Tag: attachment

  • 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

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

     

     

  • What’s Going On In There?  The Developmental Work of Pregnancy

    What’s Going On In There? The Developmental Work of Pregnancy

    “The connection between the pregnant woman and her developing fetus is perhaps the most profound but enigmatic of all the human relationships.”  (DiPietro, 2010, p. 28).

    INTRODUCTION: It’s a story we sometimes overlook entirely. Even when we do ask parents about it, sometimes we don’t catch the drama, the power, and the meaning of it.  The story is about the beginning of life, and what is happening inside the three people who are having this most profound and unsettling experience.Of course, we’ve long known that pregnancy is anything but innocuous for the one most visibly affected — the mother — but even then, we can fall short in our wondering.We know how to look backward (“What happened in there?”) when there is, later, a problem with the baby, or with one or more of the relationships.What if we had a chance to back up (long before there are symptoms of a problem), slow down, and just wonder what sort of mental activity is brewing in there, and why? What’s the point of it all? Is it really a developmental progression?  What variables impinge on the progression?  How do the parts — mom’s state of mind, dad’s dreams, baby’s sense of self, mom’s imagination about who this baby is, and the everyday things going on around this trio — all fit together, while influencing each other?That’s the sort of wondering we get to do, in this article, the first in a series on the developmental paths of early life.I wish we had room to ponder dad’s inner work.  We know it’s happening, and we know it’s important.  We’ll have to consider it another time. To be clear:  It is wondering that we’re doing herein.  We’re not establishing rules for pregnancy, or even proposing an orderly set of stages.  We’re just proposing a way to think about it all, and to imagine some implications.

    EXAMPLE #1   A crisis in a little northern Michigan town is featured in the national news.  A Farm Bureau employee in the southern part of the state inadvertently mixes a fire-retardant chemical into cattle feed. The feed is shipped north and fed to unsuspecting cattle. Soon, I pass stacks of dead cows beside barns as I pull in for home visits.  Polybrominated biphenyls are discovered in the food chain.  Word in the nearby farming communities is that this little-understood chemical might wreak havoc in the brains of humans, including babies.  Soon it will appear in breast milk.  Mothers hear about it, although they are mostly terrified to talk about it.

    If Reva Rubin was right, in an article published about this time (Rubin, 1975), that one of the key developmental/psychological tasks of the pregnant woman is her seeking safe passage for her unborn child, then what does the PBB crisis mean to a pregnant mom in rural northern Michigan?  Has she — irrationally, perhaps, but no less profoundly — come to believe she is failing to protect her baby?  Will this unspoken belief influence her capacity to move forward into other developmental tasks of pregnancy, including those needed to promote a profound sense of maternal self-confidence and authority?  Will she be able to attach to a child she fears she has harmed? When father asks her why she seems so blue, so detached, will she be able to put any of it into words?

    EXAMPLE #2   A baby is born to a mom still silently grieving the death of a previous child. The second baby was conceived just days after the death of the first one. Neither mother nor father has ever spoken of their shared loss; as a result, it seems to not actually be shared by the two of them at all.  They press forward, in silence, as if nothing has happened. Can parents attach to an unborn baby when their hearts are broken — especially when they deny it is so?

    In her brilliant description of the maturational crises of pregnancy, Grete Bibring drew our attention to the “…intense object relationship to the sexual partner [which] leads to the event of impregnation, by which a significant representation of the love object becomes part of the self” (Bibring, 1961, p. 15).  The above mom now has two pieces of unconscious psychological/developmental work to accomplish: In a state of estrangement from her husband, she must still manage to internalize the impregnation, in which the “love object becomes part of the self” (Bibring, 1961, p. 15); and she must achieve sufficient resolution of her grief over the child who has just died, in order to access needed libidinal energy for her connection to the next pregnancy, the next baby.

    Perhaps it’s too much.  Perhaps something will stand in the way of mom connecting to the new baby — or even accepting that she’s pregnant. The mother to whom this happened fell mysteriously ill immediately after the birth of the second child. She moved far away for a “recuperation period,” leaving her new son in the care of a stranger. Mom seemed unfazed by the separation. She had, indeed, come to the end of the pregnancy without finishing essential internal work.  She could — quite literally — not “face” her newborn, who would live the rest of his life with the psychological residue of his mother’s detachment.

