Handbook of Infant Mental Health, Third Edition

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Handbook of Infant Mental Health

Handbook of Infant Mental Health Third

Edition

edited by Charles H. Zeanah, Jr.

THE GUILFORD PRESS New York   London

© 2009 The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012 www.guilford.com All rights reserved No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number:  9  8  7  6  5  4  3  2  1 The editors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the editors nor publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources. Library of Congress Cataloging-in-Publication Data Handbook of infant mental health / edited by Charles H. Zeanah, Jr. — 3rd ed.    p. cm.   Includes bibliographical references and index.   ISBN 978-1-60623-315-3 (hardcover: alk. paper)   1.  Infant psychiatry—Handbooks, manuals, etc.  2.  Infants—Mental health—Handbooks, manuals, etc.  I.  Zeanah, Charles H., Jr.   RJ502.5.H36 2009   618.92′89—dc22 2009022544

About the Editor

Charles H. Zeanah, Jr., MD, is the Mary K. Sellars-Polchow Chair in Psychiatry, Professor of Clinical Pediatrics, and Vice Chair for Child and Adolescent Psychiatry in the Department of Psychiatry and Neurology at Tulane University School of Medicine in New Orleans. He is also Executive Director of the Institute of Infant and Early Childhood Mental Health at Tulane. Dr. Zeanah has a longstanding interest in infant mental health, especially abuse and neglect in young children, attachment and its disorders, psychopathology, and infant–parent relationships. Throughout his career, his clinical and research focus has been on early experiences and their effects. Since 1994, together with Julie Larrieu, PhD, and Anna Smyke, PhD, he has led a community-based intervention program for abused and neglected infants and toddlers in the New Orleans area. Since 2000, with Charles Nelson, PhD, and Nathan Fox, PhD, he has been a Co-Principal Investigator of the Bucharest Early Intervention Project, a longitudinal, randomized controlled trial of foster care as an alternative to institutional care among severely deprived, abandoned young children in Romania. Among his honors are the 2006 Irving Phillips Award for Prevention from the American Academy of Child and Adolescent Psychiatry, a 2007 Presidential Citation for Distinguished Research and Leadership in Infant Mental Health from the American Orthopsychiatric Association, the 2008 Sarah Haley Memorial Award for Clinical Excellence from the International Society for Traumatic Stress Studies, and the Blanche F. Ittelson Award for Research in Child Psychiatry from the American Psychiatric Association. Dr. Zeanah is a Fellow of the American Academy of Child and Adolescent Psychiatry, a Distinguished Fellow of the American Psychiatric Association, and a Board Member of Zero to Three.



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Contributors

Adrian Angold, MD, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina François Ansermet, MD, Department of Psychiatry and Department of Pediatrics, University of Geneva School of Medicine, Geneva, Switzerland Diane Benoit, MD, FRCPC, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Jessica L. Borelli, PhD, Department of Psychology, Pomona College, Claremont, California Neil W. Boris, MD, Department of Psychiatry, Tulane University School of Medicine, New Orleans, Louisiana Sarah R. Brand, MA, Department of Psychology, Emory University, Atlanta, Georgia Angela S. Breidenstine, PhD, Institute of Infant and Early Childhood Mental Health, Tulane University School of Medicine, New Orleans, Louisiana Margaret J. Briggs-Gowan, PhD, Department of Psychiatry, University of Connecticut Health Center, Farmington, Connecticut Charles Brinamen, PsyD, Infant–Parent Program, Department of Psychiatry, University of California, San Francisco, San Francisco, California Melissa M. Burnham, PhD, Department of Human Development and Family Studies, University of Nevada, Reno, Reno, Nevada Themba Carr, BA, Autism and Communication Disorders Center, University of Michigan, Ann Arbor, Michigan Alice S. Carter, PhD, Department of Psychology, University of Massachusetts, Boston, Boston, Massachusetts Lisa J. Cohen, PhD, Department of Psychiatry, Beth Israel Medical Center/Albert Einstein College of Medicine, New York, New York Glen Cooper, MA, Circle of Security Project, Spokane, Washington Barbara Danis, PhD, Institute for Juvenile Research, Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois



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Contributors

Carolyn J. Dayton, MSW, MA, Department of Psychology, Michigan State University, East Lansing, Michigan Cindy DeCoste, MS, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut Elisabeth M. Dykens, PhD, Vanderbilt Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, Tennessee Helen Link Egger, MD, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina Michelle Bosquet Enlow, PhD, Department of Psychiatry, Children’s Hospital Boston, Boston, Massachusetts Nicolas Favez, PhD, Department of Psychology, University of Geneva, Geneva, Switzerland Elisabeth Fivaz-Depeursinge, PhD, Center for Family Studies, University of Lausanne, Prilly, Switzerland France Frascarolo, PhD, Center for Family Studies, University of Lausanne, Prilly, Switzerland Mary Margaret Gleason, MD, Department of Psychiatry and Neurology and Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana Leandra Godoy, MA, Department of Psychology, University of Massachusetts, Boston, Boston, Massachusetts Sherryl H. Goodman, PhD, Department of Psychology, Emory University, Atlanta, Georgia Sydney L. Hans, PhD, School of Social Service Administration, University of Chicago, Chicago, Illinois Sarah Hinshaw-Fuselier, PhD, School of Social Work, University of Texas, Austin, Texas Robert M. Hodapp, PhD, Vanderbilt Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, Tennessee Kent Hoffman, RelD, Circle of Security Project, Spokane, Washington Chandra Michiko Ghosh Ippen, PhD, Child Trauma Research Program, University of California, San Francisco, San Francisco, California Kadija Johnston, LCSW, Infant–Parent Program, Department of Psychiatry, University of California, San Francisco, San Francisco, California Miri Keren, MD, Geha Mental Health Center, Petah Tiqva, Israel Jane Knitzer, EdD (deceased), National Center for Children in Poverty, Mailman School of Public Health, Columbia University, New York, New York Nina Koren-Karie, PhD, School of Social Work and Center for the Study of Child Development, University of Haifa, Haifa, Israel Julie Larrieu, PhD, Department of Psychiatry, Tulane University School of Medicine, New Orleans, Louisiana Marva L. Lewis, PhD, Tulane University School of Social Work, New Orleans, Louisiana Alicia F. Lieberman, PhD, Department of Psychiatry, University of California, San Francisco San Francisco, California Catherine Lord, PhD, Autism and Communication Disorders Center, University of Michigan, Ann Arbor, Michigan Joan L. Luby, MD, Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri



Contributors

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Megan C. Mahowald, MA, Institute on Community Integration, University of Minnesota, Minneapolis, Minneapolis, Minnesota Susan E. Marakovitz, PhD, Psychiatric and Neurodevelopmental Genetics Unit, Massachusetts General Hospital, Boston, Massachusetts Robert S. Marvin, PhD, Mary D. Ainsworth Child–Parent Attachment Clinic, Charlottesville, Virginia Linda Mayes, MD, Yale Child Study Center, New Haven, Connecticut Maia Miller, PhD, Counseling and Psychological Services, Columbia University, New York, New York Devi Miron, PhD, Department of Psychiatry, Tulane University School of Medicine, New Orleans, Louisiana Maria Muzik, MD, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan Geoffrey A. Nagle, PhD, Institute of Infant and Early Childhood Mental Health, Tulane University School of Medicine, New Orleans, Louisiana Charles A. Nelson, PhD, Department of Medicine, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts Carole Müller Nix, MD, Department of Psychiatry, University of Lausanne School of Medicine, Lausanne, Switzerland Thomas G. O’Connor, PhD, Department of Psychiatry, University of Rochester Medical Center, Rochester, New York David Oppenheim, PhD, Department of Psychology and Center for the Study of Child Development, University of Haifa, Haifa, Israel Judith Owens, PhD, Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island David B. Parfitt, PhD, Department of Psychiatry, University of Rochester Medical Center, Rochester, New York Deborah F. Perry, PhD, Center for Child and Human Development, Georgetown University, Washington, DC Bert Powell, MA, Circle of Security Project, Spokane, Washington Joe Reichle, PhD, Department of Speech–Language–Hearing Sciences, University of Minnesota, Minneapolis, Minneapolis, Minnesota Anne Rifkin-Graboi, PhD, Children’s Hospital Boston/Division of Developmental Medicine, Harvard Medical School, Boston, Massachusetts Katherine L. Rosenblum, PhD, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan Lois S. Sadler, PhD, RN, Yale University School of Nursing, Yale Child Study Center, New Haven, Connecticut Daniel S. Schechter, MD, Department of Psychiatry, University of Geneva Faculty of Medicine, Geneva, Switzerland Michael S. Scheeringa, MD, MPH, Department of Psychiatry, Tulane University School of Medicine, New Orleans, Louisiana Margaret Sheridan, PhD, Harvard School of Public Health, Boston, Massachusetts Arietta Slade, PhD, Department of Clinical and Developmental Psychology, City University of

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Contributors

New York, New York, New York; Visiting Research Scientist, Yale Child Study Center, New Haven, Connecticut Anna T. Smyke, PhD, Institute of Infant and Early Childhood Mental Health, Tulane University School of Medicine, New Orleans, Louisiana Nancy Suchman, PhD, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut Tricia A. Thornton-Wells, PhD, Vanderbilt Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, Tennessee Matthew J. Thullen, MS, AM, School of Social Service Administration, University of Chicago, Chicago, Illinois Patricia Van Horn, PhD, Department of Psychiatry, University of California San Francisco, San Francisco, California Lauren S. Wakschlag, PhD, Institute for Juvenile Research, Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois Erica Willheim, PhD, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York Jennifer Windsor, PhD, Department of Speech–Language–Hearing Sciences, University of Minnesota, Minneapolis, Minneapolis, Minnesota Charles H. Zeanah, Jr., MD, Institute of Infant and Early Childhood Mental Health, Tulane University School of Medicine, New Orleans, Louisiana Paula Doyle Zeanah, PhD, Institute of Infant and Early Childhood Mental Health, Tulane University School of Medicine, New Orleans, Louisiana

Preface

I

t is very gratifying to be writing a preface to the Handbook of Infant Mental Health, Third Edition. A third edition implies that the Handbook represents something more than a passing fad. I have been a fortunate witness to the growth of the field of infant mental health, from its quiet origins in which a handful of luminaries inspired a larger group of young professionals like me, to its broad acceptance today in community, medical, educational, legal, and even legislative settings. Increasingly, the message about the importance of early experiences for children, and the vital role of caregiving relationships seems to have taken hold. It is worth taking a moment to reflect on how amazing it is that the field’s message about early experiences has been not only transmitted but received. In his inaugural address, President Obama said, “It is … a parent’s willingness to nurture a child, that finally decides our fate.” What better measure of the acceptance of infant mental health than that! It wasn’t always so. For many years, when I said I was interested in infant mental health, the reactions typically ranged from mild bemusement to dismissive eye rolling. There were occasional exceptions, as when I proposed an intervention program to the statewide Director of Child Protective Services 15 years ago. Frustrated by years of testifying in cases of young children who had experienced abuse and neglect, and feeling like I had made little impact on the legal process for parents or children, I began to think that only a programmatic effort could make a difference. I thought that if there was a team of professionals responsible for the assessment and treatment of the child, the biological parents, and the foster parents, and if this team worked closely with Child Protective Services, perhaps we could have an impact. In anticipation of the meeting, I wrote a letter to the Director of Child Protective Services in which I told her about a mother and young child I had known. The little girl had gotten some scissors and cut off one of her pigtails that her mother had painstakingly braided and decorated with ribbons. Her mother had become so enraged about the severed pigtail that she had attacked her child briefly before being restrained by others who were present.

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Preface

What I emphasized in my letter was that for the young mother, this incident had a particular meaning. With only one pigtail, her daughter seemed “defective,” and “unacceptable,” issues that were quite important for the mother herself based on her own experiences. Her sense of unacceptability and defectiveness was something she worked hard to maintain out of awareness. Her rage reflected but also obscured the hurt she had experienced in her relationship with her own mother and represented a particularly sensitive area in her psychological makeup. I pointed out that this young mother knew that she was wrong to choke her daughter. She did not need skill-building parenting classes or even classes in anger management. She knew that she had overreacted, but she did not know why. She needed to understand why her intense emotional reaction had overwhelmed her judgment and what about her daughter’s missing pigtail reminded her of her own unhappy childhood. To my surprise, when I met with the Director and made my pitch, she paused, looked thoughtful, and then said, “The story in your letter resonated with me. You know, I am tired of investing so many resources in children and adolescents who have had such severe, entrenched problems for so long. I’d like to see what might happen if we intervene earlier. Maybe if someone worked with that mother and daughter, we could break the cycle.” At the time, hearing this from such an important gatekeeper was nothing short of amazing. Nowadays, of course, it is no longer unheard of to find state officials who understand that early experiences matter, that the meaning of a young child to a parent is crucial, and that relational treatment approaches are valuable. But in those days, understanding this, much less being willing to embark in this new direction, was rare indeed. Soon after my meeting, the Director made good on her promise of funding. The Infant Team was created, and my colleagues and I began work that has been some of the most satisfying of my career. Of course, challenges remain. As I write this preface, I am also fighting for the survival of the Infant Team in the face of massive state budget cuts. Beyond that individual program, even with all the services that have been put into place in Louisiana, nationally, and elsewhere, only a tiny fraction of the need is being addressed. And, as much as we have learned about development, we are only scratching the scientific surface. New studies, new approaches, new understandings await our creative and energetic commitment. This book attempts to include both the major themes of infant mental health during the past three decades as well as new developments and applications. Therefore, it retains the structure of the first two editions, but with updated content and a number of new topics. Even so, many worthy topics could not be included. The authors represent many of the people who are responsible for the remarkable acceptance that infant mental health has achieved beyond the halls of academia. Not all of them even consider themselves part of our field, but their efforts on behalf of young children and families in the discovery, dissemination, and application of knowledge about early childhood development and psychopathology stands as an impressive and invaluable achievement. Once again, I thank my outstanding contributors for their hard work, scholarship, and commitment. I did not intend to single out any particular contributor, but recently, Jane Knitzer died. Jane had been a leading voice in policy and advocacy on behalf of young children and their families and was always a great champion of infant mental health. From her position at the National Center for Children in Poverty, she wrote repeatedly about the need for more support for families of young children. We will sorely miss her and her ever thoughtful and effective efforts. The Guilford Press team has been great from the beginning of the first edition. Kitty Moore and Seymour Weingarten have been consistently supportive and have had remarkably clear vision about what is needed and when. More important, they have made the process enjoyable. Jeannie Tang oversaw the production of this edition and was helpful, timely, and responsive. I am indebted to them all.



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My team at Tulane has been wonderful. They inspire and inform me on a daily basis. I could not ask for a more supportive, dedicated, hardworking, selfless group. Their tireless efforts have contributed to developing a remarkable array of available services for young children and their families throughout our state and beyond. They also have provided me with a fun, caring, and stimulating work environment for many years. Diann Schoeffler assisted me not only with this book but also with just about every other professional endeavor I have engaged in for the past 7 years. Her task is unenviable, her tolerance immeasurable, and her help invaluable. Finally, my favorite—the home team. Paula, Emily, Matt, Katy and Mel—what can I say? Thanks just isn’t enough for all that you are.

Contents

I. DEVELOPMENT AND CONTEXT 1.

The Scope of Infant Mental Health

1 5

Charles H. Zeanah, Jr., and Paula Doyle Zeanah 2.

The Psychology and Psychopathology of Pregnancy: Reorganization and Transformation

22

Arietta Slade, Lisa J. Cohen, Lois S. Sadler, and Maia Miller 3.

Neurobiology of Fetal and Infant Development: Implications for Infant Mental Health

40

Margaret Sheridan and Charles A. Nelson 4.

Neurobiology of Stress in Infancy

59

Anne Rifkin-­G raboi, Jessica L. Borelli, and Michelle Bosquet Enlow 5.

Infant Social and Emotional Development: Emerging Competence in a Relational Context

80

Katherine L. Rosenblum, Carolyn J. Dayton, and Maria Muzik 6.

The Sociocultural Context of Infant Mental Health: Toward Contextually Congruent Interventions

104

Chandra Michiko Ghosh Ippen 7.

Applying Research Findings on Early Experience to Infant Mental Health Thomas G. O’Connor and David B. Parfitt



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Contents

II. RISK AND PROTECTIVE FACTORS 8.

Poverty and Infant and Toddler Development: Facing the Complex Challenges

133 135

Jane Knitzer and Deborah F. Perry 9.

Infants of Depressed Mothers: Vulnerabilities, Risk Factors, and Protective Factors for the Later Development of Psychopathology

153

Sherryl H. Goodman and Sarah R. Brand 10.

Parental Substance Abuse

171

Neil W. Boris 11.

Prematurity, Risk Factors, and Protective Factors

180

Carole Müller Nix and François Ansermet 12.

The Effects of Violent Experiences on Infants and Young Children

197

Daniel S. Schechter and Erica Willheim 13.

The Relational Context of Adolescent Motherhood

214

Sydney L. Hans and Matthew J. Thullen

III. ASSESSMENT 14.

Parent Reports and Infant–­Toddler Mental Health Assessment

231 233

Alice S. Carter, Leandra Godoy, Susan E. Marakovitz, and Margaret J. Briggs-Gowan 15.

Clinical Use of Observational Procedures in Early Childhood Relationship Assessment

252

Devi Miron, Marva L. Lewis, and Charles H. Zeanah, Jr. 16.

Infant–­Parent Relationship Assessment: Parents’ Insightfulness Regarding Their Young Children’s Internal Worlds

266

David Oppenheim and Nina Koren-Karie

IV. PSYCHOPATHOLOGY 17.

Classification of Psychopathology in Early Childhood

281 285

Helen Link Egger and Adrian Angold 18.

Autism Spectrum Disorders

301

Themba Carr and Catherine Lord 19.

Communication Disorders

318

Jennifer Windsor, Joe Reichle, and Megan C. Mahowald 20.

Intellectual Disabilities

332

Robert M. Hodapp, Tricia A. Thornton-Wells, and Elisabeth M. Dykens 21.

Posttraumatic Stress Disorder

345

Michael S. Scheeringa 22.

Sleep Disorders Judith Owens and Melissa M. Burnham

362



Contents

23.

Feeding Disorders, Failure to Thrive, and Obesity

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377

Diane Benoit 24.

Characterizing Early Childhood Disruptive Behavior: Enhancing Developmental Sensitivity

392

Lauren S. Wakschlag and Barbara Danis 25.

Depression

409

Joan L. Luby 26.

Attachment Disorders

421

Charles H. Zeanah, Jr., and Anna T. Smyke

V. INTERVENTION 27.

Child–­Parent Psychotherapy: A Developmental Approach to Mental Health Treatment in Infancy and Early Childhood

435 439

Alicia F. Lieberman and Patricia Van Horn 28.

The Circle of Security

450

Bert Powell, Glen Cooper, Kent Hoffman, and Robert S. Marvin 29.

Principles of Family Therapy in Infancy

468

Nicolas Favez, France Frascarolo, Miri Keren, and Elisabeth Fivaz-­Depeursinge 30.

The Mothers and Toddlers Program: An Attachment-Based Intervention for Mothers in Substance Abuse Treatment

485

Nancy Suchman, Cindy DeCoste, and Linda Mayes 31.

Foster Care in Early Childhood

500

Anna T. Smyke and Angela S. Breidenstine 32.

Psychopharmacology in Early Childhood: Does It Have a Role?

516

Mary Margaret Gleason

VI. APPLICATIONS OF INFANT MENTAL HEALTH 33.

Training in Infant Mental Health

531 533

Sarah Hinshaw-­F uselier, Paula Doyle Zeanah, and Julie Larrieu 34.

Infant Mental Health in Primary Health Care

549

Paula Doyle Zeanah and Mary Margaret Gleason 35.

Mental Health Consultation: A Transactional Approach in Child Care

564

Kadija Johnston and Charles Brinamen 36.

The Economics of Infant Mental Health

580

Geoffrey A. Nagle

Author Index

591

Subject Index

611

Pa r t I

DEVELOPMENT AND CONTEXT

T

hose concerned with the mental health of infants and toddlers must be aware of the twin themes of development and context. Infants become who they are gradually within multiple contexts, ranging from the intrinsic contexts of infants’ own genetics and neurobiology to the external contexts of parents, families, culture, and class. The importance of multiple contexts to understanding the young child’s development was famously underscored by the title of the Institute of Medicine Report on the Science of Early Childhood Development, From Neurons to Neighborhoods (National Research Council and Institute of Medicine, 2000). Each of these contexts transact with one another and with the developing person in complex ways over time. Of particular interest to clinicians are those contexts that are mutable. These become the focus for efforts to reduce risk processes, mobilize protective processes, and enhance infant competence. The most crucial and experience near of these mutable contexts is the primary caregiving relationship of the young child. The relationship itself, of course, is also powerfully affected by all of the other contexts. Because of its importance to the young child, the primary caregiving relationship (or relationships) is the major focus of assessment and intervention. The focus of this volume is infant mental health, and it begins with our introduction to the topic (Zeanah & Zeanah) in Chapter 1. We consider how infant mental health is defined, review its empirical foundations, and highlight the clinical, research, and policy implications of the field. In keeping with the essence of infant mental health, we underscore the twin themes of infants as actively developing and interacting with interrelated contexts. In Chapter 2 Slade, Cohen, Sadler, and Miller consider the psychology and psychopathology of pregnancy. Pregnancy is the first psychological and biological context for infant development and where the first relationship for the baby begins. Experiences for the mother and the infant during this unique period have important implications for postnatal development. In addition, a woman’s pregnancy with one child may affect her relationship with other children as well. Laudably, and in keeping with the contextual theme, the authors also consider the

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I. DEVELOPMENT AND CONTEXT

father’s experience during pregnancy. Throughout they emphasize pregnancy both as a vital developmental phase and as a period of clinical importance. Sheridan and Nelson, in Chapter 3, review the neurobiology of brain development, pointing out the numerous influences on that process and highlighting the importance of neural plasticity. Behavioral and brain plasticity are central concerns of infant mental health. Of particular value to the infant mental health practitioner is the discussion of the neurobiology of infant temperament because of its well-known importance for development and psychopathology. The authors conclude by emphasizing the need for bridging the gap between brain and behavior in human studies. In Chapter 4 Rifkin-­Graboi, Borelli, and Bosquet Enlow consider in depth the important topic of the neurobiology of stress in infancy. This complex, increasingly studied topic is an active area of research on the effects of different experiences on infant development. The authors describe how neurobiological systems respond to stress, what constitutes stress in infancy, how individual differences influence stress responsivity, and how chronic stress exposure in infancy may affect longterm responses to stress, as well as mental and physical health. Chapter 5, by Rosenblum, Dayton, and Muzik, details the process of development in the first 3 years of life, concentrating on emotional and social development. They highlight the complex transactions between infant and parent across multiple interrelated contexts that lead progressively to social and emotional competence. Throughout, they emphasize the centrality of the parent–­infant relationship as the crux of the dynamic developmental interplay of transactions impacting infant development. They delineate the processes that tend to guide the infant toward social and emotional competence and provide evidence for the positive effects of support for the parent–­infant relationship. Attending to the complex transactions between infant and parents provides opportunities for changing infants’ developmental trajectories from less to more adaptive outcomes. In Chapter 6 Ghosh Ippen emphasizes the importance of cultural differences on infant development but also on the transactions that occur between families and clinicians. She makes a compelling case for the need for careful listening, introspection about our assumptions and values, and awareness of and sensitivity to cultural differences in order to reach families of young children. She emphasizes the need for us to develop interventions that are congruent not only with the family’s culture but also with other key contextual factors. She concludes with a diversity-­awareness model that can be used to identify diversity-­related conflicts and guide interventions. The section concludes with Chapter 7, on the importance of early experiences, in which O’Connor and Parfitt revisit a debate that has been ongoing for decades in light of new evidence. Put simply, this debate concerns the degree to which early experiences have long-­lasting effects and whether or not experiences in the earliest years are more important than experiences that occur later in development. The authors point out that although important gains in this area have been made, much remains unclear. The most compelling work comes from animal studies, but the translational challenges of interpreting that evidence is considerable. They



I. DEVELOPMENT AND CONTEXT

also remind us that the field has a great need for studies that can examine complex interactions among different factors simultaneously. With new efforts, we should develop not only clearer understanding of the effects of early experiences but also address key questions about how and when these experiences may be altered in the service of enhancing social and emotional competence. REFERENCE National Research Council and Institute of Medicine. (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.

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Chapter 1

The Scope of Infant Mental Health Charles H. Zeanah, Jr. Paula Doyle Zeanah

I

nfant mental health has emerged as an increasingly important and visible clinical endeavor during the past 35 years. There are many ways to trace its origins. In the clinical realm the work of Selma Fraiberg and her colleagues in Michigan (Fraiberg, Adelman, & Shapiro, 1975) was a major early contributor, as was research in developmental psychology on the power of babies to affect their caregivers (Bell, 1968). From these beginnings, the field of infant mental health has grown dramatically both in terms of its breadth and its acceptance. In the early 21st century, the field of infant mental health stands as a broad-based, multidisciplinary, and international effort to enhance the social and emotional well-being of young children and which includes the efforts of clinicians, researchers, and policymakers. Still, as a relatively new field, a number of questions ought to be considered. For example, how is infant mental health defined? Some have expressed puzzlement or even aversion to the term “infant mental health.” The idea of an “infant,” with its associations of innocence, beginnings, and hope for a better future, does not seem to fit with “mental health,” and its associations of maladjust-



ment, stigma, and major mental illness. Is it reasonable to think of infants as having mental health problems? Or does it make more sense to think about them as being at risk for problems later? There are also questions about “infant mental health” as a profession. In a multidisciplinary field how is core knowledge versus specialized knowledge determined? Are infant mental health interventions qualitatively different from mental health interventions for older children and adolescents? Finally, how is infant mental health similar to, and distinct from, other closely related multidisciplinary fields, such as developmental psychopathology? We begin by defining infant mental health and considering its scope. We suggest that the relational framework of infant mental health distinguishes it from work with older children and adolescents. We review some of the major empirical foundations of the field, highlighting the implications of these foundations for an infant mental health perspective. Finally, we emphasize the need for comprehensive approaches to intervention and highlight some evidenced-based programs. Throughout, we emphasize the policy implications of this work. 5

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I. DEVELOPMENT AND CONTEXT

DEFINING INFANT MENTAL HEALTH A Steering Committee on Infant Mental Health was convened by Zero to Three and tasked with creating a definition of infant mental health. What emerged was a definition of infant mental health as a characteristic of the child. That is: the young child’s capacity to experience, regulate, and express emotions, form close and secure relationships, and explore the environment and learn. All of these capacities will be best accomplished within the context of the caregiving environment that includes family, community, and cultural expectations for young children. Developing these capacities is synonymous with healthy social and emotional development. (Zero to Three, 2001)

This definition seems to have met with widespread acceptance by the field (Zeanah, Gleason, & Zeanah, 2008). In addition, infant mental health can be defined as a multidisciplinary professional field of inquiry, practice, and policy, concerned with alleviating suffering and enhancing the social and emotional competence of young children. Infant mental health is multidisciplinary because the complex, interrelated nature of human development and its deviations requires expertise and conceptualizations beyond the capabilities of any particular discipline. For the same reason, it is likely that the field of infant mental health will remain pluralistic, a subspecialty within a number of different disciplines, rather than an integrated and distinct discipline itself. A definition is also needed for what we mean by the term “infant.” In pediatrics, infant usually refers to the first year of life. In mental health, there is a tradition that infant refers more broadly to the period from birth to 3 years. In this chapter, however, we use an even broader conceptualization. First, as famously declared in From Neurons to Neighborhoods (National Research Council and Institute of Medicine, 2000), focusing disproportionately on birth to 3 years “begins too late and ends too soon” (p. 7). Because there is considerable evidence regarding prenatal influences on many clinical problems in early childhood (see Robinson et al., 2008), we include prenatal experience in our conceptualization of infant mental

health. We also extend the upper age limit from 3 to 5 or so years, because much research and many clinical programs extend somewhat beyond the first 3 years. Beyond these definitions, several tenets regarding the clinical practice of infant mental health merit attention. These include a focus on strengths in infants and families, a relational framework for assessment and intervention, and a prevention orientation. Infant mental health is a strengths-based discipline. This means that clinicians work to identify strengths from which to build competence and address problems. One could rightly argue that all mental health professionals ought to work from a strengthsbased perspective, but it seems especially important in a field that focuses on the crucial and vulnerable beginnings of parent–child relationships. Our children are extensions of ourselves, and when they do not thrive, we experience it as a reflecting profoundly on us as parents. Nevertheless, being strengthsbased does not mean ignoring liabilities (Zeanah, 1998). Clinicians must identify problems in young children and in their parents unflinchingly in order to address them effectively. Further, there is often a complex interrelationship between strengths and weaknesses, such that strengths may be obscured by weaknesses but also possibly mobilized to ameliorate weaknesses. Infant–­caregiver relationships are the primary focus of assessment and intervention efforts in infant mental health, not only because infants are so dependent upon their caregiving contexts but also because infant competence may vary widely in different relationships. Assessments in infancy always are considered a form of intervention, as they may have important impacts on both infant and family. Moreover, intervention efforts always involve prevention, because the infant is considered as constantly developing, and the infant’s developmental trajectory must be attended to in addition to hereand-now adaptation. This means that there is a simultaneous focus on relieving current suffering as well as attending to future development, all through attention to primary caregiving relationships (Zeanah, Stafford, Nagle, & Rice, 2005; Zeanah, Stafford, & Zeanah, 2005; Zeanah & Zeanah, 2001). Just as young infants engender hope for a better future in general, the field of infant



1. The Scope of Infant Mental Health

mental health strives to delineate, establish, and sustain positive developmental trajectories for young children. In all of these efforts, the empirical foundations of infant mental health have broadened and deepened in ways that have important implications for practice and policies.

EMPIRICAL FOUNDATIONS OF INFANT MENTAL HEALTH Basic knowledge salient to infant mental health has been bolstered by research in genetics, basic neuroscience, child development, developmental psychopathology, and by studies of clinical disorders and their treatment. Investigations in these areas provide the empirical foundations of infant mental health.

Early Experiences Matter Considerable research has documented the importance of early experiences for the developing person. Brain circuits are being established at an extremely rapid rate in the early years of life, and various experiences influence not only how brains function but also the neural architecture of how they develop. We are only just beginning to attempt to understand the details about how experiences influence brain development, but evidence in humans on this point is growing (see Sheridan & Nelson, Chapter 3, this volume). Although mild to moderate stress can be growth promoting, so-­called toxic stress can impair the proper development of brain circuitry, which may be especially vulnerable during early childhood (Middlebrooks & Audage, 2008). If individuals develop a lower threshold for stress, thereby becoming overly reactive to adverse experiences throughout life, both physical and mental health can be compromised (see also RifkinGraboi, Borelli, & Bosquet Enlow, Chapter 4, this volume). For example, in the adverse childhood experiences (ACE) study, adults receiving treatment from a health maintenance organization (HMO) were interviewed about early childhood experiences of abuse, neglect and household dysfunction. The number of childhood risk factors was linearly related to a large number of health

7

and mental health outcomes. The more adverse experiences individuals reported having, the more likely they were to engage in risky health behaviors and to be diagnosed with disorders such as depression, alcoholism and substance abuse, heart disease, cancer, chronic pulmonary disease, obesity, and diabetes, among others (Dube, Felitti, Dong, Giles, & Anda, 2003; Feletti et al., 1998). These findings remind us that infant mental health has important implications for health as well as mental health outcomes. A related question concerns the ways in which the timing of experiences matter, usually framed as a “sensitive period” or “critical period” hypothesis. Knudsen (2004) notes that the period during which the effects of experience on the brain are particularly strong is referred to as a sensitive period, whereas experiences that provide information that is crucial for normal development and alter performance permanently are known as critical periods. Animal literature reveals that sensitive and critical periods in brain development are evident (Knudsen, 2004). Knudsen (2004) also notes that sensitive and critical periods are actually properties of neural circuits, though we may be most interested in how the effects of these various periods are expressed at the level of behavior. For example, Nelson et al. (2007) studied children removed from institutional care in the first 3 years of life and placed in foster families and reported increases in IQ. For children removed prior to 24 months the gains were substantial, but for those removed after 24 months, the gains were few. For a construct as complex as IQ, we would expect to find an enormous number of circuits with different sensitive or critical periods involved. In keeping with these findings, infant mental health has the importance of infant experience as a core principle. Escalona (1967) anticipated this emphasis almost half a century ago when she noted that it is not infant or environmental characteristics that matter so much; rather it is the infant’s subjective experience of the world. Indeed, developmental psychopathology has demonstrated that stabler individual differences lie initially in the infant–­caregiver relationship, only later becoming a characteristic of the individual child. Further, how an individual

8

I. DEVELOPMENT AND CONTEXT

thinks about relationship experiences—the internal representation or working model— is crucial because the meanings an individual attributes to experiences may alter their consequences (Sroufe, 1989; Sroufe & Rutter, 2000). For the infant mental health clinician, the task becomes nothing less than attempting to understand what an individual child’s experience is and to help that child’s caregivers empathically appreciate that experience. From a policy perspective, even more daunting is the challenge of attempting to extend this appreciation of an infant’s experience to the level of systems, such as the child protection system or the legal system. How different the lives of infants in dire circumstances might be if these large and complex systems better appreciated and valued their experiences (Knitzer, 2000).

Essential Experiences Involve Caregiving Relationships The importance of the contexts, or environments, in which infants grow and develop is well established. Appreciating the complexities and importance of context has enhanced our understanding of infant development and our ability to predict developmental trajectories (Sameroff & Fiese, 2000). Contexts exert their effects from within and from without, determining which experiences an infant has and how that infant perceives those experiences. One of the most distinctive features of the early years is the clear importance of the multiple interrelated contexts (infant–­caregiver relationship, family, cultural, and so forth) within which infants develop. For young children, infant–­ caregiver relationships are the most important experience-near context for infant development and are the distinctive focus of the infant mental health field. A considerable body of research has documented the importance of the quality of the infant–­caregiver relationship and its impact on infant development (National Research Council and Institute of Medicine, 2000). In fact, although individual differences in infant characteristics are readily identifiable, they are not particularly predictive of subsequent characteristics later in development. Positive qualities in infant–­parent relationships, such as warmth, attentive involvement, and

sensitive resolution of distress, have been linked to more optimal social, emotional, and cognitive development (see Crockenberg & Leerkes, 2000). In addition, parents who promote the development of self-­regulation and minimize problematic behavioral tendencies have children who avoid maladaptive trajectories (Degnan, Henderson, Fox, & Rubin, 2008; Gardner, Sonuga-Barke, & Sayal, 1999). Conversely, parents who have problematic relationships with their young children may increase the likelihood of maladaptive outcomes in them (Scheeringa & Zeanah, 2001). Infant–­parent relationships moderate intrinsic biological risk factors in infants (McCarton et al., 1997). That is, infants with biological difficulties, such as the complications of prematurity or adverse temperamental dispositions, have better outcomes when their caregiving environments are supportive, and they have more problematic outcomes when their caregiving environments are less supportive. Further, attachment relationships moderate the effects of prenatal stress on child fearfulness at 17 months, even after controlling for the effects of postnatal stress, as well as obstetric, social, and demographic factors (Bergman, Sarkar, Glover, & O’Connor, 2008). Infant–­parent relationships also are the conduit through which infants experience environmental risk factors (Zeanah, Boris, & Scheeringa, 1997). That is, infants experience risk factors such as poverty, maternal mental illness, and partner violence primarily through the effects of those factors on infant–­parent relationships. Infants are impacted by the risk factors that characterize their caregiving environments through their specific relationship experiences. The bottom line: Relationships can buffer or exacerbate risk. Finally, increasingly we are learning that the way in which psychopathology is expressed in young children depends on the types of relationships they have with their caregivers (Zeanah et al., 1997). Research has shown that infants, in fact, construct different types of relationships with different caregivers (Steele, Steele, & Fonagy, 1996), and they also may express symptoms in the presence of once caregiver but not with another (Zeanah, Bakshi, Boris, & Lieberman, 2000). And, there is evidence that how an



1. The Scope of Infant Mental Health

individual processes relationship experiences, through an internal working model, is importantly related to outcomes (Sroufe, 1997). For all of the above reasons, the focus of infant mental health has been dominated by a relational approach. This means that infants are best understood, assessed, and treated in the context of their primary caregiving relationships. Or as Sroufe (1989) put it, “Most problems in the early years, while often manifest poignantly in child behavior, are best conceptualized as relationship problems” (p. 70). Beyond the infant–­caregiver dyad, we must consider infant development in the context of the entire family. Not only is infant development related to characteristics of the family considered as a whole (Minuchin, 1988), but there are important effects on development from the infants individualized relationships with various family members (Crockenberg, Lyons-Ruth, & Dickstein, 1993; Favez, Frascorola, Keren, & Fivaz-­Depeursinge, Chapter 29, this volume). For example, considerable evidence indicates that the parents’ marital relationship is one of the most important influences on child development (Cummings & Davies, 2002). Sibling influences on infant development are less well studied, but they are likely vitally important. Understanding family processes is a complex undertaking. Emde (1991) has pointed out, for example, that the numbers of dyadic relationships within families increases dramatically with increasing numbers of children. Whereas two parents and one child have only three dyadic relationships to consider, two parents and three children have 10 dyadic relationships, and two parents and five children have 21 dyadic relationships, and so forth. Further, an infant’s relationships with various family members are influenced by various other relationships within the family. The numbers of dyadic relationships influencing individual family members increase from 3 for two parents and one child, to 45 for two parents and three children, to 210 for two parents and five children (Emde, 1991). Obviously, one could also consider other levels of complexities, such as how an infant and his or her relationships might be affected by the triadic relationship of his or her parents and another sibling. Nevertheless, these levels of

9

complexity are rarely considered in research or even in our clinical conceptualizations. Beyond the immediate family of the infant, still other familial influences are important, chief among which are the cultural contexts within which infants develop. Cultural beliefs and value systems define the assumptions of the group about what is important and the rules about raising children to be a certain way. Parenting beliefs, explanations, and interpretations of infant behavior are among the most important components of the cultural context of infant development (Lewis, 2000). These beliefs include sometimes subtle cultural assumptions about what facilitates infant development, the causes and amelioration of psychopathology, the roles and relevance of parenting, and many other concerns central to infant mental health. Cultures typically develop adaptively in response to larger environmental characteristics, such as the physical resources of the area in which the culture develops. Often differences among cultural belief systems can be understood within those larger contexts. In recent decades, however, technological advances have thrust different cultures together with increasing rapidity and led to intense cultural clashes, efforts at cultural coexistence, and pressures for cultural integration in the global village. All of these factors have significant implications for infant development and mental health. The policy implications of these findings are clear and can be simply stated: Policies aimed at supporting families and other caregiving relationships, such as child care, are most likely to provide needed supports for infant development (Center on the Developing Child at Harvard University, 2007).

Supporting Developmental Trajectories The rapidity and profundity of development in the first 3 years of life is unprecedented in the postnatal human life cycle. In a mere 36 months, infants change from totally dependent newborns to complex creatures who can come and go as they please; understand that they can share thoughts, feelings, and intentions with others; express themselves abstractly using symbols; and empathize with others (Zeanah & Zeanah, 2001). From an infant mental health perspective, this developmental continuum means not only think-

10

I. DEVELOPMENT AND CONTEXT

ing about where the infant is now but also where the infant has been and where the infant is going. It also requires understanding not only what capacities are emerging in the developing child but also the processes involved in establishing trajectories of development.

Risk and Protective Factors Risk and protective factors impact developmental trajectories, increasing or decreasing the risks of developmental disruptions and psychopathology. These risk factors are used to define high-risk groups, such as infants born preterm, infants of depressed mothers, and infants raised in institutions. On the other hand, risk factors are neither randomly distributed nor unrelated to one another. Complexly interacting risk factors within groups are the rule rather than the exception. In other words, although intervention programs may target single risk factors, such as substance abuse, maternal depression, or early parenthood, most of the time, infants face multiple risk factors. Studies of many types of risk factors, from mild to severe, consistently have been shown to lead to quite variable outcomes (Sroufe & Rutter, 2000). In fact, it appears that the number of risk factors rather than the nature of any one is the best predictor of outcomes (Sameroff & Fiese, 2000). For example, prenatal substance exposure is widely accepted to be a risk factor for infant development (Boris, Chapter 10, this volume). Nevertheless, Carta et al. (2001) studied the effects of prenatal exposure and environmental cumulative risks. They found that although both prenatal drug exposure and cumulative environmental risk predicted children’s developmental level and rate of growth, environmental risk accounted for more variance in developmental trajectories than prenatal drug exposure. In fact, over time, the effects of environmental risk outweighed the adverse consequences of prenatal substance exposure. Protective factors may directly reduce the effects of risk, may enhance competence, or may protect the individual against adversity (Garmezy, Masten, & Tellegen, 1984). Protective processes may operate simultaneously or successively even within the same individual in the face of different challenges and at different points in development.

As noted, the field of infant mental health has a long tradition of focusing on strengths and using strengths to minimize risks (Knitzer, 2000; Zeanah, 1998). A central concern then, for, infant mental health is how to balance the influence of risk and protective factors and their mutual effects on a child’s particular situation. In addition, in the first few years of life, it appears that environmental risk and protective factors matter more than within-the-­infant risk and protective factors. In the Rochester longitudinal study, for example, highly competent infants in high-risk environments fared worse in terms of competence at age 4 years than did low-­competent infants in low-risk environments (Sameroff, Bartko, Baldwin, Baldwin, & Seifer, 1998). Thus, identifying, supporting, and strengthening caregiver and family strengths is a fundamental principle underlying the work of infant mental health practitioners and provides direction for policymakers interested in supporting young children.

Psychopathology May Be Evident Early Can infants and toddlers experience or express psychopathology? The existence of psychopathology in infancy has been the source of considerable controversy in part because we are reluctant to believe that infants can experience or suffer from psychiatric disorders (Zeanah et al., 1997). Behavioral indicators of infant mental health include emotion regulation, the ability to communicate feelings to caregivers, and active exploration of the environment. These behaviors lay the groundwork for later social and emotional competence, readiness to enter school, and better academic and social performance. One major approach to studying psychopathology in the early years is a multidisciplinary endeavor known as developmental psychopathology. It concerns identifying developmental trajectories and those risk and protective factors and processes that increase or decrease the probability of positive developmental outcomes. Clinical disorders may be less than fully differentiated in infancy (but see Angold & Egger, 2007, regarding preschool children). Developmental psychopathology emphasizes identification of individuals with developmental delays (development is behind where it ought to be, but the child is otherwise normal) or deviance



1. The Scope of Infant Mental Health

(development is abnormal) even before an actual disorder has emerged. Thus, preventive interventions, targeted to children with risk factors but not yet manifesting a disorder, can be developed. Finally, because there is interest in the process of how disorders develop, the field of developmental psychopathology studies the evolution of disorders over time rather than simply examining signs and symptoms at a single point in time. Psychopathology often is characterized by the inability to change and adapt, but infants are constantly changing by developing. This means that infant problems must be distinguished from the often large range of normal variations in behavior and from transient perturbations in development. Obviously, one way to address this challenge is to follow children over time and determine whether problems persist. On the other hand, it is important to recognize that psychopathology and maladaptation may not produce static symptomatology; rather, the manifestations of problems may be different at different times in development. For example, indiscriminate behavior toward unfamiliar adults in early childhood is a predictor of serious peer relational disturbances in adolescence (Hodges & Tizard, 1989)—the continuity is in interpersonal disturbances, but they manifest differently at different ages. Lawful developmental transformation of symptomatology, known as heterotypic continuity, adds to the complexity of assessing psychopathology in infancy and early childhood. For an individual child, however, risk factors are less important than the actual development and functioning of that individual child at a given time. Clinicians must determine whether a given child, at a given moment, has sufficient distress or maladaptive behavior to constitute a disorder that requires intervention. This area introduces the other approach to psychopathology in infancy, which is to consider that at least some infant problem behaviors are signs and symptoms of psychiatric disorders. Clinicians have found the use of categorical diagnostic approaches to be valuable in young children, as they allow for conceptualizing how clusters of symptoms hang together and provide clearer indicators of “caseness” than do dimensional scores of various constructs. Though some still hesitate to describe early deviant behavior as psychopathology,

11

rather than risk for psychopathology, there are increasingly compelling reasons to think that doing so is a useful approach. For example, most would agree that autism represents a disorder, and there are compelling indicators that autism as a disorder is evident at least as early as the second year of life (see Carr & Lord, Chapter 18, this volume). There are almost certainly neurobiological abnormalities and behavioral differences that are evident even before the second year, but the reliability of a categorical diagnosis of autism from about 2 years of age is reasonable. New studies are beginning to show that many types of psychiatric disorders are prevalent in young children. A recent study of more than 300 two- to five-year-old children attending pediatric clinics in Durham, North Carolina found that 16% had diagnosable psychiatric disorders associated with impairment in functioning (Egger et al., 2006). This prevalence rate in nonreferred preschool children is almost identical to the 13% rate reported in older children and adolescents (Costello, Mustillo, Erkanli, Keeler, & Arnold, 2003). There also has been progress in distinguishing transient individual differences from true psychopathology. Belden, Thomson, and Luby (2008) studied temper tantrums in healthy versus depressed and disruptive preschoolers. They found that preschoolers diagnosed with disruptive behavior disorders had more tantrums, more lasting tantrums, and more violent tantrums than other children. Preschoolers diagnosed with depression, in contrast, displayed more self-harm during tantrums than their healthy or disruptive peers. The conclusion is that children having more violent tantrums and tantrums associated with self harm require more careful monitoring and perhaps referral for assessment. In addition, separation anxiety as a disorder can be differentiated from more transient separation anxiety in 2-year-old children by the degree of impairment (Egger, 2008). Despite all of these findings, there has been widespread dissatisfaction among clinicians about using DSM-IV-TR (American Psychiatric Association, 2000) criteria to diagnose disorders in young children. New diagnostic classifications systems have been created to provide more developmentally appropriate criteria, and also to provide a

12

I. DEVELOPMENT AND CONTEXT

basis for studying the construct validity of diagnoses. Zero to Three’s alternative nosology has been recently updated as DC:0–3-R (Zero to Three, 2005), and is in use in many parts of the world. In addition, the Research Diagnostic Criteria for Infants and Preschoolers (American Academy of Child and Adolescent Psychiatry, 2003) was developed by clinical investigators to enhance uniformity in research efforts. Finally, the DSMV, scheduled for publication in 2012, has an explicit goal of incorporating a developmental focus, including age-­related subtypes of disorders where the evidence warrants it (Pine et al., 2008). This level of activity underscores considerable interest in psychiatric disorders in young children. We believe that at this early stage of the science of infant mental health, both the risk and protective factor approach of developmental psychopathology and the categorical disorder approach of many clinical studies have merit and are worthy of further investigation. Each approach, in fact, may complement the other. In addition, we must concern ourselves not only with adverse outcomes but also with desired outcomes and how to achieve them. This point leads to a discussion of how best to promote healthy outcomes in infant mental health.

Social Competence and Resilience Health is sometimes defined as the absence of disease, although increasingly researchers and clinicians are concerned with health promotion, that is, in enhancing individuals quality of experience. One aspect of “quality of experience” is social competence, the ability to adapt successfully to differing social and environmental demands. Social competence, of course, is an ongoing adaptive capacity that itself may change over time in relation to different stressors and situations. A focus on competence also reminds us that symptoms alone do not make a disorder; their functional significance for the individual also must be considered. Social competence has emerged as an increasingly important outcome in infant mental health, as well as in studies of developmental psychopathology. A special form of social competence receiving increasing attention is resilience. Resilience is demonstrated by infants and young children who achieve positive out-

comes despite high-risk status, who maintain competent functioning despite stressful life circumstances, and who recover from traumatic events and experiences (Masten & Coatesworth, 1998). Increasingly, it has become clear that resilience, like competence, is a multidimensional construct, and one that changes over time and context. In addition, it may be that rather than being resilient to many problems, individuals may be resilient to some stressors but not to others (Rutter, 2000). For children in the early years, having a relationship with a caregiver who is available and responsive to their needs, able to help them navigate the demands of development over time, is likely to be the most important factor in helping them to achieve positive outcomes, maintain competent functioning under stress, and recover from traumatic experiences. Young children who have the capacity to elicit support and positive responses from others may be at an advantage in this regard (Werner & Smith, 2001). Enforcing policies that support families—­especially those that have limited resources—from the time they are expecting through their child’s early years is the best way to enhance young children’s competent functioning (Center on the Developing Child at Harvard University, 2007).

Some Early Problems Are Enduring As noted above, not all problem behaviors seen in the early years are transient. We turn next to consider examples of enduring qualities of at least some forms of psychopathology and consider the implication of these findings. We consider first the subsyndromal risk factor of aggression and then consider the categorical diagnosis of posttraumatic stress disorder.

Aggression Aggression, defiance, and temper tantrums typically peak in early toddlerhood and decrease by school entry; however, some children do not show this normative decline. In the National Institute of Child Health and Human Development (NICHD) study of child care, investigators identified a cluster of children who exhibited very high levels of aggression at age 2 years and again at age 9 years (National Institute of Child Health



1. The Scope of Infant Mental Health

and Human Development Early Child Care Research Network, 2004). Family correlates of children with stable high levels of aggression included lower social class, less maternal education, reduced sensitivity to the child, harsh and punitive parenting, depressive symptoms in the parent, and parents having fewer child-­centered attitudes. Similarly, in a longitudinal study of 318 children at ages 2, 4, and 5 a latent profile analysis resulted in two distinct longitudinal profiles of disruptive behavior (Degnan, Calkins, Keane, & Hill-­Soderlund, 2008). One high-­aggression profile was characterized by high child reactivity (children who reacted strongly and quickly to frustration) combined with highly controlling maternal behavior. Another was characterized by low child regulation (poor efforts to regulate emotions) combined with low levels of maternal control. In both of these studies, aggression is stable over time and associated with stable parental characteristics. Aggression in young children is not without consequences. Gilliam (2005) determined that state-run pre-K programs have three times the rate of expulsion of grades K–12. The reason young children get expelled from child care centers and pre-K is almost always aggression. Longer-term consequences are also important, as aggressive school-age children may begin a path toward antisocial behavior in adolescence or adulthood (Frick & Marsee, 2006).

Posttraumatic Stress Disorder It is well known that many adults and older children who have been severely traumatized develop posttraumatic stress disorder (PTSD), showing signs of hyperarousal, reexperiencing the trauma, avoiding reminders of the trauma, and/or numbing of responsiveness. A series of studies of young children has demonstrated that these same symptoms are apparent in infants, toddlers, and preschoolers, although their manifestations are different than in older children and adults because of obvious developmental differences (see Scheeringa, Chapter 21, this volume). In addition, two studies that have followed the course of traumatized young children indicate that signs and symptoms exhibited following a traumatic event are not transient. Scheeringa, Zeanah, Myers, and Putnam (2005) studied 62 children with

13

mixed traumatic experiences 4 months, 16 months, and 28 months after the trauma. They found significant stability of symptoms over the 2 years, with almost no diminishment of symptoms. Meiser-­Stedman, Smith, Glucksman, Yule, and Dalgleish (2008) studied 62 preschool children 2–4 weeks and 6 months after they had experienced motor vehicle accidents. They found that the diagnosis of PTSD was moderately stable over the 6-month interval, even though the initial assessment occurred before a month had passed from the accident. Treatment studies of PTSD that include control groups also indicate a similar persistence of symptoms over time. For example, Lieberman, Van Horn, and Ippen (2005) studied the effectiveness of child–­parent psychotherapy as a treatment of PTSD in young children exposed to partner violence. The comparison condition was case management, involving monthly telephone contact with the mothers as well as providing information about and referrals to, local mental health clinics. Immediately after treatment (1 year after the trauma), the group who received child–­parent psychotherapy showed statistically significant improvements in child posttraumatic stress symptoms, but the group receiving case management showed no significant diminishment of signs of PTSD. These results show that young children receiving case management and sometimes referral experienced stability in their symptoms over 12 months.

Implications These findings are selective rather than comprehensive, but they illustrate that it is no longer acceptable to assume that early­appearing symptomatology is always, or even usually, transient. Furthermore, there are reasons to believe that intervening earlier is more effective—at least for some domains of development. Dishion and colleagues (2008) suggest three reasons why earlier intervention may be more beneficial. First, earlier interventions may target child behaviors before they take on a more serious form. In their focus on externalizing problems, they argue that noncompliant and oppositional behaviors are easier to remediate than are lying, stealing, and proactive aggression. Second, if children are younger, then parents are also

14

I. DEVELOPMENT AND CONTEXT

younger and may have had fewer stressful experiences and more capacity to change. Third, the sense of optimism caregivers have regarding the possibility of parent–child relationship change is much higher during their offspring’s early childhood. Knudsen and colleagues (Knudsen, Heckman, Cameron, & Shonkoff, 2006) pointed out that there is a convergence of findings from child development, neuroscience, and economic research indicating that greater return on investments are to be expected when intervening earlier. Citing studies from all three areas of research, they present compelling evidence that early intervention is more likely to be effective, providing a basis for policies that support a broad array of early childhood initiatives (see Knitzer & Lefkowitz, 2006). This point leads us to consider the kinds of early intervention that infant mental health recommends.

COMPREHENSIVE INTERVENTIONS ARE NEEDED The goals of the infant mental health field are to reduce or eliminate suffering, to prevent adverse outcomes (school failure, delinquency, psychiatric morbidity, interpersonal isolation or conflicts, developmental delays and deviance), and to promote healthy outcomes by enhancing social competence and resilience. In order to accomplish these overarching goals, interventions must (1) enhance the ability of caregivers to nurture

young children effectively, (2) ensure that families in need of additional services can obtain them, and (3) increase the ability of nonfamilial caregivers to identify, address, and prevent social–­emotional problems in early childhood. The targets of intervention can be the child’s behavior, the parent’s behavior, or even the social context in which the child is developing, but the main focus of infant mental health is on strengthening or improving relationships as they impact the young child’s development and behavior. In Figure 1.1, we present a model of infant mental health services, based on a preventive health perspective (Mrazek & Haggerty, 1994; National Research Council and Institute of Medicine, 2000) that represents an update of a previous conceptualization (Zeanah, Stafford, Nagle, et al., 2005). Mrazek and Haggerty (1994) distinguished between prevention and treatment services. Preventive interventions aim to prevent the initial onset of a disorder, decrease causal factors and increase protective factors, and/ or decrease the severity or duration of a disorder. Specifically, preventive interventions emphasize altering infant and parent behaviors and family functioning in order to preserve or restore infants to more normative developmental trajectories. For example, intrinsic infant risk factors such as difficult temperament cannot be prevented, but the adverse consequences of difficult temperament, such as the emergence of behavior problems, can be a focus of prevention efforts.

State-level Coordination Collaboration, Planning, Funding and Advocacy

Local-level Coordination Collaboration, Planning, Funding and Advocacy

Universal Intervention Universal Intervention

Selective Intervention Indicated Intervention Treatment Treatment

Treatment FIGURE 1.1.  Continuum of services at state and local levels.



1. The Scope of Infant Mental Health

Mrazek and Haggerty (1994) divided preventive interventions into three distinct levels. Universal preventions are considered desirable for everyone in an eligible population; professional assistance may or may not be needed. Selective preventions target members of a group who have high lifetime or high imminent risk for subsequent problems. Finally, indicated preventions target those who manifest minimal but detectable behavioral symptoms that may later become a full-blown disorder. Treatment of existing disorders adds a fourth level to this conceptualization (see Figure 1.1). Since infants and young children grow and develop within multiple contexts, biological, social, and relationship issues are often interrelated, and a continuum of services is needed. Infants and families may seek services at any point along the continuum or more than one point simultaneously. For example, a young child who requires treatment for trauma symptoms related to abuse or neglect may also need preventive health care; access to services for basic needs such as food, shelter, or clothing; or specialized developmental services such as speech and language or physical therapy. A child being seen for a well-child visit may be identified as having behavioral problems that warrant more intensive or specialized interventions. Thus, cross-­discipline and often cross­system collaboration is essential. In fact, in the United States, major policy initiatives in infant mental health are evident in most states, supported by federal and/or state governments (Rosenthal & Kaye, 2005).

Universal Prevention Some services are believed to be important for all infants and families, either for prevention or for health promotion purposes. These universal services seek to avert or prevent the onset of problems and/or seek to enhance social–­emotional health and development. In infant mental health, approaches include education regarding normal infant health and development, increasing knowledge about what constitutes healthy parent–­ infant relationships, and access or referral to additional services as needed. Although most universal services are aimed at individuals or families, in some cases, a community approach is needed to ensure that basic

15

needs such as safe housing, appropriate nutrition, and availability of health and human services are met even before other issues can be addressed. Early child care provides one example of a universal setting for addressing infant mental health. Scarr (1998) declared that there is an international consensus about what constitutes quality child care—­namely, warm, supportive interactions with adults in a safe, healthy, and stimulating environment. Considerable evidence supports her assertion. For example, the NICHD study of early child care is a prospective, longitudinal study designed to examine concurrent, long-term, and cumulative influences of variations in early child care experiences of young children. In this study, 1,364 healthy full-term newborns were recruited in 10 sites around the United States. Investigators examined what aspects of child care were important for promoting child development across a number of domains by assessing the child, the family, and the child care setting longitudinally; among child care variables, quality of care was the most important predictor of child outcomes. Quality of care is related to cognitive and language outcomes, as well as social and behavioral outcomes, in young children (National Institute of Child Health and Human Development Early Child Care Research Network, 2005). In other words, access to quality child care is a vitally important intervention for young children and should be the focus of sustained policy efforts to help achieve that goal. An important caveat was that characteristics of the parent–child relationship were better predictor of child outcomes than any combination of child care variables (National Institute of Child Health and Human Development Early Child Care Research Network, 2006). This does not mean that child care experiences are unimportant. Rather, it emphasizes the importance of all caregiving relationships for young children, with special primacy for parent–child relationships.

Selective Approaches to Intervention Some interventions are provided to families of young children who have been selected because they are “at risk” for poorer social and emotional outcomes. Some within the group may be functioning well; others

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I. DEVELOPMENT AND CONTEXT

may be more obviously struggling. Interventions are presumably developed to address the risks inherent in the population, and typically, specific outcomes are monitored or measured. Selective interventions may be delivered in a variety of settings (e.g., health, mental health, educational, or social services), and there is a great range in the structure of such services, such as frequency or intensity, type of intervention provided, skills or behaviors that are targeted, and amount of monitoring or follow-up. A notable example of a selective prevention directed at improving maternal and infant outcomes, including the reduction of abuse and neglect in a high-risk, impoverished sample, is the work of Olds, Salder, and Kitzman (2007). They pioneered the Nurse–­Family Partnership (NFP), a nurse– home visitation intervention for impoverished first-time mothers. The preventive intervention begins prior to the 28th week of pregnancy and continues through the child’s second birthday. Though the NFP program uses attachment theory, social learning theory, and human ecology theory to ground the work, the program evolved out of a public health rather than mental health delivery approach. NFP has three major goals: to improve pregnancy health outcomes, to improve infant health and development outcomes, and to improve maternal life course development. Highly trained nurses use manualized guidelines to address issues related to personal health and health, quality of caregiving for the infant, maternal life course development, and social support. Special attention is given to the importance of establishing a trusting, consistent relationship between the nurse and the client, and the development of a safe, nurturing, and enriched parent–­ infant relationship. Through a series of randomized controlled trials, NFP has demonstrated significant impact across a variety of maternal and infant health and social outcomes, including reduction in child maltreatment, reductions in serious accidental injuries in children, delays in subsequent pregnancies, and increased maternal employment, as well as reductions in child and maternal criminal and antisocial behaviors as long as 15 years after program completion (Olds et al., 2007). Importantly, two independent groups have shown that the

program has yielded significant cost–­benefit advantages (Aos, Lieb, Mayfield, Miller, & Pennucci, 2004; Karoly, Kilburn, & Cannon, 2005).

Indicated Approaches to Preventive Intervention When subsyndromal problems are already evident in young children, indicated interventions may be applied. These interventions are aimed at preventing early manifestations of deviance from becoming clinical disorders in later development. Insecure and especially disorganized attachments between young children and their caregivers are known to be a risk factor for subsequent psychosocial adaptation. Because sensitive and responsive parenting is associated with secure attachment, van den Boom (1994) developed an intervention designed to enhance secure attachment in infants believed to be at risk because of temperamental irritability. She delivered three home visits to low-­income mothers and their 6- to 9-month-old temperamentally irritable infants. The intervention focused on increasing mothers’ sensitive responsiveness to their infants’ cues. Findings from a randomized trial of 100 infant–­mother pairs demonstrated that when infants were 9 months old, program mothers were significantly more responsive, stimulating, and visually attentive. At 12 and 18 months old, children whose mothers received the intervention were significantly more likely to be securely attached than control children (van den Boom, 1994, 1995). These findings led Juffer, Bakermans­K ranenburg, and van IJzendoorn (2007) to develop and evaluate a promising intervention called the Video-based Intervention to Promote Positive Parenting. This intervention is targeted to dyads at risk for the adverse consequences of insecure attachment and has been shown to reduce externalizing problems in young children.

Treatment of Established Disorders For young children who already have identifiable disorders, psychotherapeutic services aimed at alleviating suffering or repairing or remediating functioning are necessary. Most often these services are provided by mental health professionals trained in spe-



1. The Scope of Infant Mental Health

cific infant mental health assessment and intervention techniques. Treatment of already identified problems may be focused primarily on changing the infant (Benoit, Wang, & Zlotki, 2001), the parent and his or her behavior (McDonough, 2000), or the infant–­ parent relationship (Lieberman, Silverman, & Pawl, 2000). Stern (1995) has argued that these different forms of intervention may use different strategies and different ports of entry into the infant–­parent dyad, but all are concerned with changing the relationship as a way of changing infant behavior and experience. Treatment of established problems is concerned with current resolution of symptoms and distress but also with infants’ developmental trajectories. For these reasons, infant mental health treatment is concerned simultaneously with present and future adaptation of the child. An increasing number of treatments in infant mental health are supported empirically. Perhaps the best studied is child–­parent psychotherapy. Originally pioneered by Fraiberg and colleagues (Fraiberg et al., 1975), this treatment is a manualized intervention used primarily with high-risk families that have children less than 5 years of age. Child–­parent psychotherapy tries to establish links between the parents’ early childhood experiences and their current feelings, perceptions, and behaviors toward their infants and young children. The therapist acts as a translator of the emotional experience of parent and child, attending carefully to the parent’s stressful life circumstances and culturally derived values. A new generation of clinician researchers has more fully developed child–­parent psychotherapy, expanded its application to preschool-age children, and systematically studied its effectiveness (see Lieberman & Van Horn, Chapter 27, this volume); in fact, there are now five randomized controlled trials supporting its efficacy. Child–­parent psychotherapy has been shown to be effective at (1) reducing insecure attachment behaviors in toddlers of stressed immigrant families (Lieberman, Weston, & Pawl, 1991), (2) reducing signs of PTSD in children traumatized by marital violence (Lieberman et al., 2005; Lieberman, Ippen, & Van Horn, 2006), and (3) increasing secure attachments in infants of depressed mothers (Cicchetti, Toth, &

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Rogosh, 1999; Toth, Rogosch, Manly, & Cicchetti, 2006) and in maltreated young children (Cicchetti, Rogosch, & Toth, 2006; Toth, Maughan, Manly, Spagnola, & Cicchetti, 2002).

Challenges of Infant Mental Health Interventions Preventive interventions and treatment efforts in infant mental health share several challenges. First, it is important to involve families of young children and to listen and incorporate their concerns into the planning and implementation of interventions. This requires the development of a working alliance between parents and intervener—that is, a shared commitment to work together in the best interest of the child. The relationship between the parent and the intervener often becomes a model for the respectful and empathic way parents learn to relate to their infant. Second, practitioners must recognize that personal, familial, ethnic, cultural, professional, and organizational values impact every aspect of interventions. These values create explicit and implicit lenses through which relationships are understood. Often, the situations faced by infants and young children evoke strong feelings in the professional. Recognizing and understanding one’s own value system as well as how professional perspectives impact one’s ability to understand the dyad are an ongoing challenge. Countertransference, including problems with boundaries, value judgments, and rescue fantasies, can cloud objectivity and undermine the potential for the intervention to succeed. Adequate provider training and supervision are viewed as essential precursors to developing effective interventions (see Hinshaw-­Fuselier, Zeanah, & Larrieu, Chapter 33, this volume). A third related challenge, particularly for professionals who have been taught to focus on individuals, is keeping the focus on the infant–­parent relationship. The professional must pay attention not only to the behavioral interactions within the dyad, but also must appreciate the parent’s emotional experience of the young child, and the young child’s experience of the parent. Recognition of each of these perspectives requires a paradigm shift for most early childhood professionals,

18

I. DEVELOPMENT AND CONTEXT

and it requires significant training in order to fully understand and to integrate these perspectives into clinical work. Finally, though the evidence base in infant mental health is growing, ongoing research into preventive interventions and treatments is needed. It is important to identify the components of the intervention, such as (1) the targeted recipient; (2) methods of intervention; (3) frequency, intensity, and length of services; (4) location of service delivery; and (5) type of service provider. Then it is important to link these components with anticipated, measurable outcomes (Karoly et al., 2005). Explicating these components and applying sound research methodology will enhance the evidence base and eventually will allow us in the field to identify critical elements and combination strategies that make a difference within and possibly across programs. For example, Olds and colleagues (2002) showed that nurses outperformed paraprofessionals in terms of outcomes achieved, keeping other characteristics of the NFP model constant. This finding helps justify the extra cost of using nurses to deliver services in this intervention. There is a particular need for research that focuses on the impact of sequential preventive interventions (Mrazek & Haggerty, 1994). This area has hardly been studied at all, no doubt partly because it poses significant fiscal and logistical challenges. In developing more refined questions in intervention research, clinicians need to work closely with researchers. Ideally, the latest research findings inform clinical practice, and clinical practice informs research designs by introducing promising approaches. The ultimate goal is for clinicians to be able to select an intervention that is best suited to address an individual child’s particular problems and circumstances. Policies ensuring that families have access to individualized services will become increasingly important as our ability to match children and families with specific interventions improves.

CONCLUSIONS The field of infant mental health emphasizes the importance of caregiving relationships as having major effects on the young child’s social and emotional experience. Healthy

caregiving relationships, which are embedded within multiple social and cultural contexts, promote social competence in young children, and social competence is associated with adaptive behavioral, emotional, and cognitive outcomes. The scope of infant mental health includes clinical, research, and policy efforts and encompasses the theoretical perspectives and knowledge base of multiple professional disciplines. The complexity of the problems of infants and toddlers must be matched by the comprehensiveness of our efforts to minimize their suffering and enhance their competence. References American Academy of Child and Adolescent Psychiatry Task Force on Research Diagnostic Criteria: Infancy and Preschool. (2003). Research diagnostic criteria for infants and preschool children: The process and empirical support. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1504–1512. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Angold, A., & Egger, H. L. (2007). Preschool psychopathology: Lessons for the lifespan. Journal of Child Psychology, Psychiatry, and Allied Disciplines, 48, 961–966. Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of prevention and early intervention programs for youth. Olympia, WA: Washington State Institute for Public Policy. Belden, A. C., Thomson, N. R., & Luby, J. L. (2008). Temper tantrums in healthy versus depressed and disruptive preschoolers: Defining tantrum behaviors associated with clinical problems. Journal of Pediatrics, 152, 117–122. Bell, R. Q. (1968). A reinterpretation of the direction of effects in studies of socialization. Psychological Review, 75, 81–95. Benoit, D., Wang, E. L., & Zlotki, S. H. (2000). Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: A randomized controlled trial. Journal of Pediatrics, 137, 498–503. Bergman, K., Sarkar, P., Glover, V., & O’Connor, T. G. (2008). Quality of child–­parent attachment moderates the impact of antenatal stress on child fearfulness. Journal of Child Psychology and Psychiatry, 49, 1089–1098. Carta, J. J., Atwater, J. B., Greenwood, C. R., McConnell, S. R., McEvoy, M. A., & Williams, R. (2001). Effects of cumulative prenatal substance exposure and environmental risks on children’s developmental trajectories. Journal of Clinical Child Psychology, 30, 327–337.



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Center on the Developing Child at Harvard University. (2007). A science-based framework for early childhood policy using evidence to improve outcomes in learning, behavior, and health for vulnerable children. Available online at www. developingchild.harvard.edu. Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2006). Fostering secure attachment in infants in maltreating families through preventive interventions. Development and Psychopathology, 18, 623–649. Cicchetti, D., Toth, S. L., & Rogosch, F. A. (1999). The efficacy of toddler–­parent psychotherapy to increase attachment security in offspring of depressed mothers. Attachment and Human Development, 1, 34–66. Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60, 837–844. Crockenberg, S., & Leerkes, E. (2000). Infant social and emotional development in family context. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 60–90). New York: Guilford Press. Crockenberg, S., Lyons-Ruth, K., & Dickstein, S. (1993). The family context of infant mental health: II. Infant development in multiple family relationships. In C. H. Zeanah (Ed.), Handbook of infant mental health (pp. 38–55). New York: Guilford Press. Cummings, E. M., & Davies, P. T. (2002). Effects of marital conflict on children: Recent advances and emerging themes in process-­oriented research. Journal of Child Psychology and Psychiatry, 43, 31–63. Degnan, K. A., Calkins, S. D., Keane, S. P., & Hill­Soderlund, A. L. (2008). Profiles of disruptive behavior across early childhood: Contributions of frustration reactivity, physiological regulation, and maternal behavior. Child Development, 79, 1357–1376. Degnan, K. A., Henderson, H. A., Fox, N. A., & Rubin, K. H. (2008). Predicting social wariness in middle childhood: The moderating roles of child care history, maternal personality, and maternal behavior. Social Development, 71, 471–487. Dishion, T. J., Shaw, D., Connell, A., Gradner, F., Weaver, C., & Wilson, M. (2008). The family check up with high risk indigent families: Preventing problem behavior by increasing parents’ positive behavior support in early childhood. Child Development, 79, 1395–1414. Dube, S. R., Felitti, V. J., Dong, M., Giles, W. H., & Anda, R. F. (2003). The impact of adverse childhood experiences on health problems: Evidence from four birth cohorts dating back to 1900. Preventive Medicine, 37, 268–277. Egger, H. L. (2008, November). Assessing preschoolers with anxiety. Paper presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry, Chicago. Egger, H. L., Erkanli, A., Keeler, G., Potts, E.,

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Walter, B. K., & Angold, A. (2006). Test–­retest reliability of the Preschool Age Psychiatric Assessment (PAPA). Journal of the American Academy of Child and Adolescent Psychiatry, 45, 538–549. Emde, R. N. (1991). The wonder of our complex enterprise: Steps enabled by attachment and the effect of relationships on relationships. Infant Mental Health Journal, 12, 164–173. Escalona, S. (1967). Patterns of infantile experience and the developmental process. Psychoanalytic Study of the Child, 22, 197–244. Felitti, V. J., Anda, R. F., Nordenberg, D., Williams, D. F., Spitz, A. M., Edwards, V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14, 245–258. Fraiberg, S., Adelman, B., & Shapiro, V. (1975). Ghosts in the nursery. Journal of the American Academy of Child and Adolescent Psychiatry, 14, 387–421. Frick, P. J., & Marsee, M. A. (2006). Psychopathy and developmental pathways to antisocial behavior in youth. In C. J. Patrick (Ed.), Handbook of psychopathy (pp. 353–370). New York: Guilford Press. Gardner, F., Sonuga-Barke, E., & Sayal, K. (1999). Parents anticipating misbehavior: An observational study of strategies parents use to prevent conflict with behavior problem children. Journal of Child Psychology and Psychiatry, 40, 1185– 1196. Garmezy, N., Masten, A. S., & Tellegen, A. (1984). The study of stress and competence in children: A building block for developmental psychopathology. Child Development, 55, 97–111. Gilliam, W. S. (2005). Prekindergarteners left behind: Expulsion rates in state prekindergarten systems. New Haven, CT: The Edward Zigler Center in Child Development and Social Policy, Yale University Child Study Center. Available at ziglercenter.yale.edu/resources/docs/National%20Prek%20Study_expulsion.pdf. Hodges, J., & Tizard, B. (1989). Social and family relationships of ex-­institutional adolescents. Journal of Child Psychology and Psychiatry, 30, 77–97. Juffer, F., Bakermans-­K ranenburg, M. J., & van IJzendoorn, M. H. (2007). Promoting positive parenting: An attachment-based intervention. Mahwah, NJ: Erlbaum. Karoly, L. A., Kilburn, M. R., & Cannon, J. S. (2005). Early childhood interventions: Proven results, future promise. Santa Monica, CA: RAND. Knitzer, J. (2000). Early childhood mental health services: A policy and systems development perspective. In J. Shonkoff & S. Meisels (Eds.), Handbook of early childhood intervention (2nd ed., pp.  416–438). New York: Cambridge University Press. Knitzer, J., & Lefkowitz, J. (2006). Pathways to

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early school success issue: Brief No. 1. Helping the most vulnerable infants, toddlers, and their families. New York: National Center for Children in Poverty. Knudsen, E. I. (2004). Sensitive periods in the development of the brain and behavior. Journal of Cognitive Neuroscience, 16, 1412–1425. Knudsen, E. I., Heckman, J. J., Cameron, J. L., & Shonkoff, J. P. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce. Proceedings of the National Academy of Sciences, 103, 10155– 10162. Lewis, M. (2000). The cultural context of infant mental health: The developmental niche of infant–­caregiver relationships. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 91–107). New York: Guilford Press. Lieberman, A. F., Ippen, C. G., & Van Horn, P. (2006). Child–­parent psychotherapy: 6-month follow-up of a randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 913–917. Lieberman, A. F., Silverman, R., & Pawl, J. (2000). Infant–­parent psychotherapy. In C. H. Zeanah (Ed.), Handbook of infant mental health (2nd ed., pp. 472–484). New York: Guilford Press. Lieberman, A. F., Van Horn, P., & Ippen, C. G. (2005). Toward evidence-based treatment: Child–­parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1241–1248. Lieberman, A. F., Weston, D., & Pawl, J. H. (1991). Preventive intervention and outcome with anxiously attached dyads. Child Development, 62, 199–209. Masten, A. S., & Coatesworth, D. J. (1998). The development of competence in favorable and unfavorable environments: Lessons from research on successful children. American Psychologist, 53, 205–220. McCarton, C. M., Brooks-Gunn, J., Wallace, I. F., Bauer, C. R., Bennett, F. C., Bernbaum, J. C., et al. (1997). Results at age 8 years of early intervention for low-birth-­weight premature infants: The infant health and development program. Obstetrical and Gynecological Survey, 52, 341–342. McDonough, S. (2000). Interaction guidance: An approach for difficult to engage families. In C. H. Zeanah (Ed.), Handbook of infant mental health (2nd ed., pp. 485–493). New York: Guilford Press. Meiser-­Stedman, R., Smith, P., Glucksman, E., Yule, W., & Dalgleish, T. (2008). The posttraumatic stress disorder diagnosis in preschool- and elementary school-age children exposed to motor vehicle accidents. American Journal of Psychiatry, 165, 1326–1337. Middlebrooks, J. S., & Audage, N. C. (2008). The effects of childhood stress on health across the lifespan. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Minuchin, P. (1988). Relationships within the family: A systems perspective on development. In R. A. Hinde & J. Stevenson-Hinde (Eds.), Relationships within families: Mutual influences (pp. 7–26). New York: Oxford University Press. Mrazek, P. B., & Haggerty, R. J. (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Committee on Prevention of Mental Disorders, Institute of Medicine. Washington, DC: National Academy Press. National Institute of Child Health and Human Development Early Child Care Research Network. (2004). Trajectories of physical aggression from toddlerhood to middle childhood: Predictors, correlates and outcomes. Monographs of the Society for Research in Child Development (Serial No. 278), 69, 1–144. National Institute of Child Health and Human Development Early Child Care Research Network. (2005). Child care and child development. New York: Guilford Press. National Institute of Child Health and Human Development Early Child Care Research Network. (2006). Child care effect sizes for the NICHD study of early child care and youth development. American Psychologist, 61, 99–116. National Research Council and Institute of Medicine. (2000). From neurons to neighborhoods: The science of early childhood development. Committee on Integrating the Science of Early Childhood Development (J. P. Shonkoff and D. A. Phillips, Eds.). Washington, DC: National Academy Press. Nelson, C. A., Zeanah, C. H., Fox, N. A., Marshall, P. J., Smyke, A. T., & Guthrie, D. (2007). Cognitive recovery in socially deprived young children: The Bucharest Early Intervention Project. Science, 318, 1937–1940. Olds, D. L., Robinson, J., O’Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., et al. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110, 486–496. Olds, D. L., Sadler, L., & Kitzman, H. (2007). Programs for parents of infants and toddlers: Recent evidence from randomized trials. Journal of Child Psychology and Psychiatry, 48, 355–391. Pine, D. S., Costello, E. J., Dahl, R., James, R., Leckman, J., Leibenluft, E., et al. (2008, March). Increasing the developmental focus in DSM-V: Broad issues and specific potential applications in anxiety. Paper presented at the annual meeting of the American Psychopathological Association, New York City. Robinson, M., Oddy, W. H., Li, J., Kendall, G. E., de Klerk, N. H., Silburn, S. R., et al. (2008). Pre- and postnatal influences on preschool mental health: A large-scale cohort study. Journal of Child Psychology and Psychiatry, 49, 1118– 1128. Rosenthal, J., & Kaye, N. (2005). State approaches to promoting young children’s healthy mental development: A survey of Medicaid, maternal and child health, and mental health agen-



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cies. Portland, ME: National Academy for State Health Policy. Rutter, M. (2000). Resilience reconsidered: Conceptual considerations, empirical findings, and policy implications. In J. Shonkoff & S. Meisels (Eds.), Handbook of early childhood intervention (2nd ed., pp.  651–682). New York: Cambridge University Press. Sameroff, A. J., Bartko, W. T., Baldwin, A., Baldwin, C., & Seifer, R. (1998). Family and social influences on the development of competence. In M. Lewis & C. Feiring (Eds.), Families, risk and competence (pp.  161–186). Hillsdale, NJ: Erlbaum. Sameroff, A. J., & Fiese, B. (2000). Models of development and developmental risk. In C. H. Zeanah (Ed.), Handbook of infant mental health (2nd ed., pp. 3–19). New York: Guilford Press. Scarr, S. (1998). American child care today. American Psychologist, 53, 95–108. Scheeringa, M. S., & Zeanah, C. H., Jr. (2001). A relationship perspective on PTSD in infancy. Journal of Traumatic Stress, 14, 799–815. Scheeringa, M. S., Zeanah, C. H., Jr., Myers, L., & Putnam, F. W. (2005). Predictive validity in a prospective follow-up of PTSD in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 899–906. Sroufe, L. A. (1989). Relationships, self and individual adaptation. In A. J. Sameroff & R. N. Emde (Eds.), Relationship disturbances in early childhood (pp. 70–94). New York: Basic Books. Sroufe, L. A. (1997). Psychopathology as an outcome of development. Development and Psychopathology, 9, 251–268. Sroufe, L. A., & Rutter, M. (2000). Developmental psychopathology: Concepts and challenges. Development and Psychopathology, 12, 265–296. Steele, H., Steele, M., & Fonagy, P. (1996). Associations among attachment classifications of mothers, fathers, and their infants. Child Development, 67, 541–555. Stern, D. N. (1995). The motherhood constellation. New York: Basic Books. Toth, S. L., Maughan, A., Manly, J. T., Spagnola, M., & Cicchetti, D. (2002). The relative efficacy of two interventions in altering maltreated preschool children’s representational models: Implications for attachment theory. Development and Psychopathology, 14, 877–908. Toth, S. L., Rogosch, F. A., Manly, J. T., & Cicchetti, D. (2006). The efficacy of toddler–­parent psychotherapy to reorganize attachment in the young offspring of mothers with major depres-

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sive disorder: A randomized preventive trial. Journal of Consulting and Clinical Psychology, 74, 1006–1016. van den Boom, D. C. (1994). The influence of temperament and mothering on attachment and exploration: An experimental manipulation of sensitive responsiveness among lower-class mothers with irritable infants. Child Development, 65, 1457–1477. van den Boom, D. C. (1995). Do first-year intervention effects endure?: Follow-up during toddlerhood of a sample of Dutch irritable infants. Child Development, 66, 1798–1816. Werner, E. E., & Smith, R. S. (2001). Journeys from childhood to midlife: Risk, resilience, and recovery. Ithaca, NY: Cornell University Press. Zeanah, C. H., Jr. (1998). Reflections on the strengths perspective. The Signal, 6, 12–13. Zeanah, C. H., Jr., Bakshi, S., Boris, N. W., & Lieberman, A. (2000). Disorders of attachment. In J. Osofsky & H. Fitzgerald (Eds.), WAIMH handbook of infant mental health (pp. 93–122). New York: Wiley. Zeanah, C. H., Boris, N., & Scheeringa, M. (1997). Psychopathology in infancy. Journal of Child Psychology, Psychiatry, and Allied Disciplines, 38, 81–99. Zeanah, C. H., Jr., & Zeanah, P. D. (2001). Towards a definition of infant mental health. Zero to Three, 22, 13–20. Zeanah, P. D., Gleason, M. M., & Zeanah, C. H., Jr. (2008). Infant mental health. In M. M. Haith & J. B. Benson (Eds.), Encyclopedia of infant and early childhood development (pp. 301–311). New York: Elsevier. Zeanah, P. D., Stafford, B., Nagle, G., & Rice, T. (2005). Addressing social emotional development and infant mental health. In Building early childhood comprehensive systems series (Vol. 12). Los Angeles: National Center for Infant and Early Childhood Health Policy. Zeanah, P. D., Stafford, B., & Zeanah, C. H., Jr. (2005). Clinical interventions in infant mental health: A selective review. In Building state early childhood comprehensive systems series (Vol. 13). Los Angeles: National Center for Infant and Early Childhood Health Policy. Zero to Three. (2001). Definition of infant mental health. Washington, DC: Zero to Three Infant Mental Health Steering Committee. Zero to Three. (2005). Diagnostic classification of mental health and developmental disorders of infancy and early childhood, revised (DC:0– 3R). Washington, DC: Zero to Three Press.

Chapter 2

The Psychology and Psychopathology of Pregnancy Reorganization and Transformation Arietta Slade Lisa J. Cohen Lois S. Sadler Maia Miller

P

regnancy is no ordinary time in the life of a woman. At no other point in her life will so much about her change in such a brief period, or will the nature and quality of her adaptations have such far-­reaching implications for her own and her child’s physical and psychological health. On the one hand, this time of enormous transition, transformation, and reorganization is one of hope and possibility and on the other, it is a time of crisis and potential disorganization. “Good-­enough” negotiation of the developmental crisis of pregnancy is crucial to the mental health of both mother and child. Pregnancy is inherently disruptive even when it is planned and wanted. The reasons are many: For one, there are the enormous physical, hormonal, neurochemical, and neurobiological shifts that occur within the body and the brain during this period; for another, there is the renegotiation of identity and the activation of internal representations of self and other, of attachment and caregiving, that are part and parcel of impending parenthood. The degree to which the mother-to-be is able to manage and integrate these developmental shifts is related to a number of internal and external factors. One is her individual psychology. She brings to pregnancy an internal life, a



particular and unique way of experiencing and organizing her emotional world and her sense of herself and others. Her internal life is shaped, but not determined, by childhood and other formative relationships, as well as by her prior experiences of trauma and loss. By the same token, pregnancy occurs within the context of physical health as well as biological and genetic strengths and vulnerabilities. It also occurs within a network of relationships to the father of her baby, to her family, her community, and her culture, and within the profound matrix of her age and socioeconomic status. It is the unique mix of these variables that brings about the emotional upheaval that is so normal and expectable in pregnancy. Although emotional upheaval is normative, the vulnerability of this period cannot be overstated, both from the standpoint of the mother’s as well as the unborn infant’s mental health. For women whose psychological functioning is vulnerable, the emotional crisis of pregnancy may set in motion patterns that have long-term consequences for mother, baby, and the larger family. Among those most at risk during pregnancy are women with prior psychiatric difficulties, as well as those with histories of trauma, abuse, and loss (including, but not limited to, preg22



2. The Psychology and Psychopathology of Pregnancy

nancy loss). Equally if not more vulnerable are teenage mothers, who are usually coping not only with the stress of becoming a parent in the midst of adolescence but with the additional stresses of poverty, inadequate social support, and histories of disrupted attachment and trauma. These are the circumstances most likely to bring pregnant women to the attention of clinicians, and it is these women who may well require immediate and sometimes long-term intervention to help them adjust both to the upheaval of pregnancy and the arrival of a baby. In the following sections we attempt to give an overview of the various, variable, and complex factors that lead to mental health concerns during the perinatal and postnatal periods. We first consider the physical, biological, hormonal, and neural aspects of pregnancy. Next we address the emotional aspects of pregnancy, particularly as these lay the groundwork for the mother’s developing connection to, and relationship with, her unborn child. We then discuss the various relational, familial, and environmental factors that impact a woman’s psychological adaptation to pregnancy and parenthood. Finally, we examine the role of intervention in addressing psychopathology during pregnancy and in preparing at-risk mothers for motherhood.

DEVELOPMENTAL OVERVIEW OF PREGNANCY Becoming Pregnant Pregnancy begins with conception, which for the large majority of women who become pregnant, occurs as the result of sexual intercourse during the fertile phase in the menstrual cycle. The moment of conception sets in motion a range of physical, biological, and neural changes that can be reliably detected within days in both urine and blood samples. The biological aspects of conception are, however, quite distinct from their psychological aspects. Women become pregnant in a vast array of different personal, relational, and social circumstances, all of which contribute, in both small and large ways, to the psychological experience of pregnancy and to their acceptance of the pregnancy. Whether a woman had wished to become pregnant, has been easily able to

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conceive and carry a pregnancy to term, has a stable relationship with the father of the baby, is psychologically ready to be a parent within the context of her own society and culture, will—along with many other factors—­establish the context for the beginning of a new and, for the mother, lifelong relationship. Unintended pregnancy usually brings with it considerable stress, and can itself be a threat to the mother’s mental health. In addition, the inability to accept the pregnancy can affect the mother’s experience of parenting as well as the child’s later attachment status (Ispa, Huth-Bocks, Sable, Porter, & Csizmadia, 2007).

The Sequence of the Trimesters The greatest amount of fetal development takes place in the first trimester (12 weeks) of pregnancy, in which undifferentiated cells are transformed into articulated tissues and organs. The fetus is most vulnerable to toxic influences during this first trimester; for this reason mothers in` most developing countries are advised to stop smoking cigarettes and drinking coffee and alcohol when their pregnancy is confirmed. The hormonal surges that allow the pregnancy to take hold are responsible for both morning sickness as well as irritability and mood changes. The vulnerability of this period is highlighted by the fact that one in four pregnancies end in miscarriage by 10–12 weeks’ gestation. A woman may not realize that she is pregnant until she misses her period, but numerous women feel some changes in their bodies within the first few weeks of pregnancy. Nevertheless, while her body has certainly begun to change, and she may already be making changes in her diet and activity level, the fetus is still largely an abstraction. Impending motherhood does not typically feel as real or permanent as it will in later trimesters (Leifer, 1980). That said, recent developments in vaginal ultrasonography allow a view of the fetus as early as 10 weeks. This technology allows women who have routine access to hospital-based medical care to view their infant before it is born—which was impossible until only a few decades ago. This is often experienced as intensely exciting—­certainly making the baby feel more real—and often deepening the mother’s (and father’s) feelings of con-

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I. DEVELOPMENT AND CONTEXT

nection to the fetus (McKinney, Tuber, & Downey, 1996). In the second trimester fetal growth is more observable, and the baby begins to feel more real to many women. With hormones stabilizing, morning sickness and irritability generally are less severe than in the preceding trimester. The abdomen has expanded enough for the pregnancy to “show,” which is a stage that can be intensely conflicted for women, especially those with body image problems or prepregnancy eating disorders (Huganir, 1990; Rocco et al., 2005). Most important, at this point (4–5 months), women begin to feel the baby move, although undetected motion has been occurring since 7–8 weeks. Known as “quickening,” this is one of the most psychologically significant moments in a woman’s pregnancy. Many psychoanalytic theorists have noted that as the pregnant woman’s body grows, and as the baby becomes easier to imagine, felt through kicks and seen in the ultrasound, her psychological orientation turns inward. Her emotional investment is drawn away from the outside world and refocused inward toward her baby and the transformations taking place inside her (Bibring, Dwyer, Huntington, & Valenstein, 1961; Leifer, 1980). At this point, the psychological transition accelerates; not only is she becoming a mother physically, she is now evolving into one psychologically. In the third trimester the baby is largely formed, and it is time for the fetus to reach its full neonatal size. The woman gains the most weight at this point, generally up to 35 pounds. Her mobility is considerably restricted, and her sheer body mass can lead to notable discomfort, especially in the final month. During the last weeks of her pregnancy, the woman begins to psychologically prepare for childbirth and for the arrival of the baby into the world; this is likely related to the activation of oxytocin neurons immediately prior to delivery (Leckman et al., 2004). Winnicott (1956) termed this the beginning of the period of “primary maternal preoccupation,” when women begin “nesting” in a variety of ways; internally and externally, they are more and more turned to the baby’s arrival and to the enormous changes this will bring (Leifer, 1980; Lester & Notman, 1986; Pines, 1972).

Childbirth The culmination of pregnancy is, of course, childbirth. Women anticipate labor and childbirth with intense and ambivalent emotions. Labor heralds the long-­awaited arrival of their child and the cessation of their now quite cumbersome pregnancy. Yet childbirth is also likely to be a physically painful and difficult experience. In labor, a woman is inescapably confronted with the limits of her bodily control and, ultimately, with her own mortality. These realities can make labor an intensely frightening time for women, and most cultures have established practices for lessening the fear that accompanies labor. These include, for instance, childbirth companions or “doulas” who remain with the woman throughout her entire labor. The presence of supportive companions has been associated with a range of positive obstetrical and mother–­infant outcomes (Kennell, Klaus, McGrath, Robertson, & Hinkley, 1991). Mothers, grandmothers, and other female relatives serve the same function in other cultures. In Western cultures fathers are often encouraged to attend the childbirth. Many studies confirm the commonsense notion that women who feel informed about, and in some control of, the childbirth process will be less distressed and emotionally resilient during and after birth (Green, Coupland, & Kitzinger, 1990). For mothers with histories of sexual or physical abuse, childbirth can be intensely retraumatizing; for these women, interventions that allow them some control over the powerlessness that is inherent in childbirth can be crucial (Seng, 2002; Simkin, 1992).

The Neurobiology of Pregnancy Recent research has begun to investigate the neurobiology of pregnancy, which is quite complex. On the one hand, a variety of hormonal and other neurochemical changes allow the pregnancy to proceed and the fetus to develop. They are also responsible, at many levels, for the mood fluctuations and upheaval that are intrinsic to pregnancy. Other hormones, particularly oxytocin, play a crucial role in triggering maternal behavior, both immediately before and after birth, and set in motion the neural circuitry that promotes attachment in both mother and



2. The Psychology and Psychopathology of Pregnancy

baby (Feldman, Weller, Zagoory-­Sharon, & Levine, 2007; Leckman et al., 2004; Nelson & Panksepp, 1998). Feldman and her colleagues (2007) report that higher plasma oxytocin levels during the first trimester of pregnancy were associated with more indices of positive attachment in the mother– child interaction at 4 months. In addition, mothers who had higher levels of oxytocin across the pregnancy and the postpartum month reported more behaviors indicative of their forming an exclusive attachment to the baby and were more likely to report being preoccupied with the baby’s safety and future. Feldman et al. also suggested that oxytocin may interact with cortisol and other stress hormones in such a way as to reduce anxiety, increase calmness, and intensify “the incentive value of the attachment target” (Feldman et al., 2007, p. 969). And as is discussed later, hormones are further implicated in the development of psychiatric disturbances during the antenatal and postnatal periods.

PSYCHOLOGICAL PROCESSES IN PREGNANCY Affective Upheaval in Pregnancy Unsurprisingly, given the external and internal demands of impending parenthood, emotional upheaval and intermittent psychic distress is not at all unusual in pregnancy (Bibring et al., 1961; Leifer, 1980; Trad, 1990). Bibring, who was one of the first psychoanalytic writers to study pregnancy, noted that affective instability often typifies even the most “normal” and stable women during pregnancy. The majority of the pregnant women she and her colleagues evaluated during pregnancy actually looked quite disturbed and unstable. Bibring’s observations—which have been validated time and again over the ensuing decades (DiPietro, Novak, Costigan, Atella, & Reusing, 2006; Moses-Kolko & Feintuch, 2002)—are particularly interesting because the cultural stereotype of a pregnant woman suggests that her primary emotional state is uninterrupted bliss and serenity (Leifer, 1980). While these states unquestionably occur in most pregnancies, they do not usually typify the experience.

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Internal Reorganization: Object Relations, Attachment, and Representations A crucial level of reorganization occurs at an internal, psychological level. Any developmental crisis results in the activation of internalized representations of the self and of the other. For the pregnant woman, becoming a mother invariably activates her internalized object relationship with her own mother. The more complex her relationship with her mother and other important caregivers, the more fraught an experience this is likely to be (Pines, 1972). Ideally, one of the ways that a mother comes to feel like a mother is by identifying with her own mother. As Bibring and her colleagues (1961) noted, this process occurs gradually, as a woman reworks her internalized and actual relationship with her own mother over the course of the pregnancy. Often this reworking will allow a woman to see her mother in a more positive light, and to develop a vision of herself as a mother. She and her mother are mothers together, and she is less and less a child dependent on, or in conflict with, her mother. Needless to say, when pregnancy awakens particularly negative object and self representations, the development of maternal identity will be conflicted. Indeed, as has been amply documented in the clinical literature on pregnancy, there are many women for whom the anxiety, ambivalence, and conflict evoked by pregnancy are so powerful that such reworking is difficult, if not impossible (Leifer, 1980; Lester & Notman, 1986; Pines, 1972; Trad, 1990). Nevertheless, resolving and integrating such complex identifications and internalized object representations is central to a woman’s preparing herself both for motherhood and for her relationship with her child. When successful, such reworking offers an important opportunity for repair and resolution (Benedek, 1970). When unsuccessful, it lays the groundwork for a disrupted mother– child relationship, with grave consequences for both mother and child. The establishment of a maternal identity also involves renegotiating other aspects of her sense of self. In addition to being a woman, a daughter, a wife/partner, and— in many instances—a working person, she is now also becoming a mother. Or, she is becoming a mother to a new child, shift-

26

I. DEVELOPMENT AND CONTEXT

ing prior attachments to make room for the new. The tasks inherent in developing this new identity—which continues to develop throughout her children’s lives—are enormous. Regression, conflict, anxiety, transient depression, emotional lability and ambivalence are natural consequences of these shifts, which are so fundamental to her sense of herself. Indeed, Trad (1990) has suggested that these shifts cannot help but trigger ambivalence, the healthy expression of which is crucial to a successful adaptation to pregnancy. Intertwined with the task of reworking early relationships is the task of developing a feeling of connection to the child while at the same time acknowledging its separateness (Condon & Corklindale, 1997; Pines, 1972). During pregnancy, the baby is both part of her and separate from her at the same time. On the one hand, particularly during the latter stages of pregnancy and the early postnatal period, the woman must, in some very real sense, abandon herself to her child. Winnicott (1956) called this state “primary maternal preoccupation,” referring to mother’s process of becoming utterly preoccupied and identified with her baby, with his or her needs, rhythms, and very being. In this state, she and the baby are—­profoundly—­ together as one. At the same time, the baby’s separateness, separate within her own body, must remain real to her. She must imagine and hold in mind his or her autonomy, distinct from her fantasies, her desires, her projections, and her attributions. She must also feel secure in her own ability to retain an autonomous identity, even while surrendering her sense of self to her baby. In the same way that pregnancy activates internalized object relations, so does it activate the attachment system and its representations. From Bowlby’s (1988) perspective, the caregiving system—like the attachment behavioral system—is a primary motivational system that is activated under certain priming conditions. Specifically, Bowlby suggested that the infant’s biological predisposition to become attached occurs within the context of an equally strong biological inclination in the parent, namely, the predisposition to provide care for his or her young. This caregiving system, which is activated over the course of pregnancy, is analogous to the attachment behavioral system in children

(Solomon & George, 1996) and necessarily competes with other motivational systems, including those that govern pair bonding, sexual activity, and the like. Whereas attachment theorists reserve the term attachment to describe the child’s attachment to one stronger and wiser (i.e., the parent), many use the terms maternal– fetal attachment or prenatal attachment to describe both behavioral and representational components of the mother’s developing connection to the child (see Cannella, 2005, and Doan & Zimerman, 2003, for reviews). The degree to which a woman feels attached and connected to her unborn child, or exhibits behaviors consistent with a developing attachment to the baby, has been linked to a number of crucial parent and child outcomes, among them pre- and postbirth parental behavior (Condon & Corklindale, 1997), mothers’ experience of their babies after birth (Leifer, 1980), and to the quality of mothers’ involvement with their babies after birth (Siddiqui & Hägglöff, 2000). Various authors (Bennett, Litz, Lee, & Maguen, 2005; Doan & Zimerman, 2003) have noted that women differ greatly in when they begin to experience feelings of connection and attachment to the unborn child. For some, the feelings may begin long before a woman is even pregnant; for some, they begin early in pregnancy; whereas for others they are slow to develop. These feelings may also vary in intensity from child to child. Representations of the baby undoubtedly begin forming even before a woman becomes pregnant, for it is likely that she has, at some if not many points in her life, fantasized about having children and about being a mother. Although such representations are fairly diffuse in early pregnancy, by the second trimester they have become increasingly specific. Mothers describe the fetus as “busy,” “demanding,” “willful,” “won’t stop bothering me,” “makes me sick all the time,” and “making me feel good about life.” A woman’s representations of herself as a mother are likewise developing: “I’ll be a good mother” . . . “a controlling mother” . . . “I’m not going to be a pullout-all-the-stops mother because I love my work.” In pregnancy, there is less a known baby than an imagined baby. Thus, these representations are truly creations, based



2. The Psychology and Psychopathology of Pregnancy

less on reality than on an amalgam of the mother’s projections, hopes, dreams, attributions, and unconscious fantasies. By the third trimester differences among women in their capacity to imagine the baby and to imagine themselves as mothers can be quite striking. These are also fairly consolidated and stable. Both the content and structure of such representations speak volumes about the success of the woman’s adaptation to the tasks of pregnancy: To what degree can she imagine her baby, both as part of and apart from herself? To what degree can she imagine herself as a mother? And to what extent are these representations coherent, organized, and balanced, or contradictory, disorganized, and negatively tinged? Benoit, Parker, and Zeanah (1995) evaluated the quality of maternal representations of the child from pregnancy to 1 year. They found not only that representations were stable from pregnancy to 1 year after birth, but also that women with balanced (as opposed to disengaged or distorted) representations in pregnancy were more likely to have secure infants at 1 year. More recently, Theran, Levendosky, Bogat, and Huth-Bocks (2005) studied the stability of parental representations of the child over time. When representations were classified as either balanced or nonbalanced, 71% of the sample was stable over time, with stability being more typical of women with balanced representations. Income level, single parenthood, history of abuse, and depressive symptomatology predicted change. A number of researchers have linked the quality of a woman’s attachment to her own parents to the maternal–fetal attachment as well as to the quality of maternal representations of the unborn child. A woman’s attachment security predicts maternal–fetal attachment (Siddiqui, Hägglöf, & Eisemann, 2000) as well as the quality of prenatal representations of the baby and of self as mother (Benoit et al., 1997; Frank, Tuber, Slade, & Garrod, 1994; Huth-Bocks, Levendosky, Bogat, & von Eye, 2004; Mikulincer & Florian, 1999; Slade & Cohen, 1996; Slade et al., 1995; Zeanah, Dailey, Rosenblatt, & Saller, 1995). Unsurprisingly, both maternal–fetal attachment and the quality of prenatal representations have been linked to later infant security (Benoit et al., 1997; Hucks-Both, et al., 2004).

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Although the terms “reflective functioning” and “mentalization” have typically been reserved to describe the adult’s capacity to reflect upon the mental states of others in actual relationships (Fonagy, Gergely, Jurist, & Target, 2002; Slade, 2005), they also apply to many mothers who begin to imagine their babies as having intentions, feelings, and desires during the pregnancy. Indeed, reflective functioning plays a particular and important role in pregnancy, because the mother is necessarily holding two minds in her mind: her own changing sense of self alongside her fluctuating and intense affects and the reality of her baby, both part of and apart from her. Reflective functioning allows the mother to imagine the baby as having a mind of his or her own, coherent and knowable, both in her mind and after he or she is born. It also allows the mother to retain a sense of herself as coherent and knowable in the face of the turmoil of pregnancy.

External Reorganization Most, if not all, of a woman’s relationships will be changed by her becoming a mother. Her relationship with her partner must expand to include a third (or fourth or fifth, etc.) person, with competing needs and desires. Her relationship with her own mother will change; she is no longer just a daughter, but a daughter who is also joining the ranks of motherhood. And her relationship to her other children and to her extended network of family and colleagues changes as well. Naturally, because of the increased physiological and emotional demands of pregnancy, women grow more dependent on others during this time. They need more support from the people in their world—­husband, family, friends, and those whose job it is to help them bring the pregnancy to a healthy end. Extended families often grow more cohesive around childbirth; even strangers are more likely to engage with pregnant women, sometimes putting their hands on women’s stomachs or giving unsolicited advice about child care. Pregnancy dramatically changes the dynamics of the nuclear family, the parental marriage in particular, and the availability of support—from husbands and other extended social networks—has been found intrinsic to a healthy adaptation to

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I. DEVELOPMENT AND CONTEXT

pregnancy (Condon & Corklindale, 1997; Leifer, 1980). The woman’s experience of pregnancy is strongly affected by her social context, by the relationship with her partner, her children, and her own family of origin, and by the culture in which she lives.

THE PREGNANT FATHER For the father as well, pregnancy is a time of psychological preparation. Although there has been significantly less research addressing paternal development during pregnancy, several studies document the profound transformation men also must undergo and the active part some men take in this process (Gage & Kirk, 2002; Habib & Lancaster, 2006). During pregnancy, fathers must develop a representation of the baby and an attachment to a child that they have not yet met. As men do not directly undergo the same immense physiological changes that women do, this can be a daunting task at times, and it may be hard for some fathers to experience the baby as real, although the changes in their partners feel very real, as do the increasing responsibilities they face as parents-to-be. Interestingly, in one study the number of ultrasound visits was the strongest predictor of paternal–fetal attachment (Gerner, 2006). Other studies found that fathers who consciously chose to become fathers (Peterson & Jenni, 2003) and who perceived a central role in their identity as fathers (Habib & Lancaster, 2006) were most emotionally invested in the pregnancy. A father’s representation of his own father also affects his growing attachment to his new baby. In a 2004 study, Beaton, Doherty, and Reuter (2003) noted that expectant fathers who were either very close to their own parents during childhood or very distant from them had more positive attitudes about paternal involvement. Thus, although security of attachment in childhood facilitates a new father’s ability to create a secure and loving attachment to his own unborn baby, the reworking of insecure attachment representations can also play a critical role in paternal– fetal attachment. The marital relationship also undergoes profound changes during pregnancy. The dyad becomes a triad, and it will be at least two decades before any decision can be

made without considering the needs of their child. Pregnancy marks a profound commitment to the marriage; father and mother remain inextricably connected to each other the rest of their lives. Thus pregnancy has the potential to profoundly deepen the intimate bond of marriage. Not surprisingly, pregnancy also brings numerous stresses to the marriage; the higher the degree of marital satisfaction, the more the husband feels a part of pregnancy and childrearing. Thus, although involvement with children is a life­enhancing and life-­transforming experience for most men, the father–child relationship is highly influenced by the marital relationship, probably to a much greater degree than is the mother–child relationship. A father also may feel intense and ambivalent feelings about the changes his wife or partner is undergoing. The father may enjoy the woman’s bodily changes, feeling excited and awed by the life growing inside of her. Conversely, he may have some difficulty seeing his sexual partner’s body in so clearly a maternal form. Some men feel intense anxiety about their wife and child’s physical health (“That big head is supposed to come out of where?”). Moreover, a man may feel abandoned by his wife, who is now devoting enormous energy and attention to her pregnancy. Many men also feel excluded from a central role in the parenting process, relegated by both friends and family to the ancillary role of breadwinner and helpmate, as if pregnancy were an exclusive club to which only women can belong. Such a focus on fathers’ emotional experience illuminates a largely neglected dynamic of women’s experience of pregnancy—that although women’s need for social support is heightened during pregnancy, many women may be reluctant to share the power and emotional significance of parenthood with their mates. However, for men to become more active fathers, women have to sacrifice some of the control they have traditionally enjoyed in childrearing. A fascinating cross-­cultural phenomenon, termed couvade, speaks to how some men symbolically process the psychological challenges facing expectant fathers (Klein, 1991). “Couvade” refers to the manifestation or endorsement in a man of somatic symptoms similar to those of his pregnant partner. By somatically identifying with the pregnant



2. The Psychology and Psychopathology of Pregnancy

mother, the expectant father simultaneously draws closer to his wife, demands recognition of his role in the pregnancy process, and psychologically prepares himself for the child’s birth. Some authors have suggested biological influences on this phenomenon, and there is evidence that males and females undergo similar hormonal changes—in quality if not quantity—­during pregnancy. Specifically, both males and females demonstrate increased prolactin and estradiol and decreased testosterone at specific points in the pre- and perinatal periods (Storey, Walsh, Quinton, & Wynne-­Edwards, 2000; Zeigler & Snowdon, 2000). It is worth noting that many women undergo pregnancy without the support of the father of the baby; indeed, this is a time—­ particularly in the case of teenage or unwanted pregnancies—when many men disappear (C. H. Zeanah, Jr., personal communication, February 2, 2008). Clearly, the absence of a father, as supportive partner and as coparent, will affect the woman’s experience of pregnancy and childbearing in a number of ways. Many women involve female family members in guiding them through pregnancy and childbirth in these situations. Many others, especially in cultural groups where father absence is unfortunately common, treat father absence as a normal, if unfortunate, reality. Nevertheless, the father’s absence is keenly felt.

RISK FACTORS IN THE ADAPTATION TO PREGNANCY AND MOTHERHOOD Each woman negotiates the various developmental demands of pregnancy in her own unique way. But there are circumstances that make the adaptation to pregnancy and motherhood especially challenging. These include prior psychiatric disturbance, substance use, early or ongoing trauma and domestic violence, prior pregnancy loss, and the absence of relational, familial and social supports at this critical developmental moment. For high-risk young women, especially teenagers, the challenges of unplanned or unwanted pregnancy in the face of poverty, minimal financial, family, and social support, and single parenthood can be nearly insurmountable.

