervention (pp. 121-160). Chicago, IL: University of Chicago Press.

    Marlier L., Schaal B., Soussignan R. (1998). Neonatal responsiveness to the odor of amniotic and lacteal fluids: A test of perinatal chemosensory continuity. Child Development 69: 611–23.

    Panksepp, J., & Watt, D. (2011). What is basic about basic emotions? Lasting lessons from affective neuroscience. Emotion Review, 3, 387–396.

    Ribaudo, J. (2016). Restoring safety: An attachment-based approach to clinical work with a traumatized toddler. Infant Mental Health Journal, 37, 80–92.

    Rosenblum, K.L., Dayton, C.J., & Muzik, M. (2019). Infant social and emotional development: Emerging competence in a relational context. In C.H. Zeanah (Ed.), Handbook of Infant Mental Health (4th ed., pp. 95-119). New York, NY: Guilford Press.

    Sameroff, A.J. (2010). A Unified Theory of Development: A Dialectic Integration of Nature and Nurture.  Child Development, 81, pp. 6-22.

    Sameroff,  A.J. & MacKenzie, M. J. (2003). A quarter-century of the transactional model: How have things changed? Zero to Three, 24, 14-22.

    Schore, A.N. (2003). Affect dysregulation and disorders of the self. New York, NY: Norton.

    Schore, A. N. (2005). Attachment, affect regulation, and the developing right brain: Linking developmental neuroscience to pediatrics. Pediatrics in Review, 26, 204-217.

    Sroufe, L.A., Egeland, B., Carlson, E.A., & Collins, W. A., (2005). The development of the  person: The Minnesota study of risk and adaptation from birth to adulthood. New York, NY: Guilford Press.

    Sroufe, L. A., Coffino, B., Carlson, E.A. (2010). Conceptualizing the role of early experience: Lessons from the Minnesota longitudinal study. Developmental Review, 30, 36-51.

    Stern, N. B. (1999). Motherhood: The emotional awakening. Journal of Pediatric Health Care, 13, 8-12.

    Trevarthen, C. (2001). Intrinsic motives for companionship in understanding: Their origin, development, and significance for infant mental health. Infant Mental Health Journal, 22, 95–131.

    Trout, M. (2018). What is going on in there? Infant Crier, Fall 2018. Michigan Association for Infant Mental Health

    Vreeswijk, C.M.J.M., Maas, A.J.B.M., & Van Bakel, H.J.A. (2012). Parental representations: A systematic review of the Working Model of the Child Interview. Infant Mental Health Journal, 33, 314– 328.

    Winnicott, D.W. (1960). The theory of the parent-infant relationship. International Journal of Psychoanalysis, 41, 585-595.

     

     

  • Nineteen Protectors

    Nineteen Protectors

    After toiling for years in the minefield of nonprofit agencies, the courts, the juvenile justice system, schools, and community mental health, I eventually forayed into the land of private practice. I had been primarily trained as an infant mental health (IMH) specialist but had done some supervised play therapy training and work earlier in my career. I knew the chances of building a practice of solely IMH work was remote, so I began seeing families with young children for parent-child play therapy as well. I had a vague awareness that I had rarely worked with families that were “good enough,” where the children were sturdy and competent, unhindered by histories of loss or trauma and where parents had the psychological and material resources to meet their children’s needs. I had worked with abused and neglected children for so long that I had forgotten, if I ever knew, what a “typically developing” child—even one who was struggling emotionally for some reason—acted like.

    Smiling

    As I began to work with “voluntary” adoptive and foster families, often self-referred, I began to hear stories not unlike the ones I had heard in prior years. Parents came to me confused as to why, when trying to do things differently with their own child than had been done with them, or to love a child who felt himself to be unlovable, they were finding themselves exhausted, angry, overwhelmed and sometimes feeling helpless. I came to see that the issues these families faced were not so different from the issues faced by families I had worked with in the past, just buffered, more often than not, by less preoccupation with the provision of concrete needs. The differences in coping and in support was, nonetheless, profound. Whereas in the past, I had seen a predominance of families where the family had become “possessed by their ghosts,” now I was seeing more families where the ghosts were “transient…who [did] their mischief according to a historical or topical agenda.”1 I felt a sense of relief when I encountered parents who could describe their child with some measure of depth, who could differentiate their experience of an event as distinct from their child’s, who could express ambivalence about their ideas about parenting and who could assume some measure of responsibility for the nature of the relationship with their child. Of course, I had encountered parents such as these in the child welfare system, but often, by the time families received services, they were depleted of goodwill toward their child and the stable, loving feelings that so often protect a child during times of stress was worn thin, if ever present. In this new private practice environment, even families that were referred from child welfare or their pediatrician were coming with some measure of hope and optimism. It made all the difference.