    After several weeks, a friend — horrified to discover that mother was making no moves to see her little boy — brought them together for a visit. Decades after that brief visit, in response to a request by this newborn as an adult and father-to-be, mother wrote to him of her memories of those moments of greeting: “I felt no inclination to sweep you into the embrace I’m sure all expected.  You looked very much as I expected you to look … and we examined one another with what I fancy was a quite neutral expression.”

    Such breakdowns in the developmental work of pregnancy are often reparable. Parents play catch-up, and something allows many to “fix” the detachment or the depression that threaten life with baby. This particular mom never found her way back to her boy.  He stumbled into my office three decades later while awaiting the birth of his own firstborn son.

    EXAMPLE #3  It’s not news when a mid-adolescent becomes pregnant.  We know something of the obvious risks — that she may go through the pregnancy alone and poor, that the normal narcissism of her own developmental status might deter her efforts to invest fully in the Other inside her — but what do we know about how this will all play out developmentally?

    Pregnancy is never an “accident.”  Despite the pretense of many parents that they were uninvolved in the timing, it’s never true.  When and why it happens always has meaning.

    For Becky, it was right after a family trip to see her grandmother in North Carolina. The trip immediately preceded not only the pregnancy, but a significant change in Becky’s school performance and mood.

    Becky barely knew the boy-father, who was disinterested in her, and went on to impregnate another girl. While he evidently had no special meaning to her, the child growing inside her did. Sent to a home for unwed mothers, it was assumed Becky would give up her baby.  But she didn’t, even after discovering he was a boy. Her distance from him, throughout the pregnancy, was evident. At the delivery, one of the nurses took note of Becky sucking in her breath and mumbling, “Oh, no…” when she saw her newborn’s penis, even before she noticed his face. Nobody seemed to understand why she wanted to keep him when she felt so distanced from him.

    I met her when she returned to our little town with her son in tow. She spoke often of her expectation that her son would leave her someday.  Males always did, or so her narrative maintained. Her father, I learned, had been a military man on the base near her grandmother’s house.  Becky’s mother had been a “townie.”  He showed little interest in the pregnancy for little Becky, and appeared to be relieved when he was shipped overseas right after Becky was born. Becky grew up in her grandmother’s house with her mom, but with no dad anywhere.It looked as if Becky might be repeating the pattern; another child would be born without a daddy nearby.

    While I could not see it at the time, Becky began her interruption of the pattern by relinquishing custody of her son to her mother and stepfather before Jeremy was a year old. Her next step was to get pregnant again, this time with a military man. He was ordered to basic training at the base where her father had been 18 years earlier, so she moved back into grandma’s house.  She wrote me that her boyfriend had received orders to ship out, coincidentally to the same European country where her dad had been sent so long before.  She had pleaded with the base commander to change his orders. The father of her baby would stay.  They would marry.

    In her very last letter, Becky said she had learned that her new baby would be a girl, and that it would “…all work out, this time.  I think you know what I mean.”

    Sometimes the dynamics of pregnancy are awfully complicated, with the developmental work of pregnancy not completed for some years.

    THE DEVELOPMENTAL WORK OF PREGNANCY

    It would be unreasonable to assume that a living being as sophisticated and complex as an adult woman would treat the entrance of a human body into the insides of her innocuously, without noticing and responding.  “Noticing” and “responding” then become the work of pregnancy. In a flash, an expectant mother’s attention is riveted.  She is shaken. She does not just sit there.  She has work to do.  It will be sequential — developmental — but not perfectly so.

    THE BEGINNING:  ACCEPTANCE OF THE FOREIGN BODY

    A key element of this early work is simply acceptance of the pregnancy.  This sounds easy enough, but it’s not automatic. It involves a developmental step.  It implies traversing a threshold into motherhood, which may be rife with worrisome meaning for some moms.  It implies an unfamiliar responsibility, the need to conserve emotional energy, and the acceptance of certain limits.

    Something has come into mother’s body that did not use  to be there.  A certain resistance (not altogether unlike the natural rejection response of one’s body to a newly transplanted organ) must be overcome.  Mom must take note, her body must take note, and she must give permission.