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Psychological and Biological Factors One of the major risk factors in a woman’s adaptation to pregnancy is a prior psychiatric disturbance or symptomatology, specifically depression, anxiety, or other major psychiatric disorder (Condon & Corklindale, 1997; Leifer, 1980; Trad, 1990). Indeed, there is wide agreement that the perinatal period is a time of increased risk for psychiatric disorder; thus, women who are either vulnerable to, or have a history of, psychiatric illness are at particular risk for developing frank psychiatric pathology during pregnancy. Although psychiatric illnesses such as anxiety disorder, obsessive–­compulsive disorder, bipolar disorder, and psychotic disorders have been associated with the prenatal period, the most common psychiatric problem in pregnancy involves mood disorder, specifically depression (see Goodman & Brand, Chapter 9, this volume). Several studies have shown a sharp rise in the incidence of depression and other psychiatric disorders in perinatal women relative to the preceding periods in their lives (Kendell, Chalmers, & Platz, 1987; Kendell, Wainwright, Hailey, & Shannon, 1976), although two large studies compared perinatal women with age-, parity-, and SES-matched controls and found that the incidence of depressive diagnoses did not statistically differ from that of controls (Cooper, Campbell, Day, Kennerly, & Bond, 1988; O’Hara, Neunaber, Zekoski, Philips, & Wright, 1990). Nevertheless, in both studies pregnant women did report higher levels of depressive symptomatology (O’Hara et al., 1990). These studies have been criticized for including controls who have borne children in the past few years and therefore are still caring for young children (Moses-Kolko & Feintuch, 2002). The postpartum period is a time of particularly high risk. Prevalence rates of depression in women immediately postpartum are estimated as between 10 and 15% (Buist, 2002; Moses-Kolko & Feintuch, 2002). In many cases, perhaps 10–30%, according to some estimates, depressive episodes are recurrences of earlier illness, and up to 60% of women with perinatal depression may have recurrences later on (Cooper & Murray, 1995; Llewellyn, Stowe, & Nemeroff, 1997). Additionally, a larger percentage (80%) of women experience what may be called

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“postpartum blues,” a transient and milder form of depression that does not meet DSMIV criteria for a major depressive episode. In the vast majority of these cases, postpartum blues remit, but in some women the condition progresses into clinical depression. Many researchers have assumed that perinatal depression may be caused by the tremendous hormonal and biological changes that a woman undergoes throughout her pregnancy. Although several studies have failed to show differences in hormone levels between depressed and nondepressed perinatal women, it is likely that the relationship between hormones and psychiatric illness involves a complex interplay not easily captured by resting hormone levels (MosesKolko & Feintuch, 2002). There are also data showing relationships between estrogen levels and neurotransmitters associated with psychiatric disorders, such as serotonin and dopamine (Moses et al., 2000; Wieck et al., 2003). Clearly, environmental and psychological risk factors also play a large role in perinatal depression. Lack of spousal support, a history of childhood trauma, and stressful life events can all be contributing factors (Kendell et al., 1976; Lang, Rodgers, & Lebeck, 2006; Llewellyn et al., 1997; Moses-Kolko & Feintuch, 2002; O’Hara et al., 1990). In addition to diagnosable psychiatric disorders, many women suffer from subclinical levels of anxiety, depression, and stress during pregnancy. Women worry about the changes in their body, the health of their growing baby, the pain of delivery, and the immense role changes in their personal, romantic, occupational, and financial lives (DiPietro et al., 2006; Llewellyn et al., 1997; Moses-Kolko & Feintuch, 2002). These are important findings in relation to a growing body of literature that examines the effect of maternal stress and dysphoria during pregnancy on the pre- and postnatal well-being of the baby (Diego, Field, & HernandezReif, 2005; DiPietro et al., 2006; Monk et al., 2004). Most studies show a deleterious effect of maternal stress and dysphoric emotions on fetal and infant well-being (Diego et al., 2005; Monk, 2001; Monk et al., 2004; Moses-Kolko & Feintuch, 2002). Monk et al. (2004) measured fetal heart rate in women

undergoing a mild stressor, namely a cognitive challenge. Mothers with elevated levels of anxiety and depression showed larger increases in fetal heart rate than did their nonanxious and nondepressed counterparts. The authors suggested that increased autonomic reactivity in the fetus could be a precursor to later difficulties with affect regulation. Likewise, Diego et al. (2005) found that prenatal, but not postnatal, depression in women predicted indeterminate sleep, fussiness, and stress behaviors in neonates, further underscoring the specific effects of prenatal depression on infant well-being. Rogal, Poschman, and Belanger (2007) have linked low birthweight to depressive disorder during pregnancy. Oddly enough, one study showed a modest positive relationship between self-­reported levels of maternal anxiety and depression during pregnancy and infant mental and motor development at age 2 years (DiPietro et al., 2006). It is possible, however, that the relatively affluent and well-­educated participants had a fairly low baseline level of stress, and their increased anxiety and depression reflected active mental preparation for the profound life changes ahead. An area that has received much less attention than perinatal depression, but that seems particularly crucial in working with populations of stressed, traumatized women, is the prevalence and impact of posttraumatic stress disorder (PTSD) on pregnancy and later child outcomes. Schwerdtfeger and Nelson Goff (2007), for instance, recently reported that interpersonal trauma history has a negative effect on prenatal attachment. Recent reports suggest that as many as 3–7% of pregnant women meet diagnostic criteria for PTSD, and many of these women are likely to have comorbid mood and other anxiety disorders (Morland, Goebert, & Onoye, 2007; Smith, Poschman, Cavaleri, Howell, & Yonkers, 2006); prevalence rates are especially high (11%) in women who report prior trauma (Smith et al., 2006). Some traumatized women may well have had PTSD prior to becoming pregnant; in others the multiple stressors of pregnancy—­including the lack of control associated with bodily changes, medical procedures, as well as neuroendocrine and psychosocial changes—may result in the pregnancy itself being retraumatizing,



2. The Psychology and Psychopathology of Pregnancy

a­ lthough Smith et al. (2006) suggest that the elevations in hormone levels in pregnancy may diminish the expression of selected symptoms of PTSD. When diagnosed, PTSD in pregnancy has been associated with suicidality, panic disorder, major and minor depressive disorders, and preterm delivery (Rogal et al., 2007; Smith et al., 2006). The latter is likely due to the fact that PTSD has been associated with increased potential for engaging in high-risk health behaviors, such as smoking, alcohol and substance use, poor prenatal care, and excessive weight gain (Morland et al., 2007). In a preliminary study of a small group of high-risk, predominantly teenage pregnant women living in urban poverty, who reported significant histories of abuse and abandonment and who themselves struggled with substance use, depression, and anxiety (Patterson, Slade, & Sadler, 2005), we assessed trauma symptoms using standard measures as well as clinician report. We found that the presence of trauma symptoms—such as dissociation, numbing, and reexperiencing— was inversely correlated with a mother’s capacity to imagine the child and to imagine herself as a parent in a coherent way, that is, with her pregnancy-­related reflective functioning (RF). Prior abuse (sexual or physical) was also negatively correlated with RF. Thus, women who were struggling with the aftereffects of trauma were less likely to be able to hold their unborn child in mind. RF was also correlated with the affective tone and degree of elaboration of the woman’s representation of her unborn child; women who had higher levels of RF were better able to imagine their babies in positive terms and to provide rich and elaborated representations of them. It is important to note, however, that levels of RF and of affective tone and elaboration were generally low in this population.

Pregnancy Loss and Abortion Prior pregnancy losses and abortions also play a significant role in determining a woman’s emotional adaptation to pregnancy. As described above, from the moment she discovers she is to have a baby, the pregnant woman embarks on a complex journey of redefinition, reorganization, and reintegration.

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In the case of miscarriage or other forms of pregnancy loss, this process is interrupted and the mother’s developing attachment to the baby is shattered, often with devastating emotional consequences to her. While many studies have confirmed that women experience much greater grief following pregnancy loss than is commonly recognized (see Bennett et al., 2005, for a review), perinatal losses, defined as fetal death beyond 20 weeks gestation and through infant death 1 month postpartum, are especially devastating. At the same time, it is important to note that for women who have developed a very strong bond to the child early in their pregnancy, the grief of an early miscarriage can be as great as a perinatal loss (Bennett et al., 2005). Although a majority of women and their partners recover from this traumatic loss, some 15–25% have ongoing mental health complications (Bennett et al., 2005). Some develop PTSD, depression, and anxiety following the perinatal loss (Hughes, Turton, Hopper, & Evans, 2002). Turton, Hughes, Evans, and Feinman (2001) estimated the lifetime risk for PTSD following perinatal loss to be 29%; there is also an elevated risk (20%) for the development of PTSD in a subsequent pregnancy. Another longterm sequelae of perinatal loss is traumatic grief, which is a syndrome likely distinct from grief, depression, or PTSD (Bennett et al., 2005). Anecdoctal clinical evidence has long supported the notion that the shadows of such losses can persist for generations. The intensity of such feelings and their resonance throughout a woman’s life after the miscarriage must be understood as a function of what she has lost. She has lost a part of herself, the part identified in a profound way with her baby. Because she has received a “traumatizing blow” to revived identifications with her mother and with herself as a baby (Leon, 1986, p. 315), the adaptational “crisis” of pregnancy is harder to resolve. Miscarriage may reevoke earlier losses and, in particular, reawaken unresolved mourning; in our longitudinal study of pregnancy (Dermer, 1995; Slade & Cohen, 1996), miscarriage was significantly related to unresolved mourning on the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1996). Likewise, Hughes,

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Turton, Hopper, McGaulley, and Fonagy (2004) found that women who had experienced stillbirth and were pregnant with their next child were more likely to be unresolved on the AAI than pregnant women without a history of stillbirth. In addition, though an equal number of women in the stillbirth and control groups reported prior trauma, only those women who had experienced stillbirth were unresolved in relation to that trauma. Unresolved mourning scores following stillbirth were also predicted by poor support from family after the loss and having a funeral for the infant. In a related study, Hughes and her colleagues investigated whether the standard medical practice of allowing (if not encouraging) mothers to see and hold their dead infant might be associated with mental health and attachment variables. Holding the baby was associated with more adverse outcomes, such that women who had not held their infants were less likely to be depressed, and women who had held their stillborn child were more likely to be depressed. In addition, women who saw their stillborn infants were more likely to be anxious and show symptoms of PTSD following the stillbirth, and rates of disorganized attachment behavior were higher for children born subsequent to the stillbirth at 12-month follow-up. These results raise crucial questions about best practices following fetal demise and suggest that the impulse to help women work through the loss by seeing and holding the infant may sometimes be misguided, if not actually detrimental to the mothers’ mental health. The impulse to have another child is often strong following pregnancy loss. Despite the strength of such feelings, it is necessary to grieve the loss before embarking on another pregnancy (Leon, 1986; Zeanah, 1989). Given the complexity of the task of mourning a lost baby and a lost pregnancy, conception too soon after the loss threatens to truncate the mourning process and even to affect the capacity to become attached to later children. This is probably truest when loss occurs late in the pregnancy. At the same time, conception once the issues of loss and grief are diminished or following a miscarriage that occurs very early in the pregnancy may actually help in resolution and recovery (Leon, 1986; Zeanah, 1989). Great individual differences remain in the time each

woman and couple require to fully heal from the loss (Zeanah, 1989). Abortion is, of course, a different type of pregnancy loss. Some women elect to terminate a pregnancy because they do not feel ready to mother the child they are carrying. Other women terminate pregnancy for medical reasons, such as the presence of genetic defects or multiple fetuses. Elective and medical abortions are very different emotional events. Abortion in a viable pregnancy is typically carried out as early as possible within the first trimester, following a woman’s decision that she does not wish to, for whatever reason, proceed with the pregnancy. Although most women feel some, if not a great deal of, distress about the decision to abort, the wish not to proceed with the pregnancy typically forestalls the development of an attachment to the baby. Women in these circumstances do not allow themselves, as it were, to be psychologically pregnant. The more that a woman does begin to feel connected to the baby (which may occur as part of the process of her making a decision about whether to have a baby or not), the more painful the decision will be. Some women, particularly teenagers, entertain unrealistic, idealized fantasies of the baby-that-couldhave-been and of the magically reparative effect completion of the pregnancy would have had on their lives. In these instances, unresolved guilt, regret, or resentment can persist throughout adulthood. Medical abortions pose a far different challenge to women’s sense of psychological wellbeing. In such instances, both the baby(ies) and the self-as-­mother have been acknowledged; nevertheless, the mother ultimately agrees to terminate her pregnancy. Grief following abortions for fetal anomalies has been shown to be as intense as grief following spontaneous perinatal losses (Zeanah, Dailey, Rosenblatt, & Saller, 1993). In a study of multifetal abortions, women reported powerful feelings of guilt, anxiety, and sadness, despite the fact that selective terminations can increase the chances of carrying at least one fetus to full term, reduce risk to the mother, or reduce the often overwhelming burden of caring for multiple infants (McKinney et al., 1996). A number of women reported dreams of the lost fetus. Interestingly, the majority of these women appeared to recover from the acute distress



2. The Psychology and Psychopathology of Pregnancy

following the abortions, apparently because of the relief of finally giving birth to one or two healthy infants. The situation facing women who elect to abort fetuses whose ultimate survival would be profoundly compromised by genetic defect is somewhat different, because such children are expected to survive the pregnancy and birth. It is life that will be difficult for them and for their parents. Women often feel both guilt and grief at such decisions; guilt at not raising the child despite his or her damages and grief at the loss of the fantasy of a perfect baby. For the medical profession, multifetal abortions and medical abortions are necessary and sensible; for mothers and fathers, however, such procedures bring with them intense and complex feelings. These, too, must be addressed before the couple moves on in creating a family.

Teenage Pregnancy Women are physically capable of bearing children for much of their adult lives, from early in their second into their fifth decade of life. Usually, physical maturity precedes emotional maturity; most girls are capable of bearing children before they are legally able to drive a car or even hold a job. Adolescent women continue to bear children in large numbers in the United States, especially within neighborhoods populated by poor and minority families (Ventura, Abma, Mosher, & Henshaw, 2007). At present, just under half a million teenagers give birth every year, despite considerable efforts over the past 20 years to decrease these rates. For the first time in 15 years, U.S. teen birthrates rose by 3% in 2005 and 2006 (Martin et al., 2007). Because these mothers are still teenagers, they need to attend to their own adolescent developmental tasks while taking on complex maternal roles and responsibilities (Sadler & Cowlin, 2003). This dual developmental process requires much support (usually from family) as well as specialized teen-­parent support programs (Flannagan, McGrath, Meyer, & García Coll, 1995; Sadler & Cowlin, 2003; Sadler et al., 2007). Many teen mothers have significant mental health issues and academic failures that predate their pregnancies and stem from personal histories of abuse, depression, and PTSD, which often amplify their environmental

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stressors (Lesser & Koniak-­Griffin, 2000; Moore & Brooks-Gunn, 2002; Seccombe, 2000). For teen mothers, the majority of whom are also single parents, these multiple factors contribute to their difficulties in becoming healthy adults and responsive nurturing parents, in being able to negotiate critical family relationships needed to help raise their babies, in remaining in school, and in limiting rapid subsequent pregnancies (Sadler et al., 2007; Sadler, Swartz, & Ryan-­K rause, 2003). If individual emotional issues in teen mothers (e.g., depression, PTSD) and/or conflicted relationships with key family members (e.g., mothers with their own mental health or substance abuse problems) become overwhelming, outcomes such as incomplete schooling, child neglect or abuse, homelessness, rapid subsequent pregnancies, and further problems with depression or substance abuse are more likely to occur (Meadows-­Oliver, Sadler, Swartz, & Ryan-­K rause, 2007; Sadler, Anderson, & Sabatelli, 2001). It is important to note that youth is not always associated with poor outcomes, however. In many countries young women have children to no ill effect, largely due to extensive family support networks and established traditions that guide parenting. And in some families, where there is an extended network of supportive adults who can rally the teen’s strengths and provide the structures that she will need to continue her schooling, take care of herself and the baby physically, and remain emotionally present and available for the development of this new and profound attachment relationship, outcomes can be positive. As is described below, a variety of community interventions aid in the development of both internal and external resources.

INTERVENTION Psychotherapy and Psychopharmacological Interventions Given the potentially serious impact of maternal psychopathology on both fetal health and maternal caretaking abilities, obtaining appropriate treatment is of critical importance. In most cases, psychotherapy is the preferred treatment if the disturbance is mild. Psychotherapy can both help the

34

I. DEVELOPMENT AND CONTEXT

mother ameliorate her current difficulties and prepare her for transition to motherhood. Moreover, it has no biological side effects. In more severe cases, however, as when the mother’s health, judgment, or caretaking ability is seriously impaired, medication may be necessary. For example, a woman in an acute manic episode can engage in reckless and dangerous behavior, such as taking drugs, driving recklessly, or engaging in unsafe sex, that puts her fetus at risk. Although there are significant risks associated with medication, the research on the teratogenic effects of psychiatric medication on fetal and infant health is unfortunately limited. The best research designs would entail prospective, double-blind, placebo­controlled studies, in which mothers were randomly assigned to either receive or not receive various active medications. Because of the obvious ethical problems with this methodology, study designs to date all have been naturalistic, comparing women who chose to go on (or were put on) medications with those who did not. There are fairly extensive data from such studies, particularly in countries such as Sweden, with national health registries, but the possible confounds of illness severity, alcohol use, and cigarette smoking can cloud the picture. According to an extensive literature review on perinatal psychiatric disorders by MosesKolko and Feintuch (2002), most antidepressants are considered relatively safe, although they are not without risks, such as lower gestational age and even a slightly enhanced risk of miscarriage. Other medications, such as lithium, valproate acid, and other mood stabilizers, seem to have more severe risks, such as a greatly increased risk of spinal bifida, congenital malformations, and cardiac anomalies. Benzodiazepines, a class of drugs commonly used to treat anxiety, can depress fetal respiration and cause postnatal withdrawal. Atypical antipsychotics, which also can be used to treat severe cases of anxiety and depression (Galynker et al., 2005), may have fewer side effects, but as they are newer drugs and more recently brought to market, there are fewer data on their possible adverse effects in pregnant women (Moses-Kolko & Feintuch, 2002). In sum, the decision to take medication is a complex and difficult choice that a woman should make in collaboration with her family and her doctors.

Preventive Interventions with Pregnant Women and Their Families As must be evident from the above review, pregnancy is a time of enormous transition and reorganization, and as such presents a rich opportunity for intervention. Over the past 30 years, inspired by Selma Fraiberg’s pioneering work with infants and their mothers, clinicians across the United States have developed a wide range of interventions for pregnant women and their families. These include school-based support programs for teen parents (Sadler et al., 2007; Williams & Sadler, 2001); a wide array of group interventions for pregnant women, including psychotherapy services specifically targeted for pregnant women, which continue to follow the mother and baby once the baby is born; and—for the highest-risk women—home visiting programs that begin in pregnancy. Although such interventions take many shapes and forms, they are all based on the assumption that the rapid emotional, physical, and relational shifts that are intrinsic to pregnancy constitute a sort of crisis during which significant reworking and reorganization can take place. It is also a time when women, because of their enhanced vulnerability and need for support, are particularly open to forming a therapeutic relationship. It is unfortunately the case that there are relatively few clinical services available to pregnant women and their families in the United States, and few organized approaches to intervening during this developmentally challenging time. There are many reasons for these lacunae, but probably the most salient is the general failure of the health and mental health communities to truly appreciate the vulnerability of this period, and their unwitting acceptance of the shared cultural fantasy that this is a blissful and magical time of life. Only in the areas of teenage and other forms of socially high-risk pregnancy have interventions been rigorously researched and more broadly implemented. Generally aimed at families living in urban or rural poverty, whose vulnerabilities in the areas of physical and emotional health have been well-­established, the long-term success of these interventions has been most impressive. For the most part, although these interventions begin in pregnancy, they typically continue well into the baby’s first



2. The Psychology and Psychopathology of Pregnancy

year, and beyond. The most established and well-­researched form of pregnancy intervention in the United States is the Nurse–­Family Partnership (NFP), pioneered by David Olds and his colleagues (Olds et al., 2004; Olds, Sadler, & Kitzman, 2007). The program, which has been implemented in a variety of settings across the United States, is staffed by public health nurses who begin visiting mothers before babies are born, usually during the third trimester of pregnancy. Home visits continue through the baby’s second birthday, and are focused on multiple domains: self-care, baby care, parenting, attachment, and the development of life skills. Olds and his colleagues have emphasized that the effectiveness of this relationshipbased model depends upon the establishment of a relationship with the mother before the baby is born, when crucial internal consolidations are taking place. They have also emphasized that within this population the most at-risk women are those who are not organized enough to seek support services or attend community programs on their own; rather, the caregivers must come to them and work with them in the home. Olds and his colleagues have consistently found that this type of early and intensive intervention is associated with crucial longterm social, emotional, and health-­related outcomes in both mother and baby. The mothers who have most challenged even the most successful intervention programs, including the NFP, are mothers with significant mental health concerns, including trauma, neglect, and abandonment. Typically, these sorts of difficulties cannot be managed by public health nurses without extensive training and consultation (Zeanah et al., 1993). Over the past 5 years we have developed a home visiting program—­M inding the Baby (MTB)—that aims to integrate nursing and mental health services in interventions with high-risk pregnant women (Sadler, Slade, & Mayes, 2006; Slade, Sadler, & Mayes, 2005). Beginning in the third trimester of pregnancy, women are visited weekly by either a pediatric nurse practitioner or a master’s level social worker, who together and singly address the multiple and complex problems faced by these women. An essential aspect of the model is a focus on the mother’s developing reflective capacities over the course of her pregnancy

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and during the child’s first 2 years of life. This emphasis on the development of parental reflective functioning underlies all aspects of the intervention—­particularly the focus on health, mental health, parenting, and the development of attachment. In preliminary studies, mothers’ reflective functioning has improved significantly over the course of the intervention, and infant rates of secure attachment were higher (75%) than would be predicted even in normal, middle-class samples. It is important to note that mothers in our sample were extremely limited in their capacity to imagine the baby or themselves as mothers during pregnancy. Their representations and reflections were often stark in their blandness and superficiality; others were infused with conflict and unmetabolized anger and fear. After 2 years many of our mothers were surprisingly able to reflect upon their children’s mental experiences, as separate and distinct from their own, and represented the children and their relationship in ways that were dimensional, complex, and balanced. From the vantage point of mental health, ours was a very vulnerable population, with high rates of depression, PTSD, and other symptoms; in addition, a high proportion of our mothers had suffered physical abuse, sexual abuse, or abandonment. At 1 year, levels of depression had diminished, and mastery scores had improved. In addition, all immunizations were up to date, rates of breastfeeding were high, and there were no child welfare reports, no asthma, and no dental caries up to graduation at 2 years. These encouraging results underscore the importance of a multimodal team approach to the complex needs of this population, and they validate our emphasis on attachment and reflective functioning at all levels of the intervention.

CONCLUSIONS The success of a woman’s adaptation to the tasks of pregnancy is critical to the development of a healthy, flexible, and reciprocal mother–­infant relationship. It is only through such extraordinary transformation that a woman can become a “good-­enough” mother (Winnicott, 1965). All the work of pregnancy has a purpose: to ensure the de-

36

I. DEVELOPMENT AND CONTEXT

velopment of a healthy, secure, and loved child. A woman who is unable to manage the many adaptive tasks of pregnancy will find mothering more than difficult, and her child’s development will inevitably suffer in myriad ways. As Bibring and her colleagues (1961) noted long ago, pregnancy is a time ripe for intervention. However, it is also a time when rigid and distorted perceptions of the self and of the baby can be set in motion, setting the stage for a troubled pregnancy and a disturbed mother–child relationship. Thus, signs of trouble in a woman’s adaptation to pregnancy should be taken seriously by obstetricians, nurse midwives, and mental health professionals. When anger, ambivalence, depression, unrelenting anxiety, excessive somatization, or emotional disengagement define the woman’s experience during this period, intervention can be critical and should be initiated as soon as possible. Skilled and compassionate intervention is the best hope for setting the mother’s development back on course, protecting her developing relationship with her unborn child, and strengthening the foundation of the child and family’s future development. Acknowledgments We would like to thank the staff of the Pregnancy Project at the City University of New York for their many contributions to our longitudinal study of pregnancy and mothering; this project was supported by NIH/NICHHD (R01-HD24676). We would also like to thank the clinicians and staff of the Minding the Baby program at the Yale Child Study Center; their contributions have been at the heart of its success. This project has been supported by the Irving B. Harris Foundation, the FAR Fund, the Anne E. Casey Foundation, the Patrick and Catherine Weldon Donaghue Foundation, and NIH/NINR Pilot Study (P30NR08999) and NIH/ NICHD (R21HD048591).

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Storey, A. E., Walsh, C. J., Quinton, R. L., & Wynne-­E dwards, K. E. (2000). Hormonal correlates of paternal responsiveness in new and expectant fathers. Evolution and Human Behavior, 21, 79–95. Theran, S. A., Levendosky, A. A., Bogat, G. A., & Huth-Bocks, A. C. (2005). Stability and change in mothers’ internal representations of their infants over time. Attachment and Human Development, 7(3), 253–268. Trad, P. V. (1990). On becoming a mother: In the throes of developmental transformation. Psychoanalytic Psychology, 7, 341–361. Turton, P., Hughes, P., Evans, C. D., & Feinman, D. (2001). Incidence, correlates and predictors of post-­traumatic stress disorders in the pregnancy after stillbirth. British Journal of Psychiatry, 178, 556–60. Ventura, S. J., Abma, J. C., Mosher, N. D., & Henshaw, E. K. (2008). Estimated pregnancy rates by outcome for the United States, 1900–2004. National Vital Statistics Reports, 56. Wieck, A., Davies, R. A., Hirst, A. D., Brown, N., Papadopoulos, A., Marks, M. N., et al. (2003).

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Menstrual cycle effects on hypothalamic dopamine receptor function in women with a history of puerperal bipolar disorder. Journal of Psychopharmacology, 17, 204–209. Williams, E. G., & Sadler, L. S. (2001). Effects of an urban high school-based child care center on self-­selected parents and their children. Journal of School Health, 71, 47–72. Winnicott, D. W. (1956). Primary maternal preoccupation. In Through pediatrics to psychoanalysis (pp. 300–305). New York: Basic Books. Zeanah, C. H., Jr. (1989). Adaptation following perinatal loss: A critical review. Journal of the American Academy of Child and Adolescent Psychiatry, 28(4), 467–480. Zeanah, C. H., Jr., Dailey, J., Rosenblatt, M. J., & Saller, N. (1993). Do women grieve following termination of pregnancy for fetal anomalies?: A controlled investigation. Obstetrics and Gynecology, 82, 270–275. Zeigler, T. E., & Snowdon, C. T. (2000). Preparental hormone levels and parenting experience in male cotton-top tamarins, Saguinus oedipus. Hormones and Behavior, 38, 159–167.

Chapter 3

Neurobiology of Fetal and Infant Development Implications for Infant Mental Health Margaret Sheridan Charles A. Nelson

C

ontemporary models of development emphasize the relevance of a transaction between genetic predispositions and environmental pressures at all stages of development (e.g., see Zeanah & Zeanah, Chapter 1, this volume; Nelson & Bloom, 1997). The concept that development is embedded in context and that geneotypes may express a variety of phenotypes, given variation in this context, has never been more important than it is today. As the field of epigenetics adds to the previously known mechanisms by which the social and physical environment can influence the fundamental building blocks of our anatomy, it becomes increasingly clear that from the moment of conception, children are embedded in a complex context that influences all aspects of development. In this chapter we provide a selective review of some of the ways in which environment and genes interact to influence neurobiology and, subsequently, mental health. We begin by providing an overview of brain development and organization. Next we describe influences that are currently understood to impact mental health and for which the neurobiological instantiation of the mechanism of this impact is somewhat understood. Because our goal is to focus on research that is grounded in the brain sci

ences and has implications for infant mental health, we restrict our discussion to work that uses direct measures of central and peripheral nervous system activity. Peripheral nervous system activity can be assessed using physiological measures, such as measures of cortisol levels or cardiovascular reactivity. The central nervous system can be assessed using various techniques, including the electroencephalogram (EEG), which measures electrical activity at the scalp that is the result of the firing of groups of neurons, or magnetic resonance imaging (MRI), which measures the structure of the brain using magnetic fields. Additionally, since much of the experimental work on developmental neurobiology has employed animal models, we consider these when appropriate. Finally, we provide recommendations for future research, emphasizing current unknowns in the field of infant neurobiology and mental health.

BRAIN DEVELOPMENT The construction and development of the human brain occurs over a very protracted period of time, beginning shortly after conception and, depending on how one views 40



3. Neurobiology of Fetal and Infant Development

the end of development, continuing through at least the end of adolescence. Under the conditions of typical development a similar functional and structural brain organization arises for all humans. An organizing principle of this development lies in its inception in the neural tube. This group of cells, described in detail below, has a motor and sensory organization orientation whereby the dorsal face of the neural tube contains sensory inputs and the ventral surface contains motor outputs. In the developed human this organization is maintained in the spinal cord and, to some extent, in the cortex. The more anterior parts of the brain develop from the ventral surface of the neural tube, and the motor–­sensory organization occurs along the anterior–­posterior axis. Each human brain has several sucli (inner folds) and gyri (the outer portions of the fold) that are similar across individuals. These major sucli and gyri can be used as guides to identify lobes of the brain (see Figure 3.1). This lobar organization is the roughest grain of distinction by which parts of the brain, serving particular functions, can be identified.

EMBRYONIC ORIGINS OF NEURAL DEVELOPMENT In general, the development of the brain has a long trajectory, beginning within a

41

few weeks after conception and continuing through adolescence. Immediately following conception, the two-­celled zygote rapidly begins to divide into many more cells. About 1 week after conception, approximately 100 unstructured cells have been created, called the blastocyst. This group of cells changes structurally; the center becomes the embryoblast and an outer layer becomes the trophoblast. The embryoblast will give rise to the embryo itself, and the trophoblast will give rise to all of the supporting tissues, such as the amniotic sac, placenta, and umbilical cord. Over the course of the next weeks, the cells comprising the embryo undergo a transformation, forming inner (endoderm), middle (mesoderm), and outer (ectoderm) layers. The ectoderm gives rise to the central (brain and spinal cord) and peripheral nervous system in addition to the epidermis (or skin), mammary glands, pituitary gland and subcutaneous glands, and the membranes covering the brain and spinal cord (meninges). The first stage of brain development (neural induction) involves the formation of the primitive neural tube. The chemical agents responsible for the transformation of the ectodermal layer of the embryo into nervous system tissue are called transforming growth factors (Murloz-­Sanjuan & Brivanfou, 2002). As cells in the ectoderm multiply, a surface is formed known as the neural

Parietal Lobe Frontal Lobe Dorsal

Occipital Lobe

Anterior

Posterior

Orbital Frontal Cortex Ventral Cerebellum Temporal Lobe

FIGURE 3.1.  Adult brain organization. This figure illustrates the target of developmental growth by showing adult brain organization. Additionally, for reference in this and other sections, an orientation as to dorsal, ventral, anterior, and posterior is provided. Adapted from the Washington Digital Anatomist Program (www9.biostr.washington.edu.da.html). Copyright 1994 by the University of Washington. Reprinted by permission.

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I. DEVELOPMENT AND CONTEXT

plate. Next, a groove forms along a longitudinal axis, as seen in illustration B in Figure 3.2. This groove gradually begins to fold over onto itself and forms a tube. The tube begins to close on the 22nd day of gestation, and if all goes well, is completely closed by the 26th day. The further differentiation of the neural tube into the brain, formed from

FIGURE 3.2.  The process of neurulation. This figure illustrates the process whereby the primitive neural plate (derived from the outer layer of the ectodermal wall of the embryo) first thickens (due to cell proliferation) and then folds over onto itself (Panels A and B). Once this neural tube is formed, closure occurs at the top (rostral) and bottom (caudal) ends. Cells trapped inside the tube will give rise to the central nervous system, whereas those trapped between the outside of the tube and the ectodermal wall (see Panel C, “neural crest”) will give rise to the autonomic nervous system. From Kandel, Schwartz, and Jessell (1991). Copyright 1991 by McGraw-Hill Co. Reprinted by permission.

the rostral portion of the tube, and the spinal cord, formed from the caudal portion of the tube, is called neurulation (for recent review of neural induction and neurulation, see Lumsden & Kintner, 2003). Primitive neural cells (neuroblasts) inside the tube go on to make up the central nervous system, whereas cells between the outside of the tube and the ectodermal wall, called neural crest cells, make up the autonomic nervous system (the elements of the nervous system that regulate autonomic functions such as respiration, heart rate, etc.). See Figure 3.2 for a depiction of these cells. Once the tube itself is closed, the neuroblasts continue their massive proliferation of new neurons (neurogenesis), generally beginning in the fifth prenatal week and peaking between the third and fourth prenatal months (Volpe, 2000; for review, see Bronner-­Fraser & Hatten, 2003). During the peak of proliferation, it has been estimated that several hundred thousand new nerve cells are generated each minute (Brown, Keynes, & Lumsden, 2001). Between the time when the neural tube closes and the sixth prenatal week, this proliferation results in the formation of first three and then five “vesicles” (see Figure 3.3). At the top of the tube the forebrain (prosencephalon), which will eventually constitute the cerebral cortex and cerebral hemispheres (telencephalon) and the hypothalamus and thalamus (diencephalon), forms. Below the forebrain lies the midbrain (mesencephalon), and below the midbrain lies the hindbrain (metecephalon). The rest of the neural tube is the spinal cord. (For an excellent tutorial on cell proliferation, see McConnell, 1995.) We have just discussed the process of prenatal neurogenesis; with few exceptions, virtually every one of the estimated 100 billion neurons we possess (Naegele & Lombroso, 2001) has its genesis in this prenatal development. That is, unlike the rest of the body, the brain does not make new neurons after birth (with the known exception of the olfactory bulb and others, described fully below). Recent literature has noted some important exceptions, which we review briefly below. However, largely it is the case that the brain does not repair itself in response to injury or disease by making new neurons. Until recently, the assumption that the nervous system (aside from the olfactory bulb) contained at birth all the neurons it would



3. Neurobiology of Fetal and Infant Development

43

FIGURE 3.3.  Once the primitive neural tube is formed and cells begin to differentiate, the central nervous system begins to form. This figure illustrates the early three (Panel A) and then five (Panel B) vesicle stage of development. Specifically, the three major structures (forebrain, midbrain, and hindbrain) gradually differentiate to give rise to more elaborated structures, including the telencephalon and diencephalon (forebrain) and the metencephalon and myelencephalon (hindbrain) (the midbrain changes little at this point in development). From Kandel, Schwartz, and Jessell (1991). Copyright 1991 by McGraw-Hill Co. Reprinted by permission.

ever possess went unchallenged. However, new techniques have made it clear that at least some parts of the central nervous system show cells undergoing mitosis postnatally in humans (Gage, 2000), nonhuman primates (Bernier, Bédard, Vinet, Lévesque, & Parent, 2002; Gould, Beylin, Tanapat, Reeves, & Shors, 1999; Kornack & Rakic, 1999), and rodents (Gould et al., 1999).

As we describe above, there is now agreement in the field that in certain regions of the brain new cells are added for many years postnatally. Where this agreement breaks down is in determining precisely which regions experience this growth after birth. It is clear that there is new neuronal growth in the olfactory bulb and the dentate gyrus of the hippocampus. However, some research

44

I. DEVELOPMENT AND CONTEXT

reports growth in regions of the neocortex, such as the cingulate gyrus (part of the prefrontal cortex) and segments of the parietal cortex (for review and discussion, see Gould & Gross, 2002). There has also been at least one report of postnatal neurogenesis in the amygdala, piriform cortex, and inferior temporal cortex in nonhuman primates (Bernier et al., 2002; for review see Barinaga, 2003). One particularly relevant aspect of these cells is the observation that the addition of such cells can be influenced by experience (e.g., Gould et al., 1999). For example, the number of cells produced in the rodent dentate gyrus is increased when rats are placed in so-­called enriched contexts—those in which demands are placed on learning and memory. In contrast, stress in adulthood (e.g., the presence of novel odors, such as the smell of a fox) appears to modify the hippocampus by down-­regulating neurogenesis in the rat dentate gyrus (Gould, 2003). Interestingly, if these same animals are then housed in enriched environments, there is an up-­regulation of neurogenesis in the same area. These postnatal cells in the dentate gyrus and other areas of cortex may differ from prenatally derived cells. For example, postnatally derived cells appear to be normal, although they may have a relatively short half-life (Gould, Vail, Wagers, & Gross, 2001). Additionally, this revised view of neurogenesis is not without its critics (see Rakic, 2002). To return to the process of prenatal development, let us consider the period after prenatal neural proliferation has run its course (generally by the sixth prenatal week). At this time, primitive neuroblasts and glioblasts (glial cell precursors) begin to migrate outward in a radial direction. In the cerebral cortex, neuroblasts are guided to their target destination by radial glial cells, which essentially act as long tentacles onto which the migrating neuroblast attaches itself. The neuroblast is carried along the radial glial fiber until it reaches its target destination, at which point it detaches itself and takes up its final destination. As wave after wave of migrating neurons completes this cycle, eventually six layers (laminae) of the cortex are formed. Importantly, these layers are formed in an inside-out fashion, such that the deepest layers of the cortex are formed first, followed progressively by

more superficial layers. Thus, the oldest part of the cortex is also the deepest part. Finally, because neuroblasts migrate in a radial direction, perpendicular to the cortical surface, columns of related cells also form. Many such columns are thought to subserve specific functions, such as the role of ocular dominance columns in vision. As a rule, cell migration concludes by about the sixth prenatal month, after which these primitive cells begin their process of differentiation. Thus, these cells mature, begin to develop processes (axons and dendrites), and then make connections (synapses) among themselves. Moreover, in some parts of the brain the axons of neurons become coated with myelin, which increases the speed at which they conduct information from one neuron to another. These last two events— synaptogenesis and myelination—have variable courses of development, depending on what part of the brain is being discussed. With regard to myelination, we know that sensory and motor regions begin to myelinate before birth and, for the most part, are completely myelinated within the first months or possibly a year after birth. In contrast, the frontal lobe (particularly the prefrontal cortex) is probably not fully myelinated until close to adolescence (for discussion of myelination, see Jernigan & Tallal, 1990; Yakovlev & LeCours, 1967). Similarly, in terms of synaptogenesis we know that (1) some regions of the brain form synapses before others, and (2) all regions of the brain go through a phase of overproducing synapses, which is followed by a pruning back of these exuberant synapses until adult numbers are reached. For example, synapses in the visual areas of the brain reach their peak of overproduction by about the fourth postnatal month. This is followed by a gradual decline until about the end of the preschool period, when adult numbers of synapses are obtained. The auditory region of the brain follows a similar time course, although it is slightly displaced in time, so that the peak and pruning phases occur slightly later (see Huttenlocher & Dabhholkar, 1997a). Other areas of the brain have a much more prolonged time course. For instance, regions of the prefrontal cortex (e.g., middle frontal gyrus) do not reach their peak until closer to 1 year of age and then show a much more gradual decline, so it is not until adolescence



3. Neurobiology of Fetal and Infant Development

that adult numbers of synapses are obtained (for review of this literature, see Huttenlocher, 1994; see Figure 3.4 for an illustration of the differential time course of synaptogenesis). Additionally, recent structural MRI evidence suggests that the prefrontal cortex and some subcortical areas such as the basal ganglia or hippocampus have a prolonged developmental time course, reaching adult levels of grey/white matter ratios only in late adolescence and early adulthood (Lenroot & Giedd, 2006).

45

eral statement does not do justice to the age­specific changes that occur during the first two decades of life. Thus, the assembly of basic architecture occurs during the first two trimesters of fetal life, with the last trimester and the first few postnatal years reserved for changes in connectivity and function. The most prolonged changes occur in the wiring of the brain (synaptogenesis) and in making the brain work more efficiently (myelination), both of which show dramatic, nonlinear changes from the preschool period through the end of adolescence.

SUMMARY OF BRAIN DEVELOPMENT

NEURAL PLASTICITY

Overall, brain development begins within weeks of conception and continues through the adolescent period. Of course, this gen-

The classic examples of developmental plasticity are generally drawn from early sensory development. In theses examples, it appears

FIGURE 3.4.  As described in the text, synaptogenesis follows a different time course in different regions of the human brain. For example, synapses in the visual cortex peak before those in the auditory cortex, which in turn peaks before those in the frontal cortex. Similarly, the retraction of synapses to adult numbers begins sooner and completes its course first in visual, then in auditory, and finally in the frontal cortex. From Huttenlocher and Dabhholkar (1997b). Copyright 1997 by John Wiley and Sons. Reprinted by permission.

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I. DEVELOPMENT AND CONTEXT

there may be critical periods for development. A critical period is a time during development in which exposure to some environmental stimuli is required for typical brain development. Critical periods have been established for some sensory modalities such as vision. Maurer, Lewis, Brent, and Levin (1999) have reported that among infants born with cataracts that are removed and new lenses placed within months of birth, even just a few minutes of visual experience can lead to a big improvement in visual acuity. However, the longer the cataracts are left untreated, the less favorable the outcome. In the broad domain of visual function, we know that among Braille-­reading individuals who lost their sight after age 16, activation of the primary visual cortex is absent, whereas such activation is present among those who lost their sight before age 16 (Sadato et al., 1998). Such findings are also consistent with a critical period for visual function (Knudsen, 2004). Other areas of the brain and development of neural functions would be better characterized by having sensitive periods. A sensitive period is a time during development when the environment can have maximal impact on brain development. The difference between sensitive and critical periods is that the latter produces an inability to impact that aspect of brain develop later, whereas the former allows for development outside of the sensitive period time window. We know that between 6 and 12 months of age, the ability to discriminate phonemes from languages to which an infant is not exposed declines dramatically (for review, see Werker, 2006; Werker & Vouloumanos, 2001). Nevertheless, the door does not shut completely on retaining the ability to discriminate non-­native contrasts. For example, if before 12 months of age infants are given additional experience with speech sounds in a non-­native language, this ability is retained (Kuhl, Tsao, & Liu, 2003). A similar phenomenon occurs in the visual domain, specifically, in the domain of face processing. Pascalis, de Haan, and Nelson (2002) have reported that 6-month-olds, 9-month-olds, and adults are all equally good at discriminating two human faces, but only 6-month-olds can also discriminate two monkey faces. However, it is also the case that if 6-month-olds are given 3 months

of experience viewing monkey faces, they retain this ability (Pascalis et al., 2005). Thus, as is the case with speech, face processing also appears to go through a developmentally sensitive period, although one that can be extended with specific experience. Plasticity per se can be adaptive or maladaptive for the organism, depending on the experience and the brain’s response to the experience. For example, recovery from brain injury and the sparing of function in the face of brain injury are both examples of positive adaptation. On the other hand, cell death due to exposure to teratogens (e.g., alcohol) or lack of normal cell differentiation due to deprivation is clearly maladaptive. In both cases, of course, the brain has been modified by some experience. It is important to ask how this alteration occurs. We know that changes can occur at multiple levels, including physiological (e.g., the release of more neurotransmitters to compensate for cell death or damage), anatomical (e.g., the extension of existing axons into the space vacated by axons that have been deleted due to injury), and metabolic (e.g., the brain can “grow” new capillaries in response to the demand for oxygenated blood in an area being recruited for a new function, such as might occur with learning a new physical activity). All these changes can occur at virtually any point in the life cycle. However, in the context of development and the mission of this book, it would be useful to consider this problem at a more conceptual level. To do so brings us to the models of plasticity offered by William Greenough and his colleagues (for general reviews, see Greenough & Black, 1992). Greenough has proposed two mechanisms whereby synapses are formed based on experience. Experience-­expectant development refers to a process whereby synapses form after some minimal experience has been obtained. Greenough has proposed that the unpatterned, temporary overproduction of synapses dispersed within a relatively wide area of the brain during a sensitive period provides for the structural substrate of “expectation.” Subsequent retraction of synap­ ses that have not formed connections at all, or that have formed abnormal connections, then follows. The expected experience produces patterns of neural activity, targeting those synapses that will be selected for pres-



3. Neurobiology of Fetal and Infant Development

ervation. The assumption is that synaptic contacts are initially transient and require some type of confirmation for their continued survival. If such confirmation is not obtained, synapses will be retracted according to a developmental schedule or due to competition from confirmed synapses. By contrast, experience-­dependent development refers to a process unique to the individual, whereby specific and unique experiences influence brain development and function. The quintessential example of experience-­dependent development is learning, something we are capable of doing throughout the lifespan. In summary, experience-­expectant development is a time-­limited function that depends on experience occurring during a sensitive or critical period of development. In contrast, experience-­dependent development is not bound by time and can occur at any point in the life cycle. Experience-­expectant development tends to apply particularly to sensory and perceptual functions (e.g., the development of vision), whereas experience­dependent development can apply to virtually all behaviors. What remains to be seen is if the mechanisms of experience-­expectant development seen during critical periods will also be important for behaviors that merely have sensitive periods. Thus far, processes related to emotional development appear to be best described as experience-­dependent. In this chapter we focus on examples of experience-­dependent development in the sections that follow, emphasizing plasticity in the developing organism (for elaboration, see Nelson & Bloom, 1997; Nelson, deHaan, & Thomas, 2006).

Neural Plasticity and Early Stressful Experiences A significant amount of research on maternal stress has accumulated over the last 40 years or so. Much of this research has examined the mechanisms and impact of preand postnatal maternal stress on rat pups, monkeys, and human children, in addition to a significant body of literature on the direct effect of early stress on monkey and human development. The effects of stress hormones on young children’s development and the influence of the postnatal environment on the regulation of these hormones have been extensively studied. In humans,

47

the hypothalamic–­pituitary–­adrenal (HPA) axis regulates the production of cortisol, a glucocorticoid produced in response to stressful experiences (Gunnar, 1998; Stansbury & Gunnar, 1994). In the study of the effects of stress on brain development, researchers have made extensive use of animal models. Though animal brain development is, clearly, not identical to human brain development, parallels between animal and human brain systems have been found, and many researchers believe that animal data can inform us about human brain development. Animals are often used in place of humans as subjects when the use of human subjects would be impossible and/ or unethical. In addition, many animals can be exposed to a particular environment that only seldom occurs in human populations, allowing researchers to better understand the effect of that environment on brain development. In the following section we consider rodent, monkey, and human studies of the effect of stress on neurodevelopment. When individuals experience a frightening, novel, or otherwise stressful stimulus, a stress response begins with two stages. First a sympathetic response, mediated primarily by catecholamines (epinephrine and neuroepinephrine) is activated within a few seconds of the onset of stress. If the stressful stimulus is sufficient, after a few minutes, the HPA response begins. The activation of the HPA axis leads to a release of glucocorticoids and eventually cortisol which, in humans, can be detected in the periphery approximately 30 minutes after the onset of a stressor. Areas in the central (hippocampus) and peripheral (adrenal gland) nervous system have glucocorticoid receptors that are activated by the pituitary release of these hormones. Because the activity of the HPA axis is thought to be sensitive to emotion processes, and because activity of the system can be measured noninvasively via levels of cortisol in samples of saliva, the HPA axis has been a popular area of investigation in the study of infant emotion processes and brain development (Stansbury & Gunnar, 1994). Studies of humans and other primates have attempted to elucidate the relationship between maternal stress, early adversity, and child developmental outcomes. In the rhesus macaque, a condition called peer rearing has been studied extensively. In this condi-

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I. DEVELOPMENT AND CONTEXT

tion, monkeys are taken from their mothers after birth and reared with their same-age peers. This environment leads to significant increases in anxiety and aggression (Soumi, 2006). Given this information and the findings in rats, reviewed above, we would predict that environments with little opportunity for a sensitive primary attachment figure would result in profound neurodevelopmental changes. One example of such an environment would be institutions in which children are raised. However, the animal literature further predicts that these developmental changes may be similar in nature, if not degree, to those produced by natural variation in maternal behavior in humans. It seems likely that when measured in humans, HPA axis activation to novelty or stress and serotonin activity will be affected. Because of ethical limits on the kinds of techniques and studies that can be completed in humans, and because of the increased complication of the human system, the measures used to understand child neurobiology are significantly different from those used in most animal studies. The glucocorticoid response to a novel or stressful situation as measured by salivary cortisol can continue to be used as a measure of HPA axis reactivity. However, in humans, central serotonergic function is more difficult to assess, and multiple proxy variables or associated variables are used. One example is the use of hippocampal volume and function in children and adults. As described earlier, the hippocampus is a subcortical structure known to play an important role in learning and memory. The size of the hippocampus can be assessed in children and adults noninvasively using MRI techniques. Additionally, given its clear involvement in memory formation, memory and learning behavior and associated neural correlates can sometimes be used to assess hippocampal function. This area is significant to the research we have been reviewing because it is richly innervated by glucocorticoid receptors. However, other areas of the brain, including medial and lateral frontal regions (that are thought to be involved in effortful attention, inhibitory control, and self-­regulation of emotion and behavior) and the amygdala (that has been implicated in fear and stress reactions) appear to have high levels of glucocorticoid receptors (Gunnar, 1997, 1998)

and may also be affected by early experience. Let us begin with variations in maternal behavior in the human. Because of its complicated nature, the effects of variation in maternal behavior have been studied in a variety of ways in humans. There has been investigation of lack of caregiver attention, as in institutionalized children, and unpredictable and dangerous caregiving, as in abusive and neglectful parenting. Either of these can be conceptualized as early stressors to the child. Additionally, some work has examined normal variation in caregiving, as in attachment style or maternal sensitivity. Finally, extensive work has considered the role of maternal depression in the modulation of caregiving behavior. These last two may be conceptualized as mechanisms by which environmental or maternal stressors effect child development. As described earlier, institutionalization has a profoundly negative effect on child development. In an ongoing study (Bucharest Early Intervention Project [BEIP]) three groups of children are being followed from infancy through middle childhood. An institutionalized group is composed of children who have lived virtually their entire lives in institutional settings in Bucharest, Romania. A foster care group includes children who were institutionalized at birth and then, following an extensive baseline assessment, randomly assigned to foster care (the mean age of placement was 22 months). Finally, a never-­institutionalized group includes children living with their biological families in the greater Bucharest community (for details, see Zeanah et al., 2003). The findings from this study have been reported and reviewed in a variety of outlets (see Nelson, Zeanah, & Fox, 2007, for a recent overview). Significant differences in psychopathology were found between the institutionalized group and foster care group in that the latter had significantly fewer internalizing disorders than the institutionalized group. Thus, in contrast to internalizing disorders, foster care has shown no beneficial effects on reducing the symptoms of attention-­deficit/ hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). The rates for the never-­institutionalized group were similar to those of comparison samples in the United States and hence significantly lower



3. Neurobiology of Fetal and Infant Development

than for either of the experimental groups. Collectively, this study demonstrates that early psychosocial deprivation appears to be causally related to subsequent psychopathology, and that foster care is more effective in reducing symptoms of internalizing versus externalizing disorders. It has been amply demonstrated that adults who have survived early stressful experiences such as abuse as children are at increased risk for posttraumatic stress disorder (PTSD) and major depressive disorder (Caspi et al., 2003; Gilbertson et al., 2002). These adults also show reduced hippocampal volume and, in some instances, impairments in memory as a result (Bremner et al., 1997; Stein, Koverola, Hanna, Torchia, & McClarty, 1997). It is thought that the mechanism for action is the neurotoxic effects of circulating glucocorticoids on the hippocampus (see Nelson & Carver, 1998, for a review of the effects of stress on brain and memory development). In one study comparing twins who both experienced early abuse but only one of whom experienced combat as an adult, combat-­related PTSD was associated specifically with the effects of early stress on hippocampal volume (Gilbertson et al., 2002). It may be that early childhood abuse results in modulations of reactivity to fear-­related stimuli that makes individuals more vulnerable to PTSD in adulthood. Finally, in humans, as in other animals, natural variation in maternal sensitivity appears to be related to cortisol reactivity and potentially, psychopathology. The role of maternal sensitivity in modulating the later stress response can be conceptualized in a number of ways. Gunnar (1998) provides the following conceptualization: If elevated levels of glucocorticoids may deleteriously effect the development of the brain (e.g., reducing hippocampal volume) and, consequently, the development of competent cognitive and emotional functioning (e.g., HPA axis reactivity), evolution has likely built in mechanisms to keep these hormones at low levels during infancy. In Gunnar’s conceptualization, one of these mechanisms is maternal sensitivity. At birth, the neonate’s HPA system is highly reactive and labile (Gunnar, Brodersen, Krueger, & Rigatuso, 1996). Between 2 and 6 months of age, the infant’s stress systems are becoming organized via the transaction

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between the child and a sensitive caregiver, who buffers the reactivity of the HPA axis (Gunnar, Brodersen, & Rigatuso, 1993). Gunnar et al. (1993) found that infants who gave clear signals of their distress at 2 months and who had sensitive and responsive caregivers were likely to have an effective stress­regulatory system under maternal or dyadic regulation by 6 months of age. Stressful experiences that are not properly regulated by the caregiver before the infant is capable of self-­regulation likely influence the development of particular brain structures and reactivity of the HPA axis (Gunnar, 1997). Early repeated or chronic activation of the HPA axis, either by early stressful experiences or lack of maternal buffering against these experiences, may promote the development of anxiety difficulties and/or more anxious temperaments. Certainly, the evidence reviewed above is consistent with this view in both animals and humans. Consistent with the idea that the quality of the attachment relationship has been associated with the ability of the caregiver to buffer the activity of the HPA axis, Spangler and Grossmann (1993) found that infants who demonstrate a secure attachment relationship also demonstrate lower cortisol levels after the stressor of the Strange Situation than do insecurely attached infants. Additionally, evidence has accumulated that infant cortisol reactivity is linked with maternal cortisol reactivity, particularly when infants and mothers are physically together (Thanh Tu et al., 2007; Thompson & Trevathan, 2008). It has been hypothesized that the variable mediating the relationship between attachment status or maternal sensitivity and HPA axis activity may be the infant’s sense of his or her ability to cope with stress. According to Gunnar (1993), it is not stressors but rather the child’s appraisal of his or her ability to cope with stressors in the environment that influences the activity of the HPA axis. If adequate coping resources are available, including the child’s own competencies and resources, the child’s HPA stress response may be reduced or prevented, even in the face of great stressors (Gunnar, 1994). Presumably, securely attached children have a history of responsive and sensitive caregiving, whereas insecurely attached children have a history of inconsistent and/or rejecting

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I. DEVELOPMENT AND CONTEXT

caregiving. Securely attached children can depend on their caregivers to respond appropriately as a buffer to stress, whereas the insecurely attached children cannot depend on their caregivers to respond appropriately. Therefore, securely attached children may be more likely than insecurely attached children to judge their coping resources to be adequate in the face of stressors and consequently show less of a physiological response to stress. Nachmias, Gunnar, Mangelsdorf, Parritz, and Buss (1996) found that infants who were both insecurely attached and temperamentally prone to approach new situations with caution were particularly at risk for elevated stress reactivity, as these infants were especially prone to experience novel events as possibly threatening and to expect their caregivers to be ineffective in buffering them from the effects of stress. One situation in which mothers are unlikely to adequately buffer their infants from external stressors is when the mothers are depressed. Transmission of increased risk for psychopathology from mother to child could be both genetic and environmental. Researchers have speculated on how depression may influence brain development by considering what is known about depressed maternal behavior and what is thought to be critical for healthy emotional development in the infant. In normal mother–­infant interactions, the mother regulates her behavior to meet the needs of her infant so that the infant is appropriately stimulated (Field, Healy, Goldstein, & Guthertz, 1990). Optimally, the mother’s and infant’s attentive and affective behaviors become synchronized. In the depressed mother–­infant dyad, the depressed mother is often emotionally unavailable or affectively unresponsive; consequently, the infant may experience behavioral disorganization, and the mother’s and infant’s attentive/affective behaviors would become desynchronized. Field et al. (1990) suggested that such desynchronization leads to failure of the infant to develop arousal modulation and organized attentive/affective behavior. Many studies confirm that depressed mothers engage in less optimal interactional behavior with their infants than do nondepressed mothers. Lack of attentive/affective synchronization and exposure to high levels of negative affectivity has been found among depressed mother–­infant dyads (see Good-

man & Brand, Chapter 9, this volume). These effects may have a significant impact on the pruning of synapses and organization of neuronal groups, particularly during the first 2 years of life. Exposure to increased levels of maternal negativity, including flat affect, withdrawal, and intrusiveness, may lead to amplification of neuronal groups associated with negative affectivity and withdrawal behavior (i.e., in the right prefrontal cortex), and lack of exposure to sufficient levels of positive affectivity may lead to pruning of synapses associated with positive, approach behavior (i.e., in the left prefrontal cortex). This pattern of amplification and pruning would be expected to be reflected in relative right frontal asymmetry, a pattern commonly found among infants of depressed mothers when investigated using EEG. Once established, the cortical maps become progressively less vulnerable to change (Dawson, Hessl, & Frey, 1994). These maps guide the infant in interpreting future experiences with the external environment (Dawson et al., 1994). If exposure to maternal behavior influences infant emotional development, infants should demonstrate sensitivity to long-term effects from exposure to maternal depression during the first few years of life. Although researchers have had difficulty separating the effects of chronicity and severity of maternal depression from that of timing, there is evidence that infants are particularly sensitive to the effects of maternal depression between 6 and 18 months of age (Alpern & Lyons-Ruth, 1993; Dawson, Frey, Panagiotides, Osterling, & Hessl, 1997; Dawson et al., 1994). A number of studies have found that exposure to maternal depression during this period predicts emotional and cognitive difficulties during the preschool and early school years, regardless of mothers’ depression status during these later years (Alpern & Lyons-Ruth, 1993; Wolkind, Zajicek­Coleman, & Ghodsian, 1980). Additionally, Dawson et al. (1997) found that the number of postnatal months of maternal depression was significantly related to infant frontal EEG pattern, whereas the number of prenatal months of maternal depression was not. This finding suggests that exposure to the depressogenic environment may be necessary to produce the atypical EEG patterns seen in infants of depressed mothers.



3. Neurobiology of Fetal and Infant Development

Finally, some studies have demonstrated increased cortisol reactivity in children of depressed mothers (Essex, Kline, Cho, & Kalin, 2002). This finding indicates that differences in infant emotionality may be related to the same systems that are modified by parenting in other species and conditions. However, it is noteworthy that findings relating differences in maternal behavior associated with depression to child emotional outcomes usually consider other mechanisms. (For a more complete discussion of child emotion and frontal asymmetry, see below.) It is additionally of note that, in humans, a variety of findings linking cortisol and maternal variation in behavior have been noted, including low baseline cortisol, interpreted by some as blunted HPA axis reactivity (Schechter et al., 2004), which contrasts considerably with hypothesized and described increased HPA axis reactivity.

Summary of Neural Plasticity Collectively, it is clear that early deleterious experience can have significant negative effects on the developing brain that may persist well into childhood and beyond. It is likely that maternal care has such a dramatic effect on neurobiology at this time period because infancy is a critical point for the development of these systems. Clearly, the developing brain can be profoundly influenced by experience. Here we have discussed particular experiences that appear to impact neural development most during the first few years of life and that are frequently mediated by the parent–child relationship. It is particularly worthy of note that numerous experiences can affect neurobiology later in life, as the growing child continues to learn and develop. As the child extends his or her sphere of experience far outside the parent–child relationship, these experiences may directly affect the child and be less mediated by the parent–child interaction.

NEUROBIOLOGY OF INFANT TEMPERaMeNT Many differences in infant emotional expression have been linked to temperament, the early and stable emotional predispositions

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that appear to modulate the interaction between the child and his or her environment. In human and some nonhuman primates, rearing differences are modulated by allelic variation. It has been argued elsewhere that the effectiveness of humans at niche exploitation is the result of greater allelic variation. That is, the within-­species variety in phenotypic expression, particularly as an interaction with environmental stimuli, leads to increased ability to exploit a variety of environments (Soumi, 2006). One method researchers have used to study infant brain development, which has been of particular use in understanding the emotional life of infants, is the EEG. Scientists have employed EEG methods to study regional brain activity that generates emotion and affective style (Davidson, 1994b). The EEG reflects (1) the background electrical activity that exists in the brain at all times and (2) the summation of pools of neurons that conduct their electrical charges (brought about by synaptic activity) through extracelluar currents to the surface of the scalp. EEG recordings are taken by placing electrodes over several sites on the scalp. The electrical activity from each site is measured and analyzed compared to a baseline reference point (usually an electrode on the face). Analyses can also compare relative levels of activity at each of the sites.

Background to EEG and Emotion Much of the research using EEG measures in infants has explored the role of the prefrontal cortex in emotion generation and regulation. The prefrontal cortex is singularly capable of integrating all the elements required to generate and planfully regulate emotional expression because it has a unique neural circuitry connecting it in reciprocal relationships to the parietal and temporal regions, the limbic system, and basal ganglia (Nauta, 1971). Researchers have hypothesized that the right and left prefrontal cortex acts in concert as an approach–­withdrawal system, with the left hemisphere specialized for approach­related behaviors and emotions such as joy, interest, and anger. The right hemisphere is specialized for withdrawal-­related behaviors and emotions such as anxiety, distress, sadness, and disgust and associated with be-

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I. DEVELOPMENT AND CONTEXT

havior such as crying (Dawson, 1994a; Fox, 1994).

Studies with Infants According to Fox (1994), the approach–­ withdrawal dichotomy is present at birth, and the neonate’s initial responses to the environment are largely based on the approach versus withdrawal continuum rather than on discrete emotional responses. Infants expand their range of emotional states by adding and integrating new motor patterns associated with either approach or withdrawal, so that by the end of the first year, the approach–­ withdrawal dichotomy has been differentiated to embody the “basic” emotions that most 1-year-olds experience, including joy, interest, anger, distress, disgust, and fear (Fox, 1994). As the prefrontal cortex and corpus callosum (the bundle of fibers that connects the two hemispheres) develop over the first few years of life emotional responses become further differentiated and more complex (Fox, Bell, & Jones, 1992). Fox and Davidson (1986) have presented evidence that patterns of asymmetric frontal lobe activation, correlating with affective behavior, are present in the neonate. This and other evidence has led Davidson and others to suggest that these individual differences in emotional reactivity are influenced by trait-like individual differences in baseline asymmetry (Davidson, 1994a). Fox et al. (1992) proposed that the combination of the level of arousal of each hemisphere and the communication between hemispheres interacts to produce individual differences in response to specific emotional stimuli. Therefore, as the infant develops, the asymmetry patterns become a more solidified trait, though still susceptible to short-term changes in response to contextual influences (e.g., exposure to strong affective elicitors). Studies have demonstrated that there is modest stability in asymmetry scores between individuals by the second half of the first year of life (Bell & Fox, 1994). And this difference has been linked to temperament: High-­reactive infants who were more likely to cry at maternal separation across age demonstrated greater relative right frontal activation, whereas infants who were not likely to cry showed greater relative left

frontal activation (Kagan, Snidman, Kahn, & Towsley, 2007). The tendency to approach or withdraw appears to be stable in childhood and across time in adulthood; however, these tendencies can be influenced by early experiences (Davidson, Ekman, Saron, Senulis, & Friesen, 1990). For example, fearful individuals can learn to approach rather than withdraw from the object they fear (Davidson et al., 1990). Although approach or withdrawal behavior patterns may change as the result of experience, the original frontal asymmetry patterns may remain (Fox, Calkins, & Bell, 1994). Dawson and colleagues (e.g., Dawson, 1994; Dawson, Panagiotides, Grofer Klinger, & Hill, 1992) have suggested that it is necessary to study overall frontal activity level as well as electrocortical asymmetry to understand emotional reactivity and regulation. According to Dawson (1994), emotions can be characterized along two domains: type and intensity. She has speculated that measures of asymmetry predict individual differences in types of emotions expressed, whereas the amount of generalized frontal activity predicts differences in emotional reactivity and intensity. The two measures are uncorrelated in individuals: Expressions of both happiness and sadness were associated with general increases in activity over the frontal cortex (Dawson et al., 1992). As described above, the development of individual patterns of brain activation is believed to be the result of a continual transactional process between genetically coded programs for the formation of structures and the connections among structures and environmental influence. One manner in which genetic makeup is believed to exert its influence is via temperament. Kagan and Snidman (1991) have defined temperament as the “variety of initial, inherited profiles that develop into different envelopes of psychological outcomes” (p.  856). According to Bell and Fox (1994) and Calkins, Fox, and Marshall (1996), a child’s temperament can be represented by his or her pattern of frontal asymmetry, which is indicated via his or her threshold for positive and negative reactivity and the intensity of his or her reaction to stimuli. Researchers have found that the emotional



3. Neurobiology of Fetal and Infant Development

response to single stimuli is correlated with frontal asymmetry recorded previously in the same adult or child (Davidson & Fox, 1989; Wheeler, Davidson, & Tomarken, 1993). For instance, Wheeler and colleagues (1993) found that individual differences in the quality and intensity of adult subjects’ responses to positive and negative film clips were related to baseline asymmetry measured 3 weeks prior to the viewing of the clips. Individuals with stable, increased leftsided and decreased right-sided frontal activation described more intense positive affect in response to positive films, compared to the other subjects; subjects with increased right-sided frontal activation described more negative responses to the negative films, compared to subjects with other patterns of baseline asymmetry. Studies measuring electrocortical activity have begun to shed light on the possible underpinnings of the temperamental construct “behavioral inhibition.” Calkins et al. (1996) have defined behavioral inhibition as the tendency to withdraw and display negative affect in response to new people, places, events, and objects. Behaviorally inhibited children tend to find unfamiliar or challenging events more stressful than do noninhibited children (Reznick et al., 1986). According to Kagan and colleagues, behavioral inhibition is a categorical construct, with 10% of healthy, white American children displaying extreme behavioral inhibition; these children represent a qualitatively different group of individuals, both behaviorally and biologically, from the remaining 90% (Kagan, Reznick, & Gibbons, 1989; Kagan & Snidman, 1991; Reznick et al., 1986). Inhibited children, like depressed adults, exhibit left frontal hypoactivation (Davidson, 1992, 1994a; Henriques & Davidson, 1990), compared to their peers. Davidson (1994a) suggested that these findings indicate that inhibited children, who are wary to approach novel objects and people, may have an approach deficit (as opposed to an overactive withdrawal system). Frontal asymmetry may also be related to a vulnerability to certain psychopathologies. Davidson (1992) proposed that a small percentage of children with the physiological profile of the inhibited child may be vulnerable to psychopathology, such as an affective disorder, in the face of relatively extreme

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life stressors later in life. However, a larger percentage may be vulnerable to subclinical characteristics such as dysthymic mood, shyness, and decreased positive affect (Davidson, 1992). This vulnerability may be related to the association between right-sided frontal asymmetry and temperament; however the independence of the contribution of frontal asymmetry to predicting these outcomes has not yet been determined. Dawson and colleagues (e.g., Dawson, Grofer Klinger, Panagiotides, Hill, & Spieker, 1992; Dawson, Grofer Klinger, Panagiotides, Spieker, & Frey, 1992) have conducted a series of experiments to examine the relation between maternal depressive symptomatology and infant prefrontal cortex development, and they have found several differences in the EEG patterns between infants of nonsymptomatic and symptomatic mothers. Though the hypothesis that the negative affect and mood common among infants of depressed mothers may reflect an endogenous trait cannot be dismissed, several researchers have suggested that infants of depressed mothers demonstrate relative right frontal EEG asymmetry as the result of repeated exposure to a depressed mother. It may be that inhibited temperament and accompanying right–left asymmetry in activation over frontal cortex, as measured by EEG, are ways of describing the phenotype associated with a vulnerable genotype (e.g., in stress the presence of at least one short allele on the 5-HTT gene). On the other hand, inhibited temperament and EEG frontal asymmetry may simply be the phenotypic result of a gene–­environment interaction. Dawson et al. (1994) have noted that vulnerability to depressed mothering may be due to the state of the prefrontal cortex and the salient developmental tasks to be achieved during that period of development. From 6 to 18 months, there is a rapid growth of the prefrontal cortex as well as a period of synaptic excess in this region (Chugani & Phelps, 1986; Dawson et al., 1994; Huttenlocher, 1979). Because the prefrontal cortex plays a critical role in the development of self-­regulatory behaviors during this time, and because these self-­regulatory behaviors are heavily influenced by parental behavior, the period of 6–18 months may be a time of particular vulnerability to the effects of ma-

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I. DEVELOPMENT AND CONTEXT

ternal depression on prefrontal cortex development and the ability to regulate emotion (Dawson et al., 1994). The way in which maternal depression influences frontal activity in the infant is not well understood. However, in the context of the literature (reviewed above) on the influence of variations in maternal care on neurodevelopment, it seems reasonable to conclude that this relationship may involve more than the genetic transmission of temperamental predisposition.

Summary of Infant Temperament The prefrontal cortex plays a critical role in emotion generation and regulation from an early age. This region of the brain appears to be dichotomized into an approach–­ withdrawal system, with the approach system localized to the left prefrontal cortex and the withdrawal to the right prefrontal cortex. The relative activation and interaction of the left and right prefrontal cortices are thought to be associated with individual patterns of emotional reactivity. Research also suggests that individual activation patterns are initially somewhat plastic and become more fixed over time. These differences may be related to what has been described as infant temperament—that is, stable patterns of emotional reactivity that appear to influence childhood and adult behavior and psychopathology. Indeed, despite our discussion of temperament, in this, as in the previous section, we present significant evidence for the interaction between environment and individual variables in shaping infant and adult neurobiology

CONCLUSIONS Our goal in writing this chapter was to provide a framework for considering how research in the brain sciences can facilitate our understanding of infant mental health. We began by providing an overview of brain development. Here we demonstrated that even as early as the first months after conception, the embryonic and fetal brain can be influenced by exogenous factors, such as maternal stress. We then proceeded to show that experiential effects on brain development continue postnatally. Indeed, aside from sensory

functions (e.g., the development of the visual system or the speech system onto which the language system scaffolds itself) and possibly some aspects of emotional development, we made it clear that experience can exert its influence on brain development well beyond the first years of life. It is likely that this long period of influence is made possible by two events. The first is the relatively long trajectory of overproducing synapses and then the retraction of these exuberant connections based on experience. The second is the potential for synapses to be altered by experience at many points in the lifespan (e.g., increased dendritic arborization due to experience). In this section, we illustrated the usefulness of animal models in understanding early development by extensively describing recent work in the rodent and monkey that demonstrates the importance of parenting in shaping neurobiology. The potential for the brain to be modified by experience was richly illustrated by the next topic we discussed: the relation between brain and affect as measured by the EEG. Here it was made clear that infants of depressed mothers show altered patterns of EEG activity, suggesting that these patterns may have come about in response to exposure to maternal depression. Unfortunately receiving far less study are the effects of positive rearing experiences on infant brain development; for example, we do not know whether there are beneficial effects to being reared by highly competent, sensitive caretakers, and if there are, how these effects would be manifested by the EEG, and whether there is a critical or sensitive period for these effects to be realized. In a related fashion, we know nothing about protective factors, such as those that might transpire in a family with a depressed mother but with an infant of positive temperament and an otherwise high-­functioning family. Finally, also unknown is the extent to which we can intervene in the life of the “atrisk” (for depression or other internalizing disorders) infant, based on the principles of neuroscience. It is desirable to think that the trajectory of infants affected by negative experiences can be positively altered by intervening life events, such as by (1) successfully treating the mother’s depression or (2) providing the infant with compensatory experiences. Again, going to the rodent model, a



3. Neurobiology of Fetal and Infant Development

recent paper demonstrated that differences in adult HPA axis reactivity resulting from early stressful experiences in rats could be reversed by the application of enriching environments during the pubertal period (Francis, Diorio, Plotsky, & Meaney, 2002). It should be apparent that we have much work ahead of us. A particular area of need lies in the development of methods that are suitable for studying the relation between brain development and behavioral development. In addition, we also need adequate conceptualization as to what risk and protective factors mean in the context of neural plasticity. Finally, we need a better understanding of the role of intervention in modifying the relationship between early experience and pathology. The last 10 years have seen increased information on these topics. It continues to be of utmost importance, we believe, that research in the behavioral and neurosciences mutually inform each other. It is our hope that investigators in both research areas continue to join forces to present a unified front in improving our understanding of infant development and in creating intervention programs that are based on sound neuroscientific principles. Acknowledgments We would like to thank Michelle Bosquet for her numerous helpful contributions to the writing of this chapter. Writing of this chapter was made possible, in part, by a grant to Charles A. Nelson from the National Institutes of Health (No. MH078829); by an endowment created by Richard and Mary Scott to Charles A. Nelson; and by a fellowship from the Robert Wood Johnson Foundation program for Health and Society Scholars to Margaret A. Sheridan.

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Smaller hippocampal volume predicts pathologic vulnerability to psychological trauma. Nature Neuroscience, 5(11), 1242. Gould, E. (2003, July). Neurogenesis in the adult brain. Paper presented at the Merck Summer Institute on Developmental Disabilities, Princeton University, Princeton, NJ. Gould, E., Beylin, A., Tanapat, P., Reeves, A., & Shors, T. J. (1999). Learning enhances adult neurogenesis in the hippocampal formation. Nature Neuroscience, 2, 260–265. Gould, E., & Gross, C. G. (2002). Neurogenesis in adult mammals: Some progress and problems. Journal of Neuroscience, 22, 619–623. Gould, E., Vail, N., Wagers, M., & Gross, C. G. (2001). Adult-­generated hippocampal and neocortical neurons in macaques have a transient existence. Proceedings of the National Academy of Sciences USA, 98, 10910–10917. Greenough, W. T., & Black, J. E. (1992). Induction of brain structure by experience: Substrates for cognitive development. In M. R Gunnar & C. A. Nelson (Eds.), Minnesota symposia on child psychology: Vol. 24. Developmental behavioral neuroscience (pp.  155–200). Hillsdale, NJ: Erlbaum. Gunnar, M. R. (1993, March). Adrenocortical reactivity: Who is more stress vulnerable, the inhibited or bold child? Paper presented at the biennial meeting of the Society for Research in Child Development, New Orleans, LA. Gunnar, M. R. (1994). Psychoendocrine study of temperament and stress in early childhood: Expanding current models. In J. Bates & T. D. Wachs (Eds.), Temperament: Individual differences at the interface of biology and behavior (pp. 175–198). New York: American Psychological Association. Gunnar, M. R. (1998). Quality of early care and buffering of neuroendocrine stress reactions: Potential effects on the developing human brain. Preventive Medicine, 27, 208–211. Gunnar, M. R., Brodersen, L., Krueger, K., & Rigatuso, J. (1996). Dampening of adrenocortical responses during infancy: Normative changes and individual differences. Child Development, 67, 877–889. Gunnar, M. R., Brodersen, L., & Rigatuso, J. (1993, March). Infant and parent contributions to the organization of adrenocortical stress reactivity. Paper presented at the biennial meeting of the Society for Research in Child Development, New Orleans, LA. Henriques, J. B., & Davidson, R. J. (1990). Regional brain electrical asymmetries discriminate between previously depressed and healthy control subjects. Journal of Abnormal Psychology, 99, 22–31. Huttenlocher, P. R. (1979). Synaptic density in human frontal cortex: Developmental changes and effects of aging. Brain Research, 163, 195– 205. Huttenlocher, P. R. (1994). Synaptogenesis, synapse elimination, and neural plasticity in human ce-



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rebral cortex. In C. A. Nelson (Ed.), Minnesota symposia on child psychology: Vol. 27. Threats to optimal development: Integrating biological, psychological, and social risk factors (pp.  35– 54). Hillsdale, NJ: Erlbaum. Huttenlocher, P. R., & Dabhholkar, A. S. (1997a). Regional differences in synaptogenesis in human cerebral cortex. Journal of Comparative Neurology, 387, 167–178. Huttenlocher, P. R., & Dabholkar, A. S. (1997b). Developmental anatomy of the prefrontal cortex: Evolution, neurobiology, and behavior. Baltimore: Brookes. Jernigan, T. L., & Tallal, P. (1990). Late childhood changes in brain morphology observable with MRI. Developmental Medicine and Child Neurology, 32, 379–385. Kagan, J., Reznick, J. S., & Gibbons, J. (1989). Inhibited and uninhibited types of children. Child Development, 60, 838–845. Kagan, J., & Snidman, N. (1991). Temperamental factors in human development. American Psychologist, 46, 856–862. Kagan, J., Snidman, N., Kahn, V., & Towsley, S. (2007). The preservation of two infant temp­ eraments into adolescence. Monographs of the Society for Research on Child Development, 72(2). Kandel, E. R., Schwartz, J. H., & Jessell, T. M. (1991). Principles of neural science. New York: McGraw-Hill. Kornack, D. R., & Rakic, P. (1999). Continuation of neurogenesis in the hippocampus of the adult macaque monkey. Proceedings of the National Academy of Sciences, 98, 5768–5773. Knudsen, E. I. (2004). Sensitive periods in the development of the brain and behavior. Journal of Cognitive Neuroscience, 16(8), 1412–1425. Kuhl, P. K., Tsao, F. M., & Liu, H. M. (2003). Foreign-­language experience in infancy: Effects of short-term exposure and social ­interaction on phonetic learning. Proceedings of the National Academy of Sciences, 100, 9096–9101. Lenroot, R. K., & Giedd, J. N. (2006). Brain development in children and adolescents: Insights from anatomical magnetic resonance imaging. Neuroscience and Biobehavioral Reviews, 30(6), 718–729. Lumsden, A., & Kintner, C. (2003). Neural induction and pattern formation. In L. R. Squire et al. (Eds.), Fundamental neuroscience (2nd ed., pp. 363–390). New York: Academic Press. Maurer, D., Lewis, T. L., Brent, H. P., & Levin, A. V. (1999). Rapid improvement in the acuity of infants after visual input. Science, 286(5437), 108–110. McConnell, S. K. (1995). Strategies for the generation of neuronal diversity in the developing central nervous system. Journal of Neuroscience, 15, 6987–6998 Murloz-­Sanjuan, I., & Brivanfou, A. H. (2002). Neural induction: The default model and embryonic stem cells. Nature Reviews Neuroscience, 3(4), 271–280.

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Nachmias, M., Gunnar, M., Mangelsdorf, S., Parritz, R. H., & Buss, K. (1996). Behavioral inhibition and stress reactivity: The moderating role of attachment security. Child Development, 67, 508–522. Naegele, J. R., & Lombroso, P. J. (2001). Genetics of central nervous system developmental disorders. Child and Adolescent Psychiatric Clinics of North America, 10, 225–239. Nauta, W. J. H. (1971). The problem of the frontal lobe: A reinterpretation. Journal of Psychiatric Research, 8, 167–187. Nelson, C. A., & Bloom, F. E. (1997). Child development and neuroscience. Child Development, 68, 970–987. Nelson, C. A., & Carver, L. (1998). The effects of stress and trauma on brain and memory: A view from developmental cognitive neuroscience. ­Development and Psychopathology, 10, 793–809. Nelson, C. A., de Haan, M., & Thomas, K. M. (2006). Neuroscience and cognitive development: The role of experience and the developing brain. New York: Wiley. Nelson, C. A., Zeanah, C. H., Jr., & Fox, N. A. (2007). The effects of early deprivation on brain–­ behavioral development: The Bucharest Early Intervention Project. In D. Romer & E. Walker (Eds.), Adolescent psychopathology and the developing brain: Integrating brain and prevention science (pp.  197–215). New York: Oxford University Press. Pascalis, O., de Haan, M., & Nelson, C. A. (2002). Is face processing species specific during the first year of life? Science, 296, 1321–1323. Pascalis, O., Scott, L. S., Kelly, D. J., Dufour, R. W., Shannon, R. W., Nicholson, E., et al. (2005). Plasticity of face processing in infancy. Proceedings of the National Academy of Sciences, 102, 5297–5300. Rakic, P. (2002). Adult neurogenesis in mammals: An identity crisis. Journal of Neuroscience, 22, 614–618. Reznick, J. S., Kagan, J., Snidman, N., Gersten, M., Baak, K., & Rosenberg, A. (1986). Inhibited and uninhibited children: A follow-up study. Child Development, 57, 660–680. Sadato, N., Pascual-Leone, A., Grafman, J., Deiber, M., Ibanez, V., & Hallett, M. (1998). Neural networks for Braille reading by the blind. Brain, 121(7), 1213–1229. Schechter, D. S., Zeanah, C. H., Jr., Myers, M. M., Brunelli, S. A., Liebowitz, M. R., Marshall, R. D., et al. (2004). Psychobiological dysregulation in violence-­exposed mothers: Salivary cortisol of mothers with very young children pre- and post-­separation stress. Bulletin of the Menninger Clinic, 68(4), 319–336. Soumi, S. J. (2006). Risk, resilience, and gene × environment interactions in rhesus monkeys. Annals of the New York Academy of Sciences, 1094(1), 52–62. Spangler, G., & Grossmann, K. E. (1993). Biobehavioral organization in securely and insecurely

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Siegler (Vol. Eds.), Handbook of child psychology (6th ed., Vol. 2, pp. 3–57). New Jersey: Wiley. Werker, J. F., & Vouloumanos, A. (2001) Speech and language processing in infancy: A neurocognitive approach. In C. A. Nelson & M. Luciana (Eds.), Handbook of developmental cognitive neuroscience (pp.  269–280). Cambridge, MA: MIT Press. Wheeler, R. E., Davidson, R. J., & Tomarken, A. J. (1993). Frontal brain asymmetry and emotional reactivity: A biological substrate of affective style. Psychophysiology, 30, 82–89. Wolkind, S. N., Zajicek-­Coleman, E., & Ghodsian, M. (1980). Continuities in maternal depression. International Journal of Family Psychiatry, 1, 167–182. Yakovlev, P. I., & LeCours, A.-R. (1967). The myelogenetic cycles of regional maturation of the brain. In A. Minkowski (Ed.), Regional development of the brain in early life (pp. 3–70). Oxford, UK: Blackwell Scientific. Zeanah, C. H., Jr., Nelson, C. A., Fox, N. A., Smyke, A. T., Marshall, P., Parker, S. W., et al. (2003). Designing research to study the effects of institutionalization on brain and behavioral development: The Bucharest Early Intervention Project. Development and Psychopathology, 15, 885–907.

Chapter 4

Neurobiology of Stress in Infancy Anne Rif kin-­Graboi Jessica L. Borelli Michelle Bosquet Enlow

U

nderstanding the impact and significance of stress during infancy, a developmental period particularly important to subsequent emotional, cognitive, and physical trajectories (e.g., Couperus & Nelson, 2006), is critical. Such an understanding will allow for better insight into individuals’ functioning—both during infancy and later life. For example, understanding the consequences of stress in infancy may help to explain why some older children and adults, with seemingly little recent exposure to trauma or even external stress, may present with “stress-­related” behavioral, cognitive, and emotional difficulties. To this end, this chapter focuses on four questions related to the neurobiology of stress reactivity and regulation, with particular emphasis on infancy. The first question to be addressed is how neural circuits respond to acute stress. Next, we contemplate the types of experiences that constitute stressors for infants and how infants respond to these experiences. Third, given that variation in stress responsivity has been documented repeatedly in the literature, we consider the roles of genetic factors in stress reactivity. Finally, the chapter more fully explores the question of how repeated and chronic exposure to stressors shapes



subsequent stress responsivity and development independent of genetic considerations.

RESPONSE OF NEURAL CIRCUITS TO ACUTE STRESS A number of peripheral and central nervous system regions are involved in responses to acute stressors, and both the degree of coordination between regions and the modulation of responses are often considered indices of health (Bauer, Quas, & Boyce, 2002). In infancy, as in adulthood, regions important to stress responsiveness are likely to include components of the two major divisions of the nervous system: the peripheral nervous system (i.e., cranial nerves, spinal nerves, and the autonomic nervous system) and the central nervous system (i.e., the brain and spinal cord). When infants encounter an external threat, information travels through the peripheral nervous system (PNS) that can lead to responses from a subcomponent of the PNS (i.e., the autonomic nervous system [ANS]) and/or responses from the central nervous system ([CNS], e.g., see Breedlove, Rosen­zweig, & Watston, 2007). In particular, three neurobiological responses to threats are especially likely: ANS sympathetic–­ 59

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adrenal medulla activation; CNS amygdala– locus coeruleus activation; and CNS hypothalamic activation, which can directly lead to excitation of the hypothalamic–­pituitary–­ adrenocortical (HPA) axis. Normative development may influence functioning of these systems as well as the multiple neural structures and neurotransmitters that lead to their activation and inhibition.

Developmental Influences on Stress Responsivity Though similar neuroanatomical regions are likely involved in infant and adult stress responsivity, coordination and modulation of the regions may differ by developmental stage. This difference is partly because coordination is subject to environmental influence, with much work suggesting that in young mammals coordination is initially shaped by caregiving. In rodents, research indicates that mothers may serve as “regulators,” with maternal care and contact influencing the regulation of states (e.g., body temperature) that are essential to life, and which may be influenced by separation and stress (Hofer, 2006). Likewise, in humans, findings indicate that the acquisition of the ability to regulate stress is a developmental process that progresses from complete dependence on the caregiver for regulation in the neonatal period to dyadic regulation in infancy to self-­regulation by the preschool years, with more sensitive caregiving supporting the development of more optimal stress regulation abilities (Gunnar & Donzella, 2002; Sroufe, Egeland, Carlson, & Collins, 2005). In addition, the degree of response, as well as the type of response may be influenced not only by properties of the threat itself, but also by the meaning the individual attributes to the stimulus, which in turn may be influenced by his or her previous experiences (Lazarus & Folkman, 1984). On the whole, infants have relatively short histories of stressful experiences; therefore, to a certain degree, stress reactivity in the neonatal period is likely driven more by evolutionarily based predispositions and other individual characteristics of the infant (e.g., temperament) than previous experiences with stressors, whereas later in development the influence of past experiences may be greater.

Furthermore, modulation by regions associated with meaning making via memory (e.g., the hippocampus), fear learning (e.g., the amygdala), and reasoning (e.g., the prefrontal cortex) may also differ for neuroanatomical reasons. That is, regions associated with these processes continue to develop into adolescence and even adulthood (reviewed in Toga, Thompson, & Sowell, 2006). Likewise, many such regions are affected by gonadal (e.g., testosterone) and adipose (e.g., leptin) hormones (e.g., Herman et al., 2003; Walf & Frye, 2006), and levels of these hormones vary by developmental stage. Finally, normative changes in developmental neurobiology are especially important to the HPA system, a critical system involved in stress reactivity. Shortly after birth, the HPA axis is highly reactive, meaning that HPA responses can be stimulated easily (Gunnar, Conners, & Isensee, 1989). During later infancy, individuals undergo a period of HPA hyporesponsivity, signifying that only small HPA responses to stimuli occur. In human infants, this dampening of the HPA system has been found to begin as early as the second month of life (Lewis & Ramsay, 1995) and to extend until the second year (e.g., Gunnar, Brodersen, Krueger, & Rigatuso, 1996). Thus, a failure to show increases in cortisol in response to stress during this hyporesponsive phase may reflect inflexibility of the HPA system at that point in development.

ANS Sympathetic Nervous System Responses to Stress As noted, one expectable reaction to stress is engagement of the ANS. In some cases, the parasympathetic division may respond via the vagus nerve to reduce arousal (e.g., slow heart rate; see Porges, 2003). More frequently, however, another aspect of the ANS—the sympathetic–­adrenomedullary system (SAM)—increases arousal via the peripheral release of hormones. In particular, the sympathetic nervous system can signal the adrenal medulla to release norepinephrine [NE] and epinephrine [EPI]). Because of the effects of these hormones, SAM is often considered the arbiter of the fight or flight response to stress: These hormones increase respiration, cardiovascular tone, and blood flow to skeletal muscles while simultane-



4. Neurobiology of Stress in Infancy

ously inhibiting vegetative functions (e.g., digestion). The ANS also interacts with the other two systems frequently involved in responses to stress (i.e., the locus coeruleus–­amygdala system and the HPA axis). Peripherally released EPI and NE can signal bodily states via the PNS, which can result in changes in CNS activity (see reviews in Ellis, Jackson, & Boyce, 2006; Porges, 2003; Tsigos & Chrousos, 2002). Likewise, CNS areas such as the hypothalamus and brainstem affect the sympathetic nervous system (SNS; Diamond, Scheibel, & Elson, 1985).

CNS Locus Coeruleus–­Amygdala Activity Central NE is released by an area of the brainstem termed the locus coeruleus. Stressors can lead to an increase in locus coeruleus activity, which can then increase the firing rate of corticotropin-­releasing factor (CRF) neurons in the amygdala (see reviews in Ellis et al., 2006; Porges, 2003; Tsigos & Chrousos, 2002). These CRF neurons, in turn, can increase the firing rate of locus coeruleus NE neurons, creating a positive feedback loop between the locus coeruleus and the amygdala. The locus coeruleus–­amygdala loop can affect HPA activity. For example, the locus coeruleus influences the prefrontal cortex, which can indirectly modulate HPA activity. In addition, once excited, the amygdala may increase HPA activity by inhibiting the inhibitory influence of gamma-­aminobutyric acid (GABA) neurons of the bed nucleus of the stria terminalis on the hypothalamus (Herman et al., 2003).

HPA Axis Functioning

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(5-HT) released by the raphe’ nucleus; possibly CRF from the bed nucleus of the stria terminalis; glutamate from other areas of the hypothalamus; possibly dopamine (DA) from the thalamus; and through blood or cerebrospinal fluid components (e.g., immune factors and hormones) (reviewed in Herman et al., 2003; also see Figure 4.1). In addition, other regions may indirectly signal the hypothalamus when they respond to “anticipatory stress” (e.g., situations that, if left unchecked, could lead to reactive stress; e.g., encountering predators, aggressive conspecifics, and dangerous environments). Indirect input can also involve the hippocampus and frontal cortex. Interestingly, these areas typically, but not always, limit stress responsivity. For example, the hippocampus, which itself receives input from a number of areas, can modulate PVN activity via “direct” inhibitory regions. As another example, the prefrontal cortex, which receives input from a variety of areas, including the locus coeruleus, raphe nucleus, and thalamus, as well as dopaminergic regions, can indirectly modulate PVN activity via excitation of inhibitory regions and activating regions. Not surprisingly, there is much cross-talk between many of the “anticipatory” areas. In addition to its influence on the amygdala, the prefrontal cortex also interacts with the hippocampus (Herman et al., 2003; Lovallo & Thomas, 2000; also see Figure 4.1). Finally, many of the regions important to PVN activation are influenced by adrenal hormones such as cortisol, which is an end product of HPA activation. Depending on the structure involved, cortisol either increases or decreases hypothalamic activity.

Influences on the Hypothalamus

Hypothalamic Influences on the Pituitary and Adrenals

The amygdala and the prefrontal cortex are not the only regions able to influence the region of the hypothalamus (i.e., the paraventricular nucleus [PVN]) essential to HPA activity. “Direct” signals to the PVN occur in response to “reactive stress” (i.e., situations that cause bodily changes, such as pain, toxins, and cardiovascular alterations). Direct activation of PVN neurons occurs in a variety of ways, including via NE and EPI released by the nucleus of the solitary tract; serotonin

The release of CRF from PVN hypothalamic neurons is often considered the direct starting point of HPA axis activity. When CRF is released and occupies receptors within the anterior pituitary, a polypeptide termed pro­opiomelanocortin (POMC) is released. This large peptide is cleaved into smaller peptides, including adrenocorticotropic hormone (ACTH). In response to ACTH, the adrenals release steroid hormones—­corticosteroids, including mineralocorticoids (e.g., aldoster-

62

I. DEVELOPMENT AND CONTEXT Locus Ceruleus

A

B

(NE)

Prefrontal Cortex*

Other Inhibiting Areas

Hippocampus*

Locus Ceruleus (NE)

Amygdala* (CRF, also GABA)

Other Potentiating Areas

Prefrontal Cortex*

Raphe’s Nucleus

Hippocampus*

Amygdala* (CRF, also GABA)

Other Potentiating Areas

Other Inhibiting Areas

(5HT)t

(5HT)

Adrenals (GC’s, eg., CORT)

PVN of the Hypothalamus (CRF)

HPA Axis

HPA Axis

PVN of the Hypothalamus (CRF)

Pituitary (ACTH)

RN

Pituitary (ACTH)

Adrenals (GC’s, eg., CORT)

FIGURE 4.1.  A partial representation of circuitry influencing (A) and influenced by (B) hypothalamic–­ pituitary–­adrenal (HPA) axis activity. Pathways may be inhibitory or excitatory. The HPA axis is depicted in gray circles. Neurotransmitters and hormones in parentheses include: ACTH, adrenocorticotropic hormone; NE, noradrenaline; CORT, cortisol; CRF, corticotropin-releasing hormone; 5-HT, serotonin; GABA, gamma-­aminobutyric acid; GC, glucocorticoid. *There is much cross-talk between areas such as the prefrontal cortex, hippocampus, and amygdala.

one) and glucocorticoids (e.g., corticosterone in rats and cortisol in humans), as well as some sex steroids; however, of the steroid hormones, the glucocorticoid response is greatest. Extensive research with infants and adults has provided important data about the functioning of the HPA axis in response to stress. Data suggest that the peak glucocorticoid response to an acute stressor typically is evident in saliva within 20 minutes of stressor onset, though there is individual variation in peak response times, ranging from 15 to 30+ minutes (Ramsay & Lewis, 2003). In addition, studies have shown cortisol reactivity to be constrained by the diurnal variation of the system. In addition to being responsive to the environment, HPA activity follows a daily rhythm. In general, cortisol levels are lowest in the evening and rise

within 45 minutes of waking. After their initial morning peak, cortisol levels are expected to decline rather sharply, and as the day progresses, continue to decline, though at a lesser rate.

Glucocorticoid Influence on Neural Receptors After release, cortisol may bind to a protein (cortisol binding globulin), and only the unbound (i.e., “free”) form of cortisol is able to interact with receptors and thus exert an effect through them. Free cortisol is able to bind to two forms of corticosteroid receptors: mineralocorticoid and glucocorticoid receptors. Both types of receptors are present in the brain, but they may serve different functions and are differentially expressed; fewer neural regions express mineralocorticoid receptors as compared to glucocorticoid



4. Neurobiology of Stress in Infancy

receptors (de Kloet & Reul, 1987). Glucocorticoids have a higher affinity for mineralocorticoid receptors than they do for their “own” glucocorticoid receptors. Therefore, when only small amounts of glucocorticoids are available, the majority of glucocorticoid receptors are not occupied, but when HPA activity is high, more glucocorticoid receptors become occupied (reviewed in de Kloet, Oitzl, & Joels, 1999). The ratio between mineralocorticoid and glucocorticoid receptor occupation may influence pre- and poststress functioning in psychological, cognitive, behavioral, and biological domains. For example, mineralocorticoid occupation aids in memory formation and immune function, whereas glucocorticoid receptor activation leads to decreases in some memory abilities and immune suppression (Sapolsky, Romero, & Munck, 2000). Because daily rhythms lead to higher levels of circulating glucocorticoids at specific times of day, and hence, a likely greater degree of mineralocorticoid occupation at different times of day, acute responses to stress may also vary by time of day. That is, an identical stressor administered to the same individual in the morning (when glucocorticoid levels are comparatively high) should have different outcomes than when delivered in the afternoon (when glucocorticoid levels are comparatively low), since it will lead to  differential ratios of mineralocorticoid­to-­glucocorticoid occupation and hence different receptor-­mediated results.

Glucocorticoids and Feedback Loops Glucocorticoids may act via these corticosteroid receptors to increase or decrease further CRF and, consequently, HPA activity. For example, acting on receptors in the amygdala, glucocorticoids can exert positive feedback and increase hypothalamic CRF activity. Glucocorticoids may also act on neuronal receptors in the prefrontal cortex, hippocampus, and hypothalamus to limit further hypothalamic CRF activity (Herman, Ostrander, Mueller, & Figueiredo, 2005; also see Figure 4.2). Therefore, alterations in the expression and function of both types of corticosteroid receptors, as well as alterations in the degree of pituitary and adrenal activity, can contribute to the con-

63

tinuation versus cessation of HPA activity. This finding is relevant because, as discussed below, chronic exposure to stress hormones and neurotransmitters may disrupt these feedback mechanisms, leading to system dysregulation and impeding individuals’ abilities to curtail subsequent responses to acute stress.

Adaptive Value of HPA Activity In addition to affecting memory and immune functioning, glucocorticoids may both complement and limit the effects of quicker­acting neurobiological responses to stress (i.e., increases in CRF, EPI, and/or NE). For example, glucocorticoids can work with CRF, EPI, and/or NE to increase heart rate and energy (i.e., glucose) availability, but work against the anorextic effects of CRF to increase appetite, especially for carbohydrates (reviewed in Sapolsky et al., 2000). Overall, glucocorticoid effects on cognitive and physical processes are considered to have an adaptive value in that they promote survival in times of threat (Sapolsky et al., 2000). In essence, Sapolsky (2004) suggests that in such times, an individual is best served by shunting the majority of his or her energy to the areas of the body and brain that will aid in immediate survival. Therefore, glucose should be directed to muscles to aid in flight or fight and to brain areas directed at attending to the threat, rather than remembering extraneous cues (see also Lupien et al., 2006). Likewise, in times of immediate alarm, he argues, it makes evolutionary sense to shut down systems involved in growth and reproduction until less energy is needed to respond to danger.

STRESSFUL EXPERIENCES/ RESPONSES IN INFANCY Defining Stress A number of opinions concerning the nature of stress have been offered throughout the years (e.g., Lazarus & Folkman, 1984; Mason, 1968; Selye, 1956). Following, among others, John Bowlby (e.g., 1969) and Michael Meaney and colleagues (e.g., Cameron et al., 2005), we adopt a broad, phylogenetically based perspective on the types of situations that constitute stress. That is,

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I. DEVELOPMENT AND CONTEXT

Working Definition of Stress: Stimuli Indicating an Immediate (A) or Eventual (B & C) Threat to Survival

B. Examples of Situations that Increase the Likelihood of Experiencing an Immediate Threat in Humans Darkness Loss of Group Membership Low Status Infant Separation From Parent Maternal Unavailability (e.g., via rejection, withdrawal in times of danger)

A. Examples of Immediate Threats Predation/ Violence Starvation Natural Disaster

C. Cues that are Closely Tied to A and/or B in Humans

+

“Low Energy” Behavioral Strategy Is Insufficient to Overcome

HPA Activation

(in some cases)

Social Rejection Feelings of Shame and Lack of Control

SNS Activity

Lack of Optimal Maternal Care (not only withdrawal and rejection but also, e.g., a lack of sensitivity and instrusiveness)

FIGURE 4.2.  A schematic presentation of our working definition of stress. Immediate and eventual threats at the individual or species level are considered “stressors” that may result in behavioral and/ or endocrine responses.

we not only consider immediate threats but also situations and cues that were likely to have been tied to such events within a species’ evolutionary history (see Figure 4.2). Thus, we arrive at three categories of potential stressors: immediate threats, impending threats, and cues reliably tied to threats. Acknowledging the importance of an evolutionary perspective is also in keeping with findings from a recent meta-­analysis and review paper by Dickerson and Kemeny (2004), who demonstrated that an evolutionary-based hypothesis was able to explain why some laboratory paradigms more reliably result in HPA activity than do others. They argued that as social primates, we are (1) dependent on group membership for survival and reproduction; (2) primed to be keenly aware of feelings that frequently occur in conjunction with threats to group membership (e.g., rejection) and status (e.g., failure; see also Sapolsky, 1990, 2004); and,

furthermore, (3) that when we anticipate or feel rejection and/or failure, we may also anticipate needing additional energy (e.g., glucose via cortisol) to rectify the situation. As expected, they found that laboratory situations containing the potential for social rejection and a loss of status reliably led to increases in cortisol in adult humans across a number of studies. Likewise, others have similarly cited a lack of controllability as a cause for HPA activation in infancy and early childhood (e.g., Lewis & Ramsay, 2005; Luby et al., 2003).

Immediate Threats and Their Consequences Natural Disasters and Other Extreme Events Though natural disasters can be considered immediate threats to survival, studying responses to such natural disasters at the mo-



4. Neurobiology of Stress in Infancy

ment they first occur is exceedingly difficult. On a behavioral level, it may be expected that, as with many other stressors, human infants are predisposed to search out their primary caregivers (Bowlby, 1969; Suomi, 1999). This expectation is based on the idea that human infants are comparatively helpless and that parental protection affords them an increased chance of survival. In other words, in response to threats, infants may be predisposed to respond with what McEwen and colleagues (e.g., Lupien et al., 2006) might term a lower-cost behavioral strategy—­namely, searching out their mothers—­although in initial encounters with extreme situations, higher-cost endocrine responses (e.g., increased catecholamines and CRF) might still be expected (e.g., Heim, Newport, et al., 2000). Because infants are so dependent on their caregivers for modulation of their stress reactions, infants’ responses to extreme situations of trauma are highly influenced by their caregivers’ responses. A caregiver’s own traumatic stress responses may impede his or her ability to provide sensitive care and, consequently, manage the infant’s distress. A high co-­occurrence of trauma symptoms in parents and very young children following a shared trauma (“relational PTSD”) has been noted and attributed to the impact of poor parental regulation (e.g., withdrawal; overprotection) on the child’s ability to self-­regulate, particularly during a period of development when the child is especially dependent on the parent for regulation (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006; Scheeringa & Zeanah, 2001). In such situations, higher-cost endocrine responses may be especially likely, and may be expected to have ramifications well past the cessation of the traumatic experience.

Abuse In addition, higher-cost endocrine responses might also be expected in situations where the parent is the source of the threat. Like natural disasters, abuse can be considered an immediate threat to survival. However, in response to abuse, a behavioral predisposition for approach is unlikely to lead to the cessation of threat since the parent is also the source of the threat. Thus, highercost endocrine alternatives may be likely, as

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the lower cost approach strategy increases, rather than decreases, the threat. This idea is in keeping with those expressed by attachment researchers who consider infants’ “disorganized attachment behaviors” to be the product of a paradox created when a parent is frightening. Namely, they propose that infants are influenced by competing predispositions: the drive to flee the source of fear (i.e., the frightening parent) and the drive to approach the parent for protection (Main & Hesse, 1990). Indeed, infants of maltreating parents often exhibit disorganized behavior, which can include displays of both approach and avoidance (van IJzendoorn, Schuengel, & Bakermans-­K ranenburg, 1999). In addition, disorganized infants have been found to show prolonged endocrine responses to mild stress, perhaps indicating a lack of lower-cost behavioral alternatives (Spangler & Grossmann, 1993).

Impending Threats and Their Consequences As with immediate threats, in the face of impending threats infants may be predisposed to search out their primary caregivers (Bowlby, 1969). Bowlby suggested that a variety of stimuli may serve as cues for impending threats or “natural cues to danger” for human infants because, within our evolutionary history, they were associated with precarious circumstances, such as increased likeliness of predation. Examples of situations that may indicate impending threats include novelty, stranger approach, and separation from the caregiver.

Environmental Novelty Bowlby suggested that one natural cue to danger is environmental novelty. Interestingly, Ahnert and colleagues (Ahnert, Gunnar, Lamb, & Barthel, 2004) have recently observed increases in cortisol during an “adaptation to preschool” phase, when young children are exposed to their classroom in the presence of their caregiver, as compared to what is observed in the familiar home environment. The authors suggest that these significant increases may have been due to exposure to a novel environment, along with the challenges of forming new social relationships.

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Stranger Approach Bowlby also suggested that stranger approach is a natural cue to danger. When examining 24-month-olds’ responses to this threat, Buss and colleagues (Buss, Davidson, Kalin, & Goldsmith, 2004) reported that toddlers who were free to approach their mothers showed less incidence of behaviors associated with HPA activation (i.e., freezing and fear behavior; see Gunnar & Vazquez, 2006) than did children who were prevented from doing so via physical restraint.

Separation Bowlby additionally proposed that separation from the primary caregiver, especially during novel circumstances, may serve as a natural cue to danger for human infants for multiple reasons. For example, separation may signal impending danger because, throughout ground-­living primate evolution, separation could result in starvation, an inability to escape from predation, and other such threats. During relatively short separations, the HPA response may be mitigated by the infant’s ability to find lower-cost solutions. For example, Gunnar and Nelson (1994) found that, in response to maternal separation, cortisol did not increase among 1-yearolds who took advantage of the opportunity to interact with a babysitter, whereas it did increase among infants who withdrew and even among infants who fell asleep (Gunnar, Larson, Hertsgaard, Harris, & Brodersen, 1992). Because low-cost behavioral strategies during long-term separation may be limited (i.e., during separation infants cannot approach their parents), increases in endocrine activity may be expected. In fact, human and nonhuman primate infants are frequently found to respond to maternal separation with increases in HPA activation (reviewed in Gunnar, Brodersen, Field, McCabe, & Schneiderman, 1992). For example, during the transition to day care, a form of parent–­infant separation, research finds that many infants and preschoolers (Dettling, Parker, Lane, Sebanc, & Gunnar, 2000; Tout, de Haan, Campbell, & Gunnar, 1998; Watamura, Donzella, Alwin, & Gunnar, 2003, but see de Haan, Gunnar, Tout,

Hart, & Stansbury, 1998) exhibit higher cortisol levels throughout the day. In fact, one recent study (Ahnert et al., 2004) of seventy 15-month-olds reported that, compared to home levels, there was a 75–100% increase in cortisol levels during the first 2 weeks children were left at day care without their mothers. Furthermore, they found that cortisol levels during these prolonged separations were substantially higher than those observed during the “adaptation to day care” phase. These findings suggest that, at least for some infants, lower-cost strategies may have been available when the only salient threats were environmental novelty and the potential for social rejection, as opposed to what occurred during the transition phase, when the maternal separation threat also existed.

Cues Tied to Immediate/ Impending Threats As noted, feelings of uncontrollability and failure may serve as stressors because they are likely closely tied to a loss of group membership and/or the likelihood of social rejection (Dickerson & Kemeny, 2004). Similarly, other cues may be closely tied to immediate and/or impending threats in infancy. Considering the importance of parents to the protection of infants, parental unavailability, rejection, and neglect may all be closely linked to poor chances of surviving environmental threats, should they occur. In addition, throughout our species’ history, changes in forms of parental care, such as increases in neglect and intrusiveness, may have often indicated that the developing infant will likely face a harsh environment, including an increased likelihood of experiencing immediate environmental threats, such as predation, abandonment, violence, and malnourishment (see Cameron et al., 2005).

Parental Unavailability, Rejection, and Neglect Consistent with Bowlby’s idea that an infant’s best chance of survival during times of danger is to seek out a haven of safety or “attachment figure,” certain forms of nonoptimal parenting (e.g., rejection, neglect, withdrawal) may suggest a decreased chance of surviving because they may be indicative



4. Neurobiology of Stress in Infancy

of a lack of parental availability during times of threat (see, for e.g., Bugental, Martorell, & Barraza, 2003, for work on unavailability, harsh parenting, and basal and reactive cortisol). In an experimental simulation of the effect of maternal depression on infant behavior, Cohn and Tronick (1983) found that when mothers became facially noninteractive during a face-to-face interaction with their 3-month-olds, infants reacted by appearing agitated and wary—a posture that remained even after mothers began interacting with their infants again. Additionally, others (Haley & Stansbury, 2003) have found that when mothers and their 5- to 6-month-old infants take part in this StillFace Paradigm, infants show a rise in cortisol and in heart rate. These findings suggest that parental emotional unavailability may be a threat for which infants do not have a low-cost behavioral response.

Other Forms of Nonoptimal Care As discussed by Meaney and colleagues (e.g., Cameron et al., 2005) and reviewed in this section, other forms of nonoptimal parenting behavior, such as nonresponsiveness, intrusiveness, hostility, or overcontrolling behavior, may be considered stressors because they serve as signals that are closely tied to the likelihood of experiencing threats as part of daily life. Likewise, though exhibited forms of behaviors differ across species, relations between the patterning of parenting behavior and environmental circumstance have been observed in a variety of species. In monkeys, developmentally inappropriate increases in mother–­offspring contact are associated with both low rank (briefly reviewed in Nicolson, 1987) and forced separation (e.g., Sanchez et al., 2005). In humans, nonoptimal maternal behavior (e.g., Klebanov, Brooks-Gunn, & Duncan, 1994) is associated with riskier (e.g., impoverished, violent) environments, and in fact, lower socioeconomic status is linked to higher basal cortisol levels in infancy (Wailoo et al., 2003). In addition, both insecure attachment and maternal depression are associated with nonoptimal parenting (e.g., Field, Hernandez-Reif, & Diego, 2006; Madigan et al., 2006; van IJzendoorn, 1995), as well as riskier environments (Cutrona, Wallace, &

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Wesner, 2006; Fish, 2004). Thus, it may not be surprising that maternal depression is associated with concurrent increases in basal cortisol (Field, Healy, Goldstein, & Perry, 1988), and that infants of depressed mothers who show comparatively high rates of intrusive behaviors show higher levels of NE, EPI, and DA at 6 months (Jones et al., 1997).

INDIVIDUAL/GENETIC INFLUENCES ON STRESS RESPONSES Despite the usefulness of thinking about species-wide cues to danger, it is impossible to ignore data demonstrating that individuals vary in the degree to which they perceive and/or respond to threats. In some cases, significant mismatches between HPA activity and context (e.g., extremely low activity during situations that would make most people anxious) may be a source for concern and/or predictive of other neurobiological functions (Buss et al., 2004; Keenan, Gunthorpe, & Grace, 2007). Prenatal influences (Field, Diego, & Hernandez-Reif, 2006; Rieger et al., 2004; Wadhwa, 2005; Yehuda et al., 2005), gender (Sanchez et al., 2005; Stroud, Salovey, & Epel, 2002), and clinical status (e.g., reviewed in Gunnar & Vazquez, 2006) may all influence individual variation in stress responsivity. In addition, it is becoming increasingly clear that genetics can influence resting states important to HPA responses, acute stress responses, and outcomes associated with chronic stress. Some of the inspiration for this realization comes from work with candidate genes relevant to the neuronal circuitry described above. Furthermore, associations in early life between chronic stress and hypocortisolemia—­lowered HPA basal functioning and lowered HPA reactivity—are also an impetus for these considerations.

Candidate Genes and Stress Responsivity Catecholamines As noted above, the catecholamine NE, as well as other catecholamines such as EPI and DA, may all directly and indirectly contribute to CRF release and thereby be

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I. DEVELOPMENT AND CONTEXT

especially important to biological responses to stress. Catechol-O-methyltransferase (COMT) is important to the breakdown of catecholamines, and variation in the COMT gene has recently been found linked to plasma EPI responses to psychosocial stressors in adults (Jabbi et al., 2007). Although we are not aware of similar research with COMT in children, attachment researchers have begun examining the effects of genetically based differences in dopaminergic functioning on children’s responses to brief laboratory separations from their caregivers. Here, less functional forms of a DA receptor have been related to “disorganized” responses to separation (e.g., Lakatos et al., 2002; but see Bakermans-­K ranenburg & van IJzendoorn, 2004), which have themselves been linked to increased cortisol levels (Hertsgaard, Gunnar, Erickson, & Nachmias, 1995; Spangler & Grossmann, 1993; but see Spangler & Schieche, 1998). Interestingly, new research further suggests that this same DA receptor mutation may allow infants to be increasingly receptive to environmental influences, which may shape their responses to separation (van IJzendoorn & Bakermans­K ranenburg, 2006).

Serotonin Serotonin functioning may influence the development of brain structures important to stress responsivity (e.g., reviewed in Korte, Koolhaas, Wingfield, & McEwen, 2005). In addition, it is also important, in an immediate sense, to the release of CRF in a wide variety of ways. It can, for example, impact areas that are associated with the release of CRF, such as the amygdala and hypothalamus, and it can also impact areas such as the hippocampus, which tend to inhibit CRF release. Variants of genes implicated in serotonergic functioning have been found to be directly, and in interaction with environmental influences, related to suicidality and/ or depression (Caspi et al., 2003; Lemonde et al., 2003), the latter of which is often associated with chronic life stress (Goodman, 2002). With regard to the HPA axis, in particular, genetic variation thought to eventually result in lower serotonin levels has been linked to increased HPA reactivity and aggression in young monkeys who experienced

early deprivation (reviewed in Suomi, 2006). Findings such as these have led to suggestions that different genetic predispositions may result in susceptibilities to fright versus fight responses (Korte et al., 2005), as well as differential vulnerabilities for fright behavior (Ellis, Jackson, & Boyce, 2006) and differential vulnerabilities for fight-and­fright behavior in response to threat (Suomi, 2006).

