Selective nontreatment and spina bifida: A case study in ethical theory and application

Defective newborn children are to be considered human persons. Thus, primary duty in proxy consent is to act with the infant's best interest in mind. This duty may at times override the otherwise prima facie right to life, but only under restricted circumstances. Refinements of McCormick's “relational potential” criteria and of ordinary-extraordinary means analysis prove useful in such decisions. Utilitarian considerations of social consequences have impact but can be kept subsidiary. The importance for decision making of available child support services is considered. Spina bifida is used throughout as an example of issues discussed.     

The You-I event: on the genesis of self-awareness

I present empirical evidence suggesting that an infant first becomes aware of herself as the focal center of a caregiver's attending. Yet that does not account for her awareness of herself as agent. To address this question, I bring in research on neonatal imitation, as well as studies demonstrating the existence of a neural system in which parts of the same brain areas are activated when observing another's action and when executing a similar one. Applying these findings, I consider gestural exchanges between infant and caregiver, such as reciprocal smiles and imitative vocalizations. Lacking self-awareness at first, the infant is unaware of her own agency. By returning her unwitting gesture, the caregiver singles out for her—thanks to neural matching—the gesture's kinesthesis. Moreover, the caregiver's smile, imitative vocalization, or other gesture is the form that focusing takes. The kinesthesis of the infant's gesture, in being singled out, is experienced by the infant as what the caregiver is focusing on. It is experienced as being within the focal center. In this way, the infant becomes aware of herself as a bodily entity acting toward the caregiver. Exchanges that involve matching are at first essential, I argue, in making the infant present to herself in action. Matching will cease to be necessary, but self-awareness continues to depend fundamentally on others until the acquisition of language, when the child becomes capable of talking to herself as if she were the caregiver.     

Infant's action skill dynamically modulates parental action demonstration in the dyadic interaction

When interacting with infants, human adults modify their behaviours in an exaggerated manner. Previous studies have demonstrated that infant‐directed modification affects the infant's behaviour. However, little is known about how infant‐directed modification is elicited during infant–parent interaction. We investigated whether and how the infant's behaviour affects the mother's action during an interaction. We recorded three‐dimensional information of cup movements while mothers demonstrated a cup‐nesting task during interaction with their infants aged 11 to 13 months. Analyses revealed that spatial characteristics of the mother's task demonstration clearly changed depending on the infant's object manipulation. In particular, the variance in the distance that the cup was moved decreased after the infant's cup nesting and increased after the infant's task‐irrelevant manipulation (e.g. cup banging). This pattern was not observed for mothers with 6‐ to 8‐month‐olds, who do not have the fine motor skill to perform the action. These results indicate that the infant's action skill dynamically affects the infant‐directed action and suggest that the mother is sensitive to the infant's potential to learn a novel action. A video abstract of this article can be viewed at: https://www.youtube.com/watch?v=VNS2IHwLIhg&feature=youtu.be     

Infant Developmental Outcomes: A Family Systems Perspective

The aim of the current study was to examine whether parental mental health, parent–infant relationship, infant characteristics and couple's relationship factors were associated with the infant's development. Forty‐two families took part at three time points. The first, at 3 months postpartum, involved a video recorded observation (CARE‐index) of parent–infant interactions. At 5 months postpartum, in‐depth clinical interviews (the Birmingham Interview of Maternal Mental Health) assessed parental mental health and parental perceptions of their relationship with their infant, their partner and their infant's characteristics. Finally, the Bayley Scales III was carried out 17 months postpartum to assess the infants' cognitive, language and motor development. A higher mother–infant relationship quality was significantly associated with more optimal language development, whilst a higher father–infant relationship quality was associated with more advanced motor development. Additionally, maternal postnatal post‐traumatic stress disorder had a negative impact on the infant's cognitive development, whilst maternal prenatal depression was associated with a less optimal infant's language development. The largest prediction was afforded by parental perceptions of their infant's characteristics. The findings indicate that such perceptions may be crucial for the infant's development and imply that negative internal parental perceptions should be considered when assessing risk factors or designing interventions to prevent negative child outcomes. Copyright © 2013 John Wiley & Sons, Ltd.     