    For a young woman of rape, this may be a huge step. Already there was an intrusion of another kind.  Now she must somehow separate that intrusion (of the rapist’s body) from the part of himself he left behind.  She must find a way to reject the first while accepting the second.  This is a tall order.

    Even without the violent or controlling intrusion of rape, merely the intrusion of the foreign body of the baby may be enormous for a woman who has never felt much control over her own body.

    For a mom living in a war-torn part of the world, even allowing herself to consider that life is beginning inside may bring on anticipatory grief, as the likelihood is high that this new life will have a very short term indeed.

    Under circumstances in which the safety of the fetus is more-or-less assured, however, mom will move forward (albeit unconsciously) toward acceptance of the intrusion of this “foreign body” (Bibring, 1961, p. 15), and incorporate it into her own. Mom and baby become one. (For this reason, death of the unborn baby in this early part of pregnancy may feel to mom like the death of part of herself.)

    She will eventually reach through this haze of lack-of-identity and confusion and say, essentially, “Yes.” It’s an unconscious act, of course, this affirmation, this acceptance.  It’s not necessarily an act of acceptance of a person, yet, since little in the way of an identity is yet available.

    This mostly-unconscious act of saying “Yes” may not be a one-time thing; the unconscious “decision” may be revisited several times.  As Lederman’s research showed us, acceptance of the pregnancy is not the same as acceptance of the baby, or of motherhood (Lederman, 1984, p. 17).  But accomplishing this first, delicate, unconscious act means her body can go on (instead of working to eliminate the intruder), and her mind can go on (tucking the fetus within so there is really no difference between that-which-is-mother, and that-which-is-baby — the safest possible place for baby to be, unless it isn’t).

    A NOTE ON THE DIFFERENCE BETWEEN ACCEPTING THE FOREIGN BODY AND WANTING TO BE PREGNANT

    [box style=”rounded” border=”full”]We’ve always been eager to understand how a mother’s attitude toward her prenate affected his later development, and many of us entertained private theories, based on our clinical work, about such connections. But wantedness, per se, is not really the point of this description of mother’s developmental work of acceptance.  We’re not suggesting that the developmental work of pregnancy requires that all mothers reach a certain plateau of acceptance of the pregnancy, of the baby, and of motherhood.  There is reason to believe that these are separate kinds of acceptance, perhaps reached at different times, perhaps never equivalently in all mothers. Mothers are fully entitled to tons of ambivalence, mountains of giddiness and terror, and various acts of reliving the past and predicting the future through dreams and strange — but perfectly normal — flights of ideas.  Our purpose here is not to take the mystery out and find categories (much less diagnoses) for the normal work of getting ready.  Our purpose is to come to an appreciation of the nuance and complexity of what goes on inside. We’re not looking for pathology; we’re looking for an understanding of what this marvelous inner work usually is.[/box]

    THE MIDDLE: IMAGINING AND THE EMERGENCE OF IDENTITY

    Having moved through acceptance of the intrusion of the foreign body, mom is now free to picture her baby; such imagining will constitute much of the work of the next developmental stage. Romantic notions aside, creating an identity for the being(s) growing inside may be tough, confusing, dismaying, complicated … and magical.

    In this second developmental stage, the outlines of an identity begin to be formed in mother’s imagination. This may be an exhilarating time, as mother’s imagination infuses baby with the best-of-all-possible-characteristics from her own and her partner’s histories. For some moms, however, the door opens to worrisome thoughts:

    • “My mom demeaned me during my whole childhood for being fat. I think my baby is fat.  What will mom say when she looks at my baby?”
    • “I feel mad at him sometimes, even now. What if I just don’t like him?”
    • “What if he’s weird, like Uncle Joey?”

    On and on it goes, this powerful developmental dance.  Thoughts are inconsistent and sometimes illogical.  Dreams are all over the place.  Ever so slowly, however, the notion of a person emerges.  It used to be that this developmental step — this emergence of an otherness —began sometime after quickening, after the baby announced herself suddenly and profoundly with a kick. But the near-universal use of routine ultrasound now pushes this second developmental step earlier in the pregnancy.  It can be joyful and affirming and real. Whatever else it is, it’s certainly far from innocuous.

    THE END:  DIFFERENTIATION

    Could it possibly be that mothers are obligated to say “good-bye” before they have fully said “hello”? In a sense, the answer is yes.