Gamma-­Aminobutyric Acid As also noted above, GABA can exert important inhibitory effects on the activation of the hypothalamus, and it can inhibit inhibitors of hypothalamic activity. Thus, genetic alterations that influence GABA may also impact stress responsivity. Although to our knowledge, no investigation of GABA receptor gene variants in human infants has yet occurred, associations between GABA polymorphisms and HPA activity in adults have been reported (e.g., Uhart, McCaul, Oswald, Choi, & Wand, 2004).

Corticotropin-­Releasing Factor CRF is an especially important neurotransmitter for both the locus coeruleus–­ amygdala and the HPA responses to stress. Interestingly, recent findings suggest that a CRF haplotype (set of genetic variants) is linked to behavioral inhibition (Smoller et al., 2005), a construct long thought to have a genetic component and known to influence infants’ HPA responses to separation (e.g., Nachmias, Gunnar, Mangelsdorf, & Parritz, 1996). For example, children in the clinical range of internalizing symptoms tend to have higher basal cortisol (Kagan, Reznick, & Snidman, 1987). Shyness and internalizing distress in boys (Dettling, Gunnar, & Donzella, 1999; Tout et al., 1998) and social fearfulness (Watamura et al., 2003) in boys and girls have been found related to greater increases in cortisol across the day (see Vermeer & van IJzendoorn, 2006, for a meta­analysis on cortisol and day care). In contrast, however, research with 15-month-olds suggests that behaviors typically not expected among inhibited children, such as anger proneness (van Bakel & Riksen-­Walraven, 2002), poor self-­control, and aggression, are linked to heightened cortisol (Dettling et al.,



4. Neurobiology of Stress in Infancy

1999). Still, these results may not be at odds with one another: Recent research suggests that inhibition, as compared to surgency, is associated with increased cortisol responsivity when aggression is first taken into account (Gunnar, Sebanc, Tout, Donzella, & van Dulmen, 2003). Although the functional significance of the implicated CRF haplotype is not known, Smoller and colleagues (2005) speculate that it could contribute to greater CRF release and increased anxiety via increased activation of the amygdala as well as disruption of serotonin’s effects within the hippocampus.

Corticosteroid Receptors Glucocorticoids, an “end product” of the HPA axis, may also affect HPA activity and reactivity via feedback loops. That is, glucocorticoids can act through corticosteroid receptors to either increase or decrease subsequent HPA responses. Genetic variation in corticosteroid receptors has been found related to basal (nonstress) cortisol levels (e.g., Rosmond et al., 2000).

Genetic Variation and HPA Functioning When stress produces an HPA response, it should lead to increased (and not decreased) HPA activity followed by cessation due to negative feedback. However, because chronic exposure to stress hormones and neurotransmitters can impair negative feedback processes, when stressors are continual, hypercortisolemia (i.e., increases in nonstress cortisol levels and accompanying increased HPA responsiveness) is generally expected. Nevertheless, the body may continue to adapt and eventually there may be a down-­regulation of, for example, adrenal receptors, leading to hypocortisolemia. This down-­regulation is generally believed to occur after prolonged exposure, and only after the trauma has passed (Heim, Ehlert, & Hellhammer, 2000). Still, why do we find hypocortisolism in infants and very young children exposed to conditions such as institutionalized rearing, maltreatment, maternal insensitivity, or natural disasters (reviewed by Gunnar & Vazquez, 2006)? The stressors (e.g., institutionalization) may be ongoing, and, even when the stressors have ceased, compara-

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tively little time has passed since stressor onset. In addition, as in adulthood, hyperversus hypocortisolemia may be influenced by concurrent psychopathology or personality factors. Furthermore, in developmental research, internalizing disorders tend to be associated with hypercortisolemia whereas externalizing disorders tend to be associated with hypocortisolemia, though both conditions may be associated with past adversity. Thus, these findings suggest the importance of considering genetic susceptibilities to baseline as well as reactive HPA activity.

Susceptibilities for “Fight” versus “Fright” One explanation for basal and reactive differences in HPA functioning involves differential susceptibilities for “fight” versus “fright” behavior. Korte and colleagues (2005) have suggested that genes contribute to two types of personalities: “hawks” and “doves.” Hawks are thought to have higher levels of gonadal (e.g., testicular) hormones and lower levels of serotonin than do doves. Accordingly, hawks are also more likely to have lower levels of circulating corticosteroids, which fits with the idea that serotonin influences hypothalamic CRF. Therefore, even during normative circumstances, hawks should have lower levels of occupied mineralocorticoid receptors than do doves. Thus, the first time hawks encounter danger, they are not expected to engage in freezing behavior because this such a stance requires mineralocorticoid receptors to be nearly fully occupied. However, during such encounters, central and peripheral NE (and peripheral EPI) may substantially increase, but a large degree of HPA responsivity is not expected. Because glucocorticoids have higher affinities for mineralocorticoid receptors than glucocorticoid receptors, it is implied that such mild HPA reactivity may allow only for increased occupation of ­mineralocorticoid receptors, but still little occupation of glucocorticoid receptors. Therefore, glucocorticoid-­receptor-­mediated behaviors, such as fear conditioning, are unlikely to occur, but mineralocorticoid­mediated behaviors are likely. For example, in the presence of high levels of gonadal hormones, increased occupation of mineralocorticoid receptors is expected to permit

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“fight” behavior, and, in fact, aggressivity is an expected reaction among individuals who are comparatively low in 5-HT when they experience acute increases in 5-HT (as occurs during stress). Furthermore, with chronic stress, hawks may become excessively aggressive (e.g., display externalizing disorders) and suffer from states associated with chronic sympathetic ANS activity (e.g., sudden cardiac death, atypical depression). In contrast, because doves are considered to have increased basal serotonin functioning, they may experience increased hippocampal growth, and, given this structure’s relation to memory formation, engage in deeper exploration. However, because of the higher levels of basal glucocorticoids in doves as compared to hawks, doves’ mineralocorticoids may be more fully occupied at the moment they encounter stress. This full occupation is suggested to allow doves to freeze the first time they encounter danger. Furthermore, it is implied that, partly because of higher 5-HT, doves may also respond to danger with comparatively greater HPA activity. Therefore, glucocorticoid receptors may also become occupied in times of stress to facilitate fear conditioning. Consequently, when a dove next encounters similar environmental circumstances, even when danger is not present, he or she may freeze. In addition, in the face of chronic stress, doves are likely to experience higher glucocorticoid levels that may eventually down-­regulate corticosteroid receptors and accordingly prevent negative feedback. Thus, the hypothalamus may not receive “negative feedback,” and the stress response may continue for too long. Eventually, prolonged CRF activity may lead to hyperactivity of the amygdala, decreases in hippocampal and prefrontal functioning, and associated increases in major depression. Hippocampal dendritic remodeling (a potentially reversible change in dendritic length and branching) as well as neuronal apoptosis (cell death) may also occur. Recalling the influences of the prefrontal cortex and hippocampus, these changes may further inhibit negative feedback from a neurobiological perspective. In addition, because of the hippocampal and frontal contributions to higher-order processing, alterations in these structures may also lead to increasing difficulties in memory and complex reasoning.

Thus, Korte and colleagues’ (2005) model may explain why some “hawk” children (e.g., those higher on externalizing disorders) living in chronically stressful situations exhibit lower basal cortisol and reactivity, whereas “dove” children (e.g., those higher on internalizing disorders) living in chronically stressful situations tend to exhibit higher basal cortisol and cortisol reactivity. Extending from Korte and colleagues’ (2005) model, among genetically predisposed hawks (who accordingly began life with a predisposition for lower HPA activity), ongoing chronic stress is likely to lead to externalizing behavior, but not a noticeable up-­regulation of HPA activity; among genetically predisposed doves (who accordingly began life with a predisposition for higher HPA activity), ongoing chronic stress is likely to, at least initially, up-­regulate HPA activity and result in hypercortisolemia and internalizing behaviors.

Susceptibilities for Fright (and Fight) A line of related and intriguing arguments has been put forth by Boyce and colleagues (Boyce & Ellis, 2005; Ellis et al., 2006). Drawing on Korte and colleagues (2005), Boyce et al. also suggest that there are “hawks” and “doves” and that each strategy of stress regulation has its own costs and benefits. However, whereas Korte and colleagues suggest that the two genetic profiles lead to two different responses to stress, Boyce and colleagues suggest that some individuals are more responsive to environments than are others, and that more environmentally responsive individuals are likely to suffer “dove-like” behavioral consequences of stress as well as positive consequences of extremely nurturant environments (see also Suomi, 2006). They further suggest that being a “hawk” may only be optimal in chronically moderately (but not severely) stressful environments. Boyce and colleagues (Boyce & Ellis, 2005; Ellis et al., 2006) also suggest that apparent conflicts in studies reporting associations between HPA activity level and optimal outcomes may be due to differences in the risk characteristics of samples. For example, when children are drawn from relatively low-risk groups (i.e., encompassing both chronically moderately stressful and



4. Neurobiology of Stress in Infancy

highly nurturing backgrounds), higher reactivity may appear to be associated with more positive outcomes (e.g., less externalizing behavior). Conversely, when children from high-risk groups are compared to children from moderately stressful groups, higher reactivity may be associated with relatively worse outcomes, such as increased anxiety and depression.

The Influence of Past Experience Certainly not all encounters with stressors represent first-time occurrences. When stress is repeated and/or chronic, individuals may respond quite differently to subsequent stress than they did during initial encounters. In fact, repeated and chronic stress may shape the likelihood of both low-cost (behavioral) and higher-cost (endocrine) responses, via alterations in psychological strategies and interpretations of threats, changes in neural circuitry, and alterations in neuroanatomy. Furthermore, these effects may interact with one another. For example, neurobiological changes may alter structures important to cognition and psychological coping. Over time, these effects may influence not only psychological functioning and stress reactivity but also physical health. Fortunately, new research is beginning to demonstrate the potential benefit of interventions on psychological as well as biological changes that result from stress in young children (e.g., Dozier, Peloso, et al., 2006).

Psychological Strategies and Interpretations of Threats Clinicians and researchers from various theoretical perspectives emphasize the role of past experiences on an individual’s interpretation of, and reaction to, acute stressors (e.g., Fonagy, Gergely, Jurist, & Target, 2002; Young, Weinberger, Beck, & Barlow, 2001). For example, attachment researchers have been especially interested in the ways in which children’s experiences with caregiving influence their subsequent interpretations of, and responses to, stress. Infants who experience sensitive care respond differently to separations from their caregivers than do infants who have experienced rejecting, inconsistent, and/or frightening care. The former exhibit a “secure” pattern of response. Fol-

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lowing a brief laboratory separation, secure infants show what is considered to be an infant’s natural predisposition during times of stress: to approach the caregiver in reaction to the stress of separation and then return to exploration. In contrast, infants who have not experienced optimal care will, upon reunion, avoid the caregiver, cling and fuss at the caregiver, and/or still or appear disorganized (Madigan et al., 2006; van IJzendoorn, 1995). These varying behaviors are interpreted as reflecting strategies, or a lack thereof, on the part of infants during times of stress (Main, 2000). Because infants of sensitive parents have come to expect comfort, they use what may be the lowest-cost behavioral strategy—­caregiver approach—in responding to separation. Infants of rejecting parents have learned that the minimization of affect is important in preventing further separations and even abandonment; hence when threats are comparatively less severe (i.e., short-term separations). they avoid the parent in order to maintain proximity (also see Main, 1981). Infants of inconsistent parents display extreme distress to maintain parents’ attention. Finally, infants of frightening parents may be overwhelmed by the combination of fear of separation and fear of the parent and thus display disorganized behavior (Hesse & Main, 1999). Indeed, most research suggests that these strategies are independent of genetic factors and are products of past experience, with sensitive parenting leading to security, rejection to avoidance, inconsistency to ambivalence, and frightening behavior to disorganization. Importantly, then, in response to laboratory stress, it may be expected that, in contrast to infants who are secure in their relationships with their parents, infants who are unable to use optimal low-cost behavioral strategies will instead exhibit increased physiological responsivity to stress. Indeed, Spangler and Grossman (1993) and Hertsgaard et al. (1995) have reported attachment-­related differences in cortisol following separation. In addition, secure infant attachment has been found to buffer effects of behavioral inhibition on cortisol responses to short laboratory separations (Spangler & Schieche, 1998), novel situations (Nachmias et al., 1996), and inoculation (Gunnar, Brodersen, Nachmias, Buss, & Rigatuso, 1996), and, in older chil-

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dren, to interact with behavioral inhibition to influence ANS activity (Stevenson-Hinde & Marshall, 1999). Finally, in the aforementioned transition to day care study (Ahnert et al., 2004), the quality of attachment relationships was predictive of infants’ cortisol levels during the adaptation phase, but not the separation phase; as noted by the authors, these data suggest that mothers of secure children, when present, were helping children to manage threats associated with peers and environmental novelty.

Biological Reactivity In addition to shaping psychological interpretations and reactions, past experience may also sensitize the neurocircuitry involved in responses to stress. In fact, the majority of rodent work suggests that longterm HPA activity alters neural circuitry and neuroanatomy to contribute to the prolonged and dysregulated “dove” responses to stress, described above. Nevertheless, what is abundantly clear is that, independent of genetic contributions, among tested strains of rodents, experimental manipulations causing changes in maternal care play an impressive role in shaping stress responsivity. For example, adult mice that experienced early life stress in the form of a lack of optimal maternal behaviors and/ or maternal deprivation, have been found to exhibit alterations in neurotransmitters and receptors important to a variety of neural circuits involved in stress responses and mental health, including 5-HT, DA, and NE functioning (Brake, Zhang, Diorio, Meaney, & Gratton, 2004; Caldji, Francis, Sharma, Plotsky, & Meaney, 2000; Ladd, Owens, & Nemeroff, 1996; Liu et al., 1997; Vazquez, Lopez, Van Hoers, Watson, & Levine, 2000). Likewise, in monkeys, forced separation and developmentally inappropriate patterns in mother–­infant contact have consequences for later stress responsivity (Sanchez et al., 2005), as do other forms of repeated and/or chronic early life stress (e.g., Pryce et al., 2005). Although longitudinal human research has not examined the biological consequences of early life stress into adulthood, retrospective research suggests similar pathways from early experience to adult reactivity (e.g., Luecken, 2000; Pruessner, Champagne, Meaney, & Dagher, 2004).

With regard to findings relevant to the SAM system, little animal work specifically focuses on the effects of early life experience and later adrenal medullary output. Still, recent work suggests that early experience affects peripheral NE activity in tissue specific ways (Young, 2000). As for findings especially relevant to subsequent locus coeruleus and amygdalar activity, early life stress can result in later decreases in the expression of GABA receptors in the amygdala and locus coeruleus, more CRF receptor expression in the locus coeruleus (Caldji et al., 2000), and increased CRF messenger ribonucleic acid (mRNA) in the amygdala (Plotsky et al., 2005). In terms of findings especially relevant to subsequent HPA activity, early life stress has been related to alterations in locus coeruleus cells known to impact the hypothalamus (Liu, Caldji, Sharma, Plotsky, & Meaney, 2000), increased CRF mRNA in the hypothalamus, increases in basal HPA levels and HPA responsivity, and alterations in corticosteroid receptor expression in areas important to curtailing stress responses, such as the hippocampus (Francis, Caldji, Champagne, Plotsky, & Meaney, 1999). Similarly, human research suggests that children whose mothers were depressed during their infancy and/or infants who have not received optimal care exhibit increased HPA reactivity (Ashman, Dawson, Panagiotides, Yamada, & Wilkinson, 2002). In addition, a growing body of research has examined the effects of chronic stress (e.g., institutionalization) on daily cortisol levels (reviewed in Gunnar & Vazquez, 2006). As one example, foster care in infancy has been found related to both atypically high and low cortisol levels in later childhood (Dozier, Manni, et al., 2006).

Neuroanatomical Structures and Functioning Over time, psychological biases toward interpreting experiences as stressful, chronic HPA activity, and sensitization of neural circuits along with deficits in negative feedback may be expected to result in changes in brain structures. These changes can occur, for example, via cell death (apoptosis) and changes in microstructures important to receiving information (dendritic remodeling)



4. Neurobiology of Stress in Infancy

(reviewed in Korte et al., 2005; e.g., Sapolsky & Steinberg, 1999). For example, the hippocampus is one of the meaning-­making structures that can modulate hypothalamic activity; in addition, glucocorticoids may occupy receptors in the hippocampus to induce neurochemical limitations on subsequent hypothalamic activity, and, likely indirectly, locus coeruleus–­amygdala activity. Thus, volumetric loss in this structure may be especially problematic, though recent work suggests that this loss may, in some cases, be reversible (McEwen & Chattarji, 2004). Although it has not been possible to demonstrate the effects of stress on human infants in such intricate neurobiological detail, longitudinal work has demonstrated that nonoptimal parental behavior and/or maternal depression in infancy is related to alterations in brain activity as indicated by differential EEG power (Dawson et al., 2003) and hemispheric lateralization (e.g., increased right frontal activity and decreased left frontal activity; Jones, Field, & Davalos, 2000). In addition, a recent study with human infants modeled after rodent research (Hane & Fox, 2006) found that naturally occurring variations in maternal care predicted individual differences in infants’ stress reactivity, operationalized as greater right frontal electroencephalography activity, and that the observed differences in stress reactivity were not explained by temperament. In addition, though researchers have not examined whether the comparatively subtle maternal behaviors associated with maternal depression predict gross anatomical changes, magnetic resonance imagining (MRI) indicates that childhood abuse, which is associated with alterations in HPA activity, is also associated with smaller neuroanatomical structures, including the hippocampus (e.g., Stein, Koverola, Hanna, & Torchia, 1997) and frontal cortex (e.g., De Bellis et al., 2002). Not surprisingly, nonoptimal maternal care and maternal depression are sometimes linked to cognitive difficulties that may extend into early adolescence, especially in the realm of attention and impulse control, which are themselves suggestive of difficulties in frontal functioning (e.g., Fearon & Belsky, 2004; Hay et al., 2001; but see Kurstjens & Wolke, 2001). Furthermore, maternal care and depression are associated with poor behavioral outcomes, many of

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which may be expected among those with slightly impaired frontal functioning; these include difficulties in school (Hay et al., 2001), both internalizing and externalizing disorders (Dawson et al., 2003), and depression in adulthood (Bureau, Easterbrooks, & Lyons-Ruth, 2009). Therefore, it appears likely that early negative experience not only shapes psychological strategies for interpreting and managing distress, but also influences the very structures necessary to perform these complex processes and limit further locus coeruleus–­amygdala and HPA activity. Thus, in keeping with the longstanding sentiments of many clinicians, research is now demonstrating that intervention early in life is important to the prevention of difficulties in emotional, cognitive, and biological domains, all of which may be expected to interact with one another to increase vulnerabilities for difficulties in mental, and even physical, health.

CONCLUSIONS Infancy represents a time of relative psychological and biological openness to new experiences. In fact, some aspects of normative development require environmental input, whereas in other cases, variation in experience may shape subsequent psychological and biological processes. Such flexibility is extraordinary from a scientific perspective and awe inspiring from the stance of prevention and intervention, as it may too signify a period during which much positive change is possible. However, because of the psychological and biological plasticity inherent to infancy, it may also represent a time where extreme, repeated, and/or chronic stress is especially harmful. Although acute stress may be manageable by a variety of behavioral and endocrine responses, chronic stress may lead to detrimental psychological, biological, and cognitive results. Thus, given the potential for significant lifelong ramifications of stress in infancy, this chapter concentrated on four key questions: how do neurobiological systems respond to stress?; what constitutes stress in infancy and which of the aforementioned neurobiological responses are expectable in these circumstances?; how might ge-

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netics influence stress responsivity?; and how does repeated and/or chronic stress exposure in infancy shape subsequent responses to stress as well as overall mental and physical health? The degree to which these questions are now answerable indicates that knowledge concerning the neurobiology of stress should soon be thoroughly integrated into interventions with young children and their parents. References Ahnert, L., Gunnar, M. R., Lamb, M. E., & Barthel, M. (2004). Transition to child care: Associations with infant–­mother attachment, infant negative emotion, and cortisol elevations. Child Development, 75(3), 639–650. Ashman, S. B., Dawson, G., Panagiotides, H., Yamada, E., & Wilkinson, C. W. (2002). Stress hormone levels of children of depressed mothers. Development and Psychopathology, 14(2), 333–349. Bakermans-­K ranenburg, M. J., & van IJzendoorn, M. H. (2004). No association of the dopamine D4 receptor (DRD4) and -521 C/T promoter polymorphisms with infant attachment disorganization. Attachment and Human Development, 6(3), 211–218. Bartels, M., de Geus, E. J. C., Kirschbaum, C., Sluyter, F., & Boomsma, D. I. (2003). Heritability of daytime cortisol levels in children. Behavior Genetics, 33(4), 421–433. Bauer, A. M., Quas, J. A., & Boyce, W. T. (2002). Associations between physiological reactivity and children’s behavior: Advantages of a multisystem approach. Journal of Developmental and Behavioral Pediatrics, 23(2), 102–113. Bogat, G. A., DeJonghe, E., Levendosky, A. A., Davidson, W. S., & von Eye, A. (2006). Trauma symptoms among infants exposed to intimate partner violence. Child Abuse and Neglect, 30(2), 109–125. Bokhorst, C. L., Bakermans-­K ranenburg, M. J., Fearon, R. M. P., van IJzendoorn, M. H., Fonagy, P., & Schuengel, C. (2003). The importance of shared environment in mother–­infant attachment security: A behavioral genetic study. Child Development, 74(6), 1769–1782. Bowlby, J. (1969). Attachment, separation, and loss (Vol. 1). New York: Basic Books. Boyce, W. T., & Ellis, B. J. (2005). Biological sensitivity to context: I. An evolutionary–­developmental theory of the origins and functions of stress reactivity. Development and Psychopathology, 17(2), 271–301. Brake, W. G., Zhang, T. Y., Diorio, J., Meaney, M. J., & Gratton, A. (2004). Influence of early postnatal rearing conditions on mesocorticolimbic dopamine and behavioural responses to psychostimulants and stressors in adult rats. European Journal of Neuroscience, 19(7), 1863–1874.

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Chapter 5

Infant Social and Emotional Development Emerging Competence in a Relational Context Katherine L. Rosenblum Carolyn J. Dayton Maria Muzik

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erhaps no aspect of developmental change is more salient to parents than their young child’s social and emotional behavior over the first years of life. The emergence of the first social smile is anticipated eagerly, and parents worry about the meaning of their infant’s cries. Emotion and socially relevant words dominate parents’ early descriptions of their young child’s personality: “He’s such a happy baby,” “He’s so shy,” or “She just loves people.” The fascination with development in these domains is by no means limited to parents. The study of the emotional and social experience of infants and young children has a long and rich tradition in the philosophical and empirical literatures (e.g., Aristotle, 1941; James, 1884). Although often studied as separate domains, it is clear that within the child, social and emotional developments are fundamentally intertwined. For example, as the young child’s ability to differentiate emotions unfolds, there is an increasing capacity to rely on the emotional expressions of others to determine how to respond to a certain situation. Consider the glance of a 1-year-old child toward his or her mother when first meeting someone new. This new “use” of the other to navigate a social situation (often considered a social advance) is entirely de-



pendent on the young child’s ability to differentiate and respond to another’s affective expression (which could be considered an emotional advance). Changes in each of these domains across the first years of life are dramatic. The newborn infant arrives with limited capacity for self-­regulation; emotion expressions are most likely reflective of biologically based signals, evolutionarily designed to engage the other in providing protection and care, and the infant still depends on the other to respond to his or her physical and emotional needs. In just a matter of months the infant’s emotional experience is markedly more complex. He or she can engage others in interaction, express delight in face-to-face games, convey feelings of sadness or anger through differentiated facial expression, and strategically use his or her parents’ emotional expressions to determine how to respond to a given situation. This rapid developmental progress is not limited to infancy; the toddler begins to show signs of responding empathically to others, and with increasing self-­awareness shows evidence of more complex “self­conscious” emotions such as shame, embarrassment, and guilt. Earlier social interactive experiences are internalized, and the young child uses the day-to-day lived experience of 80



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social and emotional interactions to guide responses to current interactions with others. Across all of these developments what emerges is a move toward increasing social–­ emotional competence in the infant. With development the young child evidences increasing capacities for emotion regulation and coping, more complex affective expressions and understanding, and more sophisticated interactions with important others in his or her social world. In the context of facilitative environments the young child’s trajectory of greater competence is accompanied by increasing feelings of self-­efficacy, security, and trust. Our understanding of infant social–­ emotional development is informed by both normative developmental processes as well as by development in contexts of risk. A common goal of many infant mental health interventions is to support families and young children in maintaining, returning to, or developing a trajectory of social–­emotional competence. Thus we aim to provide a foundation for the chapters that follow, with an emphasis on the normative processes involved in social and emotional development and implications for infant mental health.

THEORETICAL MODELS FOR SOCIAL AND EMOTIONAL DEVELOPMENT Several theoretical models explaining developmental process in the social and emotional domains have been suggested. The maturational model is perhaps the most basic, and from this perspective individual development represents an innate unfolding of preset maturational time points (Gesell & Armatruda, 1947). Higher-order capacities are seen as the result of growth of brain and physical body functioning. The developmental progression of emotional expressions, for example, may be seen as reflecting this type of “unfolding timetable.” Broader integrative models address the individual in context. Bronfenbrenner’s (1979) conceptualization of the child’s experience in terms of a widening series of contexts that mutually influence one another, the ecosystem model, emphasizes both immediate environments (e.g., parent–child interactions)

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that directly impinge on children’s daily lived experience, as well as more distal contexts (e.g., institutions) that don’t directly interact with the child but influence development indirectly (e.g., child care policies, cultural values). These contexts are likely to shape many of the aspects of infant social and emotional development. Transactional models consider “the interplay between child and context across time, in which the state of one affects the next state of the other in a continuous dynamic process” (Sameroff, 1993, p. 4). This perspective has clear implications for social and emotional development. For example, as parents respond to their child’s emotional displays, their reactions (e.g., perhaps frustration with a difficult-to-­soothe infant) shape the quality of the infant’s response to them (e.g., more distress as the infant reacts to parents’ frustration). Both partners in the infant–­parent dyad shape each other’s social and emotional experience in a dynamic, ongoing fashion. Current research in the biological domain has also underscored the complex interactions between biological (genetic) disposition and environmental contexts. A gene–­ environment interaction model emphasizes the ways in which individuals’ biological propensities interact with environmental characteristics to shape the course of development. For example, parental caregiving can alter the social developmental course of children who have genetic vulnerability for shy/inhibited temperamental traits (Fox et al., 2005). Several more specific models are relevant to a consideration of social and emotional domains. Attachment theory (Bowlby, 1969/1982) has contributed enormously to current conceptualizations of infant social development; the formation of attachment relationships is considered the predominant organizing force of infant and young child social development. Early interactions with care providers both promote survival and form the basis for later, more complex representations of caregivers as available and responsive. Individual differences in attachment security are evident in the ways the young child can use the attachment figure as a secure base, and these differences have implications for social and emotional development in a broadening array of contexts.

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Temperament models emphasize individual differences, typically viewing young children as varying in certain characteristics that both shape their experience of the environment as well as their responses to it. Temperament models often emphasize biologically based individual differences, though current research suggests a more complex interplay with the environmental context (e.g., Fox et al., 2005). Whereas some features of temperament are less apparently related to social and emotional development (e.g., activity level), other features are inherently linked (e.g., emotionality and mood). It is likely that the impact of a child’s emotionality on social functioning depends on his or her skills at emotion regulation (Lemerise & Arsenio, 2000). Most emotion regulation models emphasize the young child’s abilities to control, modify, and manage aspects of his or her emotional reactivity and expressivity. Individual differences in emotion regulation are often considered to be related to differences in the caregiving context (Calkins & Hill, 2007), though clearly children who vary in temperament also face different tasks in regulating their emotions (Lemerise & Arsenio, 2000; Thompson, 1990). For example, a child with a positive disposition and a high threshold for distress has a very different regulatory challenge than one who is more prone to intense and persistent negative emotions.

TRANSITIONS IN SOCIAL AND EMOTIONAL DEVELOPMENT The first years of life involve dramatic change across multiple domains. Developments in each of these domains, however, are not evenly distributed across time. Despite some apparent underlying continuity and gradual unfolding, there are also periods of rapid change and reorganization, sometimes referred to as biobehavioral “shifts” or “transitions” (Davies, 1999; Emde & Buschsbaum, 1989). Although earlier stages involved the unfolding and emergence of certain capacities, during these periods of reorganization new capacities become integrated and dominant (Goodlin-Jones, Burnham, & Anders, 2000). We outline here several prominent developmental shifts within the social and emotional domains.

2–3 Months Most of the newborn infant’s behavior is accounted for by endogenous rhythms and internal states. Following the 2- to 3-month shift, and corresponding to rapid neurological changes, much more of infants’ daily life is spent in wakefulness, and infants are more focused and better organized (Bowlby, 1969/1982). This shift has clear implications for social interactions and engagement, and it is often most readily apparent to parents in terms of their infant’s emotional expressions and social responses. By 2 months, most infants have begun to display social smiles, and about 2 weeks later, there is evidence of cooing vocalizations in response to social encounters. These advances typically elicit delight in parents and other caregivers. Parents begin to experience their infant as having more responsiveness and more consistent characteristics.

7–9 Months This period involves a rapid increase in the differential response of the infant to familiar, primary caregivers. The infant clearly discriminates between care provided by the attachment figure and that provided by less familiar others. Thus this period has been coined the “onset of focused attachment” (Emde & Buschsbaum, 1989). Infants who previously did not protest separation may now cry when the parent leaves the room. Stranger anxiety becomes prominent. Advances in memory and cognition permit more anticipation or expectation regarding social routines and interactions. For example, whereas the younger child may have laughed on the completion of an interactive game, during this period infants may laugh in anticipation of the mother’s return during the peek-a-boo game (Lieberman, 1993; Saarni, 1999).

18–21 Months This period is characterized by the emergence of self-­awareness and increases in symbolic representation. Infants display more independence, and social interactions are increasingly facilitated by their emerging symbolic capacity (e.g., language). Social referencing is prominent; the child under-



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stands different affective expressions in the parent and uses them to guide responses to novel situations (Feinman, Roberts, Hsieh, Sawyer, & Swanson, 1992). In addition, toddlers increasingly use affective expressions instrumentally; for example, a child may seem to smile or pout to “get her [or his] way.” Infants remember past events and sequences and have formed representations based on repeated events—which in turn guide later behavior in new contexts. With increasing awareness of separateness comes corresponding increases in mood swings, secure base behavior, and sense of vulnerability (Lieberman, 1993; Mahler, Pine, & Bergman, 1994). During this time the toddler begins to display more self-­conscious emotions—those that seem to require some sense of awareness of self and other, including feelings of shame, guilt, embarrassment, and empathy (Lewis, 2000).

EMOTIONAL DEVELOPMENT From the first weeks of life emotional reactions help to organize the infant’s responses to the environment and function as powerful communicative signals. Emotional processes reflect changes in physiology, cognition, and social functioning, and in turn impact each of these domains. Parents direct a great deal of activity toward helping the infant to organize emotional reactions—­either by amplifying displays of desired emotions or through efforts to divert or redirect unwanted ones. Two primary theoretical perspectives are employed in the study of emotion: structuralist and functionalist approaches. Structuralists focus on the underlying processes that constitute emotion (e.g., what are the physiological components of anger?), as well as the developmental unfolding of emotion experience (i.e., what emotions can a child experience at a given age?) and are consistent with maturational models (Izard & Malatesta, 1987). Izard and colleagues have identified a group of “primary” or “discrete” emotions—­interest, joy, surprise, sadness, anger, disgust, contempt, fear, shame, guilt, and shyness—that are considered to reflect more or less universal emotion expressions and related recognition abilities. Consistent with this approach, a great deal of research has focused on developing a comprehensive

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taxonomy for identifying infant affective expressions, when they emerge, and how they evolve over the course of early development. Functionalists, in contrast, emphasize the ways in which emotions serve as “processes of establishing, maintaining, or disrupting the relations between the person and the internal or external environment, when such relations are significant to the individual” (Campos, Campos, & Barrett, 1989, p.  395). Emotions, from this perspective, are defined in terms of their function—that is, what they do. In this way, emotions may regulate other psychological and behavioral processes. For example, feelings of fear in young toddlers may result in their running to a parent to seek comfort, whereas feelings of comfort may allow them to reengage in a play activity. Although there is controversy regarding whether certain discrete emotions exist from earliest infancy as innate, universal, biologically determined phenomena, it is generally agreed that emotional development involves increasingly more complex interactions between emotional, cognitive, physiological, and social–­environmental systems (Bell & Wolfe, 2004; Fogel et al., 1992). We thus begin with a description of research on the unfolding of emotion expression across the first years of life, followed by an examination of the interpersonal contexts of infant emotional development.

Development of Emotion Expression Newborns are capable of a more limited range of discrete emotional expressions, but with development, display a broader range of emotions and grow more responsive to a wider variety of eliciting conditions. There are at least three early appearing primary emotions, that is, those evident from the earliest weeks and months of life: distress, positive/joy, and interest expressions. Present at birth, distress reactions differentiate over time into more refined discrete emotions, including sadness, disgust, fear, and anger (Izard & Malatesta, 1987). For example, general distress is the infant’s primary response to inoculation at 2 months, but by 19 months anger is predominant (Izard, Hembree, & Huebner, 1987). Positive emotion expressions, including smiles, typically emerge by 2–3 months, with laughter often

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apparent by 3–4 months. More complex affective blends also emerge over the first year of life; for example, one study of 6-montholds revealed indicators of jealousy, indexed as diminished joy, heightened anger, and increased negative affect, when the attention of a preferred caregiver was directed to another (Hart, Carrington, Tronick, & Carroll, 2004). With the onset of self-­awareness in the second year of life many secondary or “self-­conscious” emotions become evident (Lewis, 2000), including embarrassment, shame, guilt, and pride. For example, Barrett, Zahn-­Waxler, and Cole (1993) observed two approaches taken by 2-year-olds after they believed that they had broken the experimenter’s “favorite doll.” One group of children tried to fix the situation (the “amenders”), and a second group sought to avoid the experimenter, usually by smiling with their faces averted (the “avoiders”). The researchers suggest that the amenders were demonstrating behavior consistent with feelings of guilt, whereas avoiders were presumably feeling something akin to shame. Many social, cultural, and biological factors are likely to determine the types of reactions an individual child will have to specific emotion-­evocative situations. For example, guilt may be more acceptable in many Western cultures (Walbot & Scherer, 1995), whereas shame is often perceived as more aversive and disturbing. Many collectivistic cultures, in contrast, view shame as an emotion that helps to facilitate appropriate social bonds and compliance (Cole, Tamang, & Shrestha, 2006; Kitayama, Marcus, & Matsumoto, 1995).

Infant Sensitivity to Others’ Emotional Signals Emotional expressions are critical social signals, and thus not surprisingly infants become attuned and responsive to the emotional signals of others at a very young age. By 2-months infants are capable of discriminating among distinct human expressions (e.g., Oster, 1981), including the intensity levels of some expressions. This early capacity for discrimination does not, however, imply “understanding” others’ expressions; such an understanding involves a process that continues to unfold across the first several

years of life. Corresponding to developments in the cognitive domain, the 8- to 9-monthold infant begins to appreciate that others’ emotional messages pertain to specific objects or events. Social referencing describes the infant’s ability to use others’ expressions to help shape his or her own responses to the environment. This ability is well established by 12 months of age (Feinman, Roberts, Hsieh, Sawyer, & Swanson, 1992), but also increases in complexity over time. For example, 18-month-olds appear to engage in “emotional eavesdropping,” whereby they use information from interadult emotional expressions in order to determine whether to approach an object (Repaccholi & Meltzoff, 2007). Beyond the ability to detect the emotional expressions of others, infants also develop expectations regarding others’ affective displays during social engagement. Peek-a-boo games initiated by adult caretakers tap the infant’s ability to expect the adult’s smiling face following a period of disengagement. Researchers have studied these expectations through the use of procedures designed to interrupt “usual” interactive contingencies. For example, the Still-Face Procedure (Tronick, 2003) is a structured, adult–­infant interactive task that typically includes (1) a period of face-to-face free play; (2) a period during which the adult holds a still, emotionally unresponsive expression; and (3) a reengagement period during which the dyad returns to face-to-face play. Between 2- to 9-months-of-age infants display heightened negative affect, and corresponding physiological arousal, during the still-face phase, presumably because they recognize that this disruption in affective exchange is discrepant and undesirable (Rosenblum, McDonough, Muzik, Miller, & Sameroff, 2002; Tronick, 2006; Weinberg & Tronick, 1996). As emotional detection and expectation abilities develop, the capacity for empathic responding also reveals developmental changes in the young child’s sensitivity to others’ emotional displays. For instance, the process of emotional “contagion” (e.g., when other infants in a day care center start to cry after one starts crying) is generally considered an infantile “preempathic” capacity (Saarni, 1999). Later in development, toddlers have been observed to display more advanced empathic responding, reflect-



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ing a higher-order cognitive capacity that permits better perspective taking with others. Expressions of concern (e.g., a worried look, patting, asking “Baby okay?”) or efforts to generate hypotheses about what has caused another’s distress (e.g., asking “Baby owie?”) suggest an emerging sensitivity to the distress of others. This growing ability for empathy is likely to have a basis in how others have responded to infants’ own displays of distress. For example, abused toddlers make fewer empathic gestures but are more personally upset by, or aggressive toward, distressed peers (Main & George, 1985), whereas infants whose mothers were more responsive during the first year of life show more empathic concerned attention and fewer personal distress reactions to others at 18 months (Spinrad & Stifter, 2006).

Temperament, Genes, and Emotions in Infancy Beyond the changes that occur across development, children differ in their emotional “makeup,” and these differences are often described in terms of temperamental variations. For example, highly reactive, irritable babies are frequently described as “difficult,” whereas infants more prone to positive emotions and less reactive are described as “easygoing.” Although temperament includes more than emotions, emotionality is considered to be an important component. In this chapter we consider another related domain, emotion regulation, separately in a later section. Consistent with the gene–­environment interaction model, temperament has been understood as a biologically based set of behavioral tendencies that influence how an individual will approach, respond to, and interact with the larger social world (Rothbart & Bates, 1998). In defining temperament some researchers have emphasized a narrow set of dimensions, (e.g., activity level, emotionality, and socialibility; Buss & Plomin, 1984), whereas others argue for a broader array (e.g., proneness to distress and fear, soothability, attention span, persistence, and positive emotionality; Rothbart & Derryberry, 1981; Thomas & Chess, 1977). However, there is general consensus that emotional reactivity is a critical feature of temperament. Reactivity refers to the excitability or

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arousability of the individual’s response system (Rothbart & Derryberry, 1981), such as how quickly the infant expresses distress in response to an unfamiliar stimulus, how intense the distress is, and how long the infant takes to recover. Over the past several decades studies have yielded mixed evidence regarding the stability of temperamental features over time. Evidence for modest stability includes the seminal longitudinal research of Thomas and Chess (1977), who investigated several temperamental dimensions in infancy and defined groups of “easy,” “difficult,” and “slow-to-warm” children, with the “difficult” group (approximately 10% of infants) showing high levels of negative mood, irregularity in body functions, and slow adaptation to the environment. Subsequent longitudinal research demonstrated that those children who presented with high levels of negative emotional behaviors early in life, indexed as negative affect and aggression, had more behavior problems in middle childhood (age 5) and adolescence (ages 14–17). Yet while early childhood negative affect and aggression were significantly intercorrelated (r = .63), only those children who displayed aggression at age 3 were more aggressive in middle childhood, and in turn had more behavior problems in adolescence (Lerner, Hertzog, Hooker, Hassibi, & Tomas, 1988). Others have studied behaviorally inhibited infants (approximately 15% of a larger sample) who exhibit extreme fear and inhibition when exposed to novelty (e.g., Calkins & Fox, 1992; Kagan, Reznick, Clarke, Snidman, & García-Coll, 1984); results indicated modest stability from infancy to middle childhood (approximately 30% remained inhibited; Fox, Henderson, Rubin, Calkins, & Schmidt, 2001). Furthermore, behavioral inhibition in infancy proved to be a significant predictor of anxiety disorders, particularly social anxiety in later childhood (Kagan, Snidman, McManis, & Woodward, 2001; Schwartz, Snidman, & Kagan, 1999). Although assessment of temperament is often based on behavioral observations, more recent studies reflect advances in biological research. Individual differences in infant temperament are currently thought to originate in genetic variations underpinning behavioral, neuroendocrine, and physiological regulatory processes (see Propper

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& Moore, 2006, for review). The human genome consists of approximately 30,000 genes that code essentially all structures of the human body and also regulate functioning across these structures. Genes come in variations of size, referred to as alleles, and these different alleles often translate into variations in gene activity level (i.e., “gene expression”). Current research explores associations between alleles of a given gene and temperamental vulnerability. Recently, genes coding for the activity level of two receptors in the brain—the dopamine D4 receptor (DRD4) and the serotonin transporter receptor (5-HTTLPR)—have been identified as underlying mechanisms for some key temperamental variations, specifically, to individual differences in approach behaviors and inhibition, attention, and novelty seeking (Auerbach, Benjamin, Faroy, Geller, & Ebstein, 2001; Ebstein et al., 1998; Kluger, Siegfried, & Ebstein, 2002). For example, infants possessing the short versus long allele of the DRD4 gene are rated by their mothers as higher in negative emotionality at 2 and 12 months of age, and infants with the short allele of the serotonin transporter gene (“short” 5-HTTLPR allele) have been found to display heightened fear and behavioral inhibition (Auerbach, Faroy, Ebstein, Kahana, & Levine, 2001; Auerbach et al., 1999). Research also suggests an additive effect across DRD4 and 5-HTTLPR; infants with short alleles on both genes display more negative emotion reactivity than infants who carry only one risk allele (Auerbach, Faroy, et al., 2001; Auerbach et al., 1999). While these risk alleles appear to play a direct role in infant temperamental variations, current research on gene–­environment interactions underscores the critical influence of early social experience on gene functioning. Environmental factors can either ameliorate or potentiate genetically based temperamental risk (Caspi et al., 2003; Fox et al., 2005; Kaufman et al., 2004), and this finding holds important implications for intervention. For example, children who were 5-HTTLPR risk carriers and had experienced childhood abuse were more likely to develop depression later on, but only when their caregivers were themselves under heightened stress (Kaufman et al., 2004). Similarly, behaviorally inhibited infants who were carriers of the 5-HTTLPR risk allele were at increased risk

for behavioral inhibition in middle childhood only when their caregivers reported low social support (Fox et al., 2005). Finally, a recent study found that although maternal insensitivity was associated with later externalizing behavior, this was only true in the presence of infant DRD4 genetic risk status. Insensitive parenting coupled with infant genetic vulnerability led to a sixfold increase in child aggressive behaviors in the preschool years (Bakermans-­K raneburg & van IJzendoorn, 2006). These gene–­environment interactions are consistent with a transactional perspective and have been described in the “goodnessof-fit”-model (Seifer, 2000), which argues that the consequences of temperamental vulnerability are dependent on the way the infant’s temperament interacts with the demands of the specific environment. Parents who understand and sensitively respond to their children’s behavior, even when the behavior is considered “difficult,” may help their children learn to regulate their temperamental challenges more effectively, thus preventing later development of behavioral problems (Ghera, Hane, & Malesa, 2006; Teti & Candelaria, 2002). In contrast, parents who react to infant difficulty with harsh parenting or reduced sensitivity increase their children’s risk for later maladjustment (Bates, Pettit, & Dodge, 1995; Belsky, Hsieh, & Crnic, 1998; Crockenberg, 1981). Taken together, these findings suggest that temperamental “difficulty” does not reside within the individual alone, but is significantly shaped or modified by the environmental context. As suggested here, one important environmental influence involves the parent’s ability to sensitively respond to the child’s emotions as they unfold over the course of development.

Parental Responses to Infant Emotions The impact of parenting on infant emotional development and expression has been studied from a number of different perspectives. Multiple aspects of infant emotional behavior, including expressiveness, self- and other­directed emotion regulatory behaviors, and soothability, have been linked, for example, to parents’ own emotional expressiveness (e.g., Garner, 1995), awareness of emotional states (Gergely & Watson, 1996), and emo-



5. Infant Social and Emotional Development

tional dysregulation (e.g., depression) (Field, 1994). From early infancy parents perceive a wide array of emotions in their young children, and these attributions of emotion can have important implications, as evidenced by research on how parents’ own mental health colors the appropriateness of emotions they perceive (Dix, 1991; Leerkes & Crockenberg, 2003). For example, mothers at risk for less secure attachment relationships with their infants make fewer benign, and more hostile, attributions regarding ambiguous infant facial expressions (Rosenblum, Zeanah, McDonough, & Muzik, 2004). Across parent–­infant dyads parents’ emotional exchanges with their infants tend to follow meaningful patterns of interaction. Stern (1985) has written extensively about his observation of mother–­infant emotional exchange, noting that the affective interactions have a dynamic “shape” to them, and that patterns of engagement vary across mother–­infant dyads. Infant mental health, Stern suggests, is strongly affected by the synchrony of the interaction. Indeed, asynchronous interaction, observed when one of the partners is not sensitively attuned and responsive to the cues of the other, has been demonstrated to negatively affect infants’ early emotional development (Malatesta, Culver, Tesman, & Shepard, 1989; Tronick & Weinberg, 1997). Tronick and Cohn (1989) observed that although the coordination and synchrony of mother–­infant dyads increased from 3 to 9 months, they typically spent more time in “miscoordinated” or “asynchronous” states than in synchronized matching states. These results, consistent with a mutual regulation model (Tronick, 2006), suggest that the process of disruption and repair may be a critical part of the developmental process. For example, Rosenblum and colleagues (2002) observed that some mothers and infants used positive affect (e.g., peek-a-boo games) to “reconnect” following the interactive disruption imposed by the Still-Face Procedure, and this was associated with indicators of more enhanced relationship security. The process of emotional exchange has been proposed to play a central role in the infant’s emerging ability to recognize and regulate his or her own emotional states (Lewis & Ramsay, 2005). Gergely and Wat-

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son (1996), for example, provide a compelling account of the role of maternal affective mirroring, suggesting that mothers’ ability to accurately perceive, mentally transform, and then display a “marked” exaggerated response to the infants’ emotional displays is related to the infants’ own ability to internalize and understand emotional experience. Disturbances may arise when parents display a purely mirrored form of infants’ distress without the accompanying “marking.” For example, parents whose emotion regulation style is characterized by a tendency to overactivate emotional arousal may simply mimic their infants’ emotional expression, without processing and transforming the emotion. This “pure mirroring” may escalate infants’ emotional state because it fails to provide the necessary containment and assistance in coping with the experienced emotion. With development language plays an increasingly important role in young children’s understanding of emotion (Garner, 2003; Meins, Fernyhough, & Wainwright, 2003). Verbal acknowledgment of mental states, which could be considered a form of verbal mirroring, is increasingly used in place of facial mirroring to facilitate infants’ emotion understanding. To illustrate, in a recent study children whose mothers used more mental-state language with them at 15 and 24 months, for example, making reference to child desire (e.g., “You want that rattle?”) or emotion (e.g., “That surprised you!”), performed better on structured emotion understanding tasks (Taumoepeau & Ruffman, 2006). Across early development, parents and caretakers are essential in helping infants express and manage their developing emotions. Through these affective exchange processes, disruption–­repair sequences, and physical and verbal mirroring, infants begin to internalize emotion awareness, understanding, and early emotional self-­regulation abilities.

Emotion Regulation Child emotion regulation is increasingly recognized as a core component of social–­ emotional competence, functional in almost all of a child’s transactions with the world (Calkins & Hill, 2007; NICHD Early Child Care Research Network, 2004). As children move into the preschool years they are

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largely expected to control their emotions in the service of their own, and society’s, goals (Sroufe, Egeland, Carlson, & Collins, 2005), and indicators of emotional dysregulation are often the basis of clinical referral. Children who are well regulated (both in emotion and behavior) are better able to adapt to contextual and situational changes in the environment in a flexible and spontaneous manner, as well as to delay their reactions (e.g., exert control) when appropriate (Eisenberg et al., 2001). From a developmental neuroscience perspective, emotion, cognition, and the developing neural mechanisms of regulation are dynamically linked and work together to help the infant and young child process information and engage in emotion-­regulatory action (Bell & Wolfe, 2004), a process that unfolds from infancy into the preschool years and beyond (Kopp, 1989). Important reviews have addressed the controversial topic of how to best define and measure emotion regulation (see Cole, Martin, & Dennis, 2004). Many of these definitions, however, share a perspective that emotion regulation processes include behaviors, skills, and strategies—­conscious or unconscious, effortful or automatic—that modulate, inhibit, or enhance emotional experiences and expressions (Calkins & Hill, 2007). Although both positive and negative emotions can be regulated and used to achieve goals (e.g., smiling to enhance interactive repair, or anger to eliminate a barrier), child emotion regulation as a dynamic process is often most readily observed in contexts of challenge that afford negative emotions (Cole et al., 2004). When confronted with challenging situations, the infant or young child can utilize a variety of behavioral emotion regulation strategies to cope with heightened arousal, including distress reactions, avoidance, and self-­comforting behaviors; a repertoire of available strategies that increases over time (Calkins & Hill, 2007; Kopp, 1989; Thompson, 1990). For example, in early infancy the capacity for gaze aversion and motor control allows the infant to shift attention away from a negative event (e.g., something that is overwhelming) to something more positive (e.g., a toy) and thereby modulate negative affect (Calkins, 2004; Johnson, Posner, & Roth-

bart, 1991; Kochanska, 2001). Parents can assist in this process through their efforts to divert the infant’s attention (Crockenberg & Leerkes, 2004; Johnson et al., 1991). By the end of the first year infants are more active in their attempts to modulate distress. They are increasingly able to plan behavior and can act intentionally to signal others to assist them in modulating their affective states. During the second year of life infants move from more passive to more active methods of emotion regulation, and although caregivers continue to play an important role, toddlers are increasingly able to use specific strategies to manage different affective states. Challenging events may elicit more or less effective regulation of the distress across infants. For example, Lewis and Ramsay (2005) observed 4- and 6-month-old infants’ anger and sadness in response to situations that prevented them from achieving a desired goal. Infant displays of sadness were related to greater stress hormone reactions (i.e., cortisol production), whereas displays of anger were not, suggesting a more adaptive role of anger. Infant anger in response to goal blockage is often associated with attempts to overcome the obstacle (Lemerise & Dodge, 2000). In contrast, sadness may reflect infants’ perceived lack of control over the situation, or perception of task failure, without corresponding coping to facilitate adaptive physiological regulation (Lewis & Ramsay, 2002, 2005). The capacity for effective emotion regulation is often considered to have strong social origins, based in the early interactions between parent and infant (Calkins & Hill, 2007; Cole, Teti, & Zahn-­Waxler, 2003; Kopp, 1989; Stern, 1985; Stifter, 2002; Thompson, 1990). For example, less dyadic synchrony between mothers and their 3-month-olds in the Still-Face Procedure is associated with less effective physiological regulation of the challenge task (Moore & Calkins, 2004). Among 2-year-old children negative maternal behavior is related to poor physiological regulation, less adaptive emotion regulation, and noncompliant behavior (Calkins, Smith, Gill, & Johnson, 1998). In contrast, maternal positive guidance is associated with 18-month-old toddlers’ effective use of distraction and mother-­oriented regulating behaviors during a frustration­inducing task (Calkins et al., 1998), and



5. Infant Social and Emotional Development

6-month-olds show less distress when their mothers respond contingently to their efforts at self-­soothing (e.g., gaze aversion; Crockenberg & Leerkes, 2004). Ultimately, many factors, including the social environment, maturational processes, and temperament, influence emotion regulation capacities during the first years of life. Each child’s capacity for effective emotional self-­regulation develops within a relational context and becomes a core element of the child’s self-­regulation and social–­emotional competence.

Infant Mental Health Implications Given the vast number of expressive interchanges that occur between parent and infant during the first months of life (Magai, 1999), the influence of parents’ emotional engagement with their infant is likely to hold significant consequences for infant emotional development. Thus, from an infant mental health standpoint, it is critical to asses the parent–­infant emotional “dance” (Stern, 1985), and to observe both the process of affective synchrony as well as the process of repair following disruptions (Rosenblum, Dayton, & McDonough, 2006; Tronick, 2006). The emotional tone of early experience provides a framework within which the infant develops his or her own affective repertoire. Thus, a parent’s reduced capacity, for example, in the case of untreated depression or anxiety, to engage in emotionally positive interaction with the infant may take on an especially important role (Kogan & Carter, 1996). Although the identification and assessment of negative emotionality, or hostile-­negative dyadic interactions, is often the focus of infant mental health intervention, research indicates that the absence of positive affect may be an even more important harbinger of problems in the emotional domain (Rosenblum et al., 2006). Current research also underscores the importance of recognizing that the challenges of parenting are different for different groups of infants. For example, parents of temperamentally “difficult” infants face greater challenges in soothing their children, and their children appear to be more sensitive to lapses in their caregiving. Leerkes and Crockenberg (2003) suggest that mothers

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who are successful at calming their temperamentally difficult infants may develop higher degrees of sensitivity than either mothers with temperamentally “easy” infants, or mothers who have difficult infants but are unsuccessful at soothing. When parents view their temperamentally challenging infants as sootheable, they display higher levels of sensitive caregiving (Ghera et al., 2006). Thus helping parents to recognize these challenges as surmountable is likely to have positive impacts. Taken together, these studies suggest that both parents and infants play an important role in the development of infant emotion regulation and social–­emotional competence. In the following section we focus more fully on the social context within which these emotion regulation capacities emerge and develop.

SOCIAL DEVELOPMENT Infants are born into complex social networks and enter the world with strong propensities for forming social–­affective bonds with others. From the first primary attachment relationship to increasingly complex social relations with extended family, peers, and others, the young child is immersed in a world of social relatedness. Social developmental milestones across the first 3 years are strongly rooted in cognitive and neurological advances, and are embedded in the broader social context. Table 5.1 provides an overview of this developmental process, highlighting central tasks, the context of these advances, and the young child’s corresponding social developmental milestones. The social context of these advances progresses from primarily the parent–­infant relationship to include other significant relationships, including peers, extended family, or child care relationships. The coordination of these advances initially reflects primarily parent-led sequences, but with time incorporate greater infant initiative and back-andforth interactions. With continued development these interactive encounters reflect the establishment of goal-­corrected partnerships, wherein the infant and adult negotiate their exchanges with an awareness of each other as separate, yet interdependent, selves.



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Primarily the parent– infant relationship

Parent–infant and close family relationships

Parent–infant and close family relationships

Parent–infant relationship

Reciprocal exchange

Infant initiative

Onset and establishment of focused attachment

Primarily the parent– infant relationship

Regulation

Emerging sociability

Social context(s)

Developmental task

Parent provides secure base Infant relies on parent for comfort and protection during times of distress or perceived threat Infant explores the environment in the presence of caregiver

Infant initiation of play with others, as well as an increasing ability to direct activities Infant embellishes on others’ initiations

Back-and-forth exchanges between infant and others

Parent-led system of coordinated engagement with the infant Face-to-face interaction with increasing mutual gaze Parent language and verbalization toward infant

Parent assists the infant in regulating sleep, feeding, distress, and arousal

Coordinated behaviors

Stranger anxiety, separation distress Emergence of person permanence (i.e., ability to keep the parent in mind even when he or she is not present) Secure base behavior

Evidence of intentionality and goal direction—the infant shows a preference for certain activities and leads attention Delight in games (e.g., peek-a-boo)

Infant increasingly responsive to social bids

Increased eye-to-eye contact Emergence of social smiles Social vocalizations

Developing attentiveness to the social world Increasing coordination of parent–infant interactions

Select milestones

TABLE 5.1.  Social Developmental Tasks, Contexts, and Milestones across the First 3 Years of Life

7–18 months

6–9 months

3–6 months

2–3 months

0–3 months

Ages



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Broader social context, Infant has an awareness of self including parents, family, Infant determines and selects his or her own goals peers, care providers and intentions apart from parents

Broader social context, Child displays an emerging awareness that the including parents, family, caregiver’s intentions are separate from his or her peers, care providers own The coordination of sequences increasingly reflects exchanges between two autonomous yet interdependent individuals

Siblings, peer relationships

Self-assertion and independent selfconcept

Recognition, continuity, and emergence of a goalcorrected partnership

Establishing peer relationships

Note. Data from Sander (1975); Sparrow, Balla, & Cicchetti (1984); and Sroufe (1989).

Child engages in meaningful interaction with siblings and peers in play groups, day care environments, and other settings

Broader social context, Infant displays an awareness of others’ point of including parents, family, view peers, care providers Infant seeks others’ facial expressions in order to understand new situations

Emergence of joint attention

Increasing interest in other children Moves from solitary to parallel play Rough-and-tumble play with peers Evidence of empathic concern regarding peer distress

Emerging recognition of the permanence and continuity of primary relationships Increasing ability to negotiate and coordinate behavior in terms of the goals of the other Empathic responding

Mirror self-recognition Use of “no” and temper tantrums Increasing autonomy Egocentric reasoning

Imitative learning Social referencing Expresses affect instrumentally or purposefully

18–36 months

18–36 months

18–24 months

9–12 months

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I. DEVELOPMENT AND CONTEXT

While attachment relationships are not the only context for infant social development (Crockenberg & Leerkes, 2000), attachment theory is a predominant model for understanding early parent–­infant relationships. In the following section we therefore provide an overview of how parent–­infant attachment relationships develop, moving from a discussion of universal processes to a review of individual differences in the quality of attachment relationships. We consider the caregiving context of attachment security and how early experiences serve as relational templates for later social relationships.

Infant–­Parent Attachment Relationship Attachment theory (Bowlby, 1969/1982) emphasizes the fact that human infants exist for an extended period of time in a state of dependency wherein proximity to a caretaker is essential for both physical survival and the development of psychological health (e.g., security, emotion regulation; Simpson, 1999). The primary evolutionary function of this proximity is to promote survival of the dependent infant, but with development attachment relationships evolve to include more complex functions. The infant is increasingly able to use the attachment figure as a secure base, deriving the security needed to allow for exploration of the environment when safe, and the protection and comfort needed in times of fear or distress (Sroufe & Waters, 1977). Across diverse cultural contexts, maternal attachments are often primary, although shifting work–­family balances within many (especially Western) cultures has resulted in fathers spending increasing amounts of time actively parenting their children (Hofferth, Pleck, Stueve, Bianchi, & Sayer, 2002). Relative to maternal attachments, contemporary theory and research suggest that infant–­ father attachments emphasize the infant’s ability to explore versus the propensity to seek comfort when distressed (Grossmann et al., 2002; Paquette, 2004). Across mothers and fathers, however, attachment relationships serve as a foundation for the early establishment of affect and arousal regulation. Individual differences in the quality of these early relationships appear to have implications for the young child’s emerging emotion regulation, sense of self-­efficacy, and social

relatedness outside the parent–child context (Sroufe et al., 2005).

Individual Differences in Attachment Relationships Whereas from an evolutionary perspective infants are biologically driven to form attachment relationships, individual differences in the quality of these relationships have been the focus of abundant research over the past decades. Ainsworth and colleagues developed a laboratory-­administered procedure, the Strange Situation Protocol (SSP), to assess individual differences in the quality of attachment relationship patterns (Ainsworth, Blehar, Waters, & Wall, 1978). Through the induction of stressful challenges the SSP provides an opportunity for observation of the process of interactive repair; challenges include exposure to an unknown environment, interaction with an unknown adult, and two separations from, and reunions with, the parent. These challenges are intended to activate the infant’s attachment strategy, and the infant’s behavior during this procedure is observed with special attention paid to the ways the infant uses the parent to regulate his or her emotional states following separation. Ainsworth described three organized patterns characterizing how infants (and parents) negotiate this attachment-­behavior-­eliciting task: the secure, the anxious-­avoidant, and the anxious-­ambivalent attachment patterns (Ainsworth et al., 1978). Infants demonstrating secure attachments to their caregivers were able to openly and genuinely display their emotions and use their parents to help regulate their distress. Once comforted, these infants returned to exploratory play. Their balanced and open regulatory strategy was not surprising in light of home observations that suggested these infants had mothers who were generally sensitive and tender in their caretaking interactions. The infants appeared to “trust” the parent to provide care and protection, and indeed, these mothers were contingently responsive and attuned to the expressed needs and desires of their infants. In contrast, infants with an anxious­avoidant pattern behaved as if they did not need comfort from their parent at all, although physiological indicators revealed



5. Infant Social and Emotional Development

high levels of arousal and distress. Avoidant children played independently and often seemed impervious to their parents’ presence or absence. During home observations mothers of avoidantly attached infants were rejecting of infant distress. Thus the behavioral strategy shown by anxious-­avoidant infants has been understood as an effort on the children’s side to maintain proximity to the parents by deactivating their own displays of emotional needs (Magai, 1999). The third pattern, anxious-­ambivalent attachment, was characterized by a heightened activation strategy. These infants appeared desperate to have contact with their parents, but appeared unable to be soothed by the parent once reunited. Thus these infants were unable to return to exploratory play (Magai, 1999). Mothers of ambivalently attached infants were observed to be fairly inconsistent in their care, and their interactions with their infants were often not contingently based on the infants’ cues. The infants’ heightened emotion activation was thus understood as an effort on the children’s side to keep the parents responsive and involved. A fourth attachment pattern was later articulated by Main and Solomon (1986) and labeled disorganized. These children, often with histories of maltreatment, abuse, and neglect, seemed to lack a coherent, organized strategy for gaining proximity to their parents when distressed, but instead displayed bizarre or uncoordinated behaviors in response to the stressful paradigm. For example, some of these infants temporarily froze or displayed conflicted approach–­ avoidance behaviors toward their parents, as if expressing ambivalence and fear in their attempts to gain proximity. Because mothers of disorganized infants have been found to display both frightening and frightened behaviors (e.g., bizarre vocalizations, sudden intrusive physical movements, reacting with fear to infant behaviors; Lyons-Ruth & Jacobvitz, 1999), these infants experience an understandable conflict regarding how and whether to seek proximity and care from their attachment figure.

Early Attachment and Later Social–­Emotional Competence Longitudinal research has followed children from infancy into early adulthood and con-

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firms that, in general, the quality of early attachment relationships holds consequences for children’s later social and emotional competence, though later life events also moderate the stability of these associations (Grossmann, Grossmann, & Waters, 2005; Sroufe et al., 2005). In general, children who build a secure attachment with their caregiver early in life continue to hold a secure working model of relationships in mind and show the most optimal developmental outcomes in later years. In contrast, children with avoidant attachment histories appear to expect rejection within the context of relationships, and research indicates reduced interpersonal competence later in life, particularly when coupled with other risk factors. These children are more vulnerable to becoming emotionally insulated, hostile, and antisocial themselves, potentially provoking adults and peers into rejecting them (Weinfield, Sroufe, Egeland, & Carlson, 1999). For example, previously avoidant children are likely to exhibit greater hostility and scapegoating of peers than their secure and ambivalent resistant counterparts (Suess, Grossmann, & Sroufe, 1992). Children with ambivalent, resistant histories have learned to behave in an overaroused manner in an attempt to garner the emotional warmth that has been offered inconsistently. In early childhood these children are described as more hesitant in exploring novel situations, immature, and easily frustrated; more likely to be neglected by their peers (in contrast to the rejection that avoidant children face); more likely to display separation anxiety; more socially isolated and/or hostile; and less empathic to other children’s displays of distress than their secure counterparts (Horvath & Weinraub, 2005; Kestenbaum, Farber, & Sroufe, 1989; Sroufe, 1983). The most vulnerable group appears to be infants with disorganized attachment patterns. This pattern evolves in the face of a child’s fear and uncertainty regarding how the parent will react, given a history of frightened or frightening responses that might include seductive enmeshment, helplessness, hostility, or abuse. Thus, not surprisingly, the outcomes of these infants are relatively poor; studies have documented a host of problematic outcomes, including

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I. DEVELOPMENT AND CONTEXT

more controlling behavior in early childhood, more hostile/aggressive behavior toward peers, more externalizing and internalizing behavior problems, and developmental lags that include lower academic self-­esteem and achievement (for review, see Green & Goldwyn, 2002; Lyons-Ruth & Jacobvitz, 1999).

Parental Influences on Infant Social Development The caregiving context plays a critical role in the development of infant attachment security and early social–­emotional competence. Here we consider several domains of parental influence on the infant and young child’s social–­emotional development, including parenting behavior, verbal engagement with the infant, and the parents’ own attachment representations.

Caregiving Sensitivity Beginning with Ainsworth’s seminal home studies, maternal caregiving sensitivity (e.g., warmth, attunement, and acceptance) has been suggested as the primary mechanism underlying infant attachment relationships (Ainsworth et al., 1978). The role of caregiving sensitivity, particularly in response to infant distress (McElwain & Booth-­Laforce, 2006), has since been confirmed across multiple studies, although later research has not demonstrated effects as strong as Ainsworth’s original work (De Wolff & van IJzendoorn, 1997). More recently, other factors have been identified that may shape the development of attachment patterns; for example, child temperament (Mangelsdorf, McHale, Die­ ner, Goldstein, & Lehn, 2000), the broader child care context (Aviezera, Sagi-­Schwartz, & Koren-Karie, 2003; Sagi, van IJzendoorn, Aviezer, & Donnell, 1994), or other aspects of caregiving such as dyadic regulation and emotional availability (Biringen, 2000; Harrist & Waugh, 2002). These and other studies confirm that many aspects of the caregiving context contribute to infant attachment outcomes. The role that fathers play in the social development of their young children has only recently been given more attention. In general, research has failed to find an association

between traditional (e.g., mother-­derived) assessments of fathers’ sensitivity and infant attachment (Braungart-­R ieker, Garwood, Powers, & Wang, 2001; Grossmann et al., 2002; van IJzendoorn & De Wolff, 1997). However, there is evidence that other paternal behaviors, such as the ability to be emotionally supportive and challenging during play interactions, may have an important role in supporting the infant’s exploration (rather than proximity seeking, as assessed in the SSP), and may therefore be more salient aspects of the father–­infant relationship (Grossmann et al., 2002). There has been a surge of interest in parents’ verbal attributions of mental states to their infants, or mind-­minded comments (Meins, Fernyhough, & Fradley, 2001; Meins et al., 2003). Mind-­mindedness refers to a parent’s tendency to treat the infant as an individual with a mind. For example, parents high in mind-­mindedness comment on their child’s interests, desires, feelings, and beliefs during interaction (e.g., “You want that ball, don’t you?” or “Are you so sad?”). A parent low in mind-­mindedness tends to view the child more concretely in terms of need states and behaviors, or in terms of the parent’s own perspective (e.g., “You’re just being fussy”). Mothers’ mind-­minded comments during interactions with their 6-month-old infants are correlated with behavioral sensitivity and interactive synchrony (Meins et al., 2001; Muzik & Rosenblum, 2003; Rosenblum, McDonough, Sameroff, & Muzik, 2008) and indeed, some evidence suggests that mothers’ appropriate mind­minded comments may be a stronger predictor of attachment security at 1-year than maternal behavioral sensitivity (Meins et al., 2001). In addition, mind-­minded comments in the first year of life have been linked to 4-year-old children’s understanding of other peoples’ mental states, or “theory of mind” (Meins, Fernyhough, & Johnson, 2006).

The Role of Mental Representations Attachment theory postulates that throughout early development, daily lived experiences of interactions with the primary caregiver are stored as memory templates. These internal working models (Bowlby, 1982), or mental representations, incorporate both the cognitive and affective elements of early



5. Infant Social and Emotional Development

caregiving experiences (Crittenden, 1990), and are thought to guide behaviors and expectations within other social relationships, including parents’ relationships with their children. In the following section we discuss influences of parental representations, both regarding parents’ representations of past relationships with their own parents and current representations of their children, on parenting behavior and infant attachment. Parents’ Representations of Their Own Early Relationship Experiences.  Research on adult attachment representations has focused primarily on individuals’ current state of mind with respect to their early attachment relationships, assessed via the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985). The AAI yields four main categories (autonomous, dismissive, enmeshed, and unresolved) that correspond, respectively, to the four infant attachment categories (secure, avoidant, ambivalent­resistant, and disorganized). Primary among the factors differentiating the autonomous (secure) versus nonautonomous adult attachment patterns is the ability to psychologically access and coherently articulate affectively charged thoughts and events without the need to minimize (as in the dismissing category) or distort (as in the preoccupied category) the information (Main & Goldwyn, 1984). Thus, regardless of the specific content of the childhood events being recounted (e.g., memories of abuse or neglect vs. love and support in childhood), the critical factor is how openly and coherently the adult can describe these memories in his or her narrative report of past events. Parents’ internal working models of relationships also function as emotion regulators in the relational context (Rosenblum et al., 2006; Zimmermann, 1999) and are likely to influence the degree to which parents can openly and genuinely identify and orient to their children’s emotions (Cassidy, 1994). For example, mothers’ AAI attachment classifications have been related to the way they conveyed emotions toward their infants while singing to them; dismissive mothers were found unable to modify their singing to adjust for infant distress (Milligan, Atkinson, Trehub, Benoit, & Poulton, 2003). Conversely, mothers with autonomous AAI classifications have been observed to be more

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sensitively attuned to a wider range of infant affects than nonautonomous mothers (Haft & Slade, 1989). The power of these representations is evident from the high level of intergenerational correspondence between parental (even grandparental) representations and child security. Recent work by Dozier and colleagues (Dozier, Stovall, & Albus, 2001) illustrates the power of these effects in the context of a natural experiment, following child placement with a foster parent. After only 3 months of placement, there was significant correspondence between children’s attachment security and the foster parents’ AAI classifications, with rates comparable to intact mother–child dyads. Parents’ Representations of Their Children.  While the AAI research confirms the influence of parents’ own childhood representations for their infants’ attachment security, these representations are rather distal to the parent–child relationship in the here and now. Recent attention has been paid to the more proximal role of parents’ representations of their children, of parenting, and of their relationships with their children (Mayseless, 2006), and a number of interviews have been developed to tap into these representations (Aber, Slade, Berger, Bresgi, & Kaplan, 1985; George & Solomon, 1996; Zeanah & Benoit, 1995). These more proximal representational assessments have been employed in low- and high-risk samples (Benoit, Parker, & Zeanah, 1997; Rosenblum et al., 2002), pre- and postnatally (Benoit et al., 1997; Huth Bocks, Levendosky, Theran, & Bogat, 2004), and in healthy or at-risk pediatric populations (Coolbear & Benoit, 1999). In general, parents’ mental representations of their child and of parenting, both pre- and postnatally, are significantly related to their children’s attachment security, at rates comparable to the AAI (Benoit et al., 1997; Huth-Bocks et al., 2004). In addition, parental representations are linked to how parents engage with their infants (Dayton, Levendosky, Davidson, & Bogat, 2007; Slade, Belsky, Aber, & Phelps, 1999; Vizziello, Antonioli, Cocci, & Invernizzi, 1993; Zeanah, Keener, Stewart, & Anders, 1985). Despite the evidence for links between parents’ representations, sensitivity, and in-

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fant attachment, results of meta-­analyses of these studies have identified a “transmission gap” (De Wolff & van IJzendoorn, 1997), in that parenting sensitivity explains only 23% of the association between parental and child working models. A number of explanations for this gap have been proposed, including the need to consider other contextual factors and a broader array of caregiving behaviors. At a very proximal level, for example, parent positive affect or delight (e.g., Rosenblum et al., 2002) or the quality of verbal mirroring (Meins et al., 2001) may be more important transmitters of relational security than maternal behavioral sensitivity per se. Nonetheless, current research does suggest that parenting sensitivity is likely to play a critical, albeit less direct role than previously thought. For example, another study indicated that mothers who were not autonomous on the AAI yet had secure infants were more behaviorally sensitive than nonautonomous mothers with insecure infants (Atkinson, Goldberg, & Raval, 2005). From an intervention perspective this finding is particularly intriguing, pointing to our need to know more regarding factors that facilitate sensitive parenting in adults with insecure states of mind.

Reflective Functioning and Insightfulness Reflective functioning is a clinically meaningful concept that refers to the individual’s ability to appropriately attribute mental states and beliefs to others (Fonagy & Target, 1997). Because this capacity includes the ability to understand the motivational forces that underlie behavior, high reflective functioning helps to make infant behavior more meaningful and predictable. Reflective functioning has also been posited to be directly associated with the individuals’ ability to tolerate ambivalent or painful affect without the need to minimize, distort, or split off such unwanted emotional experiences. Thus the parent who has the capacity to engage in reflective functioning is likely to respond to the child’s emotional needs and reactions with openness and acceptance, which in turn foster in the child a sense that both positive and negative emotions are tolerable and can be integrated. The capacity for reflective functioning has been coded both from parents’ adult attachment narratives as well as from interviews

designed to assess parents’ representations of their children, and it has been related to infant attachment security (Fonagy, Steele, Moran, Steele, & Higgitt, 1991; Schechter et al., 2005; Slade, Grienenberger, Bernbach, Levy, & Locker, 2005). Relatedly, the Insightfulness Assessment (IA) is a narrativebased interview designed to assess parents’ insight and empathic understanding of their children’s experiences (Koren-Karie, Oppenheim, & Dolev, 2002). The IA asks parents to observe video recordings of their young child and respond to a series of questions that tap into insightfulness, such as “What do you think your child was thinking or feeling?” Responses to the IA have also been related to child attachment security and parenting sensitivity (Koren-Karie et al., 2002). Parental reflective functioning and insightfulness are evident when parents acknowledge and tolerate complex feelings, acknowledge intergenerational or other contextual influences, display openness and complexity in representations of the child, and search for mental meaning that underlies their own and their child’s behavior. Low reflective functioning is evident when parents only rarely acknowledge feelings or mental states, fail to acknowledge the influence of psychological processes on their own or others’ behavior, or generate extremely stereotyped, action-­versus-emotion-­oriented explanations for behavior. Extant research has underscored the importance of parental reflective functioning for children’s development, particularly in the face of early parental or child adversity or hardship. For example, reflective functioning has been observed to be particularly predictive of child attachment when mothers had experienced significant childhood adversity (Fonagy, Steele, Steele, Higgitt, & Target, 1994), and thus may provide an important psychological buffer that promotes optimal child adjustment and resilience, particularly in the context of risk.

Infant Mental Health Implications The infant mental health field has long appreciated the centrality of the parent–child relationship, and today there are an increasing number of manualized relationship­focused intervention models; evidence for the efficacy of these interventions is accumulating (Berlin, 2005; Sameroff, McDonough,



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& Rosenblum, 2004). What these interventions share is a focus on the assessment and treatment of the infant in a social, relational context. Results of a recent meta-­analysis indicate that infant attachment outcomes are most improved when services are, among other things, delivered to a clearly defined risk population and when the focus is on enhancing parenting sensitivity (Bakermans­K ranenburg, van IJzendoorn, & Juffer, 2003). This emphasis on sensitivity is consistent with research that suggests that outcomes for children with sensitively responsive parents, even if the parents themselves maintain a number of other risk factors, are better than for those who evidence less sensitive parenting. For example, in a large and diverse sample Belsky and Fearon (2002) observed that children with secure attachment histories whose mothers became insensitive during toddlerhood had lower psychosocial functioning scores at 3 years, compared to children with insecure attachment histories whose mothers were sensitive later in development. This finding suggests that more proximal parenting behaviors are highly predictive of child outcomes and can even overcome early insecure attachment histories. Interventions to enhance parenting sensitivity can have important positive effects on children’s social–­emotional outcomes (Bakermans-­K ranenburg et al., 2003), particularly for those parents and infants who are most vulnerable. For example, intervention effects may be strongest for those parents with highly temperamentally reactive infants (Klein Velderman, Bakermans­K ranenburg, & Juffer, 2006). Other comprehensive models of intervention, such as the Circle of Security attachment-based intervention, have also documented treatment efficacy and target not only parenting sensitivity but also parents’ abilities to understand their children’s emotional communications, parents’ mental representations, and parents’ capacity for reflective reasoning about child behavior (Hoffman, Marvin, & Cooper, 2006).

CONCLUSIONS The first years of life are remarkable for the rapid transformations in both the social and emotional domains. New capacities emerge

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with regularity, and with the development of newly acquired skills the infant moves toward greater levels of social–­emotional competence. When developmental milestones are met and supported, social–­emotional competence is evident in the young child’s emerging awareness and understanding of his or her own and others’ emotions; capacity for empathic involvement; ability to adaptively cope with aversive emotions and challenging circumstances; open and trusting emotional communication within relationships; ability to rely on others for safety and support; and ability to explore, play, and carry forward a sense of effectance and trust (Saarni, 1999; Sroufe et al., 2005). When developmental milestones for competence in the social and emotional domains are not met, or when the developmental trajectory is set awry, later deficits in the social–­emotional domains are more likely to unfold. The field of infant mental health has long recognized that social–­emotional competence emerges from a dynamic developmental interplay of complex transactions across maturational, environmental, biological, and interpersonal contexts. Assessment and intervention that attend to the infant within this dynamic developmental context are central to returning the young child to, or maintaining him or her on, this powerful track toward increasing social–­emotional competence. References Aber, J. L., Slade, A., Berger, B., Bresgi, I., & Kap­ lan, M. (1985). The Parent Development Interview. Unpublished manuscript. Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the Strange Situation. Hillsdale, NJ: Erlbaum. Aristotle. (1941). The basic works of Aristotle (J. I. Beare, Trans.). New York: Random House. Atkinson, L., Goldberg, S., & Raval, V. (2005). On the relation between maternal state of mind and sensitivity in the prediction of infant attachment security. Developmental Psychology, 41(1), 42–53. Auerbach, J., Benjamin, J., Faroy, M., Geller, V., & Ebstein, R. (2001). DRD4 related to infant attention and information processing: A developmental link to ADHD? Psychiatric Genetics, 11(1), 31–35. Auerbach, J., Faroy, M., Ebstein, R., Kahana, M., & Levine, J. (2001). The association of the dopamine D4 receptor gene (DRD4) and the serotonin transporter promoter gene (5-HTTLPR)

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of parenting on infant emotionality: A multi-level psychobiological perspective. Developmental Review, 26, 427–460. Repaccholi, B. M., & Meltzoff, A. N. (2007). Emotional eavesdropping: Infants selectively respond to indirect emotional signals. Child Development, 78, 503–521. Rosenblum, K. L., Dayton, C. J., & McDonough, S. (2006). Communicating feelings: Links between mothers’ representations of their infants, parenting, and infant emotional development. New York: Cambridge University Press. Rosenblum, K. L., McDonough, S., Muzik, M., Miller, A., & Sameroff, A. (2002). Maternal representations of the infant: Associations with infant response to the still face. Child Development, 73(4), 999–1015. Rosenblum, K. L., McDonough, S. C., Sameroff, A. J., & Muzik, M. (2008). Reflection in thought and action: Maternal parenting reflectivity predicts mind-­minded comments and interactive behavior. Infant Mental Health Journal, 29, 362–376. Rosenblum, K. L., Zeanah, C. H., McDonough, S., & Muzik, M. (2004). Video-taped coding of working model of the child interviews: A viable and useful alternative to verbatim transcripts? Infant Behavior and Development, 27(4), 544– 549. Rothbart, M. K., & Bates, J. E. (1998). Temperament. In N. Eisenberg (Ed.), Handbook of child psychology: Social, emotional, and personality development (Vol. 3, pp.  105–176). New York: Wiley. Rothbart, M. K., & Derryberry, D. (1981). Development of individual differences in temperament. In M. E. Lamb & A. L. Brown (Eds.), Advances in developmental psychology (Vol. 1). Cambridge, NY: Cambridge University Press. Saarni, C. (1999). The development of emotional competence. New York: Guilford Press. Sagi, A., van IJzendoorn, M. H., Aviezer, O., & Donnell, F. (1994). Sleeping out of home in a kibbutz communial arrangement: It makes a difference for infant–­mother attachment. Child Development, 65(4), 992–1004. Sameroff, A. (1993). Models of development and developmental risk. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp.  3–13). New York: Guilford Press. Sameroff, A., McDonough, S., & Rosenblum, K. L. (Eds.). (2004). Treating parent–­infant relationship problems: Strategies for intervention. New York: Guilford Press. Sander, L. W. (1975). Infant and caretaking environment: Investigation and conceptualization of adaptive behavior in a system of increasing complexity. In E. J. Anthony (Ed.), Explorations in child psychiatry (pp. 129–166). New York: Plenum Press. Schechter, D. S., Coots, T., Zeanah, C. H., Davies, M., Coates, S. W., Trabka, K. A., et al. (2005). Maternal mental representations of the child in

an inner-city clinical sample: Violence-­related posttraumatic stress and reflective functioning. Attachment and Human Development, 7, 313– 332. Schwartz, C. E., Snidman, N., & Kagan, J. (1999). Adolescent social anxiety as an outcome of inhibited temperament in childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 38(8), 1008–1101. Seifer, R. (2000). Temperament and goodness of fit: Implications for developmental psychopathology. In A. J. Sameroff, M. Lewis, & S. M. Miller (Eds.), Handbook of developmental psychopathology (2nd ed., pp. 257–276). New York: Kluwer/Plenum. Simpson, J. A. (1999). Attachment theory in modern evolutionary perspective. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications (pp. 115–140). New York: Guilford Press. Slade, A., Belsky, J., Aber, J. L., & Phelps, J. L. (1999). Mothers’ representations of their relationships with their toddlers: Links to adult attachment and observed mothering. Developmental Psychology, 35(3), 611–619. Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal reflective functioning, attachment, and the transmission gap: A preliminary study. Attachment and Human Development, 7, 283–298. Sparrow, S., Balla, D., & Cicchetti, D. (1984). Vineland Adaptive Behavior Scales. Circle Pines, MN: American Guidance Service. Spinrad, T. L., & Stifter, C. A. (2006). Toddlers’ empathy-­related responding to distress: Predictions from negative emotionality and maternal behavior in infancy. Infancy, 10(2), 97–121. Sroufe, L. A. (1983). Infant–­caregiver attachment and patterns of adaptation in preschool: The roots of maladaptation and competence. In M. Perlmutter (Ed.), Minnesota symposium in child psychology (Vol. 16, pp.  41–83). Hillsdale, NJ: Erlbaum. Sroufe, L. A. (1989). Relationships, self, and individual adaptation. In A. J. Sameroff & R. N. Emde (Eds.), Relationship disturbances in early childhood (pp. 70–94). New York: Basic Books. Sroufe, L. A., Egeland, B., Carlson, E. A., & Collins, W. A. (2005). The development of the person: The Minnesota study of risk and adaptation from birth to adulthood. New York: Guilford Press. Sroufe, L. A., & Waters, E. (1977). Attachment as an organizational construct. Child Development, 48, 1184–1199. Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books. Stifter, C. A. (2002). Individual differences in emotion regulation in infancy: A thematic collection. Infancy, 3, 129–132. Suess, G. J., Grossmann, K. E., & Sroufe, L. A. (1992). Effects of infant attachment to mother



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and father on quality of adaptation in preschool: From dyadic to individual organisation of self. International Journal of Behavioral Development, 15(1), 43–65. Taumoepeau, M., & Ruffman, T. (2006). Mother and infant talk about mental states relates to desire language and emotion understanding. Child Development, 77(2), 465–481. Teti, D. M., & Candelaria, M. (2002). Parenting competence. In M. H. Bornstein (Ed.), Handbook of parenting: Applied parenting (2nd ed., Vol. 4, pp. 149–180). Mahwah, NJ: Erlbaum. Thomas, A., & Chess, S. (1977). Temperament and development. New York: Brunner/Mazel. Thompson, R. (1990). Emotion and self-­regulation. In R. A. Thompson (Ed.), Nebraska symposium on motivation (pp. 367–467). Lincoln, NE: University of Nebraska Press. Tronick, E. Z. (2003). Things still to be done on the still-face effect. Infancy, 4, 475–482. Tronick, E. Z. (2006). The inherent stress of normal daily life and social interaction leads to the development of coping and resilience and variation in resilience in infants and young children. Annals of the New York Academy of Sciences, 1094, 83–104. Tronick, E. Z., & Cohn, J. F. (1989). Infant–­mother face-to-face interaction: Age and gender differences in coordination and the occurrence of miscoordination. Child Development, 60, 85–92. Tronick, E. Z., & Weinberg, M. K. (1997). Depressed mothers and infants: Failure to form dyadic states of consciousness. In L. Murray & P. J. Cooper (Eds.), Postpartum depression and child development (pp.  54–81). New York: Guilford Press. van IJzendoorn, M. H., & De Wolff, M. S. (1997).

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Chapter 6

The Sociocultural Context of Infant Mental Health Toward Contextually Congruent Interventions Chandra Michiko Ghosh Ippen Don’t walk behind me; I may not lead. Don’t walk in front of me; I may not follow. Walk beside me that we may be as one. —Ute proverb

Natalia, a 25-year-old mother with postpartum depression, contemplates sending her 5-month-old son back to Mexico to be cared for by his grandparents. Alma, a 17-year-old teenager raised in the foster care system, seems uncooperative with the reunification plan for her 9-month-old daughter but unwilling to give up her daughter. Duane, 27 months old, is in danger of being expelled from preschool because of aggression toward other children. His maternal grandmother, who picks him up from school, appears pleasant but is not able to fully communicate with school staff because her first language is Tagalog. His father is nice but unresponsive to the school’s concerns. These are just some of the families we might meet through our work as infant mental health practitioners. As we endeavor to help them, partnership and dialogue are the cement with which we construct our inter

ventions. Without dialogue, trust in our own values and assumptions can blind us to the real truths of our clients’ lives and lead us to develop interventions that do not match their context or goals. Especially when working with families whose sociocultural context differs from ours, we must recognize that our perspective, including views about safety, parenting, and child behavior, may differ significantly from theirs. The executive summary of From Neurons to Neighborhoods (Shonkoff & Phillips, 2000) suggests that poor uptake and high attrition from early childhood programs raise issues regarding the degree to which the services we develop and offer are compatible with the needs and lives of those we seek to serve. As a field, if we are to reduce the growing disparities in access to and quality of services evidenced across multiple systems, we must begin by acknowledging that despite our best intentions and indefatigable efforts, we are failing many. We need to hear their perspective to understand why this may be. 104



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Although perhaps unconventional, my goal is that every aspect of this chapter—the tone, voice, and content—­convey the importance of dialogue, recognizing that the perspective I offer is biased by my experience. Therefore, before you read further and embark on what I hope becomes part of a larger discussion, I thought you should know something about me. I am half East Indian (Bengali) and half Japanese, the child of immigrant parents who moved to the United States as adults and worked as child protective services workers. I was born and raised in San Francisco, grew up middle class but attended private schools, studied to become a psychologist in Los Angeles, and relearned Spanish while working in the schools and homes of Southeast Los Angeles. I now work at the University of California at San Francisco (UCSF) Child Trauma Research Program, a clinical research program that focuses on understanding how exposure to trauma affects children (ages birth to 5) and investigates the efficacy of child–­parent psychotherapy (Lieberman & Van Horn, 2005), a dyadic, attachment-based, culturally informed treatment for young children exposed to trauma. Our program serves predominantly low-­income, ethnically diverse families. The majority of the caregivers have experienced multiple traumas. Seventy-five percent of our clinical staff speaks Spanish; I am the only non-­Latina Spanish speaker. My cultural heritage and personal experiences created the lens through which I see the world and influence the viewpoint I present in this chapter, in the same way that your culture and experiences shape your response to and reflections on this material. If you take nothing else from this chapter, I hope it is the belief that in order to appreciate the cultural context and worldview of those with whom we work, we must first understand where we come from and how our internal reactions, interpretation of events, and interventions are affected by the contexts in which we developed and function (García Coll & Meyer, 1993; Lewis, 2000; Lieberman, 1990). Our own responses as clinicians and as individuals are always shaped by our context, and we must not only acknowledge our reactions but try to understand why we feel the way we do. How, in the course of our development, were we “taught” to feel this way? Regardless of our answer, when working with

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individuals who feel differently, it is essential that we spend the time necessary to engage in a respectful dialogue that helps us to understand their perspective. Intense emotions are often associated with discussions related to culture and diversity, in part because when our group has experienced or perpetrated trauma, discrimination, or oppression, speaking about this reality can be painful. In addition, our values and beliefs shape our reality and to alter them would be to give up the safety of what we know. Rather than deny our reactions, we need to acknowledge that if we feel this way, the families with whom we work likely do too. In addition, we need to recognize that although the dialogue may be difficult, when these things are left unspoken, the difficulty remains and may seriously undermine intervention. This chapter begins with a presentation of population statistics to highlight the increasing need for a focus on diversity. Next, prior discussions of multiculturalism, cultural competence, and cultural sensitivity are reviewed to orient us to the goal of developing interventions that are congruent not only with the family’s culture but with other key contextual factors. Providing information regarding specific groups is beyond the scope of this chapter. Instead, the chapter discusses theoretical models that help maintain a focus on context and on potential differences. It ends with the introduction of a diversity awareness model that can be used to identify diversity-­related conflicts and guide intervention. Throughout the chapter, examples from research and clinical work are provided as food for thought. I hope you will stop and think about each example, share it and discuss it with others. Doing this work requires experience-based knowledge, not just analytical frameworks; it’s about engaging in a dialogue with those who are different from us and expanding the way we think and intervene. Before beginning, I would like to acknowledge that I will likely overlook many important issues, some because of the constraints of space and organization and others because they are outside my contextual awareness. I encourage you to think actively about what applies to you and to those with whom you work and to ask yourself, what is not said when it should be?

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THE MULTICULTURAL CONTEXT In 2006 the National Center for Cultural Competence released a tool that allows organizations to assess their cultural and linguistic competence. The instrument begins with two basic questions: (1) Can the agency “identify the culturally diverse communities” in its service area? and (2) Is the agency familiar with “current and projected demographics?” Current U.S. Census data (2005) show an ethnic distribution of 66.9% white, 14.4% Latino/Hispanic, 12.8% black, 4.3% Asian, 1.5% multiracial, 1% American Indian and Alaskan Native, and .2% Native Hawaiian and other Pacific Islander. Projections, although imperfect (note the lack of projections for multiracial individuals), suggest that by 2050 the distribution will be 52.8% white, 24.3% Latino/Hispanic, 13.2% black, 8.9% Asian, and .8% American Indian and Alaskan Native. For some states, these shifts will be more pronounced. For example, by 2050, California’s Latino population is expected to grow from 15 to 53.6% (U.S. Census, 2000). These statistics have special significance for infant mental health practitioners because birth rates shift before the change is reflected in the census. So we must ask ourselves, are we prepared to serve the infants, toddlers, and preschoolers in our communities? Most discussions about culture inevitably lead to a discussion of socioeconomic status because some ethnic minority groups are more likely to experience economic hardship. U.S. poverty data show that 22.5% of black and 20.8% of Hispanic families live below the poverty level, compared to 5.9% of non­Hispanic white families (Proctor & Dalaker, 2003). Through its interaction with multiple risk factors, poverty influences major aspects of development, including brain development, intellectual and academic functioning, and physical and mental health (Aber, Jones, & Cohen, 2000; Knitzer & Perry, Chapter 8, this volume; Sameroff & Fiese, 2000). Therefore, in adopting a multicultural perspective, we cannot ignore the context of socioeconomic class. However, as noted at the first National Multicultural Conference and Summit (Sue, Bingham, Porché-Burke, & Vasquez, 1999), significant aspects of diversity, such as gender, sexual orientation,

ability and disability, and religious affiliation, must also be incorporated into a multicultural focus, given their association with difference and misunderstanding. Using this criteria, additional factors to consider might include immigration status, acculturation, trauma history, age, and rural versus urban residence. This broadening of the multicultural focus seems both overwhelming and essential: overwhelming because it is difficult to keep all these factors in mind, assess for them, and determine how they impact intervention; essential because each factor contributes to our overall understanding of the “problem” and its potential solutions, and because contextual factors interact to produce a unique reality. Imagine, for example, how assessment and intervention with 27-month-old Duane might shift as you gradually learn the following information. Duane has been referred because he has significant language delays and is in danger of being expelled from preschool for biting peers. His mother, who is African American, lives in another state. His dad, who is first-­generation Filipino American, is his primary caregiver. He is gay and recently moved in with a new partner who is from Nicaragua. This new arrangement enraged Duane’s maternal grandmother who, up until this time, had been supportive of Duane’s father because she felt he was giving her grandson a good home. The context of the larger setting can also not be ignored because working with this family in San Francisco might be different from working with them in Atlanta or Salt Lake City. Where does your mind go first? What questions would you be asking? How might Duane’s context affect his language? Why does he bite? What would you want to know about his family? How about his preschool? What might it mean if he were in a predominantly white or predominantly Asian preschool? How might the teachers’ and the family’s cultural beliefs coincide or conflict on topics such as who is responsible for misbehavior in the school? Why is the city context important? This example is meant to highlight the importance of incorporating a broad multicultural focus. Imagine if we did not create an atmosphere of safety and openness where this information could be shared; our intervention might suffer from a lack of awareness of key contextual factors.



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Each new piece of information leads to new questions and hypotheses and to potentially different pathways for intervention. In addition, we must think about how what we learn may provoke reactions in us that have the potential to affect the way we interact with this family. The urgent need for a multicultural focus is expressed in the fourth goal of the Surgeon General’s national action agenda on children’s mental health: to “eliminate racial/ethnic and socioeconomic disparities in access to mental healthcare services” (U.S. Public Health Service, 2000, p.  6). This agenda calls for us to adopt a multicultural perspective in every aspect of our work. We must increase access to “culturally competent, scientifically-­proved services”; establish procedures that engage diverse families; recruit and train providers who represent the diversity of the community; conduct research on diagnosis, prevention, treatment, and service delivery issues to address disparities; and develop policies both in our agencies and in our broader communities that are sensitive to the needs of diverse populations.

CONTEXTUALLY CONGRUENT INTERVENTION As we embrace a multicultural perspective, we must ensure that that our lens is not too narrowly focused on the family and its culture but also includes an examination of the broader context (Brave Heart & Spicer, 2000; Levine et al., 1994; Lieberman, 1990). In our fast-paced world, “cultural competence” is not enough. We need our interventions to be contextually congruent. By this I mean that interventions incorporate a focus not only on culture but also on the family’s history, current situation, and future goals. I use this term not to disregard in any way the importance of culture, not to unnecessarily complicate things, and not because those who have written about culture have ignored context. I do it because I believe that contextual congruence is our true goal, and naming it gives us something for which to strive. Let me share my reasoning. First, we cannot hold too tightly to cultural “truths,” for culture is dynamic in nature and constantly changing. Cultures have always changed,

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but in today’s technological world, changes occur even faster than before. Chen, Cen, Li, and He’s (2005) study of shyness across three cohorts of elementary school children in China illustrates this point. In 1990 shyness was associated with academic achievement, peer acceptance, and teacher ratings of competence and leadership. In 1998 the relationship was weaker, and in 2002, shyness was associated with peer rejection, teacher-rated school problems, and depression. This study, although with older children, connects change in social context and economic values, within a relatively homogeneous culture and within the same physical context of Shanghai, to change in cultural values. Migration and contact with other cultural groups can lead to even larger and more rapid changes through the processes of acculturation and assimilation (García Coll, Ackerman, & Cicchetti, 2000). Second, a culturally compatible intervention that ignores changes in context is not competent or congruent with the true needs of the family. For example, in a Japanese family where the father, a businessman, returns home at 11:00 p.m., keeping a toddler up at night so he or she would have a chance to interact with the father would be compatible with cultural beliefs about the importance of family, and with hierarchical values calling for respect of the father’s wishes. In fact, this is often done in Japanese families. However, with changes in the context, the child’s entry into preschool, the beginning of afternoon classes (e.g., music and swimming), and the mother’s participation in English classes for which she has homework, this strategy may lead to sleep deprivation, which in turn may cause problems in affect regulation, increased maternal stress, and problems in the parent–child relationship, any of which might lead to a referral. In most cases, families will shift to accommodate their values and the demands of the situation, but if they do not, and we are called on to help them, we will need to consider the entire context, which includes the family’s values and the demands of the situation. Lastly, as illustrated in the following example, cultural values and situational demands often conflict. Natalia immigrated to the United States from Mexico 2 years ago, fleeing her physically abusive husband and harsh economic circumstances and leaving

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her 1-year-old son with her mother. She currently has a 5-month-old son, who is in fulltime day care while she works as a prep cook. She is depressed and appears to take little pleasure in her interactions with her son. He, in turn, shows little connection to her. She is thinking about sending him to Mexico to be cared for by her mother. To help Natalia and her family, we need to understand not only who she is (her culture and personal experiences), but where she is (e.g., financial needs, threats to safety, social position as an illegal immigrant), and her goals for her family’s future. Her culture leads her to value family and the maternal role, yet circumstances require that she work to survive and be able to send money to her son in Mexico. Loss of family support and her view of herself as a “bad mother” make it difficult for her to parent her son in the way she would like and lead her to wonder whether he might be better off without her. After understanding her reality, we might hypothesize that the healing dialogue for Natalia is one that allows her to speak about immigration-­related losses (her son, family, country, and sense of self) and recognize the link between her values and her behavior. By doing this, she may be able to resolve internal fragmentation caused by clashes between her cultural values and her behavior and be able to go from seeing herself as inadequate to viewing herself as a loving and caring mother who is dealing with a difficult reality. This change in self-­perception may, in turn, lead to a change in her ability to parent her son. This does not mean, however, that she will necessarily keep him with her, but there is hope that even if she does send him to Mexico, her ability to connect with her true feelings, have a more compassionate view of herself, and see her relationship with her children as ongoing may make it less likely that she repeats the pattern of having children and then feeling she cannot care for them. In addition, there is hope for the therapist who can view the treatment not as a failure but as helping Natalia to change her attributions of herself and her child even though it could not alter the realities she faces. A holistic approach where the object (the family or culture) is not viewed as separate from the field (the particular situation or context) encourages the development of interventions that are responsive to both and

may be more syntonic with the reality faced by ethnic minorities and groups differing from the majority culture. Gutierrez and Sameroff (1990) found that acculturated Mexican American mothers were more perspectivistic than non-­H ispanic white mothers, meaning that they were more likely to integrate psychological, constitutional, and environmental influences when attempting to understand children’s behavior. Ethnic minorities tend to function in at least two different cultural contexts (Sue, Arredondo, & McDavis, 1992). To do this competently, they need to hold multiple perspectives and apply them appropriately to different situations. To match the complexity of their lives, our interventions need to incorporate multiple perspectives. Fortunately, as a field, we are well grounded in context. From its inception, infant mental health has recognized relationships and context as shapers of development (Fitzgerald & Barton, 2000). The Zero to Three Infant Mental Health Task Force (2001, p. 1) defines infant mental health as the “developing capacity of the child from birth to 3 to: experience, regulate, and express emotions; form close relationships; explore the environment and learn . . . all in the context of family, community, and cultural expectations for young children.” Our core values of relationship-based practice, self-­reflection, and reflective supervision (Gilkerson, 2004) lead us toward greater contextual awareness because they help us attend to the dynamic interplay of contextual factors that shape children’s development, to think about our reactions during interactions, and to devote time to reflect on potential differences in a safe and supportive space. The challenge comes from the fact that culture includes attitudes, values, beliefs, and behaviors that are shared by a group and passed on from generation to generation (Matsumoto, 1997), often without explanation, an “unconscious transmission of adaptive childrearing mechanisms” (Lieberman, 1990, p. 103). In time, we forget why we do what we do, and we take for granted that this is the way things should be. Diversity, by definition, focuses on differences among people in these beliefs, attitudes, values, or behaviors. Thus, when working with those who differ from ourselves on key contextual factors, we are faced with being sensitive or



6. The Sociocultural Context of Infant Mental Health

“competent” when our core, unconscious values may be challenged. Central to most discussions of cultural competence or cultural sensitivity is the need for knowledge of both our own and our clients’ worldviews and assumptions and a valuing of reciprocal, responsive, respectful, relationships (Barrera & Corso, 2002; Lieberman, 1990; Sue, et al., 1992). Sue (1998) highlights the importance of being scientifically minded, forming and testing hypotheses based on what we know, and judiciously integrating knowledge of the family’s cultural context while appreciating individual differences. García Coll and Meyer (1993) offer questions to facilitate the development of a meaningful dialogue: “Is there a problem? Why is there a problem? What can be done? And, who should intervene to address the problem?” (p. 61). They remind us that our clients’ answers may not be the same as ours. Perhaps the most comforting view of the task before us comes from Lieberman (1990), who eloquently notes that cultural sensitivity is akin to attunement and can be viewed as a form of interpersonal sensitivity that involves knowing something about the idiosyncrasies and context of that person and being open to finding out what we don’t know. This return to our relationship-based roots gives us a safe base from which to explore our differences and reminds us that as we do this work, we will focus not only on what we need to fix but on what is strong and protective—both in ourselves and in those with whom we work.

THEORETICAL MODELS As noted at the second National Multicultural Conference and Summit, “there is no one way to conceptualize human behavior, no one theory that captures and explains the realities and experiences of various forms of diversity” (Bingham, Porché-Burke, James, Sue, & Vasquez, 2002, p. 84). This statement honors the complexity of human experience but should not be interpreted as discounting theory. Instead, it calls for a multitheoretical approach to enhance the flexibility of our interventions when we work with diverse populations. Below are models and theoretical perspectives that help us develop contextually congruent interventions. I first propose

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a new model that is meant to functions as a lens to help us see and understand different perspectives. I then describe hierarchical and ecological models and discuss how they affect our perception of context and intervention and how they may be viewed using the lens of my model.

Attachment, Culture, and Trauma The attachment, culture, and trauma (ACT) model integrates these domains as three contextual forces that shape development and perception. Whereas attachment and culture are undeniably important to infant mental health, the inclusion of trauma may seem less warranted. However, the prevalence of trauma in the historical past of many ethnic groups and in the current lives of young children justifies its presence in the model. A nationally representative study of married or cohabiting couples estimates that in 1 year, 29.4% of children (15.5 million) experience partner violence (McDonald, Jouriles, Ramisetty-­M ikler, Caetano, & Green, 2006). Although this study does not include child age, others have found that children ages 0–5 are more likely to witness domestic violence (Fantuzzo, Boruch, Beriama, & Atkins, 1997) than older children. The same is true of abuse and neglect. Child maltreatment data show that in 2005, 3.6 million children experienced a child protective services (CPS) investigation; and children ages 0–3 had the highest rates of victimization (U.S. Department of Health and Human Services, 2007). The need to include trauma in the model is underscored by research demonstrating the long-term effects of exposure. Scheeringa, Zeanah, Myers, and Putnam (2005) found unremitting symptoms and functional impairment 2 years after an initial assessment revealed symptoms in trauma-­exposed children ages 20 months to 6 years. Moreover, adverse childhood experiences (ACE), including abuse and witnessing domestic violence, have been found to predict the leading causes of adult death and disability (Felitti et al., 1998) and have been found to be more prevalent in certain ethnic minority groups (Koss et al., 2003). The content of ACT is not new. Developmental science asserts that “human development is shaped by dynamic and continuous interactions between biology and experi-

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ence,” and “culture influences every aspect of human development” (Shonkoff & Phillips, 2000, p. 3). We have learned how trauma alters the developmental trajectory (Cicchetti, Toth, & Maughan, 2000; Pynoos, Steinberg, & Piacentini, 1999). Researchers and clinicians have clearly discussed the connection between attachment and trauma (Hesse & Main, 2006; Lieberman, 2004), attachment and culture (van IJzendoorn & Sagi, 1999), and trauma and culture (DeVries, 1996; Lewis & Ghosh Ippen, 2004). What is new is the joining of these forces and examination of how interactions among them may shape behavior, feelings, and thoughts, including beliefs and values (see Figure 6.1). Cole, Tamang, and Shrestha’s (2006) study of emotion socialization in two Nepalese cultures, the Tamang and Brahman, demonstrates how hidden interactions among attachment, culture, and trauma can shape values, behaviors, and expression of feelings. Interviews with elders and observations of interactions with 3- to 5-year-old children showed that in response to anger, Tamang caregivers were more likely to disapprove, rebuke, or tease the child, whereas Brahmans were more likely to nurture, reason, or coax the child to feel better. In contrast, Tamang were more likely to react to children’s shame by teaching and nurturing, whereas Brahmans ignored almost 75% of instances of shame. Why would these two groups re-

spond differently to anger and shame? Why, as noted by the authors, would the Tamang appear to be cultivating self-­effacement? Through Western eyes, the Tamang and Brahman look similar. They live in the same area, subsist on what they farm, and would both be categorized as collectivistic, valuing group harmony over autonomy and individual interests. However, they differ in social status and religion. The majority culture of Nepal is Hindu, and Brahmans are highcaste Hindus. Tamang are Buddhist and as a minority group are subjected to racism and prejudice. Looking at the realities of presentday Nepal provides some explanation for the difference in emotion socialization practices, but history makes these differences seem not only understandable but adaptive and necessary for survival. In the 18th century, after the Gorkhali conquest of Nepal, land was stripped from the Tamang and given to the Brahmin and Chhetri classes. The Tamang were made to work the land they had owned as bonded laborers and near-­slaves (Tamang, n.d.). In 1856 Nepali civil code established the Tamang as Sudra or Dalits, a low caste in the Hindu system, which meant that they could be enslaved or killed (Bhattachan, 2003; Tamangsamaj.com, n.d.). This code remained in place until 1962. By understanding this history, we see how trauma shaped cultural beliefs about emotions and parental responsiveness to child behavior.

Attachment

Thoughts Am I safe? Am I loveable?

Anger Sadness Feelings

Discipline Parenting Behavior

Trauma

Culture

FIGURE 6.1.  ACT model.



6. The Sociocultural Context of Infant Mental Health

A powerful example that further demonstrates interconnections among attachment, culture, and trauma is shared by Bradshaw, Schore, Brown, Poole, and Moss (2005, p. 807): The air explodes with the sound of high­powered rifles, and the startled infant watches his family fall to the ground, the image seared into his memory. He and other orphans are then transported to distant locales to start new lives. Ten years later, the teenaged orphans begin a killing rampage, leaving more than a hundred victims.

The story is “Elephant Breakdown,” the tale of young elephants who witnessed their parents’ death and grew up to kill rhinoceroses. It is a true story. While elephants are a metaphor for humans, their story provides a clear example of how trauma can produce disruptions in attachment and culture that can lead to social, relational, and psychological pathology. Elephant society by nature is matriarchal, characterized by close extended family. From birth to age 1, mothers and a network of female caregivers constantly snuggle and touch the infant. During the first 8 years of life, elephants generally remain within 15 feet of their mothers. Trauma and loss caused by elephant poachings have disrupted these close attachments and have nearly destroyed elephant culture, which involved numerous rituals and traditions, including the socialization of adolescent males through older all-male groups. The result is both surprising and expected. The loss of that which has been traditionally valued and organizing disrupts their world. The elephants show signs of posttraumatic stress disorder (PTSD) and complex trauma, including abnormal startle, unpredictable asocial behavior, depression, and hyperaggression. Elephants have been attacking humans and each other. In parks with trauma­affected elephants, 90% of male deaths are attributable to other males, compared to 6% in stabler communities. The lessons learned from the Nepalese study and the elephants are relevant to our work as infant mental health practitioners because they teach us that present-day interactions (parent to child and practitioner to family) are shaped by ACT forces and by history. They help us see that the ghosts are

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not only in the nursery (Fraiberg, Adelson, & Shapiro, 1975) but in our society. The legacy of historical trauma persists in sociocultural contexts fraught with poverty, racism, discrimination, and oppression because these processes serve as reminders that the horrors, which often remain unspoken, are not yet fully banished from reality. Thus before we attempt to change parental behaviors that are not consistent with the way we want things to be—­behaviors we might label as “controlling,” “intrusive,” “withdrawn,” or “resistant”—we must understand that they likely evolved as part of, and may continue to serve, a protective function. As we develop interventions for families whose sociocultural context differ from ours, we will need to assess for historical and present-day realities linked to threat, fear, sadness, and anger, and we will need to facilitate dialogue about those undesirable realities when it seems appropriate and relevant. In addition, interventions that incorporate and embrace the original strengths of a cultural group may be especially meaningful and effective. In our work with young children whose fathers have beaten their mothers, we have seen how urgently many of these children have needed to claim some good part of their fathers. It is as if they are telling us, “If my father is all bad, and I am half my father, then I am bad, so I need some part of him to be good if I am to be good.” The same may be true of culture. We all need to know that we came from a group that is or was strong and good. So, at the same time that we look for “angels in the nursery” (Lieberman, Padrón, Van Horn, & Harris, 2005), we must also look for the angels in our cultural history, our ancestral angels. Oyate Ptayela (“taking care of the nation”), a parenting curriculum for Lakota families, exemplifies this approach (Brave Heart & Spicer, 2000). The intervention fosters healing from historical trauma through a return to indigenous beliefs, including Woope Sakowin (“the seven sacred laws”), tiospaye (“extended family”), and lena wakan heca, the belief that children are sacred—gifts from the Creator. The following case example shows how these principles may be integrated into treatment. Paula, a 33-year-old therapist, struggled to understand Alma, a 17-year-old teenager

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who did not want her baby but refused to give her up. Alma displayed an inability to connect with her daughter, Lucia, despite Paula’s best interventions. It was only after a home visit where Paula noticed a small basket that Alma had woven as part of an art class that Alma began to speak of her past. Her mother, who was part Navajo and used to live on the reservation, knew how to make baskets. Alma usually ignored that part of her heritage because she was mostly Mexican and had spent most of her youth in and out of foster homes, while her mother alternated between desperately seeking her and deciding she could not keep her. Alma and Paula discussed how this pattern was connected to the historical trauma of Indian boarding schools, which were an effort to “civilize” Indian children by forcibly separating them from their families and their culture. Alma began to understand her mother’s rejection of her in light of historical, cultural factors. Slowly, in the intersection of attachment, culture, and trauma, Alma’s ambivalence toward Lucia became understandable, not just to Paula but to Alma. Alma was able to speak of the difficulties she imagined her mother had faced and to link the alcoholism and domestic violence she had seen in her town to its traumatic roots. She began to carry Lucia in a sling, and she noted that maybe her great-great-­grandmother had carried her baby in a similar way.