Watching,waiting, and wondering: Applying psychoanalytic principals to mother-infant intervention

There is general acceptance that the intergenerational repetition of relational patterns is transmitted within the interactions between mother and infant. The highly invested nature of the mother-infant relationship makes it a prime arena for the playing out of unresolved relational conflicts of the mother. This occurs through the mother's responses to her infant in which she projects into the infant certain disavowed but highly invested positive or negative attributes. This leads to the interactional re-creation of a whole relational system reflecting the mother's current and past relationship experiences. When a mother's conflictual past is unresolved and unmitigated by current relationships, her interactions with her infant are more driven by such perceptions than by real appraisal of the infant's actual attributes. The sleeping, eating, and behavioral management problems of infancy are often manifestations of such situations. A deceptively simple set of instructions to the mother, to become a nonintrusive observer of her infant and only interact at the infant's initiative, allows a role for the infant's initiative in changing interactions and thus potentially changing a relational system.     

THE STUDY AND TREATMENT OF MOTHERS AND INFANTS,THEN AND NOW: MELANIE KLEIN'S “NOTES ON BABY” IN A CONTEMPORARY PSYCHOANALYTIC CONTEXT

This paper draws on Melanie Klein's (unpublished) observational notes of her infant grandson, written primarily in 1938 and 1939. Apart from moving glimpses into a young family's life, the notes contain astute observations of an infant's behavior and emotions. Compared with Klein's published writings, the style is less theoretical and polemical. Later, in his latency years, Klein's grandson was in analysis with Marion Milner, who in 1952 published a paper drawing on the treatment. The present paper focuses on (1) how observations and treatment of the same child and his family by clinicians in close relationships with each other (Klein, Milner, and Winnicott) fertilized reciprocal influence but also brought into question the validity of Klein's observations, and (2) the relative merits and contributions of various modalities in understanding the infant's psyche, including experimental research, direct observation, parent–infant psychotherapy, and reconstructions from older patients—as occurs, for example, in psychoanalysis.     

“Of Course All Relationships Are Unique”: How Co-creative Processes Generate Unique Mother–Infant and Patient–Therapist Relationships and Change Other Relationships

The question of the uniqueness of relationships is examined: How do relationships come to be unique? What are some of the features of their uniqueness? And how can relationships, be it the mother—infant relationship or the patient—therapist relationship, have unique rather than archetypical effects on other relationships? A model of relationship uniqueness is presented that argues that mother and infant, and patient and therapist, co-create dyadic states of consciousness—states of making implicit and explicit sense of the world—out of their normally messy exchanges of age-possible meanings. These co-creative processes lead to change in the infant's and child's state of knowing the world, and also change the way the patient makes sense of the world and ways of being with others. Additionally presented are (I) a critique of attachment theory's assumption that the mother—infant relationship is the prototype of later relationships; (2) a critique of models of therapeutic change that see adult analysis as working primarily in the same domain as the workings of the mother-infant relationship; (3) a brain model of co-creative relational processes, Relational Activation Patterns (RAPs); and (4) possible psychodynamic processes in infants.     

Some considerations about personality structure in child psychosis

This paper begins by describing the three main areas that can be addressed in seeking to bring about change in parent?–?infant work, and questions the extent to which a brief therapy model may be generally effective. Following a clinical example, there is a discussion of the nature of the process of change with this particular population. Drawing on ideas from Paula Heimann and others it is suggested that the ‘ghost in the nursery’ described by Fraiberg represents an ‘unassimilated object’ that may frequently be projected on to the infant but is also likely to appear elsewhere. It is argued that, especially if therapy relieves the infant of this projection, it will most often manifest its presence in the couple's relationship. In consequence, it is this relationship that should be a primary focus for our interventions, particularly as this also provides the essential context for the infant's psychological development.     