    As time went on, I was referred an increasing number of intact, biological families. This was a completely new game. Without the evident history of abuse, loss, neglect or abandonment implied by involvement in the child welfare or adoption system, I was on my own, so to speak, to discern the nature of the ghost…transient or possessive? Tenacious or permeable? How I would help families identify and say goodbye to their ghosts? It was a different kind of challenge. Sometimes, I was referred an “easy” family. Clair was from such a family. Bright, vivacious and expressive at 3.5 years old, four weeks earlier Clair had been bitten in the face by the beloved family dog, Rex, who then “disappeared.” Clair’s parents, Mark and Emily, called for services after the childcare staff noted Clair had suddenly and increasingly become terrified of spiders and ants, such that she was now resisting going outside with the rest of the children during playground time. I saw the parents alone for an intake interview. Though clearly concerned about their daughter, they both presented with an air of ease, freely conversing and openly thinking about their and Clair’s experience in a rich and coherent way. Emotions evident in the intake included their concern for their daughter, the worry and guilt they were experiencing, anger at themselves for not protecting Clair and a strong sense of pleasure in being her parents. They were able to give a rich and detailed picture of Clair, of her imagination; her sense of humor, which included making up funny words and enjoying making them laugh; her sense of drama and her capacity for play. They described her as having been confident and outgoing before the dog bite, but said she had become increasingly clingy and easily frightened. The parents described their sense of guilt for not heeding the warning signs that their dog was increasingly territorial, particularly following the birth of their now 6-month-old son. Clair had accepted their explanation without question that Rex went to live on a farm where he had more room to roam. They felt slightly conflicted about not telling her the full truth—that he had been euthanized due to the aggression—but they wished to protect her from any undue feelings of guilt should she associate the bite with his death. What was striking, against the backdrop of a longer history of working with vulnerable parents who had grave difficulty apprehending or considering their child’s unspoken worries, was that Clair’s parents could do so without prompting. It was also telling that both parents spoke freely and neither seemed to dominate. Emily was emotionally more intense than Mark, but they seemed to negotiate areas of differing perspectives, which were minimal, freely. I felt confident in their capacity to build an alliance with me on behalf of their daughter.

    As we planned for Clair’s first visit to see me, I let the parents know that I suspected Clair had transformed her fear of her dog, the traumatic stress of the bite and his disappearance into a smaller, more manageable fear: spiders and ants. At her age, she was grappling both with the continued need for parental protection and support as well as the need to feel a sense of mastery and competence.2 Her symptoms of increased clinging, nightmares and a few toileting accidents also suggested some regression in the face of the anxiety about the sudden harm that befell her. I suggested that we use play as the medium to help her express her worries and they agreed. They did not need much convincing that young children often express their feelings, thoughts and wishes in play vs talk. Their capacity to understand their child’s developmental needs and to accept my guidance and support also marked something of a shift from working with families with less-than-secure attachment templates. These parents could be flexible in their understanding of their daughter and use me as a source of support.3 I helped them consider how they would introduce me to her and they liked the idea of telling her I was a person who would help her with her worries and fears.

    In preparation for Clair’s first visit, I made sure the spider and bumble bee puppets were at the top of the puppet bin in my office. As she entered the office, she initially stayed close to her mom. I let her know my office was a place where children with worries came to play and talk, that she could “play or not play, talk or not talk.” The choice was hers. I had prepped Emily that we would let Clair take the lead in play, and that we would not provide directives or instructions. As they settled in, another clue to Emily’s capacity to support Clair would be if Emily could allow Clair to set the pace. She responded to Clair’s exploration and mirrored Clair’s interest in the toys. Though I had hoped that Clair would notice the puppets, I did nothing to draw her attention to them. Within minutes, the child who was afraid of spiders and ants found her way to the puppets and pulled them out. She squealed and tossed the spider to her mom, who asked Clair what she should do with the spider. Clair said, “Smash him!” Emily pretended to smash the spider into the ground. Over and over, Clair retrieved the puppet and re-enacted the same scene, as her tense anxiety began to dissolve into laughter. I commented how good it felt that her mom could take care of the scary spider. In that first session, Clair eventually explored the rest of the room and as the time came to end, she agreed she wanted to come play again.

    In the second session, Clair went right to the puppet bin, put on the bee puppet and gave her mom the spider puppet. With a somewhat muted expression, Clair began to sting the spider puppet. In a stage whisper, I asked Clair what the spider puppet should be saying. “Owww, stop it!” Clair replied. As Emily followed Clair’s lead, Clair became increasingly animated. Intuitively, Emily comprehended what Clair was conveying and began to add emotion to her responses, saying, “Owww, that hurts! I don’t like that!” and “You are scary…go away!” I verbalized the pretend aspects of Emily’s responses so that Clair, who, at 3, could still confuse reality with fantasy, would not become overwhelmed. I was relieved to see Emily’s capacity to read Clair’s underlying emotions and to put her daughter’s experience into words, albeit displaced into play. Offering Clair a “mirror”4 of the fear and pain she experienced would allow her to know that her parents understood her experience and could help her make sense of it. Ultimately, this would help Clair digest and master the experience. Emily’s capacity to attune to Clair’s internal state bode well for her recovery. The ultimate aim was to reduce the feelings of helplessness and fear Clair was currently experiencing and to regain a sense of being safe and protected. What was also notable in these first two sessions was Clair’s ease in orienting to the room, not in an indiscriminate way, but in a relaxed, curious mode. Children with histories of more complex and relational trauma are often far more chaotic and unfocused in their play and exploration or inhibited and overly cautious and compliant. Another difference was the rapidity with which she was transforming her play, it was dynamic, not grim or stagnant.5