Hierarchical Models What do we need? What are our goals? What motivates us? Hierarchical models categorize our answers to these questions and arrange the resulting groupings into steps. Maslow’s (1954) hierarchy of needs, the best-known hierarchical model, places physiological needs at the base, followed by safety, belongingness, self-­esteem, and self­actualization. Each step represents a potential target of intervention. As infant mental health practitioners, we must recognize that our hierarchies consciously and unconsciously shape our interventions. Consider the question: What is the goal of treatment? We provide case management when we think that physiological needs are not met and target the relationship when we feel that the child’s need for safety or belongingness is thwarted. In general, this approach makes

sense. However, before acting, we must consider the family’s value hierarchy and determine whether our values are consistent with theirs. We may target one step when they are on another, we may ignore a value fundamental to their hierarchy, or we may differ in our core values and thus differ in our expectations of parenting behavior and child development. As we do our work, we must recognize that all models are biased by context. Maslow’s hierarchy, for example, one of the preeminent models in the field of psychology, is a product of historical, cultural, and personal events. Maslow first proposed his paper, “A Theory of Human Motivation,” in 1943, when the world was learning about the Holocaust. Milgram and Kohlberg linked their respective studies on obedience to authority and human morality to their need to understand the atrocities of World War II (Schwartz, 2004). Maslow, the son of Russian Jewish immigrants who came to the United States at the turn of the 20th century, was motivated by the same events to find the good in human beings. However, the needs he selected and the order in which he placed them were influenced by his experience. His placement of belongingness in the middle of the hierarchy may be related to his childhood, which he described in the following way: “I was a terribly unhappy boy. My family was a miserable family and my mother was a horrible creature. I grew up in libraries and among books without friends” (as cited in Hoffman, 1988, p.  1). The absence of religion and spirituality in Maslow may be a product of the anti-­Semitism he endured and his reaction to his mother’s threats that God would strike him down if he misbehaved. His focus on self-­esteem and self­actualization echoes Jewish teachings that value personal responsibility, a related but autonomous self, and the pursuit of knowledge through study (Borowitz, 1984). In a journal entry dated March 7, 1968, Maslow wrote: “My whole value-laden philosophy of science could certainly be called Jewish—at least by my personal definition. I certainly wasn’t aware of it then” (as cited in Hoffman, 1988, p. 306). In the field of infant mental health, we might design a hierarchy where belongingness occupies a more fundamental position, given the link between attachment and healthy infant



6. The Sociocultural Context of Infant Mental Health

development and the fact that in infancy, attachment is linked to safety and to the ability to get physiological needs met. However, our definitions of belongingness may vary based on our context. How connected should we be? In what ways do we connect? Schulze, Harwood, and Schoelmerich’s (2001) study of non-­Hispanic white and Puerto Rican mother–­infant dyads demonstrates how differences in parental values translate to differences in child behaviors. Interviews revealed cultural differences in values: Non-­H ispanic whites endorsed goals related to autonomy, whereas Puerto Ricans valued goals associated with relatedness. These differences were reflected in the self-­feeding behavior of their 12-month-old infants: Videotaped observations showed that 81.4% of non-­H ispanic white infants self-fed, in comparison to 3.6% of Puerto Ricans. Fernald and Morikawa’s (1993) study of mother–­infant play behaviors in Japanese and American dyads shows how differences in socialization goals can translate to differences in mother–child play interactions. They found that American mothers were more likely to label objects and use play to promote linguistic competence, whereas Japanese mothers were more likely to use play in a way that fostered social and polite interactions. If we were to intervene with either a Japanese or an American dyad, would our socialization goal and the intervention that stems from it be compatible with theirs and with the problem? The answer to this question may vary depending on the problem that brings us together; say, aggressive behavior, autism, or a language delay. In all cases, it would be important that we not impose a treatment that would alter parent– child interactions to match our intervention goals without first speaking with the family about their goals. Beyond culture, trauma and subsequent secondary adversities can affect both the individual’s ability to achieve basic needs and the subjective perception of whether a need has been met. This effect was evident in the treatment of Marissa, a 34-month-old African American girl referred to a Los Angeles clinic with her foster-­mother, Denise. Marissa was placed with Denise when she was 10 months old. As Denise described, she always had all the food and care she needed, but she hoarded food, and they often found her

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eating trash from the garbage. Denise felt that this behavior reflected poorly on her. She worried that others would think she had not “done right” by Marissa. Initially, treatment focused on strengthening Marissa and Denise’s strained relationship, but Marissa would not engage. She persisted in dumping out all the toys (dishes, food, animals) and then stared into space and became disorganized. A newspaper clipping sent by Denise’s caseworker provided an important clue to this behavior. It detailed Marissa’s history. As an infant, she was severely neglected and was found surrounded by trash, which she appeared to have eaten in order to survive. With this information, treatment shifted from encouraging her to play to following her play. It became clear that the piles of toys with which she surrounded herself recreated her original life. In stealing food, she showed us that her body remembered the time when she did not have food. Her foster mother’s distress about her food issues affected her sense of safety and her ability to connect. It was not enough to focus on the fact that her context had shifted. We needed to see that her need was real, given her context. To summarize, hierarchical models provide a framework for organizing our values and for thinking about levels and targets of intervention. Contextual forces can influence the organization of our hierarchies, the way we select the needs that comprise them, and our perceptions of whether needs have been met. Ecological models, presented in the next section, show how forces outside of us influence our perceptions of whether we can reach our goals and lead us to wonder how we can obtain what we want for ourselves and our children, given the society and environment in which we exist.

Ecological Models In calling psychology the “science of the strange behavior of children in strange situations with strange adults for the briefest possible periods of time,” Bronfenbrenner (1977, p.  513) challenged the field to view children in the contexts in which they exist and the way they shape development. He defined the question as “How are intrafamilial processes affected by extrafamilial conditions?” (Bronfenbrenner, 1986, p.  723). In

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other words, how does our environment, real, perceived, and remembered, influence the way in which we socialize our children to survive in the world. Bronfenbrenner stressed that individuals exist in multiple ecological contexts. Each setting can impact development, as can interactions among settings. His model organizes contexts in nested systems. The microsystem includes the immediate setting in which the individual is found (e.g., family, school, home). The mesosystem includes interrelationships among settings, and the exosystem encompasses settings that indirectly affect us, even when we are not part of them. For example, city funding may affect clinic policies, which may affect the family’s treatment, or the media (e.g., Disney) may affect the way the child perceives herself. Macrosystems are prototypes, blueprints that shape human development, much like hierarchies. At the mesosystem level, when settings where the young child lives differ in their values, conflicts may ensue that can affect development. Take, for example, the following quote from a preschool director cited in a study by Parmar, Harkness, and Super (2004, p. 102): “Asian kids are very quiet in the classroom settings. I think their parents are very pushy at home and also they have very high expectations from their preschoolers, which I do not think does any good, but we help them to be themselves here.” How might the parents feel upon hearing the director’s words? Even if the director never says these words to the parents, is this message unconsciously transmitted? What happens if the child begins to behave in a louder, “free” way at home? García Coll and colleagues (1996) proposed an integrative model that focuses on three aspects of context that are usually ignored: (1) social position (race, social class, ethnicity, and gender); (2) racism, prejudice, discrimination, and oppression; and (3) segregation (residential, economic, social, and psychological). They suggest that these pathways create the unique experience of multicultural groups and shape their children’s development. Although the majority of the differences discussed thus far in the chapter have involved nonmalicious differences in perspective, before ending this chapter I consider the prevalence of racism, including

institutional racism, discrimination, and oppression in today’s society. Only by acknowledging the fact that a wound continues to exist can a healing dialogue begin. Slavery was abolished on April 16, 1862, but reminders of historical trauma and actual experience of trauma, racism, discrimination, and oppression persist for African Americans and many other groups. The Tuskegee syphilis study, a 40-year experiment where 399 black men were denied treatment for syphilis so that scientists could study the disease’s natural progression, ended in 1972. Official government recognition of the horrific nature of this study came only in 1997 with Clinton’s presidential apology (Gamble, 1997). The diagnosis of homosexuality was removed from the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1973, yet a new category of “sexual orientation disturbance” remained until 1980, and the homosexuality diagnosis was not removed from the Classification of Mental and Behavioural Disorders (ICD) until 1992 (Mendelson, 2003). Indian boarding school ended in the 1930s but was followed by U.S. tribal termination policies, which removed tribal lands and rights. The struggle to regain what was lost continues today. These are a few examples out of a multitude selected specifically because they show how our society, not just individuals, has shaped the context. They also demonstrate that these wounds are not ancient history; some have occurred within our lifetime. The lack of governmental response to Hurricane Katrina and the overrepresentation of African American and Native American children in our foster care system make the reality of racism and oppression current events (Casey Family Programs, n.d.). Ogbu’s (1981) cultural–­ecological model suggests that parents are aware of these hostile contexts. They want their children to survive and thrive, so they teach them the skills necessary to navigate their context. Different contexts require different skills. You cannot judge a skill without knowing its context. In a situation in which a bully physically assaults our child, we may teach our child to fight. If we expect that people will one day judge our children based on the color of their skin or the texture of their hair,



6. The Sociocultural Context of Infant Mental Health

Diversity Awareness Model

then we might teach them about that reality. Interviews with parents of African American preschoolers showed that the majority used racial socialization messages: 88.8% spoke to their youngsters about racial pride, 74.1% discussed spirituality, 66.5% talked about bias, and 64.8% conveyed messages related to mistrust (Caughy, O’Campo, Randolph, & Nickerson, 2002). Parents who shared these messages with their children reported fewer behavior problems, suggesting that dialogue about context may be protective. This study and the historical facts noted above emphasize that the unpleasant, historical past that most of us would like to forget is experienced as an ever-­present ecological reality for many. Trauma is kept alive through these reminders, and it continues to influence relationships between parents and children and among cultural groups. If we accept that this reality is true, then we must ask, “Is dialogue about this ever-­present reality part of our interventions?” Is it part of our conceptualization, supervision, and interactions with families? If not, what is the reason and how does our silence in this area impact intervention and outcome?

Clinician’s Experience

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Bingham et al. (2002) discuss the importance of engaging in difficult dialogues. To do this requires two basic conditions: (1) that we recognize that there is a dialogue to be had, and (2) that we create sufficient safety and time to allow the discussion to proceed. A visual model (see Figure 6.2) may also guide our thinking. Because the work and the truth generally lie in the intersections, the model is based on a Venn diagram, a mathematical image depicting relationships. Each circle represents a different context or perspective. Our work involves intersections between self, client, and supervisor. The work is also affected by the system (e.g., clinic) and society, and, when there are multiple clients (e.g., child and parent), by the multiple client contexts. As infant mental health practitioners, we guide others on their journey. Generally, the course and its passage are smooth. However, differences in perspectives may lead to rocky intersections. When there is a conflict, we first determine which circles in the model are involved. Physiological arousal within our own bodies signals our involvement and

Client’s Experience

Supervisor’s Experience

System’s Experience

Cultural Context

FIGURE 6.2.  Diversity awareness model.

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suggests that before we proceed, we need to understand our own reactions and context. When we “own” the issue, the correct intervention may be introspection. When the issue divides us from our clients, the most useful course may become clear only after considering the full map—the hierarchies, contexts, and forces of ACT that have shaped each participant’s current position. By doing this, we may be better able to develop contextually congruent interventions; interventions that guide family members in a way that is responsive to where they are, where they’ve come from, and where they hope to go. To show how this type of process might unfold, I share an example from my work with Jason, a 3-year-old African American boy whose parents separated after a long history of mutual domestic violence. Jason kicked and hit adults and children. He was in danger of being expelled from day care. His mother worried that he would grow up and be like his father. For these reasons, I was surprised when, in response to Jason telling us that he hit another child because that child hit him, Jasmine, his mother, said, “Good—I’m glad you taught him.” I intervened awkwardly, suggesting that she did not mean this and that she wanted Jason to learn other ways of dealing with children, but she looked at me and said “No, he has to learn how to defend himself. If [child’s name] doesn’t stop, I’ll go down there myself and teach him not to mess with my kid.” A rift between us was created. I went home wondering how she could be this way. Hitting was incompatible with the way I was raised. Adults were supposed to protect children. In my own private school history I had witnessed only one physical fight, and the adults had intervened immediately. Jasmine, in turn, felt judged and misunderstood. Fortunately, we had a solid prior relationship. We met alone, and I asked how she felt about Jason’s being hit. The question prompted a flood of information. She felt that the teachers did nothing to protect her son because they viewed him as a bully. She remembered how other kids used to tease her when she was little because she had hives. She wanted her son to be able to protect himself. Indeed, he needed to be able to protect himself because he was growing up as a black boy in the United States.

She couldn’t afford to have him “be soft.” As she spoke, I could see how differences in our contexts had led to differences in our approach, but we shared a common goal: to keep Jason safe. As I echoed her desire to protect Jason, we reconnected. We considered how her history affected both her desire to have Jason defend himself and her fear when he behaved aggressively. We explored Jason’s context of witnessing violence and his fear of his own aggression. Jasmine began to say that Jason was little. Perhaps it was too early and self-­defense could begin at age 6. I, in turn, acknowledged the reality that some day he would need to learn self­protection skills. One last example shows the way a supervisor and trainee used the diversity awareness model to facilitate joint reflection about differences in perspectives. Vanessa, a therapist in training who is originally from Nicaragua, expressed frustration with her client Eva, an immigrant from Honduras. Eva had brought in papers for Vanessa to translate, and Vanessa had felt that the request interfered with their work. The supervisor and Vanessa both reflected on Vanessa’s perspective. Eva’s 2-year-old son Juan showed serious developmental delays and signs of depression, and Vanessa wanted to begin parent–child play sessions, which she thought would help Juan. They then began to think about Eva’s perspective, including the meaning of the papers for her. Vanessa shared that the papers were a jury summons and noted that she thought that was odd because Eva should not be eligible for jury duty (she is not a U.S. citizen). As she said this out loud, Vanessa and the supervisor both began wondering about how Eva might have felt about being asked to go to court, given that for her, court may be associated with deportation. “I can’t believe I didn’t see this, and I’ve had family members go through it,” said Vanessa. As she looked at the intersection, she saw multiple realities: her own desire to help this family, the mother’s stress about a situation that threatened her family’s safety, and the son’s need to connect with his mother. These examples provide a glimpse of how we might use this model to help us process diversity-­related conflicts. The model helps us focus on the multiple perspectives involved and the contexts that shaped them.



6. The Sociocultural Context of Infant Mental Health

The hope is that by doing this we can return to a strengths-based conceptualization that recognizes that although a given reaction may not be desirable, in light of the person’s experiences of attachment, culture, and trauma, it is completely reasonable and expected.

SUMMARY This chapter is just a beginning. There is much left unsaid, particularly about the dimensions along which groups differ (e.g., collectivism, fatalism, personal vs. group responsibility) and how these differences are related to key behaviors salient to our field (e.g., play, praise, emotional socialization, control) and to intervention. There are more than 100 studies that I wanted to include in this chapter. Perhaps my inability to “say it all” parallels our inability to “teach it all” to the families with whom we work. The truth, as I am slowly learning, is that our work does not rest on what we teach but on how we relate (Pawl & St. John, 1998). Through dialogue, we help families reflect on their context, so that they are able to choose the direction they want for their lives. In Western tradition we often believe that there is a single truth, a “Holy Grail.” A holistic approach helps us embrace dialectics: times when multiple truths are equally valid. Dialectics help us reconcile, transcend, and accept apparent contradictions (Nisbett, Peng, Choi, & Norenzayan, 2001). The ACT model is meant to function as a lens that helps clarify and validate alternate perspectives. The diversity awareness model was designed to help us visually contemplate interactions among ourselves, our clients, and larger systems, and to think about how we each may hold different but equally valid perspectives. By exploring realities different from our own, we can help those with whom we work move forward in a way that is congruent with their context. This chapter itself is a journey, so to come full circle, I end with words from my cultural heritage. The Bengali poet Rabindranath Tagore said, “If you shut the door to all errors, truth will be shut out.” Mistakes and misunderstandings are inevitable, but our response to them can transform the experience. The last word comes from my Obaa-

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chama, my Japanese grandmother, a small woman whose voice rang through the house as she watched sumo wrestling: ganbatte! It is a battle cry, an encouraging call to act that says that we are together as we tackle the challenge of integrating context into all aspects of our work. It means, “Go for it!” “Do your best,” “Work hard,” “Good luck,” “Keep at it.” Ganbatte. References Aber, J. L., Jones, S., & Cohen, J. (2000). The impact of poverty on the mental health and development of very young children. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 113–128). New York: Guilford Press. Barrera, I., & Corso, R. M. (2002). Cultural competency as skilled dialogue. Topics in Early Childhood Special Education, 22(2), 103–113. Bhattachan, K. B. (2003). Indigenous nationalities and minorities of Nepal. Retrieved February 14, 2008, from nipforum.org/bhattachan_report. pdf. Bingham, R. P., Porché-Burke, L., James, S., Sue, D. W., & Vasquez, M. J. T. (2002). Introduction: A report on the National Multicultural Conference and Summit II. Cultural Diversity and Ethic Minority Psychology, 8(2), 75–87. Borowitz, E. B. (1984). The autonomous Jewish self. Modern Judaism, 4(1), 39–56. Bradshaw, G. A., Schore, A. N., Brown, J. L., Poole, J. H., & Moss, C. J. (2005). Elephant breakdown. Social trauma: Early disruption can affect the physiology, behavior, and culture of animals and humans over generations. Nature, 433, 807. Brave Heart, M. Y., & Spicer, P. (2000). The sociocultural context of American Indian infant mental health. In J. D. Osofsky & H. E. Fitzgerald (Eds.), World Association of Infant Mental Health handbook of infant mental health (pp. 153–179). New York: Wiley. Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513–531. Bronfenbrenner, U. (1986). Ecology of the family as a context for human development: Research perspectives. Developmental Psychology, 22(6), 723–742. Casey Family Programs. (n.d.). Child welfare fact sheet. Retrieved April 17, 2007, from www.casey. org/MediaCenter/MediaKit/FactSheet.htm. Caughy, M. O., O’Campo, P. J., Randolph, S. M., & Nickerson, K. (2002). The influence of racial socialization practices on the cognitive and behavioral competence of African American preschoolers. Child Development, 73(5), 1611–1625. Chen, X., Cen, G., Li, D., & He, Y. (2005). Social functioning and adjustment in Chinese children: The imprint of historical time. Child Development, 76(1), 182–195.

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Cicchetti, D., Toth, S. L., & Maughan, A. (2000). An ecological–­transactional model of child maltreatment. In A. J. Sameroff, M. Lewis, & S. M. Miller (Eds.), Handbook of developmental psychopathology (2nd ed., pp. 689–722). Dordrecht, Netherlands: Kluwer Academic. Cole, P. M., Tamang, B. L., & Shrestha, S. (2006). Cultural variations in the socialization of young children’s anger and shame. Child Development, 77(5), 1237–1251. DeVries, M. W. (1996). Trauma in cultural perspective. In B. A. van der Kolk A., C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effect of overwhelming experience on mind, body, and society (pp. 398–413). New York: Guilford Press. Fantuzzo, J., Boruch, R., Beriama, A., & Atkins, M. (1997). Domestic violence and children: Prevalence and risk in five major U.S. cities. Journal of the American Academy of Child and Adolescent Psychiatry, 36(1), 116–122. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (1998). The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258. Fernald, A., & Morikawa, H. (1993). Common themes and cultural variations in Japanese and American mothers’ speech to infants. Child Development, 64(3), 637–656. Fitzgerald, H. E., & Barton, L. R. (2000). Infant mental health: Origins and emergence of an interdisciplinary field. In J. D. Osofsky & H. E. Fitzgerald (Eds.), World Association of Infant Mental Health handbook of infant mental health (pp. 2–36). New York: Wiley. Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problem of impaired infant–­mother relationships. Journal of the American Academy of Child Psychiatry, 14, 387–421. Gamble, V. N. (1997). Under the shadow of Tuskegee: African Americans and health care. American Journal of Public Health, 87(11), 1773–1778. García Coll, C., Ackerman, A., & Cicchetti, D. (2000). Cultural influences on developmental processes and outcomes: Implications for the study of development and psychopathology. Development and Psychopathology, 12, 333–356. García Coll, C., & Meyer, E. C. (1993). The sociocultural context of infant development. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp. 56–69). New York: Guilford Press. García Coll, C. T., Lamberty, G., Jenkins, R., McAdoo, H. P., Crnic, K., Wasik, B. H., & Vazquez García, H. (1996). An integrative model for the study of developmental competencies in minority children. Child Development, 67(5), 1891– 1914. Gilkerson, L. (2004). Irving B. Harris distinguished lecture: Reflective supervision in infant–­family programs: Adding clinical process to nonclinical settings. Infant Mental Health Journal, 25(5), 424–439. Gutierrez, J., & Sameroff, A. (1990). Determinants

of complexity in Mexican-­A merican and Anglo­A merican mothers’ conceptions of child development. Child Development, 61, 384–394. Hesse, E., & Main, M. (2006). Frightened, threatening, and dissociative parental behavior in lowrisk samples: Description, discussion, and interpretations. Development and Psychopathology, 18, 309–343. Hoffman, E. (1988). The right to be human: A biography of Abraham Maslow. Los Angeles: Tarcher. Koss, M. P., Yuan, N. P., Dightman, D., Prince, R. J., Polacca, M., & Sanderson, B., et al. (2003). Adverse childhood exposures and alcohol dependence among seven Native American tribes. American Journal of Preventive Medicine, 25(3), 238–244. Levine, R. A., Dixon, S., Levine, S., Richman, A., Leiderman, P. H., Keefer, C. H., et al. (1994). Childcare and culture: Lessons from Africa. Cambridge, UK: Cambridge University Press. Lewis, M. (2000). The sociocultural context of infant development: The developmental niche of infant–­caregiver relationships. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 91–107). New York: Guilford Press. Lewis, M., & Ghosh Ippen, C. (2004). Rainbow of tears, souls full of hope: Cultural issues related to young children and trauma. In J. D. Osofsky (Ed.), Young children and trauma: Intervention and treatment (pp. 11–46). New York: Guilford Press. Lieberman, A. F. (1990). Culturally sensitive intervention with children and families. Child and Adolescent Social Work, 7(2), 101–120. Lieberman, A. F. (2004). Traumatic stress and quality of attachment: Reality of internalization of infant mental health. Infant Mental Health Journal, 25(4), 336–351. Lieberman, A. F., Padrón, E., Van Horn, P., & Harris, W. W. (2005). Angels in the nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 26(6), 504–520. Lieberman, A. F., & Van Horn, P. J. (2005). Don’t hit my mommy: A manual for child–­parent psychotherapy with young witnesses of family violence. Washington, DC: Zero to Three Press. Maslow, A. H. (1954). Motivation and personality. New York: Harper. Matsumoto, D. (1997). Culture and modern life. Pacific Grove, CA: Brooks/Cole. McDonald, R., Jouriles, E. N., Ramisetty-­M ikler, S., Caetano, R., & Green, C. E. (2006). Estimating the number of American children living in partner-­violent families. Journal of Family Psychology, 20(1), 137–142. Mendelson, G. (2003). Homosexuality and psychiatric nosology. Australian and New Zealand Journal of Psychiatry, 37, 678–683. National Center for Cultural Competence. (2006). Cultural and linguistic competence policy assessment. Retrieved April 9, 2007, from www. clcpa.info/documents/CLCPA.pdf.



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Nisbett, R. E., Peng, K., Choi, I., & Norenzayan, A. (2001). Culture and systems of thought: Holistic versus analytic cognition. Psychological Review, 108(2), 291–310. Ogbu, J. U. (1981). Origins of human competence: A cultural–­ecological perspective. Child Development, 52(2), 413–429. Parmar, P., Harkness, S., & Super, C. M. (2004). Asian and Euro-­A merican parents’ ethnotheories of play and learning: Effects on preschool children’s home routines and school behaviour. International Journal of Behavioral Development, 28(2), 97–104. Pawl, J., & St. John, M. (1998). How you are is as important as what you do in making positive differences for infants, toddlers, and their families. Washington, DC: Zero to Three Press. Proctor, B., & Dalaker, J. (2003). Current population reports, P60-222, poverty in the United States: 2002. Washington, DC: U.S. Census Bureau. Pynoos, R. S., Steinberg, A. M., & Piacentini, J. C. (1999). A developmental model of childhood traumatic stress and intersection with anxiety disorders. Biological Psychiatry, 46, 1542–1554. Sameroff, A. J., & Fiese, B. H. (2000). Models of development and developmental risk. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 3–19). New York: Guilford Press. Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F. W. (2005). Predictive validity in a prospective follow-up of PTSD in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 44(9), 899–906. Schulze, P. A., Harwood, R. L., & Schoelmerich, A. (2001). Feeding practices and expectations among middle-class Anglo and Puerto Rican mothers of 12-month-old infants. Journal of Cross-­C ultural Psychology, 32(4), 397–406. Schwartz, E. (2004). Why some ask why. Social psychologists, Kohlberg (1927–1986) and Milgram (1933–1984) dramatically broadened our understanding of how “ordinary people” can end up doing terrible things; Holocaust survivors. Judaism: A Quarterly Journal of Jewish Life and Thought. Retrieved May 5, 2007, from www.encyclopedia.com/doc/1G1-133233195. html.

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Shonkoff, J. P., & Phillips, D. A. (2000). From neurons to neighborhoods. Washington, DC: National Academy Press. Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling and Development, 70, 477–486. Sue, D. W., Bingham, R. P., Porché-Burke, L., & Vasquez, M. (1999). The diversification of psychology: A multicultural revolution. American Psychologist, 54(12), 1061–1069. Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53(4), 440–448. Tamang, R. (n.d.). Nepal Tamang Ghedung. Retrieved February 13, 2008, from www.tamangs. com/tmgorgs.htm. Tamangsamaj.com (n.d.). About Tamang. Retrieved February 13, 2008, from www.tamangsamaj. com/about_tamang.php. U.S. Census Bureau. (2000). Projections of the resident population by race, Hispanic origin, and nativity: Middle Series, 2005 to 2007. Retrieved January 20, 2007, from www.census.gov/population/projections/nation/summary/np-t5-g.pdf. U.S. Census Bureau. (2005). U.S.A. Quick facts. Retrieved March 20, 2007, from quickfacts.census.gov/qfd/states/00000.html. U.S. Department of Health and Human Services. (2007). Child maltreatment 2005. Retrieved June 1, 2007, from www.acf.hhs.gov/programs/ cb/pubs/cm05/cm05.pdf. U.S. Public Health Service. (2000). Report of the Surgeon General’s conference on children’s mental health: A national action agenda. Washington, DC: Department of Health and Human Services. Retrieved April 11, 2007, from www. surgeongeneral.gov/topics/cmh/childreport.htm. van IJzendoorn, M. H., & Sagi, A. (1999). Cross cultural patterns of attachment: Universal and contextual dimensions. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 713–734). New York: Guilford Press. Zero to Three Infant Mental Health Task Force. (2001). What is infant mental health? Retrieved April 11, 2007, from www.healthychild.ucla. edu/First5CAReadiness/Conferences/materials/ InfantMH.definition.pdf.

Chapter 7

Applying Research Findings on Early Experience to Infant Mental Health Thomas G. O’Connor David B. Parfitt

T

he extent to which, and the mechanisms by which, early experiences carry long-term implications for development and psychopathology are rudimentary topics with substantial implications for how infant mental health is practiced and conceptualized. Substantial progress has been made in understanding the impact of early experiences and exposures on mental health; but important uncertainties remain, and there continues to be a good deal of debate in the area. Our goals in this chapter are to review some of the central concepts and research findings concerning the “early experiences” debate and to consider their application to infant mental health. Along the way, we consider the leading theoretical positions and a variety of methodological paradigms and approaches, emphasizing the literature on humans but making inevitable reference to animal work. Throughout, we attend to some of the more major themes that characterize research and thinking in this area, such as translational research and the adoption of biopsychosocial and biobehavioral models.

DEVELOPING MODELS OF EARLY EXPERIENCE A basic developmental question asked by clinicians, scientists, parents, and poets is, To what extent do early experiences of the infant—both the good and the bad— carry long-term significance? If there are long-term effects on the psychology and/or biology of the individual, then how do we understand how these are carried forward in time? Knowledge about these issues has substantial influence on the practice of infant mental health and on the placement of infant mental health in the broader context of public health and prevention. Before addressing the early experience or exposure question, it is first helpful to note the robust evidence for small- to moderatesized stabilities in individual differences on behavioral traits; examples include temperament and behavioral adjustment from early childhood to adulthood, including even prediction of adult occupational functioning (e.g., Caspi, 2000). This modest degree of intraindividual or rank-order stability from early childhood is an important ingredient 120



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for conceptualizing how experiences may alter an individual’s life-­course trajectory because it helps set some parameters on how much an individual’s trajectory may be altered. Although this modest degree of rankorder stability is impressive, it does imply that there is a great deal that is unstable or not predicted (or predictable). More pertinent to this volume is the observation that long-term prediction of behavioral outcomes from infancy is difficult. In fact, most of the studies showing substantial stability in behavioral patterns from early development did so based on assessments that occurred well past infancy, as in the case of the Caspi paper (2000) and Kagan and Moss (1962/1983) in their classic study. If there are examples of prediction from infancy (e.g., behavioral inhibition; Kagan, Snidman, Kahn, & Towsley, 2007), they are small in number. What does the apparent lack of intraindividual instability from infancy or, more broadly, the first 3 or so years of life mean? It may imply, for example, a great degree of plasticity or susceptibility to environmental input in infancy; immaturity of psychobiological systems that carries no particular significance for understanding development or susceptibility to environmental input; and/ or simply weak measurement of relevant phenotypes in infancy. Even if there are few examples of behavioral stability from infancy, there are compelling examples of how infant or prenatal exposures have lasting effects. In the case of nutrition, folic acid has been shown to dramatically alter physical development (e.g., MRC Vitamin Study Research Group, 1991); in the case of chemical exposures, lead exposure predicts later cognitive ability (Canfield et al., 2003). Aside from the obvious public health relevance, what makes the studies on folic acid and lead exposure especially compelling is that they imply a clear effect of timing of exposure and persistence of effect following exposure (or lack of exposure, in the case of folic acid). A hypothesis now being examined in some detail is whether stress exposure can be thought of in similar ways. If early stress exposure did have a lasting effect on the individual in a causal way, then there would be dramatic implications for developmental theory, and infant mental health would have a prime public health

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status. This is the kind of question that is perhaps of most relevance to mental health clinicians working with young children, and it is the focus for the remainder of the chapter.

Assessing the Effects of Early Experience One reason why the early experience debate has persisted and has generated such a diversity of opinion is that there are few human studies that are designed to test early experience hypotheses. That is not to say that we do not have careful, detailed follow-up studies of children exposed to major early stressors and traumas; there are many of these. Instead, the limitation is that, in most circumstances, early risk exposures—­poverty, poor parenting, parental mental illness, family conflict—are not limited to early development or precisely timed (at any point in development). In fact, most environmental risks of clinical interest are continuous and remarkably intransigent. As a result, isolating the effect of early experiences per se is not possible; relatedly, it has been difficult to isolate the effects of adversity at later points in development during which there may be important normative shifts, such as puberty. Many empirical examples could be cited here; child–­parent attachment is particularly illustrative. In the impressive 20-year followup reported by Waters, Merrick, Treboux, Crowell, and Albersheim (2000), infants who had a secure attachment relationship with their mother were described as coherent and secure in the way that they talked about their parental relationships as young adults. That finding does not imply that it is the early attachment that was formative; it is just as likely that the accumulation of “secure-­ogenic” parenting for many years—­ secure attachment is moderately stable—led to the secure behavior seen in the adults. Disentangling the impact of early attachment experiences from subsequent attachment experiences has been a perennial difficulty; even studies that take advantage of naturally occurring changes in infant’s/children’s attachment quality (Belsky & Fearon, 2002) are unable to rule out important confounding factors or selection effects. The difficulties of sorting out the role of early experience are compounded by the tendency for most major stressors, such as the

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ones noted above, to overlap concurrently and longitudinally (a high degree of overlap is just as true for protective factors). However sophisticated the data analysis is, it is simply not possible to disentangle causes and effects that are, by their nature, interwoven in development. And, even if a study were undertaken that could somehow address these limitations, the findings might not generalize to any recognizable population. It is interesting to note, in this context, that the early experience debate has been substantially and robustly resolved in the animal literature. That is because the methodological confounds in human research have been effectively bypassed. Indeed, animal studies provide an abundance of evidence attesting to the long-term impact of early social experiences, from general stress exposure to more specific adversities such as disrupted rearing (Cacioppo et al., 2002; Fleming, O’Day, & Kraemer, 1999; Francis, Diorio, Liu, & Meaney, 1999; Hofer, 1994; Sanchez, Ladd, & Plotsky, 2001; Weaver et al., 2004). It is tempting to apply the general lessons from these animal findings to humans, and that is done routinely, sometimes rather cavalierly. Unfortunately, the limits of biological generalization across and within species do not always attract sufficient attention. One example is the difference in attachment behavior in New and Old World monkeys, notably the extent to which patterns of caregiving experiences are linked with offspring outcomes—which appear far stronger in the latter (Suomi, 1999). Other examples of nongeneralizability concerning general stress system physiology include differences between rodent species and even differences between strains of the same species (Parfitt, Walton, Corriveau, & Helmreich, 2007; Sanchez et al., 2001). Of course, there are many good examples of a parallelism between animal and human research findings; the point here is simply that the animal findings provide a basis for hypothesis generation for human research, but they need to be translated into human terms before firm conclusions can be supported. Another methodological point is that many research paradigms used in animal studies may not have much applicability to humans. Much of the animal work is oriented to testing the lasting effects of precisely timed and limited (i.e., acute) stress exposure. Howev-

er, precisely timed stressors are the exception rather than the rule in human research (e.g., Glynn, Wadhwa, Dunkel-­Schletter, ChiczDemet, & Sandman, 2001). Instead, clinical and policy concern is with those individuals exposed to chronic stress because these are the individuals most likely to develop mental and somatic health problems. Animal studies using chronic stress paradigms (e.g., Coplan et al., 1998) may be in a better position to inform human health processes. Similarly, many of the kinds of high-­stress conditions that are of particular importance in mental health work, such as foster care and the impact of repeated placements with caregivers, have no parallel paradigm in animal work— and would likely either not work or have a very different meaning. The implication is that some developmental–­clinical questions might not have an animal model and so be answerable only in clinical research. Animal studies also benefit from well­controlled experimental conditions, a feature not present in clinical studies. In fact, the necessary experimental interventions in humans occur very rarely because of a variety of practical and other difficulties. The Bucharest Early Intervention Project, which is discussed below, is a notable exception (Nelson et al., 2007; Zeanah, Smyke, Koga, & Carlson, 2005). As an alternative to experimental designs, clinical investigators often rely on “experiments in nature” (Bronfenbrenner, 1979) for gaining leverage in testing hypotheses about early experiences in humans. Natural experiments provide opportunities to test developmental hypotheses that would not be possible because of ethical or practical reasons. Examples include studies of children who were rescued from institutional deprivation (Gunnar, Morison, Chisholm, & Schuder, 2001; O’Connor et al., 2000) and follow-up studies of adults whose mother experienced prenatal famine induced by war (Brown, van Os, Driessens, Hoek, & Susser, 2000). As we review below, these are the sorts of studies that provide some of the most challenging data in this area.

Candidate Models to Account for Early Experience We highlight three prominent models for conceptualizing early experience. This is not an exhaustive set but an illustrative one that



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demonstrates meaningful differences in how early exposure/experience may shape longterm development. Which model is being tested is sometimes not made explicit in each research study, but it is implicit in the design that is used. So, for example, a study that examines the impact of a parenting intervention delivered only in infancy may be able to test the early experience hypotheses (e.g., that parenting interventions in infancy may have lasting effects on child–­parent attachment); on the other hand, such a design could not test the hypothesis that early interventions are any more or less effective than interventions delivered postinfancy (because there was no comparison with a sample in which only a postinfancy intervention was applied). It is important to discern how the research design sets limits on which hypotheses can be tested; this is not always made clear from the discussion of the results and is exceedingly rare in accounts of research findings in the popular media. A first example of a developmental model concerning early experience is the sensitive period hypothesis. Some neural circuits are believed to be experience-­expectant (Greenough, Black, & Wallace, 1987), meaning that these circuits are especially sensitive to, or “expect,” environmental inputs (experiences) to occur. The presumption is that many experience-­expectant processes involve sensitive periods—­definable windows in the development of the organism in which certain environmental input is needed in order for normal development to proceed; the same environmental input provided outside this developmental window would not have the same effect. Alternatively, a sensitive period model predicts that risk exposure within a definable period in development may have permanent effects; the same exposure outside this window would have no or minimal lasting effects. In research based on this model, which is dominant in animal work, the organism is typically exposed to severe and usually precisely timed pathogenic environments rather than to a continuum of risk conditions. Outcomes of interest tend to be severe disturbance rather than normal variation, and the focus is on species-(a)typical behavior or gross pathology rather than individual differences. Knudsen (2004) makes the important point that sensitive periods need to be con-

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sidered as properties of neural circuits (that underlie the behavioral outcomes). He discusses several possible dynamic mechanisms that might operationalize sensitive periods at this level, including axon elaboration, synapse elimination, and synapse formation. Equally important is the need to demonstrate a cellular or neural circuit account for the closing of sensitive periods; this has proved more elusive. This is a more detailed level of analysis than has been shown—or may be possible to show—in clinical (human) research. We emphasize two key features of Knudsen’s treatment of the cellular basis of sensitive periods to our discussion. The first is that there are parallel principles of the sensitive period model (e.g., in terms of the role of developmental timing) whether the focus is on cellular levels of analysis or, as in this chapter, behavioral levels. The second is that the clarity of the cellular or behavioral sensitivity “effect” will be far more difficult to discern for more complex behaviors such as attachment and social competence, which involve multiple brain areas (compared with, say, development of vision). One of the lessons from comparative research is that the boundaries that define the sensitive period depend on the species, with more rigidly defined and narrow windows among lower animals and greater variation in more advanced animals. Berardi, Pizzorusso, and Maffei (2000) demonstrated this principle for visual acuity, for which available data are probably most complete (see also, Hensch, 2004). One of the more interesting findings from animal research is that some sensitive periods may be under some degree of genetic control (Huang et al., 1999; Kinnunen, Koenig, & Bilbe, 2003), and this is an area likely to attract greater attention. An alternative model is the developmental programming or adaptive programming model. The idea in this model is that the organism adapts to early environmental input; that is, some feature of the organism (e.g., processes involved in glucose metabolism or stress regulation) is “set” according to early input, and this “setpoint” persists into adult life. Variation in early environmental exposure will determine an organism’s set point. A concern with adaptation or preparedness implies a focus on the fit between the organism and its current (or later) environment rather than normal versus deviant, as

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such (Gluckman & Hanson, 2005). Unlike the sensitive period model, which has only minor influence on human research, the adaptive programming model is emerging as a prominent one in human research on cardiovascular disease and other disease states (Barker, 1992). The idea that early exposures may have significance for child health is not so new (e.g., Mackenzie, 1906), but only somewhat recently have there been rigorous empirical demonstrations; the database on this topic in human work is now enormous. Applications of the programming model to psychological outcomes is fairly new (O’Connor, Heron, Golding, Glover, & ALSPAC study team, 2003; Rutter, O’Connor, & Study Team, 2004), but is emerging as an important theme in developmental research on mental health. A further developmental model places emphasis not so much on the early environment per se, but rather on the life-­course patterns of exposure, adopting a trajectory notion (Bowlby, 1988; Schaffer, 2000). According to this perspective, early experiences predict long-term outcomes only insofar as early risk exposure is maintained, reinforced, or accentuated by subsequent events. In other words, early risk exposure would be predicted to confer limited or no risk for future development if there is no current risk and/ or if there are substantial compensatory or protective factors present. This model, which tends to dominate human developmental research and is the basis for much of the thinking about resilience, requires an intensive measurement approach compared with, say, the sensitive period model. According to the life-­course model, assessments of only early exposure are not adequate because they are unable to examine how these early exposures are accentuated or nullified by later risk exposure. It is this model that is, in principle, most interested in individual differences and mild cumulative risk exposure rather than more limited and severe risk exposure. And, the model is significant in making no (or only quite limited) claims about a loss of plasticity in development. A major hypothesis of this trajectory model is that early adversity leads to an increased likelihood of early developmental failures or poor adaptation, which increase the likelihood of subsequent poor adjustment (Bowlby, 1988). Nonetheless, although early and sustained risk exposure

will likely lead to poor adjustment, the trajectory model or metaphor does not rule out the possibility that normal developmental can be achieved—­although with perhaps enormous (and impractical) levels of intervention. Set against these three developmental models is an nondevelopmental model that states that the timing of exposure and the organization of developmental events does not matter. The basic diathesis stress model is based on this assumption. That is, the constitutional predisposition toward some disease—the diathesis—need not incorporate any aspect of the individual’s development: An individual with a diathesis may respond to stress with pathology without regard to when in development the stress occurs. One way to demonstrate differences among developmental models is by reference to several external criteria. Among the more powerful to differentiate these models are (1) the importance of timing of an exposure or intervention; (2) the potential for resilience (e.g., positive adaptation following earlier exposure or developmental failure); and (3) a focus on individual differences versus species-­t ypical behavior. In any event, the ultimate question is how well each of these models fits the data and how well adapted the research design is for the model.

EARLY DEPRIVATION Probably the most dramatic and important set of studies to test alternative versions of the early experience hypothesis are those that have followed up children who experienced early institutional deprivation. These studies are well positioned because there is an extraordinary disjunction between early risk exposure—among the most severe studied in humans—and subsequent experience, usually in low- to normal-risk environments. The extreme nature of the early deprivation and the extreme nature of the discontinuity in risk exposure may make the lessons inapplicable to other populations; and these studies do not include children whose deprivation was experienced only after infancy. Nonetheless, they offer powerful leverage for testing the persistence of early deprivation effects. Other chapters in this volume provide reviews of attachment (see Chapter 5) and



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of the concept of attachment disorder (see Chapter 26), two phenotypes that are closely linked with early deprivation and institutional rearing. In this chapter we review the basic general findings for what research findings suggest about the effects of early deprivation on human psychological development. Clinical observations and strong early conclusions from Bowlby (1951), Spitz (1965), and others stimulated debate about the importance of the early months and years for normal psychological development. The animal work that followed (e.g., for nonhuman primate work, see Cameron, 2004; Coplan et al., 1998; Harlow & Suomi, 1970; Hinde & Spencer-Booth, 1971; Sabatini et al., 2007) largely reinforced the claims about the importance of early experiences for normal social relationships (for nonhuman primates). The (back) translation to humans was given a dramatic push by the recent studies that followed children who experienced severe deprivation from institutional rearing. What distinguishes these studies from the work in previous decades (e.g., Wolkind, 1974) was their attention to methodological rigor, most notably, sampling, measurement, and duration of follow-up. The findings were both familiar and challenging. Findings to date from this substantial and growing literature can be summarized in a fairly straightforward way (for more detailed reviews, see, e.g., Gunnar & Quevedo, 2007; O’Connor, 2006; van IJzendoorn & Juffer, 2006) because there is a good deal of replication across the studies. Most reports are from children who experienced early institutional rearing in Romania, although data from adoptees from other countries have also been considered extensively (Gunnar & van Dulmen, 2007; O’Connor et al., 2000; van IJzendoorn & Juffer, 2006); data have also been reported from interventions conducted within institutions, although these are predictably rare (Nelson et al., 2007). Probably the most striking observation across all studies concerning the effects of early deprivation is the degree of variability in outcomes—­across multiple outcomes and occasion of measurement. In the case of intellectual ability, for example, scores among those who experienced deprivation for as long as 2 years range from the impaired to well above average (Beckett et al., 2006).

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The implication is that any model posed to account for the effects of early experiences on later development must at least allow for (if not account for) individual differences. An equally impressive observation— again, for many behavioral outcomes—is that the duration of deprivation has a persisting effect on long-term development. That is, the effect of early deprivation does not “go away” once the children have had adequate time for developmental catch-up (O’Connor et al., 2000). Findings on intellectual development from the English and Romanian adoptee (ERA) study illustrate the point. Beckett and her colleagues (2006) found that, among Romanian adoptees assessed at age 11 years, the average IQ on the Wechsler scales was 101 for those who were adopted before 6 months, 86 for those adopted between 6 and 24 months, and 83 for those adopted after 24 months (and before 42 months). Given that there were no major detectable differences among the families—­ implying minimal selection bias—it might be concluded that the effects of early deprivation on intellectual performance persist years after the deprivation ended and despite many years in resourceful, caring homes. Longer-term follow-up data also suggest that the persistence of deprivation restricted to the early months of life may not have lasting effects. Thus, in the ERA study, the children adopted before 6 months do not show a statistically significant difference from noninstitutionalized children, but do differ from those children adopted after 6 months; moreover, among the later-­adopted children (6–42 months), there was no strong link between outcome and duration of deprivation at the later follow-up assessments at age 11 years (Beckett et al., 2006; Rutter et al., 2007). That pattern, apparent for cognitive ability and severe attachment problems, raises the question of whether 6 months may be a meaningful point defining a sort of ontogenetic vulnerability. Other studies, notably the meta-­analysis of van IJzendoorn & Juffer (2006), suggested that the likelihood of adverse effects on attachment and social relationships among internationally adopted children might be set at 12 months; that is, it is principally adoptions after 12 months that might be expected to have difficulties. Gunnar and colleagues (Gunnar & van Dulman, 2007) suggested something similar in their

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investigation of behavioral/emotional problems in their large study of international adoptees. Finally, Nelson et al.’s (2007) impressive intervention study of children in institutions suggested that the period in which a dramatic effect of altering the institutional environment on intellectual functioning may be even wider (out to 24 months); whether or not that study can address the sensitivity hypothesis, the findings provide some of the strongest causal evidence that a dramatic improvement in intellectual functioning is possible in children who experienced early profound deprivation. Of course, even if there were a clear cutoff point—and it is far from certain that there is or what it might be—it remains the case that the individual differences are substantial. That is not a finding that, to date, has emerged from the animal work, which has generally found strong and clear evidence of timing effects. Given the animal findings on genetic influences on sensitive periods noted above, it is natural to suppose that some of the variability in effects obtained in humans may be genetic in origin, but so far we lack data to test this hypothesis adequately. And, attempts to define periods of particular vulnerability will need to consider how they may apply differentially across behavioral domain and biobehavioral system. Finally, not all of the effects of deprivation from institutionalization persist; there is developmental catch-up, most notably in many areas of physical development, that has been shown in many studies of early-­deprived children; and, the degree of catch-up may itself depend on the age at which children were removed from the depriving environment (see O’Connor et al., 2000; Miller, Chan, Comfort, & Tirella, 2005; van IJzendoorn & Juffer, 2006).

Associations between Early Exposure and Later Development Advances in neuroscience methods have spurred considerable interest—exuberance may be more apt—in identifying possible biomarkers or indicators of biological mechanisms in research on early experience. The principle behind this effort is not to make the observed behavioral findings any more “real”; rather, it is to provide an additional layer of explanation, identify potential tar-

gets for biological treatments, and expose otherwise hidden sources of variability (e.g., where variation in the effect of early exposure may be moderated by genetic vulnerability). Clinical application of neuroscience findings to infant mental health assessment and treatment may be substantial, modest, or minimal; it is too soon to tell. In the meantime, research into possible mechanisms is an important target for research, and it is an area that deserves special attention from the variety of clinicians and policymakers concerned about infant mental health. Several biological systems have been implicated as candidate mechanisms to explain the persisting effects of early stress exposure, and a number of techniques have been applied. Some of these are difficult or impossible to assess in humans in a meaningful way, and so we must rely on animal data. For example, there is considerable animal evidence that the neuropeptides oxytocin and vasopressin are involved in parenting, affiliation, pair bonding, and other forms of social relationships (Carter, 1998; Insel, 2003; Winslow, 2005). These are, then, obvious candidates as mediators of a long-term effect of poor early parenting on disruptions in social and attachment relationships in the child. That hypothesis cannot be directly assessed in humans, however, because oxytocin gathered outside the central nervous system may not index oxytocin level or function in the brain. There may be ways around this methodological stumbling block (e.g., Meinlschmidt & Heim, 2007), and this is clearly an area in which methodological refinements could have a large impact on scientific progress. Other systems and neurotransmitters implicated as having a role in mediating early experience include opioids and dopaminergic pathways in the brain (Chugani et al., 2001; De Bellis, 2005; Pryce, Dettling, Spengler, Schnell, & Feldon, 2004). In fact, one of the more promising lines of research has used brain imaging to examine structure and function in the brains of children who experienced early deprivation and continue to show evidence of impaired adjustment, including reduced glucose metabolism in the orbital frontal cortex, prefrontal cortex, and medial temporal structures that include the amygdala and hippocampus (Chugani et al., 2001; Eluvathingal et al., 2006).



7. Research Findings on Early Experience

The range of brain areas and neurotransmitter systems so far examined implies that there are most likely several brain processes that may act in combination or additively. It is for this reason that newer imaging strategies that reveal connectivity may be especially valuable (Eluvathingal et al., 2006). Probably the best studied mechanism involving early stress exposure is the hypothalamic–­p ituitary–­a drenocortical (HPA) axis. There is now considerable evidence that early stress exposure, derived from caregiving deprivation, early trauma and loss, or other sources, is associated with alterations in HPA axis functioning, indexed most commonly by levels of cortisol, a stress hormone that can be measured from saliva. One set of follow-back studies (e.g., Heim, Newport, Bonsall, Miller, & Nemeroff, 2001; Meinlschmidt & Heim, 2005) reported that early adversity, such as maltreatment or parental loss, was associated with alteration in salivary cortisol. Studies that assess children with well-­documented exposure to maltreatment also show disturbances (e.g., Cicchetti & Rogosch, 2007; Dozier et al., 2006). Findings from the above studies are somewhat difficult to collate conceptually or methodologically, however, because of the wide variety in how HPA axis data were collected and analyzed. Indeed, there remain formidable challenges in measuring and understanding HPA axis data from salivary cortisol, though many investigators remain optimistic about this approach. And, although there is a suggestion that it is early exposure to stress that accounts for the HPA axis effect, that conclusion cannot be derived from any of the studies because the definition of early experience is varied (up to 14 years in one study) and leverage in detecting an early exposure per se is, as noted previously, nearly impossible in observational (i.e., nonintervention) studies. The extent to which the HPA axis is modified by early stress exposure and may be “corrected” by therapeutic intervention is a matter of ongoing research. There are important and suggestive findings from psychosocial/parenting interventions (e.g., Brotman et al., 2007; Fisher et al., 2006) and from more radical interventions, namely adoption (Gunnar & Quevedo, 2007; Gunnar et al., 2001). Progress in the methodology of HPA axis assessment and greater use of interven-

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tion studies are needed to propel this area of research further. A lesson for research of this type is that it would be unlikely for a single mechanism to mediate the link between early deprivation and later outcomes, particularly those outcomes as biologically influenced and evolutionarily significant as attachment or cognitive ability. This research, which is at least partly driven by technical abilities, will require considerable cross-­disciplinary work and careful clinical observation.

APPLICATION TO PREVENTION AND INTERVENTION Applications of the early experience debate are no longer merely a topic for scientific or policy discussion; increasingly, commercial interests have sought to capitalize on the interest in early experience. For example, companies have put forth videos and other programs targeting parents of young children (“Baby Einstein” and the like). Claims about the positive impact of these programs have been made, even though there is no sound evidence that they fulfill their advertised benefits (Garrison & Christakis, 2005). In fact, quite the reverse may be true, at least in some cases. In their study of over 1,000 parents, Zimmerman, Christakis, and Meltzoff (2007) found that each hour of viewing baby DVDs/videos was associated with an almost 17-point decrease in communicative/ language development in 8- to 16-montholds; there was no significant link in 17- to 24-month-olds. Similarly misleading claims about the role of early experience and what it means for the type or intensity of clinical treatment are also widely made, most notoriously in the case of “holding” therapies for children with suspected attachment disorder (see O’Connor & Zeanah, 2003). The point here is that there is no reason to presume that clinical or other applications of the early experience debate will await clear findings from research, or that the applications will provide a fair and balanced interpretation of the evidence. Very different interpretations about early interventions are derived from the models of early experience outlined above. And, as the subsequent review of findings implied, none of the available models quite fits the data,

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particularly the combination of substantial individual differences coupled with a striking persistence of effect—at least, in some cases. More specifically, the data do not yet suggest that there is a point after which intervention may not be effective; neither do they imply the reciprocal: that there is period in development before which intervention must occur to derive benefit. In short, we cannot, from existing data, make the sort of concrete determination that is often asked in applied settings. That is not to say that we do not have evidence for long-term positive effects of early interventions. Well-known examples include the work of Olds et al. (2004), Reynolds (Reynolds & Robertson, 2003), Ramey and colleagues (Campbell, Pungello, Johnson, Burchinal, & Ramey, 2001), and Cicchetti and Toth (Toth, Rogosch, Manly, & Cicchetti, 2006). These groups have shown that psychosocial interventions delivered in the first years of life (including prenatally) may have lasting effects that persist into adulthood. These studies do not necessary imply that early intervention is more effective than later intervention; they were not designed to do that (i.e., no group in the studies receives a comparably intensive, late-onset intervention). Extending the design of these studies to include a matched intervention delivered only later in development—if that were possible—would help address the scientific question of how important timing is on the effects of an intervention. But, given the positive evidence for early interventions that is now available, the additional and complex issue of timing of the intervention may not be one that is of paramount interest to practitioners and policymakers (and it would no doubt prove to be exceptionally difficult to test in a rigorous fashion, in any event). On the other hand, another lesson from the early experience research—the magnitude of individual differences in response to early adversity—is a matter with ready practical application. Identifying sources of individual differences to early intervention will help target those subgroups most likely to benefit and provide a strategy for altering and/or supplementing standard interventions. There is another cautionary note in the application of research findings to clinic and community: It is often poorly executed. In

the earlier cited case of folic acid, for example, Botto et al. (2005) found that the recommendations on the use of folic acid had “no detectable impact on incidence of neural tube defects”; this was so regardless of the recommendations’ form, timing, and intended target (p. 570). Given the strength of the findings on folic acid, that is a sobering observation. There may well be parallels with infant mental health; casual observation would suggest that the knowledge base is several steps ahead of routine clinical practice. On a more positive note, there is now a good deal of interest in supporting evidence-based treatments in community settings. For example, the wide-­spread popularity of nurse–­ family partnerships (based on the work of Olds and colleagues) is a good example of evidence-based practice. But, that may not be typical. Anecdotal evidence indicates that communication about concepts that are presumed to be obvious to those working in the mental health field is, at best, mixed. In the area of attachment, for example, there are many signs that the message about what attachment is (and what it is not) have been poorly communicated or misused. Perhaps the most severe example is the way in which attachment and “attachment therapy” have been promoted for children with severe attachment disturbances (see, O’Connor & Zeanah, 2003, for a discussion). Fortunately, there are also some good examples, such as Helping Babies from the Bench: Using the Science of Early Childhood Development in Court, a video produced by Zero to Three. And, for example, the work of Mary Dozier with infants in the social care system is improving the way in which attachment, early experience, and evidence-based practice are understood in applied settings.

CONCLUSIONS The early experience debate remains largely unresolved regarding most psychological and biobehavioral outcomes and processes in humans (see Bruer, 1999; Clarke & Clarke, 2000). Particularly informative and challenging are findings from studies of children whose experience of deprivation was limited to the first months or years of life. These findings, and findings from such designs as experimental interventions and natural ex-



7. Research Findings on Early Experience

periments, will move the discussion forward in important ways in the near future. And, whereas most of the current work tends to focus on single mechanisms viewed from a single methodology, advances in neuroscience techniques and greater collaborative efforts will provide the opportunity to triangulate on mechanisms. Nonetheless, there are obstacles. Many reviews that consider how the animal evidence informs our understanding of early adverse environmental exposures on human development underplay the daunting translational task, and popular accounts of the early experience debate are too quick to ignore central methodological constraints. Greater integration of animal and human work may help, and there is also much to be done in promoting the public understanding of science in this area. Finally, a key next step, as Knudsen, Heckman, Cameron, and Shonkoff (2006) articulated, is to understand not only that there are clinical applications of the early experience debate, but that there are economic applications as well (see Nagle, Chapter 36, this volume). References Barker, D. J. (Ed.). (1992). Fetal and infant origins of adult disease. London: Tavistock. Beckett, C., Maughan, B., Rutter, M., Castle, J., Colvert, E., Groothues, C., et al. (2006). Do the effects of early severe deprivation on cognition persist into early adolescence?: Findings from the English and Romanian Adoptees study. Child Development, 77, 696–711. Belsky, J., & Fearon, R. M. (2002). Early attachment security, subsequent maternal sensitivity, and later child development: Does continuity in development depend upon continuity of caregiving? Attachment and Human Development, 4, 361–387. Berardi, N., Pizzorusso, T., & Maffei, L. (2000). Critical periods during sensory development. Current Opinion in Neurobiology, 10, 138–145. Botto, L. D., Lisi, A., Robert-­Gnansia, E., Erickson, J. D., Vollset, S. E., Mastroiacovo, P., et al. (2005). International retrospective cohort study of neural tube defects in relation to folic acid recommendations: Are the recommendations working? British Medical Journal, 330, 571. Bowlby, J. (1951). Maternal care and mental health. Geneva, Switzerland: World Health Organization. Bowlby, J. (1988). Developmental psychiatry comes of age. American Journal of Psychiatry, 145, 1–10. Bronfenbrenner, U. (1979). The ecology of human

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development: Experiments by nature and design. Cambridge, MA: Harvard University Press. Brotman, L. M., Gouley, K. K., Huang, K. Y., Kamboukos, D., Fratto, C., & Pine, D. S. (2007). Effects of a psychosocial family-based preventive intervention on cortisol response to a social challenge in preschoolers at high risk for antisocial behavior. Archives of General Psychiatry, 64, 1172–1179. Brown, A. S., van Os, J., Driessens, C., Hoek, H. W., & Susser, E. S. (2000). Further evidence of relation between prenatal famine and major affective disorder. American Journal of Psychiatry, 157, 190–195. Bruer, J. T. (1999). The myth of the first three years. New York: Free Press. Cacioppo, J. T., Bernstein, G. G., Adolphs, R., Carter, C. S., Davidson, R. J., McClintock, M. K., et al. (Eds.). (2002). Foundations of social neuroscience. Cambridge, MA: MIT press. Cameron, J. L. (2004, June). The use of animal models for mechanistic and developmental studies. Paper presented at the NIMH workshop on the prevention of depression in children and adolescents, Rockville, MD. Campbell, F. A., Pungello, E. P., Johnson, S. M., Burchinal, M., & Ramey, C. T. (2001). The development of cognitive and academic abilities: Growth curves from an early childhood educational experiment. Developmental Psychology, 37, 231–242. Canfield, R. L., Henderson, C. R., Jr., Cory-­Slechta, D. A., Cox, C., Jusko, T. A., & Lanphear, B. P. (2003). Intellectual impairment in children with blood lead concentrations below 10 microg per deciliter. New England Journal of Medicine, 348, 1517–1526. Carter, C. S. (1998). Neuroendocrine perspectives on social attachment and love. Psychoneuroendocrinology, 23, 779–818. Caspi, A. (2000). The child is father of the man: Personality continuities from childhood to adulthood. Journal of Personality and Social Psychology, 78, 158–172. Chugani, H. T., Behen, M. E., Muzik, O., Juhasz, C., Nagy, F., & Chugani, D. C. (2001). Local brain functional activity following early deprivation: A study of postinstitutionalized Romanian orphans. NeuroImage, 14, 1290–1301. Cicchetti, D., & Rogosch, F. A. (2007). Personality, adrenal steroid hormones, and resilience in maltreated children: A multilevel perspective. Development and Psychopathology, 19, 787–809. Clarke, A. M., & Clarke, A. D. B. (2000). Early experience and the life path. London: Jessica Kingsley. Coplan, J. D., Trost, R. C., Owens, M. J., Cooper, T. B., Gorman, J. M., Nemeroff, C. B., et al. (1998). Cerebrospinal fluid concentrations of somatostatin and biogenic amines in grown primates reared by mothers exposed to manipulated foraging conditions. Archives of General Psychiatry, 55, 473–477.

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De Bellis, M. D. (2005). The psychobiology of neglect. Child Maltreatment, 10, 150–172. Dozier, M., Manni, M., Gordon, M. K., Peloso, E., Gunnar, M. R., Stovall-McClough, K. C., et al. (2006). Foster children’s diurnal production of cortisol: An exploratory study. Child Maltreatment, 11, 189–197. Eluvathingal, T. J., Chugani, H. T., Behen, M. E., Juhasz, C., Muzik, O., Maqbool, M., et al. (2006). Abnormal brain connectivity in children after early severe socioemotional deprivation: A diffusion tensor imaging study. Pediatrics, 117, 2093–2100. Fisher, P. A., Gunnar, M. R., Dozier, M., Bruce, J., & Pears, K. C. (2006). Effects of therapeutic interventions for foster children on behavioral problems, caregiver attachment, and stress regulatory neural systems. Annals of the New York Academy of Sciences, 1094, 215–225. Fleming, A. S., O’Day, D. H., & Kraemer, G. W. (1999). Neurobiology of mother–­infant interactions: Experience and central nervous system plasticity across development and generations. Neuroscience and Biobehavioral Reviews, 23, 673–685. Francis, D., Diorio, J., Liu, D., & Meaney, M. J. (1999). Nongenomic transmission across generations of maternal behavior and stress response in the rat. Science, 286, 1155–1158. Garrison, M. M., & Christakis, D. A. (2005). A teacher in the living room?: Educational media for babies, toddlers and preschoolers. Menlo Park, CA: Kaiser Family Foundation. Gluckman, P., & Hanson, M. (2005). The fetal matrix. New York: Cambridge University Press. Glynn, L. M., Wadhwa, P. D., Dunkel-­S chletter, C., Chicz-Demet, A., & Sandman, C. A. (2001). When stress happens matters: Effects of earthquake timing on stress responsivity in pregnancy. American Journal of Obstetrics and Gynecology, 184, 637–642. Greenough, W. T., Black, J. E., & Wallace, C. S. (1987). Experience and brain development. Child Development, 58, 539–559. Gunnar, M. R., Morison, S. J., Chisholm, K., & Schuder, M. (2001). Salivary cortisol levels in children adopted from Romanian orphanages. Development and Psychopathology, 13, 611– 628. Gunnar, M. R., & Quevedo, K. (2007). The neurobiology of stress and development. Annual Review of Psychology, 58, 145–173. Gunnar, M. R., & van Dulmen, M. H. (2007). Behavior problems in postinstitutionalized internationally adopted children. Development and Psychopathology, 19, 129–148. Harlow, H., & Suomi, S. (1970). The nature of love—­simplified. American Psychologist, 25, 161–168. Heim, C., Newport, D. J., Bonsall, R., Miller, A. H., & Nemeroff, C. B. (2001). Altered pituitary–­ adrenal axis responses to provocative challenge tests in adult survivors of childhood abuse. American Journal of Psychiatry, 158, 575–581.

Hensch, T. K. (2004). Critical period regulation. Annual Review of Neuroscience, 27, 549–579. Hinde, R. A., & Spencer-Booth, Y. (1971). Effects of brief separation from mother on rhesus monkeys. Science, 173, 111–118. Hofer, M. A. (1994). Hidden regulators in attachment, separation, and loss. Monographs of the Society for Research in Child Development, 59(2–3), 192–207. Huang, Z. J., Kirkwood, A., Pizzorusso, T., Porciatti, V., Morales, B., Bear, M. F., et al. (1999). BDNF regulates the maturation of inhibition and the critical period of plasticity in mouse visual cortex. Cell, 98, 739–755. Insel, T. R. (2003). Is social attachment an addictive disorder? Physiology and Behavior, 79, 351–357. Kagan, J., & Moss, H. A. (1983). Birth to maturity. New York: Wiley. (Original work published 1962) Kagan, J., Snidman, N., Kahn, V., & Towsley, S. (2007). The preservation of two infant temperaments into adolescence. Monographs of the Society for Research in Child Development, 72(2), 1–75. Kinnunen, A. K., Koenig, J. I., & Bilbe, G. (2003). Repeated variable prenatal stress alters pre- and postsynaptic gene expression in the rat frontal lobe. Journal of Neurochemistry, 86, 736–748. Knudsen, E. I. (2004). Sensitive periods in the development of the brain and behavior. Journal of Cognitive Neuroscience, 16, 1412–1425. Knudsen, E. I., Heckman, J. J., Cameron, J. L., & Shonkoff, J. P. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce. Proceedings of the National Academy of Sciences USA, 103, 10155–10162. Mackenzie, W. L. (1906). The health of the schoolchild. London: Methuen. MRC Vitamin Study Research Group. (1991). Prevention of neural tube defects: Results of the Medical Research Council vitamin study. Lancet, 338, 131–137. Meinlschmidt, G., & Heim, C. (2005). Decreased cortisol awakening response after early loss experience. Psychoneuroendocrinology, 30, 568– 576. Miller, L., Chan, W., Comfort, K., & Tirella, L. (2005). Health of children adopted from Guatemala: Comparison of orphanage and foster care. Pediatrics, 115(6), E710–E717. Nelson, C. A., III, Zeanah, C. H., Fox, N. A., Marshall, P. J., Smyke, A. T., & Guthrie, D. (2007). Cognitive recovery in socially deprived young children: The Bucharest Early Intervention Project. Science, 318(5858), 1937–1940. O’Connor, T. G. (2006). The persisting effects of early experiences on psychological development. In D. Cicchetti & D. Cohen (Eds.), Developmental psychopathology: Vol. 3. Risk, disorder, and adaptation (2nd ed., pp.  202–234). New York: Wiley. O’Connor, T. G., Heron, J., Golding, J., Glover, V.,



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& ALSPAC study team. (2003). Maternal antenatal anxiety and behavioural/emotional problems in children: A test of a programming hypothesis. Journal of Child Psychology and Psychiatry, 44, 1025–1036. O’Connor, T. G., Rutter, M., Beckett, C., Kreppner, J. M., Keaveney, L., & the English and Romanian Adoptees Study Team. (2000). The effects of global severe privation on cognitive competence: Extension and longitudinal followup. Child Development, 71, 376–390. O’Connor, T. G., & Zeanah, C. H. (2003). Attachment disorders: Assessment strategies and treatment approaches. Attachment and Human Development, 5, 223–244. Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D. W., et al. (2004). Effects of nurse home-­visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114, 1550–1559. Parfitt, D. B., Walton, J. R., Corriveau, E. A., & Helmreich, D. L. (2007). Early life stress effects on adult stress-­induced corticosterone secretion and anxiety-like behavior in the C57BL/6 mouse are not as robust as initially thought. Hormones and Behavior, 52, 417–426. Pryce, C. R., Dettling, A. C., Spengler, M., Schnell, C. R., & Feldon, J. (2004). Deprivation of parenting disrupts development of homeostatic and reward systems in marmoset monkey offspring. Biological Psychiatry, 56, 72–79. Reynolds, A. J., & Robertson, D. L. (2003). Schoolbased early intervention and later child maltreatment in the Chicago Longitudinal Study. Child Development, 74, 3–26. Rutter, M., Colvert, E., Kreppner, J., Beckett, C., Castle, J., Groothues, C., et al. (2007). Early adolescent outcomes for institutionally-­deprived and non-­deprived adoptees: I. Disinhibited attachment. Journal of Child Psychology and Psychiatry, 48, 17–30. Rutter, M., O’Connor, T. G., & the English and Romanian Adoptees Study Team. (2004). Are there biological programming effects for psychological development?: Findings from a study of Romanian adoptees. Developmental Psychology, 40, 81–94. Sabatini, M. J., Ebert, P., Lewis, D. A., Levitt, P., Cameron, J. L., & Mirnics, K. (2007). Amygdala gene expression correlates of social behavior in monkeys experiencing maternal separation. Journal of Neuroscience, 12, 3295–3304. Sanchez, M. M., Ladd, C. O., & Plotsky, P. M.

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(2001). Early adverse experience as a developmental risk factor for later psychopathology: Evidence from rodent and primate models. Development and Psychopathology, 13, 419–449. Schaffer, H. R. (2000). The early experience assumption: Past, present, and future. International Journal of Behavioral Development, 24, 5–14. Spitz, R. A. (1965). The first year of life. New York: International Universities Press. Suomi, S. (1999). Attachment in rhesus monkeys. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment (pp. 181–197). New York: Guilford Press. Toth, S. L., Rogosch, F. A., Manly, J. T., & Cicchetti, D. (2006). The efficacy of toddler–­parent psychotherapy to reorganize attachment in the young offspring of mothers with major depressive disorder: A randomized preventive trial. Journal of Consulting and Clinical Psychology, 74, 1006–1016. van IJzendoorn, M. H., & Juffer, F. (2006). The Emanuel Miller Memorial Lecture 2006: Adoption as intervention. Meta-­analytic evidence for massive catch-up and plasticity in physical, socio-­emotional, and cognitive development. Journal of Child Psychology and Psychiatry, 47, 1228–1245. Waters, E., Merrick, S., Treboux, D., Crowell, J., & Albersheim, L. (2000). Attachment security in infancy and early adulthood: A twenty-year longitudinal study. Child Development, 71, 684–689. Weaver, I. C., Cervoni, N., Champagne, F. A., D’Alessio, A. C., Sharma, S., Seckl, J. R., et al. (2004). Epigenetic programming by maternal behavior. Nature Neuroscience, 7, 847–854. Winslow, J. T. (2005). Neuropeptides and nonhuman primate social deficits associated with pathogenic rearing experience. International Journal of Developmental Neuroscience, 23, 245–251. Wolkind, S. N. (1974). The components of “affectionless psychopathology” in institutionalized children. Journal Child Psychology and Psychiatry, 15, 215–220. Zeanah, C. H., Smyke, A. T., Koga, S. F., & Carlson, E. (2005). Attachment in institutionalized and community children in Romania. Child Development, 76, 1015–1028. Zimmerman, F. J., Christakis, D. A., & Meltzoff, A. N. (2007). Associations between media viewing and language development in children under age 2 years. Journal of Pediatrics, 151, 364–368.

Pa r t II

RISK AND PROTECTIVE FACTORS

T

he cumulative risk model is now widely accepted. Simply put, this model states that the number of risk factors that an infant or dyad or family shares is more predictive of many adverse outcomes than any particular combination of risk factors. Considerable evidence has accumulated demonstrating that the cumulative risk model is well supported for many types of outcomes. Many studies are criticized for isolating single risk factors and looking at their correlates, potentially yielding misleading results. Given this lack of specificity, we may ask why a section on risk factors would be organized by specific factors. Answers to this question are largely pragmatic. Many intervention programs target specific risk factors, such as interventions or programs for adolescent mothers or substance abuse intervention programs. The fact that children of mothers in each program share increased risk for language delays, for example, does not mean that there is no value in organizing an intervention around these specific maternal characteristics. Experience with particular populations who may share common thematic struggles or respond to specific treatments is ample reason for organizing interventions (or chapters) by single risk factors. In any case, risk factors most often co-occur and may even interact with one another to lead to deleterious outcomes. Many of the chapters in this section review research that is not only concerned with risk factors but also with risk processes. In clinical settings, of course, risk factors are less meaningful for a particular dyad or family than actual contributors to the clinical picture. That is, once a clinical problem is evident, the probabilistic construct of risk must give way to identifying modifiable factors that are contributing to the disturbed behavior. Perhaps the most commonly encountered risk factor in infant mental health is poverty. Rarely occurring in isolation, poverty encompasses multiple risks factors and processes. Knitzer and Perry in Chapter 8 review research that documents deleterious effects of poverty on both limiting resources of families and compromising emotional well-being of parents. They highlight investments needed to strengthen parent–­infant relationships by providing supportive and therapeutic opportunities to low income parents. They call for family-­focused policies that

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are aimed at both reducing poverty and improving parenting, as well as building bridges between these two objectives. In Chapter 9 Goodman and Brand review recent research on maternal depression. They discuss important advances in identifying the effects of depression on pregnant women and new mothers, as well as short-term and long-term effects on infants. They describe the likely mechanisms through which depression affects infants, as well as the roles of risk and protective factors. In keeping with a contextual approach, they also highlight research on the role of fathers of infants who are affected by their mothers’ depression. They note that maternal depression as a risk factor for infant mental health is not only treatable but preventable, and they call for more efforts to reduce the intergenerational effects of depression. In keeping with the theme of multiple risks and complex risk processes, Boris, in Chapter 10, provides an overview of the complex issue of substance abuse in parents of young children. He describes several pathways through which substances may affect infant mental health. First, direct prenatal exposure is known to be associated with a variety of effects on infant behavior and development. Second, genetic effects may influence parent and infant behavior both separately and together. Finally, the effects of cumulative social adversities that accompany substance abuse may further contribute to risks. Each of these pathways provides indications about how families may be approached clinically and indications about the necessary components of intensive interventions. One of the best-known biological risk factors in infant mental health is preterm birth. In Chapter 11 Muller Nix and Ansermet describe this risk condition in all of its complexity. They present recent research and provide a trauma perspective on parents’ experience. They use the complexity of the problem to call for multifaceted interventions designed to address the interrelated biological, developmental, social, and emotional determinants of prematurity and their potential consequences. They emphasize the importance of the role of the mental health clinician in working directly with parents on their relationship with the infant, and also the role of working with the staff in the medically complex environment of the intensive care nursery. In Chapter 12 Schechter and Willheim review the effects of exposure to violence on infant mental health. They present research suggesting that many factors must be considered, including the nature of the exposure to violence, infant constitutional factors that may heighten vulnerability and/or resilience, the developmental context in which the violence occurs, and the infant’s relational context. Because the last of these is the one factor that clinicians can impact, Schechter and Willheim describe in detail the complex relational effects of violence exposure and highlight important prevention and treatment efforts that have been mobilized to reduce long-term sequelae. In the concluding chapter of the section (Chapter 13), Hans and Thullen discuss adolescent motherhood. In addition to the focus on mother and infant, they also consider the influence of mother–­grandmother and mother–­father relationships on teenage mothers and their babies, as well as the social networks of adolescent parents. This larger relational context points to the kinds of complexity needed in crafting comprehensive interventions for young mothers and their infants.

Chapter 8

Poverty and Infant and Toddler Development Facing the Complex Challenges Jane Knitzer Deborah F. Perry

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ach year, approximately 4 million babies are born in the United States. Of these, about 800,000 babies are born into “officially” poor families, and another 900,000 babies are born into families that struggle mightily to make ends meet. Altogether, a stunning 42% of all infants and toddlers in the United States—over 5 million children— are growing up in low-­income families with incomes under 200% of the official poverty level. What science tells us about how to ensure that these babies thrive and what policies are in place to put that knowledge into practice are critical for the workforce for the next generation. This chapter explores a series of questions, the answers to which can help shed light on the complex interactions among poverty and developmental forces. This information can serve both as a spur to new research and as a framework for developing a more coherent policy response that can support the kinds of emerging clinical interventions described throughout this book. The chapter is organized in three sections. The first highlights the demographic realities that so greatly impact and shape the experiences of young children in low-­income families. The second explores emerging research that is moving the inquiry from doc

umenting the associations between poverty and, too often, negative developmental outcomes to better understanding of the ways in which poverty actually impacts these outcomes. The third section turns the spotlight on the current policy framework and how it impacts the range and quality of the services and supports that are available to low-­income families. This section highlights the ways in which current policies need to be strengthened and where new policy frameworks need to be crafted to better integrate the lessons from science.

WHO ARE POOR INFANTS AND TODDLERS? “Official” poverty was defined as an annual income of $17,170 for a family of three in 2007. But the official poverty level is based on an outdated formula developed in the 1960s. It estimates that families spend about onethird of their incomes on food, but it ignores the cost of child care and underestimates the burden of housing costs. It also fails to take into account taxes, benefits, or regional cost differences (Cauthen & Fass, 2006). Hence, it is not surprising that research based on real family experiences shows consistently 135

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that it takes about twice the official poverty level for families to provide basic necessities. However, despite major efforts to redefine poverty in more appropriate ways (Citro & Michael, 1995; Dalakar, 2005), from a policy perspective, the official poverty level continues to be used when public resources are allocated—­specifically, to determine which families are eligible for public programs. Altogether, of the 5.2 million babies and toddlers in low-­income families, about 21% are in families with incomes at or below the official poverty level, including the 1.2 million children from 0 to 3 (10% of all infants and toddlers) who are in families with incomes that are at 50% or less than the official poverty level. Another 22% of infants and toddlers, or 2.7 million very young children, are in families whose income is between 100 and 200% of the poverty level. Although the official poverty line sounds like a firm divide, in reality, low-­income families move in and out of official poverty. These variations in income can impact eligibility for benefits from month to month. But even more significantly, families with incomes between 100 and 200% of poverty are generally just one crisis away from poverty; they live “at the edge,” without any savings or assets to stand between them and a broken car or missed rent payment Near poor families are also penalized because they lose eligibility for benefits more quickly than their income increases (Cauthen, 2006). Beneath these overarching numbers is a much more nuanced and complicated picture, with significant variations by race, ethnicity, and immigrant status that have powerful implications for research, policy and clinical/practice agendas. America’s babies are leading the way toward the society that America will become, that is, a much more racially and ethnically diverse one. Fifty-five percent of all infants and toddlers born in this country are white, which means that white infants and toddlers are still in the majority, but not by much. (Whites comprise 67% of the total population.) Twentythree percent of all infants and toddlers are Hispanic, 14% are black, 4% are Asian, and 3% are “other.” Less than half of 1% are Native American, but there are a few states in which Native American children comprise a much more significant part of the population.

Poverty and low-­income status disproportionately impact babies of color. Less than one-third of all white babies (30%) are in low-­income families, compared to nearly two-­thirds of black (66%), Hispanic (63%), and Native American babies (63%). About 25% of Asian babies are in low-­income families. Children of recent immigrants— who now comprise one out of every five children—are also more likely to be in poor or low-­income families than children of American-born parents. Half of these children are in low-­income families, one-third of them in households in which no adult is proficient in English (Gozdziak, 2006, cited in Dinan, 2006). Together, all these children of color are harbingers of a new America that is much more culturally diverse than the current America; by 2030, it is estimated that less than half of U.S. children will be non-­H ispanic white, and the majority will comprise a mix of other ethnicities and races (Mather, 2009). Two other features of populations of young children in low-­income families are also relevant. The first is that there is considerable variation across the states in the percentage of young children who are in low-­income families, with rates ranging from 21 to 58% (Stebbins & Knitzer, 2007). This wide range has important implications for state as well as national policies. Also startling is the reality that the younger the children are, the more likely they are to be in families that do not have adequate income (DouglasHall, Chau, & Koball, 2006; see Figure 8.1). There is some evidence, furthermore, that the impact of poverty on younger-aged children, depending upon its duration and depth, has more significant negative effects than poverty experienced by older children (Duncan & Brooks-Gunn, 1997)—a finding that has important policy implications.

The Family Context: A Demographic Portrait The data just highlighted represent only one portion of the portrait of America’s low­income babies and toddlers. A risk and resilience framework calls for equal attention to how demographic and psychosocial risks and strengths are distributed among parents of young children. Three demographic factors are particularly relevant: parental



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Percent (%) 50 40 30 20 10 0

43%

42%

5.2 million

41%

3.3 million

1.6 million

21%

19%

19%

2.6 million

1.6 million

0.8 million

Under 3

3–4

5

39% 10.8 million

17% 4.8 million

6–12

Low-income 35% 7.4 million

Poor

15% 3.2 million

13–17

FIGURE 8.1.  Children living in low-income and poor families, by age group, 2005. From DouglasHall, Chau, and Koball (2006). Copyright 2006 by the National Center for Children in Poverty. Reprinted by permission.

education, parental work status, and parental marital status. All have been linked, repeatedly, to outcomes for babies and toddlers, and all interact in complex ways with income status. Parental, and especially maternal, education is one of the best predictors of a child’s educational achievement (Baum, 2004). Early language development in babies is directly related to maternal levels of education. Families with more education use more words, in more complex ways, and often with more positive tone—­factors that all contribute to better language development in young children (Hart & Risley, 1995; Ramey & Ramey, 2004). In turn, better language skills translate into greater odds for successful early school entry. Overall, one-­quarter of all low-­income babies and toddlers have parents with less than a high school education. Another 36% of the babies have parents who have just a high school education, and 38% have some college. Again, there are significant disparities by race and ethnicity: 63% of Native American, 62% of Hispanic, and 50% of black infants and toddlers live with parents who have a high school education or less. Contrary to stereotypes, most low-­income parents work; in fact, 51% of low-­income babies and toddlers have at least one parent who works full-time, and another 30% have parents who work parttime. The corresponding distribution for the population as a whole is 73% working full time and 17% working part-time. The problem is that parents in the low-­income brackets do not earn enough to support a family.

In other words, a large group of low-­income babies and toddlers largely have undereducated parents who work very hard but cannot earn enough money to lift their families out of poverty or to provide their children with the experiences that more affluent young children frequently enjoy. Finally, just under half (49%) of all infants and toddlers in low-­income families live in two-­parent families. For these families, marriage does not protect against economic hardship. But even in the single-­parent families, fathers are often unofficially in the picture, particularly around the time of the baby’s birth (Special Analysis prepared by NCCP Annual Social & Economic Supplement, 2008). Beyond these broad demographic factors, it is also important to attend to the subgroups of infants and toddlers who face combinations of parental, environmental, and/or other risk factors, including extreme poverty, that lessen the odds for their healthy development. Early Head Start evaluation, based on data disaggregated by combinations of risk factors, for example, found that babies and toddlers in families experiencing four or more demographic risk factors did not benefit from the program in the same way that other participants did (Love et al., 2004). Other data suggest that what have been called parental “adversities,” particularly related to depression, substance abuse, and intimate partner violence, alone or in combination with each other and with demographic risk factors, represent even more severe threats for babies and toddlers. There are no census data on the prevalence of

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these parental psychosocial risk conditions in the lives of infants and toddlers, but a recent synthesis suggests that symptoms of parental depression in parents of young low­income children are as high as 48% (Early Head Start Research and Evaluation Project, 2003) and that about 10% of these children have substance abusing parents (Knitzer & Lefkowitz, 2006). Rates of maltreatment for infants and toddlers are higher than for any other age group, with rates estimated to be 16 per 1,000. Similarly, whether or not babies are born to immigrant parents also has important consequences for development, since they are more likely to be in low-­income families—61% compared with 40% of those born to native parents (Douglas-Hall et al., 2006). The vast majority of these babies come from Mexico or other Spanish­speaking countries and cultures, but all across America are communities with “new Americans” from other countries, some of them war torn, with families escaping from traumatizing situations. These factors have enormous implications for those who deliver services, and they underscore the importance of reaching these families in a culturally competent manner (Dinan, 2006). Immigrant status also impacts the public benefits to which these babies have access. In theory, babies born to immigrant parents are U.S. citizens and entitled to all the benefits available to other babies of comparable income status, but in reality, the current pervasive anti-­immigration sentiment creates fear in families, forestalling or prohibiting that involvement with the “helping” systems. Finally, it is important to emphasize the persistence of seemingly intractable disparities. In U.S. society, poverty and related risk factors disproportionately impact children and families of color. From the start, infants in families of color are born earlier and smaller, with black babies facing consistently higher rates of low birthweight and preterm delivery (U.S. Department of Health and Human Services, 2006b). Higher rates of chronic health conditions (e.g., asthma, sickle cell disease) further erode their well-being and place increased care and financial burdens on families. For new immigrants from Spanish-­speaking countries (as well as many already have), lack of sufficient numbers of health care providers who are bilingual or

bicultural is a major problem, as caregiver behaviors and beliefs about illness are culturally mediated. At one level, this lacuna has led to new insights and practices related to cultural competence. But at another level, it is, in fact, young children who bear the burden of an unequal social playing field.

POVERTY AND SOCIAL– EMOTIONAL DEVELOPMENT For decades, research has documented in excruciating detail what is now a truism: Children growing up in poverty are exposed to great numbers and types of risk factors and manifest poor development across multiple domains (Aber, Jones, & Raver, 2007; Duncan & Brooks-Gunn, 1997; McLoyd, 1998; Ryan, Fauth, & Brooks-Gunn, 2006). More recent research, however, is moving beyond a focus on patterns of association to expand our understanding of the specific pathways or mechanisms through which poverty takes its long-­lasting toll on children’s well-being. Below we review some of the research that has been published since the last edition of the Handbook of Infant Mental Health (Zeanah, 2000), focusing particularly on those studies that seek to elucidate poverty’s impact on young children’s social–­emotional and behavioral health—which, as the entirety of this volume underscores, necessitates a focus on the mental health of the family.

Conceptual Model The conceptual model that frames our review (see Figure 8.2) is influenced by a great deal of work that has come before us, most notably a groundbreaking paper by Yeung, Linver, and Brooks-Gunn (2002). Using structural equation modeling to analyze data from a large, nationally representative sample, these authors integrated the two dominant theoretical approaches to understanding the effects of poverty on young children’s development: the investment perspective and the family process model. The investment perspective, initially articulated by an influential economist (Becker, 1981; Becker & Thomes, 1986), views the main pathways through which income affects children’s future outcomes as those elements directly associated with money and time. With



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Poverty: Income Timing Depth Duration Financial Stress

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Process: Parental Mental Health Parenting Behavior Marital Quality Siblings, Others Young Child’s Mental Health Structure: Home Enviornment Neighborhood Schools Child Care Quality Resilience: Moderates effects of poverty on outcomes at level of family, neighborhood, and child

FIGURE 8.2.  Our conceptual model.

more money, parents can (1) purchase more stimulating toys, books, and games; (2) afford higher-­quality child care and (later) private schools; (3) purchase a home in a safe neighborhood; and (4) have more available leisure time to engage in activities with their children. The family process model posits that the main mediators of the effects of income on children’s outcomes are the emotional well-being of parents (in particular, mothers) and the qualities of family interactions, particularly those related to stress. The early roots of this perspective, often referred to as the “family stress” model, are often attributed to the foundational research by Elder (Conger & Elder, 1994; Elder & Caspi, 1988). Researchers focusing on the investment perspective have argued that these variables are particularly salient for children’s cognitive development and later school achievement, whereas the family stress literature has typically sought to account for differences in children’s social–­ emotional outcomes. Yeung, Linver, and Brooks-Gunn (2002) combined both perspectives in a single conceptual model, arguing that both pathways are important to understanding why, in the aggregate, children in poverty fare worse than their higher-­income peers. In addition, they contend that the specific variables of greatest theoretical interest in the invest-

ment model may, in fact, interact with central variables in the family stress pathways. For example, stress related to paying for food and housing or lack of access to health care could lead to changes in parenting behavior that are linked to children’s outcomes. These authors also address cognitive and behavioral outcomes in this work and focus on young children—a specific gap in the family stress literature which had emphasized adolescent well-being and outcomes. Finally, this work was strengthened by the selection of a data set that contained a large number of theoretically important variables, measured over time in a large sample. In short, the integration of both the investment and family stress perspectives makes a significant contribution to our understanding of how poverty affects young children’s development. Similar to the current resolution of the nature versus nurture debates of old, which argues not only do both matter, but the interaction of both matters even more, the evidence about the two pathways suggests that both structural characteristics (be those the quality of the available child care, the safety of the neighborhood, or the availability of high-­quality learning materials) related to the family investment frame and the affective quality of the child’s environment are critical. The evidence also suggests that it is difficult to pull these domains

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apart: Sufficient income to purchase better­quality child care (investment frame) means that, on average, these caregivers will be better trained and likely warmer and more responsive (family, process frame). Likewise, many of the negative effects of structural characteristics that differ in the homes and neighborhoods of families in poverty will likely be mediated through process pathways (i.e., mother’s mental health and parenting behaviors). Therefore, we see these as reciprocally related constructs that both contribute to children’s well-being (Figure 8.2).

New Methods Expand Models More sophisticated definitions of poverty as well as more nuanced theories have been needed to guide the selection of variables to measure and include in studies. Research conducted over the last decade has also benefited from the creation of several large data sets derived from high-­quality longitudinal studies focused on low-­income populations, as well as a significant increase in the use of multivariate statistical modeling techniques that allow researchers to test proposed mechanisms and pathways and measure more complex constructs associated with the experience of poverty. Advances in our understanding of the pathways through which economic disadvantage impacts the well-being of families and young children have come from the convergence of three primary forces: greater sophistication of the statistical tools that can be applied to data analysis, the availability of more data sets that have variables that are theoretically relevant to low-­income families, and advances in the development of more nuanced theories of mechanisms and pathways. New multivariate analytic techniques allow developmental scientists to answer new questions from large population-based samples about the relationships between income and outcomes as well as about the trajectories of development in both lowerand higher-­income families. Nationally representative samples of young children, such as the Early Childhood Longitudinal Studies (ECLS), which follow two large cohorts (from birth through kindergarten, and from kindergarten through eighth grade; ECLS-B and ECLS-K, respectively), are adding to the published literature on the unique risks and

protective factors that operate during the early childhood period (U.S. Deaprtment of Education, National Center for Education Statistics, 1999). Still other researchers are gathering data from large observational studies that further enhance our knowledge base. For example, the Three-City study has followed a group of about 2,400 low-­income families recruited in 1999 when their children were either less than 4 years old or between 10 and 14. These families, from Boston, Chicago, and San Antonio, Texas urban neighborhoods, were then followed up at two later time points. In addition to the longitudinal data, the researchers have an “embedded development study” that gathered detailed videotaped caregiver–child interaction data, time-diary studies, and observational data on the quality of child care. The exclusive focus on low-­income parents in this sample allows us to explore the heterogeneity of the experiences of low-­income parents and children, as well as to measure variables of theoretical interest in more depth and over time, such as changes in parenting practices. Another new data set that offers an equally rich source of high-­quality data over the early childhood period is the Fragile Families and Child Well-Being study. This team of researchers recruited a cohort of nearly 5,000 families in cities across the United States; three-­quarters of these babies were born to unmarried mothers. This study design allows for the in-depth exploration of the intersection between low-­income and single-­parent status. The main study has been supplemented with new funding from the National Institute of Child Health and Human Development (NICHD) to follow these families into middle childhood; and a large array of complementary studies have been funded by government and philanthropic organizations to address special topics, such as parental resources and child well-being, fatherhood and incarceration, and couple dynamics and father investments. These studies will begin to fill an important gap in what is known about the role of fathers in low-­income families. And finally, another set of recent studies resulted from systematic “experiments” with different combinations of welfare-towork programs (e.g., New Hope; see Huston et al., 2005). Together, these new methodological approaches and longitudinal data sets have al-



8. Poverty and Infant and Toddler Development

lowed researchers to define poverty in more complex ways. Instead of simply considering an individual’s income at a single point in time, recent studies have sought to capture the dynamic nature of poverty as it affects children’s development. For example, using a large sample of families from the Panel Study of Income Dynamics (PSID), Wagmiller, Lennon, Kuang, Alberti, and Aber (2006) applied a specific statistical modeling technique (i.e., latent class analysis) to determine four distinct patterns in the experience of poverty during childhood: long-term poor, moving out of poverty, moving into poverty, and nonpoor. This innovative approach takes into account the timing of the experience of poverty—­adding to a growing body of evidence that underscores early childhood as a particularly vulnerable time to experience the negative effects of poverty. Others add measures of the subjective experience of financial stress to objective measures of income (e.g., Gershoff, Raver, Aber, & Lenon, 2007; Mistry, Biesanz, Taylor, Burchinal, & Cox, 2004); financial stress is particularly salient as a mediator of income to family stress variables. Researchers have also stressed the importance of the “depth” of poverty, often defined as falling below 50% of the federal poverty level, which may be differentially related to many of the investment perspective variables such as lack of stable housing and food insecurity. Further augmenting the findings from developmental psychology, social demography, and public health are new data on the physiological mechanisms that underlie the early impact of stress on developing brains and bodies (); and the growing body of work on gene–­environment interactions as they contribute to mental health outcomes (National Scientific Council on the Developing Child, 2005; Knudsen, Heckman, Cameron, & Shonkoff, 2006; Rutter & Silberg, 2002).

Poverty and Social–­Emotional Health Direct Effects of Income The research on the direct effects of income overall show only modest impacts both for social–­emotional and cognitive arenas. Thus, with respect to social–­emotional behaviors, for the most part, there is little

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evidence of direct effects across data sets, analytic methods, and theoretical models. Further, in those few studies where direct effects of income on early childhood mental health are reported, the magnitude of these effects tends to be quite modest (Dearing, McCartney, & Taylor 2006). Similarly, some studies report some residual (direct) effects of income on cognitive outcomes, but only after other mediators are placed in the multivariate models. The effects tend to be relatively small and to emerge first during the toddler period, suggesting that they may be seen as early roots of academic disadvantage (see Ryan et al., 2006 for a comprehensive review of the school readiness literature).

Indirect Effects of Income Most of the recent research examining the links between poverty and young children’s mental health explores the indirect effects of income on outcomes through mediating variables. Two sets of findings are particularly important. First, increasingly nuanced research continues to identify parenting as the most significant mediator of poverty. Second, the research is also showing the importance of nonparenting experiences, particularly early child care and broader neighborhood characteristics. This research reflects the confluence of the factors cited above: new and better data sets and methods coupled with advances in theory that allow research to test theory-based hypotheses on sufficiently large samples of low-­income families. Below, we briefly summarize the research.

Parenting Poverty exerts its strongest influence on young children’s outcomes through its effects on parenting. Studies have examined a wide array of specific parenting behaviors that are associated with early childhood mental health. These include how consistently or harshly parents discipline their children, how emotionally available a mother may be during infancy, parental expressed emotion and warmth, and, increasingly, the critical role that parental depression plays in disrupting positive parenting in many low­income families (see Goodman & Brand, Chapter 9, and Rosenblum et al., Chapter 5, this volume). Researchers have sought to

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examine the dynamics of the experience of depression on young children, (Petterson & Albers, 2001), the longer-term effects of exposure to a depressed mother (Grace, Evinder, & Stewart, 2003), and the degree to which interventions can have a significant impact on women suffering from depression (Nylen, Moran, Fanklin, & O’Hara, 2006; Robinson & Emde, 2004). Researchers are also beginning to track the impact of multiple maternal risks that often coexist with depression, particularly substance abuse and intimate partner violence (Whitaker, Orzol, & Kahn, 2006). Growing attention to fathers and other caregivers is likely in the future.

Early Childhood Environments While the majority of research on the impact of poverty on social and emotional development focuses on the family process pathways, there is growing evidence to suggest that structural characteristics of the “environment of childhood poverty” may interact with parenting behaviors to affect outcomes. For example, Evans (2004) provides a review of the physical and environmental risks that characterize many of the neighborhoods and homes of children growing up in low-­income families. With limited financial resources, families are often exposed to higher levels of toxins, poorer air quality, and greater noise pollution, which may lead to compromised physical health in parents and infants alike. More relevant to social development are higher rates of community violence to which low-­income families are exposed, impacting infants and toddlers through the stress this places on caregivers, and later restricting young children’s access to outdoor play with peers due to safety concerns (Evans, 2004). The evidence that physical characteristics of the homes and neighborhoods of low­incomes families contribute significantly to their overall experience of income insecurity has grown as researchers have added to their sophistication in measuring these important ecological contexts (Beyers, Bates, Pettit, & Dodge, 2003; Caughy & O’Campo, 2006; Caughy, Randolph, & O’Campo, 2002; Kohen, Brooks-Gunn, Leventhal, & Hertzmann, 2002; O’Campo, 2003). Another important context for understanding how structural features of the environment effect young children’s social and

emotional development is child care. Many low-­income families lack access to high­quality infant and toddler child care because it is too expensive. Both structural and interpersonal characteristics of child care are important predictors of cognitive and social outcomes for young children; research has consistently documented greater gains in cognition for low-­income children who are in high-­quality child care settings (Loeb, Fuller, Kagan, & Carrol, 2004; NICHD Early Child Care Research Network, 2005; Ryan et al., 2006).

Moderating Effects of Poverty Whereas poverty overall has been shown to have negative effects on young children, the consequences of extreme or chronic poverty may be even more significant. There is also evidence that children in poverty are exposed to more risk factors, and the effects of these risk factors are worse for them. This phenomenon—­referred to as double jeopardy (Parker, Greer, & Zuckerman, 1988)—is an example of risk “moderation”: That is, there are worse consequences for children who are in families with very low incomes. For example, Dearing et al. (2006) used a new measure of poverty—an income-to-needs ratio—that begins to address relative, not just absolute, poverty, and to examine early impacts of poverty. (The income-to-needs ratio divides household income by the poverty threshold for a family of a given size.) Focusing on the first 54 months of life, the researchers compared outcomes for three categories: (1) chronically poor young children who lived in families with income-to-needs ratios under 1.0, that is, in poverty at three or more of the longitudinal assessments; (2) transiently poor young children whose family incometo-needs ratios fell below 1.0 at only one or two time points; and (3) young children who lived in never poor families where the income to needs ratio always exceeded 1.0. These authors found that the association between family income and externalizing behaviors was considerably larger for children who experienced chronic poverty. That is, chronicity of poverty over the early childhood period moderated the direct effect of family income on externalizing behavior problems.



8. Poverty and Infant and Toddler Development

At the same time, it should also be noted that moderating factors can lead to positive results and override the negative probabilities. In fact, although there are scores of studies that document poorer outcomes for children raised in poverty, many children and families do well and are deemed resilient. Resilience, definition, involves the intersection between exposure to a known risk factor and the positive adaptation manifest by individuals in the face of this adversity (Luthar, 2006). The current focus of many resilience researchers is to identify both risk and particularly protective factors that might modify the negative effects of adverse life circumstances, as well as to identify underlying mechanisms or processes (Luthar, 2006). This type of information, in turn, allows for the design and testing of interventions that strengthen protective factors, such as promoting the presence of a strong positive relationship with at least one parent (or other caring adult), or teaching effective parenting skills (e.g., warmth coupled with appropriate discipline) that predict resilient trajectories. Likewise, high-­quality responsive caregiving in child care can buffer the effects of poverty on young infants and toddlers (Luthar, 2006). Findings from neurobiology and behavioral genetics are also helping to better elucidate the physiological underpinnings of how economic adversity may take its toll on young children as well as how specific gene–­ environment interactions may mediate or moderate these relationships. For example, based on research by Gunnar (Gunnar & Donzella, 2002), it is becoming clear that that exposure to excessive amounts of stress during the first few years of life—­especially so-­called “toxic” stress, which results in chronic activation of the hypothalamic–­ pituitary–­adrenocortical axis—can actually disrupt the architecture of the developing brain and result in permanent changes in the infant’s stress response system (National Scientific Council on the Developing Child, 2005; Rifkin-­Graboi et al., Chapter 4, this volume). Other provocative findings have been reported through twin studies, which are uniquely able to partition the relative contribution of genetic and environmental factors. Kim-Cohen, Moffitt, Caspi, and Taylor (2004) reported that genetic factors may

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contribute up to 70% of the variation in behavioral resilience found in a large sample of monozygotic twins. However, the pathways are not simple. They pointed out that these genetic contributions take the form of so-­called “passive” transmissions: Children inherit genes that account for some portion of their ability to regulate their emotions well, and these genes may also account for the warm, loving behavior in parents. Or they could result from “active” gene–­environment interactions: In this case, the genetic contribution of the parent results in child characteristics that actually elicit warm, loving, parenting behaviors. Although these researchers did not pinpoint specific genes that might mediate these relationships, others have begun to link the presence or absence of specific genes with specific outcomes. For example, Caspi et al. (2002) reported a protective effect of the presence of a specific form of the monoamine oxidase-A (MAO-A) enzyme gene for children who were maltreated; those individuals who had the genotype associated with high levels of the MAO-A enzymes were less likely to develop antisocial disorder, compared to similar maltreated children with low levels of the gene. These same authors reported that the relationship between stressful life events and depression was moderated by a genotype (variations in the 5-HTT gene): Those with the gene that promotes efficient transport of serotonin were less likely to develop depression (Caspi et al., 2003).

Directions for Future Research As this review of the literature suggests, there is a great deal of work underway exploring the complex interplay between poverty and child development. As advances in behavioral genetics and neurobiology continue to be integrated with developmental research, it is important to make sure that the best available science is brought to bear on questions that are relevant to policymakers and practitioners. Dearing et al. (2006) argue that study designs that examine the impact of changes in poverty status over time in the same child are particularly relevant for policymakers; data derived from “within-child” study designs allow policymakers to see that children can recover from the negative effects of poverty, given sufficient changes in

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their economic conditions. There is also a need to expand the research by investigating more than one child in each family, as these designs add to our understanding of the child-level factors at work in resilience. As knowledge about the interplay between parent- and child-level factors grows, there is also a need for more research that considers the family as the level of analysis (KimCohen et al., 2004; Luthar, 2006). It is also critical to address one of the disconnections between what is in the published literature and the realities of poverty in the United States. There are simply too few high-­quality studies that examine the critical role of culture in all of these processes. As noted, growing numbers of immigrant families are navigating the rocky waters of low-­income life in America; many of these stressors are similar to those experienced by American-born families. But for those families who may have entered the country illegally and those with very limited English, these stressors are compounded by lack of access to services and income supports. These are not families that typically enroll in research studies, although there is a growing number of community-based studies from which important insights into both the stressors and strengths of these families raising young children will be gained (see, e.g., Le, Lara, & Perry, 2008). Clearly, there is a critical need for more research to close the gap in our understanding of how cultural forces and factors mediate and moderate the effects of poverty in these families.

TOWARD SCIENCE-INFORMED POLICIES Both the demographic data and the increasingly nuanced understanding of how poverty impacts early development have enormous, if largely unaddressed, implications for public policies. For example, a policy framework to promote improved outcomes for infants and toddlers ought to be informed by the integrative conceptual model highlighted above. Thus the overarching goals ought to center on improving both family investment capacity/income and family processes, particularly parenting processes, through voluntary opportunities afforded to low-­income parents (except in cases where harm to babies

and toddlers requires state intervention). This means strengthening the policy focus on poverty reduction strategies, strengthening family-­focused interventions to improve parenting, and building links between these two sets of policies. It also means recognizing the importance of nonfamilial influences on development and ensuring that child care and neighborhood settings promote resilience and healthy outcomes. Below, drawing especially on a recent analysis of early childhood policies across the United States (Stebbins & Knitzer, 2007), we map current policies onto this conceptual framework.

Promoting Family Economic Security and Access to Basic Benefits As noted earlier, many low-­income families are resilient and would do fine if they could earn enough money to support themselves. But too often they can’t. For example, for a single parent to earn twice as much as the poverty level, a job would have to pay $19 an hour. In fact, most low-wage-­working parents earn at or just above the minimum wage, which, according to federal law, is $6.55, shortly to go up to $7.25. But much more needs to be done. Although more than half of the states have minimum wages that are higher than the current federal level, many states require that families with incomes below the poverty level pay personal income taxes. To make it, low-­income parents need some combination of wage supplements and what are often called “work support” benefits, such as access to health care for themselves and their children, help with housing (which they rarely get), and child care. These benefits can ensure that children get basic services when there is a gap between what families earn and what is needed to support themselves. The good news is that there is a set of national strategies that do provide a foundation for economic security. For example, the federal Earned Income Tax Credit (EITC), along with Social Security (Cauthen, 2005), is America’s largest antipoverty program. The EITC reduces the tax burden on lowwage families and, in some instances, provides a wage supplement. But not all families who could benefit know about it. In response, there have been local campaigns to improve access. For example, Louisiana, through its



8. Poverty and Infant and Toddler Development

Solutions to Poverty campaign (SToP), has embarked on a statewide campaign as an investment to increase state revenues (because of the spending that would occur). States also supplement the federal EITC with their own programs, but only 14 have refundable EITCs, which means that if the amount of credit a family receives exceeds the amount the family owes, it gets a refund (Stebbins & Knitzer, 2007). Similarly, there is a federal legislative infrastructure to support a range of benefits to low-­income families, including basic health and child care for families who cannot purchase care on their own, through programs such as Medicaid; the State Child Health Insurance Program (SCHIP); the Women, Infants, and Children Supplemental Nutrition Program (WIC), which is one of the few major benefit programs targeted only to young children, and particularly infants and toddlers and pregnant women; and the Child Care and Development Block Grant. Because states often have choices in how they implement these programs, the picture across the country is complex. For example, recognizing, as noted above, that in most parts of the country it takes twice the poverty level for families to begin to meet their needs without help, 41 states provide health care coverage to families at or above 200% of the official poverty level. However, only 16 states provide access to child care to families earning 200% or more of the official poverty level. This means that where a baby is born matters greatly to what kind of supports are available. For example, a young child in New Jersey has access to public health insurance, whereas a child from North Dakota in a family with half the income does not (Stebbins & Knitzer, 2007). This disparity may be good for states rights, but it is not good for children. Further, access alone is not enough. The benefits also need to be of sufficient quality to yield positive outcomes from the investment. That is, sadly, too often not the case. For example, many low-­income young children, including infants, are not receiving recommended health and dental screenings that are consistent with good pediatric practice. To encourage outreach to children who are Medicaid eligible, the federal government sets a benchmark of 80% of enrolled children receiving at least one health screen

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each year. Only seven states reported that more than 80% of 1- and 2-year-olds receive at least one screening, with one state screening only 36% (Stebbins & Knitzer, 2007). The picture with respect to policy efforts to ensure quality child care is even more problematic. About 400,000 infants and toddlers are in subsidized child care, with countless others in informal care delivered by relatives and neighbors (often known as kith and kin care). The subsidy program serves far fewer families than need help to pay for child care. Even worse, over the past several years, half the states have actually reduced access to subsidized child care (Stebbins & Knitzer, 2007). Moreover, evidence suggests that too often the quality of this early child care is wanting, particularly for infants and toddlers. Only 9% of infant and toddler care was deemed high quality in one study, and only 25% of child care for preschool-age children was of high quality (Kreader, 2005). Yet only eight states meet licensing standards recommended by national organizations (and only 14 for 4-year-olds). In some states, one caregiver is allowed to care for up to nine toddlers (Stebbins & Knitzer, 2007). Other problems that can negatively impact infants and toddlers in child care include high rates of staff turnover. Because babies become attached to caregivers, the lack of continuity in relationships can be problematic, especially for infants and toddlers coming from unstable home environments. Close to half the states do report that they require that each infant or toddler in care have a primary caregiver, but it is not known what kinds of mechanisms are in place to monitor this criterion, and informally, reports of babies and toddlers with ever-­changing caregivers are common (Stebbins & Knitzer, 2007).

Toward a Coherent Framework Substantively, one major challenge is the lack of a coherent science-based framework to guide the development of policies to improve family processes, or what Knitzer (2001) called relationship-based policies. The take-home message from science is that effective, nurturing, consistent parenting is central to healthy developmental outcomes for young children, particularly infants and toddlers. Research and clinical practice also

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suggest that effective parenting, in addition to adequate income, requires that parents be physically and mentally healthy, and that they have the knowledge and skills to respond to the particular characteristics and needs of their babies (which includes having age-­appropriate expectations for what babies and toddlers can and cannot do). It also requires that parents have access to outside information from physicians and others to help them identify early signs of developmental and emotional challenges in their young children. And, for the most high-risk parents, intensive efforts are needed to test the extent to which they can learn new parenting strategies and skills (Dicker, Beckmann, & Knitzer, 2009). Further, policies should recognize that strategies to support effective parenting start at least at, if not before, pregnancy. And finally, any parenting program must account for the important role that culture plays in determining what form positive parenting practices will take—as everything from where babies sleep and how long toddlers are carried around by adults is culturally mediated and has implications for social and emotional development. The current set of policies in place that map onto this knowledge base is thin. Efforts to ensure that parents of young children are physically and mentally healthy are limited at best. Thus, although infants and toddlers are likely to have access to health care, their parents typically do not. In 35 states working parents are eligible under Medicaid only if their incomes are under 100% of poverty; in 12 states under 50% of the official poverty level. Only four states extend eligibility to parents at or above 200% of the poverty (Stebbins & Knitzer, 2007). Given that the health status of low-­income parents is often poor, this lack of access is a barrier that may be linked with ineffective parenting. Of particular concern is the inability of low-­income parents, particularly mothers, to get help with mental health and challenges related to depression, as well as intimate partner violence and substance abuse. These risks are widespread, as noted above, and they are known to impact children’s development negatively. Yet, despite their widespread prevalence, there is no policy imperative to treat risk factors that impair effective parenting even for infants and toddlers. In other words, for the many parents

who are raising young children while coping with undiagnosed and untreated depression (or other mental illness) and/or who struggle with substance abuse or domestic violence, ensuring their access to health and mental health should be a core part of a parenting policy agenda, as well as embedded in an infant/toddler mental health policy agenda. One policy strategy that many countries implement (not the United States) is paid family leave for new parents. Although there is limited scientific research to support a significant relationship between more progressive parental leave policies and child well-being, there is a strong rationale for supporting policies that permit families to choose to spend more of the earliest months with a new baby. And at least one study, based on interviews with more affluent new parents, found that a shorter leave was associated with maternal depression and less healthy “preoccupation” with the infant (Feldman, Sussman, & Zigler, 2004). Under current federal law, parents working in settings with over 50 employees can take up to 12 weeks of unpaid leave following the birth/adoption of a new baby. But the reality is, there are not many families who can afford to do this; and low-­income families are least equipped to lose 12 weeks of pay. Although five states pay for maternal leave through the disability system, only California provides for paid leave for biological and adoptive parents (Stebbins & Knitzer, 2007). Parental leave allows for protected time for new parents to build relationships with their babies, but in this society, work attachment is privileged over infant–­parent attachment. Helping parents improve their parenting skills and promote more positive interactions with their babies and toddlers at a time when the brain architecture is being built so rapidly is clearly the central challenge for a policy framework that supports early effective parenting. It is also a complex challenge, best implemented through a public health lens, that would encompass strategies to promote effective parenting, identify and help parents who need more targeted assistance, and intervene early and with appropriate intensity when parenting is more problematic. Across the country, communities are struggling to implement various approaches to helping parents. But too often the efforts are fragmented, and funding is difficult to



8. Poverty and Infant and Toddler Development

sustain. Fairly typical is the experience in San Mateo County, California, where there was a very successful foundation-­funded effort to train all providers working with babies in Touchpoints, an intervention designed to help parents and caregivers learn how to read babies’ cues. Once the foundation support ended, there was no ongoing source of public dollars to sustain this effort (as cited in Knitzer & Lefkowitz, 2006). Similarly, efforts to screen for parental depression in the context of pediatric practice represents a commitment to prevention and early intervention to improve parent functioning, but policies to train staff, to build referral networks, and particularly to ensure reimbursement, remain challenging, although states and communities are making efforts to put the pieces in place (Rosman, Hepburn, & Perry, 2005). Perhaps the policy supports that are most lacking, however, are for broadly based, comprehensive, two-­generational child development and family support programs. Early Head Start, which is a national model that does have federal support, serves pregnant women and infants and toddlers at or below the poverty line (although recent legislation permits eligibility up to 130% of poverty). The program has been the subject of careful research that has shown a pattern of modest gains across a wide array of parenting practices (i.e., improved family processes) and child outcomes, particularly for families with moderate risks. Conceptually, Early Head Start is particularly important because it is a two-­generational model that encompasses specific child-­focused and family-­focused strategies, a combination that researchers suggest may be the most effective (Knitzer, 2008). It also has the potential to build in a stronger focus on family economic security, thus better linking the two conceptual pathways that interact to shape the consequences of very early poverty in childhood. But although Early Head Start is almost 15 years old, it is basically stuck, serving less than 3% of the eligible population. Estimates are that only 10 states supplement federal dollars with state dollars. Home-­visiting programs targeted to families of infants and toddlers too are often seen as part of an array of parenting programs, and one, the Nurse–­Family Partnership program, has a strong evidence base (Olds,

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2002). Within the early childhood field there is some controversy as to whether it is wiser to invest in Early Head Start–type programs, evidence-based home-­visiting programs, or other national models, such as Educare, which have not been the focus of gold standard research but that require a 0–5 commitment based on an enhanced model of Early Head Start and Head Start. Whatever the view, the bottom line is that federal support for developmentally appropriate programs that are grounded in relationshipbased strategies for infants and toddlers has been, and continues to be, woefully limited. Notwithstanding the buzz about early brain science, the policy response to date has been sluggish at best.