    As moms traverse the winding and complicated road from being alone in their bodies to becoming mothers, it appears there are two acts of differentiation that — while usually accomplished with little effort or even conscious attention — seem, nonetheless, developmentally important:

    • The “…growth of the pregnant woman from the role of the ‘daughter of the mother’ to the ‘mother of her baby’” (Schroth, 2010, p. 4). In other words, mother separates herself from her own mother as part of her preparation to become the mother of her baby. It seems a significant and meaningful step. In order to feel her power as a woman and to create a new view of herself as an efficacious, capable, intentional mom in her own right, she must assert that she is no longer merely her mother’s child. She is a mother, herself, perhaps resembling her mom in some ways, but wholly distinct in others.
    • The shift from the unconscious perception of the baby as part of the Self to the perception of the baby as an Other. In other words, mother separates herself from the baby who was fused with her as part of her preparation to encounter him as a unique and distinct human being.  Attachment, by definition, relies on accomplishment of this developmental task; otherwise, we’re left with mother everlastingly confusing the baby with herself, while the baby remains confused about the boundaries between self and other.

    Psychoanalysts Jenoe Raffai in Hungary and Gerhard Schroth in Germany developed a systematic facilitation for this final developmental work (Raffai, 1995 and Schroth, 2010).  Offered during the last weeks of pregnancy, the facilitation supports moms conversing with their unborns in ways that acknowledge the differentiation while opening up lines of communication that may be helpful during delivery, and may feel familiar to both mom and baby as they later begin to attach during the first postpartum days.  Schroth suggests that a kind of empathic “mirroring” (Schroth, personal communication) by the mother may support the unborn baby’s sense of being seen and known before birth.

    Practical results of this facilitation showed up in outcome studies on deliveries in Hungary and Germany. In the first Hungarian cohort of 1,200 mothers who participated in such facilitations, the rate of premature birth dropped to 0.1% (compared to the average of 8%); the cesarean section rate dropped to 6% (compared to the average of 30%); and the rate of postpartum depression dropped to nearly zero (from the average of 15%) (Raffai, 1995 and Schroth, 2010).

    French child psychiatrist Miriam Szejer suggested, “By the end of the pregnancy… the fetus and the mother no longer live by the same rhythms” (Szejer, 2005, p. 69).  I’ve come to believe that this is as it should be.

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

    BARRIERS TO ACCOMPLISHMENT OF THE DEVELOPMENTAL WORK

    No one would be surprised if a mom whose last baby died might delay the very first developmental step (acceptance of the intrusion of the foreign object), when such acceptance —or even acknowledgment — might cause so much pain.  She may barely have begun the
    “…reorganization of the survivor’s sense of self to find a new normal” (O’Leary and Warland, 2016, p. 3). A strong sense of her capacity to protect her unborn may now elude mom (as well as dad, in ways often invisible to most observers), which may lead to a disinclination to imagine that they are pregnant again. One researcher, with decades of experience interviewing and supporting families after prenatal or infant loss, reports that “…most parents entering a new pregnancy believe … that grief for the deceased child will diminish” (O’Leary and Warland, 2016, p. 6), only to discover that grief is actually resurrected by the new pregnancy. Understand that we’re not implying that a baby conceived after loss cannot be accepted, but only that the developmental work of acceptance may, quite naturally, encounter a bit of resistance.

    The developmental work of which we speak may be complicated by the loss of one baby — a “vanquished twin” — while the other one remains, lying inside.  Mom now has the work of grief and the work of acceptance all at the same time. Sometimes a mom simply cannot simultaneously do both.  So she may, without ever noticing what she is doing, turn over the work of grieving the lost twin to her partner, or delay it entirely. (The remaining/surviving baby is, of course, witness to it all.)

    Sometimes interference comes from the outside world. What if mom is preoccupied with a sense that she is physically at risk (due to domestic violence, for example)?  She needs emotional energy to do the developmental work of pregnancy, but that energy is being drained away.  She cannot revel in a focus on self (already — and normally — a bit muddled, with unclear boundaries between that-which-is-fetus and that-which-is-mother), because the context of ease and safety is missing. Essential self-indulgence feels absurdly inaccessible in this state of uncertainty and unease.

