The Infant Crier

Tag: Pregnancy

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

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

     

     

  • 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

  • Pathways to Parenting: Prenatal Bonding in Mothers and Fathers

    Pathways to Parenting: Prenatal Bonding in Mothers and Fathers

    “In giving birth to our babies, we may find that we give birth to new possibilities within ourselves.”
    – Myla and Jon Kabat-Zinn, Everyday Blessings: The Inner Work of Mindful Parenting, 2014

    For many parents, pregnancy represents a time of reorganization that leads to psychosocial growth and the hope of new possibilities.  The coming of a new baby inspires shifts within the psychological worlds of the parents as their emotional ties to the infant begin to take shape. The development of these ties is critical because they are related to parents’ postnatal feelings about the baby (Vreeswijk, Maas, Rijk, & van Bakel, 2014), and they provide psychological fuel for the demanding work of postnatal infant care (Rapael-Leff, 2005).  Importantly, a parent’s prenatal thoughts and feelings about his or her infant are also associated with postnatal parenting behaviors (Dayton, Levendosky, Davidson & Bogat, 2010; Dubber, Reck, Muller & Gawlik, 2015; Hjelmstedt & Collins, 2008).  Just as the infant will ultimately develop an attachment to the parent, the parent develops a complementary caregiving system that provides motivation to protect and nurture the infant (Solomon & George, 1996), and this system comes online during pregnancy.

    To date, the majority of the research informing our understanding of prenatal parent-infant relationship development has been with mothers (Slade, Cohen, Sadler & Miller, 2009).  More recently, prenatal bonding in fathers has also been the subject of research. Across studies, accumulating evidence suggests that: one, pregnancy represents the beginning of the parent-infant relationship for both women and men (Vreeswijk et al., 2014), and two, the quality of this relationship is related to postnatal parenting for both mothers and fathers (Dubber et al., 2015; Hjelmstedt & Collins, 2008). Focusing exclusively on mothers, D.W. Winnicott put it this way:

    I suggest, as you know I do, and I suppose everyone agrees, that ordinarily the woman enters into a phase, a phase from which she ordinarily recovers in the weeks and months after the baby’s birth, in which to a large extent she is the baby and the baby is her. There is nothing mystical about this. After all, she was a baby once, and she has in her the memories of being a baby; she also has memories of being cared for, and these memories either help or hinder her in her own experiences as a mother.

    — Winnicott, 1966 (as cited in Winnicott, 1987)

    In the IMH field we take Winnicott’s words to heart every day in our work with parents and infants; we talk to parents explicitly about their own child rearing histories, and we help them make conceptual links between past and present.  Indeed, attachment theory argues that a parent’s own relational history, described as “memories” by Winnicott and as “Ghosts” or “Angels” by more contemporary authors (Fraiberg, Adelson, & Shapiro, 1975; Lieberman, Padron, Van Horn, & Harris, 2005), is influential in the formation of the parent-infant relationship. Extensive research in the attachment field supports this link (Mayseless, 2006), and our clinical work with families reinforces its importance.

    Pregnancy represents the first point in development when we have clinical access to the parent-infant relationship.  Therefore, whether we are working with expectant parents or helping parents reflect on their prior pregnancy and birth experiences, understanding the role of risk and resilience factors in pregnancy can extend the clinical window backward to the place where the parent-infant relationship first took shape.

    Risk and Resilience in the Lives of Expectant Mothers

    For women, pregnancy involves both physical and psychological processes that contribute to the deepening of the maternal-fetal bond over time (Yarcheski, Mahon, Yarcheski, Hanks, & Cannella, 2009; Slade, et al., 2009; Zeanah, Carr, & Wolk, 1990).  The quality of the mother’s physical health and psychological well-being during pregnancy is fundamentally tied to that of the fetus.  Prenatal risk factors that the mother is exposed to, therefore, have the potential to influence her own health, the health of the fetus and her psychological connection to her unborn baby.  Exposure to intimate partner violence (IPV), for example, increases the risk for infant mortality and morbidity (Sharps, Laughon, & Giangrande, 2007).  It also affects the mother’s psychological tie to the fetus.  IPV exposure during pregnancy is associated with less positive internal working models of the infant for mothers (Huth-Bocks, Levendosky, Theran, & Bogat, 2004), and is ultimately related to less sensitive early parenting behaviors (Dayton, Levendosky, Davidson & Bogat, 2010; Dayton, Huth-Bocks & Busuito, 2016).

    Symptoms of psychological distress including depression, anxiety and post-traumatic stress disorder (PTSD) can also influence the maternal-fetal bond (Dayton, Hicks, Goletz, Brown, 2017; Luz, George, Vieux & Spitz, 2017).  Estimated rates of clinical depression during pregnancy range from 10% to 30% for mothers (Ashley, Harper, Arms-Chavez, & LoBello, 2016), and untreated depression is associated with less optimal maternal-fetal bonding (Yarcheski, et al., 2009; Alhusen, Gross, Hayat, Rose, & Sharps, 2012). It is important to note, however, that much of this work has been conducted with married or cohabitating Caucasian parents from middle-income socioeconomic groups (Yarcheski, et al., 2009). In light of the economic and racial health disparities in pregnancy and birth outcomes (Lu & Halfon, 2003), more research that extends this work to economically and racially diverse samples of parents is needed.