Synchrony in the Triad: A Microlevel Process Model of Coparenting and Parent‐Child Interactions

Guided by a microanalytic approach to the study of relationships, we assessed parent, infant, and coparental behaviors during triadic interactions in 94 parents and their 5‐month‐old firstborn child. Relational behaviors in each family subsystem—mother‐infant, father‐infant, and coparenting—were microcoded. Marital satisfaction and infant temperament were self‐reported. No differences were found in the infants' behavior toward mother and father or in the time spent with each parent. Mothers' and fathers' relational behavior during parent‐infant episodes were generally comparable, yet mothers vocalized more and the latency to father's displaying positive affect was longer. Conditional probabilities indicated that under conditions of coparental mutuality, fathers showed more positive behaviors than mothers. Lag‐sequential analysis demonstrated that change in the infant's social focus between parents followed change in coparental behavior. Fathers' coparental mutuality was independently predicted by maternal behavior during mother‐child episodes, father marital satisfaction, and infant difficult temperament, whereas mothers' coparental mutuality was only linked with fathers' relational behavior. Results highlight the importance of including a microlevel perspective on the family system at the first stages of family development.     

The Developmental Origin of Metacognition

We explain metacognition as a management of cognitive resources that does not necessitate algorithmic strategies or metarepresentation. When pragmatic, world‐directed actions cannot reduce the distance to the goal, agents engage in epistemic action directed at cognition. Such actions often are physical and involve other people, and so are open to observation. Taking a dynamic systems approach to development, we suggest that implicit and perceptual metacognition emerges from dyadic reciprocal interaction. Early intersubjectivity allows infants to internalize and construct rudimentary strategies for monitoring and control of their own and others' cognitions by emotion and attention. The functions of initiating, maintaining, and achieving turns make proto‐conversation a productive platform for developing metacognition. It enables caregiver and infant to create shared routines for epistemic actions that permit training of metacognitive skills. The adult is of double epistemic use to the infant—as a teacher that comments on and corrects the infant's efforts, and as the infant's cognitive resource in its own right. Copyright © 2012 John Wiley & Sons, Ltd.     

Marco Conci interviews Marco Bacciagaluppi

Abstract

Following both Bion's and Aulagnier's thought, this paper seeks to examine two functions of psychotic syntax within the nonpsychotic personality. The first function is the creation of a split between voice and meaning in the mother–infant relationship, a split whose aim is to disengage contact with contents that cannot be metabolized and that are associated with the mother's denied death wish toward her infant. The second function pertains to the use of psychotic syntax as a way of denying separateness and annihilating the “speaking I.” Both functions will be exemplified by clinical case studies. In conclusion, psychotic language will be discussed as a “hybrid language” generated by an incestuous relationship between the mother's and the infant's language.     

suspicion of sudden infant death syndrome & injuries to infants: the effects of type of death certifier,training, and economics

This paper examines the level of suspicion by death certifiers when ruling infant deaths as accidents. Data were gathered on economic factors, amount of training in death investigation received, and personal characteristics for 1995 from 776 medical examiners or coroners. Findings indicate that personal and social factors such as age, education, and population have negligible or no effects on the level of suspicion held by death certifiers in manner of death rulings for infants. The findings from this study do suggest there is potential for inaccurate rulings of infant death due to lack of training, education, and economic resources depending on the events surrounding an infant's death and whether the death certifier is a coroner or medical examiner.     

Early stages of initiative and environmental response

Research results on the association between maternal response to infant' initiative and the development of such initiatives is being presented. This study is based on 239 feeding situations belonging to 41 mother–infant pairs videotaped at home at 30-day intervals, from the beginning of spoon-feeding until 1 year of age. The results showed that the basic hypotheses of this study were confirmed. There was a clear association between maternal responses to initiatives of the infant and four variables: Initiatives, Attempted Initiatives, Aversive Behavior, and Conflictivity. A favorable maternal response went along with more initiatives, fewer Attempts, less Aversivity, and less Conflictivity. Conflictivity was understood as reciprocal exchange of antipathetic reactions such as opposition, disgust, and hostility. Therefore, conflicts show struggle and confrontation between both members of the interaction. Aversivity is the infant's sole reaction to disgust, distaste, or opposition. As the infant risks confrontations with the care-giver to sustain her initiatives, we can say that, although highly influentiable by maternal response, Initiative is a contribution of the infant to her own development. Thus, in our view, a developing self shows an emerging capacity to initiate actions of his/her own. This becomes a relational issue as soon as the infant's initiative hits the interactional field, causing an environmental response that ultimately will allow or impede initiative. In case of impediments, the strong reaction of the infant will produce an impact upon the progressive stages of construction of the relationship, and certainly will be influential upon the further development of the infant's self.     