    And on it goes, through the entire pregnancy.  To notice these challenges is not to suggest psychopathology.  It is to acknowledge how complicated the work is, which makes it more than a little awe-inspiring that moms somehow navigate these unconscious waters so well.  The aim of such understanding need not be the elimination of all challenges.  Rather, the aim might be to support more of it becoming conscious, which then gives the family access to the narratives that naturally arise.  For example, dad might later be able to say to his son: “Your grandma got very sick while mom was carrying you inside.  Mom was sad about it.  She didn’t get to just think about herself, and about you. That’s why we’re making cupcakes for her, and for you, today.  Today is about nothing except the two of you being together, with no worries.”

    Or mom might explain this narrative to her pre-teen daughter: “You’ve always had to work extra hard to get me to let you go.  I know.  I’m sorry.  Believe it or not, we’ve been fussing about this since you were inside me.  You were ready to separate from me before I was ready to let you be your own little person. I heard you, but I couldn’t get myself ready to let you go. That’s probably why you were several days late in being born, and why I sometimes act goofy and scared when you want to try something on your own.  I get it. Sorry.”

    SUPPORTS IN THE ACCOMPLISHMENT OF THE DEVELOPMENTAL WORK

    Recent research teaches us that the growth of maternal self-efficacy (MSE) during pregnancy is an important inoculant against perinatal depression, and is a predictor of satisfaction with both the childbirth experience and with later parenting (Fulton, et al, 2012). Achievement of high levels of MSE does not result merely from being surrounded by cheerleaders, of course.* The formula for one’s perception of self-efficacy may include self-evaluation of one’s abilities in specific domains, but it may also include a range of internal perceptions, including long-standing self-narratives about one’s personal power and agency, and one’s “remembered care from their own parents” (Fulton, et al, 2012, p. 331). One of the joys of the developmental work that rests on delicious and healthy self-absorption is that these perceptions can be made conscious, can be mused upon, and can even be revised.  During some parts of pregnancy, some moms find themselves dreaming about events that haven’t been thought of in many years; calling family members from whom they have been estranged; asking their own parents surprising questions; looking at yearbooks and photo albums and otherwise digging into old memories and narratives — all part of a noble effort to pull together an efficacious sense of self.

    * It doesn’t hurt, of course, to have one’s attributes and capabilities highlighted during and after pregnancy. But one study of the relationship between social support and MSE turned up an interesting finding: “…partner support was unrelated to both maternal self-efficacy and depressive symptomatology” (Haslam, et al, 2006, p. 286), whereas higher levels of parental support were related to higher levels of MSE.

    Perhaps planning for the delivery, itself, can constitute a piece of developmental work.  We have seen mothers wrap themselves protectively around their bellies as they declare how they want the upcoming process to unfold.  Does maternal self-efficacy increase when a mother asserts herself in ways not previously associated with her personality?  Must we take note of the potential loss of self-efficacy when it does not go according to plan? French obstetrician Michel Odent affirms a truth felt by many women: “In the age of industrialized childbirth, the mother has nothing to do.  She is a ‘patient’” (Odent, 2002, p. 29).  Perhaps less scoffing at assertive women who are looking not only for a better start for their babies but for a greater sense of their own authority in the world might be in order.  As a mother prepares the way for birthing her unborn, maybe she’s also doing yet more developmental work.

    CONCLUSION

    It can be seen that the developmental work of pregnancy is not a one-off and may not be tidily sequential.  It builds on itself (thus the descriptor we’ve been using: developmental).  It may be messy and clumsy, moving in fits and starts, and it may be unnerving to partners, employers and extended family members (if not the mother herself).  But it has purpose and meaning. Decks are cleared, issues revisited (if not resolved), hopes investigated, fears aroused anew (perhaps so they can be put to rest — or, at least, put into storage for a bit). Mom gets a chance to greet herself, to re-invent herself, to meet parts of herself she had forgotten.  She gets a chance to feel integrated, even as she may worry that she’s falling apart.  She gets a chance to feel powerful, even in the face of so much inner challenge, with more to come.

    Guess who benefits from all of this?

