Month: March 2017

  • 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.
  • Grass Roots Growth and Change

    Grass Roots Growth and Change

    For many decades, the creative energy of members of the Michigan Association for Infant Mental Health (MI-AIMH) has contributed to the knowledge and understanding of infant mental health principles and practices for thousands of professionals across disciplines in the infant and family field. Beginning with the first infant mental health conference in 1977 and continuing with the publication of MI-AIMH Training Guidelines in 1986, policy papers promoting infant mental health (1985 to 1997), manuals and monographs (1989 to 2015), learning tools (2002 to 2016) and practice DVDs (2012 to 2016), MI-AIMH and its members have made their mark as national leaders, defining and supporting infant mental health.

    In addition to producing materials for professionals and parents to promote relational health, MI-AIMH members developed a set of standards, the MI-AIMH Competency Guidelines®1 (2002), as well as a systematic approach to work force development, the MI-AIMH Endorsement for Culturally Sensitive, Relationship-Focused Practice Promoting Infant Mental Health® (2002), for the infant and family field. Linked to the MI-AIMH Training Guidelines (1986) and professional development indicators identified by the Michigan Department of Education (1996), the standards and plan provide a framework for use across systems and at multiple levels to promote infant mental health. Both provided an extraordinary focus for MI-AIMH for the last 10 years. Experts in the infant and family field recognized the standards and plan as a pathway for best practice and professional recognition in a diverse and rapidly expanding infant mental health field.2,3

    Michigan continued to lead the initiative and by 2013, 13 associations had licensed the MI-AIMH standards and work force plan to support knowledge, skills and reflective practice approaches for the development and promotion of infant mental health in their states. The oversight and quality assurance demands for a small MI-AIMH staff were considerable. The MI-AIMH leadership and leaders in other member states recognized that future strength and growth would require organizational change. The MI-AIMH Board of Directors subsequently engaged in a strategic planning process with knowledge and support from non–MI-AIMH leaders and proposed the creation of a separate organization to manage the endorsement. The organization was incorporated as the Alliance for the Advancement of Infant Mental Health, Inc.® By June 2016, the Alliance® shareholders approved an 11-member Board of Directors, officers, member qualifications and a set of by-laws to govern the organization. What was once a small, grass roots effort developed by MI-AIMH had grown to be a sizable national and international movement, co-lead by MI-AIMH and a new leadership structure, with over 27 infant mental health associations in the United States and one in West Australia.

    US Alliance members mapOf note, MI-AIMH leaders were instrumental in partnering with non–MI-AIMH stakeholders to identify priorities for the new organization that included the following: Sustainability funding for the Alliance®, expansion of the endorsement criteria to recognize those working with children 3 through 5, exploration and advocacy for Medicaid reimbursement of infant mental health services at the state and federal levels, development of training models and higher education programs specific to the competencies, consistent messaging and communication across state associations, building capacity for reflective supervision and consultation in each state and evaluation and research of reflective practice and the endorsement process. These priorities set an ambitious course for the new organization and led to considerable challenge and change for MI-AIMH.

     

    Accomplishments in 2016United Kingdom Alliance Map

    MI-AIMH and Alliance® leaders together coordinated Alliance® activities in 2016 and used distance technology regularly to support and strengthen a sense of community among the IMH leadership across all 27 state associations and Western Australia. Priority projects included:

    • The development of an early childhood mental health endorsement (ECMH-E) specifically for those working in service settings or on behalf of children 3 to 5 years of age and their families
    • The Spanish translation of the Endorsement®, its application system (EASy) and supporting materials to extend this initiative to monolingual Spanish-speaking professionals
    • The completion of the development of the RIOS (Reflective Interaction Observation Scale) to identify core elements of reflective supervision and consultation, under the committee lead of Christopher Watson, PhD, University of Minnesota and with members from Michigan, Indiana, Rhode Island, Connecticut, Texas, Colorado, Kansas and Washington
    • The co-hosting of the 1st Alliance RSC Symposium, in August 2016, at the University of Michigan, Ann Arbor, with over 115 people in attendance
    • A renewed focus on competency-informed training and education that encourages relationship building and reflective practice at the 10th Alliance Board Meeting and Leadership Retreat in Scottsdale, Arizona in October 2016
    • The exploration of ways that states fund infant and early childhood mental health services, examining requirements for Medicaid funding to support and sustain infant-family interventions and treatment services and linking with Zero to Three’s Social Policy network for information exchange
    • The successful funding of research faculty across Michigan universities to evaluate the efficacy of Infant Mental Health Home Visiting (IMH Home Visiting), which is vital for moving the service from a promising practice to an evidence-based practice

    Australia Alliance mapIn summary, MI-AIMH’s creative energy and leadership for over 40 years has led to an explosion of interest and shared commitment in Michigan and across the country to the promotion of early development and relational health, as well as continuing investment in the principles and practices of infant mental health.