    Protective factors for healthy and adaptive maternal-fetal bonding have also been identified. For instance, Yarcheski and colleagues (2009) conducted a meta-analytic review and found that, across many independent studies, increased levels of social support were associated with increases in the strength of the maternal-fetal bond.  From biological and psychological perspectives, this finding makes a lot of sense.  In relation to contextual stressors such as violence exposure, social connection has a countervailing influence on the human bio-behavioral regulatory system. Connection with trusted others is physically and psychologically calming and has important biological correlates such as lowering cortisol levels and initiating the release of oxytocin. These biological responses to social connection calm the nervous system and may thereby support the development of the maternal-fetal bond via increases in a mother’s sense of psychological and physical safety.

    Findings from this body of literature have important translational implications for the early parenting field.  IMH interventions during pregnancy that help women free themselves from violent relationships, process and heal from the violence they have been exposed to, and decrease their symptoms of psychological distress are clearly indicated.  Further, and consistent with the central aims of many IMH programs, increasing a mother’s social support network may help promote a positive bond with her unborn baby, ultimately leading to more positive birth outcomes and a healthier postnatal mother-infant relationship.

    The Father’s Prenatal Journey

    The meaning of fatherhood in the United States has changed in important ways over the past few decades (Lamb, 2010).  Men are now more actively involved in the daily lives of their children (Bianchi, 2011), and the importance of fathering to the social-emotional development of children is more frequently acknowledged (Lamb, 2010).  When fathers are involved very early in the lives of their children, they have the opportunity to form foundational and enduring relationships with them, and outcomes for mothers and babies are improved. The positive health effects associated with father involvement begin in pregnancy with improved prenatal, birth, and neonatal health outcomes and significantly lower per-infant healthcare costs (Alio, Salihu, Kornosky, Richman, & Marty, 2010; Salihu, Salemi, Nash, Chandler, Mbah, & Alio, 2013). In contrast, a lack of father involvement in pregnancy is associated with significantly higher infant mortality rates (Alio, Mbah, Kornosky, Wathington, Marty & Salihu, 2011).  Given these compelling findings, supporting the prenatal father-infant bond is an important target of intervention that has the potential to improve birth and relationship outcomes for fathers, mothers and infants.

    Though less is known about the factors that affect the development of the prenatal father-infant bond, preliminary research suggests that psychological distress in fathers, including depression and anxiety, may be one risk factor for lower levels of prenatal bonding (Luz, George, Vieux & Spitz, 2017; Dayton, et al., 2016). Preliminary work also suggests that, on average, fathers may experience higher levels of emotional distance from their unborn babies, relative to mothers (Vreeswijk et al., 2014).  Much of this research has involved samples of middle-class, Caucasian fathers, however. As a result, less is known about how risk factors such as violence and poverty exposure may affect the developing father-infant relationship in pregnancy.

    To address the relative paucity of prenatal studies of fathering in contexts of risk, ongoing research at the Motown Family Relationships laboratory located at Wayne State University’s Merrill Palmer Skillman Institute, is currently investigating prenatal relationship development in urban-dwelling fathers, with the goal of informing early interventions with fathers.  A central finding of this work is that a father’s belief in the importance of early fathering to the health and well-being of the infant is robustly associated with stronger prenatal bonding: Fathers who believe that early fathering is important tend to report experiencing stronger bonds with their unborn infants (Dayton, Hicks, Goletz, Brown, 2017). This is an important finding because fathers in low-income groups are exposed to social narratives that describe fathering primarily in economic terms, and poverty-exposed fathers are clearly disadvantaged in this respect. Furthermore, qualitative data from this study suggest that many fathers have a difficult time grasping their importance during infancy and tend to view their parenting role as more influential when their children are older (i.e., preschool aged and above) (Dayton, et al., 2016). Helping fathers understand the importance of their early relationship with their infant beginning in pregnancy can help shift the narrative from fathering as a mainly financial role to the importance of the early father-infant relationship in promoting the healthy development of the infant.

    These cumulative findings have significant implications for IMH work with fathers and their families.  Most important, there is a need for early intervention protocols that communicate to fathers the centrality of the early father-infant relationship as a foundation on which the long-term parent-child relationship is built.  IMH practitioners are ideally positioned to engage fathers in clinical work and to help fathers negotiate the barriers that may prevent them from full involvement with their infants.  However, it is important to acknowledge that the vast majority of IMH workers are women. As women, our own histories have likely resulted in feelings and beliefs about the relative importance of fathers in the lives of infants and young children.  To authentically engage with fathers, therefore, we must examine our own feelings and challenge our own biases.  A mother-centric approach has dominated the IMH field since its inception.  Shifting our individual and collective views about early fathering will help move the field toward a more balanced family-centric approach and, ultimately, improve the lives of the families we care so deeply about.

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