The sandwich model: The ‘music and dance’ of therapeutic action

My premise is that a ‘layered’ approach is necessary to understand the process of exchanges that result in therapeutic change. I imagine these processes occurring in three layers – although the number of domains in which change is taking place is actually infinite – such as in a sandwich. The top layer, or top slice of bread of the sandwich, represents a broad view of the change process; it is non‐linear and includes the feature of uncertainty, a general principle of dynamic systems theory. The middle layer, or the meat of the sandwich, is explained by theories that are immediately and clinically useful to a therapist, such as psychoanalytic theories. These are primarily linear theories and use language and symbols to ‘tell a story of what happened’. The bottom layer, or bottom slice of bread of the sandwich, is the micro‐process; this layer includes the moment‐to‐moment patterns of coordinated rhythms that both communicate meaning and provide the essential scaffold for all higher‐level change processes. The micro‐process also requires a non‐linear theory to make sense of its variability and emergent properties. Taking a bite out of the sandwich will include a ‘polysemic bundle of communicative behaviors’ (Harrison and Tronick, 2011). I will illustrate the ‘sandwich model’ with the clinical case of the analytic treatment of a 5 year‐old boy.     

Immobility reaction at birth in newborn infant

Objective

To describe an immobility reaction (IR) that was not previously reported at or immediately after birth in human newborns.

Method

We analyzed 31 videos of normal term vaginal deliveries recorded from Time 0 of birth defined as the as the moment that lies between the birth of the thorax and the pelvis of the infant. We searched for perinatal factors associated with newborn's IR.

Results

IR at birth was observed in 8 of the 31 newborns. The main features of their behavior were immobilization, frozen face, shallow breathing and bradycardia. One of the 8 newborns had sudden collapse 2 h after birth. We found significant relationships between maternal prenatal stress (PS) and IR (p = .037), and a close to significant one between infants’ lividness at Time 0 and IR (p = .053). The first breath of the 31 newborns occurred before and was not associated with the first cry (p < .001).

Discussion

The main features of IR at birth are similar to those of the universal most severe response to severe stress or danger. The relationship with PS suggests that children who had IR at birth might be at risk for similar disorders as those associated with PS. Sudden neonatal collapse of one of the IR newborns needs further research to determine if they are at risk for sudden infant death syndrome.

Conclusion

This first report of an IR reaction at birth in human infants could open up new paths for improving early neonatal care. Further research is needed for maternal PS, stress hormones, umbilical cord blood pH measurements in IR newborns. The challenge of education and support for parents of IR newborns is outlined.     

Infant behaviors influence mothers’ provision of responsive and directive behaviors

Mother–infant interactions are important to infant development because they are predictive of infants’ social, cognitive, and language development (0070 and 0150). Because maternal responsive and directive behaviors are associated with differential infant outcomes, it is important to investigate influences on mothers’ provision of responsive and directive behaviors. Yet, the dyadic interaction literature is predominantly unidirectional from maternal behavior to infant outcomes. Therefore, the current study examined infant initiating behaviors and consequent maternal responses in a sample of 26 13-month-old infants and their mothers, videotaped during 5 min of free-play. Findings revealed that infants produced a variety of initiatives, and that these different infant initiatives prompted differential patterns of maternal responsive versus directive behaviors. Further, results of analyses of divergent types of maternal directive behaviors – Responsive Directives, ReDirectives, and Intrusive Directives – also may help clarify major discrepancies in the current literature regarding the positive and negative effects of maternal directiveness.     

Maternally administered interventions for preterm infants in the NICU: Effects on maternal psychological distress and mother–infant relationship

Although studies have examined the effects of interventions focused on preterm infants, few studies have examined the effects on maternal distress (anxiety, depressive symptoms, post-traumatic stress symptoms, parenting stress) or parenting. This study examined the effects of the auditory–tactile–visual–vestibular (ATVV) intervention and kangaroo care (KC) on maternal distress and the mother–infant relationship compared to an attention control group.240 mothers from four hospitals were randomly assigned to the three groups. Maternal characteristics in the three groups were similar: 64.1% of ATVV mothers, 64.2% of KC mothers, and 76.5% of control mothers were African American; maternal age averaged 26.3 years for ATVV mothers, 28.1 for KC mothers, and 26.6 for control mothers; and years of education averaged 13.6 for ATVV and KC mothers, and 13.1 for control mothers. Mothers only differed on parity: 68.4% of ATVV and 54.7% of KC mothers were first-time mothers as compared to 43.6% of control mothers. Their infants had a similar mean gestational ages (27.0 weeks for ATVV, 27.2 for KC, and 27.4 for control) and mean birthweights (993 g for ATVV, 1022 for KC, and 1023 for control).Mothers completed questionnaires during hospitalization, and at 2, 6 and 12 months corrected age on demographic characteristics, depressive symptoms, state anxiety, post-traumatic stress symptoms, parenting stress, worry about child health, and child vulnerability (only at 12 months). At 2 and 6 months, 45-min videotapes of mother–infant interactions were made, and the HOME Inventory was scored. Behaviors coded from the videotapes and a HOME subscale were combined into five interactive dimensions: maternal positive involvement and developmental stimulation and child social behaviors, developmental maturity, and irritability.Intervention effects were examined using general linear mixed models controlling for parity and recruitment site. The groups did not differ on any maternal distress variable. Kangaroo care mothers showed a more rapid decline in worry than the other mothers. The only interactive dimensions that differed between the groups were child social behaviors and developmental maturity, which were both higher for kangaroo care infants. Change over time in several individual infant behaviors was affected by the interventions. When mothers reported on the interventions they performed, regardless of group assignment, massage (any form including ATVV) was associated with a more rapid decline in depressive symptoms and higher HOME scores. Performing either intervention was associated with lower parenting stress. These findings suggest that as short-term interventions, KC and ATVV have important effects on mothers and their preterm infants, especially in the first half of the first year.     