    Looking Ahead for MI-AIMH

    What next? MI-AIMH’s leadership capability and creative ingenuity, so effective in the first 40 years, will continue to characterize the organization as new leaders emerge and commit to infant mental health policies and practices in Michigan and the Alliance® becomes a separate entity governing cross-systems and infant mental health work force development and recognition beyond Michigan. The relationship between the two organizations will remain strong. MI-AIMH and Alliance® staff will continue to share space and tasks for the foreseeable future; MI-AIMH members will continue to share leadership responsibilities for the Alliance®. Growth and change will require strong working relationships between the leaders of these two organizations, as well as empathy, support, honesty and flexibility. The goals of both organizations intersect…


    References

    1. Michigan Association for Infant Mental Health (2002/2016). Competency Guidelines®. Southgate, MI: Michigan Association for Infant Mental Health.
    2. Annapolis Coalition, 2007
    3. Weatherston D, Kaplan-Estrin M, Goldberg S. Strengthening and recognizing knowledge, skills, and reflective practice: the Michigan Association for Infant Mental Health Competency Guidelines® and Endorsement® Infant Mental Health Journal. 2009;30:648-663.
  • Resilience

    Resilience

    The first time I actually thought about resilience was while I was working as a psychologist at a Child and Adolescent Psychiatric Hospital. I was asked to test the sister of a young child who had been diagnosed with childhood schizophrenia. The family structure consisted of the oldest daughter, age 9, who had been given the diagnosis; Chloe, the middle sister, age 7, referred for testing; a younger sister, age 5, who was having behavioral difficulties; and their parents. Mother had also been diagnosed with schizophrenia and father had some symptoms that might be considered as Asperger’s Syndrome.

    The child whom I was asked to test was doing well in school and at home. She was engaging, animated, emotionally warm, and related quite well. The Director of the hospital had questioned her positive adjustment given the family constellation. He felt that with the child’s genetic vulnerability and the family disturbance, this child could not possibly be as well as she appeared.

    When I completed the test battery, I confirmed her positive adaptation. There was no intellectual or emotional indication of any maladjustment. The Director dismissed my findings and told me to do further testing. When I came back with the same results he shook his head, flipped the test report at me and said that it could not be so, a child with a strong biological vulnerability in an environment that was less than optimal could not be as well-adjusted as she was. In one session, I recalled asking her why she was not worried about eating food from the refrigerator that her mother said might be poisoned. She looked at me and said, “Just because my mother says it, it doesn’t mean I have to believe it! It might be bad for her, but that doesn’t mean it’s bad for me!”

    Some years later, I read E.J. Anthony’s book The Invulnerable Child. He had used the term “invulnerability” rather than “resilience” to make the point of psychological invincibility.1 Murphy and Moriarty felt that “invulnerability” was too strong a term.2 They stated: “In our use of “vulnerability” there is no completely invulnerable child–we are concerned with the degree and locus of vulnerability in relation to the intensity and quality of the stress.” (p. 248)

    Anthony agreed with Murphy and Moriarty and gave a wonderful example that has stayed with me over the years. He talked about a hammer that struck three objects, one at a time. The first object shattered into many pieces, the second was dented and the third, when struck with the hammer, made a beautiful, melodious sound. This was a beautiful metaphor for resilience. In a context of extreme adversity there are some who are crushed, others who are bruised and still others that weather the adversity and may even be strengthened.

    The construct of resilience has remained with me as it strums the chords of my own development, spending my early years in a low-income neighborhood, living in a project, having a mentally ill mother and uninvolved father, getting less than average grades in school and getting rejected from colleges. Along the journey, I had a series of “surrogate fathers”: a basketball coach, some wonderful male professors when I finally got in to college, a mentor who took me into a graduate program because he believed in taking marginal students and a mentor, Dr. Stanley Greenspan, with whom I later wrote two books on bipolar patterns in children.

    What are the factors that enable children who experience serious and chronic adversity to weather these conditions? Why are some children shattered by adversity while others experience bruises and others even thrive? Sometimes siblings living in the same family have totally different outcomes. The research on resilience has gone through four waves. The first wave was largely a descriptive wave that was focused on answering the question: “What makes a difference?” During this period, investigators were focused on developing measures and gaining an understanding of characteristics of people, environments and relationships that enabled individuals to weather adversity. During the second wave, the emphasis was on how protective processes worked. The emphasis shifted from “what” to “how”. In the third wave, there was a shift to looking at intervention, clinically and experimentally.3  In the present wave, we are looking at resilience through a multidisciplinary lens. With the use of neuroscience methods, we are now studying “the human genome, epigenetics, and the human brain in action as well as statistical strategies for analyzing complex multivariate data.”3