Policies to Help Infants, Toddlers, and Families at the Highest Risk of Poor Outcomes Another policy vacuum exists for higher-risk infants, toddlers, and families, particularly where psychosocial relationship-based issues are involved. As part of the Individuals with Disabilities Education Act, federal policymakers have built a potentially powerful policy response to babies and toddlers with developmental delays through the federal Early Intervention Program. This program requires the formulation of an individualized family service plan—­explicitly acknowledging that the developmental needs of infants and toddlers must be addressed in the context of their families’ needs, strengths, and priorities. It also, in theory, allows states to serve infants and toddlers at risk of developing delays. However, because of limited resources, only a few states include at-risk infants and toddlers in the program, and most are making eligibility even more restrictive for those with developmental delays. Also problematic is that early interventionists— most often occupational, physical, and speech therapists—­t ypically are not trained to detect and respond to social and emotional delays and relationships problems, so generally, babies with social and emotional delays, or at risk of them, do not access services. On the other hand, a recent amendment does require that all babies and toddlers involved in substantiated abuse and neglect cases be referred for early intervention assessment. However, here too, the resource gap looms

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large. Estimates indicate that there are about 156,000 babies and toddlers already in foster care and thus eligible, but in fact, recent data suggest that only about 17,000 babies have been referred (Rosenberg, Smith, & Levinson, 2007), and in many places, clinicians simply do not refer. With respect to child-­specific risks, however, the bottom line is that a policy that can be improved is in place. With respect to infants and toddlers in families who are at risk by virtue of family circumstances, the policy picture is less promising. Piecing together a service response requires complex fiscal strategic planning (Johnson & Knitzer, 2005; Kaye, May, & Abrams, 2006; Perry, 2007). The basic safety net program, which serves the poorest families, is Temporary Assistance to Needy Families (TANF). Unfortunately, TANF has emphasized connecting parents with the workforce, largely without attention to the health and well-being of their children. Relatively little attention has also been given to addressing the so-­called barriers to work that many of these parents experience, and virtually no recognition that barriers to work (defined typically as low educational levels, mental health issues, substance abuse, intimate partner violence, and poor health) are also barriers to effective parenting. A stronger policy focus on helping very poor families with infants and toddlers access combined parenting and work-­linked strategies might yield two-­generational benefits linked to both improved workforce attachment and child outcomes. To date, polices to address the needs of this special population have not been on the state or federal policy agenda (Knitzer & Cohen, 2007). Another set of strategies that could help high-risk families is being tested in scattered programs around the country. The approach involves embedding more intensive interventions that provide some combination of treatment for parental risks with parent– child interventions and sometimes child­focused interventions as well as Early Head Start and home-­visiting programs (Knitzer & Lefkowitz, 2006). However, given Medicaid and other fiscal restrictions, such demonstrations do not get taken to scale. In some states, for example, it is not possible to pay for parent–child therapies through the children’s mental health system and/or to pay for non-­office-based services. Through the leadership of the Commonwealth Fund,

a philanthropic organization, a number of states are crafting policy and fiscal strategies to maximize the impact of Medicaid in supporting infant and early childhood mental health strategies (Kaye et al., 2006). However, the recently enacted Deficit Reduction Act, which significantly restructures Medicaid, has resulted in new federal policies that make these, and related efforts, such as expanding mental health consultation in child care, even more difficult. Further, there has been a dismaying lack of attention to babies who must be removed from their homes, estimated to be about 156,000 in 2005. Promising approaches are emerging (Dicker et al., 2009; Osofsky & Lederman, 2004), but there is insufficient attention gives to this population in current federal policy.

TOWARD THE FUTURE The scientific case for a strengthened focus on policies that improve family economic security as well as family processes and early relationships for infants and toddlers, particularly those at the highest risk, is clear. A more responsive policy agenda is critically needed. Here we highlight 10 recommendations: 1.  Promote stronger anti-­poverty measures and work supports (e.g., access to child care and transportation) for all families with young children. 2.  Ensure that eligibility for benefit programs that support early development, particularly health and child care programs, is set at 200% of the poverty level (or higher) across the states. 3.  Build a two-­generation focus into public assistance programs (e.g., TANF) to support healthy parenting as well as workforce attachment. 4.  Increase targeted funds to enhance high-­quality infant and toddler child care for all low-­income children. 5.  Significantly expand Early Head Start–like programs for the poorest families to maximize the potential to jump-start healthy social, emotional, and cognitive development in babies and toddlers. 6.  Expand the federal Early Intervention Program (Part C of the Individuals with Disabilities Education Act) to ensure that infants and toddlers with, or at risk of, developmen-



8. Poverty and Infant and Toddler Development

tal delays, attachment disturbances, or other relationship-based problems get appropriate help in a timely, culturally relevant, and family-­strengthening way. 7.  Explicitly support reimbursement, through existing federal legislation such as Title V and Medicaid, for parenting interventions that promote healthy early development, and/or develop targeted legislation that provides incentives to states to help communities implement evidence-based practices, including interventions for parents with young children in child welfare. 8.  Integrate mental health services and supports, particularly through consultation strategies and the use of research-­informed therapies for families and caregivers, into the existing programs that serve young children and their families, and offer incentives for programs that provide multigenerational interventions (see Perry, Kaufmann, & Knitzer, 2007). 9.  Build a strategic policy framework that promotes effective parenting with the same degree of conviction that policies currently promote parental work. Such a framework would encompass multiple efforts: for example, (a) strengthening the focus on effective parenting in existing policies through both public health systems (e.g., Title V and Medicaid) and the child and adult mental health systems; (b) supporting communityand state-based strategic planning that address parents and improving provider skills of those who work directly with parents, including physicians; and (c) ensuring that high-risk parents, particularly those affected by substance abuse, intimate partner violence, or depression, both during pregnancy and through the infant/toddler years, are identified and receive treatment, as appropriate. 10.  Strengthen the advocacy on behalf of a birth–5 policy agenda. Those who would use science to improve policies through recommendations like these and others that have been proposed (Knitzer, 2008; Shonkoff, Lippitt, & Cavanaugh, 2000) for infants and toddlers face daunting challenges. Traditionally, policy on issues affecting children has grown out of a child-­saving frame that includes, implicitly, saving children from bad parents in poor families. This has led to a set of measures that result in a focus on high-cost remedia-

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tion, for example, through juvenile justice and child welfare. This chapter calls for a strategic investment in prevention and early intervention programs. Such an undertaking requires that we challenge not just stereotypes about the poor, but also the embedded, almost knee-jerk American value of individualism that makes it difficult to build policies that place children and families, not just children, at the center. Unfortunately, notwithstanding ecological and developmental theories about how multiple contexts influence development, the policy response is to view family-­focused policies as a threat to, rather than a support system for, families. On the other had, the growing evidence about high-­quality two-­generational early childhood interventions that can improve developmental outcomes in ways that save money may, over time, be persuasive. Right now, there is evidence that the return-on­investment arguments are driving state investments in pre-K programs largely for 4-year-olds. However, it is noteworthy that at least two of the demonstration studies that are so central to making the case for two­generational interventions actually started at or before birth: Abecedarian and the Chicago Child Parent Centers. Moreover, findings from the longitudinal study of Early Head Start show that kindergarten children who had continuous access to high-­quality early experiences, starting with Early Head Start as infants and toddlers, do better once they enter kindergarten than those with discontinuous or poor-­quality experiences (U.S. Department of Health and Human Services, 2006b). This new wave of research, in the hands of informed advocates, may turn the tide for the next generation of babies born in America, and may continue to inform promising efforts to strengthen policies for infants and toddlers in other countries as well. References Aber, J. L., Jones, S., & Raver, C. (2007). Poverty and child development: New perspectives on a defining issue. In J. L. Aber et al. (Eds.), Child development and social policy: Knowledge for action. Washington, DC: American Psychological Association. Angel, R., Burton, L., Lindsay Chase-­Lansdale, P., Cherlin, A., & Moffitt, R. (2009). Welfare, children, and families: A three-city study [Computer

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the child in juvenile court. In J. D. Osofsky (Ed.), Young children and trauma: Intervention and treatment. New York: Guilford Press. Parker, S., et al. (1988). Double jeopardy: The ­impact of poverty on early child development. Pediatric Clinics of North America, 35, 1227– 1240. Perry, D. F. (2007). Strategic financing of early childhood mental health services. In D. F. Perry, R. K. Kaufmann, & J. Knitzer (Eds.), Social and emotional health in early childhood: Building bridges between services and systems (pp. 211– 232). Baltimore, MD: Brookes. Perry, D. F., Kaufmann, R. K., & Knitzer, J. (2007). Social and emotional health in early childhood: Building bridges between services and systems. Baltimore, MD: Brookes. Petterson, S. M., & Albers, A. B. (2001). Effects of poverty and maternal depression on early child development. Child Development, 72(6), 1794– 1813. Ramey, C. T., & Ramey, S. L. (2004). Early learning and school readiness: Can early intervention make a difference? Merrill-­Palmer Quarterly, 50(1), 471–492. Rosenberg, S., Smith, E., & Levinson, A. (2007). Identifying young maltreated children with developmental delays. In R. Haskins, F. Wulczyn, & M. B. Webb (Eds.), Child protection: Using research to improve policy and practice (pp. 34– 43). Washington, DC: Brookings Institution. Rosman, E., Hepburn, K., & Perry, D. F. (2005). The best beginning: Partnerships between primary health care and mental health and substance abuse services for young children and their families. Washington, DC: National Technical Assistance Center for Children’s Mental Health, Georgetown University Center for Child and Human Development. Rutter, M., & Silberg, J. (2002). Gene–­environment interplay in relation to emotional and behavioral disturbance. Annual Review of Psychology, 53, 463–490. Ryan, R. M., Fauth, R. C., & Brooks-Gunn, J. (2006). Childhood poverty: Implications for school readiness and early childhood education. In S. Spodek & O. Saracho (Eds.), Handbook on the education of young children (pp.  323–341). Mahwah, NJ: Erlbaum. Shonkoff, J., Lippitt, J., & Cavanaugh, D. (2000). Early childhood policy: Implications for infant mental health. In C. H. Zeanah, Jr. (Ed.), Hand-

book of infant mental health (2nd ed., pp. 503– 518). New York: Guilford Press. Stebbins, H., & Knitzer, J. (2007). Early childhood policies: A report of the Improving the Odds Project. New York: National Center for Children in Poverty. Available at www.nccp.org/publications/pub_725.html. The Bendheim-­T homan Center for Research on Child Wellbeing. (2008). The fragile families and child wellbeing study. Retrieved from www.fragilefamilies.princeton.edu/public/asp on February 12, 2008. U.S. Department of Education, National Center for Education Statistics. (1999). ECLS, Kindergarten class of 1998–1999. Washington, DC: Author. Available at www.nces.ed.gov/ecls/kindergarten.asp. U.S. Department of Education, National Center for Education Statistics. (2007). Early childhood longitudinal study, birth cohort (ECLS-B) 9-month–­preschool restricted-use data file and electronic codebook (CD-ROM). (NCES 2008034). Washington, DC: Author. U.S. Department of Health and Human Services. (2006a). National healthcare disparities report. Agency for Healthcare Research and Quality. Rockville, MD: Author. Available at www.ahrq. gov/qual/nhdr06/nhdr06.htm. U.S. Department of Health and Human Services. (2006b). Research to practice: Preliminary findings from the Early Head Start prekindergarten follow-up. Administration for Children and Families. Rockville, MD: Author. Available at www.acf.hhs.gov/programs/opre/ehs/ehs_resrch/reports/prekindergarten_followup/prekindergarten_followup.pdf. Wagmiller, R. L., Lennon, M. C., Kuang, L., Alberti, P. M., & Aber, J. L. (2006). The dynamics of economic disadvantage and children’s life chances. American Sociological Review, 71, 847–866. Whitaker, R., Orzol, S., & Kahn, R. (2006). Maternal mental health, substance abuse, and domestic violence in the year after delivery and subsequent behavior problems in children. Archives of General Psychiatry, 63, 551–560. Yeung, W. J., Linver, M. R., & Brooks-Gunn, J. (2002). How money matters for young children’s development: Parental investment and family process. Child Development, 73(6), 1861–1879. Zeanah, C. H., Jr. (Ed.). (2000). Handbook of infant mental health (2nd ed.). New York: Guilford Press.

Chapter 9

Infants of Depressed Mothers Vulnerabilities, Risk Factors, and Protective Factors for the Later Development of Psychopathology Sherryl H. Goodman Sarah R. Brand

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epression in mothers of infants has raised concerns for all who are involved with such families, given common understandings of the essential role of mothers in caring for their infants’ physical and emotional needs and how depression is likely to interfere with the performance of that role. The associations of depression with parenting and infant development are complex. Over the last few decades, researchers have contributed substantial knowledge to our understanding of the issues involved. In this chapter we review the research on depression in women (both pre- and postnatal, since effects may begin during pregnancy), the psychological functioning of infants of depressed mothers (especially those who may be vulnerable to the later development of psychopathology), and the likely mechanisms by which depression in mothers effects their infants. Throughout, we summarize the knowledge on alternative pathways from infant vulnerabilities to the later development of psychopathology, emphasizing the roles of risk and protective factors. Although the bulk of the research on the effects of parental depression on infants has focused on mothers, we also point to the work that has been conducted on fathers with depression and to the potential role of fathers of infants

who are affected by their mothers’ depression and suggest further work that is needed. Finally, we describe the prevention and treatment work that has been evaluated for its effectiveness and suggest work that needs to be conducted.

DEPRESSION: DEFINITIONS AND MEASUREMENT Researchers define clinically significant depression either in terms of the set of symptoms, duration, and impairment by which an individual meets criteria for a mood disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) or in terms of a high score on a self-­report symptom rating scale of depression. DSM-IV divides mood disorders into depressive disorders (sometimes referred to as unipolar depression) and bipolar disorders. Bipolar disorder, which requires the presence of one or more manic or hypomanic episodes, has less often been the focus of studies of maternal depression and is not discussed in this chapter. DSM-IV further divides depressive disorders into major depression and dysthymia. A diagnosis of major depression requires the 153

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occurrence of one or more episodes during which the individual exhibits, over a period of 2 weeks or more, depressed mood (in children or adolescents, this might be irritable mood) or a loss of interest or pleasure in almost all daily activities, along with a number of other symptoms, including weight loss or gain, loss of appetite, sleep disturbance, psychomotor agitation or retardation, fatigue, feelings of guilt or worthlessness, and concentration difficulties. A diagnosis of dysthymia requires a more chronic but less intense mood disturbance, with the individual having exhibited some symptoms of depression for most of a 2-year period (1 year in children and adolescents). Other researchers forego the diagnostic system and either use continuous scale scores or rely on established cutoffs on self-­report measures of depression symptoms. The most commonly used such measures are the Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1997) and the Centers for Epidemiological Studies—­ Depression Scale (CES-D; Radloff, 1977). For perinatal depression, the most commonly used measure is the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987). High scores on these scales may not be specific to depression or may reveal more transient depression than would meet diagnostic criteria. Depending on the population sampled, women who score high on these measures likely include some who would meet diagnostic criteria and others who would be considered subclinical due to not meeting one or more of the criteria for a DSM-IV diagnosis (numbers of symptoms, duration, severity, or impairment). Subclinical levels of depression are also of clinical interest as they predict future onset of depressive episodes (Lewinsohn, Seeley, Soloman, & Zeiss, 2000). Further, it may be the manifestation of depressive symptoms rather than the diagnosis of depression per se that is related to birth and childhood outcomes (Weinberg et al., 2001). Perinatal depression is not a separate diagnosis according to the DSM-IV. Typically, clinically significant perinatal depression is operationalized as major depression, as defined by the DSM-IV (American Psychiatric Association, 1994). Within the depressive disorders in the DSM-IV, pregnancy is not given any special consideration. On the other

hand, “postpartum” is an added “specifier” to refer to the timing of a major depressive episode. As with depression at other times in women’s lives, perinatal depression is also commonly defined as exceeding empirically established cutoff scores on rating scales, most typically the EPDS (Cox et al., 1987). Although designed to take into account the many ways that symptoms of depression may be masked by typical pregnancy and postpartum experiences (e.g., sleep problems, weight changes, energy loss), the EPDS has some shortcomings. First, it was developed among a sample of postpartum women; therefore, it may not accurately assess depression among antenatal women. Second, owing to its development in Scotland, some language in the EPDS is potentially confusing in the United States (e.g., “Things have been getting on top of me,” and “I have felt scared or panicky for no very good reason”). Nonetheless, it is the best of available instruments to assess perinatal depression and the most commonly used. Moreover, for many of the women experiencing perinatal depression, the episode will not be their first or their last because depression is a recurrent disorder. In the general population, over 80% of depressed patients have more than one depressive episode (Belsher & Costello, 1988); over 50% relapse within 2 years of recovery (Keller, Shapiro, Lavori, & Wolfe, 1982). Not surprisingly, then, prior depression has been found to be the strongest predictor of the development of depression during pregnancy and postpartum, increasing the risk of clinically significant symptoms four to five times relative to women without a history of depressive episodes (Marcus, Flynn, Blow, & Barry, 2003; O’Hara & Swain, 1996). This finding holds true even after controlling for many other factors (Rich-­Edwards et al., 2006).

Prevalence Between 6 and 17% of women experience an episode of major depression at some point in their lifetimes, a rate that is between one and a half to three times higher than that found in men (Kessler, 2006). Depression rates are especially high among women of childbearing ages (Wilhelm, 2006). The widely differing definitions of perinatal depression likely



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contribute to the wide range in estimates of the prevalence of depression symptoms and disorder occurring during pregnancy and the postpartum. In addition to definition issues, the variability in estimates is due to sampling characteristics that are also known to be associated with rates of depression in general populations, such as poverty, being a teenage mother, and other sociodemographic risk factors. Recent review articles (Bennett, Einarson, Taddio, Koren, & Einarson, 2004; Gavin et al., 2005) have called for studies of larger and more representative samples in order to narrow the wide 95% confidence intervals found in many studies and meta analysis.

Prevalence of Depression in Pregnant Women Rates of clinically significant levels of depressive symptoms during pregnancy have been reported to range from 8 to 51% (Bennett et al., 2004; Gotlib, Whiffen, Mount, Milne, & Cordy, 1989). This broad range reflects both definitional and sampling diversity. For the more clearly defined DSM-IV major depressive episodes during pregnancy, rates range from 10 to 17% (Evans, Heron, Francomb, Oke, & Golding, 2001; Gotlib et al., 1989; Johanson, Chapman, Murray, Johnson, & Cox, 2000), although meta-­analyses report significant variability in this estimate as well (Gavin et al., 2005).

Prevalence of Depression in Mothers of Infants Postpartum “blues” are quite common, characterizing 20–80% of new mothers (O’Hara, Schlechte, Lewis, & Wright, 1991). As estimated in a recent meta-­analysis, postpartum major or minor depression occurs in as many as 19.2% of women within the first 3 months after delivery (Gavin et al., 2005). The more narrowly defined major depression was estimated to occur in 7.1% of new mothers (Gavin et al., 2005). Thus depression is common, especially among women of childbearing and childrearing ages, and recurrent or persistent. On these bases alone, its presence in mothers has fueled concern for its potential to disrupt aspects of caregiving known to be critical for healthy child development. In the next section we introduce a developmental psychopathology perspective for understanding

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the research on how depression in mothers affects their infants.

VULNERABILITIES IN INFANTS OF DEPRESSED MOTHERS Depression in pregnant and postpartum mothers has been found to be associated with several aspects of infants’ adverse development, which are known to be vulnerabilities to the later development of psychopathology.

Attachment Across multiple studies, clinically significant maternal depression was significantly associated with lower rates of secure attachment and, marginally, with higher rates of avoidant and disorganized attachment (from 17 to 28%, on average; Martins & Gaffan, 2000). Further, when clinical samples were compared to community samples, significantly higher effect sizes were found in the clinical samples, perhaps due to the chronic nature of clinical depression, along with the accompanying dysfunction between episodes (Atkinson et al., 2000). Some researchers have examined moderators and mediators of this association. For example, insecure states of mind in mothers strengthened the association between maternal postnatal depression and infant insecure attachment (McMahon, Barnett, Kowalenko, & Tennant, 2006). Another significant moderator is infant physical status. In particular, premature birth significantly moderated the association between maternal postnatal depression symptom level and infants’ quality of attachment to their mothers, even after controlling for level of neonatal health complications (Poehlmann & Fiese, 2001). One potential mediating relationship has not been supported. That is, although toddlers of depressed mothers showed the expected higher rates of insecure attachment, relative to others, this association was not found to be accounted for by contextual risks (Cicchetti, Rogosch, & Toth, 1998). In turn, infants’ quality of attachment is associated with vulnerability to the later development of depression. Specifically, insecure attachment may lead children to have negative expectancies for other relationships

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and negative self-­perceptions, leaving them vulnerable to depression (Cummings & Cicchetti, 1990; Sroufe, Egeland, Carlson, & Collins, 2005). Insecure attachment has also been found to be associated with reduced left frontal brain activity, whether or not the mother had been depressed (Dawson et al., 2001). Thus the developmental course is likely to be even more complicated for insecurely attached infants of depressed mothers than for other insecurely attached infants.

Emotional and Behavioral Functioning and Regulation Several other indices of infants’ emotional and behavioral functioning have also been found to be associated with maternal depression. Of particular concern are low levels of positive affect, high levels of negative affect, and difficulties in regulating emotion and behavior, given evidence that these are vulnerabilities to the later development of depression, as is reviewed here. A few researchers began their studies during pregnancy and thus were able to examine the associations of prenatal depression with infants’ emotional or behavioral functioning. Among these findings, mothers who had been depressed or scored high on depression rating scales during pregnancy rated their infants as crying more and being more difficult to soothe (Zuckerman, Bauchner, Parker, & Cabral, 1990). Their infants have also have been observed as showing more negative affect (Huot, Brennan, Stowe, Plotsky, & Walker, 2004) and engaging in more gaze aversion while interacting with their mothers (Boyd, Zayas, & McKee, 2006). Further, infants of mothers depressed during their third trimester of pregnancy scored lower on the orientation subscale of the Brazelton Neonatal Assessment Scale (Brazelton, 1984), had more abnormal reflexes, and had less optimal scores on the Lester and Tronick excitability and withdrawal factors (Lundy et al., 1999). Others focused on maternal anxiety or stress during pregnancy, which are of interest because of strong associations between depression in women and both anxiety and stress (Klein, Corwin, & Ceballos, 2006; Monroe & Hadjiyannakis, 2002). Maternal trait anxiety measured during pregnancy has been found to be associated with infants’

perceived “difficult” temperament at 4 or 6 months postpartum, independently of postpartum depression and sociodemograhic and obstetrical risk factors (Austin, Hadzi­Pavlovic, Leader, Saint, & Parker, 2005). Prenatal stress also explained 3.3–8.2% of the variance in 3- and 8-month-olds’ attention regulation and difficult behavior and in 8-month-olds’ attention regulation, measured with both maternal report and observations (Huizink, Robles de Medina, Mulder, Visser, & Buitelaar, 2002). Infants of postnatally depressed mothers have higher levels of negative affect and lower levels of positive affect during play and during interaction with the depressed mother and others (Field, Pickens, Fox, Gonzalez, & Nawrocki, 1998) and with premature, ineffective efforts to self-­regulate (Tronick & Gianino, 1986). Infants of women with elevated symptom levels of depression, compared to those whose mothers score low, have also been rated by observers as drowsier or fussier, less relaxed or content, and as engaging in less toy exploration and less focused play (Abrams, Field, Scafidi, & Prodrmidis, 1995). Similarly, observers rate infants of clinically diagnosed depressed mothers, compared to those with nondepressed mothers, as tenser, less happy, and as showing less tolerance for lab procedures and less distress during maternal separation (Cohn & Campbell, 1992). Infants’ emotional and behavioral functioning has been found to be a vulnerability factor for the later development of depression and other psychopathology (Fox, 1994; Southam-Gerow & Kendall, 2002). For example, infants’ frustrated attempts to obtain needed external regulation from depressed mothers has been observed to lead to their engaging in self-­directed regulatory behaviors, foretelling a retreat from engagement with the social world (Tronick & Gianino, 1986). More broadly, less ability to self­regulate emotions might emerge as a generalized dysregulation of emotion and behavior or, more specifically, as heightened sensitivity to stressors (e.g., interparental conflict, parental distress); a threatened sense of emotional security; undercontrolled behavior with parents and peers, including aggression; or, alternatively, overcontrolled behavior or suppression of emotions as a way of coping with stressful situations (Cohn & Tronick,



9. Infants of Depressed Mothers

1983; Zahn-­Waxler, Iannotti, Cummings, & Denham, 1990). That is, these aspects of functioning may foretell either aggression or withdrawal (Cummings, Keller, & Davies, 2005). Infants’ more predominant negative affect is also of concern because it may be associated with a tendency to elicit sad affect in interacting partners (Field et al., 1988) and with a predisposition to negatively biased perceptions (Fagen & Prigot, 1993). Negative affect itself is also related to later learning difficulties (Bugental et al., 1992). Thus, the aspects of infants’ emotional and behavioral functioning and regulation that have been found to be associated with either antenatal or postnatal depression in mothers has implications for problems in adaptation to situations encountered later in development, suggesting multiple pathways for the development of depression and other psychological problems.

Neuroendocrine and Psychophysiological Functioning It is now understood that stress during pregnancy influences aspects of fetal development that are relevant to later emotional and behavioral functioning (Wadhwa et al., 2002). It is also understood that important aspects of brain functions and neurobehavioral mechanisms continue to emerge after birth. Relevant to the latter point, researchers are beginning to understand the extent to which the infant brain is sensitive to early life stress. The frontal lobe, which plays a large role in the regulation of emotion, has been the major focus (see Graham, Heim, Goodman, Miller, & Nemeroff, 1999, for a review). Thus perinatal depression and the often co-­occurring stress and anxiety may influence infants’ neuroendocrine and psychophysiological functioning both during fetal development and in postnatal life. Consistent with these ideas, researchers have found that infants of mothers depressed during their third trimester of pregnancy show higher levels of cortisol and norepinephrine at birth, along with lower levels of dopamine, than infants of mothers who were not depressed during pregnancy (Lundy et al., 1999). Researchers report similar findings in infants in association with postpartum depression: Infants of postpartum de-

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pressed mothers have elevated levels of stress hormones (norepinephrine and cortisol) relative to infants of mothers who score low on depression scales (Field, Fox, Pickens, & Nawrocki, 1995; Lundy et al., 1999). Both prenatal and postnatal depression have been found to be associated with lower vagal tone (Dawson et al., 2001; Field et al., 2004; Field, Pickens, Fox, Nawrocki, & Gonzalez, 1995). Infants with depressed mothers also exhibit atypical patterns of frontal electroencephalograph (EEG) asymmetry: Compared to infants of nondepressed mothers, infants of depressed mothers exhibited reduced left frontal brain activity during playful interactions with their mothers (Dawson et al., 1999; Field, Fox, et al., 1995; Lundy, Jones, et al., 1999). In a follow-up study when the children were 4–5 years old, children’s frontal brain activation, along with the family’s contextual risk level, mediated associations between mothers’ depression and child behavior problems (Dawson et al., 2003). These aspects of neuroendocrine and psychophysiological functioning in infants, based on extensive research on cortisol, vagal tone, and EEG asymmetries, are of concern as evidence of vulnerability to the development of psychopathology. Cortisol is widely accepted as an index of stress reactivity, including in infants (Gunnar, 2006). Yet among infants, it is important to interpret findings on cortisol cautiously, given evidence that high day-to-day and weekto-week intraindividual variability in basal cortisol is typical of infants between 5 and 8 months, whether due to their hyperreactive hormonal systems or to their being extremely sensitive to variations in their environments (de Weerth & van Geert, 2002). Intraindividual variations of cortisol changes in response to stress are smaller and show modest associations, even across time, from ages 4–6 months (Gunnar, Brodersen, Krueger, & Rigatuso, 1996). Findings of predictive associations from infant cortisol reactivity to later indices of emerging psychopathology include higher newborn cortisol levels (measured following heel-stick blood draws) associated with 6-month-olds’ mother-rated diminished distress to limitations, a dimension of temperament (Gunnar, Porter, Wolf, & Rigatuso, 1995). This association, which is in the opposite direction of simi-

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lar associations found with older children, was interpreted by the authors as suggesting that greater reactivity, particularly early in infancy, may predict better regulation even by later in the first year, as has been found by Porges, Doussard-­Roosevelt, and Maiti (1994). Other findings link infants’ low cortisol reactivity with secure attachment (Gunnar & Vazquez, 2001). With regard to EEG asymmetry, in studies of unselected infants and adults, right-brain activation is associated with the experience and expression of the negative emotions of sadness and distress, a tendency to withdraw and avoid interaction, and lower behavioral initiation, whereas activation of the left frontal region is associated with positive emotions of joy and interest (Davidson & Fox, 1982; Fox, 1994; Gotlib, Ranganath, & Rosenfeld, 1998). In depressed adults, reduced left frontal activity was not only present during episodes but persisted into remission (Davidson, Schaffer, & Sharon, 1985; Henriques & Davidson, 1990). In addition, the atypical pattern exhibited by children with depressed mothers has been found to be predictive of an infants’ vulnerability to experience negative affect (Davidson & Fox, 1989) and thus may be a marker of current or chronic depressed mood state (Field et al., 1995). Asymmetry in 7- to 12-montholds is associated with infant affect, indexed by latency to cry in response to maternal separation (Bell & Fox, 1994). Also, nearly all 3-month-olds who showed right frontal asymmetry continued to show the same pattern at age 3 years and also were observed to be more inhibited relative to other children (Jones et al., 1998). Of all three of these constructs, vagal tone shows the strongest evidence of reliability and stability (Fracasso, Porges, Lamb, & Rosenberg, 1994), and along with the other measures, shows strong associations with the later development of psychopathology (Porges, 2005). This is also a particularly useful index of stress reactivity in infants because it can be reliably recorded as early as 1 week in infants (Jones et al., 1998). Also intriguing is emerging evidence linking these neuroendocrine and psychophysiological vulnerabilities to each other. In newborns, higher baseline vagal tone was significantly correlated with higher cortisol levels, following heel-stick blood draws

(Gunnar et al., 1995), and in 6-month-old infants, higher basal and stressor reactive cortisol levels were associated with relatively greater right EEG asymmetry (Buss et al., 2003).

Cognitive-Intellectual Functioning Infants of depressed mothers have been found to score lower on the Bayley Scales of Infant Development and, for toddlers or preschool-age children, on the McCarthy Scales of Children’s Abilities (Field, Estroff, et al., 1996; Hay & Kumar, 1995; Jones et al., 1998; Murray, 1992; Whiffen & Gotlib, 1989). Similar effects are found for exposure to prenatal stress (King & Laplante, 2005). Maternal postpartum depression has also been found to influence children’s cognitive functioning prospectively to age 11 years, even after controlling for socioeconomic status (SES; Hay et al., 2001). While scores on the Bayley and other scales of infant development are not perfect predictors of future intellectual functioning, infants’ scores on the Bayley are important because they have been found to be predictive of cognitive functioning later during childhood (DiLalla et al., 1990; Rose & Wallace, 1985). Cognitive and intellectual functioning, although sometimes conceptualized as a moderator in models of risk for children with depressed mothers (Goodman & Gotlib, 1999), also may be important to consider as an outcome. Trouble concentrating and making decisions, as well as other symptoms, may emerge as early signs of depression in the offspring and have the strong potential to interfere with intellectual and academic functioning, while by adolescence the associated school failures may increase the risk of depression (Lewinsohn et al., 1994).

Possible Mechanisms of Effects Heritability Among the primary mechanisms to explain the development of psychopathology in infants of depressed mothers is heritability, alone and in relationship with environmental factors. Genetics are likely to contribute substantially to psychobiological systems in infants of depressed mothers that are associ-



9. Infants of Depressed Mothers

ated with the development of psychopathology. Estimates of heritability of depression in children have ranged widely, most likely due to problems in measuring depression (e.g., the source of information, use of rating scales vs. diagnoses) and variability in severity, children’s ages, and gender. Evidence also suggests that heritability is unlikely to be specific to depression. Rather, it likely contributes to the risk for the other disorders that have been identified in higher rates in children of depressed mothers, relative to others (Moldin, 1999; Tsuang & Faraone, 1990). At the same time, researchers have found intriguing support for the serotonin transporter (5-HTTLPR) gene in stress–­ diathesis models. Caspi et al. (2003) found that a functional polymorphism of this gene moderated the prospective association between stressful life events and depression in a birth-­cohort sample of young adults. The importance of identifying susceptibility genes for major depression is tied to the promise of revealing the biological mechanisms regulated by these genes that may increase vulnerability to the development of depression in children who inherit these gene variations. Accepting the idea that identifying genes associated with heritability of depression, per se, is unlikely, others have studied heritability of the vulnerabilities to depression, such as those in the Goodman and Gotlib (1999) model. Evidence of significant levels of heritability have been found for individual differences in behavioral inhibition and shyness (Cherny, Fulker, Corley, Plomin, & DeFries, 1994), low self-­esteem (Loehlin & Nichols, 1976), neuroticism (Tellegen et al., 1988), sociability and expression of negative emotion (Plomin et al., 1993), subjective well-being (Lykken & Tellegen, 1996), and frontal EEG asymmetry (Anokhin, Heath, & Myers, 2006). High levels of heritability are even found for individual differences in the autonomic processes related to reactivity to emotional stimuli, such as heart rate variability and vagal tone (Davidson, Ekman, Saron, Senulis, & Friesen, 1990; Healy, 1992; Porges, 2001) and at least basal levels of indices of hypothalamic–­adrenal (HPA) axis activity (if not reactivity) (Bartels, Van den Berg, Sluyter, Boomsma, & de Geus, 2003; Wust, Federenko, van Rossum, Koper, & Hellhammer, 2005; Young, Aggen, Prescott,

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& Kendler, 2000). It seems essential to include heritability in models of psychopathology transmission from depressed mothers to their infants. Other advances in the study of heritability include tests of several proposed theoretical models of the interface between genetics and other mechanisms to explain associations between maternal depression and child psychopathology (Goodman, 2003). These include passive, reactive, and active gene–­ environment correlation or covariation (Goldsmith, Gottesman, & Lemery, 1997; Rutter et al., 1997); gene–­environment interactions such as stress–­diathesis models (Caspi et al., 2003; Monroe & Simons, 1991); genetic vulnerabilities interacting with other biological vulnerabilities or cognitive vulnerabilities (Coccaro, Silverman, Klar, Horvath, & Siever, 1994); genes interacting with other genes (Goldsmith, Gottesman, et al., 1997); stress–­diathesis models with diatheses other than genetics (such as temperament; Cicchetti & Toth, 1998; Goldsmith, Buss, & Lemery, 1997; Sameroff, 1995); and child qualities evoking environmental qualities (Field, Healy, Goldstein, & Guthertz, 1990; Teti & Gelfand, 1991). Twin studies also reveal that genetic factors are significant in influencing individual differences in susceptibility to environmentally mediated risk. For example, Silberg et al. (2001) found support for an environmentally mediated effect of independent, negative life events on adolescent depression only in the presence of parental emotional disorder.

Depression in Pregnancy and Risk Mechanisms Among several possible mechanisms relevant to fetal development, maternal cortisol has attracted the most attention. Basal maternal cortisol accounts for 50% of the variance in the fetus’s levels of cortisol, suggesting some placental transfer of cortisol (Gitau, Cameron, Fisk, & Glover, 1998; Glover, 1997). Evidence from preclinical studies suggests that fetal exposure to high glucocorticoids produces lasting damage to the hippocampal area (Uno et al., 1994), increasing the risk of infants being born with dysfunctional neuroregulatory systems. The latter might be apparent in a susceptibility to show elevated cortisol in response to stress, in EEG asymmetries, in lower cardiac vagal

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tone, in a predilection to experience negative/withdrawal emotions, and other early signs of vulnerability. Beyond transmission through neuroendocrine mechanisms, reduced urinary artery blood flow to the fetus is another way in which risk for the development of psychopathology may be transmitted from depressed (and stressed or anxious) mothers to their infants. Maternal anxiety during pregnancy has been associated with reduced uterine blood flow during the third trimester of pregnancy, which was in turn associated with lower birthweight and premature birth (Glover, 1997). Reduced uterine blood flow may interfere with the transmission of nutrients from the mother to the fetus. Finally, fetal activity level and fetal heart-rate variability are gaining some interest as further possible mechanisms of transmission of risk from depressed pregnant women to their infants. In Glover’s work, maternal trait anxiety and stress in the third trimester are also associated with higher fetal heart rate, which, like reduced uterine blood flow, was associated with lower birthweight and also with lower neonatal attention orientation and arousal (Emory, Walker, & Cruz, 1983; Glover, Teixeira, Gitau, & Risk, 1998; Teixeira, Fisk, & Glover, 1999).

Parenting Impairments as Risk Mechanism The qualities of parenting that are associated with healthy infant development are well known and reviewed elsewhere (Sroufe et al., 2005). Mothers with depression may lack the reliable and responsive parenting known to be necessary for infants’ healthy attachment relationships. In addition to lack of responsiveness, researchers have begun to identify certain qualities of parenting as stressful for infants, such as intrusiveness or hostility. Both Dawson et al. (2003) and Field (2002) have proposed that good-­quality parenting is required to support healthy brain development that continues into the first few years of postnatal life (we elaborate on this point later in the chapter). In any case, depressed mothers’ inadequate parenting has implications for infants’ subsequent adaptation, suggesting multiple alternative pathways for the development of depression. Next we review the findings on both of these parenting aspects that have been found to be more

common in depressed mothers’ parenting of infants than in other mothers. Unresponsive or Neglectful Parenting.  Inattentive or emotionally unresponsive mothers of infants are central to both Tronick and Gianino’s (1986) mutual regulation model and Field’s (1985) psychobiological attunement model. According to both of these models, a mother’s failure to respond to her infant’s need for help with behavioral or affective regulation ultimately contributes to the infant’s difficulty in developing arousal modulation. Initially, the infant becomes agitated in attempts to elicit responses from the mother, then withdraws and begins to show signs of depression. Findings consistent with these models come from studies of infants whose mothers were instructed to simulate depression as well as studies of infants with depressed mothers. In the now well-­established Still-Face Paradigm, even when nondepressed mothers are instructed to respond to their infant’s positive affect displays with a still face, their infants respond with sober expressions and avert their gaze from their mother (Cohn & Elmore, 1988; Cohn & Tronick, 1983). In nearly three decades of work on the paradigm, infants’ observable disturbance (increased gaze aversion and decreased smiling) in response to this experimental manipulation have been well replicated in infants from 2 to 9 months of age (Adamson & Frick, 2003). Although there is no general agreement on how to explain the phenomena, most often invoked are notions of infants’ expectations in social interactions with their mothers. Most central to the concerns of this chapter are findings that the paradigm represents parenting that is more typical of depressed mothers’ faceto-face interaction with their infants than others’, and that this quality of depressed mothers’ interactions is stressful to infants (Haley & Stansbury, 2003; Moore, Cohn, & Campbell, 2001; Stoller & Field, 1982). In routine face-to-face interactions between depressed mothers and their infants, these mothers have been observed to display less positive affect, more frequent expressions of sadness, and fewer expressions of interest than well mothers. For example, mothers’ higher levels of depression symptoms were associated with less synchrony in their interaction with their 6-month-old



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infants (Lundy, 2002). In a much larger sample, depressed mothers interacting with their 2-month-old infants were observed to be less sensitively attuned and less affirming of their infants’ behavior (Murray, Fiori­Cowley, Hooper, & Cooper, 1996). Infants with depressed mothers have been observed to engage in behaviors such as gaze and head aversion, consistent with the idea that the infants were using self-­regulatory behaviors to minimize the negative affect associated with maternal unresponsiveness. Some researchers observed infants’ reactions to the withdrawn or unresponsive parenting that has been found more commonly in depressed than in well mothers of infants. For example, Lyons-Ruth and her colleagues found that infants whose mothers related to them in a fearful and withdrawn manner, in contrast to intrusive mothers (as described in the next section), were more likely to develop disorganized secure attachment styles with signs of apprehension and dysphoria (Lyons-Ruth, Lyubchik, Wolfe, & Bronfman, 2002). In a longitudinal study, infants of depressed mothers whose behavior with their infant had been classified as withdrawn when the infant was 3 months of age, showed less adaptive interactive behavior and lower scores on the Mental Scale of the Bayley Scales of Infant Development at 1 year than infants of nonwithdrawn depressed mothers (Jones et al., 1997). Boys may be particularly vulnerable to a withdrawn maternal interaction style, perhaps associated with boys’ greater need for regulatory support (Weinberg et al., 2006). Intrusive, Harsh, or Coercive Parenting.  Inadequate parenting may also be characterized as intrusive, harsh, or coercive. Researchers have revealed that maternal depression is associated not only with a withdrawn, unresponsive pattern of interaction with their infants, but also with a pattern of hostile–­intrusive overstimulation (Cohn, Matias, Tronick, Lyons-Ruth, & Connell, 1986; Field et al., 1990). Mothers with depression, relative to others, have been observed to overstimulate, to be more physically intrusive (e.g., poking and jabbing their infants), to more often interfere with the infants’ exploratory activities, and to show more hostile and irritable affect (Cohn et al., 1986; Lyons-Ruth, Zoll,

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Connell, & Grunebaum, 1986; Malphurs et al., 1996). Maternal hostility and intrusiveness, in turn, has been found to be associated with infant avoidance and fussiness. Intrusive or hostile mothers interfere with their infants’ autonomous functioning (Egeland, Pianta, & O’Brian, 1993). Cohn et al. (1986) observed that infants interacting with their intrusive mothers protested less than 5% of the time and spent 55% of the time avoiding their mothers. Field and colleagues noted a high frequency of fussing in infants interacting with their intrusive mothers (Field et al., 1990). One study has shown that girls may be more vulnerable than boys to intrusive mothering, whereas, as stated above, boys are more vulnerable than girls to withdrawn mothering (Weinberg & Tronick, 1998). Each of these behavioral reactions could contribute to risk for depression, especially in terms of the infants’ contribution to transactional patterns. Unpredictable Parenting.  Although some researchers treat withdrawn and intrusive parenting as types of parenting that characterize subsets of depressed women (Field, Hernandez-Reif, & Diego, 2006), others observe that mothers with depression are likely to alternate between withdrawn and intrusive modes of interacting with their infants (Lyons-Ruth et al., 2002). Even if this unpredictable pattern is true of only a subset of depressed mothers, it is of concern given that this pattern is likely to be particularly experienced as stressful by infants and may adversely influence their neurobiological development during early postnatal life. For example, infants exposed to unpredictable parenting may develop the pattern of reduced left frontal electrical brain activity. These neurobiological alterations are associated with a diminished capacity to experience joy and a heightened tendency to experience negative affect and, thus, may contribute to risk for developing depression and other problems (e.g., Jones et al., 1997).

Adversity as a Risk Mechanism Perinatal depression, like depression that occurs at other times, often emerges in the context of a range of psychosocial adversities. Adversities themselves have well-known

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associations with infant vulnerabilities for the development of psychopathology (Rutter, 2000). Thus researchers have been challenged to understand the independent, interacting, and possibly mediating relationships between maternal depression and adversities and the emergence of infant vulnerabilities to the development of psychopathology. Depression, especially during the pregnancy and postpartum period, is often accompanied by high levels of anxiety and stress, which may be both etiological (Kendler, Kessler, Neale, Heath, & Eaves, 1993; Monroe & Simons, 1991) and consequential of depression (Hammen, 1991). Both state and trait anxiety as well as perceived stress and hassles are highly associated with depression in samples of pregnant women (Austin et al., 2005; DaCosta, Larouche, Dritsa, & Brender, 2000; O’Connor, Heron, Glover, & Team, 2002). Other adversities often accompanying depression include restrictions on individuals’ levels of general functioning, such as those problems that characterize individuals with personality disorders (Klein, Durbin, Shankman, & Santiago, 2002; O’Sullivan, 2004). In a sample of pregnant women, depression symptom levels were strongly negatively associated with problems in social functioning and with emotional problems interfering with work or other activities (McKee, Cunningham, Jankowski, & Zayas, 2001). Several researchers have examined independent and interacting contributions of maternal depression and adversities to the emergence of vulnerabilities to the development of psychopathology in infancy. Some researchers find that adversities and maternal perinatal depression each independently predict infant vulnerabilities. For example, both adversity and postpartum depression at infant age 2 months predicted infant attachment (Murray et al., 1996). More research is needed to determine the model that best explains associations between maternal depression and adversities and infant functioning.

FATHERS AND THEIR ROLES The role of the father has often been ignored when examining the effect of maternal depression on infants (Connell & Goodman, 2002). As outlined by Goodman and Gotlib

(1999), fathers have the potential to increase the risk for psychopathology in children of depressed mothers or serve as a protective factor for their children. Of particular concern has been psychopathology in the fathers of infants whose mothers are depressed. Assortative mating increases the likelihood that a woman with depression will have a spouse who also has a psychiatric illness or disorder or a family history of psychiatric illness (Matthews & Reus, 2001). In other words, children of depressed mothers have a higher than average likelihood of having a father with psychopathology, which, through genetics and/or environmental influences, can serve as an additional risk factor. Depression in fathers adds to the genetic risk for depression in children as much as depression in mothers (Kendler, Gardner, Neale, & Prescott, 2001). Nevertheless, the actual genetic mechanism of transmission may differ depending on whether the depressed parent is the mother or the father (Kendler et al., 2001). Given the high likelihood of infants with depressed mothers having a father who also has psychopathology, more research is needed to understand how these influences may both differ and work together. In the few studies of the effects of paternal depression and other disorders on infant and young children’s outcome when the mother is also depressed, fathers’ psychopathology is typically found to contribute to the prediction of child psychopathology beyond that explained by maternal depression (Eiden & Leonard, 1986; Goodman, Brogan, Lynch, & Fielding, 1993; Thomas & Forehand, 1991; Weissman et al., 1984). For example, in one such study, higher levels of paternal depression were associated with higher levels of internalizing behavior in children and predicted child internalizing problems even after controlling for maternal depression (Marchand & Hock, 1998). In one of the few studies of postpartum depression in fathers as well as mothers, the health behaviors recommended by pediatricians (e.g., putting the baby to sleep on his or her back, putting the child to sleep while awake) were least likely to be followed when both parents were depressed and most likely to be followed when neither parent was depressed (Paulson, Dauber, & Leiferman, 2006). Although not specific to maternal depression, the general literature on roles of fathers



9. Infants of Depressed Mothers

finds that fathers play a moderating role in associations between maternal parenting and child outcomes. For example, mothers’ parenting is found to be more positive in the presence of available and supportive fathers (Crnic, Greenberg, Ragozin, Robinson, & Basham, 1983; Crockenberg, 1986; Tamis-LeMonda & Cabrera, 2002; Teti & Gelfand, 1991). Also relevant are findings that in the context of good marital relationships, fathers are more involved with their children relative to fathers with poor marital relationships (Shannon, Tamis-LeMonda, & Margolin, 2005). Fathers can also have a positive moderating effect on infants. In a longitudinal community sample that followed children and their families from infancy to kindergarten, fathers with high levels of warmth buffered children from maternal depression during infancy, although only if the father spent relatively small amounts of time with the infant (Mezulis, Hyde, & Clark, 2004). They also found that even if the father was also depressed, if he spent small amounts of time with the infant, then he or she had fewer internalizing problems at kindergarten age than if the father spent greater quantities of time with the infant. These findings suggest the need for further study to sort out the roles of quantity and quality of infants’ time with fathers in the context of maternal depression. Another way that fathers may influence the risk for psychopathology in children of depressed mothers is through their relationship with the child’s mother. Maternal depression is often accompanied by marital conflict, and depression commonly co-­occurs with perceptions of relationships as less supportive or available (Brown & Harris, 1978; Fredman, Weissman, Leaf, & Bruce, 1988). There has also been support for the association between depression symptoms, less social support, and poorer marital adjustment in pregnant women (O’Connor et al., 1998; Zelkowitz et al., 2004) and in the postpartum (Cutrona & Troutman, 1986; O’Hara & Swain, 1996)

CLINICAL PRACTICE Research has unequivocally established the effect of depression during pregnancy and postpartum on poor infant and childhood

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outcome. As described in this chapter, these vulnerabilities to the development of a psychiatric disorder later in life are seen in infants in the areas of attachment, emotion and behavior regulation, neuroendocrine and psychophysiological functioning, and cognitive and intellectual functioning. Despite the promise that preventive or early interventions may prevent the later development of depression and other disorders, very few interventions have been developed. Research groups such as Field and her colleagues, Cicchetti and his colleagues, and Weissman and the sequenced treatment alternatives to relieve depression (STAR*D) have found empirical support for the effects of interventions for both infants and their depressed mothers. This research is reviewed here. Given deficits that have been identified in infants’ physiological self-­regulation, Field and her colleagues examined the effectiveness of infant massage therapy, a relatively short-term (6 week) intervention that is cost effective (mothers are taught to massage the infant in a group setting). Infants of depressed adolescent mothers benefited, as indicated by an association of the intervention with lowered salivary cortisol levels directly following the massage; weight gain (more so than infants who were rocked as opposed to massaged) throughout the protocol; improved emotionality, sociability, soothability temperament dimensions; and improved face-to-face interaction ratings (Field, Grizzle, et al., 1996). Pregnancy massage has also been successfully used as a similar intervention, in order to reduce levels of stress hormones in the mothers and to decrease obstetric complications, thus potentially preventing some of the known vulnerabilities in infants of depressed mothers (Field, 2002) Other interventions target the problems with insecure attachment that have been found in infants of depressed mothers. Toddler–­parent psychotherapy is an intervention to promote secure attachment in toddlers of depressed mothers. When toddlers of depressed mothers who received the intervention were compared to those who did not receive the intervention and a control group, the children in the intervention group had comparable rates of secure attachment to those in the control group whose mothers were not depressed. Toddlers of depressed mothers who did not receive the intervention continued to show higher rates

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of attachment insecurity (Cicchetti, Toth, & Rogosch, 1999). Others consider that facilitating mothers’ recovery from depression is likely to benefit children’s outcome. Weissman and her STAR*D colleagues were among the first to examine the change in diagnosis and symptoms in children of mothers who were treated with antidepressants. Children of the women who had a full remission of depression after a 3-month treatment with antidepressants (33% of study subjects) showed an 11% decrease in diagnosis compared to an 8% increase in diagnosis seen in children whose mothers did not recover from depression during the study window. In children who had no diagnosis prior to the study, none developed a diagnosis if their mother showed a remission in depression, compared to 17% of the children who acquired a diagnosis if their mother did not improve (Weissman et al., 2006). Although each of these interventions is promising, much work remains to be done. Prevention of depression is increasingly recognized as an effective approach (Le, Munoz, Ippen, & Stoddard, 2003). Important next steps regarding perinatal depression are to develop better measures of depression in pregnancy and the postpartum, to institute systematic screening for perinatal depression, to reduce barriers to interventions, and to continue to design and test ways to intervene in the mechanisms and outcomes associated with depression in mothers. Finally, more longitudinal studies are needed to learn more about trajectories from the vulnerabilities noted in infants of depressed mothers—both paths to recovery and to disorder. References Abrams, S. M., Field, T., Scafidi, F., & Prodrmidis, M. (1995). Newborns of depressed mothers. Infant Mental Health Journal, 16, 233–239. Adamson, L. B., & Frick, J. E. (2003). The still face: A history of a shared experimental paradigm. Infancy, 4, 451–473. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Anokhin, A. P., Heath, A. C., & Myers, E. (2006). Genetic and environmental influences on frontal EEG asymmetry: A twin study. Biological Psychology, 71, 289–295.

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ations (Vol. 59). Chicago: University of Chicago Press. Fracasso, M. P., Porges, S. W., Lamb, M. E., & Rosenberg, A. A. (1994). Cardiac activity in infancy: Reliability and stability of individual differences. Infant Behavior and Development, 17, 277–284. Fredman, L., Weissman, M. M., Leaf, P. J., & Bruce, M. L. (1988). Social functioning in community residents with depression and other psychiatric disorders: Results of the New Haven Epidemiologic Catchment Area study. Journal of Affective Disorders, 15(2), 103–112. Gavin, N. I., Gaynes, B. N., Lohr, K. N., MeltzerBrody, S., Gartlehner, G., & Swinson, T. (2005). Perinatal depression: A systematic review of prevalence and incidence. Obstetrics and Gynecology, 106, 1071–1083. Gitau, R., Cameron, A., Fisk, N. M., & Glover, V. (1998). Fetal exposure to maternal cortisol. Lancet, 352, 707–708. Glover, V. (1997). Maternal stress or anxiety in pregnancy and emotional development of the child. British Journal of Psychiatry, 171, 105–106. Glover, V., Teixeira, J., Gitau, R., & Risk, N. (1998, April). Links between antenatal maternal anxiety and the fetus. Paper presented at the International Conference on Infant Studies, Atlanta, GA. Goldsmith, H. H., Buss, K. A., & Lemery, K. S. (1997). Toddler and childhood temperament: Expanded content, stronger genetic evidence, new evidence for the importance of environment. Developmental Psychology, 33, 891–905. Goldsmith, H. H., Gottesman, I. I., & Lemery, K. S. (1997). Epigenetic approaches to developmental psychopathology. Development and Psychopathology, 9, 365–387. Goodman, S. H. (2003). Genesis and epigenisis of psychopathology in children with depressed mothers: Toward an integrative biopsychosocial perspective. In D. Cicchetti & E. Walker (Eds.), Neurodevelopmental mechanisms in the genesis and epigenesis of psychopathology: Future research directions (pp.  428–460). New York: Cambridge University Press. Goodman, S. H., Brogan, D., Lynch, M. E., & Fielding, B. (1993). Social and emotional competence in children of depressed mothers. Child Development, 64, 516–531. Goodman, S. H., & Gotlib, I. H. (1999). Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychological Review, 106, 458–490. Gotlib, I. H., Ranganath, C., & Rosenfeld, J. P. (1998). Frontal EEG alpha asymmetry, depression, and cognitive functioning. Cognition and Emotion, 12, 449–478. Gotlib, I. H., Whiffen, V. E., Mount, J. H., Milne, K., & Cordy, N. I. (1989). Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum. Jour-



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C h a p t e r 10

Parental Substance Abuse Neil W. Boris

P

arental substance use is an important public health problem and a complex risk factor impacting infant development. According to the most recent available data, about 5% or approximately 200,000 neonates in the United States were exposed to illicit drugs in utero (Substance Abuse and Mental Health Services Administration, 2008a) while just over 10% (more than 400,000 neonates) were exposed to alcohol (Substance Abuse and Mental Health Services Administration, 2008b). Estimating the social cost of substance abuse is complex because the intangible costs of parental substance abuse have not been adequately captured (French, Rachal, & Hubbard, 1991). Intangible costs might include, for instance, the costs of malnutrition associated with drug use, a factor relevant to infant development. Even when such intangible costs are not considered, the overall cost of drug abuse in the United States in 2002 is estimated to have been $180.9 billion (Office of National Drug Control Policy, 2004). As Lester, Boukydis, and Twomey (2002) noted in the second edition of this volume, the projected costs of maternal substance abuse are also rarely considered. For instance, extra educational expenditures multiply over time



for those children with deficits in attention and cognitive processing due, in part, to prenatal drug exposure. Given that about 1 in 10 pregnancies is impacted by drug and/ or alcohol use, the absolute numbers of affected infants and children is large. It would be one thing if effective and accessible interventions for pregnant women were available—some of the future costs associated with parental substance abuse might be mitigated. Unfortunately, a recent meta-­analysis concluded that there is no evidence that outpatient treatment of pregnant women substance abusers results in abstinence or in improved pregnancy outcomes (Terplan & Lui, 2007). The lack of evidence, however, reflects more than one problem. First, the number of well-­designed trials of treatment for pregnant drug-using women is few. Second, the intensity of intervention represented by these trials is limited; it would not be surprising if outcomes and intensity of treatment were linked. Finally, access to care for pregnant women is low, and evaluation of other types of programs (e.g., residential treatment) has not been adequate to draw broad conclusions (Greenfield et al., 2004). Of course, access to substance abuse treatment in the United States is of serious 171

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concern for all adults, not just pregnant women. Infants and young children who are not exposed to drugs in utero may still be adversely impacted by parental drug use. It is discouraging, that, for instance, large-scale studies of persons with both mental health and substance abuse conditions suggest that few receive drug treatment (Wu, Ringwalt, & Williams, 2003). A significant proportion of adults with comorbid mental health and substance abuse conditions are parents of infants and young children. The limited treatment options for substance-­abusing parents means that infants and young children suffer (Luthar, Suchman, & Altomare, 2007). The adverse effects of parental substance abuse may be difficult for clinicians to unpack. Recent research suggests that the ways in which parental substance abuse affects infants can be framed along three basic dimensions. First, there are direct effects—­exposure to drugs in utero impacts the developing fetus in ways that result in developmental consequences. Second, there are genetic effects—­parents who abuse substances are more likely to have underlying traits that influence parenting behavior. Finally, parental substance abuse is linked to a series of other risk conditions impacting the social environment of infants. When risk factors combine, negative developmental effects can be large and lasting. In individual cases, it is either impossible or impractical to separate direct effects, genetic effects, and the effects of cumulative risks on a given infant’s development. For the clinician, however, tracing the impact of substance abuse on a given infant’s development will require considering the interplay among all three dimensions. Likewise, effective intervention often requires family-based strategies that target key developmental processes impacted by all three dimensions. This chapter is organized around the three dimensions. First, evidence regarding the developmental effects tied to direct exposure to drugs and/or alcohol is reviewed, using alcohol and cocaine as examples. Next, parental genetic effects associated with substance abuse are considered and linked to the available data on the parenting practices of substance abusers. Finally, the importance of considering co-­occurring risk factors as they impact the developing infant is underscored.

DIRECT EFFECTS OF SUBSTANCE ABUSE The direct effects of substance exposure on the developing fetus have been studied intensively, though such research is complicated by numerous factors (Shankaran et al., 2007). One factor that complicates research on direct effects is the variation that occurs in the degree to which different substances impact fetal organ systems. Alcohol, for instance, is a potent neurotoxin. Even though the mechanisms by which alcohol affects neuron growth are complex, the end result of fetal alcohol exposure early in pregnancy can be the death of large numbers of neurons (Olney, Farber, Wozniak, Jevtovic-­Todorovic, & Ikonomidou, 2000), and a series of neuroanatomical changes associated with alcohol exposure have been documented (Chen, Maier, Parnell, & West, 2003). Other drugs, such as cocaine, may injure neurons but generally not by directly killing them (Ren, Malanga, Tabit, & Kosofsky, 2004). Although cocaine can cause blood vessels to contract, and this contraction can result in injury to fetal organs or to the placenta, cocaine’s direct effects on neurons appears to be less of an issue (Plessinger & Woods, 1993). A second factor complicating research on direct effects is that the timing, dose, and duration of exposure may be critical in determining how the fetus is impacted—­ factors that are almost always difficult to pin down. So, for instance, even though alcohol is a direct neurotoxin, a recent review suggests that low-to-­moderate alcohol use in pregnancy has not been shown definitively to adversely affect fetal and infant development (Henderson, Gray, & Brocklehurst, 2007). On the other hand, there is evidence that even sporadic use in pregnancy has been linked to fetal alcohol effects, and such sporadic use is not uncommon among women who drink during pregnancy (MartínezFrías, Bermejo, Rodríguez-­Pinilla, & Frías, 2004). The question of how much alcohol exposure is enough to directly affect a given infant may be unanswerable. Here, a third factor that complicates research on the direct effects of substance abuse comes into play, namely, that maternal substance exposure may be associated with other important factors in fetal development



10. Parental Substance Abuse

that potentiate direct effects. For instance, maternal alcohol abuse during pregnancy is strongly associated with poor nutritional status, and there is good evidence that it is the combination of alcohol exposure and a poor nutritional environment that most influences the developing brain (Guerrini, Thomson, & Gurling, 2007). Other factors such as maternal age, chronic alcohol use, and higher parity may also play a role in increasing the likelihood that a given fetus’s exposure will lead to full-blown fetal alcohol syndrome (Niccols, 2007). Cocaine’s effects may also be potentiated by poor maternal nutrition, and inadequate weight gain during pregnancy is common among cocaine abusers (Shankaran et al., 2004). Here again, the limits of research on direct effects is apparent. Because cocaine use also is associated not only with poor weight gain, but also with use of other drugs and/or alcohol, documenting the direct effects of cocaine alone is quite difficult (Shankaran et al., 2007). There is much we don’t know about the effects of alcohol and cocaine on the developing fetus. Still, the clinician should be familiar with diagnosing fetal alcohol syndrome and should be aware of limited though important longitudinal data on prenatal cocaine exposure.

Alcohol Effects The best available data confirm that fetal alcohol exposure is among the most common preventable causes of developmental disorders in the United States and that public health interventions to influence alcohol intake by women of childbearing age (and their partners) are a worthy investment (Floyd, O’Connor, Bertrand, & Sokol, 2006). Fetal alcohol syndrome (FAS), the neurodevelopmental syndrome characterized by physical stigmata, cognitive deficits, and impaired pre- and postnatal growth has been described for decades (Calhoun & Warren, 2007). Nevertheless, only recently have uniform diagnostic criteria for FAS been developed (Floyd, O’Connor, Sokol, Bertrand, & Cordero, 2005). Part of the struggle to characterize FAS involves the fact that individual infants may be more or less affected. Various terms, including fetal alcohol spectrum disorders (FASD), are used to describe the large number of children (a majority of those exposed) who are affected but do not meet

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criteria for “classic” fetal alcohol syndrome (Niccols, 2007). For the infant mental health clinician, recognizing the behavioral and developmental stigmata of alcohol exposure is a key to shaping interventions. Recent reviews suggest that even children who are at the more affected end of the FAS spectrum have developmental consequences that are not captured simply by reductions in IQ. It is true that verbal and nonverbal intelligence are often affected in alcohol-­exposed individuals (Kodituwakku, 2007). Nevertheless, IQ tests alone give an incomplete picture of alcohol-­related deficits. Three functional deficits—­reductions in processing speed, deficits in working memory, and inattentiveness—have been argued to be central in affected children (Kodituwakku, 2007; Niccols, 2007). Deficits are more readily apparent in alcohol-­exposed versus comparison children as task complexity increases, and this is true in domains of function as disparate as visual processing and language use (Kodituwakku, 2007). Not surprisingly, alcohol exposure is also linked to changes in social behavior in infancy. Early impairments in state regulation give way to difficulty reading social cues such that, as a group, preschoolers with FAS have difficulty differentiating familiar from unfamiliar caregivers and can appear excessively friendly or socially indiscriminant (Kelly, Day, & Streissguth, 2000). As they age, affected children can develop severe problems with adaptive functioning. Many meet criteria for attention-­deficit/hyperactivity disorder (ADHD) by the preschool years, and disruptive behavior often further complicates early learning deficits (Streissguth et al., 2004; Whaley, O’Connor, & Gunderson, 2001).

Cocaine Effects Compared to alcohol exposure, data on cocaine exposure and developmental functioning over time is sparse. The strongest link in the literature is one that documents an association of maternal cocaine use during pregnancy and birth outcomes such as preterm delivery, low birthweight, and transient neurobehavioral problems (Shankaran et al., 2007). The long-term implications of these birth outcomes, however, are not well documented, and cocaine’s role in more severe

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birth defects has not been established. Still, data from a few longitudinal, controlled studies initiated during the upswing in cocaine use in the United States in the early 1990s converge to suggest that prenatal cocaine exposure is consistently associated with mild attentional deficits and decreased emotional expressiveness over time, even when controlling for confounding factors (Frank, Augustyn, Knight, Pell, & Zuckerman, 2001). On one hand, as noted in Lester et al. (2002), the costs of addressing even small learning-­related deficits in a large number of children exposed to cocaine prenatally are impressive. On the other hand, the deficits associated with cocaine exposure are neither common enough nor severe enough to suggest that even a minority of cocaine-­exposed infants would be predictably affected. Instead, the same longitudinal data suggest that the relative impact of factors affecting the infant’s postnatal environment must also be considered. Although calls for considering prenatal drug exposure to be a reliable marker for social risk are longstanding (cf. Conners et al., 2003; Tronick & Beeghly, 1999), recent research suggests that addiction is a complex biosocial problem with genetic underpinnings. For the infant mental health clinician, emerging research on behavioral phenotypes associated with parental substance abuse can guide assessment and inform intervention.

PREDICTORS OF PARENTAL SUBSTANCE ABUSE Predicting which parents will struggle with drug dependence (and which infants will therefore be affected) is becoming possible. Twin and other genetically informed studies are especially helpful in identifying traits associated with substance abuse and estimating the degree to which those traits are heritable (Kendler, Myers, & Prescott, 2007). For example, the link between early impulsivity and later substance abuse has now been demonstrated, using longitudinal studies of at-risk groups (e.g., children of substance abusers). Verdejo-García, Lawrence, and Clark (2008) summarized this line of research as follows: “These studies have elegantly demonstrated that (1) children of

SUD [substance use disordered] parents have elevated impulsivity before drug exposure and (2) impulsivity indices are strong and reliable predictors of later drug initiation and drug and alcohol problems” (p. 791). In effect, impulsivity is a strong predictor of substance abuse and dependence, and it turns out that the relationship between preexisting impulsivity and substance abuse holds for different substances including cocaine and alcohol. Similar research on novelty seeking (a trait that is related to impulsivity) is consistent: Novelty seeking is linked to conduct problems, including substance abuse (Hiroi & Agatsuma, 2005). Research in this area has not stopped at identifying links between traits and later substance abuse. Instead, the search for the genes and gene products that potentiate drug use is proceeding at a rapid pace (van den Bree, 2005). However, to date, longitudinal studies that consistently identify gene products associated with substance abuse are lacking. Still, genetically informed research is illuminating. For instance, a longitudinal study investigating predictors of early alcohol use among maltreated children and a matched comparison group revealed a strong link between childhood maltreatment and early alcohol use (Kaufman et al., 2007). A clearer picture of early alcohol use, however, came when genetic and environmental factors were considered together. Children with a particular serotonin transporter gene (5-HTTLPR) were at increased risk for early alcohol use, and there was an interaction between having the short-­allele (s-­allele) of this gene and maltreatment. Children who experienced maltreatment and also were born with the s-­allele of the serotonin transporter gene were at greatest risk to initiate alcohol use early in life. The severity of maltreatment experiences, the existence of early psychopathology, and poor mother–child relations also predicted early alcohol use (Kaufman et al., 2007). This study, and others like it, emphasizes that genetic factors are important in determining how individuals respond to environmental triggers. Identifying which neurotransmitters are key in the reward pathways that make individuals susceptible to drug use holds promise for new and more effective interventions (Gass & Olive, 2008). For the infant mental health clinician, the promise of interventions to treat substance



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abuse is only one piece of a larger puzzle. What is to be done, for instance, with the impulsive caregiver, whose unpredictability impacts the relationship with their infant? How can impulsivity be assessed in the clinical setting and what is the impact of this trait on a given parent–­infant relationship? To date, there are limited data to guide clinicians in dealing with the caregiver who is both impulsive and substance abusing. Nevertheless, recent data suggest that tracking caregiver impulsivity in interactions is important. Chen and Johnston (2007), for instance, found that mothers’ inattention (a trait strongly linked to impulsivity) was associated with inconsistent discipline of, and less involvement with, their 4- to 8-year-old children. Furthermore, the same study revealed that maternal impulsivity was negatively associated with reports of positive discipline. These relationships held even when child behavior, maternal depressive symptoms, and sociodemographic factors were controlled for. The findings from this study dovetail with others showing that, for instance, fathers with ADHD are more critical and negative regarding their children’s symptoms (Arnold, O’Leary, & Edwards, 1997), and mothers with ADHD monitored their children with ADHD less and were less consistent with these children than were mothers who did not meet criteria for ADHD (Murray & Johnston, 2006). Caregiver impulsivity, an issue of particular relevance for substance-­abusing mothers, is critical for clinicians to track. There is evidence that, for instance, cocaine-­abusing mothers tend to be disruptive and intrusive when observed interacting with their infants in the first year of life (Burns, Chethik, Burns, & Clark, 1997; Mayes et al., 1997). Though there is some inconsistency in studies of drug-using mothers and their offspring, most investigations have found that maternal substance abuse is a good marker for problematic interactive behavior. The majority of studies have considered dyadic interactions in the preschool years (Johnson, 2001; Mayes & Truman, 2002). Though few longitudinal, controlled studies exist, maternal intrusiveness and hostility among cocaine-­abusing mothers of 3-year olds has been documented to be higher than that evident among matched non-drug-using mothers followed over time (Johnson et al.,

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2002). Furthermore, caregiver intrusiveness has been linked to disorganized attachment in prenatally drug-­exposed toddlers (Swanson, Beckwith, & Howard, 2000). It has even been suggested that the combined evidence from neuroimaging and neurobiological studies is revealing how cocaine directly disrupts neuroregulatory systems important in driving parent responsiveness (Swain, Lorberbaum, Kose, & Strathearn, 2007). The first important contribution of genetic studies for the clinician is that they help reframe the “impossible” substance-­abusing client as a person who inherited a set of behavioral traits (e.g., impulsivity) that made it far more likely that he or she would fall victim to substance abuse. Interventions for substance-­abusing parents have too often emphasized confrontation and even blaming (Miller & Rollnick, 2002). The inheritance of, for example, a short allele of a transporter gene is not a choice. Although viewing substance-­abusing caregivers as helpless victims is equally unhelpful, blaming them is not justifiable in light the evolving science of how one becomes a substance abuser. The second important contribution of studies of genetic-based risk factors is to identify traits that affect the interactive dance between caregiver and infant and are likely to be more common in substance-­abusing caregivers. Here is where caregiver impulsivity, for instance, has its own direct effects on the infant. Even subtle shifts in interactive behavior—­shifts known to be associated with both cocaine and alcohol abuse—can have significant developmental consequences over time (Tronick, Weinberg, Seifer, et al., 2005). Using observational procedures in assessing drug-­affected dyads, including the Still-Face Procedure for infants and structured interactive procedures for toddlers and preschoolers, is essential (see Miron, Lewis, & Zeanah, Chapter 15, this volume). Learning to recognize when caregivers fail to read their infants’ cues is critical. Tracking inconsistency and intrusiveness, hallmarks of caregivers who are impulsive and substance using, must be a focus of assessment when caregiver substance abuse is in the differential. For substance-­abusing caregivers, both guilt and shame are often important factors influencing their behavior. It is not unusual for substance-­abusing caregivers to report

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“making up” for neglecting their infants during periods of active substance use by overstimulating their infants when not using as actively. Such “on again, off again” patterns may reveal themselves through narrative interview. With substance-­abusing caregivers, narrative interviews are an essential complement to direct observation of parent–­infant interchange (see Oppenheim & Koren-Karie, Chapter 16, this volume). It is also important to remember that substance abuse is known to be a marker for broader social risk conditions (Hans, 1999; Liu et al., 2003). The clinician must look for specific traits linked to parenting deficiencies known to affect substance abusers while also assessing the broader social context of the infant.

SUBSTANCE ABUSE: MARKER FOR SOCIAL RISK Recently, the transaction between the individual and his or her environment has been accepted as being a driving force in determining developmental outcomes (Sameroff & Mackenzie, 2003). Put another way, infants both act upon their social environment and are acted upon by that environment. In the context, for instance, of maternal substance abuse, the data already reviewed in this chapter suggest that infants may be affected directly by alcohol or cocaine while also having a primary caregiver who is atrisk for interactive difficulties. As the infant develops, for example, the caregiver’s impulsiveness may pervade the infant’s social experience and lead to difficulties in early emotion regulation. Furthermore, these infants may have been directly affected by prenatal alcohol exposure and also inherited the tendency toward impulsivity. It is when such early risk is compounded by postnatal environmental factors known to be associated with substance abuse that infant development is most severely affected. A recent birth cohort study from the United States illustrates how risk conditions aggregate and how they may affect the infant’s development (Whitaker, Orzol, & Kahn, 2006). After the majority of more than 4,200 mothers of infants from 18 U.S. cities were interviewed 3 years into the study, the relationship between child behavior (as

reported by mothers) and maternal mental health, substance use and domestic violence was estimated. Reports of child aggression, anxiety/depression, and inattention/hyperactivity at age 3 were related in a stepwise fashion to the number of risk conditions (maternal mental health, substance use, and/ or domestic violence) reported at age 1, even when controlling for a variety of sociodemographic factors (e.g., income, ethnicity, maternal age, maternal education, birthweight) and for paternal mental health and substance use. As with other studies (Sameroff, Seifer, Barocas, Zax, & Greenspan, 1987), particular maternal risk conditions early in a child’s life—in this case, including maternal substance use—were no more predictive of child behavior at later ages than other risk conditions. Rather, it was the cumulative occurrence of risk factors that was most predictive of early behavioral difficulties. For instance, child symptoms above the cutoff in the anxious/depressed domain were evident in 9%, 14%, 16%, and 27% of the sample when zero, one, two, or three maternal risk conditions were present, respectively. The clustering of risk conditions is common when maternal substance abuse is present. For instance, substance abuse during pregnancy and maternal depression often co-occur (Chandler & McCaul, 2003). Furthermore, there are associations between maternal substance abuse and family and neighborhood violence (Ondersma, Delaney-Black, Covington, Nordstrom, & Sokol, 2006). In fact, with the possible exception of direct toxic effects from alcohol, the available data suggest that it is the co-­occurrence of family risk in the presence of maternal substance abuse that accounts for most of the negative developmental effects associated with the substance abuse (Shankaran et al., 2007). For the clinician, it is essential to identify which co-­occurring risk conditions are impacting families in which caregiver substance abuse is an issue. Unfortunately, longitudinal studies suggest that maternal substance abuse at birth is a potent predictor of child protective services involvement in the preschool years (Street, Whitlingum, Gibson, Cairns, & Ellis, 2008), underscoring the need to engage with mothers who use substances and mitigate risks when possible. Despite the challenges that maternal substance abuse presents to the clinician,



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interventions hold great promise. Having an infant to care for can be a great motivator for substance-­abusing caregivers. In fact, being pregnant or having a dependent child is associated with retention in residential drug treatment programs particularly when the program has high percentages of other pregnant or parenting women enrolled (Grella, Joshi, & Hser, 2000). Retention in residential programs, in turn, is associated with higher rates of treatment success, with more than two-­thirds of women who spent 6 months or more in residential treatment in a recent large cross-site study reporting abstinence 6–12 months after discharge (Greenfield et al., 2004). As model interventions such as the Circle of Security (Powell, Cooper, Hoffman, & Marvin, Chapter 28, this volume) are disseminated, effectively addressing mother–­infant interactions while mothers are engaged in treatment becomes possible. Such interventions are capable of improving early attachment security, which is a powerful protective factor in infant development (Edwards, Eiden, & Leonard, 2006). Maternal substance abuse is a potent risk condition. Infant development can be affected through interrelated mechanisms; direct prenatal effects, genetic effects (that influence parent and infant both separately and together), and cumulative social risks are all clinically important. Only intensive intervention is likely to be effective. Fortunately, models for such intervention exist and hold great promise for mitigating risk. The rewards of working with substance-­abusing caregivers are great, and it is with such highrisk families that clinicians can have their greatest impact. References Arnold, E. H., O’Leary, S., & Edwards, G. H. (1997). Father involvement and self-­reported parenting of children with attention deficit hyperactivity disorder. Journal of Consulting and Clinical Psychology, 65, 337–342. Burns, K. A., Chethik, L., Burns, W. J., & Clark, R. (1997). The early relationship of drug abusing mothers and their infants: An assessment at eight to twelve months of age. Journal of Clinical Psychology, 53(3), 279–287. Calhoun, F., & Warren, K. (2007). Fetal alcohol syndrome: Historical perspectives. Neuroscience and Biobehavioral Reviews, 31(2), 168–711.

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Chandler, G., & McCaul, M. E. (2003). Co­occurring psychiatric disorders in women with addictions. Obstetric and Gynecology Clinics of North America, 30(3), 469–481. Chen, M., & Johnston, C. (2007). Maternal inattention and impulsivity and parenting behaviors. Journal of Clinical Child and Adolescent Psychology, 36(3), 455–468. Chen, W. J., Maier, S. E., Parnell, S. E., &West, J. R. (2003). Alcohol and the developing brain: Neuroanatomical studies. Alcohol Research and Health, 27(2), 174–180. Conners, N. A., Bradley, R. H., Mansell, L. W., Liu, J. Y., Roberts, T. J., Burgdorf, K., et al. (2003). Children of mothers with serious substance abuse problems: An accumulation of risks. American Journal of Drug and Alcohol Abuse, 29(4), 743– 758. Edwards, E. P., Eiden, R. D., & Leonard, K. E. (2006). Behavior problems in 18- to 36-monthold children of alcoholic fathers: Secure mother–­ infant attachment as a protective factor. Development and Psychopathology, 18(2), 395–407. Floyd, R. L., O’Connor, M. J., Bertrand, J., & Sokol, R. (2006). Reducing adverse outcomes from prenatal alcohol exposure: A clinical plan of action. Alcoholism: Clinical and Experimental Research, 30(8), 1271–1275. Floyd, R. L., O’Connor, M. J., Sokol, R. J., ­B ertrand, J., & Cordero, J. F. (2005). Recognition and prevention of fetal alcohol syndrome. Obstetrics and Gynecology, 106(5 Pt. 1), 1059–1064. Frank, D. A., Augustyn, M., Knight, W. G., Pell, T., & Zuckerman, B. (2001). Growth, development, and behavior in early childhood following prenatal cocaine exposure. Journal of the American Medical Association, 285, 1613–1625. French, M. T., Rachal, J. V., & Hubbard, R. L. (1991). Conceptual framework for estimating the social cost of drug abuse. Journal of Health and Social Policy, 2(3), 1–22. Gass, J. T., & Olive, M. F. (2008). Glutamatergic substrates of drug addiction and alcoholism. Biochemistry and Pharmacology, 75(1), 218–265. Greenfield, L., Burgdorf, K., Chen, X., Porowski, A., Roberts, T., & Herrell, J. (2004). Effectiveness of long-term residential substance abuse treatment for women: Findings from three national studies. American Journal of Drug and Alcohol Abuse, 30(3), 537–550. Grella, C. E., Joshi, V., Hser, Y. I. (2000). Program variation in treatment outcomes among women in residential drug treatment. Evaluation Review, 24(4), 364–383. Guerrini, I., Thomson, A. D., & Gurling, H. D. (2007). The importance of alcohol misuse, malnutrition and genetic susceptibility on brain growth and plasticity. Neuroscience and Biobehavioral Reviews, 31(2), 212–220. Hans, S. L. (1999). Demographic and psychosocial characteristics of substance-­abusing pregnant women. Clinical Perinatology, 26(1), 55–74. Henderson, J., Gray, R., & Brocklehurst, P. (2007).

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Systematic review of effects of low-­moderate prenatal alcohol exposure on pregnancy outcome. British Journal of Obstetrics and Gynaecology, 114(3), 243–252. Hiroi, N., & Agatsuma, S. (2005). Genetic susceptibility to substance dependence. Molecular Psychiatry, 10(4), 336–344. Johnson, A. L., Morrow, C. E., Accornero, V. H., Xue, L., Anthony, J. C., & Bandstra, E. S. (2002). Maternal cocaine use: Estimated effects on mother–child play interactions in the preschool period. Journal of Developmental and Behavioral Pediatrics, 23(4), 191–202. Johnson, M. O. (2001). Mother–­infant interaction and maternal substance use/abuse: An integrative review of research literature in the 1990s. Worldviews on Evidence-Based Nursing, 8(1), 19–36. Kaufman, J., Yang, B. Z., Douglas-­Palumberi, H., Crouse-Artus, M., Lipschitz, D., Krystal, J. H., et al. (2007). Genetic and environmental predictors of early alcohol use. Biological Psychiatry, 61(11), 1228–1234. Kelly, S. J., Day, N., & Streissguth, A. P. (2000). Effects of prenatal alcohol exposure on social behavior in humans and animals. Neurotoxicology and Teratology, 22, 143–149. Kendler, K. S., Myers, J., & Prescott, C. A. (2007). Specificity of genetic and environmental risk factors for symptoms of cannabis, cocaine, alcohol, caffeine, and nicotine dependence. Archives of General Psychiatry, 64(11), 1313–1320. Kodituwakku, P. W. (2007). Defining the behavioral phenotype in children with fetal alcohol spectrum disorders: A review. Neuroscience and Biobehavioral Reviews, 31(2), 192–201. Lester, B. M., Boukydis, C. F. Z., & Twomey, J. E. (2002). Maternal substance abuse and child outcome. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 161–175). New York: Guilford Press. Liu, J. Y., Roberts, T. J., Burgdorf, K., & Herrell, J. M. (2003). Children of mothers with serious substance abuse problems: An accumulation of risks. American Journal of Drug and Alcohol Abuse, 29(4), 743–758. Luthar, S. S., Suchman, N. E., & Altomare, M. (2007). Relational psychotherapy mothers’ group: A randomized clinical trial for substance abusing mothers. Development and Psychopathology, 19(1), 243–261. Martínez-Frías, M. L., Bermejo, E., Rodríguez­Pinilla, E., & Frías, J. L. (2004). Risk for congenital anomalies associated with different sporadic and daily doses of alcohol consumption during pregnancy: A case-­control study. Birth Defects Research Part A, Clinical and Molecular Teratology, 70(4), 194–200. Mayes, L. C., Feldman, R., Granger, R. H., Haynes, O. M., Bornstein, M. H., & Schottenfeld, R. (1997). The effects of polydrug use with and without cocaine on mother–­infant interaction at 3 and 6 months. Infant Behavior and Development, 20(4), 489–502.

Mayes, L. C., Grillon, C., Granger, R., & Schottenfeld, R. (1998). Regulation of arousal and attention in preschool children exposed to cocaine prenatally. Annals of the New York Academy of Sciences, 21(846), 126–143. Mayes, L. C., & Truman, S. D. (2002). Substance abuse and parenting. In M Bornstein (Ed.), Handbook of parenting: Vol. 4. Social conditions and applied parenting (2nd ed., pp. 329–359). Mahwah, NJ: Erlbaum. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press. Murray, C., & Johnston, C. (2006). Parenting in adults with attention-­deficit-­hyperactivity disorder. Journal of Abnormal Psychology, 115, 52–61. Niccols, A. (2007). Fetal alcohol syndrome and the developing socio-­emotional brain. Brain and Cognition, 65(1), 135–142. Office of National Drug Control Policy. (2004). The economic costs of drug abuse in the United States, 1992–2002 (Publication No. 207303). Washington, DC: Executive Office of the President. Olney, J. W., Farber, N. B., Wozniak, D. F., Jevtovic­Todorovic, V., & Ikonomidou, C. (2000). Environmental agents that have the potential to trigger massive apoptotic neurodegeneration in the developing brain. Environmental Health Perspectives, 108(Suppl. 3), 383–388. Ondersma, S. J., Delaney-Black, V., Covington, C. Y., Nordstrom, B., & Sokol, R. J. (2006). The association between caregiver substance abuse and self-­reported violence exposure among young urban children. Journal of Traumatic Stress, 19(1), 107–118. Plessinger, M. A., & Woods, J. R., Jr. (1993). Maternal, placental, and fetal pathophysiology of cocaine exposure during pregnancy. Clinical Obstetrics and Gynecology, 36(2), 267–278. Ren, J. Q., Malanga, C. J., Tabit, E., & Kosofsky, B. E. (2004). Neuropathological consequences of prenatal cocaine exposure in the mouse. International Journal of Developmental Neuroscience, 22(5–6), 309–320. Sameroff, A. J., & Mackenzie, M. J. (2003). Research strategies for capturing transactional models of development: The limits of the possible. Development and Psychopathology, 15(3), 613–640. Sameroff, A. J., Seifer, R., Barocas, R., Zax, M., & Greenspan, S. (1987). Intelligence quotient scores of 4-year-old children: Social–­environmental risk factors. Pediatrics, 79(3), 343–350. Shankaran, S., Das, A., Bauer, C. R., Bada, H. S., Lester, B., Wright, L. L., et al. (2004). Association between patterns of maternal substance use and infant birth weight, length, and head circumference. Pediatrics, 114(2), E226–E234. Shankaran, S., Lester, B. M., Abhik, D, Bauer, C. R., Bada, H. S., Lagasse, L., et al. (2007). Impact of maternal substance use during pregnancy on childhood outcome. Seminars in Fetal and Neonatal Medicine, 12, 143–150.



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Street, K., Whitlingum, G., Gibson, P., Cairns, P., & Ellis, M. (2008). Is adequate parenting compatible with maternal drug use? A 5-year followup. Child: Care, Health, and Development, 34(2), 204–206. Streissguth, A. P., Bookstein, F. L., Barr, H. M., Sampson, P. D., O’Malley, K., & Young, J. K. (2004). Risk factors for adverse life outcomes for fetal alcohol syndrome and fetal alcohol effects. Journal of Developmental and Behavioral Pediatrics, 25, 228–238. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2008a). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 084343). Rockville, MD: Author. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2008b). The NSDUH Report: Alcohol Use among Pregnant Women and Recent Mothers: 2002 to 2007. Rockville, MD: Author. Swain, J. E., Lorberbaum, J. P., Kose, S., & Strathearn, L. (2007). Brain basis of early parent–­ infant interactions: Psychology, physiology, and in vivo functional neuroimaging studies. Journal of Child Psychology and Psychiatry, 48(3–4), 262–287. Swanson, K., Beckwith, L., & Howard, J. (2000). Intrusive caregiving and quality of attachment in prenatally drug-­exposed toddlers and their primary caregivers. Attachment and Human Development, 2(2), 130–148. Terplan, M., & Lui, S. (2007). Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions. Cochrane Database of Systematic Reviews, 17(4), CD006037.

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Tronick, E. Z., & Beeghly, M. (1999). Prenatal cocaine exposure, child development, and the compromising effects of cumulative risk. Clinical Perinatology, 26(1), 151–171. Tronick, E. Z., Messinger, D. S., Weinberg, M. K., Lester, B. M., Lagasse, L., Seifer, R., et al. (2005). Cocaine exposure is associated with subtle compromises of infants’ and mothers’ social–­emotional behavior and dyadic features of their interaction in the face-to-face still-face paradigm. Development and Psychopathology, 41(5), 711–722. van den Bree, M. B. (2005). Combining research approaches to advance our understanding of drug addiction. Current Psychiatry Reports, 7(2), 125–132. Verdejo-García, A., Lawrence, A. J., & Clark, L. (2008). Impulsivity as a vulnerability marker for substance-use disorders: Review of findings from high-risk research, problem gamblers and genetic association studies. Neuroscience and Biobehavioral Review, 32(4), 777–810. Whaley, S. E., O’Connor, M. J., & Gunderson, B. (2001). Comparison of the adaptive functioning of children prenatally exposed to alcohol to a nonexposed clinical sample. Alcoholism: Clinical and Experimental Research, 25, 118–124. Whitaker, R. C., Orzol, S. M., & Kahn, R. S. (2006). Maternal mental health, substance use, and domestic violence in the year after delivery and subsequent behavior problems in children at age 3 years. Archives of General Psychiatry, 63(5), 551–560. Wu, L. T., Ringwalt, C. L., & Williams, C. E. (2003). Use of substance abuse treatment services by persons with mental health and substance use problems. Psychiatric Services, 54(3), 363–369.

C h a p t e r 11

Prematurity, Risk Factors, and Protective Factors Carole Müller Nix François Ansermet

P

reterm birth is a complex condition that has become a public health problem in industrialized countries. It has two major consequences. First, it puts the infant’s life and its outcome at stake, particularly for babies with very low birthweight (< 1500 grams) or very low gestational age (< 32 weeks). Second, it leads to intense emotional reactions in parents, including traumatic reactions, that have an impact on the infant and on the parent–­infant relationship. Remarkable advances in neonatology in the past 2 to 3 decades, with dramatic progress in resuscitation procedures, have resulted in increased survival rates of very preterm infants, leading to growing concern for their development and quality of life. For more than 20 years, a number of investigations aimed at understanding the multiple and overlapping factors that may be involved tried to clarify the risk and protective factors that contribute to quality of life in these vulnerable infants. More than ever, it seems essential to apply a multifaceted approach to this effort in order to effectively address the complex, interrelated biological, developmental, social, and emotional determinants. After review-



ing epidemiological data, this chapter will mainly address the emotional, environmental, and relational dimensions that can moderate or mediate the effects and outcome of prematurity. Indeed, as biological problems play a major role in preterm birth and infant outcome, so psychological and social factors are also important. An infant’s level of stress, as well as a parent’s subjective experience and abilities to adjust to a premature birth, critically influence the infant’s later competencies and development. In any case, these aspects have to be understood as key factors modulating the biological adversities of the child’s experiences. More precisely, this chapter explores the impact of a preterm birth on vulnerabilities, strengths, and adaptive reactions of both parents and infant, with particular attention to the traumatic dimension of this event. In the clinical work with these families, the parental psychic history, conscious or unconscious, plays a fundamental role in the unfolding of the parent–­preterm infant relationship, making this time for each family a singular one, each endowed with special meanings and unique outcomes. 180



11. Prematurity

DEFINITION AND CATEGORIZATION Preterm infants are infants born at less than 37 completed weeks of gestation. Preterm birth is classified as “late preterm birth” from 34 to 37 completed weeks of gestation, “very preterm birth” from 28 to 33 completed weeks of gestation, and “extremely preterm birth” before 28 weeks of gestation, with increasing neonatal mortality and morbidity with earlier births. Lack of systematic routine data collection for gestational age is one of the major challenges for accurately comparing the incidence of premature birth and infant outcomes among different studies. Incidence of premature birth is also based on birthweight, especially when accurate information on gestation is missing. The traditional subclassifications are: less than 2,500 grams for low birthweight (LBW), less than 1,500 grams for very low birthweight (VLBW); and less than 1,000 grams for extremely low birthweight (ELBW). Rates of LBW are more likely to be affected by a wide variation in genetic and nutritional factors in infants or by intrauterine growth restriction factors, and represent a less accurate estimate of the incidence of premature birth than do VLBW and ELBW rates (Fox, 2002).

CAUSES OF PRETERM BIRTH The multifactorial causes of prematurity include individual behavioral and psychosocial factors, environmental exposures, medical conditions, infertility treatments, and biological and genetic elements. Many of these factors occur in combination, particularly in parents who are socioeconomically disadvantaged or members of racial and ethnic minority groups (Behrman & Stith Butler, 2006). Limited social support, racial discrimination, low education, and negative life events are all considered as adverse factors (Dole et al., 2003). Present conditions of conception contribute to the increased rate of preterm birth, with a growing proportion of births among woman over 34, and multiple births following assisted reproductive therapy or ovulation induction. Changes in pregnancy follow-up procedures (early ultrasound dating, preterm induction, and ce-

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sarean delivery) also play a role (Adashi et al., 2003). During pregnancy little is known about how to prevent a preterm birth. Treatment efforts are primarily focused on inhibiting contractions in women with preterm labor. This approach has not decreased the incidence of preterm birth but can delay delivery long enough to allow administration of antenatal steroids and the transfer of the pregnant mother to a hospital which can provide appropriate care for her and her fetus, reducing the rates of perinatal mortality and morbidity (Behrman & Stith Butler, 2006). From strong evidence in animal studies, recent research has explored antenatal maternal stress or anxiety as possibly linked to adverse birth outcome (Seckl & Meaney, 2006). Although this link has not been firmly established, Dole, among others has shown an increased risk of preterm birth related to pregnancy anxiety (Dole et al., 2003). Possible mechanisms include changes in maternal uterine blood flow and transplacental passage of cortisol from mother to fetus (Glover & O’Connor, 2005). Maternal antenatal depression also may have an incidence on preterm delivery, but studies are not consistent (Dayan et al., 2006; Dole et al., 2003).

INCIDENCE In 2005, the percentage of preterm births was 12.7% in the United States (MacDorman & Mathews, 2008). It has increased steadily since the mid-1980s in the United States, Canada, and Europe (Ananth, Joseph, Oyelese, Demissie, & Vintzileos, 2005; Lumley, 2003), especially for infants born at less than 28 weeks gestation. In 2004, 12.5% of births in the United States were preterm, with significant persistent racial, ethnic, and socioeconomic disparities (Behrman & Stith Butler, 2006; Getahun, Ananth, Selvam, & Demissie, 2005). The rate for African American women was 17.8%, whereas it was 11.5% for European American women. In Europe, incidence of preterm birth is lower than in the U.S. In 2000, the incidence was between 5 to 8% (Blondel, Macfarlane, Gissler, Breart, & Zeitlin, 2006). One explanation is that since the 1930s most European countries have provided, to a much greater extent than has

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the United States, broad healthcare coverage and social protection before and after delivery (Papiernik & Goffinet, 2004).

MORTALITY AND SURVIVAL In 2005, 68.6% of all infant deaths occurred to preterm infants, up from 65.6 % in 2000 (MacDorman & Mathews, 2008). Progress in perinatal and neonatal care have significantly improved the rates of survival for these infants (Ananth et al., 2005; Wheller, Baker, & Griffiths, 2006). In the United States the mortality rate has decreased for all preterm infants, between 1989 and 2001, from 3.3 to 2.4% (Ananth et al., 2005). Infants who formerly did not survive are now part of the extremely premature cohort. A review of ELBW infants, showed that with current methods of care, particularly the use of antenatal steroids, the limits of viability have been reached (Ancel, EPIPAGE Group, 2008). From 1995 to 2001, considering birthweight, the mortality rate declined by 15.4% for preterm babies born weighing between 750 and 999 grams, 9.7% for those born weighing between 500 and 749 grams but only by 5.4% for those less than 500 grams (Mathews, Menacker, & MacDorman, 2003). Nevertheless, preterm birth is still associated with a substantial excess of childhood mortality and morbidity. In industrialized countries, including the United States, it is now the most common cause of infant mortality, with 95% of those deaths occurring in infants who were born very preterm (< 32 weeks gestation) or with VLBW (< 1,500 grams), and two thirds of those deaths occur during the first 24 hours of life (Callaghan, MacDorman, Rasmussen, Qin, & Lackritz, 2006).

OUTCOMES OF PREMATURITY If the preterm infant survives, the concern becomes quality of life, and a number of studies have explored the preterm infant’s outcome in childhood and adolescence. From a pediatric and developmental perspective, preterm infants are at greater risk than full-term infants not only for mortality, but for a variety of health and developmen-

tal problems. The degree of infant maturity at time of birth is a major determinant of these risks (Escobar et al., 2006). Infants born after 32 weeks of gestation represent the greatest number of preterm infants, and experience more complications than infants born at term. Very preterm infants, VLBW infants, or preterm infants who suffer medical complications are the most at risk for long-term developmental, psychological, emotional, or behavioral problems. Moderating factors play an important role: higher maternal age, higher socioeconomic status, and education level are related to fewer impairments for infants (Behrman & Stith Butler, 2006). One possible explanation is that mothers are more inclined to cognitively and socially stimulate their preterm infant (Singer et al., 2003). Still, results from different studies are difficult to compare and sometimes yield contradictory findings, primarily due to methodological differences, in particular, considering preterm population either according to gestation (< 34 weeks, < 28 weeks) or to birthweight (< 1,500 grams; < 1,000 grams).

Neurodevelopmental Outcomes Most children born preterm do not suffer major neurodevelopmental impairments, like cerebral palsy, mental retardation, and severe neurosensory impairments (blindness, deafness), but that risk increases with decreased gestational age (Allen, 2008). Since 2000, furthermore, a decrease in the rates of cerebral palsy and overall neurosensory impairments has been found (Robertson, Watt, & Yasui, 2007; Wilson-­Costello et al., 2007). In the early 2000s, that rate was around 5% of cerebral palsy in survivors of less than 1 kg birthweight infants (Hack & Costello, 2008). This has been associated with changes in practice including cesarean section delivery, increased use of antenatal steroid therapy, and a decrease in postnatal dexamethasone use. Nevertheless, many children born preterm demonstrate more subtle neurodevelopmental disorders, as has become apparent in recent studies. They include language disorders, learning disabilities, attention-­deficit/ hyperactivity disorder (ADHD), minor motor dysfunction or developmental coordination disorders and/or sensorimotor



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problems, behavioral problems, and emotional difficulties that lead to functional impairments, cognitive impairments, academic difficulties (reading and spelling for example), social–­emotional problems (e.g., poor self-­esteem and peer relationships), and problems at home (Allen, 2008; Behrman & Stith Butler, 2006; Bhutta, Cleves, Casey, Cradock, & Anand, 2002; Hall et al., 2008; Salt & Redshaw, 2006). Even for children who were not born very prematurely these difficulties can be important. A study found that for children born at 30–34 weeks gestation, cognitive impairment was the most common disability (Marret et al., 2007). Measures of brain structure and function are predictive of neurodevelopmental outcomes, and recent studies examine children with magnetic resonance imaging (MRI), as well as neonatal ultrasound (Behrman & Stith Butler, 2006). If improvements in perinatal care have led to a reduction in the major destructive parenchymal brain lesions (such as cystic periventricular leucomalacia and haemorrhagic parenchymal infarction), with abnormal motor developmental and cerebral palsy, it is hoped now that MRI information will help to identify neonates with disturbances to brain growth and function underlying developmental impairments. Measurements of the size, volumes, and growth rates of regions of the brain, such as the corpus callosum, ventricular system, cortex, deep grey matter, and cerebellum, are altered following preterm birth (Cheong et al., 2008; Inder, Warfield, Wang, Huppi, & Volpe, 2005). Application of advanced MRI and processing techniques in the neonatal period and later, let subtle alterations in brain development become apparent, in particular microstructural abnormalities of cerebral white matter (Boardman & Dyet, 2007; Counsell et al., 2008; Nagy et al., 2003). The exact relation between these findings and the clinical situations are still unclear (Hart, Whitby, Griffiths, & Smith, 2008).

Emotional and Behavioral Outcomes Preterm infants are also at risk of developing behavioral and emotional problems during infancy, childhood, and adolescence. At 6 months of age, they have been described as more stressed, with less approach behavior and more problems with self-­regulation

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(Wolf et al., 2002); in early childhood (0–4 years old), more difficult, with less adaptability, activity, attention, and persistence than full-term infants (Chapieski & Evankovich, 1997; Tu et al., 2007) and during later childhood (5–11 years), with more behavioral and attention problems (boys more than girls) (Bhutta et al., 2002; Dahl et al., 2006), less adaptability, and fewer leadership and social skills (Anderson & Doyle, 2003; Chapieski & Evankovich, 1997). Symptoms of attention-­deficit/hyperactivity disorder (ADHD) are reported to occur two to six times more frequently in these children than in full-term children (Anderson & Doyle, 2003; Bhutta et al., 2002; Foulder-­Hughes & Cooke, 2003), and prevalence at adolescence varies between 13 and 23% (Botting, Powls, Cooke, & Marlow, 1997; Elgen, Sommerfelt, & Markestad, 2002; Stjernqvist & Svenningsen, 1999). These rates are higher among ELBW or lowest gestationalage infants. In general, outcome data are sparse and often contradictory for preterm adolescents, relying mainly on adolescent, parent, or teacher self-­report questionnaires. Studies show clear differences between adolescents’ perceptions of themselves and their parents’ or teachers’ perceptions. Intriguingly, preterm-born adolescents report having less problems than full-term adolescents. On the contrary, their parents and teachers report more social, depressive, and ADHD-related problems and describe less social and school competences in these children (Dahl et al., 2006). Furthermore, preterm adolescents perceived their quality of life (i.e., well-being, happiness, and satisfaction) as similar to that of their full-term adolescent counterparts. They reported no greater number of health problems or lower self-­esteem (Indredavik, Vik, Heyerdahl, Romunstad, & Brubakk, 2005), but their parents reported reduced quality of life for their adolescents (Dinesen & Greisen, 2001). Patton and colleagues showed an association between prematurity and a substantially high rate of depressive disorder in late adolescence (Patton, Coffey, Carlin, Olsson, & Morley, 2004). In some studies preterm young adults (ages 20–23 years) report a comparable health and quality of life to a control group (Saigal et al., 2006). Delinquency, alcohol, or drug use was less frequent (Cooke, 2004; Hack et al.,

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2002). One study of Walther and colleagues on a Dutch cohort gives a more pessimistic point of view, with 40% of ELBW young adults not being able to become fully independent individuals (Walther, den Ouden, & Verloove-­Vanhorick, 2000).

PRETERM INFANTS’ PAIN AND STRESS At birth, preterm babies have left the adaptive environment of the womb too early and are subject to intrusive medical procedures that although necessary, may inflict pain and stress and sometimes build a state of traumatic helplessness. The profound changes occurring in the infants’ brain organization at this time and their total dependency on caregivers leave them highly sensitive to environmental input. A number of specific circumstances in addition to medical care procedures, can induce pain and stress on infants and need to be acknowledged, such as respiratory distress or other medical complications, environmentally inappropriate sources of sensory stimulation in the neonatal intensive care unit (NICU) (e.g., excessive noise, overly bright lighting, and uncomfortable positioning in the incubator; Bullinger, 2005), and a certain separation from parents’ attention and affection during intensive care. There is evidence suggesting that even routine tactile procedures may be stressful for preterm infants (Holsti, Grunau, Whifield, Oberlander, & Lindh, 2006).

Assessment of Pain and Stress Contrary to what was believed in the past, premature infants are able to feel pain. By 24 weeks gestation, the nervous system elements required for the transmission of painful stimuli are functional. Accurate and reliable observation and assessment of infant pain, stress, and self-­regulation capacities are essential, and several validated instruments can be used for this purpose, helping to organize appropriate interventions. These include the Neonatal Behavioral Assessment Scale (NBAS; Brazelton & Nugent, 1995) and the Assessment of Preterm Infants’ Behavior (APIB; Als, Lester, Tronick, & Brazelton, 1982), both used with babies close

to discharge, and the Observation Sheet of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP; Als, 1986; Als et al., 2004) used during hospitalization, the Neonatal Facial Coding System (NFCS; Grunau & Craig, 1987), and the Premature Infant Pain Profile PIPP, or Behavioral Indicators of Infant Pain (BIIP) Scale (Holsti, Grunau, Oberlander, & Osiovich, 2008; Stevens, Johnston, Petryshen, & Taddio, 1996), both of which give specific information on pain experience. Facial and bodily increased or decreased activity, increased heart rate, and decreased oxygen saturation are recognized as indicators of preterm infant pain and stress (Grunau et al., 2005; Holsti, Grunau, Oberlander, & Whitfield, 2004). Als’s conceptualization of the preterm newborn development (i.e., synactive theory; Als, 1986) allows clinicians to observe and assess not only infants’ signs of stress but also its autoregulatory abilities. Infants’ degree of stress is monitored specifically, with attention to disorganized motor behaviors, trouble in autonomic regulation, and unstable or unclear sleep–awake state regulation. Any adverse stimulation leads to stressful reactions in one or several of these subsystems and challenges the infant’s availability for social communication with possibly longterm developmental consequences (Anand & Scalzo, 2000). On the contrary, adaptive stimulations permit preterm infants to remain stable in these different dimensions of observation, available for social interaction and exploration of the environment in a beneficial way.

The Sensorimotor Approach The sensorimotor approach focuses on the needs of the infant and considers its sensorimotor development level. In particular, this approach tries to counteract the infant’s maladaptive, stereotypic movements and abnormal postures due to the dysstimulations lived by the infant in the NICU, while normal sensorimotor experiences are enhanced (Bellefeuille-Reid & Jakubek, 1989). Some studies explored sensory competencies of the infant (olfactives, tactiles in particular) in order to use them as help for the infant’s regulation toward stimulations, with the aim of controlling stressful reactions (Gou-



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bet, Rattaz, Pierrat, Bullinger, & Lequien, 2003; Pihet, Bullinger, Mellier, & Schaal, 1997). Other authors, using sensorimotor theories, have an interesting approach to the preterm baby’s stress. Their conceptualization states that preterm babies’ insufficiently organized nervous systems cannot alone respond healthily to sensory inputs. The support of infants’ sensorimotor and tonic balance allows them to organize themselves toward the stimuli of their environment. It is certainly one of the important aspects of the infant’s care, besides the relational aspect, to avoid subjecting the infant to longterm, stressful reactions that may accentuate the vulnerability of the preterm neonates to stress-­related complications, somatic as well as psychological. Infants who can actively engage the stimulation are not at risk of being helplessly overwhelmed by it or forced to defend against it (Bullinger, 2005). This engagement helps infants to construct an accurate, reliable, and coherent picture of their body and environment.

Infant Reactivity to Subsequent Stress Several studies have demonstrated that perinatal exposure to stressful events may influence infants’ later reactivity to subsequent stressors. Taddio, Katz, Iiersich, and Koren (1997) have shown for example, that nonanesthetized newborns who are circumcised demonstrate higher physiological and behavioral reactions to the subsequent stress of inoculation that occurs 2–4 months after birth. The mode of delivery has also been related to subsequent reactions to vaccination, with highest cortisol levels during inoculation in infants who were born by assisted delivery (forceps or vacuum) and lowest response in infants born by elective cesarean section (Taylor, Fisk, & Glover, 2000). Exposure to repetitive painful and stressful procedures may lead to altered neurobehavioral responses to subsequent stressful events, with decreased behavioral responses and increased physiological responses (Grunau et al., 2005; Grunau et al., 2007). A recent study showed altered basal cortisol reactions in extremely preterm infants between 3 and 18 months (corrected age), going from lower salivary cortisol at 3 months to higher basal cortisol at 8 and 18 months, compared with term infants. These

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findings suggest a possible “resetting” of basal cortisol levels and long-term “programming” of the HPA axis (Grunau et al., 2007). Even mild subsequent stressors can involve an altered biobehavioral reactivity of the hypothalamic–­pituary–­adrenal axis (HPA) and cortisol level (Meaney, 2001). The persistent sensitization of the HPA axis to even mild stress in adulthood and its repercussions on emotional regulation (LeDoux, 1998; Perry, Pollard, Blakley, Baker, & Vigilante, 1995; Yehuda & LeDoux, 2007) may form the basis for the development of mood and anxiety disorders rendering an individual vulnerable to stress-­related psychiatric disorders such as depression, anxiety disorders, or posttraumatic stress disorder (PTSD) upon further stress exposure (Heim & Nemeroff, 1999). Seckl and Meaney (2006) stated that severe maternal stress during pregnancy can affect the infant’s HPA axis and be related to subsequent neuropsychiatric disorders, possibly including PTSD. Intriguingly, some of these effects appear to be “inherited” by a subsequent generation, itself unexposed to exogenous glucocorticoids, which imply epigenetic-­persistent markers. In spite of the importance of difficult early experiences, the future of the preterm infant cannot be regarded as one of a fully determined outcome. The neural plasticity of the brain must be considered—the potential reorganization of memory traces that constantly occur through mutative life experiences, changing the physiological impact as the meaning of primal experience (Ansermet & Magistretti, 2007).