The role of sustained attention,maternal sensitivity,and infant temperament in the development of early self-regulation

This study investigated infant predictors of early cognitive and emotional self-regulation from an intrinsic and caregiving environmental perspective. Sustained attention, reactive aspects of infant temperament, and maternal sensitivity were assessed at 10 months (n = 124) and early self-regulation (including executive functions, EF, and emotion regulation) was assessed at 18 months. The results indicated that sustained attention predicted early EF, which provide empirical support for the hierarchical framework of EF development, advocating early attention as a foundation for the development of cognitive self-regulation. Maternal sensitivity and surgency predicted emotion regulation, in that infants of sensitive mothers showed more regulatory behaviours and a longer latency to distress, whereas high levels of surgency predicted low emotion regulation, suggesting both the caregiving environment and temperament as important in the development of self-regulation. Interaction effects suggested high sustained attention to be a protective factor for children of insensitive mothers, in relation to emotion regulation. In addition, high levels of maternal sensitivity seemed to foster development of emotion regulation among children with low to medium levels of sustained attention and/or surgency. In all, our findings point to the importance of both intrinsic and extrinsic factors in infant development of self-regulation.     

HANDBOOK OF ATTACHMENT,THIRD EDITION: THEORY,RESEARCH, AND CLINICAL APPLICATIONS JudeCassidy and Phillip R.Shaver (Eds.), New York: Guilford Press, 2016, 1,068 pp., ISBN 978‐1‐4625‐2529‐4

Jude Cassidy and Phillip R. Shaver's third edition of the Handbook of Attachment has emerged and set a new bar for formative texts on pivotal issues related to the field of attachment. This state‐of‐the‐science reference on attachment eloquently intertwines attachment theory, research, and clinical applications, giving us innovative conceptualizations and perspectives on both implications for clinical advancement and directions for future research. This handbook moves basic research findings quickly into the realm of clinical and community applications, providing the field with new information about intervention procedures and outcomes while setting the stage for theoretical advancement. New chapters reflect the way we think about the interweaving of attachment, development, and infant mental health research and application. From the authors’ opening “Overview of Attachment” to the summary overview and evaluation of the field, “The Place of Attachment in Development” by attachment‐research pioneer L. Alan Sroufe, this third edition broadly delivers the most significant and important information that the field has on attachment. Researchers, clinicians, and professionals will benefit from this handbook as it presents with the most up‐to‐date, innovative, and thorough presentation of attachment theory.     

A categorical approach to infants’ individual differences during the Still-Face paradigm

Cluster analysis was used to create patterns of individual differences reflecting infant behaviors during the initial interaction episode of the Face-to-Face Still-Face (FFSF) paradigm. The clusters were used as the basic unit of analysis for studying infant and maternal behavior and dyadic coordination (i.e., matching and reparation) across FFSF. Seventy-five 4-month-old infants participated with their mothers. Cluster analysis identified three patterns: a Socially Engaged cluster (33%) exhibited high levels of social engagement with their mothers; a Disengaged cluster (60%) showed a tendency to be low in social interaction and a Negatively Engaged cluster (7%) showed high negative emotionality. During the Still-Face episode, the Socially Engaged cluster reacted by reducing focus on their mother and shifting their attention elsewhere, while infants in the Disengaged cluster reduced focus on the environment. Although both the Socially Engaged and Disengaged clusters increased in negative emotionality during the Still-Face, the Socially Engaged group largely recovered during the Reunion, whereas the Disengaged group displayed more negative emotion. The Negatively Engaged cluster demonstrated high levels of negative affect throughout the entire procedure. Mothers of Negatively Engaged infants showed less positive engagement and more social monitoring than mothers in other clusters during all episodes. Dyadic interaction differed between groups, with greater levels of matching and reparations in the engaged group, less in the Disengaged group, and very little coordination in the Negatively Engaged cluster. Findings highlight the role of distinctive patterns of infants’ individual differences in determining early dyadic functioning.