    Masten’s research has helped to uncover some of the major factors that promote resilience. These are factors that have been found to be the primary themes that individuals who are resilient seem to share:

    1. Attachment relationships and support systems: Masten states that in every review of resilience, close relationships and bonds with other people have been included as key protective factors. High-quality relationships lead to feelings of safety and security in children.4
    2. Agency and motivation: The motivation to adapt to one’s environment and to experience mastery. This motivation for mastery and the experience of pleasurable affects was studied by Robert White (1959) in his work on “effectance motivation.”4
    3. Learning and intelligence: Strong executive skills including problem solving, higher scores on intelligence tests and higher level thinking skills such as the ability to think abstractly are associated with resilience and adaptation.4
    4. Self-regulation: Self-regulation is necessary for delay and inhibition that creates the opportunity to problem solve. Self-regulation is also a key component of school readiness.5
    5. Faith, religion, and other sociocultural systems: Masten reported that in the research on resilience, individuals reported that these factors played a protective role in their abilities to weather adversity.4

    motherandtoddler001Looking back on that initial evaluation that I described at the beginning of this article and thinking about my interviews, testing and time spent with Chloe, four of these themes were clearly evident. She was a child who excelled in school and had the strong support of her teachers and her peer group. She was a child who had strong “sending power,”6 which relates to the strength and clarity of a child’s social signals. Some children are weak in their ability to send social signals and their signals are hard to interpret, while others send very strong and clear signals that are easy to pick up. I had the feeling of enjoyment in her presence. Her feistiness was engaging. In addition, her test scores on the WISC were within the High Average to Superior range, indicating an evenness in her development of intellectual skills and strong verbal ability that suggested an interest in reading as well as interpersonal relating. The incident in which she described her feelings about eating despite her mother’s warnings is a clear example of her motivation for mastery and her message that she was her own person! Finally, her striking ability to be present in the moment and to demonstrate “effortful control” at a young age indicates her ability for delay, self-control and self-regulation. All of these factors were suggestive of a positive outcome under stressful conditions.

    As I am writing this article I am thinking about the power of resilience even in its most severe forms. I am reminded of two present day experiences of resilience that are related to a severe form of mental illness, two adults whom I have treated and followed in psychotherapy—for twenty years in one case and just less than twenty years in the other—a boy whom I first met when he was 4 years old and a girl whom I met at 6 years old. Both of these children were evidencing signs of severe disruptive mood dysregulation that was finally diagnosed as pediatric bipolar disorder. I worked with each of them for periods of time, punctuated by periods in which I saw them and their families over the years. As they moved into adolescence and then adulthood, both shared a common denominator of tenacity, the refusal to give up and the commitment to maintaining close connections to me. Both families felt that they would be permanently disabled; however, both of them refused to agree with these conclusions. The boy, now a man, has almost completed community college—on the Honor Roll—and is determined to have a professional career. The girl, now a woman, has recently been accepted to a Master’s program in the mental health field. The tenacity to hold onto our relationships has been enormous.

    The power of relationships is something we need to stress in our training and supervision of students and professionals. Often, to the outside world the child’s primary attachment figures are thought to be the child’s parents. However, a child’s primary attachment figure may be unknown to the outside world because that person may not be part of the child’s family. A child can choose an individual who has been a constant, consistent and “special” person and with whom the child has an important bond. For me, my primary attachment figure was a surrogate father figure with whom I spent a great deal of time after school throughout my elementary and junior high school years. He was the person who I trusted most, to whom I confided when I was experiencing difficulty and who I looked for first to share my successes.

    Resilience is a complex relational construct. To understand it, we must look at the individual and the multiple systems that affect the child. We must understand not only the child’s primary caregivers, but also the systems outside the family, including school, neighborhood and outside community. Those individuals most affecting the child may not be immediately visible, and any valid research to understand resilience must go beyond the immediate environment.


    References

    1. Anthony EJ, Cohler B, eds. The Invulnerable Child. New York, NY: Guilford Press; 1987.
    2. Murphy LB, Moriarty AE. Vulnerability, Coping and Growth: From Infancy to Adolescence. New Haven, CT: Yale University Press; 1976.
    3. Masten A, Cicchetti D. Resilience in Development: Progress and Transformation. In: Cicchetti D, ed. Developmental Psychopathology, Third Edition, Volume 4: Risk, Resilience, and Intervention. New York, NY: John Wiley & Sons; 2016:271-333.
    4. Masten A. Risk and Resilience in Development. In: Zelazo PD, ed. The Oxford Handbook of Developmental Psychology, Vol. 2: Self and Other. Oxford, UK: Oxford University Press; 2013.
    5. Blair C. Stress and the development of self-regulation in context. Child Development Perspectives. 2010;4:181-188.
    6. Mahler M, Pine F, Bergman A. The Psychological Birth of the Human Infant. New York, NY: Basic Books; 1975.