PARENTS’ TRAUMATIZATION A Developmental Crisis in the Perinatal Period The period from pregnancy to about 2 years of age creates unique emotional experiences for most parents, that from a psychoanalytic perspective, can be considered as a developmental crisis even when the child is born at term and in good health. Indeed, there is potential reelaboration of parental conscious or unconscious past experiences, or of unresolved conflicts, particularly those linked to childhood experiences, and potential modifications of the identifications to parental

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figures. New identifications with their own parents and their newborn child are accompanied by emotions and memories that can sometimes be destabilizing or problematic, as can be seen in parental postpartum psychopathology.

Parental Anxiety and Depression in the Case of a Premature Birth Premature birth is recognized as a stressful and emotionally demanding experience with long-term impact on both parents. Until now, most studies have explored parents’ experiences and responses in the form of persistent anxiety and/or depression (Miles, Holditch-Davis, Schwartz, & Scher, 2007; Padden & Glenn, 1997; Singer et al., 1999). Mothers reported more stress than fathers and poorer adjustment to the preterm birth (Hughes & McCollum, 1994; Jackson, Ternestedt, & Schollin, 2003). Stressors that can influence parents’ abilities to cope with the prematurity event include: the infant’s immaturity and severity of medical status (gestational age, birthweight, Apgar scores, length of hospitalization and postnatal complications); emotional risk factors in parents (separation from infant, alteration of parental role during hospitalization, difficulty in understanding the infant, anxiety about infant outcomes); and psychosocial dimensions (economic, personal, and family factors, pre- and perinatal experiences), and relationship with health care providers (DeMier et al., 2000; Dudek-­Schriber, 2004; Meyer et al., 1995; Miles, Burchinal, Holditch-Davis, Brunssen, & Wilson, 2002). Mothers and fathers have been found to display differences in the number and severity of perceived stressors (Hughes & McCollum, 1994), with mothers showing more sensitivity to stress. After discharge, mothers can suffer from depression and anxiety for months (Miles et al., 2007).

Parents’ Posttraumatic Reactions Only recently have a few studies explored parents’ experience from a trauma perspective, that is, considering the preterm birth as a traumatic event. Symptoms of posttraumatic reactions usually occur within 3 months of the traumatic event and can follow an acute or chronic course (American

Psychiatric Association, 2000). Studies indicate that parents of preterm infants report a high incidence of PTSD reactions, even up to a 1 year after the infant’s birth (DeMier et al., 2000; Holditch-Davis, Bartlett, Blickman, & Miles, 2003; Jotzo & Poets, 2005; Pierrehumbert, Nicole, Muller Nix, Forcada Guex, & Ansermet, 2003). Kersting’s prospective study found significantly higher PTSD symptoms, as well as depression and anxiety symptoms, in mothers of high-risk preterm infants, up to 14 months after giving birth (Kersting et al., 2004). In another study, preventive trauma intervention for mothers resulted in significantly less traumatic impact at discharge, although without intervention 77% of preterm mothers showed significant psychological trauma 1 month after birth and 49% 1 year later (Jotzo & Poets, 2005).

PARENTAL DISCOURSE Research with a qualitative approach provides a number of elements that help to understand the prematurity event. Besides data from standardized questionnaires, qualitative data, particularly from interviews with parents, are a meaningful complement to understanding parents’ subjective experience of prematurity (Borghini & Muller Nix, 2008; Jackson et al., 2003; Meyer, Zeanah, Boukydis, & Lester, 1993; Padden & Glenn, 1997).

Parental Experience of the Preterm Infant’s Birth Parental experience of preterm birth has been described from a clinical point of view in a substantial body of literature. In their discourse, parents speak often of the infant’s birth as a moment of shock, finding it impossible to think, and experiencing numbness, void, and confusion that prevents them from fully appreciating the situation (Muller Nix, Nicole, Forcada Guex, & Ansermet, 2001). These reasons may be understood as a defense against unbearable feelings related to the sudden interruption of the pregnancy. Everything moves too quickly and is unexpected. The child is barely born, but already at risk of death. Even when that risk seems to have passed, uncertainty concern-



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ing the baby’s outcome is constantly present (Ansermet, 1999). And this uncertainty is one of the most difficult feelings for parents to bare, sometimes becoming overwhelming during the weeks or months of hospitalization. The very difficult separation from the infant at birth, who needs immediate intensive care, is accompanied by intense fear for its survival. Meeting the infant in the NICU can be disturbing for parents, the infant being difficult to look at, too small, looking strange in color and proportion. Parents may feel that “it” doesn’t resemble a baby yet and looks very ill, thoughts that may lead to frightening images of death and disability. Lack of intimacy with the baby, so essential to the parent–­infant relationship, is recalled by parents as a major challenge. The immaturity of preterm babies, who are less able to respond to parents’ solicitations than full-term babies, limits the gratifying reciprocity of interactions. There is a risk of misunderstanding if parents don’t clearly comprehend the infant’s limited abilities and experience them instead as a personal affront. Parents are challenged to assert themselves as parents and to be recognized as such by their family and social environment (Minde, 2000). The uncertainty about the infant’s outcome can delay parents’ psychological investment in the baby (DeMier et al., 2000). Parents successively experience a variety of emotions that range from intense anxiety, depression, frustration and helplessness, to guilt and rage. Mothers’ guilt can be especially intense, with a feeling of having failed to carry the infant to term (Holditch-Davis, Miles, & Belyea, 2000). These various emotions are important, although painful, because they help parents to recognize the preterm baby’s reality as much as their own new parenthood (Pancer, Pratt, Hunsberger, & Gallant, 2000), and to find meaning in what is happening. Sometimes overwhelming, these emotions can keep parents at a distance from the child in an attempt to avoid them or, on the contrary, the feelings may push them to overstimulate the baby in a desperate search for a reassuring response from the infant. In the long run, parent emotional turmoil can jeopardize the establishment of a harmonious parent–­infant relationship (Levy-Shiff, Sharir, & Mogilner, 1989) and

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can be the origin of mother–­infant attachment difficulties (Minde, Whitelaw, Brown, & Fitzhardinge, 1983).

Retraumatization, or the Aftermaths of the Preterm Birth Medical complications can greatly prolong the baby’s hospitalization and the uncertainty about his or her outcome. They are recognized as major stressors for parents and can constitute a series of retraumatizing moments. The infant’s transfer to another unit or hospital, or even the infant’s discharge represent similar stressful turning points (Zanardo, Freato, & Zacchello, 2003). Feelings of being abandoned or even rejected by the hospital staff when not yet secure in their parenthood is a challenge for many parents. Some parents respond to these difficult moments with exaggerated ambivalence toward the infant. Anxious and frustrated, they sometimes want to protect themselves from renewed traumatic fears. Each retraumatizing moment carries a risk of parental withdrawal of investment towards the infant, but also represents an opportunity for parents to invest more decisively in their infant. It is an opportunity to express their feelings, to overcome their exaggerated ambivalence, to find meaning in what is happening, and to affirm their desire to invest in the infant and their parenthood, despite the difficult circumstances. During their infant’s hospitalization, parents remain vulnerable to repeated retraumatization, necessitating ongoing emotional support (Kersting et al., 2004).

Supporting Parents’ Investment of Their Infant A major protective factor of the parent–­ infant relationship is active participation in the infant’s care, experience of sensory proximity and intimacy with the infant, and responsibility for the infant. Their confidence in their parenthood has to be reinforced repeatedly during hospitalization and evaluated before discharge. Insecure parents at discharge are more likely to have difficulties with their infant at home, which may lead to persistent parent–­infant relationship problems.

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Parents’ Traumatic Experience, A Psychodynamic Approach From a psychoanalytic point of view preterm birth may be understood as a paradigmatic example of trauma in the perinatal period, with parents abruptly confronted with an event for which they were not able to prepare themselves (Freud, 1916–1917, 1920; Winnicott, 1989). Symptoms of traumatic stress are most often present at birth, but can also manifest during a secondary stressful event that brings forward parental fears for the infant’s survival, sometimes more intensely than at the infant’s birth. The hospitalization of the preterm baby may represent an ongoing trauma, with frequent retraumatization linked to the fluctuations in the baby’s medical condition. Furthermore, the cause of parents’ emotions can be related not only to the present situation but also to their preexisting psychic history. The parental traumatic experience can be conceptualized as a threefold process. The first phase is shock, including numbness, fears, difficulty thinking clearly (at birth). The second is the core of the psychic work of the trauma, the experience of a succession of emotions that need to be worked out over time, gaining meaning and loosing their intrusive quality (during hospitalization, retraumatizing moments). The third phase is resolution, when the trauma is sufficiently worked through so that difficult emotions no longer restrain parental feelings and affective investments in the infant.

PARENT–INFANT INTERACTIONS Parents’ Stress and Quality of Parent–­Infant Interactions Parents’ experiences and behavior, and infants’ characteristics, must be considered as transacting with one another over time, bringing a specific quality to each particular dyad of parent–­infant. In healthy at-term babies, maternal distress, in particular with depression symptoms, is recognized to be associated with less positive mother–­infant interactions. Few studies have explored the relationship between maternal psychological distress and the quality of parent–­preterm infant interaction (Feeley, Gottlieb, & Zelkovitz, 2005; Singer et al., 2003).

Parents’ thoughts and feelings greatly influence their behavior (Fraiberg, 1982). The infant himself with its characteristics elicit them, and parent and infant reciprocally affect one another over time in a way that involves complex feedback systems (Beckwith & Rodning, 1996; Goldberg & DiVitto, 1995). Early investigations pointed out that preterm infants are less alert, attentive, active, and responsive than full-term infants, and preterm infants’ mothers are more active, stimulating, intrusive, and at the same time, more distant in mother–child interactions, than full-term infants’ mothers (Barnard, Bee, & Hammond, 1984; Field, 1979; Minde, Perrotta, & Marton, 1985). These differences have persisted to 2 years of age in some studies (Minde, 2000). The stimulating attitude of preterm mothers has been the object of debate, viewed by some authors as an adaptive and compensatory response to the specific difficulties presented by the preterm infant’s immaturity (Goldberg & DiVitto, 1995), and seen by others as intrusive and controlling behavior, detrimental to the preterm infant’s outcome (Butcher, Kalverboer, Minderaa, Doormaal, & Wolde, 1993; Field, 1979). Further studies have described preterm infants and their mothers as relatively competent in their interactive behavior (Schermann-­Eizirik, Hagekull, Bohlin, Persson, & Sedin, 1997), especially after the first year of the infant’s life (Greenberg, Carmichael-Olson, & Crnic, 1992). These contrasting findings can be explained by the medical advances over the last 20 years, greater parental presence and involvement with the infant’s care, as well as increased emotional support given to the parents during the neonatal period (Als, 1986; Goldberg & DiVitto, 1995). However, smaller and more immature preterm infants are now surviving, with longer infant hospitalizations. Long-term interference with parent–­infant intimacy is still at risk (Keilty & Freund, 2005).

Dyadic Quality of Mother–­Infant Interaction and Infant’s Outcome Mother and infant quality of interaction at 6 and 18 months has been explored in a study in relation to the severity of prematurity as well as with maternal posttraumatic stress reaction (Muller Nix et al., 2004). Moth-



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ers of high-risk premature infants as well as mothers who were highly stressed in the perinatal period were found to be less sensitive and more controlling in dyadic play with their infant than full-term mothers and their infants were more compliant towards their mothers. Interestingly, maternal traumatic experience was the major factor influencing maternal as well as infant interactional characteristics, when both maternal posttraumatic reactions and infant severity of prematurity were taking into account. Dyadic quality of mother–­preterm infant interaction (matching maternal with their infant interactive behavior) has also been examined and two specific dyadic patterns were identified, a “cooperative” pattern (sensitive mother with a cooperative infant), and a “controlling” pattern (mother controlling with a compulsive–­compliant infant) (Forcada Guex, Pierrehumbert, Borghini, Moessinger, & Muller Nix, 2006). These contrasted dyadic patterns of interaction were found to have a significantly different impact child outcome (see next paragraph).

Parental Representations of Attachment and Parent–­Infant Interactions Maternal attachment representations of infants have been assessed using the Working Model of the Child Interview (WMCI; Zeanah & Benoit, 1995) and showed that at 18 months only 30% of mothers of preterm infants < 34 weeks of gestational age had secure attachment representations, vs. 57% for mothers of full-term infants (Borghini et al., 2006). Quality of maternal attachment representations was correlated with mothers’ posttraumatic stress reactions. Most often representations were “distorted representations” in mothers reporting high levels of stress, “disengaged representations” in mothers reporting low levels of stress, and “balanced representations” in full-term mothers. Interestingly, regarding dyadic patterns of interaction and maternal attachment representations, although “cooperative” dyadic patterns of interaction were found in fullterm dyads (68%) and in preterm dyads (28%) (Forcada Guex et al., 2006), maternal representations of attachment were very different in these two groups: full-term mothers showed mainly balanced representations, whereas preterm mothers displayed balanced and disengaged representations. Mothers of

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“controlling” dyads showed mainly distorted representations.

PARENTAL STRESS AND INFANT OUTCOME Parents’ subjective experience has a crucial impact on infants’ experiences, development, and outcome (Goldberg & DiVitto, 1995; Korja et al., 2008; Pierrehumbert et al., 2003; Wijnroks, 1999). The quality of the early parent–­infant relationship is a critical factor affecting later infant competencies (Wijnroks, 1998). It represents an important mediating variable between perinatal risk factors and the infant’s developmental outcome (Magill-Evans & Harrison, 2001; Singer et al., 2003). Sensitive and responsive maternal interactional behavior has been related to better infant cognitive and social competencies (Beckwith & Rodning, 1996; Singer et al., 1999). Postpartum maternal depression has been acknowledged to have negative effects on cognitive, emotional, and behavioral development in the child. This suggests that maternal depression in the case of prematurity might have similar consequences. Singer and colleagues (2003) demonstrated that maternal distress following preterm birth was related to low frequency of cognitive growth of their infant at both 8 and 12 months. Parents’ posttraumatic reactions were found to be related to infant problems at 18 months (Pierrehumbert et al., 2003). Preterm infants of mothers, but not of fathers, with posttraumatic stress reactions presented more behavioral symptoms (particularly sleeping problems) at 18 months, than mothers of full-term infants. Although infant outcome was related to severity of prematurity and to maternal posttraumatic stress reactions, the latter was the mediating factor of infant outcome. This finding emphasizes the central role of parents’ emotional reactions in the infants’ subsequent development. Other studies have confirmed the importance of parental affective experience on infants’ outcome. Maternal stress has been pointed out as an important mediating factor between infant neonatal stress and its quality of focused attention at 8 months corrected age (Tu et al., 2007). Child development at 36 months has been found to be more closely related to maternal distress and

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social support than to early physiological factors (Miceli et al., 2000). Parental stress in early infancy can represent a risk factor for later child behavioral problems (Kaaresen, Ronning, Ulvund, & Dahl, 2006). Considering parent–­infant pattern of interaction and infant outcome, one study showed that in dyads of a sensitive mother with a cooperative infant, the infant outcome is comparable to the one of full-term infants. On the contrary, in dyads of a controlling mother with a compulsive–­compliant infant, the infant outcome is significantly less positive, with more behavioral symptoms (particularly eating problems) and lower developmental social skills then for full-term infants (Forcada Guex et al., 2006). The former pattern appears to be a protective factor and the latter a risk factor, independently of perinatal risk factors and of the family’s socioeconomic background. These findings emphasizes the importance of therapeutic interventions in consultation–­ liaison work in the NICU aimed at parent–­ infant interactions and early psychotherapeutic consultations with parents when needed.

PARENTS–STAFF RELATIONSHIP Parents’ relationship with the hospital staff is of considerable importance and involves many challenges. Parents may experience mixed feelings of gratitude and ambivalence, of dependence and rivalry toward the staff. At first, most parents feel helpless in caring for their baby, but when the baby is less dependent on life support, they need to affirm their role as parents (Jackson et al., 2003). This transition can create tension, as some hospital staff members may unknowingly encourage parents’ dependency on them. After discharge, insecure parents often look for reassurance, sometimes from their pediatrician, but sometimes from the infant, which may complicate the child’s emotional development.

PARENTAL REPRESENTATIONS OF INFANT AFTER DISCHARGE Parents are usually relieved to have their infant at home. They often describe that

moment as a second birth of the infant. They can nevertheless still express excessive anxiety for the child. They may be highly concerned about the infant’s attainments and developmental milestone achievements. These concerns can in some cases prevent them from fully enjoying the relationship with their infant and discovering his or her personality. In some cases they can have difficulty describing their infants’ individual characteristics. Paradoxically, parents can express simultaneously serious concerns and idealized representations of their infant’s abilities. They sometimes express lack of confidence in their parenting abilities and feelings of rivalry toward other caretakers of the child. This underscores how important it is for pediatricians to be aware of these potential difficulties and to follow up with parents, since these problems are not always easily expressed by parents or easily recognized in parent–­infant relationships at first sight.

INTERVENTIONS A number of authors have aimed to better define parent and infant needs during hospitalization and have proposed intervention programs in order to promote early parent–­infant intimacy. Some are centered on the parents, others on the infant or on the parent–­infant relationship (Kaarresen et al., 2006). Zeanah and colleagues (1984) described three major approaches to help parents in the intensive care nursery: crisis intervention, supportive psychotherapy, and insight­oriented psychotherapy. Often these different approaches may be indicated at different points in the hospitalization. A psychoeducational support for example, has been found to effectively help parents and prevent posttraumatic stress reactions. Helping parents to partner in providing care to the infant in the NICU, enhancing parental feelings of self-­efficacy, and reducing the distress associated with the infant’s birth and hospitalization are all important interventions (Holditch-Davis et al., 2003). Nurses can help parents to voice their feelings in the context of a supportive and empowering environment. During hospitalization, attentive observa-



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tion of the baby can take place in the presence of parents and nurses in a beneficial way. Parents often have a traumatic representation of the infant, a compact image, fixed by fear for the infant’s survival or handicap. An observation of the infant during clustered care helps parents to discover the infant’s specific characteristics, to understand the infant’s behavior and limited interactional abilities, and to see his or her unique personality, all helping to reinforce their investment in the child (Borghini & Forcada Guex, 2004; Golse, 1999; Lebovici & Stoleru, 1994). Interventions centered on the infant’s needs and aimed at minimizing its distress are very important. They necessitate a precise attention to the infant environment, a control of its stimulating or dysstimulating quality, and promote individualized developmental care of the infant. An example is the Neonatal Individualized Developmental Assessment Care Program (NIDCAP; Als, 1986; Als et al., 2004). Supportive interventions are not always effective or sufficient for parents facing successive crisis in the course of prolonged hospitalization of their infant. A flexible psychotherapeutic intervention is an appropriate approach when parents are experiencing difficulties in relating to their infants, with the goal of diminishing parental suffering and promoting the growth and development of the parent–­infant relationship. Psychotherapy should always be accompanied by information, suggestions, or advice in order to help parents meet the infant’s specific needs. Insight-­oriented psychotherapy may be indicated when parents experience significant conflicts related to their own psychic history that manifest in difficult relationships with staff members or continued difficulties in their relationship with the infant (Zeanah, Canger, & Jones, 1984). This approach helps parents to be more aware of the past experiences that are interfering in the relationship with their infant. In general, early individualized familybased interventions during neonatal hospitalization and the transition to home, have been shown to reduce parental stress and depression, increase parental self­esteem, and  improve positive early parent–­ preterm ­infant interactions (Dudek-­Schriber, 2004).

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The mental health consultant in the NICU serves as a liaison who helps to clarify parents’ experiences to the staff and the underlying meaning of parental defensive reactions, as well as assisting the staff in understanding and clarifying their own feelings and possible reactions toward the parents, with the aim of differentiating the position of parents and staff toward the baby, and helping the staff to support parent–­infant relationships.

CONCLUSIONS The preterm infant experience of early stress in critical phases of development may result in a persistent vulnerability and emotional reactivity to secondary stress later in life and it is therefore important to recognize infants’ signs of stress, as well as signs of competencies. Pursuing research on prematurity is of crucial public health importance as severe prematurity is an increasing phenomenon in several occidental countries. Parents’ emotional and affective experiences play a fundamental role in the quality of the parent–­preterm infant relationship and the infant’s outcome. The parental experience can be understood as a traumatic one, as shown in the clinical exploration and the research data. The infant mental health professional’s role is also crucial. Two aspects may be distinguished: liaison work with the hospital staff, and therapeutic work directly with parents and infants aimed at improving the parent–­infant relationship. Preterm birth is certainly accompanied by a number of risk factors that can revive unresolved psychic conflicts in parents that sometimes require specific therapeutic interventions. Even so, infants’ autoregulatory abilities and parents’ capacities to elaborate the traumatic conflicts must not be underestimated in their potential to effect dynamic transformation. The consequences of a preterm birth do not have to follow a causal evolution, with determined repetition and a logic that derives from risk factors. Potential reorganization of experiences through brain neural plasticity should open new frames of research (Ansermet & Magistretti, 2007). This is especially true if it is accompanied with appropriate supportive or therapeutic intervention.

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Acknowledgments We would like to thank Margarita Forcada Guex and Elena Martinez for their helpful and thoughtful comments on this paper

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Muller Nix, C., Forcada Guex, M., Pierrehumbert, B., Jaunin, L., Borghini, A., & Ansermet, F. (2006, July 8–12). Prematurity, maternal stress and mother–child interactions. Paper presented at the 10th World Association for Infant Mental Health meeting, WAIMH, Paris. Muller Nix, C., Nicole, A., Forcada Guex, M., & Ansermet, F. (2001). Prématurité, représentations et traumatisme parental [Prematurity, parental representations and traumatism]. Revue Médicale de la Suisse Romande, 121(3), 241–246. Nagy, Z., Westerberg, H., Skare, S., Andersson, J. L., Lilja, A., Flodmark, O., et al. (2003). Preterm children have disturbances of white matter at 11 years of age as shown by diffusion tensor imaging. Pediatric Research, 54(5), 672–679. Padden, T., & Glenn, S. (1997). Maternal experience of preterm birth and neonatal intensive care. Journal of Reproductive and Infant Psychology, 15, 121–139. Pancer, S. M., Pratt, M., Hunsberger, B., & Gallant, M. (2000). Thinking ahead: Complexity of expectations and transition to parenthood. Journal of Personality, 68(2), 253–279. Papiernik, E., & Goffinet, F. (2004). Prevention of preterm births, the french experience. Clinical Obstetrics and Gynecology, 47(4), 755–767. Patton, G. C., Coffey, C., Carlin, J. B., Olsson, C. A., & Morley, R. (2004). Prematurity at birth and adolescent depressive disorder. British Journal of Psychiatry, 184, 446–447. Perry, B. D., Pollard, R. A., Blakley, T. L., Baker, W. L., & Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation, and “use­dependent” development of the brain: How “states” become “traits”. Infant Mental Health Journal, 16(4), 271–291. Pierrehumbert, B., Nicole, A., Muller Nix, C., Forcada Guex, M., & Ansermet, F. (2003). Parental post-­traumatic reactions after premature birth: Implications for sleeping and eating problems in the infant. Archives of Disease in Childhood: Fetal and Neonatal Edition, 88(5), F400–F404. Pihet, S., Bullinger, A., Mellier, D., & Schaal, B. (1997). Reponses comportementales aux odeurs chez le nouveau-ne premature: Etude preliminaire. [Behavioral responses of preterm newborns to odors: Preliminary study]. Enfance, 1, 33–46. Robertson, C. M., Watt, M. J., & Yasui, Y. (2007). Changes in the prevalence of cerebral palsy for children born very prematurely within a population-based program over 30 years. Journal of American Medical Association, 297(24), 2733– 2740. Saigal, S., Stoskopf, B., Pinelli, J., Streiner, D., Hoult, L., Paneth, N., et al. (2006). Self-­perceived health-­related quality of life of former extremely low birthweight infants at young adulthood. Pediatrics, 118(3), 1140–1148. Salt, A., & Redshaw, M. (2006). Neurodevelopmental follow-up after preterm birth: Follow up after two years. Early Human Development, 82(3), 185–197.

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Schermann-­Eizirik, L., Hagekull, B., Bohlin, G., Persson, K., & Sedin, G. (1997). Interaction between mothers and infants born at risk during the first six months of corrected age. Acta Paediatrica, 86(8), 864–872. Seckl, J., & Meaney, M. J. (2006). Glucocorticoid “programming” and PTSD risk. Annals of New York Academy of Sciences, 1071, 351–378. Singer, L. T., Fulton, S., Davillier, M., Koshy, D., Salvator, A., & Baley, J. E. (2003). Effects of infant risk status and maternal psychological distress on maternal–­infant interactions during the first year of life. Journal of Developmental and Behavioral Pediatrics, 24(4), 233–241. Singer, L. T., Salvator, A., Guo, S., Collin, M., Lilien, L., & Baley, J. (1999). Maternal psychological distress and parenting stress after the birth of a very low-birth-­weight infant. Journal of the American Medical Association, 28(9), 799–805. Stevens, B., Johnston, C., Petryshen, P., & Taddio, A. (1996). Premature infant pain profile: development and initial validation. Clinical Journal of Pain, 12(1), 13–22. Stjernqvist, K., & Svenningsen, N. W. (1999). Tenyear follow-up of children born before 29 gestational weeks: Health, cognitive development, behaviour and school achievement. Acta Paediatricae, 88(5), 557–562. Stromme, P., & Hagberg, G. (2000). Aetiology in severe and mild mental retardation: A population-based study of norwegian children. Developmental Medicine and Child Neurology, 42, 76–86. Taddio, A., Katz, J., Iiersich, A. L., & Koren, G. (1997). Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet, 349, 599–603. Taylor, A., Fisk, N. M., & Glover, V. (2000). Mode of delivery and subsequent stress response. The Lancet, 355, 120. Tu, M. T., Grunau, R. E., Petrie-­T homas, J., Haley, D. W., Weinberg, J., & Whitfield, M. F. (2007). Maternal stress and behavior modulate relationships between neonatal stress, attention, and basal cortisol at 8 months in preterm infants. Developmental Psychobiology, 49(2), 150–164.

Walther, F. J., den Ouden, A. L., & Verloove­Vanhorick, S. P. (2000). Looking back in time: Outcome of a national cohort of very preterm infants born in the Netherlands in 1983. Early Human Development, 59(3), 175–191. Wheller, L., Baker, A., & Griffiths, C. (2006). Trends in premature mortality in England and Wales, 1950–2004. Health Statistics Quarterly, 31, 34–41. Wijnroks, L. (1998). Early maternal stimulation and the development of cognitive competence and attention of preterm infants. Early Development and Parenting, 7, 19–30. Wijnroks, L. (1999). Maternal recollected anxiety and mother–­infant interaction in preterm infants. Infant Mental Health Journal, 20(4), 393–409. Wilson-­Costello, D., Friedman, H., Minich, N., Siner, B., Taylor, G., Schluchter, M., et al. (2007). Improved neurodevelopmental outcomes for extremely low birthweight infants in 2000–2002. Pediatrics, 119(1), 37–45. Winnicott, D. W. (1989). The mother–­infant experience of mutuality. In Psychoanalytic explorations. Cambridge: Harvard University Press. (Original work published 1969) Wolf, M. J., Koldewijn, K., Beelen, A., Smit, B., Hedlund, R., & deGroot, I. J. (2002). Neurobehavioral and developmental profile of very low birthweight preterm infants in early infancy. Acta Paediatrica, 91(8), 930–938. Yehuda, R., & LeDoux, J. (2007). Response variation following trauma: A translational neuroscience approach to understanding PTSD. Neuron, 56, 19–32. Zanardo, V., Freato, F., & Zacchello, F. (2003). Maternal anxiety upon NICU discharge of highrisk infants. Journal of Reproductive and Infant Psychology, 21(1), 69–75. Zeanah, C. H., & Benoit, D. (1995). Clinical applications of a parent perception interview in infant mental health. Child and Adolescent Psychiatric Clinics of North America, 4(3), 539–554. Zeanah, C. H., Canger, C. I., & Jones, J. D. (1984). Clinical approaches to traumatized parents: Psychotherapy in the intensive-care nursery. Child Psychiatry and Human Development, 14(3), 158–169.

C h a p t e r 12

The Effects of Violent Experiences on Infants and Young Children Daniel S. Schechter Erica Willheim

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n reviewing the literature over the past 10 years on the effects of violence on infant and early childhood development, we begin this chapter with a conclusion: There is no longer any question that experiences of violence and maltreatment adversely and enduringly alter neurobiological development, psychological and social functioning, and subsequent expectations of the environment (Kaufman, Plotsky, Nemeroff, & Charney, 2000). The questions that remain are to what degree and in what ways is early development affected by violent experience and maltreatment. In other words: •• Which effects follow from specific types of, and frequency of exposures to, events? •• What is the impact of an individual infant’s or child’s constitution? •• Is there a differential impact of adverse events depending on specific critical periods of development? •• What is the effect of the exposure in the context of specific relationships in which the meaning of the experience(s) is coconstructed? Answering these questions is crucial to the clinical assessment and effective treatment



of the sequelae of violent experiences during early childhood and subsequently. Following an overview of pertinent epidemiology regarding the scope of early childhood exposure to violence, we briefly discuss the nature of the trauma and known sequelae of violence exposure. Next we review historical, psychological, and neurobiological aspects of the following dimensions: individual differences and gene–­environment interactions, violence exposure in the context of critical developmental periods, and the relational context of violence exposure and related meaning making. Finally, we review what is now known and under study regarding interventions specifically targeted at interrupting or ameliorating the deleterious effects of early childhood exposure to violent trauma. Although we have organized this chapter into four broad dimensions (exposure, constitution, development, and attachment), it is important to state at the outset that, in reality, it is quite difficult to tease apart these dimensions. A helpful metaphor may be that of looking through a crystal. In examining the effects of violence on very young children, whichever side of the crystal you gaze into, you cannot help but see all other sides reflected back. 197

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EPIDEMIOLOGY OF EXPOSURE TO VIOLENCE In many ways, the past decade in the United States has been an unfortunate naturalistic case study in the multiple modalities by which children may be exposed to violence. Children can be the victims of, or witnesses to, interpersonal, familial, community, and international violence. The World Trade Center attack in 2001 and the start of the Iraq war in 2003 literally brought home the impact of terrorism and war for this generation of American children. From the Columbine High School shootings of 1999 to the nursery school knife attack in western Belgium of 2009, the media has repeatedly sent a message to parents over the past decade that even the youngest children are not necessarily protected from lethal violence in school settings to which parents entrust their children’s safety. Additionally, we are increasingly cognizant of the degree to which children have become witnesses of actual violence through the media. We begin with the available data on national exposure rates, with particular attention to the experience of very young children. In 2005, approximately 3.6 million children were the subject of child protective services (CPS) investigations nationally. From these reports, the total estimated number of children determined to be victims of abuse or neglect was 899,000, a rate of 12.1 per 1,000 same-age children in the general population (U.S. Department of Health and Human Services, 2006). Overall, 63% of child maltreatment victims suffered neglect, 17% physical abuse, and 9% sexual abuse. Just over half of the victims (54.5%) were 7 years old or younger. The highest rate of victimization was found for the 0–3 group, with an incidence of 16.5 per 1,000, followed by 4- to 7-year-olds with 13.5 per 1,000. The types of maltreatment suffered by children under 3 years old were 73% neglect, 12% physical abuse, and 2% sexual abuse. Out of an estimated 1,460 child fatalities due to maltreatment, nearly 77% were children under 4 years of age. In comparison to the overall estimated rate of 1.96 deaths per 100,000 children, infant boys under the age of 1 had a fatality rate of 17.3, and infant girls under the age of 1 had a rate of 14.5 deaths. Nearly 80% of all maltreated children were abused by a parent.

The figures typically cited for child exposure to intimate partner violence have been 10–20% of children yearly, that is, between 3.3 and 17.8 million youth (Carlson, 2000). However, this estimation is problematic (Gelles, 1997; Osofsky, 2003) because it was originally derived from data that are now more than 20 years old (Straus, Gelles, & Steinmetz, 1980) and only included homes with children between the ages of 3 and 17. We do know that for each year between 1993 and 2004, children under the age of 12 lived in households, an average of 40% of which (nearly 350,000) was the site of intimate partner violence (IPV; Catalano, 2006). A more recent study, using a nationally representative sample, estimated that approximately 15.5 million children were living in homes where domestic violence had occurred at least one time in the preceding year, with 7 million children likely exposed to more severe IPV (McDonald, Jouriles, Ramisetty­M ikler, Caetano, & Green, 2006). In order to examine not only the frequency with which children witness IPV but also their age and level of sensory exposure, Fantuzzo and Fusco (2007) worked with a large Northeastern county police department to collect exposure data. As assessed by the responding police officers, children were present for 43% of domestic violence episodes, 92% of which involved violence against the children’s mother. The authors report that 81% of the children present either heard and/or saw the event, and that 60% of these directly exposed children were younger than 6 years old. An earlier study in Rhode Island reported similar findings: Children were present at 44% of all domestic violence episodes, with 47% of child witnesses less than 6 years old (Gjelsvik, Verhoek-­Oftedahl, & Pearlman, 2003). The prevalence of child exposure to violence has been further highlighted by reports of the co-­occurrence of child maltreatment and IPV. In a national sample of 3,612 female caregivers of children in the CPS system but living at home, 44.8% of the sample reported lifetime physical violence perpetrated by an intimate partner, with 29.% reporting IPV in the preceding year alone (Hazen, Connelly, Kelleher, Landsverk, & Barthm, 2004). This finding is consistent with previous findings of a median co-­occurrence rate of 41% (Appel & Holden, 1998) and 30– 60% (Edleson, 1999).



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Definitions of community violence vary in their scope but generally refer to violence experienced or witnessed in proximity to homes, schools, and neighborhoods. Stein, Jaycox, Kataoka, Rhodes, and Vestal (2003) have compiled a comprehensive review of studies investigating child exposure to community violence, conducted between 1991 and 2002. Despite variations in community samples, definitions of exposure, and study methodologies, one conclusion emerged: Children living in low-­income, urban, and predominantly minority communities were repeatedly found to experience extraordinarily high rates of community violence exposure. Only a handful of studies has investigated prevalence rates for mothers and preschoolers (ages 3–5) living in high-risk urban centers. In Washington, DC, using an innovative child interview technique, parents and children separately reported on rates of child exposure to violence (Shahinfar, Fox, & Leavitt, 2000). Overall, 66.5% of parents and 78.1% of children reported that the child had witnessed, or been the victim of, at least one violent incident. In Boston, Linares et al. (2001) asked mothers to report on their own degree of exposure and that of their child, excluding IPV. They found that 81% of mothers and 42% of children witnessed one event, 21% of children witnessed three or more events, and 12% of children witnessed eight or more events. In Los Angeles, 71% of mothers reported witnessing violence, and 65% reported victimization. The mean number of maternal and child community violence exposures was 10.69 and 10.09, respectively (Farver, Xu, Eppe, Fernandez, & Schwartz, 2005). There are no reliable estimates of how many very young children are affected by terrorism and war around the world (Costello, Erkanli, Fairbank, & Angold, 2002), but the United Nations Children’s Fund (UNICEF, 2004) estimates that 300 million children worldwide are subject to violence, exploitation, and abuse. Approximately 250,000 are currently serving as child soldiers, 2 million children are sexually exploited, 20 million children have been displaced from their homes, and since 1990, 1.6 million children have died in armed conflicts. The United States is home to increasing numbers of child refugees who have been exposed to war and terrorism and who suffer relatively

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high rates of posttraumatic stress disorder (PTSD; Allwood, Bell-Dolan, & Hussain, 2002). The media and Internet are additional forms of violence exposure that are of increasing interest and importance. Inability to distinguish media presentations from real and/or personal experience at an early age also raises questions in terms of the complexity of traumatic exposure for very young children. That violent media has behavioral effects on preschool-age children has been known for many years (Stein & Friedrich, 1972). Recent studies of families with young children have demonstrated an association between familial preference for viewing violent media and history of actual and/or current traumatization in the primary caregiver who allows and/or promotes the violent media viewing (Schechter, 2006).

NATURE OF THE EXPOSURE Exposure to a traumatic event is generally defined in terms of proximity to the event, degree of injury or exposure to injury and/ or loss of life, as well as perceived threat of injury and/or loss of life. Since infants and very young children have a limited capacity to judge threat and rely on their caregivers for survival, exposure becomes a more complex issue for this age group. However, the effects of violent trauma and maltreatment on psychopathology in infants and young children are increasingly well documented. A common finding, regardless of age group, is the association between violent trauma and risk for a broad range of psychiatric conditions covering domains of functioning as varied as sleeping, feeding, elimination, anxiety, mood, somatization, behavior, attentional regulation, language development, dissociative processes, self­endangering behaviors, as well as numerous autoimmune and other medical conditions (Driessen, Schroeder, Widmann, von Schonfeld, & Schneider, 2006; Dube et al., 2001; Seng, Graham-­B ermann, Clark, McCarthy, & Ronis, 2005). Although child maltreatment may vary in terms of type, severity, developmental stage, perpetrator, and chronicity, the deleterious effects have been conclusively established (Cicchetti & Lynch, 1995). For example, maltreated children generally exhibit greater internalizing

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and externalizing problems, lower levels of ego resiliency, and greater ego undercontrol. Abuse in infancy and toddlerhood negatively impacts later middle childhood adjustment, and children with histories of both sexual and physical abuse demonstrate the lowest levels of ego resiliency and highest rates of ego undercontrol (Manly, Kim, Rogosch, & Cicchetti, 2001). When the caregivers on whom the infant or young child is dependent are themselves the source of threat, such as in the instances of maltreatment and family violence, profound effects are noted in virtually every area of subsequent development, including fundamental disturbances of relatedness (Cicchetti, Toth, Bush, & Gillespie, 1988). Witnessing domestic violence in childhood is linked to adult aggression in intimate relationships (Ehrensaft et al., 2003). In a meta-­analysis of over 100 studies on child witnesses to domestic violence, Kitzmann, Gaylord, Holt, and Kenny (2003) concluded that within childhood, there is a significant association between exposure and behavioral, social, and academic problems. Interestingly, the outcomes for children who witness IPV are significantly different from nonwitnesses, but not significantly different from those of physically abused children. Preschool witnesses have been shown to suffer disturbances in multiple domains, with severe internalizing and externalizing symptoms (Lieberman, Van Horn, & Ozer, 2005). Levendosky, Leahy, Bogat, Davidson, and von Eye (2006) have shown that infants exhibit trauma symptoms and externalizing behaviors (aggression, negative emotional reactivity, activity level) in cases where severe violence has occurred and their mothers suffered trauma. Consistent with Scheeringa and Zeanah’s model of relational PTSD (2001), maternal functioning can serve as a mediator and/or moderator between current domestic violence and infant externalizing behaviors, with maternal regulation either inhibiting or promoting infant regulation and resilience. Community violence has been found to negatively impact cognitive performance as well as peer relations in preschoolers (Farver, Natera, & Frosch, 1999). The effects of community violence on internalizing and externalizing behaviors in young children similarly appear to be mediated or buffered by maternal psychological functioning (Bai-

ley, Hannigan, Delaney-Black, Covington, & Sokol, 2006; Margolin & Gordis, 2000). Terrorism and war erode the safety and predictability of a young child’s world. Critical variables are the degree of exposure, amount of family support during and after, impact on primary caregivers, degree of life disruption, and degree of social chaos. In studies of direct exposure, a dose–­response effect is found, with greater exposure resulting in more severe risk of PTSD (Pine, Costello, & Masten, 2005). For preschoolers living in war zones, higher levels of traumatic exposure are related to severity of behavioral and emotional symptoms (Thabet, Karim, & Vostanis, 2006). Indirect exposure appears to have a more deleterious effect on children with prior trauma but does not necessarily result in PTSD for most children (Pfefferbaum et al., 2003). For young children indirect exposure does, however, create an atmosphere and perception of danger that can induce separation anxiety, new fears, and avoidant behaviors (Pynoos, Schreiber, Steinberg, & Pfefferbaum, 2005). A study via maternal report on 1- to 4-year-old children in Israel found a differential pattern of associations between types of trauma exposure: direct exposure to terrorism, media exposure to terrorism, and other trauma (Wang et al., 2006). Direct exposure was significantly associated with an increased risk of externalizing and internalizing problems. Exposure to television coverage for a minimum of 5 minutes daily or more was associated with a greater risk of emotional reactivity and sleep problems. Oppositional behavior and other forms of externalizing and aggressive behavior were also noted. Non-­terrorism-­related trauma produced greater anxiety and other internalizing symptoms without notable externalizing symptoms. These traumatic events tended to be nonviolent (e.g., car accidents, other accidents, dog bites, medical/surgical trauma). Among those young children who do develop PTSD, a substantial number also have comorbid psychopathology, including oppositional defiant disorder and other anxiety disorders (Scheeringa & Zeanah, 2008; Scheeringa, Zeanah, Myers, & Putnam, 2003). Yet, some traumatized preschool children develop no discernable psychopathology and may display subtler or subthreshold difficulties that defy presently used diagnos-



12. The Effects of Violent Experiences

tic categories. The nature of exposure, gene–­ environment interaction, developmental factors, and attachment relationships may steer the individual victim of violent trauma down multiple pathways of psychopathology without obvious PTSD. Despite low rates of concurrent childhood PTSD, the notion of resilience to mental disorder has significant limitations. In fact, the rates may be deceptively low in childhood and particularly in early childhood for several reasons. First, as Scheeringa has shown (Scheeringa, Wright, Hunt, & Zeanah, 2006) the symptoms required for the diagnosis of PTSD, as described in the DSM-IV, are not developmentally attuned to the capacities of most very young children (i.e., symptom criteria B, C, and D: reexperiencing, avoidance, and hyperarousal respectively). Second, a more challenging problem occurs when a very young child meets the DSM-IV traumatic event criterion (i.e., “Criterion A”) for the diagnosis of PTSD. The meaning of a given experience as “traumatic” is likely not understood as such by infants and very young children, even though anxiety is generated in response to the sense of traumatization by caregivers and/or others in the environment. This is to say that infants and toddlers do not often have the capacity to accurately appraise threat and the consequences of traumatic exposures, and so depend on their caregivers for this appraisal. Finally, the linking of PTSD symptoms temporally to the occurrence of a violent event is required for the diagnosis of PTSD. For many infants and preverbal children, this temporal link will not be possible to make. For example, a foster child may present with symptoms of full-blown PTSD but without any record of clear physical or sexual abuse. So, in such cases, one may infer PTSD or rule-out PTSD pending more information. And yet, even infants have the capacity to develop avoidance and hyperarousal to traumatic reminders, if not discernable reexperiencing symptoms (Kaplow, Saxe, Putnam, Pynoos, & Lieberman, 2006). Regardless of the age of the child, a discernable and enduring or frequently recurring change of behavior that is associated with impairment and/or distress, following an index event or coinciding with a prolonged exposure (i.e., to domestic violence or maltreatment), is the most likely sign of a need for evaluation of psychopathology, re-

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gardless of whether the behaviors or symptoms fit neatly into any particular diagnostic category.

CONSTITUTIONAL DIFFERENCES IN INFANTS Threats to the infant’s survival, whether directly to his or her person or to his or her caregiving system, result in activation of the fight–­fl ight–freeze response associated with fear conditioning. Failure to extinguish the fear response and the psychobiological cost of that failure are thought to lead to posttraumatic psychopathology. Activation of the two principal stress-­reactivity mechanisms associated with fear conditioning are most often prompted by the limbic system, most prominently the amygdala, leading to activation of the sympathetic branch of the autonomic nervous system (i.e., increased heart rate) via quick-­acting noradrenergic emission, and the hypothalamic-­pituitary–­ adrenal axis via the slower-­acting central glucocorticoid secretion (i.e., leading to increased circulating cortisol, binding at central nervous system sites such as the hippocampus and medial prefrontal cortex). Increased cortisol levels also result in an elevation of blood glucose, which sustains the organism during the fight–­fl ight–freeze response and helps to quell the sympathetic nervous system arousal (see Rifkin-­Graboi et al., Chapter 4, this volume). Children exposed to marital violence and maltreatment have been shown to have increased activation of both of these systems (Saltzman, Holden, & Holahan, 2005). Evidence has accumulated that chronic exposure to stress in early childhood is tantamount to an environmental toxin affecting the developing central nervous system and leading to enduring adverse effects across a range of brain structures and functions, as well as mental and physical problems and susceptibility to illness (McEwen, 2003). However, it is not just what happens and when it happens to the infant that determines long-term outcome. It matters quite clearly who that infant is, constitutionally, in terms of how the effects will manifest. The field of infant mental health is rapidly assimilating recent understanding of “gene–­ environment interactions” or (“G × E”). In the Dunedin study (Caspi et al., 2002), a func-

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tional X-linked variant or “polymorphism” of the gene encoding the neurotransmitter­metabolizing enzyme mono­­amine oxidase-A (MAO-A) was found to moderate subsequent effects of physical abuse, thereby explaining variability in outcome. Those with the variant conferring high levels of MAO-A expression were less likely to develop violent and other deviant behavior indicative of antisocial behavior. These findings were replicated and extended in two other studies of abused and neglected white children (Nilsson et al., 2007; Widom & Brzustowicz, 2006), although another study with a more diverse sample failed to replicate this effect (Huizinga et al., 2006). Further study is thus needed in this area. At least two studies have demonstrated the association between life stress and negative life events, as well as major depression, in the presence of a specific genetic polymorphism (Caspi et al., 2003; Silberg, Rutter, Neale, & Eaves, 2001). In the latter study, presence of the short allele of the promoter region of the serotonin transporter gene (5-HTT) in combination with life stress was considered to be a risk factor for depression. Specific inherited genetic variants may thus augment risk for traumatic life experiences to cause the organism to follow one or another developmental path (Fischer et al., 1997). Developmental differences are also challenging. For example, because adult patients with PTSD due to childhood physical and sexual abuse were noted to have had lower hippocampal volumes (Bremner et al., 1997), one possibility proposed was that individuals born with smaller hippocampi would be vulnerable to PTSD. This hypothesis was supported in a twin study (Gilbertson et al., 2002). DeBellis et al. (2002), however, did not find that maltreated children showed these differences in the hippocampus, as compared to nonmaltreated matched controls— even though maltreated children exhibited other differences, such as the size of the midsagittal corpus callosum. Most recently, a prospective study of children with PTSD has shown that, consistent with the work of Sapolsky (2000), traumatic stress-­associated insult to the hippocampus during formative development is associated with smaller hippocampi subsequently (Carrion, Weems, & Reiss, 2007). We have very few data about children in the first 3 years of life, however.

DEVELOPMENTAL CONTEXT In describing the effects of trauma upon development, Fischer et al. (1997) have stated that “contrary to the standard assumption that psychopathology stems from developmental immaturity,” psychopathology is actually a form of “adaptation” to trauma, with the individual deviating from normative developmental frameworks (p.  749). With respect to maltreatment, Fischer et al. note that children who are victims of maltreatment have normal developmental complexity but distinctive affective–­cognitive organizations with specific features such as negative attribution biases in play and distorted representations of interactions. Similarly, Cote, Vaillancourt, Barker, Nagin, and Tremblay (2007) have shown that hostile parenting interferes with the redirection of normative aggression to socially acceptable behavior, and is significantly associated with higher levels of interpersonal difficulties, including hostile peer-­directed aggression persisting beyond 2 years of age. Development has also been shown to impact the risk for maltreatment (Horner­Johnson & Drum, 2006) as well as the expression of the effects of maltreatment and violent trauma by virtue of its being delayed or otherwise fundamentally or pervasively disturbed (Turk, Robbins, & Woodhead, 2005). Just as the preverbal infant has been shown to express adverse effects of violent traumatization, the language-­delayed or disturbed preschooler also has been shown to display behavioral signs of violent traumatization to the trained clinician (Cook, Kieffer, Charak, & Leventhal, 1993; Turk et al., 2005). Further complicating the interaction of violent trauma and child development, maltreatment has itself been associated with language delay in vocabulary, production of syntactic structures, as well as internal state language (Beeghly & Cicchetti, 1994; Eigsti & Cicchetti, 2004). The tragedy remains, however, that violent experience and maltreatment during the first 5 years of life can do the most damage to the developing brain and mind, and yet it is during this same period when the majority of abuse, neglect, and family violence occurs. It is also during this period when the forms of parental psychopathology and substance abuse that often contribute to the



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occurrence of traumatic events are at their most noxious. Next we discuss the impact of developmental organization on the shaping of what constitutes an exposure, as experienced by the child victim; the neurobiological effects of exposure; and the encoding, processing, and retrieval of traumatic memory and its influence on the effect of subsequent traumatic experience.

Developmental Considerations of Exposure In reviewing the language of the DSM-IV, we can readily appreciate how infants and young children may not be aware that an event has posed to them “actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” even though most children are exposed to one or more of these events from infancy onward (Copeland, Keeler, Angold, & Costello, 2007; Costello et al., 2002). Similarly, an infant or toddler might perceive an event as life threatening that would not be felt as life threatening to an older child or adult; for example, a parent pushing another parent violently during an argument, or a sibling pushing the toddler down in a bathtub, resulting in the child’s head being briefly submerged in very shallow water. Rather, very young children may show fear for other reasons. As Eth and Pynoos (1994) have described in reviewing cases of children who have witnessed the homicide of a parent, young children are more likely to find an unanticipated aspect most disturbing, such that the clinician needs to ask, in an open-ended way, what was scary to the child. For example, the removal of the parent’s corpse by strangers in an ambulance may be more disturbing than the actual murder. Additionally, concepts of human malevolence and death are not fathomable in the first 3 years of life, but emerge between 3 and 5 years (Barrett & Behne, 2005). A man wielding a gun in the near vicinity may not be inherently frightening to the infant or toddler. However, beginning with the developmental achievement of secondary intersubjectivity at approximately 8–10 months, infants are able to experience the fear felt by others around them and become frightened. Even infants younger than 8 months are able to sense their caregivers’ fear and

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hyperarousal, and may become distressed in response to the reaction of the caregiver to the impending trauma, rather than to the threat itself. By 18 months, as toddlers develop increased representational capacity that allows them to compare mental representations of expected appearances and behaviors based on prior relational experience, with new input, they attain greater capacity to appreciate, reenact, and remember real-life experiences, including a potential threat to themselves and their caregiver(s) (Lukowski et al., 2005; Simcock & DeLoache, 2006). Scheeringa and Zeanah (1995) found that the most powerful trauma factor in young children following exposure to a traumatic event was threat to the caregiver. This finding was replicated in a study of children 1–18 years (Scheeringa et al., 2006).

Neurobiology We noted earlier in this chapter that violent trauma early in life—­particularly when involving repeated and severe exposure—­ impacts the central nervous system, brain development, and the overall health of the individual (McEwen, 2003). We now review in greater depth the underlying neurobiology of the sequelae of violence exposure in a developmental and relational context. Preclinical studies have shown that areas of the brain that are particularly prone to the adverse effects of maltreatment and violent trauma during the first 3–5 years of life include (1) those that have a prolonged postnatal developmental period, (2) those with a high density of glucocorticoid receptors, and (3) those that have the potential for postnatal neurogenesis (Teicher et al., 2003). These areas include, most prominently, the hippocampus, amygdala, corpus callosum, cerebellar vermis, and the cerebral cortex. When a rat infant undergoes severe stress, such as repeated foot shocks, the hippocampus fails to form the expected density of synaptic connections. Normative pruning of these connections nonetheless occurs later in the prepubertal period, so adult animals who were repeatedly stressed in infancy end up with far fewer synaptic connections in this region (Andersen & Teicher, 2004). These results support Carrion et al.’s (2007) findings that differences in hippocampal volume

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in patients with PTSD are more likely due to the neurotoxicity of stress hormones than to a constitutional size difference. Clinical implications of hippocampal and amygdalar damage due to stress hormones may include increased propensity for confusion of past and present, flashbacks, and dissociative symptoms (Sakamoto et al., 2005). The corpus callosum is a heavily myelinated region of the brain that is associated with hemispheric integration. High levels of stress hormones during infancy and early childhood have been associated with suppressed glial cell division, which is critical for myelination (Berrebi et al., 1988). DeBellis et al. (2002) observed that reduced corpus callosum size was the most significant structural finding noted in children with a history of maltreatment and PTSD. Disturbances in the myelination of the corpus callosum and cortex due to excessive exposure to glucocorticoids during the first 3 years of life may explain some of the difficulties that maltreated preschool-age children have in integrating cognitive and emotional information and in taking others’ perspective, in comparison to nonmaltreated age-­matched controls (Pears & Fisher, 2005). Among the most exciting research that illustrates the interaction of development and traumatic experience is that regarding the differential effects of specific types of maltreatment and violent trauma on the brain at critical periods of development through early adulthood in both animal and human models (Hall, 1998; Teicher, Tomoda, & Andersen, 2006). For example, repeated episodes of child sexual and physical abuse were associated in the same group of subjects with reduced hippocampal volume if the abuse was reported to occur in early childhood, but with reduced prefrontal cortex volume if the abuse occurred during adolescence (Teicher, 2005). Similar exposure during different, temporally discrete windows of development may have very different clinical implications.

Effects on Memory The psychological and neurobiological implications of exposure to traumatic events also involve the infant and young child’s developmentally determined capacity to encode, remember, and recall those events in order

to subsequently make meaning of their experience. Recent evidence suggests that even prior to 1 year of age, infants’ capacity to recall events is well underway. By the end of the second year of life, long-term memory is reliably and clearly present, especially when there have been reinforcing memories (i.e., repeated exposures or explicit reminders), which are unfortunately all too common in cases of maltreatment and family violence (Bauer, 2006; Hartshorn & Rovee-­Collier, 2003). Based on her review of the literature, Fivush (1998) has noted that traumatic events perceived before the age of 18 months are frequently not verbally accessible, whereas events experienced between 18 and 36 months can often be coherently recounted and retained as long-term memories. Two important case studies have raised the issue of memory and recall in infancy and early childhood. Two young children endured severe direct exposure to the murder of their primary caregiver, one at 12 months (Gaensbauer, Chatoor, Drell, Siegel, & Zeanah, 1995) and the other at 19 months (Kaplow, Saxe, Putnam, Pynoos, & Lieberman, 2006). Both cases suggest that under such extreme circumstances traumatic memories are encoded in detail and consolidated, although they may yet not be readily accessible to verbal narrative memory. Such individuals with early exposure remain vulnerable to triggers of their traumatic memories. As is found in many children who were maltreated prior to 2 and 3 years of age, they may display difficulty in regulating their emotional responses when confronted with high degrees of negative emotion in themselves or others. They may also have difficulty in developing coherent, balanced self-­representations, consistent behavioral organization, and trust leading to the development of new relationships (Hartman & Burgess, 1989). Early chronic and/or severe exposure to violence and/or maltreatment has also been noted to lead to greater pervasive insult to memory functions and to promote dissociative processes that can interfere with memory retrieval (Howe, Cicchetti, & Toth, 2006; Nelson & Carver, 1998). One mechanism for this biological insult to memory function is thought to be primarily the effect of excessive glucocorticoids, which damage the developing structures involved in memory contextualization and storage, such as the



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hippocampus (Sapolsky, 2000; Sapolsky, Uno, Rebert, & Finch, 1990). It is clear that over the course of formative development, exposure to violent trauma and maltreatment can affect the degree and nature of changes in the neurobiology of the brain.

THE RELATIONAL CONTEXT In support of the notion that exposure is extensively shaped by relational experience, Freud and Burlingham (1943) said the following about young children’s experience during the London Blitz in World War II: The war acquires comparatively little significance for children so long as it only threatens their lives, disturbs their material comfort, or cuts their food rations. It becomes enormously significant the moment it breaks up family life and uproots the first emotional attachments of the child within the family group. London children, therefore, were on the whole much less upset by bombing than by evacuation to the country as a protection from it. (p. 37)

The violent traumatization of an infant or very young child, whether due to maltreatment or exposure to familial, community, war, or terroristic violence, is most significantly a breach in safety. Unlike older children or adults, very young children experience their world contextually, from within the embrace of the primary attachment relationship (Scheeringa & Zeanah, 2001). Their sense and expectation of safety are therefore inherently bound to the caregiver. To appreciate the effects of violence on young children requires an understanding of the goals and mechanisms involved in the attachment relationship as well as the ways in which trauma impacts attachment.

Attachment, Safety, and Violence In the anchoring concept of attachment theory, the ethological wisdom of a caregiver–­ infant behavioral system is seen as ensuring species’ survival (Bowlby, 1969). The infant’s drive to maintain safety is paramount and is expressed in attachment behaviors that may phenotypically change over time but that serve the same purposeful goal of achieving “felt security” (Bretherton, 1990). Perturbations in the infant’s ability to achieve felt se-

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curity necessarily result in adaptations that may be more or less pernicious, depending on the quality and degree of frustration. In response to the primary attachment figure’s track record of providing “felt” security, the infant constructs an “internal working model” of self and other. This internal representation consolidates over the first 3 years of life and guides the infant’s expectations and behaviors in times of stress. The experience of violence, with its attendant physiological “felt anxiety,” might therefore be conceptualized as the exact affective opposite of felt security. The young child does not yet have the cognitive ability to mediate feelings of fear that result when exposed to violence, either as victim or witness. For young children, the caregiver’s role is to function as external regulator of negative or overwhelming internal affect and sensation. Several violence scenarios may be imagined in which the caregiver is unavailable to soothe infant anxiety: when the caregiver is being victimized, when the caregiver is a witness to violence and becomes too hyperaroused or too dissociated/avoidant to provide safety, or when the caregiver is the source of the violence—as in the case of parental child abuse (Carlson, 2000). A toddler who has internalized a working model in which he or she is unprotected and repeatedly left subject to overwhelming fear—one of the definitional criterion for trauma—may develop what has been termed distortions in secure-base behavior (Lieberman & Pawl, 1990). Such distortions are, in fact, attempts by the child to manage unmanageable anxiety without the actual or “real time” mentally represented assistance of the caregiver. If early childhood is characterized by a relational context in which the child’s ability to manage stress is determined by caregiver response, then the mental health status of the caregiver becomes a vital concern. Fraiberg, Adelson, and Shapiro (1975) called attention to the profound effects of maternal mental health on the developing child. The “ghosts in the nursery” that Fraiberg et al. described were malevolent internalized attachment figures who had subjected the caregiver to various forms of maltreatment during his or her own childhood. Fraiberg et al. observed that caregiver traumatization in the past resulted in (1) his or her present-day inability to respond appropriately to infant anxiety,

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or (2) his or her engagement in behavior that actually induced anxiety. From an attachment perspective, the infant’s working model of self and other is thereby shaped by the caregiver’s disturbed attachment representations. Exploring representational models, Fonagy et al. (Fonagy, Moran, Steele, Steele, & Higgitt, 1991; Fonagy, Steele, Moran, Steele, & Higgitt, 1993) identified the capacity for “reflective functioning” as an awareness of a meaningful relationship between underlying mental states (feelings, thoughts, motivations, intentions) and behavior in and between both self and others. Fonagy’s group found that caregiver reflective functioning was significantly predictive of infant attachment classification. The caregiver’s capacity to “read” infant mental states accurately, and with inference of meaning, allows for sensitively attuned responses that create a subjective experience of security/safety and support the infant’s developing capacity for self-­regulation (Bretherton & Munholland, 1999). However, when engaging in reflective functioning leads to the experiencing of highly negative affect, certain aspects of mental functioning may be defensively inhibited (Fonagy, Steele, Steele, Higgitt, & Target, 1994) or excluded (Bretherton, 1990). A caregiver in a state of defensive inhibition will be incapable of accurately responding to and reflecting the child’s mental state, leaving the child to manage states of arousal and anxiety on his or her own. Consistent with this formulation is the finding that young children assessed as having a disorganized attachment have caregivers who are often unresolved with respect to past traumatic experience (Lyons-Ruth & Jacobvitz, 1999). In short, caregiver history of attachment relationships and of trauma exposure determines not only the dyad’s quality of attachment, via reflective functioning, but additionally the manner in which trauma exposure will be processed by both child and caregiver. Thus, traumatic violence can interfere with the initial development of a secure and organized attachment or derail a previously secure attachment if the caregiver is sufficiently adversely affected. Disturbances in attachment, in turn, confer increased for (1) recovery from trauma exposure by the child and/or caregiver (Fisher, Gunnar, Dozier, Bruce, &

Pears, 2006), (2) enactment of maltreatment by the traumatized caregiver (Cicchetti, Rogosch, & Toth, 2006), (3) child exposure to trauma via inadequate caregiver monitoring (Schechter, 2006; Schechter, Brunelli, Cunningham, Brown, & Baca, 2002; Schechter et al., 2005), and (4) subsequent repetition and transmission of risk by the traumatized child and/or caregiver (Weinfield, Whaley, & Egeland, 2004). Such evidence supports the contention that we must view infant mental health disturbances through the dual conceptual lenses of attachment theory and trauma theory (Lieberman, 2004). Recognition of the importance of the relational context surrounding experiences of trauma in clinical assessment and treatment has emerged in several applications, one of which described mediating, moderating, and mixed mediating–­moderating effects on PTSD within the parent–child relationship (Scheeringa & Zeanah, 2001), and another that considers the importance of assessing parents’ awareness of child states following terrorism or disaster (Coates, Schechter, & First, 2003).

Relational Neurobiology Like all psychological functions, the child’s expectations in relation to attachment figures have neurobiological correlates. In addition to the effects of cortisol noted earlier, physical abuse, compounding its clear effects on emotion regulation and separation anxiety within the context of attachment, has been found to be associated with attentional dysregulation and selective biases to angry and negative affect (Pollak & Torrey­Schell, 2003). Moreover, from early infancy, children are dependent on their attachment figures to reflect back to them how they are feeling and to make sense of their experience. Expectation of contingent responsiveness during early infancy has been described empirically in the work of Gergely and Watson (1996), who also first described the “marking” of the infant’s affect by the primary caregiver—the processing and modulation of that affect, which feeds back a sense of empathy as well as serving a modulatory function for the baby, beginning in the period of the second to fifth months of life. Subsequently, Gergely (2001) noted that lack of marking



12. The Effects of Violent Experiences

and overidentification with the child’s perspective may interfere with affect regulation, particularly around crises and trauma. We now know that specific neural circuits in the developing brain, among which the mirror neuron system figures prominently, are crucial to the development of social cognition, self-­awareness, affect regulation, and learning (Iacoboni & Dapretto, 2006). The functional implications of these cortical premotor planning and parietal structures in the context of early development are only just beginning to be understood. The impact of violence exposure on the development of these circuits with respect to expression of aggression remains to be studied Myron Hofer (1984) has described multiple “hidden regulators” embedded within the attachment system across mammalian species. The need for mutual regulation of emotion and arousal in humans lasts approximately as long as it takes for integrative structures in the brain to myelinate and prefrontal cortical areas to develop, all of which serve to assist the child in self-­regulation in the face of stress and fear. In other words, the primary caregiver is, during the first 5 years of life, crucial to the infant’s developing self­regulation. The hidden regulators embedded within the attachment system include those of sleep, feeding, digestion, and excretion as well as higher functions of emotion, arousal, and attention. The literature contains many examples of how the sequelae of a caregiver’s experience of violent trauma and maltreatment, PTSD, affective disorders, severe personality disorders, and substance abuse can impair this fundamental regulatory function during formative stages of development, both at the representational and behavioral levels of attachment (Lyons-Ruth & Block, 1996; Schechter et al., 2005; Theran, Levendosky, Bogat, & Huth-Bocks, 2005), and contribute to intergenerational transmission of violent trauma and maltreatment. Neurobiologically based studies of primates, specifically, macaque monkeys, have helped to elucidate the role of attachment in interrupting versus promoting intergenerational transmission of maltreatment (Barr et al., 2004; Maestripieri, 2005; Shannon et al., 2005). In Shannon et al.’s study (2005), maternal absence (i.e., neglect) was associated with decreased serotonin replenishment, a finding associated with mood and impulse

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disorders, as well as with increased alcohol consumption (in Barr et al.’s study, 2004). Recent research has also supported transgenerational transmission of biological response to trauma. Whether this finding proves ultimately to be a risk or resilience factor remains a question. An affected mother’s exposure to violent trauma during pregnancy (i.e., the 9/11 terrorist attacks on the World Trade Center in New York City) and her glucocorticoid stress response were linked to the glucocorticoid levels, upregulation of the receptor setpoint, and behavior of her infant by 9 months of life (Yehuda et al., 2005). Yehuda et al. (2005) found that those mothers who were pregnant, in their second or third trimester, escaped the World Trade Center, and who themselves (along with their babies) had lower salivary cortisol levels one year postpartum, were more likely to develop PTSD subsequently. More strikingly, their infants were also more likely to have lower salivary cortisol and to display greater distressed behavior to novelty by 9 months. Could this transmission of response to shared stress during pregnancy be one example at the very beginning of the organism’s life of adaptation in the service of evolution? Is the mother’s biology preparing the offspring for expectation of threat? If so, can one say that the development of PTSD (and/or other posttraumatic psychopathology) is a form of risk if no further threat actually exists, or resilience in the form of potentially beneficial hypervigilance to actual subsequent threat? As the hypothalamic–­midbrain–­limbic– paralimbic–­cortical circuits in the caregiver respond jointly to infant stimuli, as has been found in recent neuroimaging studies among normative mother–­infant dyads (Swain, Lorberbaum, Kose, & Strathearn, 2007), one can imagine a cycle of dysregulation in which unquelled infant distress becomes a stressor particularly for a traumatized parent. Indeed, while watching video clips of their children during separation and other stressful moments, group differences between violence-­exposed mothers of toddlers and nonexposed mothers have been noted with respect to measures of integrative behavior, autonomic nervous system activity, and brain activation (Schechter, 2006). We know that an important determinant of the effects of traumatic exposure (e.g., how

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long they endure) is the primary caregiver’s ability to help restore a sense of safety via regulation of infant emotion, sleep, arousal, and attention (Laor, Wolmer, & Cohen, 2001; Scheeringa & Zeanah, 2001). These emerging findings may illuminate the ways in which the experience of violent trauma and its sequelae interfere with this primary caregiving function. On a positive note, we have also begun to understand how new relationships, most dramatically that of foster care, can curb if not reverse at least some of the effects of early violent trauma exposure (Fisher et al., 2006; Zeanah et al., 2001).

PREVENtIVE INTERVENTIONS AND TREATMENT As our understanding of the relationships among violence, trauma, and early childhood has flourished (Osofsky, 2004), so has attention to prevention and intervention. The National Child Traumatic Stress Network (NCTSN: www.nctsn.org) works actively to disseminate information about effective evidence-based mental health treatment options and innovations. At the national policy level, the Office of Juvenile Justice and Delinquency Prevention, the Department of Justice’s Office of Justice Programs, and the Department of Health and Human Services have developed the Safe Start Initiative: A Federal–­Community Partnership Program (Kracke, 2001). The purpose of the initiative is to prevent and reduce the impact of family and community violence on young children (under 6 years old) by funding the expansion of partnerships among all levels of early childhood, mental health, and criminal justice service providers. The best known and studied prevention program designed to prevent abuse and neglect is the Nurse–­Family Partnership (NFP; Olds, Sadler, & Kitzman, 2007). The NFP program sends trained nurses into the homes of high-risk, first-time mothers, beginning during pregnancy and continuing until the child reaches 2 years of age. The program was designed to address poor birth outcomes, child abuse and neglect, and decreased economic self-­sufficiency. At 15-year follow-up, participant mothers were 48% less likely to be identified as perpetrators of abuse and neglect. However, the program

did not target domestic violence and had no discernable impact on reducing it. Regarding treatment of already traumatized children, the evidence base of practice is growing steadily. For example, trauma­focused cognitive-­behavioral therapy (Cohen & Mannarino, 1996) and infant/child–­ parent psychotherapy (Cicchetti et al., 2006; Lieberman, Van Horn, & Ghosh Ippen, 2005a) are well established. The use of videotape feedback also has become a valuable tool in the arsenal of early childhood intervention, especially to counteract the effects of posttraumatic avoidance and dissociation (Schechter et al., 2006). Even a single session of guided video review with severely traumatized mothers has been shown to reduce negative attributions about the child (Schechter et al., 2006). Evidenced-based interventions in foster care for young children also have been shown to reduce cortisol values, behavioral problems, and insecure attachment behaviors in the children and to reduce placement disruptions and recidivism (Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008; Fisher et al., 2006; Zeanah et al., 2001).

CONCLUSIONS This chapter has provided a framework for consideration of at least four dimensions that are essential to assessing and treating the infant or young child who may have been exposed to violent trauma and/or maltreatment: the nature of the exposure, infant constitutional factors, developmental context, and relational context. It is our hope that clinicians and investigators reading this chapter will now think: “What happened to the infant?” “Who is the traumatized infant in psychobiological terms?” “When did the trauma occur in the life course of the infant?” “Who is in the infant’s relational world who can either help or hinder making sense of what happened?” Acknowledgment The authors would like to acknowledge Ms. Jaime McCaw, Coordinator of the Parent–Child Interac-



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tion Project at the New York State Psychiatric Institute, for her helpful assistance in the editing and preparation of this chapter.

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C h a p t e r 13

The Relational Context of Adolescent Motherhood Sydney L. Hans Matthew J. Thullen

T

he birth of a child marks an important family transition. When the mother is a teenager, there are concerns that the transition to parenthood is “off time” and will place her and her baby at risk. Although most American teenage mothers come from backgrounds of limited socioeconomic opportunity, teenage childbearing cuts across all major American ethnic groups, and the largest numbers of teenagers bearing children are European American (Martin et al., 2007). Despite declining rates of adolescent childbearing during the past several decades, the United States continues to have markedly higher teenage birth rates than other Western industrialized nations (Alan Guttmacher Institute, 2001). Schools, health clinics, and community agencies continue to search for ways to best support the needs of these young families. The children of adolescent mothers are more likely than offspring of older mothers to display developmental and behavioral problems during early childhood and beyond and to become teenage parents themselves (Brooks-Gunn & Chase-­Lansdale, 1995; East & Felice, 1996; Hardy et al., 1997). Two mechanisms have been proposed for how risk is transmitted to the children of teenage mothers (Berlin, Brady-Smith, &

Brooks-Gunn, 2002). First, at a distal level, the varied sociodemographic and family conditions that are associated with adolescent childbearing in the United States, including family and community poverty, single parenthood, and limited parental education, may place children at risk (Brooks-Gunn & Chase-­Lansdale, 1995; Turley, 2003). Second, at a proximal level, the parenting behavior of the young mother and the kind of nurturing relationship she is able to establish with her child may impact the child’s development. In this chapter we focus on relationships between teenage mothers and their infants and interventions designed to support those relationships. Although infant mental health practitioners tend to focus their work on the mother and her baby, the birth of a baby also involves shifts in other family relationships (Cowan & Cowan, 1995). These emerging and realigning relationships have unique features when the mother is a teenager who may not be developmentally ready to take on the parenting role, who may continue to be parented by her own mother, and who may be involved in a fragile relationship with her child’s father. We also consider the relationships young mothers have with important people in their lives, especially their own 214



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mothers and their babies’ fathers, and interventions designed to support those relationships. Finally, recognizing the “effect of relationships on relationships” (Emde, 1991) as a central tenet of the infant mental health perspective, we also explore how young mothers’ relationships with grandmothers and partners support the mother–­infant relationship and how infant mental health practitioners working with adolescent mothers might think about their work within a broader ecology of family relationships.

ADOLESCENT MOTHER–INFANT RELATIONSHIPS Scholars, practitioners, and the public have expressed a variety of concerns about teenagers’ readiness to take on the mothering role. The sacrifices and hard work that are involved in parenting stand in contrast to teenagers’ presumed developmental needs to focus on their education, to interact with peers, and to explore a variety of identities. Many adolescent mothers do struggle to give up their lives as teenagers to assume the responsibilities of parenthood. One young mother bemoaned: “I don’t want to feel like an adult and . . . I would like to go back to just me and my boyfriend” (Easterbrooks, Chaudhuri, & Gestsdottir, 2005, p. 321). However, motherhood need not be at odds with the developmental challenges of adolescence. For many young mothers, the transition to motherhood does not so much disrupt their lives as it provides a new and positive agenda. For young women who see themselves as having limited potential in the world of school and work, being a good mother can provide a sense of accomplishment that otherwise might be unachievable. Although the public often views adolescent parenthood as a tragedy, the young mothers themselves sometimes frame it as an important and empowering transformation (McMahon, 1995). Some teenage mothers tell stories of metamorphoses into the kind of person who can be a good mother. One young mother said, “I changed a lot . . . I was more nicer, calmer, things like that . . . I stopped fighting, arguing a lot. I was trying to do better” (Brubaker & Wright, 2006, p. 1225). Other mothers talk about becom-

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ing motivated to work harder in school in order to provide a future for their children (Lashley, 2007). Concerns also focus on whether young parents have achieved the capacity for perspective taking that would allow them to understand and respond to the child’s expression of needs. Literature comparing the parenting of teenage and adult mothers has demonstrated that, on average, teenage mothers are less sensitive and responsive to their infants. They are less able to read their infants’ cues for comfort, food, and exploration accurately and more likely to respond to cues with detachment, intrusiveness, or anger (Osofsky, Hann, & Peebles, 1993; Pomerleau, Scuccimarri, & Malcuit, 2003). Compared with older mothers, teenagers engage less in affectionate behavior (Krpan, Coombs, Zinga, Steiner, & Fleming, 2005) and verbalize less with their infants (Culp, Culp, Osofsky, & Osofsky, 1991; Pomerleau et al., 2003). Although not all studies contrasting teenage and older mothers have adequately controlled for differences between the groups in sociodemographic factors, recent analyses from the Early Head Start Research and Evaluation Project suggest that mothers who gave birth as teenagers are more likely to be unsupportive, detached, and intrusive with their infants, after controlling for a variety of demographic factors (Berlin et al., 2002). Finally, consistent with the findings on reduced maternal responsiveness and elevations in hostile parenting, infants of adolescent mothers have higher rates of insecure and disorganized attachments than adult mothers (Spieker & Bensley, 1994; Ward & Carlson, 1995). Despite these average differences between adolescent and older mothers, it is important to note that adolescent mothers vary widely in their parenting behavior and attitudes (Wakschlag & Hans, 2000), and increasingly, research has focused on identifying the factors that may heighten or reduce risk within populations of young mothers. Some studies have suggested that older adolescents show more competent parenting than younger adolescents (East & Felice, 1996; Easterbrooks et al., 2005; Hess, Papas, & Black, 2002). Other research has suggested that, in adolescents, responsive parenting and positive perception of infants is related to “cognitive readiness” to parent, which includes

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knowledge and expectations about child development, commitment toward childrearing, and ability to assimilate knowledge and apply it flexibly in a childrearing context (East & Felice, 1996; Miller, Miceli, Whitman, & Borkowski, 1996). Maternal mental health has also been linked with parenting behavior among adolescent mothers. As is the case in adult mothers, depression in adolescent mothers is associated with a less responsive parenting style toward infants and young children (Leadbeater, Bishop, & Raver, 1996; Osofsky et al., 1993). In addition, studies have documented links between maternal aggression and conduct problems in young mothers and unresponsiveness to their infants (Cassidy, Zoccolillo, & Hughes, 1996). A variety of maternal dispositional and attitudinal characteristics have also been linked to differences in parenting among adolescent mothers. Mothers with a strong sense of efficacy display better parenting behavior (East & Felice, 1996; Hess et al., 2002). Adolescent mothers who hold more realistic developmental expectations show more sensitivity in interaction with their own toddlers than do other teenage mothers (Chen & Luster, 1999). Adolescent mothers of toddlers who overattribute emotions of anger and defiance to young children, in general, show less optimal and more coercive parenting behavior in interaction with their own children (Strassberg & Treboux, 2000). Teenage mothers who are able to engage reflectively in considering their own childhood histories are more sensitive to their infants (Brophy-Herb & Honig, 1999). It has also been noted that different teenage mother–­infant dyads display qualitatively different patterns of interaction (Easterbrooks et al., 2005). Many teenage mothers and infants engage in interactions that are highly, or at least adequately, mutually responsive. A subgroup of teenage mothers has trouble reading and responding to their infant’s signals. These mothers seem to act from their own agenda—­directing the play, choosing the toys, and sometimes becoming “peerlike” and competitive with their children. A different subgroup of teenagers seems somewhat helpless and passive in the free-play interactions. These mothers offer little structure to their infants—not positioning toys, making suggestions to the baby, or

commenting on their baby’s actions. These problematic subgroups each has different correlates and needs for different types of supportive intervention.

Parenting and Mother–­Infant Interventions with Adolescent Mothers Most programs targeting pregnant and parenting teenagers have prioritized preventing subsequent pregnancy and school dropout, often with less emphasis on supporting young women in their new roles as mothers and on supporting parent–child relationships (Chase-­Lansdale, Brooks-Gunn, & Paikoff, 1991). Still, a variety of intervention strategies have been developed for teenage mothers. Many of these programs are based in schools, but others deliver services in community health clinics, social service agencies, or in the young mothers’ homes. Few of these parenting programs have been evaluated, although a meta-­analytic review of 14, mostly small, interventions targeting adolescent mothers concluded that there is evidence that parenting interventions can impact maternal sensitivity, self-­confidence, and identity, as well as infant responsiveness to mother (Coren, Barlow, & StewartBrown, 2003). Most parenting programs provide teenagers with instruction in child development, infant safety, and fundamental caretaking skills. Programs that provide instruction in a structured, classroom-style format often struggle to engage young mothers. Increasingly intervention strategies have been developed that engage with young mothers’ individual interests and concerns. Making “home movie” videotapes of young women with their infants is a good strategy for engaging mothers, especially when they can keep a copy of the tape at the end of the intervention (Bernstein, 1997). Interventions based on videotapes have been effectively embedded in larger programs for adolescent parents, such as the Ounce of Prevention Fund Developmental Program (Bernstein, Percansky, & Wechsler, 1996; Hans, Bernstein, & Percansky, 1991). In one intervention study, conducted as a randomized controlled trial, mothers of 1-month-old infants watched a videotape of themselves and their infants (Koniak-­Griffin, Verzemnieks, & Cahill, 1992). Specially trained nurses pro-



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vided instructional feedback and encouraged the mothers to identify a part of the interaction about which they felt good. The discussion usually focused on issues of reading infant cues, responding to distress, and using language with young infants. Followup videotapes made a month later showed that the intervention had had an effect on maternal cognitive growth fostering of infant and on the infant’s responsiveness to the parent. Another promising individualized intervention for young mothers is Family Administered Neonatal Activities (FANA; Cardone, Gilkerson, & Wechsler, 2008). This intervention involves a set of techniques that elicit responses from newborn babies—and even unborn infants—­through which young mothers can explore and marvel in their baby’s sleep–wake cycles, perceptual and motor capabilities, personality, and preferences. Ultimately, the goal of this intervention is to support mothers in building strong emotional connections to their infants and in becoming attuned to their unborn or newly born infant’s signals. Other individualized interventions have focused on empowering teenage mothers to take on the role of mother during pregnancy and at the time of the birth. Community “doulas” are women from the teenager’s community, sometimes former adolescent mothers themselves, who provide support and childbirth education to young mothers during the pregnancy and are present at the birth to offer comfort and encouragement. Doulas help mothers connect in positive ways to their pregnancy and their baby and to see their own strengths and embrace their responsibilities as a mother (Abramson, Isaacs, & Breedlove, 2006; Glink, 1999). Results of a randomized controlled trial of doula support with young mothers suggest increased sense of maternal efficacy and greater positive interaction between young mothers and infants (Hans, 2005).

YOUNG MOTHER– GRANDMOTHER RELATIONSHIPS For most teenage mothers, their own mothers or mother figures play a very important role in their adjustment to parenthood. Not

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only are adolescents still being parented by their mothers, but they typically rely on their mothers as their most important source of support, advice, and modeling with respect to childrearing (Brubaker & Wright, 2006; Voight, Hans, & Bernstein, 1996). A centerpiece of federal welfare reform legislation, implemented a decade ago, is a mandate that unmarried minor mothers live with a parent or guardian and stay in school until achieving a high school diploma or equivalent (Gordon, 1999). Although data on residence patterns after welfare reform are very limited at this point, they suggest that more than three-­quarters of teenage mothers now reside with a parent or parent figure (Kalil & Danziger, 2000). Evidence suggests that adolescent mothers who live in multigenerational households are more likely to remain in school and graduate (Gordon, Chase-­Lansdale, & Brooks-Gunn, 2004). Perhaps surprisingly, data do not suggest that coresidence with parents benefits young women in their roles as parents, and in fact, grandmother coresidence has been associated with unresponsive parenting by both teenage mothers and grandmothers (Chase­Lansdale, Brooks-Gunn, & Zamsky, 1994; East & Felice, 1996; Gordon et al., 2004; Spieker & Bensley, 1994). The birth of a baby to a teenager necessitates a transition not only for a young mother but also for her own mother (Burton & Bengtson, 1985). Although multigenerational family patterns that are supportive of young mothers are common within African American and Latino communities (Burton, 1990; Russell & Lee, 2006), this does not mean that mothers of teenagers are eager to become grandmothers. The reality is that a teenage pregnancy is rarely a welcome family event initially. Adolescent pregnancies are almost always met by grandmothers with shock and dismay, and at best, require adjustment as grandmothers deal with the loss of their hopes for their daughter’s achievement. One grandmother said: “I was not thrilled in the beginning—a shock—but now after a long day, I am happy to see the baby” (Sadler & Clemmens, 2004, p. 221). One young mother recalled her mother’s response in a similar manner: “She went off, she was acting crazy. She got mad, said ‘you’re having an abortion.’ . . . And then she finally learned to accept it” (Brubaker & Wright, 2006, p. 1219).

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Early parenthood for teenagers may be linked to early grandparenthood for their mothers. Grandmothers may feel that they are too young to be grandmothers and may be resentful of the timing of the pregnancy—­ sometimes just after their youngest children are in school and when they are beginning to make plans for the next step in their own aspirations, such as returning to school or changing jobs. As one grandmother reflected in response to her daughter’s complaint that she had a negative attitude toward her grandchildren: “This is not easy to deal with. . . . I don’t want to start anew. . . . I want to be myself! . . . I’ve been raising kids by myself since I was 16, and now I’m at the place where I can do some things that I want for [myself] and I don’t want to start all over again. I don’t want it” (Wakschlag, 1992, p. 158). In addition to being a surprise, grandmotherhood may also be the beginning of heavy obligations to care for the younger generation again and to provide economically for multiple generations of the family. Because of welfare reform in the United States, many grandmothers are often working in low-wage jobs and have economic responsibilities for their families that do not allow them to stay home and raise their grandchildren. The birth of a baby to a teenager is a financial stress for a family, and the added responsibilities of a new child in the home often lead to role overload for young mothers and for grandmothers who take on heavy child care responsibilities (Culp, Culp, Noland, & Anderson, 2006). Not surprisingly, there are often interpersonal stresses and conflicts between young mothers and their mothers. Many of the disagreements are typical of those for all adolescents and their families, focusing on topics such as household chores, school, and boyfriends (Sadler & Clemmens, 2004). However, many tensions focus directly around issues of caring for the infant. Grandmothers who take their roles as mentors and heads of household seriously may feel thwarted by the young mother’s lack of acceptance of responsibility or acknowledgment of her expertise. One grandmother describes this situation: “Sometimes she thinks she knows everything, and she doesn’t want to listen. I tell her, I know what I’m doing. When you try to teach her, sometimes she gets mad” (Sadler & Clemmens, 2004, p. 222).

The severity of the relationship distress is usually perceived as even greater by the young mother than by the grandmother (Caldwell, Antonucci, & Jackson, 1998). Young mothers may feel burdened by the responsibility of caring for the infant, but resentful or ambivalent about needing to rely on their mothers for support (East & Felice, 1996). From the perspective of one young mother: “It was a constant pull and a constant draining. . . . It became a point that I didn’t feel like she was my child at all. I really didn’t have any say-so over anything” (McDonald & Armstrong, 2001, p. 217). Although these stresses are very real, for most young mothers and grandmothers, they can be resolved through the “power of the baby” to help them stay focused on their shared goals and to work together (Sadler & Clemmens, 2004). Apfel and Seitz (1991), drawing on data from African American families, have suggested four models by which multigenerational families adapt to adolescent motherhood. In the “parental replacement model” the grandmother assumes near total responsibility for rearing the baby. In contrast, in the “parental supplement model” the grandmother and mother share the primary caregiving responsibilities. In the “supported primary parent model” the young mother is primarily responsible for the care of the child but receives regular assistance. In the “parental apprentice model” the grandmother actively educates the mother to be a parent but without supplanting her in the parent role. Although some data suggest that this last model has the most benefits for the mother as a parent (Oberlander, Black, & Starr, 2007), the parental supplement model may be the most common in practice, because it provides the greatest flexibility for coping with the shifting demands of life. SmithBattle (1996) also describes the benefits of the apprenticeship model in which the grandmother provides support and encouragement, shares caregiving in a fluid manner, but does not take over caregiving responsibilities. She notes that for apprenticeship to work, it must be embedded in a broader family climate of trust and mutuality that allows the young mother to be receptive to advice and assistance. Young women need to be taken seriously as mothers, not allowed to feel burdensome or incompetent, and definitely not left to experience



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the challenges of parenting on their own. One grandmother said about her 15-yearold daughter: “I kiss her every day and tell her I’m proud of her because she gets up, she goes to school, and as soon as she comes home she takes over the responsibility of her baby” (Ispa, Thornburg, & Fine, 2006, pp. 113–114). Notably, these grandmothers, rather than feeling competitive with their daughters for the affection of the baby, are able to experience pride and pleasure in their daughter’s parenting and in the connection between their daughter and the baby. One grandmother said: “I eat it up. It’s just so beautiful. When he cuddle up on his mother, I love it” (SmithBattle, 1996, p. 61). SmithBattle also warns that families can sometimes adapt a pattern of “adversarial care” in which a young mother is forced into her role as a mother or excluded from it. These are families in which issues of control and authority are central to their interactions—in which there is competition over the baby, conflict over caregiving tasks, and hypercritical attitudes. One grandmother quoted herself, nagging: “ ‘What do you mean he hasn’t been fed yet? What do you mean he hasn’t been changed yet? What do you mean he hasn’t had a nap today?’ And I know I’m real quick to judge and step in there and want to take over and do it, so it’s a constant battle within myself, not to be judgmental and be dictatorial” (SmithBattle, 1996, p. 59). From the perspective of the young mother, “My mom always jumping in and tell me what to do. She always jumps in, every day, all day, about every little thing” (p. 60). Such dynamics make it difficult for the young mother to gain experience interacting with her baby—­either because the grandmother takes over or because the young mother withdraws out of rebellion. A growing body of empirical research has explored ways in which relationships between young mothers and their mothers affect the young mothers’ well-being and their relationship with their baby. It is clear that relatively harmonious relations between young mothers and their own mother are important supports for the mother–­infant relationship. Support from grandmothers that is accompanied by high levels of conflict or demands to reciprocate by helping with household chores may not foster competent parenting in the young mother (Hess et al.,

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2002; Richardson, Barbour, & Bubenzer, 1991; Voight et al., 1996) and may increase parenting stress, especially when the conflict focuses on childrearing issues (Spencer, Kalill, Larson, Spieker, & Gilchrist, 2002). It is also clear that there is an optimum amount of support that mothers should provide their parenting daughters if they are to develop their skills as mothers. In families in which the grandmother has no role in child care, young mothers show less competent parenting behavior, perhaps because they have had no opportunities to see positive parenting behavior modeled (Oberlander et al., 2007). On the other end of the pendulum, when grandmothers provide high amounts of child care, young mothers form less appropriate developmental expectations for their children (Culp et al., 2006), are less sensitive to their baby (Contreras, Mangelsdorf, Rhodes, Diener, & Brunson, 1999), and their baby is less engaged with them during interactions (Easterbrooks et al., 2005). The risks associated with high levels of grandmother support have been documented in samples of African American, European American, and acculturated Latino samples (although in less acculturated Latino samples, in which values of familism and interdependence after adolescence are strong, grandmother involvement seems to have no negative effect on the parenting of young mothers) (Contreras, Narang, Ikhlas, & Teichman, 2002). The pattern of interaction between young mothers and their mothers also may be related to interactions between young mothers and their children. This parallel process has been documented in two studies of African American families, where interactions were videotaped between adolescent mothers and their mothers and between adolescent mothers and their preschool-age children. The mother–­grandmother interaction was coded for different relationship characteristics, including emotional closeness, positive affect, grandmother directiveness, and adolescent individuation (Hess et al., 2002; Wakschlag, Chase-­Lansdale, & Brooks-Gunn, 1996). Individuation in the mother–­grandmother relationship was the strongest predictor of young mothers’ parenting behavior in interactions with their children. Young mothers whose discussions with their mothers combined self-­assertion with the ability to stay

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connected despite differences, were significantly more likely to parent their preschoolers in a manner that balanced responsiveness and appropriate control. Thus, the challenge for multigenerational families with young parents is to find a balance between providing assistance and encouraging the young mother’s autonomy and competence. Striking such a balance may not be easy because it requires continual adjustments in responsibilities, roles, and relationships as the young mother gains in competence and confidence and as the child’s developmental needs shift and change. It requires a commitment to supervision and mentoring from the grandmother, on the one hand, and the capacity to stand back and allow her daughter to make mistakes as she “tries on” the parenting role, on the other. Despite these challenges, empirical evidence suggests that many families do find such a balance and that it impacts on mothers’ well-being and commitment to the parenting role over time (Apfel & Seitz, 1991).

Intervention with Adolescent Mothers and Grandmothers Research on teenage mothers and their mothers has many implications for intervention. Reducing stress for burdened grandmothers, reducing stress in mother–­grandmother relationships, and helping mothers and grandmothers negotiate their roles to achieve a balance of support and autonomy are key challenges that have implications for adolescents’ ultimate success as parents. Support or psychoeducation groups for grandmothers, young mothers, or both together hold much promise as vehicles for helping families learn to negotiate challenges, roles, and relationships. Groups can offer families specific strategies for conflict resolution and stress reduction. They also offer an opportunity to validate the important roles that all family members play in caring for the baby and to express the shared pleasure and pride they have in the child. Although the evidence base for the effectiveness of involving grandmothers in groups is thin, grandmother components have been added to teen parenting programs with some success (Roye & Balk, 1996). Home visiting components that include grandmothers and young mothers may also offer the interventionist

the opportunity to observe family routines and see how roles are negotiated in the family’s primary setting. In addition to program activities that focus directly on supporting young mother–­ grandmother relationships, infant mental health programs also need to recognize the key role that grandmothers play in families as a source of expertise on parenting (Bentley, Gavin, Black, & Teti, 1999). If the grandmother is left out of the discussion when intervention programs provide information about health and child care practices, such as feeding, sleeping, holding babies, and discipline, the intervention messages may not become part of family practice (Hanson, 1992). Moreover, disseminating parenting advice to young mothers without recognizing that the advice may be contradictory to that provided by the grandmother may not only be futile, but could be setting up the young mother for further conflict with her own mother (Korfmacher, 2008). Programs for young mothers ignore grandmothers for a variety of reasons. Many programs for pregnant and parenting teenagers are housed in schools where there may be challenges to including nonstudents in activities. Programs may have hours of operation that make it difficult for working grandmothers to participate. Other programs assume that their working alliance with a teenager will be harmed by including a family member. Some programs may have unstated biases that families of adolescent parents are dysfunctional and not likely to be helpful to them. Although early intervention programs are often reluctant to reach out to grandmothers, in one survey, 90% of young mothers indicated that it would be helpful to have family members participate in support and education programs (Crockenberg, 1986). Although they often feel they lack the skills to support their daughters, grandmothers almost always care deeply about their daughters and are highly invested in their daughters becoming good parents (Flaherty, 1988). These are powerful motivations for engaging with intervention. One research study that took the time to listen to the voices of grandmothers found that they had many suggestions for additional supports they would like to see in place, including groups, refresher courses on child development, job opportu-



13. Relational Context of Adolescent Motherhood

nities, help with housing, and child care resources (Sadler & Clemmens, 2004).

MOTHER–FATHER RELATIONSHIPS The men who father children with adolescent mothers share many sociodemographic characteristics with their partners, especially backgrounds characterized by poverty and limited educational achievement (Xie, Cairns, & Cairns, 2001). Even though only 20–40% of the partners of teenage mothers are themselves adolescents, most are relatively young men (Elo, King, & Furstenberg, 1999). The age discrepancy between young mothers and the fathers of their children is consistent with the fact that American women of all ages tend to partner with men who are 2–3 years older than themselves (Coley & Chase-­Lansdale, 1998). In recent decades the proportion of births to adolescents outside of marriage has increased dramatically so that out-of-­wedlock births to adolescents are “the rule” rather than the exception (McElroy & Moore, 1997). Although marriage rates are declining among all American ethnic groups, they remain especially low for young women of color (Martin et al., 2007). However, even though most teenage mothers are not married to their baby’s father, many of those fathers are highly involved with the mothers and children. During pregnancy most young fathers express a desire to be involved in the birth and in childrearing (Elster, 1988; Rivara, Sweeney, & Henderson, 1986), and paternal involvement tends to be most intensive soon after the birth (Lerman, 1993). Over the first few years of the child’s life, there is much variability among fathers in the degree to which they stay involved with the mother (Kalil, Ziol-Guest, & Coley, 2005a), and the pattern that has raised concern is declining paternal involvement as the child gets older (Gee & Rhodes, 2003). Although marriage is one indicator of the level of connection between a young mother and the father of her baby, other factors contribute to a more complex picture of the role of fathers in the lives of young mothers and their children. Fathers’ different ideas about the meaning of fatherhood may contribute to how they approach their relationships

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with the mother and child. The provider role remains core to many young men’s definition of fatherhood (Anderson, 1993) and is still considered the “non-­negotiable duty of all fathers” by many mothers (Roy & Burton, 2007, p.  29). Young fathers who are working are more likely to maintain involvement with their children (Danziger & Radin, 1990). Some young mothers, acting as gatekeepers between fathers and their children, may limit access to men who are not adequate providers (Ray & Hans, 1997). In contrast to those who see the provider role as primary, some men see just “being there” for their child as the core of fatherhood. One young man described fatherhood as “spending quality time with my girl. Being a key part of her life. When she gets older, I want her to know that she can count on her daddy. I don’t want her to think that I’m just there to give her money” (Paschal, 2006, p.  85). Such young men are eager to support their children in other ways, such as taking an active role in caregiving, and mothers may adjust their expectations to accept these forms of support and involvement (Johnson, 2001; Roy & Burton, 2007). Finally, some fathers attach little significance to being a father and offer little involvement with their child or support of the mother (Paschal, 2006). Many adolescent fathers struggle to reconcile their idealized vision of fatherhood and the reality of providing for their child, given their age and economic constraints (Johnson, 2001; Rivara et al., 1986). Like young mothers, young fathers may be simultaneously navigating the demands of school, employment, expectations from others, and their own identity issues while trying to engage as a father (Miller, 1997). Strain from the cumulative effect of these concurrent stressors may make it harder for fathers to engage or easier to disengage from responsibilities and relationships associated with being a father (Bowman, 1989; Kiselica, 1995; Miller, 1997). The quality of the relationship between the father and young mother may be the most important factor in determining the father’s role in the mother and child’s life over time (Coley & Chase-­Lansdale, 1998; Cutrona, Hessling, Bacon, & Russell, 1998; Furstenberg & Harris, 1993; Marsiglio, 1987). The ways in which the two parents negotiate often stressful topics such as the status

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of their romantic relationship, romantic relationships with others, the father’s financial support, caregiving roles, and decision making regarding the child, will shape and be shaped by the quality of their relationship (Ispa et al., 2006; Kiselica, 1995). Certainly, if the young parents have and maintain a romantically committed relationship, negotiating these parenting issues may proceed with relative ease. However, other relational configurations may emerge over time, from “amicable” nonromantic relationships to mutual disengagement to overt conflict. The struggle for young parents to negotiate a mutually satisfactory personal relationship can be a dynamic, sometimes volatile, process. One young mother describes the extreme fluctuation adolescent partner relationships can go through when dealing with the stress of the transition to parenthood: “He wanted to get married, but I didn’t feel that it would be right for my child because he was never around. And I said, ‘Well, what difference would it make if we got married, you wouldn’t be around?’ So I refused him, and he got very angry and pissed off and left. I’ve never seen him since” (Rains, Davies, & McKinnon, 1998, p. 311). Even expectant adolescents in a coupled, romantic relationship may be more likely to exhibit more negative and less positive interpersonal behaviors with one another than nonexpectant adolescent couples (Moore & Florsheim, 2001). How these common sources of tension between adolescent parents are dealt with can significantly influence the level of stress or support the young parents experience from one another or whether they stay involved with each other at all. The quality of the relationship between young parents is particularly important for maternal adjustment and parenting. The quality of the relationship between mother and father is positively associated with the mother’s parenting efficacy (Krishnakumar & Black, 2003). Declines in father involvement (Kalil, Ziol-Guest, & Coley, 2005b) or the quality of the relationship (Florsheim et al., 2003) are associated with increased maternal parenting stress. There is some evidence that adolescent mothers with supportive male partners are more responsive mothers (Crockenberg, 1987; Unger & Wandersman, 1988) and provide more positive childrearing environments (Cutrona et al.,

1998). Adolescent mothers with better relationships with their child’s father have also been found to exhibit less hostile-­controlling behavior with their toddlers (Florsheim et al., 2003). A supportive relationship with a partner appears to be a protective factor for parenting in young women who have themselves had problematic developmental histories (Crockenberg, 1987). Some studies have failed to find relations between support from a male partner and maternal well-being or mothering, presumably because fathers are sometimes a mixed blessing for mothers, providing them not only with support but also stress (Musick, 1994; Voight et al., 1996).

Interventions for Adolescent Mothers and Fathers Programs to foster the involvement of fathers in general have taken many different forms (see McBride & Lutz, 2004). Much of the variation in program models is due to shifting policy mandates over recent decades that emphasize different goals, such as preventing teen pregnancy, securing financial support from fathers, increasing direct father involvement with their children, and encouraging marriage (Mincy & Pouncy, 2002; Parikh, 2005). The majority of programs aiming to support paternal involvement are small, locally based initiatives (Johnson, 2001). Simply offering fathers the same services as mothers is not usually successful (Kiselica, 1995). Staff working in father programs need to be prepared to offer tangible, issue-­specific services and counseling to young men in a climate that is welcoming and respectful of the value males can bring to children’s development (Barth, Claycomb, & Loomis, 1988; McBride & Rane, 2001). Many programs attempt to offer comprehensive services that address the range of factors that contribute to father involvement over time in addition to the relationship-based factors (Barth et al., 1988; Mazza, 2002). Recognizing the centrality of the provider role to fatherhood across ethnic groups, fatherhood programs have emphasized educational and employment needs of young men. There is a need within these programs, however, to address cultural differences as well. Although European American fathers may



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often have greater economic opportunity, they may feel as though taking on a paternal role earlier than they had planned might be deleterious to their economic future (Kiselica, 1995). Also, European American and Latino fathers may experience more pressure to marry and/or cohabit with their baby’s mother. Latino fathers with relatively limited acculturation may have very traditional expectations with regard to the fatherhood role and experience distress if they are unable to fulfill it (Kiselica, 1995). Programs for young fathers can also offer services that focus directly on the father’s relationship with the baby and baby’s mother. Parent education groups, often offered prenatally, have been used successfully to increase young fathers’ knowledge about infant development and care (Westney, Cole, & Munford, 1988). Parent education is especially important for fathers who may seem to resist involvement with their children in the early years due to a lack of understanding of how to care for infants. One father shares: “When she starts all that crying and acting fidgety and stuff, I just give her to [mother of his child]. I don’t like all that. I love her, but I don’t know how to take care of her like that. . . . I’m not nervous with her, I just don’t know what to do with her. I think I’ll like handling her better when she gets older” (Paschal, 2006, p. 148). Although it is common for all fathers to become more comfortable with parenting as children enter toddlerhood and have developed communication and motor skills (Dallas, 2004), education can help young fathers feel less intimidated by infant care and afford feelings of pride and competency in parenting. Often young fathers assume that women have a special “intuition” for parenting. Once they recognize that parenting is often a “trial-anderror” process that even mothers go through to learn to read their baby’s cues, caring for the child is demystified (Johnson, 2007). Individual counseling and group components of young fatherhood programs can serve several important functions. One is to allow space in which the father can reflect on his own family experience and how that may impact his current approach to fathering (Parra-­Cardona, Wampler, & Sharp, 2006; Paschal, 2006). Counseling with the father or the father and mother jointly can also offer an opportunity for the father to

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develop interpersonal skills that may solidify and maintain his partner relationship with the mother (Moore & Florsheim, 2001). Furthermore, counseling can help the father develop strategies for building a “cordial supportive relationship” with his baby’s mother even if they do not continue to be a romantic couple (Kiselica, 1995). Bottom line: Interventions with young parenting couples need to help them avoid an “all-or­nothing” approach to relational harmony in which father involvement is contingent on his romantic relationship with the mother and/ or his financial support (Johnson, 2007). The notion of “coparenting” may be a useful framework for intervening with adolescent parents who are no longer be romantically involved. This notion shifts the focus away from maintaining the romantic couple relationship to establishing and maintaining an effective, functional relationship pertaining specifically to parenting (Feinberg, 2002). Ideally, even while their personal relationship has ups and downs, young parents can try to maintain a collaborative effort in sharing parenting responsibilities while communicating respect for the investment, significance, and judgment of one another (Feinberg, 2002; McBride & Rane, 1998). Although there is a growing body of research on coparenting among married or divorced adult couples, little is yet known about how young, nonmarried parents manage coparenting or how to intervene with young parents around achieving a parenting alliance. One study, however, has found that the strength of the parenting alliance is a strong predictor of paternal behavior, as reported by young mothers (Futris & Schoppe-­Sullivan, 2007). Programs need to help young parents (1) recognize that both of them are needed to support the child’s wellbeing and development and (2) create strategies for setting aside their interpersonal issues to support their child’s development. Finally, adopting a life-­course perspective is important in understanding the ways in which young fathers influence the young mother’s experience as a parent and are involved with their children (Roy & Burton, 2007). Young fathers’ adaptation to their role as father may take time, particularly for those who are focusing on issues of school completion and economic skill development. Young fathers themselves articulate their

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need for ongoing services as they negotiate issues of education and employment, changing people in their support environments, and their changing roles with their child’s mothers (Parra-­Cardona et al., 2006). Many young fathers may have expectations that are adjusted to their age, feeling that they will be better parents when they are older and can offer more to the child in terms of finances or paternal wisdom (Paschal, 2006). When young fathers do not seem ready to take on all aspects of the parenting role, it is important to find ways to “leave the door open” for their future involvement (Johnson, 2007). Despite the importance of the infant and toddler years as a foundation for later development, the connection of the father to the mother and child at later ages will also provide important resources and opportunities for the child.

BROADER RELATIONAL ECOLOGIES OF ADOLESCENT MOTHERHOOD Beyond the impact of mother–­grandmother and mother–­father relationships on teenage mothers and their babies, other relationships also matter. Furthermore, relationships young women have with different members of their networks are not independent of one another. In some ways, relationships work to complement and compensate for one another: When one person in her network offers high-­quality support, a young mother may have less need to seek support from other people; conversely, when one relationship is problematic, she may need to rely more heavily on others. For example, depending on the amount and quality of support provided by her family, the mother may have different needs or expectations for the father’s involvement (Cervera, 1991; Krishnakumar & Black, 2003). When mothers have strained relationships with their own family members, fathers may become particularly important as sources of support (Crockenberg, 1987) and are more likely to maintain involvement with the child (Gee & Rhodes, 2003). A high amount of grandmother support is associated with both low initial and decreased involvement of the father over the first year (Kalil et al., 2005a). Also, the negative effects of strain in the mother’s re-

lationship with the father may be buffered by grandmother support (Gee & Rhodes, 2003). Additionally, members of a young mother’s support network usually know and interact with one another and influence the relationship the other person has with the young mother and her infant. The relationship between maternal grandparents and young fathers may be especially important. Young fathers have been found to be more involved (Gavin et al., 2002) and to have a more affectionate and supportive relationship with young mothers (Krishnakumar & Black, 2003) when they have positive relationships with the young women’s mothers. These findings are consistent with growing literature on low-­income, unwed parents more generally, in which it appears that positive relationships with one another’s extended families are associated with stable, high-­father involvement and a greater likelihood of reengaging in high levels of involvement after periods of low levels of support (Ryan, Kalil, & Ziol-Guest, 2007). Maternal grandmothers may have powerful influence in shaping young mothers’ views of their partners, and as heads of households grandmothers may play powerful gatekeeping roles that may work to exclude the involvement of fathers with their daughters and grandchildren as a means of protecting their child. Alternatively, maternal and paternal family members often engage in other kinds of “kinwork” in which they recruit, enlist, and sometimes mentor young parents around the ultimate goal of the caring for the infant (Roy & Burton, 2007). When it works well, communication and understanding across families and generations may lessen stress on the young mother and father and ultimately benefit their engagement with their child (Miller, 1997). Finally, young mothers have many other important relationships that provide a context for their development as parents and their relationships with their infants. Family members other than mothers may be key sources of support to many young mothers—male relatives, extended female kin, siblings—but the empirical literature on these relationships is very limited. Similarly overlooked in the research literature on adolescent parenthood is the father’s family, even though paternal family often are an



13. Relational Context of Adolescent Motherhood

important direct resource for financial or caregiving assistance for young and unwed mothers and their children (Paschal, 2006; Roy & Burton, 2007). Sisters are often important influences on young mothers, providing child care and help with other domestic tasks (Gee, Nicholson, Osborne, & Rhodes, 2003; Voight et al., 1996). Yet those relationships with siblings may be complex and strained with all the usual rivalries that siblings may have, exacerbated by the added attention a baby elicits and the added work a baby demands on members of the household (Gee et al., 2003; Voight et al., 1996). Greater reliance on siblings for social support has been associated with greater psychological distress (Thompson, 1986) and poorer parenting behavior in teenage mothers (Voight et al., 1996). Peers have also been generally overlooked in the literature on adolescent motherhood, even though developmental theory emphasizes the importance of peers during adolescence. Although female friends with children have often been assumed to be a bad influence on young women, female friends can be a positive source of support for parenting. Female friends can provide adolescent mothers both a quantity and quality of emotional support that is comparable to, or even surpasses, that provided by kin (Lyons, Henly, & Schuerman, 2005; Richardson et al., 1991). Adolescent mothers’ support from friends has also been linked to maternal well-being (Colletta, 1981) and positive parenting behavior (Voight et al., 1996). Clearly, in order to garner an understanding of the experience of adolescent mothers as they negotiate their transition to parenthood and develop their relationship with their baby, a broader lens is needed to capture the ecology of relationships that contributes to their development as parents. Infant mental health practice and programming are grounded in a rich theoretical and empirical literature on the importance of the mother–­ infant dyad to the child’s development. We must also consider the broader relational context in which the mother and infant are embedded. We are only at the beginning of understanding how to conceptualize and study these networks of relationships, with current theoretical approaches offering thoughts about the structure and processes of informal support networks, family sys-

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tems, or coparenting networks (McHale, 2007). More attention needs to be addressed to ways in which interventions designed to support young mothers and their infants can be strengthened by helping young mothers negotiate their systems of relationships and by including important members of those systems in infant mental health interventions. Acknowledgments We were supported in this work through the Irving B. Harris Infant Mental Health Training Program at The University of Chicago. We acknowledge the contributions that Lauren Wakschlag made to the chapter on early parenthood that appeared in the second edition of the Handbook, some of which appear in the current chapter. We thank Linda Henson for her feedback on this chapter, and Waldo Johnson, who gave us insights about young fathers.

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Pa r t III

ASSESSMENT

A central activity in infant mental health involves assessment of young children and their families. Emde, Bingham, and Harmon (1993) usefully distinguished between diagnosing disorders and assessing individuals. In infant mental health, assessment involves identification of both strengths and weaknesses in individuals, in relationships, in families, and in cultures. Further, assessment may or may not lead to a diagnosis in the young child. This section presents several approaches to assessment, including parent report, structured observations, and relationship assessment. Each provides useful and sometimes distinct pictures of the child’s behavior and experience. In Chapter 14 Carter, Godoy, Marakovitz, and Briggs-Gowan provide an overview of parent report measures of child behavior. Because young children cannot report on their own internal experiences, clinicians must rely upon the reports of caregivers who know the children well. The authors argue that parent report is a necessary component of any young child mental health assessment because parents’ understanding of the young child’s development and behavior reflects the most important context in which the child develops. They also note the well-known discrepancies among different reporters, but they urge that clinicians embrace these discrepancies about the child’s personality and behavior as adding to the clinical picture. Understanding the behaviors and emotions that parents and other informants notice and the meanings they attribute to these behaviors and emotions greatly deepens an understanding of the child and potential targets of intervention. In Chapter 15 we (Miron, Lewis, & Zeanah) review some of the observational measures of young children that have been validated and consider their use in clinical settings. We begin by laying out broad guidelines that can be considered by clinicians when selecting a method for observing young children interacting with their caregivers. Next we review key aspects of, and discuss ethical and professional issues associated with, using observational procedures for assessing young children and their caregivers. We conclude by arguing that structured observational procedures offer clinicians a valuable method for both assessment and treatment of caregivers and young children.

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Oppenheim and Koren-Karie conclude the section with Chapter 16, which describes their approach to relationship assessment. In keeping with other methods of infant–­parent relationship assessment, the Insightfulness Procedure, which is aimed at classifying a parent’s insightfulness about his or her young child, integrates observational and interview methods of assessment. The goal is to determine parents’ ability to think of their child as a distinctive individual, appreciate the child’s needs and wishes, and accept the child as he or she is. Although their method is standardized and validated, the authors believe that the construct of parental insightfulness can be elicited naturalistically by clinicians when listening to parents, and they urge that it be an essential component of parent–­infant relationship assessment. References Emde, R. N., Bingham, R. D., & Harmon, R. J. (1993). Classification and the diagnostic process in infancy. In C. H. Zeanah (Ed.), Handbook of infant mental health (pp. 225–235). New York: Guilford Press.

