Infant-parent psychotherapy with an autistic toddler

This paper describes the 3½ -year treatment of an autistic toddler, who by age 5 showed normal social relationships and only minor residual cognitive features of the disorder. The treatment approach integrated infant-parent psychotherapy with techniques of special education and involved a two-person team that worked simultaneously in the family's home. The early work focused on discovering ways to mediate environmental stimulation so as to enhance the child's availability for social interaction. The treatment helped the parents understand this and explored and interpreted misconceptions about their son that interfered with parental feelings and functions. Multiple issues in the parent-child relationship and in the child's social and cognitive development eventually were addressed. This case illustrates one scenario in the development of relationships when an infant lacks the biological fittedness for social interaction. It demonstrates the possibility of ameliorating the autistic condition through a modification of infant-parent psychotherapy. The successful outcome of the case seems to be the result of several factors: The child's age at the beginning of treatment, his areas of cognitive strength, and his parents' exceptional ability to use and extend the therapy.     

'Dialectical process' and 'constructive method': micro-analysis of relational process in an example from parent-infant psychotherapy

Jung defined experience that takes place between therapist and patient as 'dialectical process', achieved through 'constructive method'. Perspectives from attachment theory, neurobiology, cognitive science, systems thinking and infancy research confirm and extend his view of the centrality of relational process in the development of self. Interactional experiences are embedded within the history of the primary parent-infant relationship and structure within the mind implicit patterns of relating. These patterns influence capacities for managing a whole lifetime of affective relational experience within the self and with others. This paper shows how parent-infant psychotherapy seeks to intervene during the formation of disturbed relational patterns. I offer detailed micro-analysis of the moment-to-moment 'dialectical process' that a mother, her four-month-old infant and myself 'constructed' together.     

Communication in early infancy: an arena of intersubjective learning

The present essay summarizes experimental, video-microanalytic and clinical aspects of the Papouseks' approach to early preverbal communication. The first section summarizes some of their video-microanalytic research on intuitive parenting and preverbal parent-infant communication. It describes the naturalistic preverbal learning context where infants learn and integrate experiences about themselves, the parent, their interrelatedness, and interactions with objects and events in the environment. The second section recapitulates research involving various kinds of experimental manipulations of the parents' communicative behavior and its effects on infant responses. The final section draws a bow to individual differences and what can be learned from the application of the still-face paradigm in clinical assessments of dysfunctional parent-infant communication.     

The impact of premature childbirth on parental bonding

The development of an affectionate parent-infant bond is essential for a newborn infant's survival and development. However, from evolutionary theory it can be derived that parental bonding is not an automatic process, but dependent on infants' cues to reproductive potential and parents' access to resources. The purpose of the present study was to examine the process of bonding in a sample of Dutch mothers (n = 200) and fathers (n = 193) of full-term (n = 69), moderately premature (n = 68), and very premature infants (n = 63). During the first month postpartum parents completed the Pictorial Representation of Attachment Measure (PRAM) and Postpartum Bonding Questionnaire (PBQ). Longitudinal analyses revealed that mothers' PRAM scores decreased after moderately preterm delivery, whereas decreases in PRAM scores occurred in both parents after very preterm delivery. As lower PRAM scores represent stronger feelings of parent-infant connectedness, our findings suggest a higher degree of bonding after premature childbirth. Results of the PBQ analysis were in line with PRAM outcomes, as parents of preterm infants reported less bonding problems compared to parents of full-terms. These findings support the hypothesis that in affluent countries with adequate resources, bonding in parents of preterm infants on average may be higher than in parents of full-term infants.     

Successful treatment of the mother-infant relationship in a mother suffering from severe postpartum depression

This paper discusses the treatment of severe postpartum depression in home-based infant-parent psychotherapy. Severe postpartum depression is examined as a psychiatric disorder in which childbirth is a necessary but insufficient cause. Home-based treatment that involved both mother and infant permitted a more comprehensive approach. By facilitating assessment of the risks to the infant from the mother's impairment by direct observation of the mother-infant relationship, infant-parent psychotherapy helped to avoid an unnecessary hospitalization of the mother in the case example. Instead, treatment helped to build on the ego strengths of the mother in order to stabilize precarious defenses and to support her bonding with her baby.     