    One final reminder: This clumsy, dramatic, mostly unconscious work is not being done in private. There is a witness.  Certainly it’s clever for evolution to work this way, with baby and mom communicating throughout the pregnancy about who she is, about life outside, about what the baby can expect. It means that — irrespective of her conscious intentions — mom “talks” to baby; if it’s not her words, it’s her endocrine system, giving information about her heart, her state of being, her reactions to things she’s seeing or thinking about or feeling.  The baby, of course, is a perceptive listener, retaining the messages (while undoubtedly getting the meaning of some of them all wrong).

    In the end, we see that there’s meaning in every last bit of this powerful, mostly unconscious developmental work of pregnancy.

    List of References, Suggested Reading and Study Questions:

    What’s Going On In There? The Developmental Work of Pregnancy – References and Study Questions

  • An Ambivalent Attachment Reunification Story

    An Ambivalent Attachment Reunification Story

    Jacob was returned to his mother Kimberly’s care three days ago. They have had extended overnight visits for the past six weeks. This is my first visit since his return home. We met in the small living room draped off by a blanket in the doorway to keep in the heat from the space heater. Kimberly said the landlord promised he would be out later to fix the furnace that only sporadically puts out heat; she herself had thought of the idea to tie the window shut with rope to keep the cold air out. She sat on the small couch surrounded by large cardboard boxes filled with the things Jacob’s foster mother had packed up and sent with him when he came back home. Jacob ran between the boxes pulling things out—footie pajamas, bath toys, formula—and then throwing them across the room. Kimberly called his name, told him “calm down” and reached for him to come sit with her. Even at 28 months, his small body easily fit on her lap. He was diagnosed as “failure to thrive” as an infant and has remained in the lowest percentiles on the growth chart. Jacob cried and arched his back causing him to slip off his mother’s lap and down to the floor. I sat quietly observing them, holding the worries that have guided and directed our work together: “Is she ready?”, “Will he be ok?”, “Can they connect and thrive together?”

    It has been almost two years exactly since he was taken from her. Failure to protect. Failure to thrive. Kimberly has worked hard to get here. She broke up with Jacob’s father, but promotes their continued supervised visits. She went back to school and earned a certificate that allowed her to get a full-time job. She got a place of her own. She has consistently participated in infant mental health (IMH) sessions; these were supervised by the relatives Jacob was placed with in his first and second placements and then at the agency after he was placed in a non-relative home because the relatives could not adequately protect him and promote his healthy development. Jacob’s health has been central to his foster care case from the beginning, and watching and worrying when he was not taken to the doctor or fed the correct foods was difficult for me as his IMH therapist. The foster care worker and I advocated for these concerns to be addressed by Jacob’s first foster parent, Kimberly’s father. This advocacy created strain within the family and between myself and the family, especially after the foster care worker threatened to remove Jacob from the home. Ultimately, this step was taken and several relationships were in jeopardy, including Jacob’s strong relationship with his grandfather.

    During this time it was clear that Kimberly felt divided between her alliance with her father and her alliance with her son. Her own childhood history was defined by abuse and neglect from her mother, who Kimberly states she does not remember. She was removed from her mother’s care at age 3 after she was left home alone. After that, she was raised by her father and had no contact with her mother. He told Kimberly the whole story when she was 18, stating he thought she was old enough to know the truth and then make her own choice about whether to have a relationship with her mother. He said her mom had called him recently when she heard she had a grandson. Her dad said it would be ok with him if Kimberly wanted to meet her and talk. Kimberly said she thought it was too late for that, but said she is not angry with her mom. She says, “I know it’s hard to have a baby when you’re so young.”

    Portrait of a crying little boy who is being held by her mother, outdoors

    Hearing Kimberly’s story, I wonder about her own early attachments. Did her internal working model tell her she had to cry loud and long to be heard, or did she learn it was safer to keep quiet and act like she was wasn’t there? Maybe her fear of her mother made her stop and stare while also wishing she could run to her and be picked up. What did Kimberly learn from a father who knew she was being abused but didn’t remove her from the situation until she almost died? Is this the template that Jacob will carry, that you might not always be protected and maybe only saved in a crisis?