    In the third session, Clair assigned me the spider puppet and began to sting me. In a stage whisper again, I asked Clair how the spider was supposed to feel about getting stung. She said, “Mad!” I found it interesting that as she moved into a more “negative” emotion, she drew me in to the play as opposed to her mother. I did not comment on it. As Clair kept stinging the spider, I worked to elaborate more of what I imagined her experience to have been. Even though her parents had quickly responded and taken Rex off of her, she had been bitten several times. How long it must have felt like the attack had lasted and how helpless and little she must have felt. I exaggerated my responses, and moved my body and hand trying to stay out of the bee’s way. I yelled, “Stop it, Bee! That hurts, I don’t like it!” and “No matter how much I yell or move, the bee won’t stop! I’m scared!” in various forms and words. Clair took enormous pleasure in being the powerful bee, beginning to master the littleness and helplessness she had felt. As we ended the session, I commented how good it must feel to be the powerful one and how she had helped me to understand how it felt to be little and scared.

    In the next session, Clair had me adopt the spider puppet again. Wanting to weave in the theme of safety and protection, I said aloud as I was being “attacked,” “Help, somebody help me!!” with a glance and a nod toward Emily, who quickly picked up on my cue and came to my rescue, telling the bee to go away and putting her hand between the bee and the spider. Shortly after, Clair changed the game. She took the spider away from me and gave me the bee. I asked what my role was, and she told me I was supposed to chase and sting the spider. I told her I would pretend to be the scary bee, again reinforcing the fantasy vs reality aspect of our play. As the bee began to sting the spider, she ran behind her mother, who forcefully pushed my bee away saying, “You stay away from my spider! I won’t let you hurt her!” Clair giggled and came out from behind her mother to start the game again. Over and over, she declared through her play her need for her mother’s protection, and over and over again, her mother asserted her desire and capacity to protect Clair. They were working collaboratively to repair the rupture of the “protective shield” of safety that Rex had torn.6

    That style of play continued into the next two sessions, but increasingly, Clair became interested in other aspects of the playroom. She “cooked” and fed us from the kitchen area, she tucked a baby doll into the cradle, humming it to sleep. She seemed to be reminding herself of the layers of nurturing and protection she had experienced in the past and could access now. Emily reported that Clair’s clinging and fears had diminished and that she seemed to be the confident child she had been. In one session, with her father, she asked directly where he was when “Rex bited me.” He apologized directly to her and said he would work very hard to make sure she stayed safe. She paused briefly, looking at him solemnly, as if contemplating his words, then smiled slightly and offered him a cookie.

    In our last session, Clair played freely, only briefly referencing the bee and spider. She eventually settled on carefully constructing a tall house from the cardboard “bricks” in the office. Once the house was stable and sturdy, she carefully selected a number of animals and figures, surrounding the house with them. Counting in the fanciful way of 3 year olds, she announced proudly that the house had “19 protectors!” We affirmed that it was indeed a very safe, strong house.

    Infants and young children who experience a trauma within the backdrop of a secure relationship may still suffer the posttraumatic stress symptoms, but their recovery is thought to be more readily accomplished. This was true of Clair. In eight sessions, she recaptured the sense of safety and protection that had shielded her in the past. The security of the relationship with her parents allowed her to experience and express her distress, not needing to defend against it too fiercely, because she “knew” her parents had comprehended and accepted her range of feelings in the past. Their sensitive response to her distress, their willingness and capacity to seek help and the ability to let her tell her story of the feelings associated with the attack all allowed for a rapid recovery. Their capacity to meet her needs in the present, and her ability to accept their efforts at soothing her and repairing the disruption to her sense of safety, was girded by a relational history of security.


    References

    1. Fraiberg S, Adelson E, Shapiro V. Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. J Am Acad Child Psychiatry. 1975:14:387-421.
    2. Davies D. Child Development. New York, NY: Guilford Press; 2011.
    3. Wallin DJ. Attachment in Psychotherapy. New York, NY: Guilford Press; 2007.
    4. Gergely G, Watson J. The social biofeedback model of parental affect-mirroring. International Journal of Psychoanalysis. 1996;77:1181-1212.
    5. Gil E. Helping Abused and Traumatized Children: Integrating Directive and Nondirective Approaches. New York, NY: Guilford Press; 2006.
    6. Lieberman AF, Padrón E, Van Horn P, Harris WW. Angels in the nursery: the intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 2005;26:504-520.