Preventive intervention with infants and families: The NBAS model

A model for preventive intervention based on the use of the Neonatal Behavioral Assessment Scale (NBAS) is presented, and the conceptual framework underlying this approach is made explicit. The approach is based on the assumption that the neonatal period presents clinicians with a unique opportunity to influence parent-infant relations positively from the beginning. It is argued that especially under conditions of stress, this infant-centered but family-focused form of intervention can serve to prevent the compounding of problems that may occur when the caregiving environment is unable to adjust to the needs of the young infant. The aim of the NBAS-based approach is to sensitize parents to the communication cues and the unique adaptive capacities of their infants. It is the individualized nature of the NBAS-based approach that places it outside the domain of main-effects treatment modalities and renders it responsive to the particular needs of individual infants and their families. The model of intervention described herein is based on the development of a supportive therapeutic relationship between clinicians and parents and as such may serve as the first stage in a comprehensive follow-up program of support for infants and families. Guidelines for clinicians using the NBAS in clinical settings that follow from these assumptions are provided.     

Parent mind-mindedness,sensitivity, and infant affect: Implications for attachment with mothers and fathers

Previous research examining links between parenting and attachment has focused on behavioral aspects of parenting such as sensitivity. However, by assessing how parents reflect on infants’ mental states (mind-mindedness) we gain a broader understanding of parenting and how it impacts attachment. Mothers, fathers, and their infants (N = 135) participated in the Still Face Paradigm (SFP) at 3-, 5-, and 7- months of age, and the Strange Situation with mothers at 12 months and fathers at 14 months. Parent sensitivity and infant affect were coded from the SFP and all videos were transcribed and later coded for parents’ use of appropriate and non-attuned mind-mindedness toward their infants. Attachment with each parent was coded from the Strange Situation. Mixed effects models examined trajectories of parents’ mind-mindedness in relation to parent sensitivity and infant affect across attachment groups. Significant differences between parent gender and attachment category were detected. Specifically, parents who were less sensitive were also less mind-minded toward insecure-avoidant infants; parents used more non-attuned mind-mindedness when infants had higher negative affect. Findings suggest that, in addition to parent sensitivity, parents’ use of appropriate and non-attuned mind-mindedness during a parent-infant interaction provides insight into the developing attachment relationship for mothers and fathers.     

Student volunteer social support and infant intervention: A case study

The emphases in infant mental health have been in the three areas of supporting the mother-infant dyad through education, psychotherapy to help parents resolve emotional conflicts that interfere with the parent-infant interaction, and support during the acute crisis that follows an abnormal birth. The case described herein involves a child with a genetic defect born to competent parents, a chronic stressful situation that does not fit these categories. It became apparent in the first few months after the birth that both the child and parents were in need of some help in coping with the situation. An intervention was designed to help provide both the necessary stimulation for the baby and the needed emotional support for the family, while it acknowledged their skill and competencies as parents. This was done through the help of college student volunteers, who assisted the mother in the home. Developmental data recorded at birth, 7 months, 12 months, and 39 months indicate that the child is severely multiply handicapped. Interview data with the parents at those times document their personal and family difficulties, the eventual resolution as a family in dealing with this problem, and the importance of the volunteer help during that process.     

The role of the adult attachment interview in parent-infant psychotherapy: A case presentation

This case presentation describes the assessment of an infant at age 3 weeks who had a highly unusual birth experience, and the subsequent 18-month treatment of this infant and his family. The case documents the clinical benefit derived by obtaining an Adult Attachment Interview (AAI) as part of the assessment process. It also discusses the role such a procedure can have in planning and executing parent-infant psychotherapy in complex cases.     

The interaction approach to early intervention

A brief summary of research, supportive of the idea that quality of parent-infant interaction has a powerful effect on infant development, introduces an early intervention model based on that proposition. Also, central to the interaction model is the knowledge that (1) parent and infant both contribute to what happens between them and that (2) a multitude of factors, environmental and internal to parent and infant, affect the parent, the infant, and their interaction. Ten sets of principles and strategies that convey the essence of the interaction model constitute the core of this article. The principles and strategies address the importance of identifying sources of support and stress in the family, of developing relationships with both parents, and of supporting positive interactions between parents and the infant's siblings. The limitations of this model are also addressed, especially in cases where the parent is the primary risk factor. The infant's exposure to nurturing adults in quality day care programs and a more clinical approach with the parent and infant, such as Selma Fraiberg's model, may be more effective with such families.     