    Ambivalent/resistant attachment was researched and defined by Mary Ainsworth as an insecure attachment style characterized by clinging and needy behavior when engaged with the caregiver, but then an inability to be soothed or calmed by this caregiver. She theorized that this inability to be soothed comes from the child’s lack of confidence in his caregiver’s ability to consistently and/or adequately respond to his needs based on his experience with this caregiver. The child also learns to heighten their emotions to ensure the caregiver will respond.

    I have observed this pattern of heightened emotions and an inability to be soothed in this mother-son dyad. In the first few months of IMH visits when Jacob was 10 to 12 months old, he would crawl to Kimberly to be held, then almost immediately arch his back, start to cry and signal to get down. When his mother brought him in close for a kiss, he might bite her on the lips and face. When he got upset, he would scratch at his face, increasing his own distress and his mother’s concern for him as well as her feelings of helplessness.

    In a previous article about ambivalent attachment for the Infant Crier, Kate Rosenblum cited research findings that parents of ambivalent/resistant children are often highly distressed and preoccupied themselves. She states, “In my own research I have found that parents who are preoccupied have a particularly difficult time responding to their infants’ needs when their infants are distressed. Infant distress, it seems, heightened their own distress, making it very hard to respond with sensitivity. When their infants cried, these mothers often responded with their own displays of distress, including intrusive, angry and hostile behavior. It was as if these infants and their mothers were caught up in a tangled dance of strong emotions.”

    Kimberly has been observed responding to her son’s emotions by laughing at him or distancing herself by handing him over to others in the room. She would often tease him during play in early visits by holding out toys for him and then grabbing them away. As she and I have reflected together about these interactions, she has been able to wonder about Jacob’s feelings and open her perspective to his inner experience. We have wondered together about how her feelings and worries were responded to when she was a child. During Jacob’s relative foster care placement with his grandfather, I often wondered to myself if I was watching a replay of the level of care and attention Kimberly had received as a child. When concerns were raised about Jacob’s care from his grandfather, Kimberly defended her father and joined him in minimizing these concerns: “I was small too” and “He only throws up once in a while.”

    During IMH visits at his grandfather’s home, Jacob would attend to his grandfather’s voice from another room and crawl away from his mother whenever grandfather walked in. Grandfather would laugh and say, “I don’t want you. Go see your mom,” and when he was handed to her, Jacob would reach up and hit Kimberly in the face. In the beginning this would cause mom and grandfather to laugh. They would often laugh at his antics, like when he crawled so fast his face hit the floor. He learned that he could get attention by acting in a certain way, by being “the entertainer.” This seemed to be another way Jacob learned to heighten his behavior to get attention.

    Jacob’s placement in a non-relative home brought about a huge shift in the case. His nutritional and health issues were consistently addressed for the first time, and it was obvious from looking at him that he felt better. Jacob’s improved health allowed our work to have an increased focus on his inner world and the parent-child relationship. Kimberly mourned the loss of easy access to seeing Jacob now that he was not with relatives. However, her interactions seemed to reflect an increased appreciation of their time together. She was able to acknowledge feelings of jealousy and sadness over his relationship with his foster mother, who he called “Nana.” As time progressed, the foster mother became a sort of grandmother to Kimberly as well and offered her advice about helping Jacob calm down, eat his food and sleep better at night. Kimberly became more proactive in making and attending Jacob’s medical appointments. Parent-child interactions during visits became more complex and layered, building on earlier experiences and interactions. Their play together began to reflect the increased richness of their relationship as Jacob created scenarios of making food for himself and mommy.

    Jacob still cries loudly, screams in frustration and throws objects when upset, but now instead of teasing, Kimberly calls him over for a hug; instead of laughing at him, she talks softly and instead of yelling “stop”, she holds him close. Kimberly is beginning to open the door a little bit to her feelings about her own early childhood, and addressing her unresolved trauma will be an ongoing therapeutic goal. Kimberly is overwhelmed with working full time and caring for Jacob as a single parent. I wonder how she will withstand the stress with limited support. I wonder how I would fare under these same circumstances. I still have those worries about this mother and son and how they will do together, but Jacob appears to be thriving and Kimberly is following up on his nutrition and doctor appointments. She looks at him with pride and he looks to her for comfort. They have consistent daily routines, they play and cuddle together, and his antics regularly cause her to laugh. I am so grateful for everything they have taught me about the power of early relationships, and I look forward to our continuing work together.