C h a p t e r 14

Parent Reports and Infant–­Toddler Mental Health Assessment Alice S. Carter Leandra Godoy Susan E. Marakovitz Margaret J. Briggs-Gowan

To understand the whole child, it is necessary to be willing to consider multiple truths simultaneously.

I

ncluding parent reports in the form of screening or surveillance forms, standardized questionnaires, and/or semistructured and clinical interviews (Hirshberg, 1993) can aid in addressing several of the unique challenges that must be considered when conducting infant mental health assessments. Inclusion of norm-­referenced parent-­report measures may be particularly important when conducting young child assessments, whether for research or clinical purposes, because parents of young children may be less apt to articulate concerns or worries, despite the presence of problematic behaviors and/or social–­emotional issues that are clinically meaningful (Briggs-Gowan & Carter, 2008). Although the focus of this chapter is on the central role that parent reports can play in a comprehensive mental health evaluation, we are not suggesting that parent reports are sufficient or adequate in the absence of direct behavioral observations of the child and relational contexts. Rather, we recommend that clinicians and researchers consider the necessity of includ-



ing multiple approaches to learning about child behavior and development. Whether or not the evaluator construes the parent to be an excellent or biased informant, the parent’s attributions about the child’s behavior or the parent’s meaning making regarding who the child is in relation to the family can greatly influence the child’s development (Johnston & Ohan, 2005; Miller, 1995). For example, Snyder, Cramer, Afrank, and Patterson (2005) found that the interaction of parental hostile attributions and ineffective/irritable discipline in kindergarten helped predict growth in child conduct problems 1 year later. Thus, the combination of parent reports and observation are optimal in conducting young child assessments. Moreover, whereas some information about the parent–child relationship and child behaviors are best gleaned through observation, other elements may only be obtained through parent reports (Zeanah, Keener, & Anders, 1986, 1987). Evaluators can obtain information from parents not only by attending to overtly ex233

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pressed concerns but also through the use of semistructured and/or structured interviews and norm-­referenced rating scales. Parentand other adult-­informant rating scales and questionnaires are commonly employed in research applications because they are inexpensive as well as quick and easy to administer to a large number of individuals in a flexible manner (i.e., in person, via mail, online). Parents or primary caregivers are the most frequent reporters on questionnaires about young children’s development, but other adult informants (e.g., day care providers) can contribute valuable information as well, particularly to gain an understanding of the pervasiveness of problems and competencies across caregiving relationships and contexts. With advances in the psychometric properties of existing measures of infant and toddler social and emotional adjustment, use in clinical settings is increasing and strongly urged (American Academy of Pediatrics [AAP], 2001, 2006; U.S. Public Health Service, 2000). Although predominantly employed in research settings, structured and semistructured interviews with parents or caregivers allow for a more in-depth examination of child problems and competencies than do questionnaires and can be particularly helpful when determining the child diagnostic status (Egger & Angold, 2004). For example, using the Preschool Age Psychiatric Assessment (PAPA; Egger & Angold, 2004), interviewers can obtain specific examples of child behavior and inquire about the onset, offset, frequency, duration, intensity, quality, and context of occurrence through followup questions and probes. Thus, interviews can provide a forum for obtaining a more comprehensive understanding of the child’s behavior and gathering information necessary to assign diagnoses. Recent advances have led to the availability of structured and semistructured diagnostic interviews for use with very young children (Egger & Angold, 2004; Keenan et al., 2007). However, these are too rarely administered in clinical or research settings because of time constraints and training issues. We begin this chapter by addressing several challenges inherent in infant mental health assessment while highlighting the ways in which parent and other caregiver report information can facilitate a more com-

plete understanding of the child. Next, we focus on general considerations in the use of parent and caregiver informant instruments. In the second half of this chapter we offer several considerations for selecting appropriate parent-­report assessments of social–­ emotional functioning, highlighting instruments designed for use with very young children that can be employed in early identification efforts or to document multiple aspects of social–­emotional and behavioral functioning. Use of the word parent in this chapter refers to a child’s primary caregiver(s) and can therefore refer to biological, adoptive, foster parents or guardians or extended family members who care for the child on a regular basis. We use the term caregiver somewhat more broadly than the term parent, to encompass both primary caregivers and individuals who routinely spend enough time with the child to be knowledgeable about multiple aspects of the child’s social–­ emotional functioning and day-to-day behavior. Thus, caregiver may refer to extended family members and child care/day care providers who have cared for the child for at least 1 month and who care for the child on a regular basis. Determining who routinely cares for the child and whom parents include in their definition of family is a crucial first step in the evaluation process, especially given that “family” may include the nuclear family, larger extended kinship networks, or individuals in the community with whom family members have close ties (Carter & Murdock, 2001; Sue & Sue, 2003).

DOMAINS OF ASSESSMENT The context of assessment often informs the domains of functioning that will be evaluated using parent reports. Although the primary focus of this chapter is the social–­ emotional domain, gathering information about overall developmental functioning may be necessary to interpret parent reports about this domain. In particular, delays in social and emotional competencies need to be understood within a developmental framework. The parsing of expected social–­ emotional delays (that are commensurate with the child’s overall cognitive or linguistic functioning) from delays suggestive of risk



14. Parent Reports

for psychopathology requires careful consideration. For example, a child with global developmental delays would not be expected to function at chronological age level in terms of behaviors, such as self-­control and compliance, and/or social–­emotional skills, such as emotion regulation or sophistication of play schemes. It would be misleading to assume that these delays are similar in nature, meaning, and risk to social–­emotional delays that are documented when a child’s cognitive and linguistic functioning is age adequate. Therefore, if no information is available about the child’s developmental functioning, we recommend, at a minimum, gathering information about developmental functioning using a parent-­report measure such as the Ages and Stages Questionnaires (ASQ; Bricker & Squaires, 1999) or about language functioning using a measure such as the MacArthur–Bates Communicative Development Inventories (CDIs; Fenson et al., 2000). This assessment domain is critical because the child’s level of cognitive and linguistic functioning will have implications for understanding current social–­emotional adjustment and for making determinations regarding appropriate referrals for further evaluation and intervention. Children with language and cognitive delays are at elevated risk for social–­emotional problems and delays in the acquisition of social and emotional competencies (Briggs-Gowan & Carter, 2007). Thus, when a language or cognitive delay is identified, it is important to screen for social–­emotional problems and delays/ deficits in social–­emotional competence. However, if routine data are gathered about language and developmental functioning through direct assessments, it may not be necessary to use parent report to obtain information about these domains, unless it is important to examine the parent’s knowledge about the child’s development in these areas. Whether using parent reports to conduct screening, surveillance, or as part of comprehensive mental health assessments, we also advocate assessing both social–­ emotional problem behaviors and competencies (Briggs-Gowan & Carter, 1998; Carter, Briggs-Gowan, Jones, & Little, 2003; Carter, Briggs-Gowan, & Davis, 2004). Too often there is an emphasis on social–­emotional

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problems, such as aggression or inattention, without concomitant characterization of social–­emotional and behavioral competencies, such as compliance and empathy. Gathering information about social–­emotional and behavioral competencies can serve several purposes. First, the presence of a delay/ deficit in social and emotional competencies is a risk factor for the emergence of behavior problems and psychopathology (e.g., Carter, 2002; Cicchetti & Cohen, 2006; Denham & Holt, 1993). Reciprocally, competence in stage-­salient tasks increases the likelihood of later competence (Denham et al., 2003; Houck, 1999; Sameroff, Bartko, & Baldwin, 1998) and minimizes the emergence of new, and the maintenance of existing, maladaptive patterns of behavior (Carter, 2002; Keenan & Shaw, 1997; Masten, Burt, & Coatsworth, 2006; Masten & Coatsworth, 1998;). Second, assessing social–­emotional and behavioral competencies provides one avenue for evaluating the relative degree of impairment associated with extant problem behaviors (Briggs-Gowan, Carter, Skuban, & Horowitz, 2001). To the extent that problem behaviors co-occur with delays in the acquisition of stage-­salient competencies, concern for the child’s overall development is raised. Third, including questions about both positive and negative aspects of the child may minimize parental response biases (Briggs-Gowan & Carter, 1998; Carter, 2002). Finally, in clinical evaluations of young children, assessing social–­emotional and behavioral competencies may facilitate the design of interventions that capitalize on children’s strengths.

CHALLENGES IN ASSESSING INFANTS AND TODDLERS Though challenges exist when conducting any mental health assessment, several are unique to working with infants and toddlers. Understanding these challenges can enhance the evaluation process.

Limited Verbal and Metacognitive Capacities Infants and young children have no or limited verbal abilities and meta-­cognitive capacities, making it difficult, if not impossible,

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to elicit their thoughts and feelings about presenting complaints, historical behaviors, and contextual events. Therefore, caregivers play a central role in providing information about the young child’s behaviors across multiple settings and contexts, including vital information about when behaviors may have emerged and changed over time.

Contextual Influences on Young Children’s Behavior Young children’s behavior is highly sensitive to contextual and relational influences (Clark, Tluczek, & Gallagher, 2004; Tronick, 1989) and may therefore be more variable across settings than older children’s behavior. For example, in developing the Infant–­Toddler Social and Emotional Assessment (ITSEA; Carter & Briggs-Gowan, 2006), data were gathered from mothers, fathers, and child care providers. Across problem and competence domains, mothers and fathers demonstrated strong agreement with one another (mean correlation of .71) (Carter et al., 2003), whereas correlations between parents and child care providers were in the range of .26 (Moye, Briggs-Gowan, & Carter, 2000), a level of agreement similar to what has been found between parents of older children (Achenbach, McConaughy, & Howell, 1987). However, the modest overall correlation between parents and child care providers is a bit misleading, as there were significant differences in associations depending on the child care context. Specifically, when infants and toddlers were cared for by another nonparental provider in the home setting, correlations between parents and child care providers were moderately strong (average for problems = .34; competence = .50). In contrast, for infants and toddlers in traditional, center-based child care settings and family day care settings, correlations between mothers and child care providers were nonsignificant, suggesting that children’s behaviors showed little consistency across home and center-based or family day care settings (Moye et al., 2000). Given such sensitivity to contextual influences, it is optimal to gather information about the young child’s behavior in multiple settings and across different types of interactions that may elicit varied responses (e.g., play, feeding/snack, teaching challenging tasks, bedtime). As observations of mul-

tiple settings are often impractical, gathering data from informants across contexts can be extremely valuable. Analysis of the contexts in which a child has difficulties, for example, with respect to predictability and structure, often offers important clues for intervention.

Child Behavior and the Caregiving Relationship It is essential to recognize that young children’s development, behavior, and functioning are embedded within their caregiving relationships. Through affective, regulatory, and physical structuring of the environment, caregivers may strongly influence young children’s behavior (Calkins & Hill, 2007; Clark et al., 2004; Moore & Calkins, 2004; Tronick, 1998). Thus, social–­emotional behavior, adaptive functioning, and impairment should be assessed both within the context of caregiving relationships and when the child is functioning independently, at all times mindful of the child’s caregiving relationships. The age and developmental level of the child has important implications for the level of independence one would expect to observe, but assessments of the child independent of the caregiver may provide information about the extent to which the child has internalized or generalized strategies employed with the caregiver. Gathering information about the patterns and quality of current caregiving relationships (e.g., who the primary caregivers are, what kinds of supports caregivers provide) and the history of caregiving relationships (e.g., multiple transitions, abrupt losses) is imperative. Consideration also should be given to the match (or mismatch) between a child’s individual characteristics, such as temperament and developmental functioning, and the situational demands and supports provided. Problem behaviors may reflect a mismatch between the child and the caregiving environment, developmentally inappropriate caregiver expectations, or limitations in the caregivers’ capacities to meet the child’s needs (Seifer, 2000).

Limitations of Caregiver Reports May Be Amplified in Early Childhood Despite the tremendous progress in infant mental health since the publication of the



14. Parent Reports

first edition of this Handbook, there is still considerable reluctance to identify mental health problems in very young children. Moreover, parents’ lack of developmental knowledge regarding distinctions between normative misbehaviors and clinically concerning problem behaviors presents a challenge to the early detection of clinically significant psychopathology. There is increasing evidence that parents of young children are often unaware that their child’s behavior may be “problematic” and, consequently, may be less likely to be concerned about, or seek help for, extreme problem behaviors (Briggs-Gowan & Carter, 2008; Ellingson, Briggs-Gowan, Carter, & Horwitz, 2004; Glascoe, 2003). For example, in our representative birth cohort sample, 36% of parents who reported subclinical/ clinical-range scores on the Child Behavior Checklist/1½–5 (CBCL/1½–5; Achenbach & Rescorla, 2000) at 2 years of age indicated that they were “Not at all worried” or “A little worried” about their child’s behavior (Briggs-Gowan et al., 2001). Additional results from this sample (Briggs-Gowan & Carter, 2008) indicate that parental worry about social–­emotional/behavioral problems had limited value in predicting school-age social–­emotional and behavioral problems, whereas parental reports about specific behaviors on norm-­referenced problem behavior scales showed promise in detecting early, persistent, social–­emotional problems. Thus, using standardized, norm-­referenced parent­report measures, such as the ITSEA (Carter & Briggs-Gowan, 2006), Brief Infant–­ Toddler Social and Emotional Assessment (BITSEA; Briggs-Gowan & Carter, 2006), and the Ages and Stages Questionnaires—­ Social–­Emotional (ASQ-SE; Squires, Bricker, & Twombly, 2002), to gather information about specific social–­emotional and problem behaviors, in addition to inquiring about concerns or worries regarding social–­ emotional and problem behaviors, may be more critical in early childhood. Parents of young children may have greater difficulty identifying concerning behaviors because young children are less likely than older children to spend time in settings outside the home. With fewer opportunities to observe other children their child’s age or to observe their child interacting with peers, parents may have difficulty developing a normative reference and evaluating the clinical

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significance of their child’s behaviors. While parents of school-age children have opportunities to receive feedback regarding their child’s behavior from teachers, who generally have knowledge of child development, parents of younger children not enrolled in child care do not have the same opportunities to receive input from adults with knowledge about child development.

Evaluating Impairment As with older children and adults, it is important to evaluate impairment in the functioning of the young child, that is, the extent to which symptoms of psychopathology are interfering with the child’s developmental progress or participation in age-­appropriate activities. When evaluating impairment, it is crucial to consider the child’s cognitive, motor, and linguistic capacities to avoid misattributing impairment to one domain (i.e., psychopathology) that is better explained by a developmental disability or delay. Take the example of a toddler who is bottle-fed and eats only pureed baby foods and refuses solids. Although this food refusal could reflect underlying social–­emotional problems, it may be better explained by significant oral– motor deficits or delays. Thus, assessing impairment associated with psychopathology requires consideration of developmental trajectories in multiple domains. For older children and adults, impairment is typically assessed by evaluating the individual’s interpersonal, academic, occupational, and adaptive functioning and evidence of impairment is required for psychiatric diagnosis (American Psychiatric Association, 2000). Assessment of impairment in very young children may require a conceptual shift from the individual to the family system. Specifically, because very young children’s functioning is dependent on parental scaffolding and support, impairment may be evident in the degree or number of accommodations that parents make to facilitate their young child’s participation in age-­appropriate activities or developmental progress. For example, although a parent may not be able to offer examples of child impairment, the parent may have quit his or her job and restructured the household to accommodate the child’s special needs. It is not unusual for caregivers to minimize demands that would illuminate the child’s impairment

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(Carter et al., 2004). Using a framework in which young child impairment is reconceptualized within the family system, parental distress or low efficacy about the parent– child relationship or evidence that the child’s behavior interferes with the parent’s ability to maintain family routines (e.g., eating together as a family in a restaurant), household activities (e.g., making phone calls), or employment (e.g., changing work settings because of difficulty obtaining appropriate child care) can be considered an appropriate gauge of impairment (Carter et al., 2004). There are also a number of cost-­effective and expedient means of gathering information about the impact of the child’s behavior on family functioning, such as use of the Parenting Stress Index (PSI; Abidin, 1995) and the Family Life Impairment Scale (FLIS; Briggs-Gowan, Carter, Bosson-­Heenan, Guyer, & Horwitz, 2006). Additionally, several parent-­report instruments, such as the Vineland Adaptive Behavior Scales–II (Vineland-II; Sparrow, Cicchetti, & Balla, 2005) and the Adaptive Behavior Assessment System–II (ABAS-II; Harrison & Oakland, 2003), comprehensively assess the child’s adaptive functioning. Adaptive functioning that is significantly lower than cognitive functioning often reflects the child’s inability to participate in age-­expected activities or attain developmentally expected competencies. Thus, adaptive functioning represents one index of impairment.

GENERAL CONSIDERATIONS OF CAREGIVER REPORTS Several general considerations should be taken into account when using parent caregiver-­reported information, regardless of the domain assessed or assessment modality. First, in an era of globalization and transnational fluidity, understanding the ways in which race, ethnicity, and culture play a role in assessment is essential. Second, as with all assessment methods, it is critical to appreciate the strengths and limitations of parent reports. Third, while highlighting parent reports in this chapter, it is necessary to acknowledge difficulties integrating parent-­reported information with information from collateral informants and other assessment modalities (i.e., observations).

Considerations raised about parent reports are relevant for other caregivers, as well.

Considerations of Race, Ethnicity, and Culture Before considering the ways in which race, ethnicity, and culture influence the gathering and interpretation of parent reports, it is important to clarify key terms. Race refers to “a socially constructed concept of categorization and distinction within social relationships based on physical characteristics” (Suyemoto & Dimas, 2003, p. 58). Though often confounded with race, ethnicity denotes a particular kind of culture usually associated with a common geographic region or national origin (Atkinson, Morton, & Sue, 1998; Pinderhughes, 1989; Sue & Sue, 2003). Culture refers to shared values, beliefs, and practices transmitted across generations within a group (cf. Pinderhughes, 1989; Tomlinson-­Clarke, 1999). Thus, common cultural groups could include, for example, Jewish culture, lesbian culture, and deaf culture (Suyemoto & Kim, 2005). Most central to the inclusion of parent­report information with young children is the need to understand parents’ general views of childrearing and their cultural explanations of the child’s behaviors. Parents’ concerns may differ from those expressed by the clinician due to differences in background, beliefs, and expectations about child behavior and childrearing. Behavior deemed problematic by the clinician might be considered typical by the parents’ standards. Alternatively, behavior deemed typical by the clinician might be viewed as worrisome by the parent. Two children can therefore exhibit the same behavior, but differences in cultural norms and expectations will either normalize/minimize the behavior or make the behavior salient, thus leading to different rates of reporting (Mandell & Novak, 2005). Engaging parents in a dialogue about their understanding of their child’s behavior and their expectations for treatment is necessary to ensure that families from diverse backgrounds are not pathologized or misunderstood. Thus, it is necessary to talk with families about (1) perceptions of the child’s difficulties or distress; (2) how the child’s behavior is viewed relative to other child behav-



14. Parent Reports

ior in their cultural group (i.e., the norms the parents are using); (3) cultural explanations for the child’s difficulties or distress; and (4) parental experiences with, and preferences for, treatment (Christensen, Emde, & Fleming, 2004). In addition, it is important to consider “parents’ intentions for raising the child with respect to the culture of origin and the dominant culture” (Christensen et al., 2004, p. 14). Multicultural identification and intergenerational pressures and conflicts might be raised as concerns when families begin discussing their backgrounds and intentions for childrearing. With these factors in mind, clinicians and researchers who are faced with the task of selecting instruments for the assessment of a young child can think critically about the appropriateness of question content for various populations and families. Even when appropriate norms are not available for a particular family, the use of a parent-­report tool may provide an opportunity to begin discussing specific child behaviors. Individual problem and competence items that parents endorse can be reviewed to understand the threshold that parents are employing when answering questions; for example, whether or not a behavior is “Somewhat True” or “Often True.” In addition, the affective valence attributed to the behavior and the cultural meaning of the behavior, if any, should be discussed so that clinicians can determine the cultural validity of a particular measure or item, to determine, for example, that it would not be appropriate to use existing normative data. This level of assessment can lead to treatment plans that acknowledge and incorporate parents’ beliefs, concerns, and preferences, thus increasing the likelihood that families will engage in the treatment process. Researchers and clinicians must consider several factors before gathering parent­report information and attempting to have the types of conversations outlined above. It is essential that researchers and clinicians explore and reflect upon their own background, attitudes, and beliefs about race and ethnicity and increase their understanding of the factors that shape their own worldview (American Psychological Association, 2003; Hays, 2001). The processes of self-­reflection and of increasing “cultural competence” more broadly do not have stat-

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ic end points; rather, they are ongoing and dynamic. Having background information about the racial, ethnic, and cultural groups with which a family identifies facilitates assessment. Whenever possible, exploring the ways in which the racial, ethnic, and cultural groups with which the family identifies and their experiences of racism and stereotyping influence their beliefs about child behavior, childrearing practices, and help seeking is useful. These considerations will be enhanced by an understanding of the sociopolitical and historical experiences of the groups with which the family identifies (e.g., knowledge about U.S. immigration laws for a family that recently emigrated from Mexico). Though background information provides a basic framework for assessment, inquiring about a family’s lived experiences by inquiring about factors such as immigration patterns, economic conditions, parental identification with culture of origin and dominant culture, and language ability, use, and preference is also extremely helpful (Christensen et al., 2004). An understanding of oneself, the assessment tools being used, the groups with which families identify, and the potential interplay among these factors is critical to establishing a positive working relationship with parents and families. For example, you should consider how families might view you as the clinician or researcher, the questions being posed, and the clinical formulations you present based on their ratings of child behaviors. Opening up these issues with families as a topic of discussion will greatly enhance the assessment process, the working relationship, and the gathering of reliable and valid data about child and family functioning. For investigators, especially those developing new instruments or using instruments with new populations, it is useful to acknowledge that child mental health research has typically been conducted through a white, Western/Eurocentric lens rather than a culture-­centered one. In order to shift perspectives, evaluation of parent/caregiver instruments for young children should (1) include culture as a central variable of interest rather than a nuisance variable; (2) include samples representative of diverse populations; (3) appreciate within-group variability; and (4) ensure that the communities

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studied benefit from the research (American Psychological Association, 2003). Creating or modifying assessment tools that take into account racial, ethnic, and cultural variables requires gathering information, through interviews and focus groups, so that the appropriateness of questions can be determined. Pilot testing a measure within the target population to evaluate the psychometric properties (reliability, validity, and factor structure) and the cultural appropriateness of question content is important because it is rare to obtain this type of within-­ethnic group data. Investigators are encouraged to report this basic psychometric information with the population under study. Although documenting that a test or scale evidences comparable scale structure and internal consistency is useful, it is also necessary to determine whether or not a test functions in the same manner across groups (e.g., has the same sensitivity and specificity and measurement equivalence) (Sattler, 2001). Researchers and test developers are encouraged to increase diversity within samples and to gather adequately large samples to permit cross-group validation. Particularly critical to the use of parent- and caregiver­report instruments is the development of culturally sensitive language adaptations of widely used measures. Offering parents an opportunity to describe their young child in their own language enhances the quality of information gathered. While translation and back translation are necessary steps in adapting measures to various populations, these efforts are not sufficient because the translation may not be appropriate for the population under study or the family seeking treatment. We learned this lesson in a somewhat embarrassing fashion when developing the first Spanish translation of the ITSEA. The Spanish word for pacifier, used in our sample item and appropriate with families from Puerto Rico, had highly sexualized and off-­putting connotations for a sample of families of Mexican descent.

Strengths and Limitations of Parent Reports The major strength of parent reports is that parents have a developmental, contextual, historical and intimate knowledge of their child’s behaviors, temperament, and

daily routines. For example, a parent is in a unique position to report on the number of temper tantrums a child has per week, when the temper tantrums started, whether there has been a recent change in the number of tantrums, what routinely triggers the tantrums, how long they last, how other people respond to the tantrums, and what helps the child calm down. Parents are also in the unique position of being able to report on behaviors that occur infrequently and/or are rarely observed in office or laboratory settings. Obtaining information about low base-rate behaviors is critical, given that such behaviors tend to be clinically significant yet are often excluded from dimensional scales (Carter et al., 2003). Though these factors make parents attractive reporters, limitations exist that have caused some professionals to minimize and mistrust parents’ reports. Of primary concern is that parent reports can be biased such that children are depicted in either a more positive or more negative light relative to other informants or more objective sources. The most widely researched influence on parental reporting is parental affective symptoms, especially depression, which are associated with increased reports of child behavior problems and with increased cross-­informant disagreement (Briggs-Gowan, Carter, & Schwab-Stone, 1996; Najman et al., 2000; Youngstrom, Loeber, & Stouthamer-­Loeber, 2000). A depression­distortion hypothesis has been proposed to explain the positive correlation between parental psychopathology, particularly depression, and parent ratings of child behavior problems (De Los Reyes & Kazdin, 2005). However, the majority of papers that support a depression-­distortion hypothesis have yielded relatively small effect sizes, and the conclusions drawn from these studies have been called into question (Richters, 1992). Although studied less systematically, parents may underreport problems due to concerns regarding stigmatization or blame and/ or because they are not attending to their child’s problems. Biases present interpretation problems for assessments of older children as well, but heavy reliance on parent reports for very young children, often without collateral information, makes this concern more salient for this population. Measures that have a more structured format and a



14. Parent Reports

lower inference level required to make ratings tend to be more reliable and thus less influenced by parental biases (Carter, Marakovitz, & Sparrow, 2006). It is important to raise awareness about factors that influence how parents report on their children’s behavior, but even biased reports of child behavior can provide information that is necessary for developing an understanding of the whole child. Parental expectations, attributions, and interpretations of child behavior shape parenting practices and influence children’s self-­evaluations and self-­understanding, thus impacting children’s behavior (Snyder et al., 2005). It is therefore not surprising that negative parental attributions and expectations are predictive of future child behavior problems (Carter, Garrity-­Rokous, Chazan-Cohen, Little, & Briggs-Gowan, 2001; Snyder et al., 2005). Attributions about behaviors along with caregiving socialization of behaviors will likely influence whether or not a particular behavior leads to adaptive or maladaptive outcomes (cf. Fonagy, Target, & Gergely, 2006; Zeanah et al., 1986). For example, an active child whose parents welcome a high activity level, encourage physical outlets, and gently support the development of self-­control may be at lower risk for psychopathology than a child of similar activity level whose parents feel overwhelmed and use harsh parenting strategies to demand that the child be still and quiet. Moreover, when caregivers hold widely disparate views of the child’s behavior, it may reflect tension or conflict in the family system that can exacerbate the child’s problems (De Los Reyes & Kazdin, 2005). Parental expectations and evaluations may therefore be a useful point of intervention, given concerns that arise when parents’ appraisals are either too harsh or too lenient (e.g., Bugental et al., 2002). Given continuity between prenatal and postnatal expectations of child temperament (Benoit, Parker, & Zeanah, 1997; Mebert, 1989; Zeanah, Keener, Stewart, & Anders, 1985), it may be important to identify and intervene with parents who have negative views and limited knowledge of developmental expectations prior to the arrival of the child. In addition, it behooves the field to develop instrumentation that is sensitive to yea-­saying and nay-­saying biases, which can be achieved

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through inclusion of social desirability and negativity items and scales. In sum, parents are attractive reporters because they know the most about their child’s development and can report on their child’s behavior in a differentiated manner that is sensitive to historical, developmental, and contextual influences. At the same time, some parents (as well as other informants) are biased reporters, poor historians, and they can vary in their understanding and explanations of child behavior, thus posing difficulties when interpreting parent reports and making sole reliance on parent reports a questionable practice.

Benefits and Complexities of Multiple Informants Another concern in gathering parent reports is how to incorporate this information with other reports of child behavior and functioning. Use of multiple informants is helpful in painting a more complete picture of a child’s behavior and functioning, especially when the child is behaving differently across contexts and caregivers. The first step in gathering multi-­informant data is to clarify who can provide information about the child, in terms of individuals who spend sufficient time with the child and individuals whom the parents feel comfortable approaching. When obtaining information from outside sources (e.g., child care providers), care must be taken to protect the child and family’s confidentiality and to obtain written consent from parents or legal guardians. Child care providers can help supplement parent reports because they have the advantage of seeing children in a more structured setting and surrounded by peers. Additionally, child care providers tend to have a broader range of experiences with children and therefore more knowledge of normative versus atypical behaviors. Acquiring information about behavior across contexts speaks to problem pervasiveness and severity and can therefore be helpful in determining the clinical significance of behaviors (Campbell, 1995; Wakschlag et al., 2007). Moreover, when involved in case conceptualization and treatment planning, information across contexts may reveal which aspects of the caregiving environment improve versus exacerbate child behavior problems. At the

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same time, there may be situations in which a child care provider is not an accurate informant about an individual child, perhaps due to a very busy environment in which monitoring is low and only highly problematic behaviors are acknowledged or due to a strengths-­oriented bias in which behaviors of clinical concern are attributed to temperamental and/or developmental variations. Conflicting reports, which are not unusual when conducting clinical assessments of young children, can therefore reflect true differences in cross-­situational behavior, reporter biases, and/or family discord. Rules for interpreting and synthesizing conflicting information from multiple informants are scarce; thus, it remains immensely difficult to interpret conflicting reports (Kraemer et al., 2003). It is important to consider each source of information as an important piece of the puzzle requisite to understanding the whole child, rather than approaching the assessment as a search for a unitary truth (De Los Reyes & Kazdin, 2006; Kerr, Lunkenheimer, & Olson, 2007).

Parental Concern The use of standardized, or norm-­referenced, comprehensive, parent/caregiver report measures that have been supported by longitudinal research is critical to increasing the identification of early emerging psychopathology because such instruments provide information about behaviors that may not initially concern parents and clinicians. For example, although an extremely sensitive measure in relation to school-age children and adolescents, parental concern is not a strong indicator of young children’s current or future behavior problems (Briggs-Gowan & Carter, 2008; Glascoe, 2003). We have found that a large number of parents are not worried about their young children’s behavior despite the fact that they report that their children are displaying a clinically significant level of problem behaviors. It may be that parents are reluctant to raise concerns about negative behavior for fear that it will reflect poorly on the child and family. Consistent with this notion is evidence that parents are more likely to be worried about and seek help for lags in social–­emotional competence (i.e., when their children are not doing what they should be) than behavior

problems (Ellingson et al., 2004). There is still much to learn about factors that influence parental concern about child mental health and that motivate help-­seeking efforts. Moreover, even when parents raise concerns, professionals sometimes minimize the concerns, preferring to take a “waitand-see” approach. The increased use of empirically validated assessments is therefore critical to identifying children who may be exhibiting clinically significant levels of emotional and behavior problems.

SELECTING A PARENT/ CAREGIVER INSTRUMENT Selecting a parent/caregiver report tool for an infant mental health assessment requires both general knowledge about instrument selection (cf. Carter et al., 2006) and the manner in which features of early development can influence instrument reliability and validity (cf. Carter et al., 2004). The goals of the assessment should be the most important factor influencing the choice of a tool. However, decisions about assessment tools are also influenced by practical considerations and constraints, such as (1) cost of the instrument; (2) parental time commitment; (3) parental literacy; (4) staffing constraints; (5) in the case of interviews; availability of a trained staff person who can administer the interview reliably; (6) availability of translated versions of the assessment, or a translator; (7) the ethnic/cultural background of the child and family; (8) ease of scoring and interpretation; and (9) psychometric issues, such as the reliability and validity of the instrument in the target population. Such considerations are relevant to assessments with individuals of any age. Unique to infant mental health assessment is the need to (1) identify instruments that are sensitive to the rapid behavioral and developmental changes of early childhood (e.g., need shorter test–­ retest interval) and (2) recognize the greater difficulty parents experience in distinguishing normative misbehaviors from clinically concerning problem behaviors (e.g., need lower inference questions). In the next section we highlight psychometric issues relevant to instrument selection of parent­reported measures of young child mental health.



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Psychometric Assessment Issues A first analysis of an instrument requires an examination of its psychometric properties. Too often, in both clinical and research settings, measures are selected based primarily on ease of use and common practice, and psychometrics are not given adequate weight. The following section outlines psychometric issues most relevant to parent/caregiver reports in assessing young children.

Reliability Reliability broadly reflects the consistency or stability of a measure. For questionnaires, the consistency of a measure is typically evaluated by examining (1) internal consistency, or the extent to which individual items on the scale reflect the same construct, most often assessed with Cronbach’s alpha; and (2) test–­retest reliability, or the stability of a measure with repeated administrations over a short time frame. For interview assessments, the consistency of the measure across raters, or the interrater reliability, should also be evaluated. Scales with Cronbach’s alpha of .70 or greater are usually considered to have adequate internal consistency, whereas those that fall in the range of .60–.70 are viewed as having marginal internal consistency, and those below .60 are considered unacceptable. However, it also is important to recognize that some clinically informative measures of young children may not have acceptable internal consistency. This is often the case when a measure includes behaviors that rarely occur in the population (e.g., atypical behaviors related to autism spectrum disorders) or sets of behaviors that are clinically concerning but not likely to co-occur with one another. The ITSEA Atypical Behaviors Index is one such example of a set of clinically important yet rarely occurring behaviors, resulting in an index that would be expected to have low internal consistency in a normative population (Carter & Briggs-Gowan, 2006). These rare behaviors, though clinically and diagnostically informative, are often excluded from questionnaires because their inclusion reduces internal consistency. Thus, the type of information gathered influences a measure’s internal consistency, and evaluators should

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be mindful of why a measure or scale might have low internal consistency. Test–­retest reliability is typically assessed after 2–4 weeks for measures used with older children and adults (Carter et al., 2006). For measures that assess state features of the infant or toddler, test–­retest reliability should be evaluated after a briefer time interval; as noted, the rapid pace of development at this age can reduce test–­retest reliability. For example, the 2-week test–­retest reliability of infants’ sleeping behaviors from 4–6 weeks of age will likely be much poorer than the 2-week reliability estimate for these same behaviors in an older child or adult. Poor reliability estimates for the infant will likely reflect true change in the infant rather than measurement error. Reliability coefficients of .70 and above are considered good. Guidelines for test–­retest reliability are similar for questionnaire and interview format. For interview assessments, selection should be informed by interrater reliability, or the consistency of a measure across raters, along with test–­retest reliability. For psychiatric interviews the unit of reliability analysis may be symptom counts or diagnosis. In general, the more structured the assessment format and the lower the inference level required to make ratings, the greater the probability that adequate test–­retest and interrater reliability can be obtained. The availability of detailed administration manuals and/or training enhances interrater reliability.

Validity When selecting a parent/caregiver assessment tool, it is crucial to evaluate its validity, that is, its ability to measure the problem, skill, or trait it is intended to measure. Measures that have inadequate validity will artificially limit our understanding of the underlying dimensions and processes of change, which may lead to mistaken conclusions about functioning at one time point and over time. Several types of validity can be evaluated. These are described briefly here, with the example of a “Hypothetical Anxiety Measure for Preschoolers” (HAMP). 1.  Content validity or face validity. Do the individual questions or items measure the underlying construct they are purported to measure, and are the items developmen-

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tally appropriate for the target age range? For example, do items on the HAMP appropriately assess preschool anxiety? Content or face validity is often established by an expert who reviews the measure. 2.  Construct validity. How well does the measure assess the construct it is intended to measure? For example, do scores on the HAMP correlate with scores on other, validated, measures of preschool anxiety? In addition, does the measure have the expected factor structure, such that symptoms (items) cluster together onto one global scale or subscales that relate to the larger construct the measure is intended to assess. 3.  Convergent validity. Does the measure show expected positive associations with related (but not the same) constructs? For example, given an established association between depressive and anxiety symptoms, one might ask: Do HAMP scores correlate with scores on measures of depressive symptoms? 4.  Divergent validity. Does the measure show expected negative associations with other constructs? For example, do scores on the HAMP correlate negatively with measures of risk taking? 5.  Discriminant validity or between groups validity. Does the measure differentiate between young children with the problem the measure is intended to measure and young children without the problem the measure is intended to measure? For example, do young children with anxiety disorders score higher on the HAMP than young children without anxiety disorders? Another way to evaluate discriminant validity is to examine how well a tool classifies people with and without clinically significant problems or disorders. This type of discriminant validity is evaluated in terms of the measure’s sensitivity and specificity (discussed in the next section). 6.  Predictive validity. To what degree does an assessment tool measure or predict the same traits/constructs over time? For example, do scores on the HAMP at 3 years of age predict anxiety symptoms at school age? For young children, and particularly when longitudinal analysis or clinical follow-up is planned, it is critical that the assessment tool be analyzed within a developmental framework to ensure that the tool has the

same structure and measures the same constructs across developmental periods or ages. However, this is not always possible. For constructs characterized by heterotypic continuity, it may be necessary to assess the construct of interest using different items at different ages. For example, a different version of the HAMP may be required once children acquire the ability to use words to describe their internal experience.

Sensitivity–­Specificity Sensitivity and specificity, terms used when evaluating discriminant validity, provide information about how well a measure can be used for a specific classification purpose. Sensitivity refers to the proportion of children who fall within a given problem group (e.g., disorder/referral group) who are successfully classified by the measure in question. Thus, a measure that classifies as “positive” for an anxiety disorder 80 out of 100 children known to have the disorder (by some other criterion) has 80% sensitivity. Specificity refers to the proportion of children who do not have a given problem who are correctly classified as not having the problem according to the measure in question. Thus, a measure that classifies as “negative” for an anxiety disorder 90 out of 100 noncases has 90% specificity. Sensitivity should be high (and thus false negatives low) for assessment tools designed to aid in specific diagnoses or treatment recommendations (e.g., structured clinical interviews) because of the potential costs to the child and family of misclassifying a child who actually has a specific disorder as not having the disorder. However, when the goal is to screen large samples to identify at-risk individuals regardless of their diagnostic status, it often becomes challenging to maintain a balance whereby a sufficient proportion of children with problems are detected, while maintaining an acceptable rate of false positives. When scoring thresholds or cut scores are too high, screeners tend to have high specificity and a low rate of false positives, but low sensitivity, meaning that children are more likely to go unidentified. In contrast, when thresholds are too low, sensitivity will be high, but specificity will be low, leading to misclassification and potential flooding of the service system with false positives. It is therefore necessary to



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document both an instrument’s sensitivity and specificity: A general guideline: Assessment tools should be sufficiently sensitive to detect a minimum 80% of cases and allow for early preventive interventions, yet maintain false positive rates that are low enough (20% or lower) so that service systems are not unnecessarily overwhelmed. However, depending on the purpose of assessment, different criteria may be more appropriate. Sensitivity and specificity estimates for a particular measure may vary across development, especially with diagnostic conditions that have different base rates at different ages. Thus, the narrowness of age bands used for comparison should be considered when examining sensitivity and specificity, especially with rapidly changing behaviors. Moreover, evaluators should attend to the age at which sensitivity and specificity statistics have been reported, as these may not generalize across age groups. Measures of sensitivity and specificity, as well as of reliability and validity, may vary across subpopulations and the context of the assessment. These issues can be highly complex and have implications for policy as well as research and clinical applications. For example, with respect to policy, although most professionals, including the American Academy of Pediatrics (2006), advocate routine screening for autism and general behavior problems in pediatric settings, it is important to be aware of the associated challenges. Limitations of existing parent­report screeners for autism and general behavior problems have led to controversy regarding the best means for implementing these recommendations. In addition to psychometric challenges, many pediatricians believe that it is unethical and are therefore unwilling to screen for problems for which there are no available referral sources (Perrin & Stancin, 2002). Increasing the mental health system’s capacity to evaluate and treat children identified through screening will increase the likelihood that screening will be implemented and that the long-term sequelae of mental health disturbance will be minimized.

Norms Norms are designed to compare individuals to their age-based peer group and are critical to infant mental health assessments, as parents

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and other caregivers may not have adequate internal norms regarding which behaviors are normative and which are clinically concerning. Whenever possible, measures that have normative data are preferable to those with no normative data or norms based on convenience samples. Evaluators should be familiar with the sample and the conditions in which normative data were collected and should consider the relevance of these norms to the child/family or research sample of interest (Carter et al., 2006).

Response Formats A final consideration when evaluating a questionnaire or interview is the response format. Response formats vary with respect to whether a problem is judged as present or absent (as is done in many diagnostic interviews and screeners) or whether a scale allows the respondent to endorse variation in frequency of occurrence or severity of the behavior (Achenbach, 2000). Often the respondent is asked to consider simultaneously whether certain characteristics or behaviors are representative of the target child and/or how often they occur. Thus, many measures cross ratings of the frequency of a behavior with ratings of whether the behavior is typical of the child. As most social–­emotional and behavioral problems and competencies vary in frequency and/or intensity, it makes functional sense to apply a response format that can capture variation in frequency and/ or intensity (Achenbach, 2000). For example, on the ITSEA, the response format is 0 for “Not true/rarely,” 1 for “Somewhat true/ sometimes,” and 2 for “Very true/often.” An alternative response format, employed in the Behavior Checklist (BCL; Richman, 1977), requires that the parent rate the degree to which a particular behavior is perceived to be a problem. Specifically, on the BCL parents are asked to rate a behavioral category as 0 for “No difficulties,” 1 for “Moderate difficulties,” and 2 for “Definitive difficulties.” Each of these response scales is sufficient for identifying children at elevated risk for psychopathology when items are aggregated into meaningful clusters (Achenbach, 2000; Campbell, 1995). However, neither format is sufficient for determining clinical diagnostic status. Information about onset, duration, and intensity of behaviors, as well as the level of impairment, is required to de-

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termine diagnostic status and is best gathered in an interview format. On a cautionary note, a response format that is overly complex, such as one that changes with each question or that utilizes a 13-point response scale with few anchors will likely be off-­putting to parents and introduce error variance into measurement, especially for parents with more limited educational backgrounds. Items that include double or even single negatives can also complicate a measure (e.g., “Often/Very True” that this behavior is rarely present). Similarly, a “Yes/No” format may introduce error, as the threshold for difficulty may not simply be the presence/absence of a behavior, but the routine use of the behavior in appropriate contexts (e.g., eye contact). Finally, it is easier to rate one attribute or behavior at a time (e.g., child often has angry tantrums) than to be forced to indicate whether the child is more like one pole of a continuum or another (e.g., whether being angry is more characteristic than being calm).

RECOMMENDATIONS FOR INFANT–TODDLER MENTAL HEALTH ASSESSMENT In an ideal world, parent and other caregiver reports would be employed to screen for mental health concerns at every wellchild visit from infancy to adolescence. Children evidencing mild risk would be closely monitored and those evidencing moderate to significant risk would receive comprehensive evaluations. Moreover, screening would involve attention to the child’s behaviors, as well as contextual risk factors in the family and community, including exposure to violence, parental psychopathology, and harsh or neglectful parenting. Methods for such screening and evaluation currently exist, but resources to implement them are limited, in part because systems of mental health care are not sufficient to meet the needs of the infants and toddlers who would be identified through such screening and early detection. In an effort to encourage universal screening and follow-up assessment of children’s social–­emotional and behavior problems, competencies, and contextual risk, we review several types of available assessment tools in the next section.

Types of Assessment Tools Several types of tools can be used to systematically gather information about social–­ emotional problems and/or competencies from parents and caregivers, including brief screening checklists (e.g., the BITSEA [Briggs-Gowan & Carter, 2006] or the ASQ-SE [Squires et al., 2002]), more comprehensive checklists (e.g., the ITSEA [Carter & Briggs-Gowan, 2006]), and diagnostic interviews (e.g., the PAPA [Egger & Angold, 2004]). Because practical considerations and constraints often impact the choice of a tool, it is essential to be well informed about what different tools offer.

Screening Tools Screening tools, designed as brief measures for detecting children who may be experiencing problems, are most appropriate when the goal is to quickly and efficiently identify such children amid a large population. Children identified through screening may, with their families, benefit from additional follow-up, more in-depth assessment to evaluate the extent and nature of the difficulties initially detected by the screening instrument, and/or referral. Because screening tools are brief and do not provide detailed profiles of strengths and weaknesses or diagnostic information, they are inappropriate for treatment planning or for documenting treatment gains. Some screening tools are designed to detect a narrowly defined problem (e.g., autism spectrum disorders), whereas others are designed to detect a broader range of problems (e.g., social–­emotional/behavioral problems). Screening tools such as the Checklist for Autism in Toddlers (CHAT; Baron-Cohen, Allen, & Gillberg, 1992; Baron-Cohen et al., 1996) and the Modified Checklist for Autism in Toddlers (M-CHAT; Robins, Fein, Barton, & Green, 2001) are designed to detect autism spectrum disorders and would not be appropriate when the goal is to detect children with social–­emotional or behavioral problems in areas outside of autism spectrum disorders. In contrast, more global screeners such as the ASQ-SE (Squires et al., 2002) and the BITSEA (Briggs-Gowan & Carter, 2006) are designed as brief, parent-­report tools



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for identifying young children who may be evidencing problems in the broad domain of social–­emotional/behavioral problems. These screening tools would therefore be expected to identify children displaying a high degree of problem behaviors that range from aggression and noncompliance, to anxiety, and autism spectrum disorders. The BITSEA goes a step beyond problems, as it is also designed to detect children experiencing delays in social–­emotional competencies. Selecting a screening instrument that meets the goals of the screening process (narrow vs. broad, problems vs. competencies) is essential to ensure a successful screening initiative.

Comprehensive Checklists When the goal of the assessment is to gather detailed information about the specific areas in which a child is experiencing difficulty, longer, more detailed assessments are appropriate. This category includes instruments such as the ITSEA (Carter & Briggs-Gowan, 2006) and the CBCL/1½–5 (Achenbach & Rescorla, 2000), which yield both subscale and domain scores. Subscales focus on specific problem behaviors (e.g., ITSEA Peer Aggression subscale, ITSEA Sleep Problems subscale). In contrast, domain scores address a broader category of problem behaviors (e.g., ITSEA Dysregulation Domain) and are calculated using subscale scores in that area. For example, the ITSEA Dysregulation Domain score is calculated from scores on the ITSEA Sensory Sensitivity, Negative Emotionality, Eating Problems, and Sleep Problems subscale scores. Comprehensive checklists can provide a detailed and differentiated understanding of the areas in which a child is reported by the parent to be exhibiting difficulties and areas in which the child’s behavior falls in the typical range. Employing such measures ensures that parents are queried about a broad array of problem behaviors, which is important given that parents might underestimate the problematic or concerning nature of their child’s behavior.

Diagnostic Interview A final category of parent-­report assessment is the parent interview. In this category we highlight the Preschool Age Psychiatric Assessment (PAPA; Egger & Angold, 2004),

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which was developed in response to the need for a comprehensive diagnostic interview appropriate for children between the ages of 2 and 5 years. The PAPA includes all DSM-IV (American Psychiatric Association, 2000) criteria that are relevant to children in this age range, all of the items in the Diagnostic Classification: 0–3 (DC:0–3; Zero to Three, 1994), and additional, potentially relevant behaviors and symptoms that may be experienced by preschoolers and their families that are not currently in either of these two diagnostic systems. The interview also assesses impairment that is associated with specific symptom clusters, family environment and relationships, family psychosocial problems, and life events. The PAPA is conducted in a semistructured manner, with the interviewer eliciting sufficient information from the parent or other informant to rate the presence or absence of particular behaviors as well as their onset, duration, frequency, and intensity. Test–­retest reliability is comparable to that observed in diagnostic interviews for older children and adolescents (Egger et al., 2006).

CONCLUSIONS Parent and other caregiver reports offer an essential window through which children with clinically concerning infant mental health needs can be identified early and often. In addition, parent and other informants can aid in profiling the pattern of social–­ emotional and behavior problems and competencies a child exhibits currently and over time. Consideration of family background and the psychometric properties of available instruments should inform the selection of specific parent/caregiver report instruments. In this chapter we have argued that inclusion of parent report is a necessary component of any infant/toddler/preschool mental health assessment, as parents’ understanding of the young child’s development and behavior informs the context in which the child is developing and the manner in which the parent responds to the child. Rather than viewing concordance as the goal of multi-­informant, multimethod assessment, it is imperative to embrace the multiple and often competing views of the child that emerge in a comprehensive infant mental health assessment. Un-

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IV ODD and CD in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 457–468. Kerr, D. C., Lunkenheimer, E. S., & Olson, S. L. (2007). Assessment of child problem behaviors by multiple informants: A longitudinal study from preschool to school entry. Journal of Child Psychology and Psychiatry, 48, 967–975. Kraemer, H. C., Measelle, J. R., Ablow, J. C., Essex, M. J., Boyce, W. T., & Kupfer, D. J. (2003). A new approach to integrating data from multiple informants in psychiatric assessment and research: Mixing and matching contexts and perspectives. American Journal of Psychiatry, 160, 1566–1577. Mandell, D. S., & Novak, M. (2005). The role of culture in families’ treatment decisions for children with autism spectrum disorders. Mental Retardation and Developmental Disabilities Research Reviews, 11, 110–115. Masten, A. S., Burt, K. B., & Coatsworth, J. D. (2006). Competence and psychopathology in development. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Vol. 3. Risk, disorder, and adaptation (2nd ed., pp. 696–738). Hoboken, NJ: Wiley. Masten, A. S., & Coatsworth, J. D. (1998). The development of competence in favorable and unfavorable environments: Lessons from research on successful children. American Psychologist, 53, 205–220. Mebert, C. J. (1989). Stability and change in parents’ perceptions of infant temperament: Early pregnancy to 13.5 months postpartum. Infant Behavior and Development, 12, 237–244. Miller, S. A. (1995). Parents’ attributions for their children’s behavior. Child Development, 66, 1557–1584. Moore, G. A., & Calkins, S. D. (2004). Infants’ vagal regulation in the still-face paradigm is related to dyadic coordination of mother–­infant interaction. Developmental Psychology, 40, 1068–1080. Moye, E. P., Briggs-Gowan, M. J., & Carter, A. S. (2000, July). Parent and childcare provider agreement across infant childcare setting. Poster session presented at the International Conference of Infant Studies, Brighton, England. Najman, J. M., Williams, G. M., Nikles, J., Spence, S., Bor, W., O’Callaghan, M., et al. (2000). Mothers’ mental illness and child behavior problems: Cause–­effect association or observation bias? Journal of the American Academy of Child and Adolescent Psychiatry, 39, 592–602. Perrin, E., & Stancin, T. (2002). A continuing dilemma: Whether and how to screen for concerns about children’s behavior. Pediatrics in Review, 23, 264–276. Pinderhughes, E. (1989). Understanding race, ethnicity, and power: The key to efficacy in clinical practice. New York: Free Press. Richman, N. (1977). Behaviour problems in pre­school children: Family and social factors. British Journal of Psychiatry, 131, 523–527.

Richters, J. E. (1992). Depressed mothers as informants about their children: A critical review of the evidence for distortion. Psychological Bulletin, 112, 485–499. Robins, D. L., Fein, D., Barton, M. L., & Green, J. (2001). The Modified Checklist for Autism in Toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31, 131–144. Sameroff, A. J., Bartko, W. T., & Baldwin, A. (1998). Family and social influences on the development of child competence. In M. Lewis & C. Feiring (Eds.), Families, risk, and competence (pp. 161–185). Mahwah, NJ: Erlbaum. Sattler, J. M. (2001). Assessment of children: Cognitive applications (4th ed.). La Mesa, CA: Author. Seifer, R. (2000). Temperament and goodness of fit: Implications for developmental psychopathology. In A. J. Sameroff, M. Lewis, & S. M. Miller (Eds.), Handbook of developmental psychopathology (2nd ed., pp. 257–276). New York: Springer. Snyder, J., Cramer, A., Afrank, J., & Patterson, G. R. (2005). The contributions of ineffective discipline and parental hostile attributions of child misbehavior to the development of conduct problems at home and school. Developmental Psychology, 41, 30–41. Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland Adaptive Behavior Scales—­ Second Edition (Vineland-II)—Survey Interview Form/Caregiver Rating Form. Livonia, MN: Pearson Assessments. Squires, J., Bricker, D., & Twombly, E. (2002). Ages and Stages Questionnaires: Social–­ Emotional (ASQ: SE): A parent-­completed, child-­monitoring system for social–­e motional behaviors (2nd ed.). Baltimore, MD: Brookes. Sue, D. W., & Sue, D. (2003). Counseling the culturally diverse: Theory and practice (4th ed.). New York: Wiley. Suyemoto, K. L., & Dimas, J. M. (2003). Check one box only. In J. S. Mio & G. Y. Iwamasa (Eds.), Culturally diverse mental health: The challenges of research and resistance (pp.  55–81). New York: Brunner-­Routledge. Suyemoto, K. L., & Kim, G. S. (2005). Journeys through diverse terrains: Multiple identities and social contexts in individual therapy. In M. P. Mirkin, K. L. Suyemoto, & B. F. Okun (Eds.), Psychotherapy with women: Exploring diverse contexts and identities (pp.  9–41). New York: Guilford Press. Tomlinson-­Clarke, S. (1999). Culture. In J. S. Mio, J. E. Trimble, P. Arredondo, H. E. Cheatham, & D. Sue (Eds.), Key words in multicultural interventions: A dictionary (pp.  82–83). Westport, CT: Greenwood. Tronick, E. Z. (1989). Emotions and emotional communication in infants. American Psychologist, 44, 112–119. Tronick, E. Z. (1998). Dyadically expanded states of consciousness and the process of therapeutic



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C h a p t e r 15

Clinical Use of Observational Procedures in Early Childhood Relationship Assessment Devi Miron Marva L. Lewis Charles H. Zeanah, Jr.

A

n essential task for early childhood clinicians is assessing caregiver–child relationships using well-­validated, reliable, and developmentally appropriate measures in the clinical setting (Crowell & Fleischmann, 1993; Weston, et al. 2003). Some have emphasized the importance of assessing caregiver–child relationships across multiple settings and contexts (Leyendecker, Lamb, & Scholmerich, 1997), whereas others suggest that a wealth of useful information can be gained simply by observing children with their caregivers in a clinic waiting room (Crowell, 2003). Most early childhood experts agree that forming a working relationship with the child’s caregiver is important to obtaining a valid assessment. Observing young children and their caregivers is, of course, a staple of much developmental research. In this chapter we selectively review a number of specific observational methods that have been used in developmental and clinical research and that we believe have value for use in clinical settings. The Autistic Diagnostic Observation Schedule (ADOS; Lord et al., 2000) provides the model for a method that is used both for research and clinical purposes and provides separate training for each. The ADOS, however, is a disorder-­specific method, and we

are limiting this review to methods that are useful in understanding interactional patterns and relationships more generally rather than disorder-­specific approaches. One of the goals of early childhood assessment in the clinical setting is to efficiently and reliably draw conclusions about the quality of a child’s relationships with his or her caregivers. Recognizing the importance of assessing a variety of different types of caregiving relationships, we use the terms “caregiver” and “parent” interchangeably throughout this chapter. The clinical usefulness of an assessment procedure rests on its ability to guide intervention recommendations. Clinically significant differences in the child’s behavior, particularly across different caregiving relationships, first must be accurately detected. Meaningful interpretation of behaviors is enhanced by assessment procedures that provide an opportunity for naturalistic observations of interactional patterns and which are developmentally and culturally appropriate. With these overarching goals in mind, we turn first to a number of guidelines to consider when applying observational methods in clinical settings. These are drawn from guidelines suggested by Crowell and Fleischman (1993), by Zeanah and colleagues 252



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(Zeanah, 2008; Zeanah, Larrieu, Valliere, & Heller, 2000), and from our experiences applying structured procedures from developmental research to the assessment of caregiver–child relationships in clinical settings. Next, we review some specific methods that we believe have value in clinical settings. Though these procedures each has a literature describing aspects of its reliability and validity, the chief test in clinical settings is its usefulness for making diagnostic decisions and recommendations for intervention. Considering procedures in light of the guidelines listed below is meant to reflect these overarching concerns. Finally, we conclude by considering professional and ethical issues in using observational procedures in clinical settings with young children and their families.

CONCEPTUAL AND PRAGMATIC GUIDELINES We propose conceptual and pragmatic guidelines that inform the selection of particular observational paradigms for their clinical usefulness. These points build upon the guidelines proposed by Crowell and Fleischman (1993). Our guidelines are listed in Table 15.1 and elaborated below. We suggest using them as reference points in selecting observational methods.

Standardization of Settings and Procedures Children’s behaviors within the context of the family or in an unusual rather than familiar environment may vary greatly. The more an activity is standardized across caregiver–child dyads and settings, the more likely it is that differences observed during

TABLE 15.1.  Guidelines for Use of Observational Procedures in Clinical Settings 1.  Standardize assessment settings and procedures. 2.  Include both structured and unstructured activities in assessments. 3.  Ensure efficiency of assessment procedure. 4.  Ensure developmental and cultural appropriateness of the procedure to the extent possible. 5.  Ensure ease of interpretability of observations. 6.  Videotape procedures when possible.

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interactions derive from the particular dyad of interest rather than from procedural variability. We recommend that procedures used to assess caregiver–child relationships be administered in exactly the same format, in exactly the same setting, for each assessment. Creating a set of standardized instructions and training administrators in the procedure are essential. Also, having a designated procedure room and a uniform set of materials (e.g., toys, games, and puzzles), available only for assessment, helps to ensure this standardization across administrations. It is widely recognized that young children’s behavior may vary widely in the context of different relationships (Zeanah et al., 2000). Therefore, comparing the young child’s behavior with different caregivers is valuable for determining his or her overall functioning, and these comparisons are enhanced by standardized procedures. One drawback to strictly adhering to a standardized protocol is that it does not allow for flexibility to meet the needs of the dyad. For example, procedures may require modification should the child be developmentally delayed or the caregiver have physical challenges that prohibit following the protocol. Another challenge is that with increased standardization, the naturalistic aspects of caregiver–child interaction may be sacrificed. This has been a concern, for example, about the Strange Situation Procedure (Ainsworth, Blehar, Waters, & Wall, 1978), because to a large degree it constrains the behavior of the caregiver. The purpose of constraining a caregiver’s behavior is to elicit certain behaviors in the child. This may be useful clinical information, but the degree to which the caregiver’s behavior is constrained by the requirements of the protocol needs to be considered when making inferences about the meaning of observations.

Structured versus Unstructured Activities The degree to which activities ought to be structured during an observational assessment is an important consideration. As with more flexible assessment protocols, less structured activities have the advantage of being less demanding and less likely to constrain the behavior of the caregiver. Free play, included in many types of assessments, is an example of an unstructured activity.

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If the “work” of childhood is play, then it is the context of play that may serve as the most revealing observational window into children’s emotional lives. Further, observational settings that provide opportunities and supports for play enhance the validity of the interpretation of observations. Thus, developmental researchers and clinicians have observed young children at play on playgrounds, and they have observed infants in university laboratories designed to look like the natural setting of an infant’s home. More structured activities, on the other hand, have the advantage of eliciting specific behaviors in the child that are of interest, such as the separation episode of the Strange Situation Procedure or the still-face episode of the Face-to-Face Paradigm (Tronick, Als, Adamson, Wise, & Brazelton, 1978). Because observation times are necessarily limited, there are often advantages in structuring activities in order to elicit behaviors of interest. These “presses,” as they are sometimes called, are meant to examine individual differences in response to a standard situation. Procedures such as the clinical problem-­solving procedure (the “Crowell;” Crowell & Feldman, 1988; Crowell, Feldman, & Ginsberg, 1988) include some episodes that are more structured (teaching tasks) and some that are less structured (free play). Other methods might structure an overall activity, such as feeding for the Nursing Child Assessment Satellite Training (NCAST; Barnard, 1979) or hair combing in the hair-­combing task (Lewis, 1999), but allow for less structured variability within the activity.

Efficiency of Evaluation Ideally, observational procedures have ecological validity, that is, they reflect differences in interactive behavior that are apparent in the real lives of the caregiver and child. Still, one of the major purposes of observational procedures is to provide a short-cut method of learning about crucial characteristics of the dyad. Thus, the validity of the Strange Situation Procedure rests upon many hours of naturalistic observation of dyadic behavior at home during the first year of an infant’s life (Sroufe, 1983). Because this kind of observation is impractical, a reasonable short-cut is provided by a 20-minute laboratory (or clinic) procedure that has been

correlated with functioning in the home. Again, efficiency of an observational procedure often means that a behavior is elicited rather than having to wait for it to occur on its own. For example, Kagan’s (1998) work on behavioral inhibition involves creation of a novel stimulus to elicit anxious behavior in a behaviorally inhibited child, rather than merely waiting for the child to encounter a novel experience. Similarly, Wakschlag and colleagues include a frustrating task to elicit anger in young children (Wakschlag, BriggsGowan, et al., 2008; Wakschlag, Hill, et al., 2008).

Developmental Appropriateness Most observational procedures of young children and their caregivers are designed to assess stage-­salient behaviors. Because of the extraordinarily rapid pace of development in the first few years of life, many procedures are limited to specific age ranges, such as the NCAST Feeding Scale (first year of life). Some procedures are modified based on age and developmental capabilities, such as the “Baby Crowell,” or the clinical problem­solving procedure, modified for children 6–12 months of age (Zeanah et al., 1997). Others require that the clinician take into account the age and developmental capabilities of the child being observed when drawing conclusions about a child’s functioning. For example, a 10-month-old feeds quite differently from a 2-month-old child, and a clean-up episode in a 12 month old is quite different from one involving a 36-monthold. Hence, the meaning of observed behaviors will have different significance depending on the age and developmental status of the child.

Cultural Appropriateness Most of the procedures reviewed in this chapter (and used in developmental research) were developed by and for white Americans. They may have been applied to children and parents of other cultures and ethnicities mostly without considering or evaluating cultural appropriateness. The one observational procedure subjected to the most extensive cross­cultural conceptual and methodological examination in diverse populations for the past 30 years is the Strange Situation Procedure,



15. Observational Procedures

which assesses the quality of attachment in young children (van IJzendoorn & Kroonenberg, 1988). Yet, despite this extensive body of work there remains controversy regarding the validity of this procedure with different cultural groups. On the other hand, the hair combing task was developed for African American mothers and their daughters and drawn from their cultural practices. The procedure may well have applicability beyond the group in which it was developed, but this remains to be demonstrated. Ideally, as with parent-­report measures (see Carter et al., Chapter 14, this volume), clinicians will think critically about the approach they are planning to use with a particular family and judge whether it meets the test of cultural appropriateness. The guidelines proposed for cultural assessment of young children and their caregivers, presented by Christensen, Emde, and Fleming (2004), can be used in making conceptual decisions about the use of a selected observational procedure. For example, it is essential to consider the child’s caregiving network, such as extended relatives and fictive kin, when determining whom to include in the assessment (Garcia Coll & Meyer, 1993). Also important is the exploration of the caregiver’s beliefs about child development and parenting when interpreting behaviors observed (Lewis, 2000).

Interpretability of Observations and Using Videotaped Review All of the observational procedures we describe have detailed coding systems that require training to attain reliability. However, we believe that the procedures may be clinically useful even if the clinician has no training in the formal coding system. The key point is that individual differences in the behaviors observed reflect important qualities of the caregiver–child relationship. We agree with Crowell and Fleischmann (1993) that ease of interpretability without a formal coding system is essential when using observational procedures in clinical settings. Because of the subtleties of interactive behaviors, the value of videotaped review cannot be overstated. In our experience, videotaped review aids clinicians by allowing them to view and review important moments, such as understanding who leads and

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who follows, which behaviors precede and which follow others, and affective expressions. Further, reviewing tapes with caregivers and asking them about their observations allows for the detection of behaviors that had not been apparent to the clinician when the procedure was conducted. It also provides an opportunity to inquire about how caregivers interpret their own and their child’s behavior and about caregivers’ emotional responses to interactions, both at the time of the procedure and in the here and now. In addition to creating an observing ego for caregivers, reviewing caregivers’ thoughts and feelings and their impression of their child’s thoughts and feelings encourages reflective functioning (Fonagy & Target, 1997) and mind-­mindedness (Meins, Fernyhough, Fradley, & Tuckey, 2001) in them. Many forms of treatment rely heavily on videotaped review with caregivers (see Powell et al., Chapter 28, Favez et al., Chapter 29, and Suchman et al., Chapter 30, all this volume). We have also experienced the value of videotaped review for assessment and in developing plans for intervention.

OBSERVATIONAL PROCEDURES Understanding recurrent patterns of interaction between caregivers and their young children provides valuable information about strengths and weaknesses in the relationship and how best to guide interventions. Below, we consider some of the available structured methods, derived from developmental research for observing caregivers and young children, that have clinical applicability. These observational methods include well­established methodologies with decades of research to support their use, as well as newer and innovative procedures. Their characteristics are summarized in Table 15.2. We also report the construct or focal variables that may be measured by the procedure and the training required to administer or conduct the procedure. In Table 15.3 we report information on the use, and the available data on the reliability and validity of the procedures, with diverse populations. A literature search was conducted using the name of the procedure and the terms associated with culture, in order to identify studies using the procedure



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Parenting styles, proximity of child to mother, amount of touch, verbal interactions, and responsivity of mother; child compliance

HCT (Lewis, 1999) Yes

Yes

Yes

No. Basic skills in infant mental health and child development necessary.

Yes

Yes

Training required for scoring

Birth–60 months

6–60 months

11–20+ months

2–60 months

NCAFS birth–12 months; NCATS birth–36 months

1–6 months

Child’s age group

Low-income, middle-class African American dyads

Primarily middle- to upper-middle-class white dyads

Middle-class white dyads

Middle- to upperclass white dyads

High-risk infants and caregivers

Low-risk white dyads

Demographics of original sample

Interrater reliability achieved

Some evidence for reliability available

Extensive research on reliability available

Reliability well established

85% interrater reliability required for administration

Some evidence for reliability available

Reliability reported

Videotaping may be done in home or clinical setting

Videotaping equipment and specialized toys

Videotaping equipment

Videotaping may be done in home or clinical setting

Teaching manual, scale, kit (videotaping not required)

Videotaping equipment

Materials required

Note. FFSF, Face-to-Face Still Face; NCAST, Nursing Child Assessment Satellite Training; ERA, Early Relational Assessment; SSP, Strange Situation Procedure; HCT, hair-combing task; NCAFS, Nursing Child Assessment Feeding Scales; NCATS, Nursing Child Assessment Teaching Scales.

Problem solving, enjoyment, and attachment between children and caregivers

Affective and behavioral quality of interactions

ERA (Clark, 1985)

Crowell (Crowell & Feldman, 1988)

Repertoire of parallel interactive behaviors

NCAST (Barnard, 1979)

Infant attachment

Synchronicity of interactions

FFSF (Tronick et al., 1978)

SSP (Ainsworth et al., 1978)

Unique constructs measured

Procedure

TABLE 15.2.  Summary of Constructs and Reliability with Samples of Select Observational Procedures with Young Children and Their Caregivers



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TABLE 15.3.  Use, Reliability, and Validity of Observational Procedures with Diverse Populations Information on reliability and validity with diverse samples

Procedure

Use with diverse samples

FFSF (Tronick et al., 1978)

7-month-old preterm low- and middle-SES African American infants (Segal et al., 1995) 4-month-old, low-SES African American dyads (Kogan & Carter, 1996) 3- to 6-month-old Chinese and Canadian infants of diverse socioeconomic backgrounds (Kisilevsky et al., 1998)

Some information on reliability available Some information on reliability available Interrater reliability for both samples ranged from .74 to .77; found universality of still-face effect

NCAST (Barnard, 1979)

Low-income, high-risk U.S. samples of multiple racial and cultural groups (Farel et al., 1991) Used in national U.S. sample of 10, 688 multiracial groups, and normal-, low-, and very-low-birth weight children and also twins (Andreassen & West, 2007)

Reliability information available; though widely used with multiple groups, construct validity with various groups not reported

ERA (Clark, 1985)

Used with schizophrenic, depressed, and nonmentally ill women, predominately black, low income (Goodman & Brumley, 1990)

Interrater reliability = .85; no discussion of cross-cultural validity

SSP (Ainsworth et al., 1978)

Used in diverse populations (e.g., depressed mothers; Radke-Yarrow, Cummings, Kuczynski, & Chapman, 1985) and many different cultural groups and countries (van IJzendoorn & Kroonenberg, 1988)

Reliability and validity information with a variety of socioeconomic and cultural groups and nationalities available

Crowell (Crowell & Feldman, 1988)

Currently used with children ages 12–60 months and a “Baby Crowell” for 6- to 12-month-olds (Zeanah et al., 1997) Used with children in foster care from a variety of socioeconomic and racial groups (Zeanah et al., 1997)

Reliability information not available; some discussion of validity of procedure with diverse groups

HCT (Lewis, 1999)

Has not been used with populations different from original sample

Note. FFSF, Face-to-Face Still Face; NCAST, Nursing Child Assessment Satellite Training; ERA, Early Relational Assessment; SSP, Strange Situation Procedure; HCT, hair-combing task; SES, socioeconomic status.

with diverse groups. Though this search was not comprehensive, the findings are reported in Table 15.3 and may be useful in selecting observational procedures appropriate for a specific population.

Face-to-Face Still-Face Procedure The Face-to-Face Still-Face (FFSF) paradigm, originally developed by Tronick and colleagues (Tronick et al., 1978), is designed to assess the synchronicity of caregiver–­ infant interactions. In the FFSF procedure,

the caregiver and infant (up to 6 months of age) sit face to face with video cameras focused on each partner. Instructions such as “Play and talk with the baby as you usually do” allow the clinician to observe emotional communication between infant and caregiver. An episode of “still face,” in which the caregiver sits and looks directly at the baby while remaining expressionless, violates the baby’s expectation for social behavior. This sudden digression allows the clinician to assess the degree of departure from usual dyadic interaction as well as to see how the

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infant copes with the unexpected unresponsiveness. Perhaps the most frequently used procedure is as follows: 2 minutes of normal interaction, during which the mother is simply instructed to play with the infant; followed by a 2-minute still-face interaction, during which the mother is instructed to keep an expressionless or still face and to look at the infant but not to talk or touch the infant; and a second 2-minute normal reunion interaction. The episodes are separated by 15-second intertrial intervals, during which the mother turns her back to the infant (Weinberg & Tronick, 1996). Variations in the FFSF have been used, including differing segment lengths and allowing/ disallowing caregivers to touch their infants during normal interactive segments. What is interesting about observations of dyads during the FFSF procedure is not only how infants “notice” the difference in behavior during the still-face segment, but also how they recover from a period of caregiver withdrawal and how the caregiver attempts to soothe the infant during the reunion. As Weinberg and Tronick (1996) point out, the task during the reunion episode is for the caregiver and infant to repair the interaction following a prolonged interactive disruption. Recently, Tronick (2003) has reconsidered his original hypothesis that the still-face effect violates the infant’s expectations about the “rules that govern the mutual regulation of social interactions” (p. 477). Instead, he suggested that face-to-face interactions are “co-­created by an ongoing moment-to­moment dynamic process that generates unique interactive exchanges and relationships” (p. 477). The FFSF procedure can be used clinically to make interpretations about each partner’s perceptions of the other and of their relationship.

NCAST Teaching and Feeding Scales The NCAST Teaching and Feeding Scales (NCATS, NCAFS; Barnard, 1979) are used to rate mother and child behaviors. The instruments are useful for assessing children in both low- and high-risk groups, and they have been used with a variety of racial and ethnic groups. The scales were developed with the following objectives: (1) to be usable with good reliability by health profes-

sionals in a variety of settings; (2) to describe with some specificity the repertoire of behavior brought to the interaction by both members of the dyad and the contingency of their responses to one another; (3) to provide two conceptually parallel observational measures of the same mother–­infant pair in order to increase generalizability across settings; and (4) to allow for flexibility in choosing the assessment setting (Farel, Freeman, Keenan, & Huber, 1991). Unlike many procedures described in this chapter, formal scoring is recommended even for clinical use of the teaching and feeding scales. Public health nurses are trained to reliability in use of the scales as part of the Nurse–­Family Partnership intervention (see Zeanah & Zeanah, Chapter 1, this volume), for example. Particularly valuable is the naturalistic underpinnings of the methods of assessing infant cues of engagement and disengagement. The NCATS is used to rate caregiver and infant (birth–36 months) behaviors. Caregivers are asked to review a list of activities appropriate for children ranging in age from birth through 4 years and to select the first activity that their child cannot do. Once they have selected the task, the clinician instructs the caregiver to attempt to teach it to the child. The NCAFS is used to rate mother and infant (birth–12 months) behaviors during regular feeding time. In each procedure, infants receive scores according to their ability to produce clear cues and ability to respond to their caregiver. Caregivers receive scores according to their ability to respond to their infant’s cues, alleviate distress, and promote growth-­fostering situations by permitting the child to initiate behaviors. The procedure is scored immediately, and feedback is provided to the caregiver. Both the NCATS and NCAFS provide an opportunity for direct observation of the infant and parent. The caregiver can be assessed for matching his or her behavior to the child’s developmental level in either procedure. The assessments are time efficient, and the procedures are not highly complex in structure or materials. The materials needed for the NCATS are the teaching manual, scale, and kit and the child activity card. For the NCAFS, only the manual and scale are required. Because the procedures are scored immediately following their administration,



15. Observational Procedures

videotaping is useful but not required. The NCAST scales are intended for use by nurses or other professionals working with families with young children. One drawback for use of the NCAST instruments in clinics is that extensive training, including coursework in development and administration of the scales and the achievement of 85% reliability in coding, is required. As there is no manipulation implemented during the observations, natural and spontaneous interactions are readily observed.

Parent–Child Early Relational Assessment The Parent–Child Early Relational Assessment (ERA; Clark, 1985) is a semistructured interaction procedure for evaluating the quality of the relationship between infants or toddlers and their caregivers. The purpose of the ERA is to provide a phenomenological assessment of the affective and behavioral quality of interactions between the parent and child, for both research and clinical purposes, in families at risk for, or evidencing, early relational disturbances (Clark, Paulson, & Conlin, 1993). The ERA can be conducted and videotaped in a clinic or home setting. Caregivers are told that the procedure is a snapshot in time and that they will be asked, after the videotaping, how it is similar to, or different from, how things usually are. An initial “warm-up” period takes place prior to taping interaction segments, to enhance comfort and to foster the emergence of typical interactions from the dyad. Then the caregiver and child (2–60 months of age) are videotaped in four 5-minute segments. In the feeding segment the parent’s capacity for nurturing, social interaction and his or her sensitivity to the child’s cues are assessed. The child is observed for clarity of cues, affect regulation, social initiative, and responsivity to the caregiver. Observations are made of the dyad with respect to comfort, tension, and regulation. In the structured task segment the caregiver’s ability to structure the environment according to the child’s need is observed. The child is assessed for attention, persistence, and interest in complying with parental expectations. The dyad is assessed in terms of joint attention, reciprocity in negotiations, and mutuality. During the free play segment, the caregiver

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is assessed for playfulness and enjoyment of the child and ability to facilitate the child’s exploration and representational play. The dyad is rated for social interaction, mutuality, and reciprocity. In the final segment, the separation–­reunion episode, the caregiver is assessed for his or her ability and comfort in preparing the child for a brief separation. Observations are made with regard to the child’s capacity for self-­regulation as well as for the quality of the child’s mood and play during the caregiver’s absence. The dyad is assessed during the reunion episode for the quality of affect and reengagement. Following the procedure, the clinician selects sections of the videotape to review with caregivers. Caregivers are interviewed regarding their thoughts and feelings about the session, such as how typical the interaction was, and they are engaged in “wondering” about the relationship with their child, the meaning of the child’s behavior to them, who the child looks like or reminds them of, their sense of competence in the parenting role, and what is difficult or enjoyable in their interactions with their child (Clark et al., 1993). The clinical use of the ERA has been established both for the assessment of caregiver–child relationships as well as for guiding intervention. Thomas and Clark (1998) advocate using the ERA to guide assessment and interventions with caregivers and their behaviorally disruptive children. The ERA provides depth to the relational diagnostic profile by identifying areas of strength and concern in the parent–child relationship and also by identifying the meaning of the child and the child’s behavior to the caregiver. This type of information can increase the specificity of relational intervention strategies. The ERA procedure provides an opportunity for direct observation of the young child and his or her caregiver. The caregiver can be assessed for matching his or her behavior to the child’s developmental level. The assessment takes approximately 20 minutes to complete; additional time is required for review of the videotape with the caregiver. Clinicians trained in infant development and mental health as well as caregiver–­infant interactions can make observations about relationships using the ERA paradigm without having been trained formally in coding tech-

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niques. Videotaped review is a useful way to engage caregivers in discussions about parenting and the meaning of their own behavior and that of their child. Collaborating with caregivers on goals for therapeutic intervention is also facilitated by a videotaped review. The ERA tasks provide opportunities to observe caregivers and children interacting naturally and spontaneously. The procedure itself is not highly complex in its structure or materials. Nevertheless, videotaping equipment is necessary. The formal scoring system is complex and time consuming, and it is recommended that the videotape be reviewed at least five times. Each segment is scored separately on 5-point scales. The ERA manual must be supplemented by clinical experience and specific training when it is being used for research.

Strange Situation Procedure The Strange Situation Procedure (SSP), originally developed by Ainsworth and colleagues (1978), is designed to elicit child behavior that reflects both attachment needs and exploratory needs. The procedure is considered the most widely used, accepted, and best-­validated method of infant attachment assessment (Goldberg, 2001). Originally used with 11- to 20-month-olds, it has been applied to preschool children with little, if any, modification. It has also been used cross-­culturally in countries such as Germany, Japan, The Netherlands, Israel, and China (van IJzendoorn & Kroonenberg, 1988). Because the procedure has been described extensively in other sources, we will not detail it here. Although the SSP has been well validated and used extensively in studying infant attachment, the procedure has not been useful in clinic settings until recently. Because it dictates caregiver behavior to a large degree, natural and spontaneous interaction is limited. Since the introduction of the Circle of Security intervention (see Favez et al., Chapter 29, this volume), however, the SSP has new usefulness. The classification is far less important in the clinical arena than specific moments illustrating exploratory and proximity-­seeking behaviors as well as cues and “miscues” in the child’s behaviors directed toward the caregiver.

Crowell Procedure The Crowell is a clinical problem-­solving procedure that has been developed for the assessment of caregivers and their young children (Crowell & Feldman, 1988; Crowell et al., 1988). It was originally developed from the tool-use task (Matas, Arend, & Sroufe, 1978) for use with children ages 24–54 months, but has been extended with minor modifications for use with children ages 12–60 months, and a modified “Baby Crowell” has been developed for infants 6–12 months (Zeanah et al., 1997). In the Crowell, the caregiver and child engage in interaction for a series of episodes of varying lengths of time. Transitions from one episode to another are especially important as indicators of how the child uses the caregiver for support. Each of the following episodes is conducted in order: 1.  Free play. Caregiver and child are instructed to play together “as you usually play together at home.” A standard set of toys is provided in a large container. This episode is usually about 10 minutes in length, and no further instructions are given. Many important observations are possible from observing free play, including parent and child’s level of comfort with one another, the amount and kind of affection they share, their familiarity with play and having fun together, their use of the time as fun-­oriented versus task­oriented, and the sense of partnership versus solitary play conveyed. 2.  Clean-up. The first transition observed occurs when the caregiver is told at the end of free play to instruct the child that it is time for “clean-up.” The caregiver is instructed to have the child return all of the toys to the large container, but to help if needed. This episode pulls for evidence that the dyad can cooperate together sufficiently to complete a task, which most young children resist. It allows for observations of how the dyad negotiates this stressful situation. 3.  Bubbles. After the container of toys is passed out of the room, the caregiver is instructed to get out the container of bubbles and to “play with the bubbles” (no other instruction is given). This episode is included as a way of attempting to elicit positive affect between children and caregivers. Degree



15. Observational Procedures

of mutual enjoyment, pacing of the activity, and turn taking are all apparent in this episode, which lasts for about 3 minutes. 4.  Teaching tasks (usually two to four). A series of teaching tasks, based on the child’s developmental level of functioning, follows. The tasks are selected to move from slightly below the child’s developmental level to significantly above developmental level, so that the general stress level as well as the child’s needs to rely on the caregiver for help increase steadily. The tasks last generally 3–5 minutes for younger toddlers and 6–8 minutes for older toddlers and preschoolers. The clinician directing the procedure controls by phone call when one episode ends and another begins. The child’s ability to complete the task is less important than his or her ability to use the caregiver in a stressful and structured activity. Again, observations are made as to how both partners handle transitions, and whether they can have fun in the face of a demanding situation. The caregiver’s capacity to set limits, provide structure, teach effectively, provide encouragement, and maintain availability and support to the child all are important. The child’s capacities for self-­regulation, cooperation, showing affection, and learning style are also noted. 5.  Separation. Following the last task, the clinician calls and asks the caregiver to open the toy cabinet and leave the room. Caregivers are given no specific instructions about preparing the child for the departure, and how they do this is considered useful information. Once outside the room, the caregiver either remains separated from the child for 3 minutes or returns sooner if the child becomes significantly distressed. Separation provides a way of examining the child’s proneness to distress but also specifically activates the young child’s attachment system. 6.  Reunion. During the reunion, attachment behaviors such as proximity seeking, avoidance, controlling behavior, and clinging are noted, though there is no formal classification of the child’s attachment pattern. Disorganized attachment behaviors are noted, however, if present (Main & Solomon, 1990). The primary focus is on the dyad’s way of reestablishing contact after a brief separation, and the organization and congruence between the preseparation, sep-

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aration, and reunion behaviors of the child in relation to the caregiver. The session is videotaped so that it can be reviewed for interpretation. Although formal coding systems exist, the procedure can be used in clinical settings without regard to the research coding (Larrieu & Bellow, 2004; Zeanah et al., 2000). The procedure takes approximately 30–45 minutes to complete, depending upon the length of the episodes (typically longer for older children). Materials required for the procedure are extensive, including a collection of standard free-play toys, bubble bottles, and toys for the task segment appropriate for use with children ranging in ages from at least 6–60 months, ranked by difficulty, as well as a toy cabinet with a lock and key. The procedure itself is not highly complex in its structure or materials; however, time and care must be taken to demonstrate each task to the caregiver prior to the assessment. Videotaping equipment is essential in our view.

Hair-­Combing Task The hair-­combing task (HCT) offers a naturalistic, culturally syntonic practice to assess African American mothers and their young children (Lewis, 1999). Although both mothers and fathers participate in the daily task of hair combing, mothers are typically the primary hair combers. African American infant boys’ hair is not typically cut until approximately age 12 months. Until that time it may be braided, brushed, and combed as would a girl’s hair. Thus, the HCT is appropriate for systematic observations of interactions between caregivers and their young girls and infant boys. Research findings using the HCT as an observational context identify a number of significant activities that occur during this task: verbal exchanges and negotiation between the mother and child; physical touch and caregiver responsiveness to the nonverbal gestures and cues of the infant. The time spent together during the HCT may range from a few minutes to hours depending on the style the mother has selected. The infant must sit compliantly for the mother to accomplish this task.

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The mother (or caregiver being assessed) is simply asked to comb her child’s hair as she normally does in her home. Videotape of the interaction, whether in the home or clinic, is critical for a detailed analysis of the patterns of interaction that may be presented during this task. Reviewing the tape provides the opportunity to assess minute facial changes, subtle behavioral reactions, and synchronous emotional matching, as well as to reexplore the event with the caregiver. Based on analysis of videotapes of samples of African American mothers (from a variety of socioeconomic groups) combing their daughter’s hair, individual differences in the proximity with which the mother positioned her young child during the HCT have been identified. Three distinct proximity groups emerged during the HCT: close physical proximity, moderate, and functional. The proximities may range from sitting between the mother’s legs for a maximum amount of touch to the child sitting on a chair and the mother standing or sitting in a separate chair with no contact between their bodies. This variability can be easily noted and may have implications for the developing mother–child relationship. Understanding the historical significance of intergenerational legacies of the emotionally charged and painful stereotypes associated with skin color and hair underlies the emotional power of this observational method (Neal-­Barnett, López, & Owens, 1996; Russell, Wilson, & Hall, 1992). The skills needed to observe, interpret, and understand the interactions during this task are the same skills required to observe any developing relationship. Observing and commenting on the amount of touch and verbal interaction as well as caregiver responsiveness to the young child during the HCT presents rich opportunity for the clinician to begin a dialogue about the caregiver–child relationship. Exploration of intergenerational issues and perceptions the mother has of her child are potential topics generated from this task. Individual psychological, relationship-­specific, and cultural meanings of the caregiver–child interaction may be accessible. Little is known about the application of this method in other ethnic or racial groups.

ETHICAL AND PROFESSIONAL CONSIDERATIONS There are always certain ethical and professional issues to consider when conducting evaluations with children. Children, especially infants and toddlers, do not have the language skills to provide consent, or even assent, for participating in evaluations. They must rely on their caregivers to ensure that their participation is in their best interest or, at the very least, is not harmful to their well-being. Further, caregivers often want to cooperate with clinicians and therefore may encourage their child to participate in spite of his or her apparent protest. We recommend that assessments be scheduled according to the infant’s or young child’s feeding and naptime routine to promote the child’s engagement in the process. Further, even though time is often limited in clinic settings, short breaks can be scheduled for a snack or rest. Caregivers should be told that the procedure is voluntary and can be discontinued at any time. Procedures can be modified if the child’s behavior becomes unsafe or if he or she shows signs of extreme distress. For example, the separation portion of the Crowell or the SSP can be shortened if the child becomes too upset. The child should never be left alone without being monitored by an attendant in the adjacent room observing through a two-way mirror or videorecording equipment. Another consideration specific to assessing parent–child relationships is the need for clinicians to be aware of their own biases about parenting practices and styles. Although, of course, child abuse or neglect must be reported to the appropriate authorities, in order to obtain the most objective and reliable assessment clinicians should reserve judgment about caregiving and should save suggestions for the intervention phase. This restraint is particularly important when reviewing the videotape of the procedure with the caregiver. Clinicians should carefully word questions and monitor their nonverbal communication (e.g., tone of voice and facial expressions) in order to elicit genuine responses from caregivers about their interpretations of their child’s behavior. We recommend selecting a short segment of videotaped interaction and probing caregivers



15. Observational Procedures

with basic questions as a starting point for assessing their interpretations of their interactions with their child. These questions may include, “What is the child doing/thinking/ feeling?” and “What are you [the caregiver] doing/thinking/feeling?” Preserving these videotaped records of observational methods used with young children and their caregivers is enormously valuable. Doing so allows for reliable coding of behavior in research, reflective subsequent review with parents, and it provides invaluable examples of behaviors and constructs for teaching and training. Nevertheless, videotaping these procedures also presents ethical challenges. Two standards are used to protect the privacy of research participants: confidentiality and anonymity. The participant, fully informed of the procedures and measures that will be taken to protect his or her anonymity, signs a consent form, indicating an understanding of all procedures and risks. Similarly, in clinical settings, patients sign consents for evaluation and treatment and procedures. These consents allow the clinician to provide evaluation and treatment with full awareness of the patient or client. The Health Insurance Portability and Accountability Act of 1996 includes a “privacy rule” for protected health information (PHI), defined as any information about health status, provision of health care, or payment for health care that can be linked to an individual. This rule is interpreted broadly to include any part of a patient’s “medical record” or payment history. Unlike much research data or information contained in medical records, however, videotapes cannot easily disguise the appearance of caregivers and children. Digital scrambling or masking the face of participants often defeats the purpose of carefully observing facial displays of emotion. In clinical settings, videotapes become PHI. No taping should occur without the consent of the caregiver (i.e., legal guardian). The consent should specify the purposes of taping, including who will view the tapes, under what circumstances, and for what purposes. Sometimes the tapes will be used solely for clinical purposes and only the practitioner or clinical team will have access to them. At other times, the caregiver may

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consent to the use of tapes for clinical, research, and teaching purposes with students and/or professional audiences. Some consent forms may specify expiration of the consent for one or another purpose. The main focus should be on transparency and clarity to prevent misuse of PHI.

SUMMARY In this chapter we have presented some guidelines that can be considered by clinicians when selecting a method for observing young children interacting with their caregivers. We reviewed key aspects of selected established as well as new and innovative observational procedures. In addition, we briefly reported information about the reliability and validity of each procedure with diverse populations in Table 15.3. We discussed ethical and professional issues associated with using observational procedures for assessing young children and their caregivers, focusing on the issues of parent-­informed consent and child assent, as well as the importance of reserving judgment about parenting practices in order to obtain an objective assessment. Structured observational procedures offer practitioners an excellent tool for both assessment and treatment of caregivers and their young children. The breadth of available procedures provides practitioners with many options that can be used in clinical settings. References Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Oxford, UK: Erlbaum. Andreassen, C., & West, J. (2007). Measuring socioemotional functioning in a national birth cohort study. Infant Mental Health Journal, 28, 627–646. Barnard, K. E. (1979). Instructor’s learning resource manual. Seattle: University of Washington. Christensen, M., Emde, R., & Fleming, C. (2004). Cultural perspectives for assessing infants and young children. In R. DelCarmen-­Wiggins & A. Carter (Eds.), Handbook of infant, toddler, and preschool mental health assessment (pp.  7–23). New York: Oxford University Press. Clark, R. (1985). The Parent–Child Early Relation-

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al Assessment: Instrument and manual. Madison: University of Wisconsin Medical School, Department of Psychiatry. Clark, R., Paulson, A., & Conlin, S. (1993). Assessment of developmental status and parent–­infant relationships. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp. 210–221). New York: Guilford Press. Crowell, J. A. (2003). Assessment of attachment security in a clinical setting: Observations of parents and children. Developmental and Behavioral Pediatrics, 24, 199–204. Crowell, J. A., & Feldman, S. S. (1988). Mothers’ internal models of relationships and children’s behavioral and developmental status: A study of mother–child interaction. Child Development, 59, 1273–1285. Crowell, J. A., Feldman, S. S., & Ginsberg, N. (1988). Assessment of mother–child interaction in preschoolers with behavior problems. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 303–311. Crowell, J. A., & Fleischmann, M. A. (1993). Use of structured research procedures in clinical assessments of infants. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp.  210– 221). New York: Guilford Press. Farel, A. M., Freeman, V. A., Keenan, N. L., & Huber, C. J. (1991). Interaction between highrisk infants and their mothers: The NCAST as an assessment tool. Research in Nursing and Health, 14, 109–118. Fonagy, P., & Target, M. (1997). Attachment and reflective function: Their role in self-­organization. Development and Psychopathology, 9, 679– 700. Garcia Coll, C. T., & Meyer, E. C. (1993).The sociocultural context of infant development. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp. 56–70). New York: Guilford Press. Goldberg, S. (2001). Attachment assessment in the Strange Situation. In T. L. Singer & P. S. Zeskind (Eds.), Biobehavioral assessment of the infant (pp. 209–229). New York: Guilford Press. Goodman, S. H., & Brumley, E. H. (1990). Schizophrenic and depressed mothers: Relational deficits in parenting. Developmental Psychology, 26, 31–39. Kagan, J. (1998). Biology and the child. In D. William & N. Eisenberg (Vol. Eds.), Handbook of child psychology: Vol. 3. Social, emotional, and personality development (5th ed., pp. 177–235). Hoboken, NJ: Wiley. Kisilevsky, B. S., Hains, S. M. J., Kang, L., Muir, D. W., Xu, F., Fu, G., et al. (1998). The still-face effect in Chinese and Canadian 3- to 6-monthold infants. Developmental Psychology, 34, 629–639. Kogan, N., & Carter, A. S. (1996). Mother–­infant reengagement following the still-face: The role of maternal emotional availability in infant affect regulation. Infant Behavior and Development, 19, 359–370.

Larrieu, J. A., & Bellow, S. M. (2004). Relationship assessment for young traumatized children. In J. D. Osofsky (Ed.), Young children and trauma: Intervention and treatment (pp. 155–172). New York: Guilford Press. Lewis, M. L. (1999). Hair combing interactions: A new paradigm for research with African­A merican mothers. American Journal of Orthopsychiatry, 69, 504–514. Lewis, M. L. (2000). The cultural context of infant mental health: The developmental niche of infant–­caregiver relationships. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 91–107). New York: Guilford Press. Leyendecker, B., Lamb, M. E., & Scholmerich, A. (1997). Studying mother–­infant interaction: The effects of context and length of observation in two subcultural groups. Infant Behavior and Development, 20, 325–337. Lord, C., Risi, S., Lambrecht, L. K., Cook, E. H., Leventhal, B. L., DiLavore, P. C., et al. (2000). The Autism Diagnostic Observation Schedule—­ Generic: A standard measure of social and communication deficits associated with the spectrum of autism. Journal of Autism and Developmental Disorders, 30, 205–223. Main, M., & Solomon, J. (1990). Procedures for identifying infants classified as disorganized/ disoriented during the Ainsworth Strange Situation. In M. T. Greenburg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years (pp. 121–160). Chicago: University of Chicago Press. Matas, L., Arend, R. A., & Sroufe, L. A. (1978). Continuity of adaptation in the second year: The relationship between quality of attachment and later competence. Child Development, 49, 547–556. Meins, E., Fernyhough, C., Fradley, E., & Tuckey, M. (2001). Rethinking maternal sensitivity: Mothers’ comments on infants’ mental processes predict security of attachment at 12 months. Journal of Child Psychology and Psychiatry, 42, 637–648. Neal-­Barnett, A., López, I., & Owens, D. (1996, August). Neither black nor white: The impact of skin color in the Puerto Rican community. In A. Neal Barnett (Chair), Women of color on color: Healing wounds and building legacies. Round table discussion conducted at 104th annual meeting of the American Psychological Association, Toronto, Canada. Radke-­Yarrow, M., Cummings, E. M., Kuczynski, L., & Chapman, M. (1985). Patterns of attachment in two- and three-year-olds in normal families and families with parental depression. Developmental Psychology, 56, 884–893. Russell, K. Y., Wilson, M., & Hall, R. E. (1992). The color complex: The politics of skin color among African Americans. San Diego: Harcourt, Brace, Jovanovich. Segal, L. B., Oster, H., Cohen, M., Caspi, B., Myers, M., & Brown, D. (1995). Smiling and fussing in



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seven-month-old preterm and full-term black infants in the still face situation. Child Development, 66, 1829–1843. Sroufe, L. A. (1983). Infant–­caregiver attachment and patterns of adaptation in preschool: The roots of maladaptation and competence. In M. Perlmutter (Ed.), Minnesota symposium in child psychology (Vol. 16, pp.  41–81). Hillsdale, NJ: Erlbaum. Thomas, J. M., & Clark, R. (1998). Disruptive behavior in the very young child: Diagnostic classification: 0–3 guides identification of risk factor and relational interventions. Infant Mental Health Journal, 19, 229–244. Tronick, E. Z. (2003). Things still to be done on the still-face effect. Infancy, 4, 475–482. Tronick, E. Z., Als, H., Adamson, L., Wise, S., & Brazelton, T. B. (1978). The infant’s response to entrapment between contradictory messages in face-to-face interaction. Journal of the American Academy of Child Psychiatry, 17, 1–13. van IJzendoorn, M. H., & Kroonenberg, P. M. (1988). Cross-­cultural patterns of attachment: A meta-­analysis of the strange situation. Child Development, 59, 147–156. Wakschlag, L., Briggs-Gowan, M. J., Hill, C., Danis, B., Leventhal, B., Keenan, K., et al. (2008). Observational assessment of preschool disruptive behavior: Part II. Validity of the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS). Journal of the American Academy of Child and Adolescent Psychiatry, 47, 632–641.

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Wakschlag, L., Hill, C., Carter, A. S., Danis, B., Egger, H. L., Keenan, K., et al. (2008). Observational assessment of preschool disruptive behavior: Part I. Reliability of the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS). Journal of the American Academy of Child and Adolescent Psychiatry, 47, 622– 631. Weinberg, M. K., & Tronick, E. Z. (1996). Infant affective reactions to the resumption of maternal interaction after the still-face. Child Development, 67, 905–914. Weston, D. R., Thomas, J. M., Barnard, K. E., Wieder, S., Clark, R., Carter, A. S., et al. (2003). DC: 0–3 assessment protocol project: Defining a comprehensive information set to support DC: 0–3 diagnostic formulation. Infant Mental Health Journal, 24, 410–427. Zeanah, C. H., Jr. (2008). Observational procedures and psychopathology in young children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 611–613. Zeanah, C. H., Jr., Boris, N. W., Heller, S. S., Hinshaw-­Fuselier, S., Larrieu, J. A., Lewis, M., et al. (1997). Relationship assessment in infant mental health. Infant Mental Health Journal, 18, 182–197. Zeanah, C. H., Jr., Larrieu, J. A., Valliere, J., & Heller, S. S. (2000). Infant–­parent relationship assessment. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 222– 235). New York: Guilford Press.

C h a p t e r 16

Infant–­Parent Relationship Assessment Parents’ Insightfulness Regarding Their Young Children’s Internal Worlds David Oppenheim Nina Koren-Karie

A

central tenet of an infant mental health approach involves the view that the development of infants and young children is inextricably woven within the fabric of the relationships they have with their caregivers (Sameroff & Emde, 1995). The quality of these relationships, codetermined by the mutual influences of child on caregiver and caregiver on child, is thought to have a profound effect on the social, emotional, and cognitive development of the child. Caregiver–child relationships thus play a major role in the successful adaptation of the child, or, under less favorable conditions, in maladaptation and psychopathology. Within this relational matrix the capacity of the caregiver to be sensitive to the child’s cues and respond empathically to emotional signals is of crucial importance, providing the foundation for the child’s secure and healthy emotional development. Such caregiving behavior is dependent on the capacity to “see things from the child’s point of view” (Ainsworth, 1969), to which we refer as parental insightfulness. In this chapter we present a procedure for assessing the capacity for insightfulness, the Insightfulness Assessment (IA; Oppenheim & Koren-Karie, 2002), review research findings from normative and high-risk samples that support

the validity of this procedure, and discuss its clinical uses in infant mental health.

INSIGHTFULNESS: BACKGROUND The development of the IA is rooted in the work of infant–­parent clinicians and developmental researchers who argued that a full understanding of parent–child interactions, and particularly those that are constricted, conflicted, or misattuned, requires an appreciation of the internal world of the parent. In particular, understanding the parent’s representation of the child—what the specific child, and his or her behavior, emotional expressions, and characteristics mean for the parent—is seen as crucially important. Perhaps the most well-known and emotionally evocative expression of this point of view was provided by Fraiberg and her colleagues (Fraiberg, Adelson, & Shapiro, 1975). In their classic “Ghosts in the Nursery” paper they described how unresolved parental childhood conflicts may distort the representation of the child in the mind of the parent. Mothers’ representations of their child can be so intensely colored by trauma and unmet needs from their own history that they are, 266



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in effect, unable to “see” the child and lack insight to the motives and emotions underlying the child’s behavior. Fraiberg et al. (1975) further described how working through past conflicts frees the child from maternal projections, allowing the mother to “see” the child and respond empathically to his or her emotional signals and needs. Building on Fraiberg, Lieberman proposed a model delineating the way in which maternal negative attributions regarding the motives underlying the child’s behavior shape and constrain the child’s sense of self. Lieberman (1997; Silverman & Lieberman, 1999) describes a negative attribution process that is rigid, closed, and sometimes outright contradictory with observed child behavior. These negative attributions set the stage for alarming and painful self-­fulfilling prophecies. Mothers’ negative attributions (e.g., child is greedy, child is aggressive) lead to insensitive caregiving behavior (e.g., letting the baby cry for an extended period, responding harshly and punitively) which, in turn, exacerbate the child’s behavior (e.g., baby cries more, child becomes more aggressive). If this cycle is repeated consistently, two negative outcomes result. The “validity” of the distorted maternal attribution is supported (the baby really is greedy, the baby really is hyperaggressive), and the child’s behavior becomes increasingly concordant with the distorted attribution. According to Lieberman, the child has now internalized the maternal attribution, with potentially harmful developmental outcomes. The focus on parents’ internal representations of their children has not only been central in clinical theorizing but has also been a salient focus among researchers, particularly those who have used attachment theory as a framework with which to study the parent– child relationship. Using the methodology of narrative assessment first described by Main and her colleagues (Main, Kaplan, & Cassidy, 1985), Zeanah and his colleagues (Zeanah, Benoit, & Barton, 1986; Zeanah, Benoit, Hirshberg, Barton, & Regan, 1994) developed the Working Model of the Child Interview to assess mothers’ representations of their children. In this interview mothers are asked about their experience of their child’s developmental history, as well as to describe the child’s personality, how the child is like and unlike each parent, and what

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the child’s behavior is like in general and in specific situations (Zeanah, Larrieu, Scott­Heller, & Valliere, 2000). Zeanah et al. (1994) found that balanced representations, characterized by portrayal of the child as a unique individual, and an empathic appreciation for the child’s experience were typical of mothers of secure children, whereas unbalanced representations (either disengaged or distorted) were typical of mothers of insecurely attached children (see also Benoit, Parker, & Zeanah, 1997). Independently, Slade developed the Parent Development Interview, which assesses parents’ representations of their children, themselves as parents, and their relationship with their children. In the interview parents are asked to describe their current relationship with their child by providing examples from everyday life. In her recent research, Slade focused on how the interviews reveal the capacity for reflective functioning, namely, parental recognition that the child has mental states, including feelings, thoughts, and intentions, and linkage of this awareness to the child’s behavior or to other internal states (Slade, 2005). In our work on parental insightfulness we moved the investigation regarding parental representations one step further—and one step closer to the child. In the IA parents are shown several video segments of their child and asked about the child’s thoughts and feelings during the segments. Thus, in this assessment we can observe how parents’ general representations of their children are applied in order to make sense of a specific and concrete moment in the life of the child. The goal of this procedure is to simulate, as much as possible, moments from everyday life in which parents try to make meaning out of their children’s behavior and understand the motives and emotions that may underlie that behavior. Unlike “real-life” moments, however, in which these meaning­making processes are implicit, the IA operates “offline” and requires of parents to make these processes explicit by responding to questions presented by an interviewer regarding the child’s thoughts and feelings. In this way the IA allows us to understand parents’ feelings and ways of perceiving and understanding that are thought to be at the root of their caregiving behavior. Before describing the IA procedure in more detail, we

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describe the central components of the insightfulness construct.

CENTRAL COMPONENTS OF INSIGHTFULNESS Insightfulness, in our view, involves three main features: insight regarding the motives for the child’s behaviors, an emotionally complex view of the child, and openness to new and sometimes unexpected information regarding the child. By insight we refer to the parent’s capacity to identify motives that may underlie their child’s behavior. Considering such motives is necessarily based on accepting the child as a separate person with plans, needs, and wishes of his or her own. The motives proposed by the parent are framed positively and match the behavior they are intended to explain. Both understanding and acceptance are needed when considering such motives. The parent should be able to understand the motives underlying the child’s behavior, and accompany such understanding with acceptance of these motives. This stance presumably forms the basis for appropriate parental responses, especially toward challenging or unrewarding child behavior. An emotionally complex view of the child involves a believable, convincing portrayal of the child as a whole person, with both positive and negative features. Positive features are described openly, sometimes with pride, and are supported by convincing examples from everyday life. They typically outweigh negative descriptions. Negative descriptions are provided in a nonblaming, frank way so that frustrating, unflattering, and upsetting aspects of the child are discussed within an accepting framework and in the context of attempts to find reasonable and appropriate explanations for the child’s behavior. Finally, openness is also central to insightfulness. Rather than imposing a preconceived notion of who their child is, insightful parents are open to see not only the familiar and comfortable aspects of their child but also unexpected behaviors, without distortion, often updating their view of the child as they talk. Openness also involves the parent’s attitude toward his- or herself: The parent can make use of the observations of him- or herself and the child in order to take

a new and fresh look at him- or herself as a parent, without excessive criticism or, on the other hand, defensiveness. The abovementioned features promote parental insightfulness. We have also identified features gleaned from maternal interviews that constitute barriers to insightfulness. These include anger at the child or worry about the child or about related issues and lack of acceptance. Anger and worry constitute barriers to insightfulness particularly when they are present in the interview at high levels. In such cases, these emotions appear to function as “filters” through which the child is perceived and through which his or her internal experience is interpreted. At times, particularly with regard to high levels of worry, the preoccupation of the mother with herself or with other issues (e.g., the marital relationship) so dominates the interview that it leaves little room for seeing the child’s point of view. The behaviors shown on the video segments and discussed in the interview are mostly viewed through a relatively narrow prism colored by anger or worry, thus limiting the possibility of flexibly considering a wider range of possible motives or explanations for the child’s behavior. Lack of acceptance can also act as a barrier to insightfulness. Its expression in the interview may involve derogation of the child, detachment from or indifference to the child’s internal experience, or rejection of certain child behaviors or even of the child as a whole. Such a stance violates the basic function of insightfulness, as discussed earlier, which is to provide the basis for caregiving that promotes healthy emotional development in the child. Interestingly, such lack of acceptance can sometimes be observed even in conjunction with a moderate degree of insight into the child’s motives and some understanding of what may lead the child to behave or feel in a certain way. For example, a parent may compellingly describe her son’s shy, embarrassed, and self-­conscious behavior but proceed to ridicule him for this behavior. Thus, in this and other similar situations the child does not benefit from his parent’s comprehension of his underlying motives and internal experience. In sum, what is salient in insightful parents is their capacity to provide an emotionally complex, accepting picture of the child that



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includes a wide spectrum of contextually appropriate motives and an ability to update their views of the child in accordance with new or unexpected child behaviors. Narratives with these qualities are thought to reflect relationships that promote in children the feeling that their inner world is meaningful and that their thoughts and feelings are appreciated, understood, and accepted. Parents who interact with their children while taking children’s point of view into consideration are likely to be perceived by their children as a secure base—a resource to which they can turn when comfort and help are needed. Children with noninsightful parents, on the other hand, may feel that their motives and wishes are not understood and not accepted; therefore, they cannot rely on their parents to contain and regulate their negative emotions—a conclusion that leads to feelings of frustration, loneliness, guilt, and shame. Several points are important with regard to the insightfulness construct. First, insight, complexity, openness, and acceptance in the parent’s speech about the child’s inner world are more important than the specific behaviors the parent describes (Koren-Karie & Oppenheim, 2001). Thus, “listening for insightfulness” in the speech of the parent is different from a standard clinical interview in which a careful and accurate description of the behaviors described by the parent is very important. Here, the accuracy of the descriptions is not the focus, but rather whether they are part of an overall insightful framework that involves the parent’s attempt to empathically understand the motives underlying the child’s behavior. Second, insightfulness is not necessarily reflected in warm responses and may not always lead to actions that are perceived as empathic by the child. For example, limiting toddlers’ forays into potentially unsafe situations or imposing limitations regarding bedtime is not likely to be experienced positively by children. However, such behavior can very well be expressions of insightfulness, provided they are based on broader, reasonable parenting goals and deep knowledge about the specific child and the specific context in question. Finally, although up to this point we have emphasized the maternal side of the relationship, it is important to keep in mind that ma-

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ternal insightfulness is embedded in a specific relational context and therefore might be influenced by children’s characteristics (e.g., gender, temperament, specific developmental difficulties) as well. While these characteristics are important and may influence how hard or easy it is for the parent to show insightfulness, a developmental perspective on parenting (Belsky, 1984; van IJzendoorn, Goldberg, Kroonenberg, & Frenkel, 1992) highlights the inherent asymmetry between parent and child and the importance and possibility of parental insightfulness even when the child’s behavior is challenging. Our study of insightfulness in mothers of children with autism, which is described later, exemplifies this point.

ASSESSMENT OF INSIGHTFULNESS In the IA parents and children are first videotaped in three interactional contexts. Parents subsequently watch short segments from the videotaped interactions and are interviewed regarding their children’s and their own thoughts and feelings. Three vignettes representing different aspects of the parent–child relationship, such as caregiving, play, and teaching, are selected. The vignettes are drawn from interactions that are age appropriate. For example, in a study of school-age children play may involve a competitive mother–child game; in a study of preschoolers play may involve coconstructing a play narrative using dolls and props; and in a study of infants play may involve a free-play episode. The IA is introduced to parents as an opportunity to better understand their children with a particular emphasis on what they believe their child was thinking or feeling. Then they are asked whether the behaviors they saw on the video are typical of their child; and finally they are asked about the way they felt when they were watching the video. Specifically, we inquire whether their child’s behaviors surprised them, concerned them, or made them happy. These questions are presented following each of the three segments. At the end of the interview mothers are asked two general questions about their child’s main characteristics and about what strikes them most about him or her. They are also invited

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to share their own thoughts and feelings regarding their child and their parental role. Throughout the interview parents are asked to support their statements with examples from the video observations as well as from everyday life. Interview transcripts are rated on 10 scales and subsequently classified into one of four groups. The first of the four groups indicates the capacity for insightfulness, whereas the remaining three indicate a lack of insightfulness. In Table 16.1 we describe the scales in some detail because of their clinical and research usefulness. Whereas the main research focus has been on the insightfulness classifications, clinically the IA scales are very important. For example, characterizing the profile of a parent on the scales can help identify areas of strength and vulnerability in a way that is more refined than the overall classification of the parent as insightful or not insightful. This profile can help the clinician develop a treatment plan that is tailored to the specific parent. Also, some scales may be of important “prognostic” value. For example, in one intervention study involving mothers and their preschool-age children (Oppenheim, Goldsmith, & Koren-Karie, 2004), we found that among mothers who were classified as noninsightful prior to the intervention, those who received relatively high scores on the coherence scale were more likely to benefit from the intervention and make progress toward enhanced insightfulness than those receiving lower scores on that scale. Thus, the coherence scale revealed variance within the noninsightful group that proved to be important in predicting responsiveness to treatment. Finally, the IA scales may be used to detect the effects of interventions. It is possible that some interventions may not be sufficiently powerful to shift parents from noninsightfulness to insightfulness, but may help increase dimensions tapped by the IA scales such as openness, complexity, or insight. Such increases may be important steppingstones on the way to more major shifts that might occur with additional intervention or time.

The IA Classifications As mentioned above, the rating scales serve as a basis for the classification of the tran-

scripts into insightful (one) and noninsightful (three) categories. These categories reflect more than a simple summation of scale scores. The coding manual provides guidelines regarding various constellations and combinations of scale scores that lead to specific categories. The four categories are as follows.