Infant screen media usage and social-emotional functioning

There has been little research on whether and how screen media usage affects social-emotional (SE) function prior to two years of age, even though early SE development is understood to be nurtured through interpersonal experience, mainly withthe primary caregiver. This study sought to characterise infant screen media usage and understand how it may link with concurrent SE function by testing associated effects on reducing parent-infant interaction and of parent psychological factors. Questionnaire responses from 327 UK-based parents of infants aged 6–24 months showed diverse usage in the amount of time spent on screen media (‘screen time’) and amount of parental involvement (co-sharing and co-referencing). Infants with possible SE delay experienced more screen time than those at low risk. The study tested three mediation models and found support for the displacement and not distancing hypothesis based on this community sample. While screen time predicted both SE competence and SE problems, reduced parent-infant play partially mediated the effect on SE competence. Parent depressed mood was positively linked with infant SE problems, but there was little evidence that increased screen time mediated this effect. Also, parent reflective function and attitudes toward parent-infant play were unrelated to screen time. Though longitudinal study is warranted, the findings implicate screen media usage as potentially directly and indirectly relevant when addressing infant mental health.     

Modeling as an infant mental health intervention

Within the context of family therapy focused on the behavioral problems of a six year old, several observations of inappropriate interactions between the parents and their infant concerned the therapist. In consultation with an infant specialist it was decided that the therapist would avoid identifying parent-infant interactions as a further problem and would, instead, begin to model appropriate interactions during the on-going therapy sessions. The infant, initially passive, began to respond to the therapist and gradually the parents became more appropriate in their interactions with their infant. It was concluded that the modeling process minimized the stress and eliminated the need to process feelings of anger and guilt often associated with professional identification of family problems.     

A life worth giving? The threshold for permissible withdrawal of life support from disabled newborn infants

When is it permissible to allow a newborn infant to die on the basis of their future quality of life? The prevailing official view is that treatment may be withdrawn only if the burdens in an infant's future life outweigh the benefits. In this paper I outline and defend an alternative view. On the Threshold View, treatment may be withdrawn from infants if their future well-being is below a threshold that is close to, but above the zero-point of well-being. I present four arguments in favor of the Threshold View, and identify and respond to several counter-arguments. I conclude that it is justifiable in some circumstances for parents and doctors to decide to allow an infant to die even though the infant's life would be worth living. The Threshold View provides a justification for treatment decisions that is more consistent, more robust, and potentially more practical than the standard view.     

John Lind memorial symposium

John Lind, Professor of Pediatrics at the Karolinska Institute, emphasized that “the family is born in the maternity hospital.” He had a warm concern for all parents and infants and was extremely influential in both pediatric and child-rearing practices in Sweden and in the promotion of infant and caregiver-infant interaction research. Lind initiated and/or stimulated the scientific study of the infant's cry, parent-infant interactions, the role of the father in the perinatal environment, fetal and neonatal perception, and perinatal hospital practices. In many respects, his work predated contemporary emphases on perinatal coaching programs, social support (doula) during labor and delivery, parent education on childrearing, the use of ethnographic data for contemporary perinatal practices, interdisciplinary team approaches to study of infant care and development, changes in newborn nursery practices, and, above all, care and sensitivity to the initial synchronization of the parent-infant interaction system. This paper honors John Lind's contributions to our knowledge of infant development and parent-infant interaction, his influences on the field of pediatrics and the interdisciplinary study of infancy, and his commitment to enhancement of the quality of life for infants and their families. Although his life has ended, his ideas will continue to inspire and challenge the study of early human development for many years to come.     

Parenting of low birth weight infants: A review of issues and interventions

Factors that may adversely affect parenting of low birth weight infants, including infant characteristics, parental emotional responses to premature birth, and patterns of parent-infant interaction, are reviewed. In addition, intervention studies designed to improve infant developmental outcomes through influencing parenting behaviors are examined. There was great diversity in theoretical frameworks, in timing of onset and frequency of interventions, and in measurement of outcomes. The interventions that were most effective in influencing behaviors and infant developmental outcomes were those in which there were multiple long-term contacts with parents and/or those that actively involved them in the intervention. The specific theoretical framework upon which the interventions were based appeared to be of less importance in influencing results. In order to increase our knowledge and ability to provide costeffective programs, there is a need to focus attention and data collection efforts on the process and intermediary steps of intervention as well as on outcome measures. There is also a need to improve our ability to recruit and retain those families who are most at risk for parenting and infant developmental problems including those with very low birth weight infants, those whose infants have serious perinatal complications, and those with indications of high social risk such as poverty-level incomes and problems of substance abuse.     