Infantile defences in parent‐infant psychotherapy: The example of gaze avoidance

Findings from parent‐infant observational research have stimulated the development of intersubjective models of psychotherapeutic action. These models have brought out the infant as an interactive partner with the parent. Conversely, interest in describing the individual psyche of the baby has decreased, especially the unconscious levels of his/her experiences and representations. In parallel, clinicians and researchers have been less prone to apply classical psychoanalytic concepts when describing the internal world of the infant. The author argues that this is inconsistent with the fact that psychoanalytic theory, from its inception, was founded on speculations of the infant's mind. He investigates one such concept from classical theory; the defence. Specifically, he investigates if selective gaze avoidance in young babies may be described as a defence or even a defence mechanism. The investigation links with Selma Fraiberg's discussion of the phenomenon and also with Freud's conception of defence. The author also compares his views on the baby as a subject with those suggested by infant researchers, for example, Stern and Beebe. The discussion is illustrated by vignettes from a psychoanalytic therapy with a 3 month‐old girl and her mother.     

The seventh servant: The implications of a truth drive in Bions theory of 'O'

Drawing upon Bion's published works on the subjects of truth, dreaming, alpha‐function and transformations in ‘O’, the author independently postulates that there exists a ‘truth instinctual drive’ that subserves a truth principle, the latter of which is associated with the reality principle. Further, he suggests, following Bion's postulation, that ‘alpha‐function’ and dreaming/phantasying constitute unconscious thinking processes and that they mediate the activity of this ‘truth drive’ (quest, pulsion), which the author hypothesizes constitutes another aspect of a larger entity that also includes the epistemophilic component drive. It purportedly seeks and transmits as well as includes what Bion (1965, pp. 147‐9) calls ‘O’, the ‘Absolute Truth, Ultimate Reality, O’ (also associated with infi nity, noumena or things‐in‐themselves, and ‘godhead’) (1970, p. 26). It is further hypothesized that the truth drive functions in collaboration with an ‘unconscious consciousness’ that is associated with the faculty of ‘attention’, which is also known as ‘intuition’. It is responsive to internal psychical reality and constitutes Bion's ‘seventh servant’. O, the ultimate landscape of psychoanalysis, has many dimensions, but the one that seems to interest Bion is that of the emotional experience of the analysand's and the analyst's ‘evolving O’ respectively (1970, p. 52) during the analytic session. The author thus hypothesizes that a sense of truth presents itself to the subject as a quest for truth which has the quality and force of an instinctual drive and constitutes the counterpart to the epistemophilic drive. This ‘truth quest’ or ‘drive’ is hypothesized to be the source of the generation of the emotional truth of one's ongoing experiences, both conscious and unconscious. It is proposed that emotions are beacons of truth in regard to the acceptance of reality. The concepts of an emotional truth drive and a truth principle would help us understand why analysands are able to accept analysts’ interpretations that favor the operation of the reality principle over the pleasure principle—because of what is postulated as their overriding adaptive need for truth. Ultimately, it would seem that Bion's legacy of truth aims at integrating fi nite man with infi nite man.     

Clinical Interview for high‐risk Parents of premature infants (CLIP) as a predictor of early disruptions in the mother–infant relationship at the nursery

The relations between mothers' narrative regarding the infant and the premature birth and the quality of mother–infant interaction were examined in mothers of 47 very low birth weight (<1650 g) premature singletons prior to discharge. Maternal representations were assessed with the Clinical Interview for high‐risk Parents of premature babies (CLIP), a semistructured interview that explores mothers' experiences of the pregnancy, delivery, hospitalization period, thoughts and feelings about the infant, and impending discharge. Ten minutes of mother–infant interaction were videotaped, and global and microanalytic codes were used to define three interactive variables: maternal adaptation, maternal touch, and infant withdrawal. Factor analysis of the CLIP items identified two factors with eigen values of 2.00 and above, termed Readiness for Motherhood and Maternal Rejection. Regression analyses were used to predict the three interactive variables by the infant's medical condition, maternal anxiety and depression, and the CLIP factors. Maternal adaptation to the infant's signal and maternal positive touch were each uniquely predicted by the mother's readiness for the maternal role, and were each negatively related to maternal depression. The infant's interactive withdrawal was independently predicted by maternal rejection. The clinical implications of the findings and the potential use of the CLIP for routine detection of early disruptions in the mother–infant relationship are discussed. ©2003 Michigan Association for Infant Mental Health.     