To belief or not belief: Children’s theory of mind

This paper provides a minimalist framework for understanding the development of children’s theory of mind (ToM). First, I provide a critical analysis of rich interpretations of ToM tasks tapping infants’ understanding of perception, goals, intentions, and false beliefs. I argue that the current consensus that infants understand mental states is premature, and instead, that excellent statistical learning skills and attention to human faces and motion enable infants’ very good performance, and reflect an implicit understanding of behavior. Children subsequently develop an explicit understanding of mental states through talk from parents and siblings, their developing language abilities, and their developing distinction between self and other. The paper also examines corollary theories such as the idea that there are subsystems of a theory of mind (ToM), that infants use rules on false belief tasks, that minimalist theory is post hoc, and that parallel onset of success on different ToM tasks indicates an underlying ToM. The paper concludes by considering previous arguments against minimalist interpretations of infant performance.     

Maternal postnatal psychiatric symptoms and infant temperament affect early mother-infant bonding

Postnatal mother-infant bonding refers to the early emotional bond between mothers and infants. Although some factors, such as maternal mental health, especially postnatal depression, have been considered in relation to mother-infant bonding, few studies have investigated the role of infant temperament traits in early bonding. In this study, the effects of maternal postnatal depressive and anxiety symptoms and infant temperament traits on mother-infant bonding were examined using both mother and father reports of infant temperament. Data for this study came from the first phase of the FinnBrain Birth Cohort Study (n = 102, father reports n = 62). After controlling for maternal symptoms of depression and anxiety, mother-reported infant positive emotionality, measured by infant smiling was related to better mother-infant bonding. In contrast, infant negative emotionality, measured by infant distress to limitations was related to lower quality of bonding. In regards to father-report infant temperament, only infant distress to limitations (i.e., frustration/anger) was associated with lower quality of mother-infant bonding. These findings underline the importance of infant temperament as one factor contributing to early parent-infant relationships, and counseling parents in understanding and caring for infants with different temperament traits.     

Psychotherapy with the adolescent children of concentration camp survivors

Summary The offspring of people who have experienced overwhelming physical and mental trauma may themselves manifest some of the aftereffects of their parents' trauma. Some children of survivors manifest aspects of their parents' survivor syndrome. These children appear depressed, withdrawn and have difficulty establishing and maintaining interpersonal relationships. In psychotherapy, an important focus is helping the patient establish an identity that is free of the persecutory and depressive elements of the survivor syndrome. Crucial aspects of psychotherapy with survivors' children involve helping the patient deal with the emotional impoverishment and depression of his parents and alleviating resulting guilt feelings. A therapeutic approach that is both nurturant and firm seems essential to provide restitution for the affectional deprivation and to set limits for the survivors' child. Of important concern for the therapist are countertransference attitudes which may lead to rejecting the adolescent.     

Newborn behavioral observations system in rural Pakistan: A feasibility and acceptability study

The Newborn Behavioral Observations (NBO) system is a relationship-based tool that helps parents recognize their infant's competencies and learn their behavioral cues, with the goals of enhancing parental responsiveness and satisfaction in the infant-parent relationship. In our study, a pediatrician integrated the NBO into 44 pediatric health care visits of infants in rural Pakistan villages, under the remote guidance of two U.S.-based child psychiatrists. A clinician then gave the mothers a survey about their experience of the NBO and found that the mothers were highly satisfied, reporting greater appreciation of their infant's strengths, greater understanding of their infant's behavioral cues, stronger attachment to their infant, and greater self-confidence as a mother. In their consideration of these results, the authors explore cultural reasons for the mothers’ responses and generate hypotheses to inform an outcome study of a similar intervention. This was a feasibility and acceptability study and was not randomized, had no control group, and did not use objective measures of outcome.