Orientation,containment and the emergence of symbolic thinking

Orientation is viewed in this paper as an important dimension of containment for the development of thinking. Orientation refers to the particular positioning in space and time of mother and infant so they can find one another and then containment can take place. Bion's container–contained model for the development of thinking is based on the capacity of the mother's mind to function as a ‘home’ for the infant's primitive projections. Containment and orientation are explored in relation to an ancient Greek object called ‘σ?μβολον’ [symbolon], which I use here as a metaphor for the early negotiation between mother and infant to achieve a correct matching to each other's orientation. This is then mobilized and re‐enacted between analyst and patient in the psychoanalytic process. Orientation as part of the container–contained model enables us to view the development of thinking from a new perspective with greater integration of cognitive and emotional aspects. The clinical implication of the concept of orientation is explored in relation to the process of engagement/disengagement between analyst and patient and is illustrated by clinical material.     

Prologue

The discussant begins by describing her British Object-Relations perspective. She emphasizes the difference between obstructive or critical forces within the personality which are best described as a part of the self and those which are felt by the patient to have a quality of otherness about them: the latter are better conceptualized as internal objects since this is closer to the patient's subjective experience. The author stresses the importance—in Scharff's patient's inner world—of the useless maternal—and impotent paternal—object. ‘Stupid’ rather than ‘bad’ objects can affect introjective processes and limit the patient's intellectual functioning because, where the world is seen as uninteresting and unstimulating, it is therefore not worth attending to nor learning from. The author also made a further point. She saw the patient's repetitive bitter self-criticisms, although partly arising out of deprivation, depression, and abuse, as also possibly containing an element of masochistic pleasure in suffering and failure. This would raise delicate technical issues in balancing a sensitive approach to the real suffering with a clearly stated recognition of the addictive repetitive masochistic quality which accompanies it and which may be blocking recovery.     

Mother's prenatal and postpartum depression symptoms and infant's sleep problems at 6 months

Mother's prenatal and postpartum depression have been associated with infant's sleep problems. This study aimed to analyze (a) the effects of mother's prenatal and postpartum depression symptoms, including the effects of prenatal and postpartum anxiety and depression scores of the Edinburgh Postnatal Depression Scale (EPDS), on infant's sleep problems at 6 months, and (b) the interaction effect between mother's prenatal and postpartum depression symptoms and infant's sex on infant's sleep problems at 6 months. The sample was comprised of 164 mother–infant dyads whose mothers completed measures of depression at the third trimester of pregnancy, 2 weeks, 3 and 6 months postpartum and a measure of infant's sleep problems at 6 months (CSHQ-I). Mother's prenatal depression symptoms, specifically depression scores of the EPDS, predicted more infant's sleep anxiety and daytime sleepiness, while mother's depression symptoms at 2 weeks postpartum, specifically anxiety scores of the EPDS, predicted more bedtime resistance and CSHQ-I total scores at 6 months. Boys of mothers with more prenatal depression symptoms presented more sleep anxiety at 6 months. Both mother's prenatal and early postpartum depression symptoms have a negative effect on the emergence of infant's sleep problems. Additionally, boys seem more vulnerable to mother's prenatal depression symptoms.     

Decisions about life and death: Assessing the Law Reform Commission and the Presidential Commission Reports

This paper compares and critically comments upon certain aspects of the Canadian Law Reform Commission Report,Euthanasia, Aiding Suicide and Cessation of Treatment, and the United States Presidential Commission Report,Deciding to Forego Life-Sustaining Treatment. It focuses on their positions on euthanasia and on the general principles, values, and procedures that ought to govern practices of foregoing life-sustaining treatment. The paper first comments on the recent debate over the moral relevance of the killing/letting die distinction, since this issue appears crucial in assessing the rationality of the current, absolute prohibitions of direct killing in medical contexts, embodied both in law and in codes of ethics. This issue bears upon a question in the closing section—whether the withdrawal of foods and fluids is ever morally permissible.