Positively Insightful The main characteristic of these parents is their ability to see various experiences through their child’s eyes and to try to understand the motives underlying their child’s behavior. They are open to the observations of the child on the video segments and may gain new insights as they talk. Positively insightful parents convey acceptance of the child, and their speech is coherent. They talk openly about both positive and negative aspects of their child’s personality and behavior as well as of their own caregiving. It is important to stress that parents ­classified as Positively Insightful, although sharing the above characteristics, are also quite varied. Some talk about their children in a very warm and emotional manner, whereas others are more reserved and have a matter-of-fact, focused style of speech. Still other parents in this group have a didactic style and focus on their children’s cognitive competencies and achievements, and yet others are most noted by their self-­reflection.

One-Sided One-sided parents seem to have a preset conception of the child that they impose on the videotaped segments, and this conception does not appear open to change. Some Onesided parents find it difficult to maintain the focus of their speech on the child, and switch to discussing their own feelings or to other, irrelevant issues. Others overemphasize the child’s positive qualities and their exemplary relationship without being able to support their statements with episodes from everyday life or from the video segments. Still others may describe the child as “all negative” and talk only about his or her faults and misbehaviors. Importantly, some Onesided parents show warmth and affection in discussing their children.



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TABLE 16.1.  IA Scales IA Scale

Low

High

Insight into child’s motives

Mothera does not talk about possible motives for her child’s behavior.

Mother tries to understand the thoughts and feelings that may underlie her child’s behavior; she moves freely between the videotaped observations and her knowledge about her child, draws parallels between the two, and tries to gain deeper understanding.

Openness

Mother is not open to the information provided by the videotaped observations, but rather reiterates her fixed and preset ideas about the child; the observation may be dismissed as not typical of the child.

Mother is open to the information arising from the videotaped observations; she compares what she knows about her child with the video observations and modifies her perceptions, if needed.

Complexity in description of child

Mother describes the child in a unidimensional, one-sided way, emphasizing either only positive or only negative aspects.

Mother provides a believable description of the child in which he or she is described as a “whole,” with both positive and negative aspects.

Maintenance of focus on child

The child is not the focus of discussion; rather, the focus is on the mother and her feelings and thoughts or other irrelevant issues.

The child is the focus of discussion; if Mother talks about herself, she does so when she is asked or in relation to her maternal role.

Richness of description of child

Mother gives limited responses that lack substance or full responses with mostly irrelevant details.

Mother responds to the interview questions in a full, comprehensive, and vivid way.

Coherence of thought

Mother’s speech does not convey a consistent and clear picture, and it is difficult to understand what she means; responses may contain digressions and contradictions, or she may ignore the videotaped observations.

Mother is focused on the videotaped segments, and in her answer she develops ideas in a consistent, connected, and relaxed way; her speech forms an integrated and clear picture linked both to the videotaped segments and the child as a whole.

Acceptance

Mother expresses dissatisfaction or disappointment with the child, or talks about the child in a derogatory way.

Mother accepts the full range of her child’s behaviors and shows tolerance and understanding toward challenging aspects; she is open about difficulties in her child’s behavior and conveys a deep acceptance of him or her.

Anger

Mother’s speech does not include current anger, even though she can talk about behaviors that caused her to feel angry in the past.

Current anger toward the child is a central feature of mother’s talk; the child is described as having many irritating traits, and many of the behaviors on the videotaped observation elicit anger in mother.

Worry

Mother expresses belief in herself and her child’s capacity to cope with challenges.

Mother’s worry regarding the child, her own maternal behavior, or their relationship is a central, repetitive theme throughout the interview.

Separateness from child

Mother finds it difficult to talk about the child with a sense of clear boundaries; she may talk about the child’s thoughts as if spoken out loud, or refer to ideas regarding what the child might think or feel as facts.

Mother sees the child as a separate person and accepts that the child may sometimes have needs and wishes that are different from, or even contradictory to, her own.

a For

clarity the scales refer to mothers, but they apply to other caregivers as well.

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Disengaged Disengaged parents are characterized by their lack of emotional involvement during the interview. Their answers are short and limited, and they do not use the observation as an opportunity to reflect upon their child’s and their own behavior. It seems that attempts to understand what is on their child’s mind are novel to them, and they do not find them pleasurable or valuable. They may feel comfortable with answers like “I don’t know”; as a result, the reader does not get a sense of who the child is. Disengaged parents talk very little about their children’s emotions and more about their behavior. Many of them emphasize their child’s ability to be on his or her own and are pleased that the child doesn’t seem to need others.

Mixed This category involves parents who do not show one type of speech as defined in the above categories. Rather, such parents may respond to one video segment in one style, and to another segment with a different style. Furthermore, the reader cannot judge which of the styles is dominant. For example, a parent may sound overwhelmed, unfocused, or hostile in his or her responses to the three video segments, but insightful, complex, and open in the response to the two general questions.

EMPIRICAL SUPPORT Insightfulness Assessment and Attachment The conceptual foundations of the IA are strongly rooted in attachment theory, and therefore the initial research using the IA involved establishing its validity by examining its associations with infant–­mother attachment. These studies attempted to not only match the IA with infant attachment patterns at the global level (i.e., insightful/noninsightful with secure/insecure) but to match each of the four IA classifications (positive insightfulness, one-sided, disengaged, mixed) with each of the four infant attachment classifications (secure, ambivalent, avoidant, disorganized; Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1990) respectively. These specific concor-

dances were seen as important because attachment theory and research describe the specific adaptations (i.e., types of secure and particularly insecure attachment) children make to specific types of sensitive and particularly insensitive parental care. We hypothesized that parents classified as positively insightful would be likely to have children classified as secure, because their insightfulness would facilitate correct interpretations and empathic responses to their children’s signals, as well as open examination of the appropriateness (or inappropriateness) of their caregiving behavior based on their children’s reactions. Such caregiving is likely to be experienced by the child as matched to his or her emotional needs and therefore to contribute to a secure infant–­mother attachment (Ainsworth et al., 1978). We further expected that the one-sided IA classification would be associated with the insecure-­ambivalent attachment pattern. We reasoned that the unidimensional view of the child is likely to be associated with inconsistent care: When the child’s behavior is congruent with the mother’s expectations, she may respond appropriately, whereas when the child’s behavior is not congruent with the mother’s expectations, she might ignore the child or respond in a way that is not matched to the child’s needs. Another response style involving the one-sided classification shows understanding but no empathy: Some mothers in this classification show understanding of the motives underlying the child’s behavior but reject those motives. Both expressions of the One-sided stance may be experienced by the child as frustrating and confusing—the kind of caregiving presumed to lead to ambivalent attachment (Cassidy & Berlin, 1994). We expected that parents classified as disengaged would be most likely to have children classified as avoidant. Here we reasoned that the lack of emotional engagement characteristic of these parents may lead to their minimizing or even ignoring the child’s bids for closeness and protection, which may be experienced by the child as rejection. Perhaps more than any of the other IA classifications, the disengaged orientation may leave children with the feeling that although their external behavior may be acknowledged, they are not known by their caregivers as emotional and mental beings (Slade, 1999). These experi-



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ences are likely to lead the child to shut off emotional expression, particularly negative affect and needs, and would therefore be associated with an avoidant attachment (Zeanah et al., 1994). Finally, we expected that parents classified as mixed would be most likely to have children classified as having an insecure-­disorganized attachment. We argued that the lack of a coherent strategy when speaking about the child would be reflected in competing or contradictory caregiving behaviors when interacting with him or her. Such strategies have been described by Lyons-Ruth and colleagues (Lyons-Ruth, Bronfman, & Atwood, 1999) as leading to disorganized attachment. Two normative studies that focused on the links between the IA and infant–­mother attachment provided support for these associations (Koren-Karie, Oppenheim, Dolev, Sher, & Etzion-­Carasso, 2002; Oppenheim, Koren-Karie, & Sagi, 2001). In both studies mothers classified positively insightful were most likely to have securely attached children, mothers classified One-sided were most likely to have insecure-­ambivalent children, and mothers classified Mixed were most likely to have children classified insecure-­disorganized (4 × 4 concordance in the Koren-Karie et al. [2002] study was 64%, kappa = .39, p < .01; in the Oppenheim et al. [2001] study concordance was 56%, kappa = .33, p < .001). Unexpectedly, no associations were found between the disengaged classification and children’s attachment, perhaps because our samples (like all those based on studies conducted in Israel; van IJzendoorn & Sagi, 1999) included very few children classified avoidant (although see later in this section for other validity data regarding the disengaged classification). Insightfulness is thought to be expressed in sensitive and emotionally regulating caregiving behavior. Therefore another aspect of the validity of the IA involved its associations with mother–child interactions, particularly with maternal sensitivity. In one study (Koren-Karie et al., 2002) we found that mothers classified positively insightful were more sensitive in their interactions with their infants in both home and laboratory observations than those not so classified, supporting the hypothesis that insightfulness has its effects on child attachment through sensitive caregiving behavior.

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Interestingly, sensitivity did not account for all of the shared variance between maternal insightfulness and child attachment. While this could be due to limitations in the assessment of sensitivity, it also opens up the possibility that Insightfulness may have its effects on child attachment through aspects of caregiving that are not captured by assessments of sensitivity. This finding is of clinical significance because it points to the need for better understanding and assessment of the ways in which maternal representations are expressed in mother–child interactions. The sensitivity findings also increased our understanding of the disengaged classification. Although, as mentioned above, no association between this classification and child attachment was found, an association was found between this classification and maternal insensitivity: mothers classified disengaged were less sensitive than those classified as Positively Insightful. In an additional analysis of these observations (Fridman, 2005) the disengaged classification was associated with maternal speech to the infant that included a particularly low proportion of “mind-­minded” words (Meins, Fernyhough, Wainwright, Gupta, & Tuckey, 2002)—that is, words that referred to the infant as a mental agent. This was particularly true of mind-­minded words that were judged as appropriate—that is, as matched to the child’s behavior and signals. These findings support the hypothesis that the disengaged classification reflects emotional distance. Additional support for this classification was obtained from our longitudinal data. When the children of the Koren-Karie et al. (2002) study were 4-years-old, we assessed their theory of mind—that is, the capacity to understand that the external actions of others are based on those others’ beliefs, thoughts, and feelings—and discovered that children whose mothers were classified as Disengaged at 1 year had relatively low theory of mind scores, compared to those whose mothers were classified as Insightful. Taken together these findings add to the validity of the disengaged IA classification. Its lack of association with insecure attachment needs to be clarified in future studies, particularly in relation to those including children with avoidant attachments.

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Low- and High-Risk Samples Both parental and child factors may play a role in determining insightfulness, but due to the asymmetry between parents and young children, parental factors are expected to exert a stronger influence than child factors. A similar point was made by Belsky (1984) in his discussion of the determinants of parental competency. Belsky argued that parenting is influenced by parental personality and characteristics, contextual sources of stress and support, and child characteristics, and that optimal parental functioning occurs when the personal psychological resources of parents are intact even when the other factors, including the child’s characteristics, are impaired. A similar argument has been made by van IJzendoorn et al. (1992), who showed, in a meta-­analysis of attachment in samples characterized by child or maternal risk, that maternal risk more strongly decreased the percentage of secure attachments than did child risk. One way to examine the relative contribution of parental and child factors to parental insightfulness is to examine the percentage of parents classified as insightful in samples that vary with regard to risk factors associated with the parent or the child. Based on the reasoning presented above, we expected that risk factors associated with the children would have a lesser impact on the percentage of the insightfulness classification when compared with risk factors associated with the parents (in all studies these were mothers). This expectation received preliminary support in our studies. The percentage of mothers classified as insightful in our normative samples was 65 and 68% (Koren­Karie et al., 2002; Oppenheim et al., 2001; in the latter study this was the percentage when corrected for the oversampling of insecure attachments). In a sample that consisted of mothers of children with autism spectrum disorder (ASD; Oppenheim, Koren-Karie, Dolev, & Yirmiya, 2009), a condition characterized by significant impairments in communication and thus likely to present challenges to parental insightfulness, 46% of the mothers were classified as insightful (see more details about this study in the next section). In an additional sample of mothers of children with ASD (Kuhn, 2007) 55% of the mothers were classified as insightful. Thus even when the risk associated with the child

was significant, as is the case with ASD, the percentage of insightful mothers was only somewhat lower than in normative samples, and a significant proportion was nonetheless insightful. To further examine this point, we are currently studying maternal insightfulness in a sample of children with intellectual disability, also a group in which there is risk associated with the child. We hope to discover whether or not a significant proportion of this group will be classified as insightful. Difficulties associated with the parent were expected to negatively impact insightfulness more than those associated with the child. Supporting this hypothesis, we found that in a clinical sample of mothers who were sexually abused as children by a close family member, the percentage of mothers classified insightful was only 3%, and in study of high-risk mothers and their children involved in treatment, only 9% were so classified (Oppenheim et al., 2004). In an additional, ongoing study of high-risk mothers in treatment under court supervision, preliminary data show that only 11% were classified as positively insightful (Personal Communication with Tim Page, May 14, 2007). Clearly more studies in which parental and child risks vary are needed to elucidate the relative contributions of parent and child to parental insightfulness. In an ongoing study we are examining this issue in the context of foster care in a family-based group-home setting, in which the foster mothers are responsible for approximately 10 children. We are assessing the insightfulness of the foster mothers regarding two of the children under their care, one identified by an independent source as the most difficult child under this mother’s care and the other as the least difficult child. This design will enable us to further examine parental and child influences on parental insightfulness. It will also enable us to examine the impact of trauma in the child’s past on the capacity of a foster parent to show insightfulness toward that child.

Insightfulness and Autism Spectrum Disorder As mentioned above, mothers classified as insightful were observed to be more sensitive during their interactions with their children than those classified as noninsightful, supporting the idea that insightfulness provides the basis for sensitive maternal behavior. Would this also be the case when the child



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brings into the relationship with the parent significant difficulties in communication and emotional signaling, as is the case in ASD? Will maternal insightfulness still be associated with the sensitivity, as was the case with typically developing children? Or will the child’s deficits be the primary determinant of the interaction with the parent, regardless of whether the parent is insightful or not? To address this issue the insightfulness of mothers of preschoolers diagnosed with ASD was examined as briefly mentioned above (Oppenheim et al., 2009). In addition, their sensitivity in several play-­interaction contexts was observed (Dolev, 2006). The first set of findings showed that insightfulness was not associated with the children’s level of cognitive functioning or daily living skills. Specifically, it did not seem to be the case that mothers of low-­functioning children were more likely to be noninsightful. Thus, insightfulness did not appear to simply be a reflection of how well or poorly the child was functioning. Paralleling this finding, there was no association between the severity of the child’s diagnosis on the autism spectrum (with pervasive developmental disorder not otherwise specified representing a less severe form of the disorder than autistic disorder) and maternal insightfulness, again suggesting that insightfulness (or lack thereof) is not just a reflection of the child’s difficulty. In the second set of findings insightfulness was associated with maternal sensitivity; mothers classified as insightful were rated as more sensitive than those classified noninsightful. In fact, the mean sensitivity score of the mothers classified insightful was high—above the cutoff score defining the threshold for sensitive maternal behavior. Thus, the same associations between insightfulness and sensitivity that were found in typically developing children were found in the case of mothers of children with autism. Similar results have been reported by Hutman (2007), who found that insightful mothers of children with ASD were more synchronous in their interactions with their children than mothers classified noninsightful, although Kuhn (2007) failed to replicate the insightfulness–­synchrony association in her study. This failure notwithstanding, it appears to be that even when children’s input into the interaction with parents is severely limited and atypical, insightfulness is

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possible and is associated with more sensitive caregiving behavior. In fact, it could be argued that insightfulness is even more important in the case of children with communication difficulties, because they are more dependent than typically developing children on their parent’s correct understanding of their signals.

Insightfulness and Nonparental Caregivers Up to this point the significance of insightfulness was discussed only with regard to the parent–child relationship, but it is likely that insightfulness is also relevant for the relationships between nonparental caregivers and children, such as those between caregivers in child care and the children under their care. In fact, models of reflective supervision (Fenichel, 1992; Gilkerson, 2003) for child care providers operate under the assumption that enhancing the capacity for reflection regarding the child’s experience and increasing understanding of the specific child’s unique experience will benefit the quality of care children receive and contribute to children’s experience and development in day care. Amini-­Virmani (2002) examined the effects of such supervision on caregiver insightfulness by comparing two child care sites, one employing a “traditional” supervisory model and one employing a reflective supervisory model. Results showed that following 2 months of supervision, caregivers in the reflective site had higher scores on several of the IA scales, including complexity, insight, openness, and coherence, compared to those at the traditional site. Additional research is needed to replicate these findings and examine whether gains in insightfulness among nonparental caregivers benefit the children under their care in ways that are similar to the benefits of parental insightfulness.

INSIGHTFULNESS AND INTERVENTION The IA has potential for assessing the effectiveness of interventions involving the parent–child relationship, particularly those that regard the parent’s representation of the child and reflectiveness regarding the child’s inner world as important and crucial targets for intervention (e.g., Lieberman & Van Horn, 2005; Powell, Cooper, Hoffman, &

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Marvin, 2007). Currently there are several ongoing studies using the IA as a pre- and post measure, but at this time results are not yet available. An earlier study in which insightfulness was assessed before and after treatment is relevant here, not so much to demonstrate the effect of the intervention on insightfulness (because a control group was not available) but to show the interconnectedness of the therapeutic processes involving parent and child during treatment. The study (Oppenheim et al., 2004) involved a group of 32 preschoolers referred to a therapeutic preschool (Goldsmith, 2007) for a wide range of behavioral and emotional problems. Their mothers, many of whom were characterized by a wide range of risk factors such as drug and alcohol abuse, poverty, history of abuse, and mental health issues, were also involved in the treatment by participating in therapy sessions focusing on parenting issues. The findings showed that prior to treatment only 9% of the mothers were classified as insightful, and that following 7 months of treatment 50% were so classified. Additional findings linked improvements in mothers with improvements in children. Therapists’ reports regarding children’s behavior problems indicated that following treatment there was a significant drop in both internalizing and externalizing problems, but only for children of mothers who shifted from noninsightfulness prior to treatment to insightfulness following the treatment. Although the design of the study does not permit us to determine whether changes in mothers led to changes in children, or vice versa, the changes do suggest that reduction in children’s behavior problems was associated with increases in insightfulness, suggesting that insightfulness may play an important role in enhancing children’s emotional and behavioral regulation and/or maintaining children’s gains in these domains once they are achieved.

CLINICAL IMPLICATIONS OF THE INSIGHTFULNESS ASSESSMENT The assessment of insightfulness in interventions with parents and young children adds a crucial component to the clinical assessment process. It allows the clinician to explore the

roots of problematic caregiving in the meanings attributed by the parent to the child and the child’s behavior, and to therefore go beyond observations of parental caregiving to its possible sources. The IA can thus assist the therapist in identifying parental “blind spots” that block the parent’s capacity to see things from the child’s point of view. Such identification can point to specific treatment strategies and goals that will enhance the parent’s capacity for insightfulness and help the parent adopt alternative and more flexible responses to the child—­responses that will help the child feel understood and enhance the child’s capacity to manage his or her emotions and difficulties more effectively. Next we discuss several specific issues related to the clinical application of the IA, and we begin with the IA questions. Clinicians might find it helpful to use the IA questions as part of their intake or intervention process. For example, the clinician may observe the parent and child interacting and afterward ask the parent to reflect upon the child’s thoughts and feelings in that specific interaction. We highlight the idea of asking about the specific interaction rather about the child more generally because it provides an opportunity to assess insightfulness in action—the parent’s capacity or difficulty in focusing on the child’s inner world in a given moment. While in research use of the IA the segments chosen for parental reflection are standard, in clinical cases therapists can choose moments that appear to be particularly salient and emotionally significant, representing both zones of comfort in the parent–child relationship but also zones of distress and misattunement. A similar approach is used in various video-­replay intervention approaches, such as the Circle of Security (Powell et al., 2007) or Interactional Guidance (McDonough, 2004). What the IA adds are the specific dimensions that should guide the clinician when listening to the parent’s responses. For example, it appears to be useful to look for the presence or absence of insight, acceptance, complexity, and openness, as well as shifts of focus and boundary dissolutions. In other words, do parents refer to motives underlying their child’s behavior, or do they describe the overt behavior with no reference to the inner world of the child? Are parents open to thinking in a fresh manner about the child’s experiences, or do they



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dismiss new information arising from the observations? Do parents’ answers focus on their child’s point of view or do they drift to their own concerns and perspectives? In listening to parents’ descriptions of their child and his or her inner world, it is important to consider several additional points. First, prior to treatment, many parents are highly distressed by their child’s problematic behaviors. They are often at their wits’ end, many times after months of anxiety and frustration trying to handle their child’s behavioral or emotional problems with limited or no success. Consequently, their responses during the IA may reflect states of overwhelm, confusion, and sometimes considerable hostility. However, as mentioned above, even in such noninsightful and incoherent speech it is possible to identify markers—even if only weak—of the ability to openly look at the child and to think about the child in a complex and insightful way. For example, Koren-Karie, Oppenheim, and Goldsmith (2007) described two mothers who were part of an intervention focused on the behavior problems of their children and on their own parenting. Both mothers did not show insightfulness prior to the intervention, but one showed a relatively good capacity for openness and the other showed complexity in thinking about her child—both positive features in otherwise noninsightful interviews. Such markers are important because they may forecast positive changes in treatment and can help the clinician develop a treatment plan that is based on the strengths of the parent. Indeed, in both of these cases the mothers shifted to an insightful stance following the intervention, a shift that was likely to enhance their capacity to deal with their children’s difficulties and break some of the negative cycles that were characteristic of their interactions with their children. Supporting this notion, we found that in the group of mothers and preschoolers in treatment mentioned earlier (Oppenheim et al., 2004), in which almost all of the mothers were noninsightful prior to treatment, those whose scores on the coherence IA scale prior to treatment were relatively high were more likely to shift toward insightfulness during treatment. Second, in order to evaluate the capacity for insightfulness, it is important to listen not

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only to the content of parents’ descriptions regarding their children and themselves, but also to the way in which they describe their children. The essence of insightfulness does not involve the characteristics attributed to the child—which, in the clinical situation, may involve problem behaviors—as much as parents’ ability to put their children’s challenging behavior into context and talk about such behaviors with acceptance. As discussed above, it is possible to be insightful regarding the experience of the child even if the child’s behavior is, objectively speaking, difficult and challenging. The distinction between negative content and an insightful stance is particularly important when we consider therapeutic progress over time. In some cases shifts toward enhanced insightfulness in parents evolve faster than positive changes in the child. In these instances we would be likely to see the coupling of the newly found insightful stance with descriptions of significant behavioral and emotional problems in the child that have not yet improved. These are situations in which parents need significant support from their therapists to maintain their insightfulness and also to translate the insightful potential to more attuned parental behaviors. They may be helped by understanding that although their insightfulness may not yet show its fruits in improvements in the child’s behavior, it is likely to pave the way for future improvements. In fact, it is the very capacity for insightfulness that will enable parents to understand that their insightfulness is important for the child even if the child has not yet made the expected therapeutic gains. Third, the IA classification of the parents may have important implications regarding their responsiveness to treatment. Parents classified as insightful are likely to be most responsive to treatment. They are equipped with the basic capacity to appreciate the importance of the child’s inner world as playing a salient role in the child’s behavior and wellbeing, and they are therefore likely to effectively employ new ways of thinking about the child as well as to flexibly and sensitively use new strategies to address the child’s difficulties and promote the child’s behavioral and emotional regulation. Therapists are likely to feel that they have, in these parents, partners who are willing to reflect on the child’s

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as well as their own experience, and the therapeutic alliance is therefore likely to be strong. In many of these cases the source of the child’s difficulties may be external stressors such as loss, serious illness, divorce, or exposure to traumatic life events, or internal stressors stemming from the child’s particularly difficult temperament, regulatory difficulties, or developmental issues. Although the insightful parent, like most parents, will likely experience distress, anxiety, and other emotional strains in response to the child’s distress and symptoms, these responses are reactions to the child’s condition, rather than the sources of this condition, and are likely to be alleviated when parents feel that an appropriate treatment plan is put in place and the child is responding to this plan. What about the noninsightful classifications? As reviewed earlier, each of these classifications is associated with different patterns of insecure attachment, and it may be that parental responsiveness to treatment is also different. Within the noninsightful categories, we speculate that that shifts toward insightfulness are more likely if the starting point is a one-sided rather than a disengaged stance, because of the openness to the world of emotions that characterizes one-sided mothers. Although such parents speak about their children and their parental role in a confusing, overwhelmed, and self-­focused manner, they are nonetheless involved with the child and show an interest in their child’s emotional life. This involvement and interest may provide a basis from which a willingness emerges to cooperate with the therapist and the treatment plan. Disengaged parents show low levels of emotional involvement with their children and low or nonexistent interest or curiosity regarding their motives or underlying emotions. This style is likely to make it harder for them to become involved in the therapeutic process, decreasing the chances that they will gain a wider and deeper understanding of themselves or their children. It may be necessary in such cases to tailor the intervention to the disengaged style of these parents (e.g., Dozier & Sepulveda, 2004). For example, focusing, at least initially, on the child’s behavior problems and discussing better parenting strategies may be workable for disengaged parents. Hopefully this will

be only a first step to an expanded intervention that will ultimately allow parents to take the child’s experience more fully into consideration. Future intervention studies that employ the IA before and after treatment will help shed light on this issue. In sum, helping parents gain a complex, insightful, and open representation of their child can help them think of the child as a separate person with his or her own needs and wishes, which in turn provides them with an ability to demonstrate more tolerance and acceptance toward the child and his or her behavioral and emotional problems. Children of insightful parents feel that they are seen by their parents as a whole person, and that their voice is both heard and accepted. These feelings are likely to promote growth, self-­esteem, positive attitudes toward close relationships, and subjective well-being. We believe that therapists who “listen for insightfulness” in parental talk about the child will be better able to assist parents in the complex, difficult, but rewarding journey toward seeing the world from the child’s point of view. References Ainsworth, M. D. S. (1969). Maternal sensitivity scales. Available at www.psy.sunysb.edu/ewaters/senscoop.htm. Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the Strange Situation. Hillsdale, NJ: Erlbaum. Amini-­Virmani, E. (2002). Supervision and training in child care settings: A comparative study of reflective and traditional methods and their effect on caregiver insightfulness. Unpublished MSc thesis, University of California, Davis. Belsky, J. (1984). The determinants of parenting: A process model. Child Development, 55, 83–96. Benoit, D., Parker, K., & Zeanah, C. H., Jr. (1997). Mothers’ representations of their infants assessed prenatally: Stability and association with infants’ attachment classifications. Journal of Child Psychology, Psychiatry, and Allied Disciplines, 38, 307–313. Bowlby, J. (1982). Attachment and loss: Vol. 1. Attachment (2nd ed.). New York: Basic Books. Cassidy, J., & Berlin, L. (1994). The insecure/ambivalent pattern of attachment: Theory and research. Child Development, 65, 971–991. Dolev, S. (2006). Insightfulness and reaction to diagnosis in mothers of children with autism: Associations with maternal sensitivity. Unpublished doctoral dissertation, University of Haifa, Israel.



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Dozier, M., & Sepulveda, S. (2004). Foster mother state of mind and treatment use: Different challenges for different people. Infant Mental Health Journal, 25, 368–378. Fenichel, E. (Ed.). (1992). Learning through supervision and mentorship to support the development of infants, toddlers, and their families: A sourcebook. Washington, DC: Zero to Three. Fonagy, P., Steele, M., Steele, H., Leigh, T., Kennedy, R., Mattoon, G., et al. (1995). Attachment, the reflective self, and borderline states: The predictive specificity of the Adult Attachment Interview and pathological emotional development. In S. Goldberg, R. Muir, & J. Kerr (Eds.), Attachment theory: Social, developmental, and clinical perspectives (pp.  233–278). Hillsdale, NJ: Analytic Press. Fonagy, P., Steele, M., Steele, H., Moran, G. S., & Higgit, A. C. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 13, 200–217. Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant–­mother relationships. Journal of the American Academy of Child Psychiatry, 14, 387–421. Fridman, A. (2005). Maternal mind-­mindedness: Relations with maternal insightfulness and infant behavior at one year. Unpublished master’s thesis, University of Haifa, Israel. Gilkerson, L. (2003). Irving B. Harris Distinguished Lecture: Reflective supervision in infant–­family programs: Adding clinical process to nonclinical settings. Infant Mental Health Journal, 25, 424–439. Goldsmith, D. F. (2007). Challenging children’s negative internal working models: Utilizing attachment based strategies in a therapeutic preschool. In D. Oppenheim & D. F. Goldsmith (Eds.), Attachment theory in clinical work with children: Bridging the gap between research and practice (pp.  203–225). New York: Guilford Press. Hutman, T. M. (2007). Relations between mothers’ narratives about their child with autism and maternal responsiveness during play. Unpublished Dissertation. University of California, Los Angeles. Koren-Karie, N., & Oppenheim, D. (2001). Insightfulness procedure administration and coding manual. Unpublished manual, University of Haifa, Israel. Koren-Karie, N., Oppenheim, D., Dolev, S., Sher, E., & Etzion-­Carasso, A. (2002). Mothers’ empathic understanding of their infants’ internal experience: Relations with maternal sensitivity and infant attachment. Developmental Psychology, 38, 534–542. Koren-Karie, N., Oppenheim, D., & Goldsmith, D. (2007). Keeping the inner world of the child in mind: Using the insightfulness assessment with mothers in a therapeutic preschool. In D. Oppen-

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heim & D. F. Goldsmith (Eds.), Attachment theory in clinical work with children: Bridging the gap between research and practice (pp.  31–57). New York: Guilford Press. Kuhn, J. C. (2007). Maternal synchrony predicts joint attention and language gains in toddlers with autism. Unpublished doctoral dissertation, University of Massachusetts at Boston. Lieberman, A. F. (1997). Toddlers’ internalization of maternal attributions as a factor in quality of attachment. In L. Atkinson & K. Zucker (Eds.), Attachment and psychopathology (pp. 277–291). New York: Guilford Press. Lieberman, A. F., & Van Horn, P. (2005). Don’t hit my mommy: A manual for child–­parent psychotherapy with young witnesses of family violence. Washington, DC: Zero to Three press. Lyons-Ruth, K., Bronfman, E., & Atwood, G. (1999). A relational diathesis of hostile–­helpless states of mind: Expressions in mother–­infant interaction. In J. Solomon & C. George (Eds.), Attachment disorganization (pp.  33–70). New York: Guilford Press. Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. In I. Bretherton & E. Waters (Eds.), Growing points in attachment theory and research. Monographs of the Society for Research in Child Development, 50(1–2, Serial No. 209), 66–104. Main M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M. T. Greenberg, D. Cicchetti, & E. M. Cummings, Attachment in the preschool years: Theory, research, and intervention (pp. 121–160). Chicago: University of Chicago Press. McDonough, S. (2004). Interaction guidance: Promoting and nurturing the caregiving relationship. In A. J. Sameroff, S. C. Mcdonough, & K. L. Rosenblum (Eds.), Treating parent–­infant relationship problems: Strategies for intervention (pp. 79–96). New York: Guilford Press. Meins, E., Fernyhough, C., Wainwright, R., Gupta, M. D., & Tuckey, M. (2002). Maternal mind­mindedness and attachment security as predictors of theory of mind understanding. Child Development, 73, 1715–1726. Oppenheim, D., Goldsmith, D., & Koren-Karie, N. (2004). Maternal insightfulness and preschoolers’ emotion and behavior problems: Reciprocal influences in a day-­treatment program. Infant Mental Health Journal, 25, 352–367. Oppenheim, D., & Koren-Karie, N. (2002). Mothers’ insightfulness regarding their children’s internal worlds: The capacity underlying secure child–­mother relationships. Infant Mental Health Journal, 23, 593–605. Oppenheim, D., Koren-Karie, N., Dolev, S., & Yirmiya, N. (2009). Maternal insightfulness and Resolution of the Diagnosis are related to secure attachment in preschoolers with Autism Spectrum Disorder. Child Development, 80, 519–527.

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Oppenheim, D., Koren-Karie, N., & Sagi, A. (2001). Mothers’ empathic understanding of their preschoolers’ internal experience: Relations with early attachment. International Journal of Behavioral Development, 25, 16–26. Powell, B., Cooper, G., Hoffman, K., & Marvin, R. (2007). The Circle of Security project: A case study—“It hurts to give that which you did not receive.” In D. Oppenheim & D. F. Goldsmith (Eds.), Attachment theory in clinical work with children: Bridging the gap between research and practice (pp.  172–202). New York: Guilford Press. Sameroff, A., & Emde, R. N. (1995). Relationship disturbances in early childhood: A developmental approach. New York: Basic Books. Slade, A. (1999). Representation, symbolization, and affect regulation in the concomitant treatment of a mother and a child: Attachment theory and child psychotherapy. Psychoanalytic Inquiry, 19, 797–830. Slade, A. (2005). Parental reflective functioning: An introduction. Attachment and Human Development, 7, 269–281. Silverman, R. C., & Lieberman, A. F. (1999). Negative maternal attributions, projective identification, and intergenerational transmission of

violent relational patterns. Psychoanalytic Dialogues, 9, 161–186. van IJzendoorn, M. H., Goldberg, S., Kroonenberg, P. M., & Frenkel, O. J. (1992). The relative effects of maternal and child problems on the quality of attachment: A meta-­analysis of attachment in clinical samples. Child Development, 63, 840–858. van IJzendoorn, M. H., & Sagi, A. (1999). Cross­cultural patterns of attachment: Universal and contextual determinants. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 713–734). New York: Guilford Press. Zeanah, C. H., Jr., Benoit, D., & Barton, M. (1986). Working model of the child interview. Unpublished manuscript. Zeanah, C. H., Jr., Benoit, D., Hirshberg, L., Barton, M. L. & Regan, C. (1994). Mothers’ representations of their infants are concordant with infant attachment classifications. Developmental Issues in Psychiatry and Psychology, 1, 9–18. Zeanah, C. H., Jr., Larrieu, J. A., Scott-­Heller, S., & Valliere, J. (2000). Infant–­parent relationship assessment. In C. H. Zeanah (Ed.), Handbook of infant mental health (2nd ed., pp. 222–235). New York: Guilford Press.

Pa r t I V

PSYCHOPATHOLOGY

T he idea of psychopathology in the first few years of life is objectionable to some. It is disturbing to think simultaneously of babies and mental illness. Previous editions of this Handbook have made a case for the value of conceptualizing deviant behavior in young children as psychopathology. Young children exhibiting such behavior are often suffering and require treatment to alleviate it. Since those previous editions were published, accumulating research has documented that some young children show stable symptoms and signs of psychiatric disorders over time, and that many of these children are substantially impaired by these disorders. There are now compelling evidence supporting the presence of categorical disorders in early childhood. In fact, the acceptance of categorical disorders in young children is so complete that it raises the question of whether the pendulum may have swung too far. Instead of attempting to describe the similarities of disorders in infants and toddlers to disorders in older children, adolescents, and adults, we should perhaps be more carefully describing the differences. Phenomenologically, when disorders are assessed with structured psychiatric interviews of parents, similarities between disorders in younger and older individuals are more striking than differences (Angold & Egger, 2007). But this approach is only one of several that should be included in assessing psychopathology in young children. A narrow focus on categorical disorders means that the important relational focus of infant mental health may be lost. The consequences of this lost focus are potentially serious. For example, the idea of preschool children with bipolar disorder reflects overmedicalization (and overmedication) of very young children who probably have a variety of emotion regulation disturbances requiring more comprehensive approaches than mood stabilizers can provide. The study of psychopathology in the early years has just begun to get serious attention, and much still needs to be determined. As the chapters in this section make clear, both categorical and dimensional approaches to psychopathology are valuable, and there is a clear need for multiple measures and approaches. The thrust of future research needs to consider what is unique about early childhood psychopathology in addition to what is similar. Note that these chapters depict a range of disorders, from more “within the child” disorders to more relationship-­dependent disorders. What seems increas

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ingly clear is that the young child’s primary caregiving relationship may affect his or her overall adaptation if not actual symptomatology. The section begins with Chapter 17, in which Egger and Angold highlight the significant advances that have been made in classifying psychopathology in young children. They note the value of refining and validating a nosology of disorders for young children, and they directly address the most common objections to conceptualizing psychopathological deviations as categorical disorders. They also point out how much more we need to learn, and they anticipate contributions from neurobiology that will likely lead to more meaningful nosologies of mental disorders that will enhance our ability to understand and relieve suffering in young children. Carr and Lord (Chapter 18) review the substantial progress that has been made in our understanding of autistic spectrum disorders in the past decade. With this better understanding has come better methods of early identification of signs of the disorder and more meaningful efforts at early intervention. Importantly, they note the imperative to include more disadvantaged families in research on autism because of disparities in both identification and access to services that are related to social class. In Chapter 19 Windsor, Reichle, and Mahowald remind us that language and social communication develop in the context of social interactions with important caregivers. They note that for children who demonstrate language delays or deviance over time, early identification is critical. They discuss the availability but also the limitations of current language screening measures and indicate what needs to be done to refine and validate them, especially for children from diverse cultural and linguistic backgrounds. Regarding intervention, they call for inclusion of parents and other caregivers as partners who can sustain and facilitate communication skills in young children. Hodapp, Thornton-Wells, and Dykens, in Chapter 20, describe intellectual disabilities in young children. They note basic challenges in defining of intellectual disabilities and especially in how best to diagnose infants or toddlers promptly and accurately. They review considerable progress in the past two decades on genetic causes of intellectual disabilities and how genetic anomalies affect brain and behavioral functioning. They also review advances in understanding how families cope with young children with intellectual disabilities and anticipate better informed early intervention services designed to optimize outcomes for affected infants and their families. In Chapter 21 Scheeringa describes posttraumatic stress disorder (PTSD) in young children. When the first edition of this Handbook was published in 1993, there were no systematic studies of this disorder in young children, although it was recognized in case studies. Since that time, a series of systematic studies by Scheeringa and others has delineated the correlates, construct validity, and course of the disorder. This information has led to controlled studies of treatment with demonstrated efficacy. Despite these advances, of course, many gaps in knowledge remain. Among the challenges Scheeringa highlights are acquiring a better understanding of early memory capacities and the bidirectional influences of parent– child relationships, and the need for more controlled treatment studies. Perhaps the biggest challenge from an infant mental health perspective is limited detection and therefore undertreatment of young children.



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Owens and Burnham (Chapter 22) provide an overview of one of the most common disorders in infants and toddlers: sleep disorders. They review significant advances in our understanding of the course of sleep–wake state development across the first 3 years of life, discuss the most common sleep disturbances seen during this period, describe sleep disturbances in the context of other disorders, and provide an overview of common interventions. They emphasize the public health care burden related to health care costs and lost productivity of caregivers resulting from sleep disorders in young children. They also emphasize the need for a more comprehensive nosology to describe infant sleep disorders, more evidencebased clinical screening/evaluation tools, and educational interventions for caregivers and providers to raise awareness and prevention efforts. In Chapter 23 Benoit describes another common problem in young children: feeding disorders and the related problems of failure to thrive and obesity. She notes the complexity of these disorders and points out inconsistencies of definition and research methodologies used to study them. Nevertheless, she also notes an overall improvement in the quality of research over the past 10 years and anticipates substantial gains in the next decade. Wakschlag and Danis, in Chapter 24, describe disruptive behavior disorders in young children. A central problem that they address is how to distinguish true disorders from transient and normative misbehavior. In fact, considerable research has demonstrated the persistence of aggressive and disruptive behaviors in some young children from early childhood into later developmental periods. Research reviewed by Wakschlag and Danis indicates that worrisome disruptive behaviors are frequent, persistent, and qualitatively distinct from briefer, contextualized, and flexible ordinary misbehaviors of young children. Looking to the future, they call for an empirically grounded and developmentally sensitive method for classifying disruptive behavior in early childhood. In Chapter 25 Luby provides an overview of depressive disorders in early childhood. She reviews preliminary research validating the presence of clinical depression in preschool children, although she notes that despite clinical experience with infants and toddlers, there are, at present, no data to validate the presence of clinical depressive disorder in children less than 3 years of age. Here, the challenge of relationship variability in young children’s affective displays is considered. She also calls for treatment studies of mood disorders in young children. Smyke and I conclude the section in Chapter 26 with a discussion of attachment disorders in young children. Though much remains to be learned about these rare disorders, progress in the past 10 years has been substantial. We review data about the etiology, construct validity, correlates, and course of the disorder that were not even available when the preceding edition of this Handbook was published. We also note areas in need of additional research, especially individual vulnerabilities to the two distinctive types of reactive attachment disorder, sensitive periods for corrective attachment experiences, and, most urgent, treatment. Reference Angold, A., & Egger, H. L. (2007). Preschool psychopathology: Lessons for the lifespan. Journal of Child Psychology, Psychiatry, and Allied Disciplines, 48, 961–966.

C h a p t e r 17

Classification of Psychopathology in Early Childhood Helen Link Egger Adrian Angold

O

ver the last decade the infant mental health field has made real strides in characterizing psychopathology in early childhood, and this chapter reviews current approaches to the classification of such problems (unfortunately, we do not yet have consensus on a single standard), as well as the evidence for the validity and clinical utility of each approach. Despite recent advances, work on the development of a valid classification of psychopathology in early childhood still has a long way to go and lags far behind progress in relation to older children. A DSM-V workgroup (the Infant and Young Child Diagnostic Work Group), convened by the American Psychiatric Association, concluded that the “need for a valid nosology for psychiatric diagnoses in early childhood represents one of the most pressing issues in psychiatric classification” (Chatoor, Pine, & Narrow, 2007 p. 145). This chapter also provides suggestions about how the infant mental health field might address this key issue in the future. Researchers and clinicians, both within and without the infant mental health field, have wondered whether it is desirable, or even possible, to classify psychiatric disorders in infants and young children (for a review of these concerns, see Angold & Egger,

2004; Carter, Briggs-Gowan, & Davis, 2004; Egger & Angold, 2006; Emde, Bingham, & Harmon, 1993). In particular, there has been concern that diagnosing psychiatric disorders in young children is “inappropriate” because it “overpathologizes” and “medicalizes” normal variation, individual differences, transient perturbations, and relationship disturbances (Burke, 2003; McClellan & Speltz, 2003). In their chapter in the 1993 edition of this Handbook, Emde and colleagues suggested that the multidisciplinary, developmental, relationship-based, family-­centered, and prevention-­focused orientations of the infant mental health field are different from the orientations of other areas of medicine, including psychiatry. They suggested that these different perspectives make it challenging to develop a classification framework for psychopathology in early childhood within the structure of current medical/psychiatric nosologies (Emde et al., 1993). We address the major arguments that have been made against the classification of psychopathology in infants and young children and suggest that a valid nosology of psychopathology in early childhood must reflect the essential features of the infant mental health approaches that Emde and colleagues 285

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identified, while also trying to meet the standards of specificity, reliability, and validity that are used in the development of other classification systems. In fact, infant mental health perspectives should not be seen as barriers to the development of a scientifically and clinically meaningful nosology in early childhood, but rather should be considered essential components of all classifications of psychopathology from early childhood through late life. For example, the challenge of characterizing depressed mood in toddlers with limited expressive language is also faced with older children who have very low IQs, as well as with seniors with dementia that impairs their expressive language capacities. Moreover, understanding how problematic behaviors and emotions change within the context of relationships is not only informative for understanding psychopathology in early childhood, but is a key component for understanding and treating psychopathology throughout the lifespan, as family behavioral therapies demonstrate so clearly. As the infant mental field makes progress in developing a valid nosology of psychopathology for itself, it may well be able to inform and reshape our approaches to the classification of psychopathology at other ages, so that we finally reach a point where we have a shared nosology of psychopathology that is developmentally sensitive and relevant across the lifespan.

WHY A NOSOLOGY OF PSYCHOPATHOLOGY IN EARLY CHILDHOOD? What Is a Nosology? A nosology is a classification of diseases— in essence, just a list of all the separate diseases that are known to exist. However, for that nosology to be of any use, we must also be able to define the boundaries between health and illness (or normative variation and clinically significant syndromes) and the boundaries between individual disorders. In psychiatry we have become used to the presence of diagnostic manuals that attempt to operationalize these boundaries. The title of Robert Burton’s 1621 book, The Anatomy of Melancholy: What it is, with all the kinds, causes, symptoms, prognosticks and several cures of it, captures the nature and utility of

a nosology and its accompanying diagnostic manual. A nosology, whether in the realm of cardiology or mental health, should ideally result from the systematic and scientific investigation of symptoms, signs, and medical tests that leads to definitions of specific diseases and a classification of those diseases. We classify a disease so that we can summarize what “it” is, how “it” presents, how “it” affects a person now and later, and how we can treat “it.” The nosology then functions as a “shared language” that facilitates clinical decision making and communication. Just as Burton’s treatise reflected the state of 17th-­century medical knowledge, our current psychiatric nosologies and their accompanying diagnostic manuals reflect the state (and often limitations) of our current knowledge about mental disorders and are meant to evolve as new knowledge reshapes our understanding. This is true in all branches of medicine, not just psychiatry. Until recently, the infant mental health field had not, by and large, approached mental disorders of early childhood from a standard medical perspective, and so clinical classifications have reflected different conceptual approaches of varying clinical utility. Examples include the characterizations of attachment styles and temperaments, which classify variations in patterns of interactions or emotional and behavioral styles but do not specifically focus on psychopathology. However, as we have made progress in the characterization of psychopathology from early school age through adolescence, we have also identified a real need to explore whether it is possible to validate a classification of psychopathology that (1) focuses on early-onset behavioral, emotional, developmental, and relationship disorders and impairment and (2) maintains continuity with how psychopathology and psychiatric impairment are characterized at later ages. The recognition that we need a psychiatric nosology in early childhood does not dismiss the importance of other dimensions, such as the child’s social and emotional competencies or attachment style (or parental psychopathology), but rather emphasizes the utility of a specific framework for approaching mental health disorders. While we review how the multiaxial frameworks of the two major diagnostic approaches to early childhood psychopathology (DSM/ ICD-10, DSM-IV/ICD-10, and DC:0–3R)



17. Classification in Early Childhood

reflect the importance of a biopsychosocial approach to classifying and assessing psychiatric disorders, we also emphasize that classification of psychopathology is only one part of a comprehensive mental health assessment, not the sole purpose.

What Is a Disorder? A disorder is a syndrome characterized by a distinct pattern of symptoms at specified levels of intensity, frequency, duration, and/ or onset age. The criteria for diagnosing a disorder reflect decisions about the location of boundaries between “normal” and “pathological” behaviors on the symptom and the syndrome level. The characterization of a specific disorder also suggests that this disorder is a distinct syndrome, not simply a variation of a unitary syndrome. The Robins and Guze criteria that have been used to determine the validity of psychiatric syndromes later in childhood and in adulthood should also be met by early childhood psychiatric syndromes: the disorder/syndrome should reflect a systematic pattern of co­occurring features that can be reliably observed and that are associated with specific differences in natural history (e.g., course), psychological and psychosocial correlates, neurobiological correlates, environmental risk, familial and genetic factors, and possibly treatment responses (Robins & Guze, 1970). It is important to emphasize that all of these validity criteria have not been met for most DSM-IV disorders at other ages, but the exploration of these criteria have contributed to important advances in understanding and treating of many psychiatric disorders. Individuals can, and commonly do, meet criteria for more than one disorder (i.e., comorbidity). The high rates of comorbidity among psychiatric disorders in adults and children (including preschoolers; Angold, Costello, & Erkanli, 1999; Egger & Angold, 2006) suggest that our current nosologies may be identifying syndromes that are, in fact, not distinct disorders but varied presentations of an underlying syndrome that cannot be adequately characterized by our current, mostly descriptive, criteria alone. As we get closer to understanding the underlying mechanisms that cause and sustain the clusters of behavioral and emotional symptoms that we call psychiatric diagnoses, we would

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expect to have greater, though not complete, delineation of the boundaries among different disorders. Although we may strive for an etiologically based nosology in the future, we are far from being able to accomplish it at present. While it can be frustrating that we are still working with a descriptive nosology, there is substantial clinical and scientific utility to such an approach at this point in time. There has been a long debate about whether psychopathology is better conceptualized categorically (making diagnoses) or continuously (identifying dimensions of symptoms). The simple answer is that both approaches have value (Pickles & Angold, 2003). Most forms of common mental disorders show continuous distributions with no distinctive line delineating normality and psychopathology. For example, many preschoolers have one or two attention-­deficit/ hyperactivity disorder (ADHD) symptoms. We have found that each additional ADHD symptom is associated with a doubling of the probability that the child will be impaired. Children who miss meeting the criteria for an ADHD diagnoses by one symptom (i.e., have five inattentive symptoms, not six) are often impaired by these symptoms (Egger & Angold, 2006). Clearly, ADHD symptomatology can and should be thought of as a continuous construct. However, in clinical settings a decision has to be made whether to treat or not to treat a specific child. Similarly, in scientific studies, decisions have to be made about how to identify the group of children we want to study. Both of these are decision points where we draw a line to define clinical significance. Cutpoints (delineating those “at risk” or “ill”) are required to facilitate clinical practice (should we treat or not treat?), public health policy (which groups of individuals are at greatest risk and should be the target of our early intervention efforts?), and scientific inquiry (how will we define classes of individuals to study if we want to understand the causes and treatment of a particular syndrome?). Although categories of disorders have important clinical and scientific utility, they must not be understood as being wholly different from the dimensions that typically underlie them. Decisions about where to set cutpoints on the symptom and syndrome level are based on current knowledge and may change as more knowledge is

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obtained. This same is true in other areas of medicine. For example, the American Heart Association introduced a new classification of hypertension based on data showing that death from ischemic heart disease and stroke increased linearly from blood pressure (BP) levels as low as 115 mm Hg systolic and 75 mm Hg diastolic. People now have “prehypertension” if their BP ranges from 120 to 139 mm Hg systolic and/or 80 to 89 mm Hg diastolic (Chobanian et al., 2003). Thus, people who before had been told that they had “normal” blood pressure now met criteria for “prehypertension.” On a very practical level we need systems of classifications so that we can talk to each and have some level of confidence that we are talking about the same thing. The importance of maintaining this congruence has been highlighted by reports of the increased use of psychotropic medications to treat very young children. The number of preschoolage children receiving psychopharmacological treatment increased threefold from 1990 to 1995 and is still growing (Zito, Safer, DosReis, Gardner, Soeken, et al., 2002; see Gleason, Chapter 32, this volume). Physicians prescribing psychoactive medications for preschoolers are, explicitly or implicitly, applying a diagnostic nosology that leads to expectations and then actions about the nature of the problem, the treatment for the problem, and the way that they will know when the problem has been adequately addressed. However, the increase in the rates of prescriptions has not been mirrored by similar advances in measures for diagnosing disorders in young children or development of new treatment studies. In the majority of cases, treatment decisions are derived from studies of adults, adolescents, and older children. Reports of the increased used of psychotropic medication raise many questions: How are these young children being diagnosed? What criteria are being applied? Are the criteria developmentally sensitive? Do they account for age-­appropriate variation during this period of rapid cognitive, social, emotional, and behavioral development? How are the physicians distinguishing between normative individual differences, temperamental variation, and clinically significant behaviors and emotions? How will they measure whether the treatment

has been effective and the medication can be stopped? These are not abstract questions. The answers have enormous implications for treatment, early intervention/prevention efforts, as well as for our understanding of the early emergence of psychopathology. These answers will be found only if we start with a firm foundation of a shared language describing how psychopathology presents in young children.

CATEGORICAL DIAGNOSES IN EARLY CHILDHOOD Three main concerns have been raised about the classification of psychopathology in early childhood. The first concern is that the rapid physical (including neural), behavioral, emotional, and cognitive development that occurs in early childhood makes it impossible to identify valid symptoms or clusters of symptoms that can be reliably measured. Early-onset problems are transient or “risk factors,” not disorders. Individual differences in normal development or temperamental variation will be inappropriately identified as psychiatric symptoms or disorders. The second concern is that diagnosis locates problematic behavior “in the child” rather than in the relationships between the parent and child. The third concern is that children will be inappropriately “labeled” with “diseases” that will adversely shape their self­perceptions and parents’ or other caregivers’ perceptions of them. Another version of this concern is that our assessment of young children should be “strength” based rather than focused on deficits and problems. Each of these concerns arises from important questions about the nature and validity of diagnostic classifications of psychopathology—­questions that are not, for the most part, specific to young children but rather relevant across the life span. These questions include: •• Can we identify valid psychiatric disorders (“syndromes”) in very young children? •• Does identification of psychopathology ignore the child’s strengths, capacities, and potential? •• Do categorical approaches ignore the importance of relationships?



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•• Does a diagnostic approach give short shrift to risk states and therefore undercut the importance of prevention or, at least, early intervention? •• Does giving a name to a child’s distress and impairment lead to stigmatization and/or cause harm? In the rest of this chapter we attempt to address these questions.

Can We Identify Psychiatric Disorders in the Very Young? The objection that the rapid development during infancy and early childhood make it impossible to identify valid symptoms or syndromes that can be reliably measured has been heard before. Similar concerns were raised decades ago when researchers began to define the nosology of psychiatric disorders in older children. In particular, the argument was made that depression diagnosed using adult criteria did not occur in school-age children and adolescents (see Rie, 1966). However, the operationalization of criteria for specific psychiatric disorders and subtypes of disorders and the development of reliable measures of these criteria proved to be the critical first steps in demonstrating the validity of childhood psychiatric disorders (or symptom clusters), including depression. That work has now allowed the field to move on to consideration of the physiological, neural, genetic, and environmental correlates of these disorders, and their responses to treatment. For instance, the DSM criteria for depression were found to identify a valid childhood psychiatric disorder that could be reliably measured using structured psychiatric interviews, was not that uncommon, and was responsive to both medication and cognitive-­behavioral treatment (Costello, Angold, & Egger, 2005). Historically, young children’s emotional and behavioral dysregulation has been approached dimensionally, with cutpoints set to characterize subsets of children at the extreme of the distribution of (1) normative behaviors and emotions and/or (2) temperament traits. In these models, extremes of problems or temperament traits have typically been regarded as precursors of, or risk factors for, later psychopathology, rather than as manifestations of psychiatric disorders similar to those identified at later stages of life. There

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have been two approaches to the diagnostic classifications of early childhood psychopathology: (1) the DSM/ICD nosology, either unmodified or modified (e.g., the Research Diagnostic Criteria—­Preschool Age [Task Force on Research Diagnostic Criteria: Infancy and Preschool, 2003]) to be developmentally appropriate for young children, or (2) the Diagnostic Classification: 0–3, an alternative system for classifying mental health disorders in infant and toddlers (Zero to Three, 1994, 2005). These categorical approaches seek to identify clinically significant syndromes, characterized by severity, pervasiveness, persistence, and impairment, that are themselves early-onset “disorders” rather than simply risk factors for later disorders. Each of these approaches provides a particular window into understanding the phenomena of problematic behavioral and emotional dysregulation in young children. In what follows, we summarize, roughly in order of historical development, what has been learned from these four approaches.

Dimensional Approaches Checklist Measures and Symptom Scales A number of studies, from the 1940s on, have demonstrated that individual symptoms such as aggression, oppositionality, hyperactivity, fears, and social anxiety are common in young children (for a summary of relevant papers see Egger & Angold, 2006). An important contribution of these studies was the description of the distribution of normative and problematic behavior. More recently, studies have used symptom checklist measures, including the Child Behavior Checklist–1½–5 (CBCL; Achenbach & Rescorla, 2000), the Infant–­Toddler Social and Emotional Assessment (ITSEA) for children 12–36 months old (Carter, Briggs-Gowan, Margaret, Jones, & Little, 2003), DSMreferenced rating scales such as the Early Childhood Inventory–4 (ECI-4) (ages 3–6 years old; Sprafkin, Volpe, Gadow, Nolan, & Kelly, 2002), or checklist measures of specific symptom clusters such as the Preschool Anxiety Scale (PAS; Spence, Rapee, McDonald, & Ingram, 2001) to define specific types of disordered behavior in young children. In particular, the ITSEA, which can be used to

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assess children as young as 12 months old, includes scales with content typical of psychopathology research (e.g., “internalizing” and “externalizing” scales), a physical and emotional “dysregulation” scale that clearly has its conceptual roots in the temperament literature, and a scale of the child’s positive capacities. Most of these studies have been conducted with preschoolers. A few studies have included children 12–24 months old, but there is a dearth of studies with infants in the first year of life. Although checklist measures like these do not include enough symptom specificity (e.g., frequency, duration, onset) to enable researchers or clinicians to make the sorts of psychiatric diagnoses with which we are familiar at every other stage of life, they have been informative in a number of ways: (1) They show that relatively stable psychopathological characteristics can be reliably identified in preschoolers; (2) they have estimated the overall prevalence of “problematic” behavior in early childhood at somewhere between 7 and 25% (for a summary of relevant papers, see Egger & Angold, 2006)— rates quite similar to those reported in early questionnaire studies of symptoms in older children (for a review, see Achenbach & Edelbrock, 1978); (3) they have consistently identified distinct emotional (internalizing) and behavioral (externalizing) syndromes (for a summary of relevant papers, see Egger & Angold, 2006); (4) they have provided strong evidence of continuity between toddler and preschool behavioral and emotional problems and psychopathology in late childhood (for a summary of relevant papers, see Egger & Angold, 2006) and even adulthood (Caspi, Moffitt, Newman, & Silva, 1996; Stevenson & Goodman, 2001); (5) they have identified clusters of symptoms that map onto the broad and specific DSM diagnostic categories (Achenbach & Rescorla, 2000) and DSM-referenced syndromes (Spence et al., 2001); and (6) they have been the basis for demonstrations of the heritability of certain behaviors and emotions (van den Oord, Verhulst, & Boomsma, 1996), including differentiated clusters of anxiety symptoms (Eley et al., 2003). These findings refute the notion that emotions and behavior are so plastic in the preschool years that meaningful continuities over time are unlikely to be found.

Preschool Temperaments as Risk Factors For 40 years temperament research has generated findings of great relevance to the investigation of early-onset psychopathology, particularly because the concept of temperament originated in the field of infancy research (Rutter, Birch, Thomas, & Chess, 1964; Thomas & Chess, 1977) and therefore represents a “bottom-up” rather than a “top-down” approach to understanding early childhood emotions and behavior (Buss & Plomin, 1975; Goldsmith et al., 1987; Rothbart & Bates, 1998; Thomas & Chess, 1977). Broad temperament dimensions, particularly negative affectivity (which resembles adult neuroticism) and extreme temperament types, particularly behavioral inhibition and behavioral disinhibition, have been identified as risk factors for the development of psychiatric disorders later in childhood and adulthood and shown to be concurrently associated with problematic behaviors in preschoolers. Like the broad internalizing construct identified with symptom-based scales such as the CBCL, negative affectivity is a global measure of a range of negative emotions, including sadness, fear, anger, and frustration, poor adaptability, and high emotional intensity (e.g., Rothbart, Ahadi, Hersey, & Fisher, 2001). Early childhood negative affectivity has been found to predict later childhood externalizing and internalizing symptoms (e.g., Bates & Bayles, 1988; Caspi & Silva, 1995; Goldsmith & Lemery, 2000; Shaw, Keenan, Vondra, Delliquadri, & Giovannelli, 1997), as well as antisocial behavior in adulthood (Henry, Caspi, Moffitt, & Silva, 1996; Moffitt, Caspi, Dickson, Silva, & Stanton, 1996). Patterns of temperament traits in early childhood have also been linked to increased risk for later psychiatric disorders. The two extreme temperament types of behavioral inhibition (BI) and behavioral disinhibition/ exuberance (BD) have been well characterized in infants and young children (for a review, see Hirshfeld-­B ecker et al., 2003). Distinct patterns of biological arousal and reactivity highlight the differences in emotion regulation underlying these two patterns of temperamental emotionality. BI, identified in about 15% of infants and preschoolers (and young rhesus monkeys), is associ-



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ated with shyness, fear, withdrawal in novel situations, and anxious/fearful distress. BI is heritable, associated with parental anxiety disorders, has physiological accompaniments (sympathetic, cardiovascular, and cortisol hyperreactivity), and is a risk factor for anxiety disorders and depression later in childhood and adulthood (for a review, see Hirshfeld-­Becker et al., 2003). BI’s inverse, BD, is characterized by high approach, high novelty seeking, low harm avoidance, and irritable distress. BD is a putative risk factor for ADHD, disruptive behavior disorders (DBDs), comorbid DBDs and mood disorders, and aggressive behaviors (e.g., Caspi & Silva, 1995; Tremblay, Pihl, Vitaro, & Dobkin, 1994). Although temperamental characteristics have been conceptualized as risk factors for a variety of psychiatric disorders across the lifespan, early-­measured temperamental characteristics could very well also represent the early presence of the disorders themselves. The lack of conceptual clarity about the distinction between temperament and psychopathology is reflected in the number of overlapping items in temperament and psychopathology measures. Such overlap presents a serious methodological and conceptual problem for understanding the relationship between temperament and early-onset psychopathology. For example, 24 items of the 94 item Child Behavior Questionnaire (CBQ; Rothbart et al., 2001), a commonly used temperament scale, are identical to, or direct opposites of, items on the CBCL. As Lahey (2004) has pointed out, naming certain behaviors “temperament traits” and other behaviors (or even the same behaviors) “psychiatric symptoms” is not an act inherently reflective of nature, but rather an act reflective of particular theoretical perspectives. Both perspectives acknowledge the fact that there is a continuum between developmentally normative behaviors and emotions, individual (temperamental) variations, and clinically significant symptoms, with gradations based on patterns of distribution, intensity, frequency, duration, persistence, and impairment. At this point, it seems plausible that some “extremes of temperament” could qualify as psychiatric disorders (e.g., some behaviorally inhibited toddlers may meet criteria for DSM-defined social phobia), but extremity on a tempera-

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ment dimension is neither a necessary nor a sufficient condition for the identification of a psychiatric disorder. Psychiatric disorders include many symptoms that are not present on any temperament assessment, particularly at the severe end of the spectrum (e.g., suicidality, fire setting, compulsions), and so, from a measurement perspective, the temperamental approach does not cover many clinically significant phenomena. Hence, temperament constructs do not provide a conceptual framework for the full range of psychopathology and clinical need. To compare classifications in terms of psychiatric disorders (based either on clinically significant cutpoints on symptom scales or diagnostic classifications) with classifications based on temperament traits and types, studies would need to concurrently measure temperament characteristics and the full range of psychiatric symptoms, disorders, and impairments, and account for measurement overlaps between the two approaches. It would be important to include observational measures of temperament, as well as parent-­report measures, to address the overlap between the two classification systems. Studies taking this approach (with children 2 years and older) are underway and will be very informative about the role of temperament characteristics and types in conceptualizing early childhood psychopathology.

Diagnostic Approaches DSM-IV-TR and ICD-10 DSM-IV-TR (American Psychiatric Association, 2000) and ICD-10 (World Health Organization, 1992) are the dominant psychiatric classification systems used around the world. Because of the similarity between the DSM and ICD systems, as well as the lack of studies of ICD criteria in young children, here we focus on the DSM-IV-TR criteria. The DSM-IV (as well as the preceding DSM versions) was developed without attention to the emotional and behavioral problems of infants, toddlers, or preschoolers. A few DSM disorders include criteria specific to children (e.g., irritability can be the primary mood state for the diagnosis of childhood depressive disorders), require that the disorder have its onset during early childhood (e.g., the onset of some impairing ADHD

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symptoms must occur before the age of 7), or are included in a separate DSM section entitled “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” Nonetheless, none of these designations is specific to very young children (except their exclusion from a diagnosis of enuresis until age 5 or encopresis until age 4). Despite its lack of developmental specificity, the current DSM classifications have been a useful starting point for examining how psychopathology presents in early childhood, at least in children 2 years or older. For example, the DSM-IV diagnostic criteria have worked quite well as a means of advancing our understanding of the presentation and course of autism spectrum disorders (e.g., Rutter, Birch, Thomas, & Chess, 2000; Volkmar, Lord, Bailey, Schultz, & Klin, 2004). The dual approach of testing the applicability of current diagnostic criteria for identifying autism spectrum disorders in young children, while exploring the validity and clinical utility of developmentally specific criteria and/or diagnostic algorithms for use with young children, provides an exemplary roadmap for examining the validity of specific behavioral and emotional disorders in young children. Similar approaches are being taken currently in studies of earlyonset ADHD, anxiety disorders, depression, posttraumatic stress disorder (PTSD), and DBDs in young children, although the focus has been on children 2 years or older (for a review, see Egger & Angold, 2006). For example, our group (Sterba, Egger, & Angold, 2007), using parent-­interview data and confirmatory factor analyses, found that the symptoms of a number of the commonest disorders of preschoolers aggregated together in a manner very similar to that prescribed by the DSM-IV diagnostic criteria. Where the symptom content of the extracted factors differed from the DSM-IV criterion sets (depression and generalized anxiety loaded on a single factor, as did conduct disorder and oppositional defiant disorder symptoms, whereas ADHD symptoms yielded two factors), they differed in the same ways as have previously been described in older children and adolescents (Lahey et al., 2004). These data, along with a recent report from the same study showing that the overall community prevalence of DSM-IV disorders in preschoolers is around 10–15% (Egger et

al., 2006), strongly suggest that the overall structure of the common forms of child and adolescent psychopathology is already in place by the preschool years. In 2002 infant and preschool mental health researchers, sponsored by the American Academy of Child and Adolescent Psychiatry, proposed modifications of DSM diagnostic criteria for use with preschool children. Because of the paucity of empirical data on infants, the group explicitly chose to focus on children 2 years and older. These modifications were published in 2003 as the Research Diagnostic Criteria—­Preschool Age (RDC-PA; Task Force on Research Diagnostic Criteria: Infancy and Preschool, 2003; the RDC-PA is available at www.infantinstitute.org). The purpose of the RDCPA was to define clearly specified, developmentally appropriate criteria for preschool psychopathology so as to facilitate further research on the diagnostic validity of psychiatric disorders in preschoolers. This approach was patterned on the development of the research diagnostic criteria published in 1978 (Spitzer, Endicott, & Robins, 1978), which led to the operationalized diagnostic criteria in the DSM-III and research on the reliability and validity of the psychiatric nosology for adults and then for older children and adolescents. The RDC-PA started with the DSM system and modified the criteria to make them developmentally appropriate, rather than proposing a wholly new classification system. However, we believe that this top-down approach reaches its limits in children under the age of about 2 years, because the linguistic and behavioral repertoires available to children at this age are simply too different from those addressed by DSM-IV for the current diagnostic criteria to be of much use.

Diagnostic Classification: 0–3 (DC:0–3 and DC:0–3R) The Diagnostic Classification: 0–3 (DC:0– 3; Zero to Three, 1994) takes a different approach than the RDC-PA, with a primary goal of classifying disorders in infants and toddlers that are not covered in the DSM (Emde, 2003). Dissatisfaction with the DSM diagnostic system for identifying mental health and developmental disorders in chil-



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dren from birth to 3 years old led to the development of the DC:0–3 classification system in 1994 (Zero to Three, 1994). Despite its title, the DC:0–3 has commonly been used with children from birth through age 5 years old. A task force was convened in 1987 by Zero to Three—the National Center for Infants, Toddlers, and Families—an organization that represents interdisciplinary leadership in the field of infant development and mental health. Task force members included clinicians and researchers from clinical centers in the United States, Canada, and Europe. Accumulated knowledge from case discussions led to the designation of recurring patterns of behavioral problems. An initial set of diagnostic categories was identified through consensus among the members. Out of this process emerged alternative versions of DSM-IV diagnoses (e.g., for anxiety and depressive disorders), new diagnostic categories (e.g., regulatory disorders and parent– child relationship disorders), and a revised multiaxial system that places relationship characteristics and disorders on Axis II and the child’s “functional emotional developmental level” on Axis V (Zero to Three, 1994). The addition of a separate axis to define the quality of the parent–child relationship and identify disturbances in this relationship (as well as other relationships with a major impact on the young child’s physical and emotional well-being) is one of the most valuable contributions of the DC:0–3. A lack of operationalized criteria (e.g., clearly defined symptoms, symptom cutpoints, or duration criteria) as well as a lack of boundaries between many of the disorders (e.g., regulatory disorders and many of the other disorders) have limited research on DC:0–3 disorders, although a start has been made (e.g., Boris, Zeanah, Larrieu, Scheeringa, & Heller, 1998; Cordeiro, Caldeira da Silva, & Goldschmidt, 2003; Guedeney et al., 2003; Keren, Feldman, & Tyano, 2003; Reams, 1999; Scheeringa, Zeanah, Drell, & Larrieu, 1995; Stafford, Zeanah, & Scheeringa, 2003; Thomas & Clark, 1998). Despite this lack of adequate validation, DC:0–3 has been widely used in service settings, reflecting the clinical need for a developmentally appropriate approach to classifying clinically significant behaviors in young children. Recognizing that greater specificity in the diagnostic criteria was needed and that new

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knowledge needed to be incorporated into the DC:0–3, Zero to Three convened a work group tasked with revising DC:0–3 (DC:0– 3R; Zero to Three, 2005) and its work was published in August 2005. Inputs to the work included (1) an initial survey of users of DC:0–3; (2) a detailed review of the literature and of RDC-PA; (3) a second survey of users to comment on a preliminary draft of a revision; (4) further comments from individuals and identified clinical groups working in areas where particular uncertainty or differences of perspective were found; and (5) a final set of critical reviews of a penultimate revision document by a panel of expert infant mental health clinicians. A key goal of the DC:0–3R was to better operationalize the diagnostic criteria and categories so as to improve their measurement and reliability, and to facilitate research into their validity. Changes in the revised version of DC:0–3 included specification of intensity, frequency, duration, and onset of symptoms; specification of the number of symptoms needed for diagnosis; and inclusion of types and subtypes of disorders. These changes were based on empirical studies (where available) or the consensus of infant mental health researchers and clinicians who used the original DC:0–3. Many of the RDC-PA modifications were incorporated into the DC:0–3R (e.g., in PTSD, sleep disorders, feeding disorders, and many features of depression and anxiety disorders relevant for the early years). Of course, the focus of the RDC-PA on children 2 years or older meant that many of these modifications had to be adjusted to make them useful for understanding symptomatology in infants. Unfortunately, the lack of empirical research in infants means that the DC:0–3R criteria for babies are not as specific as those for toddlers and preschoolers and will need more attention in future versions of this system of classification. DC:0–3R includes a category of disorders, called “regulation disorders of sensory processing,” which are not found in the DSM/ICD systems. These disorders are defined as “difficulties in regulating emotions and behaviors as well as motor abilities in response to sensory stimulation that lead to impairment in development and functioning” (Zero to Three, 2005, p.  28). In the original DC:0–3 this category was labeled

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“regulatory disorders” and, according to the surveys of users, was widely used (Zero to Three, 2005). Based on feedback from occupational therapists who commonly identify sensory and motor regulation problems in young children, as well as from other users, the criteria for this class of disorders was revised so that each subtype includes a characteristic pattern of sensory processing difficulties, motor difficulties, and specific behaviors, as well as impairment in development and functioning. The validity of these disorders remains unclear, however, because the evidence base relating to them is almost entirely clinical-­descriptive (Miller, Robinson, & Moulton, 2004), and it is not known whether the subtypes described in the DC:0– 3R can be discriminated from anxiety disorders, DBDs/ADHD, and depression. The lack of consensus among experts and the paucity of empirical data led the task force members to conclude that there was insufficient evidence to support the inclusion of detailed symptom criteria for each of the subtypes (or the number of criteria needed for a given diagnostic classification). Instead, descriptive information was provided with the hope that future research will lead to better diagnostic criteria. DC:0–3R was intended to supplement, not replace, the DSM/ICD nosologies. The DC:0–3R explicitly provides a place on Axis 1 for coding DSM/ICD diagnoses. In particular, since the empirical support for the DSM-IV criteria for the pervasive developmental disorders has become much stronger since the publication of the first edition of DC:0–3, the DC:0–3R states under the category of “disorders of relating and communicating” that when a child meets the DSM-IV-TR criteria for any of the pervasive developmental disorders (including pervasive developmental disorder, not otherwise specified [PDD-NOS]) the clinician should record this disorder on Axis I, referencing both a DC:0–3R 800 code and the appropriate DSM code. Similarly, attention-­deficit disorder (ADD) and the DBDs, including oppositional defiant disorder, are categories that are not addressed in the DC:0–3 system, and the revised version states that these disorders should be considered and coded on DC:0–3R Axis I. Another important revision in DC:0–3R was inclusion of an explicit statement that

infants and young children may meet criteria for more than one disorder. Although the original DC:0–3 did not “forbid” identification of comorbidity, its description of the diagnostic assessment process and guidelines for prioritizing diagnoses for the purposes of treatment planning were interpreted by many users to mean that only one DC:0–3 diagnosis should be made. Because psychiatric disorders, within the boundaries of our current classification systems, are commonly comorbid at every stage of life (from preschool age through late adult life) and because the presence of comorbidity is often an important indicator of illness severity and impairment (Angold et al., 1999; Egger & Angold, 2006), this clarification was essential for allowing the DC:0–3R to appropriately reflect the realities of psychopathology. Modifications in the other four axes of DC:0–3R focused on clarification and improved utility. For example, in Axis II (the relationship classification), the Parent–­ Infant Relationship Global Assessment of Functioning (PIR-GAS) scale was revised to include more detailed gradations. A relationship problems checklist was substituted for the types of parent–­infant relationship disorders specified in the original DC:0–3 since it was determined that there was insufficient evidence to support these relationship patterns as discrete disorders. Axis IV remained the place to record psychosocial and environmental stressors, but a checklist of known stressors, along with a place to indicate the age of onset, duration, severity, and context of these stressors, was included as a guide to the assessment of this domain. Lastly, Axis V, which summarizes the child’s developmentally appropriate capacities for emotional and social functioning, was revised to clarify the scope of the domain. An unresolved issue is where impairment, both in the child’s development and functioning and in the family’s functioning, resulting from the child’s symptoms should be recorded in the DC:0–3R classification. In the DSM system, degree of impairment is recorded on Axis V as a score on the Global Assessment of Functioning (GAF score; American Psychiatric Association, 2000). However, there is no such axis in DC:0–3, since Axis V now summarizes the child’s capacities for emotional and social function-



17. Classification in Early Childhood

ing. Impairment or disability resulting from a disorder is not simply the absence of a “capacity,” as characterized in DC:0–3. The next stage of infant/preschool mental health research should bring the conceptualization and measurement of psychiatric impairment in infants, toddlers, and preschoolers to front and center. The development of a framework for early childhood impairment should focus not only on impairment in the child’s functioning and relationships but also on impairment in the functioning of the family (e.g., a parent’s inability to work outside of the home because the child has been expelled from child care). While it could be argued that identifying impairment in the family, not simply the individual, could be clinically valuable at all ages, it is vital in early childhood because young children’s functioning is inextricably entwined within the structure and function of the family. Parents may never leave their child with a babysitter because of the child’s severe separation anxiety. This absence of parental respite may not be directly impairing to the child but could have significant negative effects on the parents (as parents and as partners) and thus may indirectly impact the child. A developmentally sensitive conceptualization of impairment is necessary for defining clinical significance and therefore for identifying those children who should receive treatment or early intervention. It is also important to provide a clinically relevant way to assess the effectiveness of our treatments in actually improving a child’s and a family’s life.

WHICH SYSTEM OF CLASSIFICATION SHOULD WE USE? We should hope and strive for a developmentally sensitive classification of psychopathology in early childhood that is integrated with the systems of classification for older children and adults. Work has begun on the DSM-V, and there is some hope that the next version of the DSM might be more developmentally relevant and reflective of current knowledge about the presentation of psychopathology in young children. Future psychiatric nosologies should reflect the fact that development is not simply a phenomenon of age or stage but rather a characteristic of

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various patterns of disorders as they manifest over developmental time. A truly developmental classification of psychopathology in early childhood will emerge from an understanding of these different developmental trajectories and mechanisms, not only in relationship to manifest emotional and behavioral symptoms and impairment but also in the context of neurobiological, genetic, and environmental correlates. At this point, we know that our current classifications are imperfect and will be revised and even supplanted as our knowledge grows. For now, though, we have fairly convincing evidence that the different approaches to classification reviewed here all contribute to identifying psychopathology in early childhood. At least for children 12 months through 5 years, we have reliable tools that allow us to address questions about the development of psychopathology in this population. The availability of these tools is facilitating research focusing on development of psychopathology in younger children. Few tools for assessing symptoms in infancy exist. This lacuna reflects the lack of consensus about how to characterize psychopathology in babies. We know at a very general level that some “negative” temperamental characteristics are associated with later elevated scores on measures of general psychopathology, but, except perhaps in the area of inhibited temperament and its relationships with later anxiety (e.g., Guyer et al., 2006; Perez-­Edgar et al., 2007), we know very little about the pathways by which these continuities are established and maintained. Measures for classifying and assessing emotional distress and behavioral dysregulation, beyond the temperament construct of negative affectivity, are urgently needed for the assessment of psychopathology in infants during the first year of life. If we are to fill in these gaps, we will need follow-ups of infants that use much more refined measures of the specifics of symptomatology as they emerge. Most likely, infancy syndromes will be defined by patterns of dysregulation in crying, sleeping, eating, motor activity, sensory sensitivity, and disturbances in social relatedness. We need measures that will enable us to describe the full range of variation in these areas (e.g., not simply presence but intensity, frequency, duration, onset, and environmental and relational context of the symptoms)

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and empirically determine the boundaries between normative and clinically significant presentations, just as we have done with psychiatric symptomatology in preschoolers. Classifications such as Guedeney and Fermanian’s (2001) Infant Alarm Distress Scale, which assesses social withdrawal in infants, or Wolke’s (2009) classification of regulatory disturbances in crying, sleeping, and feeding in infancy point to the importance of recognizing the limitations of the current diagnostic criteria for characterizing very-early-onset psychopathology and testing new criteria. We should have every confidence that it is possible to do this work, just as we have done with preschoolers (and older children).

Does Identification of Psychopathology Ignore Other Important Parts of the Child? The concern that classification systems for early childhood psychopathology, particularly those that take a diagnostic approach, will ignore the importance of the child’s relationships or reduce the child’s problems to a checklist, arises, in part, from the misconception that nosology and assessment are the same thing. The purpose of a clear nosology and diagnostic manual is to facilitate diagnostic assessment and formulation. Both the DSM/ICD and DC:0–3 systems are multiaxial approaches arising from a biopsychosocial framework that seeks to understand the child’s symptoms within a wider context. As noted above, the DC:0–3 emphasizes the centrality of the parent–child relationship in the diagnostic framework, reflecting the infant mental health tenet that understanding the child’s symptoms within the context of his or her relationship with the primary caregiver is essential for a valid diagnostic formulation. A multiaxial formulation using either the DSM/ICD or DC:0–3 system is not synonymous with a comprehensive mental health assessment of a young child and his or her family. Other important information will need to be gathered, recorded, and integrated with the diagnostic assessment and formulation to inform treatment. Moreover, a good clinician will consider both a categorical and dimensional approach to symptomatology and impairment, understanding that children who are impaired but miss diagnostic criteria by one or two symptoms

may need treatment as much as those children who meet full criteria. And, of course, early intervention programs will want to identify children “at risk” so as to help those who are not yet impaired. Many of the other chapters in this Handbook, as well as Carter and colleagues’ 2004 review of assessment measures for young children (Carter et al., 2004) and DelCarmen-­Wiggins and Carter’s (2004) book on the mental health assessment of infants and toddlers, provide indepth reviews of approaches, methods, and measures for assessing psychopathology in early childhood. All three of these sources include discussions of the reliability of different measures; unresolved assessment issues, including methods for combining information from multiple informants; methods for making diagnoses in young children; methods for assessing young children’s internal distress; and approaches to the assessment of impairment. The presence of a psychiatric disorder and/or impairment due to psychiatric symptoms or disorders does not imply that the child lacks strengths, nor does it imply that the primary care relationship is not central to understanding and treating the child and the family. This point is raised as a caution against the misconception that a “strengthbased approach” to infant mental health assessment is in opposition to a “deficit-based approach” represented by the diagnostic classification of early-onset mental health problems (Perez, Newman, Bruton, & ­Peifer, 2004). Mental health evaluations—of infants, of toddlers, as well as of teenagers— are conducted in order to identify children’s suffering and impairment. Young children experience clinically significant emotional, behavioral, and developmental problems. Identifying these symptoms and disorders and the impairments they cause names the child’s suffering and the impact of this suffering on the child’s life and the life of the family. Of course, this naming is only one part of understanding the child as a whole person, with varied capacities, strengths, and potentials, and understanding the child’s relationships. On the other hand, naming strengths rather than disorders only confuses the picture and truncates a full diagnostic assessment. Certainly, targeting aspects of the parent–child relationship or bolstering the child’s strengths may be a sensible and



17. Classification in Early Childhood

effective intervention to decrease the child’s and the family’s suffering and reduce impairment. But this represents a choice about treatment, not about diagnosis.

Classifying Disorders, Not People A psychiatric nosology classifies disorders, not individuals. As we have emphasized throughout this chapter, a shared language is essential for clinical practice and scientific research. We classify disorders (syndromes, patterns of symptomatology) so that we can organize our observations and findings, define the targets for our treatment, and track whether our treatment is working. The concern that we should not “label” a young child with a psychiatric diagnosis because it will stigmatize the child reflects two difficult truths: (1) There is real stigma against those with mental illness across the age span, and (2) we currently face real limitations in our ability to treat early-onset mental health problems. The history of medicine is filled with examples of how knowledge about a disease and effective treatments for the disease reduce the stigma against people with that disease and reduce the fear of naming the problem. The popular Race for the Cure and pink-­ribboned products to support breast cancer survivors and breast cancer research would have been unimaginable when Betty Ford disclosed her battle with breast cancer in 1974 and challenged the taboo against speaking in public about cancer. The courage of those who fought the stigma by naming their disease, as well as advances in breast cancer treatment, changed “breast cancer” from a shameful label to a named foe. Similar transformation has occurred, at least in the developed world, in the diagnosis of AIDS. The problem is that withholding the name of a psychiatric disorder (“not labeling”) does not make the child’s suffering or impairment go away. In fact, in some cases, not naming the disorder can cause harm. For example, toddlers who meet full criteria for ADHD are already highly impaired across multiple relationships (parents, child care providers, siblings, peers) and in their functioning. Nearly half have already been suspended from day care or preschool (Egger & Angold, 2006). Not naming the problem and thereby failing to clarify that the child is not “bad” but

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rather has a disorder can cause further harm. Not making an appropriate diagnosis when there is effective treatment for the disorder is unethical. Consider how odd it would seem for a person to argue that a nonpsychiatric medical disorder, such as pneumonia or Type 1 diabetes, should not be diagnosed (named) because it would label the child and thus cause harm. Of course, there may be good reasons not to tell the child or others (e.g., teachers) that a child has a disorder. This could be true for a psychiatric disorder such as ADHD or for a nonpsychiatric medical disorder, but that is not an argument against the development and use of a classification of psychopathology in young children. The most important way to fight stigma and the resistance to classification is (1) by creating the evidence base for the validity of the classifications of psychopathology from infancy through the preschool period, and (2) by developing evidence-based treatments and preventive interventions that work. Our current classifications of psychopathology, for adults as well as children, are based on clinical observations about clusters of specific behaviors and emotional states. Translational research in cognitive and affective neuroscience, genetics, and epidemiology has the potential to reshape our understanding of the neurobiological mechanisms of mental disorders. As we understand more about the relationship between multiple biological systems and behavior, we should be able to define biologically and clinically meaningful nosologies of mental disorders that enable us find better way to identify and alleviate young children’s suffering. Until then, we have “good-­enough” classifications and measurement tools to push the infant mental health field forward and to care for young children with impairing emotional and behavioral problems. References Achenbach, T. M., & Edelbrock, C. S. (1978). The classification of child psychopathology: A review and analysis of empirical efforts. Psychological Review, 85(6), 1275–1301. Achenbach, T. M., & Rescorla, L. A. (2000). Manual for the ASEBA Preschool Forms and Profiles: An integrated system of multi-­informant assessment. Burlington, VT: University of Vermont Department of Psychiatry.

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Angold, A., Costello, E. J., & Erkanli, A. (1999). Comorbidity. Journal of Child Psychology and Psychiatry, 40, 57–87. Angold, A., & Egger, H. L. (2004). Psychiatric diagnosis in preschool children. In R. DelCarmen­Wiggins & A. Carter (Eds.), Handbook of infant, toddler, and preschool mental health assessment (pp.  123–139). New York: Oxford University Press. Bates, J., & Bayles, K. (1988). Attachment and the development of behavior problems. In J. Belsky & T. Nezworski (Eds.), Clinical implications of attachment. Hillsdale, NJ: Erlbaum. Boris, N. W., Zeanah, C. H., Jr., Larrieu, J. A., Scheeringa, M. S., & Heller, S. S. (1998). Attachment disorders in infancy and early childhood: A preliminary investigation of diagnostic criteria. American Journal of Psychiatry, 155, 295–297. Burke, M. G. (2003). Depression in preschool children. Journal of the American Academy Child and Adolescent Psychiatry, 42, 263–264. Buss, A. H., & Plomin, R. (1975). A temperament theory of personality development. New York: Wiley. Carter, A. S., Briggs-Gowan, M. J., & Davis, N. O. (2004). Assessment of young children’s social–­ emotional development and psychopathology: Recent advances and recommendations for practice. Journal of Child Psychology and Psychiatry, 45, 109–134. Carter, A. S., Briggs-Gowan, M. J., Jones, S. M., & Little, T. D. (2003). The Infant–­Toddler Social and Emotional Assessment (ITSEA): Factor structure, reliability, and validity. Journal of Abnormal Child Psychology, 31(5), 495–514. Caspi, A., Moffitt, T. E., Newman, D. L., & Silva, P. A. (1996). Behavioral observations at age 3 years predict adult psychiatric disorders: Longitudinal evidence from a birth cohort. Archives of General Psychiatry, 53(11), 1033–1039. Caspi, A., & Silva, P. A. (1995). Temperamental qualities at age 3 predict personality traits in young adulthood: Longitudinal evidence from a birth cohort. Child Development, 66, 486–498. Chatoor, I., Pine, D. S., & Narrow, W. E. (2007). Diagnosis of psychopathology in infants, toddlers, and preschool children. In W. E. Narrow, M. B. First, P. J. Sirovatka, & D. A. Regier (Eds.), Age and gender considerations in psychiatric diagnosis: A research agenda for DSM-V (pp. 145150). Washington, DC: American Psychiatric Association. Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L., Jr., et al. (2003). Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension, 42(6), 1206–1252. Cordeiro, M., Caldeira da Silva, P., & Goldschmidt, T. (2003). Diagnostic classification: Results from

a clinical experience of three years with DC:0–3. Infant Mental Health Journal, 24, 349–364. Costello, E. J., Angold, A., & Egger, H. L. (2005, May). Epidemiology of child and adolescent depression. Paper presented at the workshop on preventing depression in children and adolescents, Bethesda, MD. DelCarmen-­Wiggins, R., & Carter, A. (Eds.). (2004). Handbook of infant, toddler, and preschool mental health assessment. New York: Oxford University Press. Egger, H. L., & Angold, A. (2006). Common emotional and behavioral disorders in preschool children: Presentation, nosology, and epidemiology. Journal of Child Psychiatry and Psychology, 47(3/4), 313–337. Egger, H. L., Erkanli, A., Keeler, G., Potts, E., Walter, B., & Angold, A. (2006). The test–­retest reliability of the Preschool Age Psychiatric Assessment (PAPA). Journal of the American Academy of Child and Adolescent Psychiatry, 45(5), 538–549. Eley, T. C., Bolton, D., O’Connor, T. G., Perrin, S., Smith, P., & Plomin, R. (2003). A twin study of anxiety-­related behaviors in pre-­school children. Journal of Child Psychology and Psychiatry, 44, 945–960. Emde, R. N. (2003). RDC-PA: A major step forward and some issues. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1513–1516. Emde, R. N., Bingham, R. D., & Harmon, R. J. (1993). Classification and the diagnostic process in infancy. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp.  225–235). New York: Guilford Press. Goldsmith, H., & Lemery, K. (2000). Linking temperamental fearfulness and anxiety symptoms: A behavior-­genetic perspective. Biological Psychiatry, 48, 1199–1209. Goldsmith, H. H., Buss, A. H., Plomin, R., Rothbart, M. K., Thomas, A., Chess, S., et al. (1987). Roundtable: What is temperament? Four approaches. Child Development, 58, 505–529. Guedeney, A., & Fermanian, J. (2001). A validity and reliability study of assessment and screening for sustained withdrawal reaction in infancy: The Infant Alarm Distress Scale. Infant Mental Health Journal, 22(5), 559–575. Guedeney, N., Guedeney, A., Rabouam, C., Mintz, A.-S., Danon, G., Huet, M., et al. (2003). The Zero-to-Three diagnostic classification: A contribution to the validation of this classification from a sample of 85 under-­threes. Infant Mental Health Journal, 24, 313–336. Guyer, A. E., Nelson, E. E., Perez-Edgar, K., Hardin, M. G., Roberson-Nay, R., Monk, C. S., et al. (2006). Striatal functional alteration in adolescents characterized by early childhood behavioral inhibition. Journal of Neuroscience, 26(24), 6399–6405. Henry, B., Caspi, A., Moffitt, T. E., & Silva, P. A. (1996). Temperamental and familial predictors



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of violent and non-­violent criminal convictions: From age 3 to age 18. Developmental Psychology, 32(4), 614–623. Hirshfeld-­B ecker, D. R., Biederman, J., Calltharp, S., Rosenbaum, E. D., Faraone, S. V., & Rosenbaum, J. F. (2003). Behavioral inhibition and disinhibition as hypothesized precursors to psychopathology: Implications for pediatric bipolar disorder. Society of Biological Psychiatry, 53, 985–999. Keren, M., Feldman, R., & Tyano, S. (2003). A fiveyear Israeli experience with the DC: 0–3 classification system. Infant Mental Health Journal, 24, 337–348. Lahey, B. B. (2004). Commentary: Role of temperament in developmental models of psychopathology. Journal of Clinical Child and Adolescent Psychology, 33, 88–93. Lahey, B. B., Applegate, B., Waldman, I. D., Loft, J. D., Hankin, B. L., & Rick, J. (2004). The structure of child and adolescent psychopathology: Generating new hypotheses. Journal of Abnormal Psychology, 113(3), 358–385. McClellan, J., & Speltz, M. (2003). Psychiatric diagnosis in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 127–128. Miller, L. J., Robinson, J., & Moulton, D. (2004). Sensory modulation dysfunction: Identification in early childhood. In R. DelCarmen-­Wiggins & A. Carter (Eds.), Handbook of infant, toddler, and preschool mental health assessment (pp.  247–270). New York: Oxford University Press. Moffitt, T. E., Caspi, A., Dickson, N., Silva, P., & Stanton, W. (1996). Childhood-onset versus adolescent-onset antisocial conduct problems in males: Natural history from ages 3 to 18 years. Development and Psychopathology, 8, 399– 424. Perez, L. M., Newman, M. C., Bruton, N., & Peifer, K. (2004). A strength-based and early relationship approach to infant mental health assessment. Community Mental Health Journal, 38(5), 375–390. Perez-Edgar, K., Roberson-Nay, R., Hardin, M. G., Poeth, K., Guyer, A. E., Nelson, E. E., et al. (2007). Attention alters neural responses to evocative faces in behaviorally inhibited adolescents. Neuroimage, 35(4), 1538–1546. Pickles, A., & Angold, A. (2003). Natural categories or fundamental dimensions: On carving nature at the joints and the rearticulation of psychopathology. Development and Psychopathology, 15, 529–551. Reams, R. (1999). Children birth to three entering the state’s custody. Infant Mental Health Journal, 20, 166–174. Rie, H. E. (1966). Depression in childhood: A survey of some pertinent contributions. Journal of the American Academy of Child and Adolescent Psychiatry, 5, 653–685. Robins, E., & Guze, S. B. (1970). Establishment of

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diagnostic validity in psychiatric illness: Its application to schizophrenia. American Journal of Psychiatry, 126, 107–111. Rothbart, M., Ahadi, S., Hersey, K., & Fisher, P. (2001). Investigations of temperament at three to seven years: The Children’s Behavior Questionnaire. Child Development, 72(5), 1394–1408. Rothbart, M., & Bates, J. (1998). Temperament. In W. Damon & N. Eisenberg (Eds.), Handbook of child psychology: Vol. 3. Social, emotional, and personality development (5 ed., pp.  105–176). New York: Wiley. Rutter, M. (2000). Genetic studies of autism: From the 1970s to the Millennium. Journal of Abnormal Child Psychology, 28, 3–14. Rutter, M., Birch, H. G., Thomas, A., & Chess, S. (1964). Temperamental characteristics in infancy and the later development of behavioural disorders. The British Journal of Psychiatry, 110, 651–661. Scheeringa, M. S., Zeanah, C. H., Jr., Drell, M. J., & Larrieu, J. A. (1995). Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 191–200. Shaw, D. S., Keenan, K., Vondra, J. L., Delliquadri, E., & Giovannelli, J. (1997). Antecedents of preschool children’s internalizing problems: A longitudinal study of low-­income families. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1760–1767. Spence, S. H., Rapee, R., McDonald, C., & Ingram, M. (2001). The structure of anxiety symptoms among preschoolers. Behavior Research and Therapy, 39, 1293–1316. Spitzer, R. L., Endicott, J., & Robins, E. (1978). Research diagnostic criteria: Rationale and reliability. Archives of General Psychiatry, 35, 773–782. Sprafkin, J., Volpe, R., Gadow, K., Nolan, E., & Kelly, K. (2002). A DSM-IV-referenced screening instrument for preschool children: The Early Childhood Inventory–4. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 604–612. Stafford, B., Zeanah, C. H., Jr., & Scheeringa, M. (2003). Exploring psychopathology in early childhood: PTSD and attachment disorders in DC:0–3 and DSM-IV. Infant Mental Health Journal, 24, 983–409. Sterba, S., Egger, H. L., & Angold, A. (2007). Diagnostic specificity and nonspecificity in the dimensions of preschool psychopathology. Journal of Child Psychology and Psychiatry, 48(10), 1005–1013. Stevenson, J., & Goodman, R. (2001). Association between behaviour at age 3 years and adult criminality. British Journal of Psychiatry, 179, 197–202. Task Force on Research Diagnostic Criteria: Infancy and Preschool. (2003). Research diagnostic criteria for infants and preschool children:

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The process and empirical support. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1504–1512. Thomas, A., & Chess, S. (1977). Temperament and development. New York: Bruner/Mazel. Thomas, J. M., & Clark, R. (1998). Disruptive behavior in the very young child: Diagnostic classification: 0–3 guides identification of risk factors and relational interventions. Infant Mental Health Journal, 19, 229–244. Tremblay, R., Pihl, R., Vitaro, F., & Dobkin, P. (1994). Predicting early onset of male antisocial behavior from preschool behavior. Archives of General Psychiatry, 51, 732–739. van den Oord, E. J. C. G., Verhulst, F. C., & Boomsma, D. I. (1996). A genetic study of maternal and paternal ratings of problem behaviors in 3-year-old twins. Journal of Abnormal Psychology, 105, 349–357. Volkmar, F. R., Lord, C., Bailey, A., Schultz, R. T., & Klin, A. (2004). Autism and pervasive developmental disorders. Journal of Child Psychiatry and Psychology, 45(1), 135–170.

Wolke, D. (2007). [Classification of regulatory ­disturbance in infancy.] ‘Regulationsstor­ ungen’  in Lehrbuch der Verhaltenstherapie; Band 3. Sturungen im Kindesund Jugendalter, 295–312. World Health Organization. (1992). ICD-10: The ICD-10 classification of mental and behavioral disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: Author. Zero to Three. (1994). Diagnostic classification: 0–3: Diagnostic classification of mental health and developmental disorders of infancy and early childhood. Arlington, VA: National Center for Clinical Infant Programs. Zero to Three. (2005). Diagnostic classification: 0–3R: Diagnostic classification of mental health and developmental disorders of infancy and early childhood: Revised edition. Washington, DC: Zero to Three Press. Zito, J. M., Safer, D. J., DosReis, J. F., Gardner, K., Soeken, M., et al. (2002). Rising prevalence of antidepressants among U.S. youths. Pediatrics, 109(5), 721–727.

C h a p t e r 18

Autism Spectrum Disorders Themba Carr Catherine Lord

I

t has long been recognized that signs of autism emerge during infancy and the very early preschool years. The early development of autism was one of the first sources of evidence of the distinction between autism and psychoses and led to the term “infantile autism” in DSM-III (American Psychiatric Association, 1980). For many years, parents have described the onset of symptoms of autism occurring early in the second year of life (Di Giacomo & Fombonne, 1998), often, but not always, following earlier nonspecific features such as eating or sleeping difficulties, sensitivities to the environment, or even being an exceptionally “good” baby (Dahlgren & Gillberg, 1989). With increased public awareness and the broadening conceptualizations of autism to a spectrum of disorders (i.e., autism spectrum disorders [ASDs]), the general category of ASDs now includes more children with milder social impairments, accompanied by varying degrees of delays in first words or use of phrases and intellectual disability. In some of these cases, the age of first concern or identification is pushed back into later preschool. However, the belief is that most of these children are different from other children in some way from very early on (Chawarska, Klin, & Volkmar, 2003; Zwaigenbaum et al., 2005). Early



identification is seen as critically important both for intervention and for understanding the path from etiologies to brain formation and the behaviors associated with autism in later years. With the prevalence of ASDs estimated at 1 out of 150 children (Centers for Disease Control and Prevention, 2007), mental health professionals whose focus is early childhood will assume more and more of a role in assessing and following children with ASD referred at increasingly young ages. Concerns about using criteria and diagnostic categories intended for older children with children 3 years or younger are reasonable (Greenspan & Wieder, 1997). Nevertheless, as described below, there has been a wealth of research on infants at risk for autism, and there is a growing body of evidence identifying developmental trajectories, beginning in infancy and the toddler years, of children with behaviors that presage ASDs. Out of this research has come empirical data indicating stability and variability, resulting in both enthusiasm about early diagnosis (Bryson, Zwaigenbaum, McDermott, Rombough, & Brian, 2008; Landa, Holman, & Garrett-Mayer, 2007) and calls for caution (Charman & Baird, 2002). We now have some clear directions for clinical observa301

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tion and standard measures that can help us inform parents about possible diagnoses. The goal of this effort is for families and clinicians to work together to make decisions about appropriate treatments and approaches that take into account each child’s strengths and difficulties. Thus, this is a time of optimism; our understanding of ASD in infants and toddlers is increasing rapidly, and we are seeing real changes in practice.

GENERAL ISSUES IN AUTISM RESEARCH There is now a broader conceptualization of ASDs that includes autism, Asperger syndrome, and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). However, distinctions among these different diagnostic categories, particularly in young children, are relatively arbitrary and are often related to clinician preference as much as child characteristics (Ozonoff, South, & Miller, 2000). For the most part, the terms autism and ASD are used interchangeably in this chapter. There is much greater awareness that development, on many levels, must always be considered in the diagnosis and treatment of young children with ASD. Factors beginning with chronological age and including communication level, nonverbal cognitive problem solving, motor skills, family perspectives, and social environments, play important roles both in accurately identifying and planning appropriate services, especially for very young children. Finally, we do not know whether numerous genes contribute to different basic deficits that result directly in ASD or that interact with each other, with epigenetics, or with other neurodevelopmental factors to produce neurobiological risks for ASDs. However, it is well established that the risk for recurrence of ASD in subsequent siblings of children with ASD is increased, as is the risk for other, nonspecific difficulties, such as language delay (Landa & Garrett-Mayer, 2006; Zwaigenbaum et al., 2005). Though there are tests for some genetic disorders with increased risk for ASD, these disorders account for relatively small numbers of children with ASD. Interesting patterns of head growth, reflecting changes in brain volume in infants and toddlers, have emerged (Courchesne, Carper,

& Akshoomoff, 2003), and structural and functional differences have been found in the brains of older children, but not yet with sufficient consistency to be applicable to individual diagnoses. Three methodologies, each with strengths and weaknesses, have provided information about autism in infancy. Retrospective interviews or questionnaires given to parents (Dahlgren & Gillberg, 1989; Luyster et al., 2005; Stone, Hoffman, Lewis, & Ousley, 1994) are restricted by the limits of memory and parents’ observations, but they offer the broadest source of information about the greatest number of children. Home videotapes made in infancy and then scored for children who were later diagnosed with autism (Adrien et al., 1991; Baranek, 1999; Osterling & Dawson, 1994) provided important insights into early differences in children, long before diagnoses were made. They allowed researchers to note behaviors that parents may not have recognized, but are limited by their reliance on impromptu data collection. In the last 10 years the study of infant siblings of older children with ASD diagnoses has been the most common strategy to yield information about earlier onset of symptoms. These children are at increased risk for autism, with perhaps 1 in 10 having ASD and more having related developmental problems. This method allows recruiting children with autism from birth, but it is expensive and time consuming because most infant siblings do not have ASD. In addition, cohort effects have emerged in research using all of these strategies, such that children diagnosed 15 years ago, even at as young as 2 years of age, probably represent a quite different group from 2-year-old children currently referred to autism centers. For example, one study carried out with 2-year-olds diagnosed in the early 1990s found that the primary diagnostic shift for children with PDD-NOS at age 2 was toward autism diagnoses by age 5 as clinicians became more certain of the significance of symptoms (Lord et al., 2006). In contrast, several recent studies with higher­functioning children and clinicians who were likely more experienced and comfortable with early diagnoses, found larger numbers of children with PDD-NOS diagnoses moving out of the spectrum, reflecting these clinicians’ more sensitive diagnosis of PDDNOS at young ages, the less severe impair-



18. Autism Spectrum Disorders

ment of the children, and perhaps the effects of early intervention (Kleinman, Ventola, et al., 2008; Turner & Stone, 2007).

THEORIES OF THE NATURE OF AUTISM There is currently no strong, unifying theory of autism that addresses the developmental changes seen from infancy through childhood either in terms of neurobiological pathways or through a higher-order model. Research about infants with autism is anticipated to make a major contribution to theory by providing evidence of how the disorder “unfolds”; hopes are high that this information will have direct relevance for prevention and/or treatment. Much research has focused on whether early deficits in autism are specific to social information (e.g., faces, voices) or social contexts (e.g., interaction with people vs. objects) (Dawson et al., 2004). It is clear that children with ASD have difficulty with social information and contexts, but it is not clear whether this difficulty is due to deficits in uniquely social brain systems, to deficits in feedback systems affected by lack of social experience (e.g., if a child does not look at faces with nearly the frequency of other children, for whatever reason, this may contribute to lack of knowledge about faces; Carver & Dawson, 2002), or to more general deficits in attention or cognition that have particular relevance for social skills by affecting engagement and motivation (Mundy & Acra, 2006). These deficits are further magnified by lack of experience and lack of engagement. Cognitive researchers have mostly emphasized higher-order cognitive skills, such as Theory of Mind (BaronCohen, 2001), central coherence (see Happé & Frith, 2006, for a review), and executive functioning (Griffith, Pennington, Wehner, & Rogers, 2003) and then worked backward to look for infant and preschool precursors in areas such as joint attention, response inhibition, eye tracking of social events, and categorical learning. Such higher-order cognitive deficits affect nonsocial as well as social skills (Minshew & Siegel, 1995). Another way in which these approaches have been organized, which is relatively independent of the above perspectives, is to discriminate behavioral activating systems,

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such as those involved in children’s efforts to initiate interaction or joint attention (often accompanied by positive affect), from behavioral inhibition, in which a child selectively responds to various stimuli. The latter overlaps with conceptualizations of “sticky attention,” which refer to infants’ inability to shift gaze between objects or events (Landry & Bryson, 2004; Zwaigenbaum et al., 2005). There have been numerous attempts over the years to relate these hypotheses to basic differences in arousal (either under- or overarousal) and to perception, though to date, these hypotheses have not been substantiated when studies are well controlled (Chawarska, Klin, & Volkmar, 2003; Sigman, Dissanayake, Corona, & Espinosa, 2003). Finally, on the basis of population and family studies, investigators have argued that it is possible to separate different dimensions of autism, including communication, social development, and restricted/repetitive behaviors and interests, in a way that suggests that these are relatively independent domains that all happen to be affected within ASD (Bolton et al., 1994; Happé, Ronald, & Plomin, 2006; Piven, Palmer, Jacobi, & Childress, 1997). Other research has found a more general “autism phenotype” in which deficits in nonverbal communication and social functioning and repetitive behaviors and interests are not easily separable (Hus, Pickles, Cook, Risi, & Lord, 2007). In family members of children with autism and some population studies, difficulties with restricted and repetitive behaviors are more likely to be reported as impairing when there is a combination of social and communication deficits. Language level affects both social functioning and measurement of that functioning so significantly that it has to be considered in any analysis of behavior with ASD individuals. However, this is less an issue for very young children because many of them do not yet use words to communicate. Comorbidity between ASD and hyperactivity/ attention deficits and between ASD and language or intellectual disabilities affects both diagnosis and treatment planning, as well as research (Charman et al., 2005). It has been proposed that the current heterogeneous conceptualization of restricted, repetitive behaviors in DSM-IV (American Psychiatric Association, 1994) be reconsidered in terms of at least two different kinds

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of repetition: (1) sensorimotor behaviors associated with both ASD and intellectual disabilities, and (2) insistence on sameness, which is also not specific to autism but is less tied to intellectual functioning and age than repetitive sensorimotor behaviors (Bishop, Richler, & Lord, 2006; Bodfish, Symons, Parker, & LewisBarbera, 2000). As well­defined genetic syndromes associated with autism become identified for study, questions about the degree to which these domains develop independently may come closer to resolution.

AUTISM IN INFANCY From the earliest description of Kanner (1943), autism has been described as a disorder that manifests in infancy, yet diagnostic systems have failed to provide a conceptualization of how autism looks in the early years. DSM-IV was the first to encompass more of a developmental perspective in its description of ASD, but field trials to establish its diagnostic criteria were not inclusive of children below the age of 3 years (Volkmar et al., 1994). Consequently, the conceptualization of the disorder put forth by DSM-IV includes behaviors relating to pretend play, peer interaction, and developed language— all behaviors that are not consistently present in typically developing children until the second and third years of life (Osterling, Dawson, & Munson, 2002). By 12 months of age, infants on the spectrum show lower levels of social interaction and communication than typically developing infants (Osterling & Dawson, 1994). What many parents and researchers have observed to be a qualitative lack of social relatedness can be broken down into several features. Infants with autism are less likely to show interest in others (Osterling et al., 2002), which is evidenced by fewer occurrences of social smiling and social interest and less frequent expressions of positive affect (Zwaigenbaum et al., 2005). A lack of warm, joyful expressions with gaze has been found to be one red flag in differentiating between infants with autism and infants who are typically developing (Wetherby et al., 2004). At the heart of a qualitative lack of social relatedness in infants on the spectrum

are abnormalities in eye gaze. Atypical eye contact is evident in 12-month-old infants (Zwaigenbaum et al., 2005) and continues to be abnormal throughout the second year of life and even longer (Chawarska, Klin, Paul, & Volkmar, 2007). Infants with autism have been observed to exhibit a deficit in their tendency to orient to social stimuli in general (Osterling & Dawson, 1994). Atypicalities in eye gaze and social orientation are related to one of the most central features of autism in infants and toddlers: deficits in joint attention (e.g., responding to others’ attempts to get them to “share” or follow attention as well as initiate “catching” others’ gaze, which are manifested during the first year and persist into the second year of life; Charwaska, Klin, et al., 2007). They are less likely to look at objects held by people and less frequently engage in the pointing behaviors of joint attention (Wetherby et al., 2004). Many theorists propose that deficits in joint attention lead to the language impairments often evident in infants and toddlers on the spectrum. Infants on the spectrum use complex babbling and words less frequently than typically developing infants by 12 months of age (Werner & Dawson, 2005), and by 2 years of age, lower levels of both expressive and receptive language ability are not uncommon (Zwaigenbaum et al., 2005). For infants with substantial verbal utterances, a tone of voice that is characterized by unusual prosody is often observed (Wetherby et al., 2004). Lower frequencies of conventional, physical, or depictive gestures are also common. More striking even than the lack of individual features of social and communicative functioning is the difficulty of children with ASD in integrating eye gaze, facial expression, gesture, and sound (Wetherby et al., 2004). This basic lack of integration and coordination remains a striking feature of autism across the lifespan. In addition to deficits in social and communicative function, infants on the spectrum also show abnormalities in motor development and sensory processing, and in the emergence of restricted and repetitive behaviors and interests. Some infants at 12 months of age have high levels of sensory sensitivity and sensory-­oriented behaviors (Osterling & Dawson, 1994; Zwaigenbaum et al., 2005).



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Some exhibit higher levels of unusual behaviors such as repetitive motor actions, with or without objects or self-­stimulation (Osterling & Dawson, 1994; Wetherby et al., 2004). Repetitive movements or posturing of the body, arms, hands, or fingers and motor mannerisms such as jumping, hand flapping, or toe walking have been observed in the second year of life (Chawarska, Klin, et al., 2007; Wetherby et al., 2004), but more restricted interests and repetitive behaviors are observed as children reach preschool (Charman et al., 2005; Lord, 1995). Parental reports of infants whose early development was initially described as normal and who then experienced a loss of communication and social skills led researchers to examine patterns of loss in infants and toddlers later diagnosed with autism. Indeed, 20–40% of parents of children with autism report a regression characterized by a loss of words and a loss of additional social skills (Lord, Shulman, & DiLavore, 2004; Werner & Dawson, 2005). There is a unique pattern of development associated with ASD that includes loss of social skills and sometimes words after a period of more (though not necessarily completely) normal early development and then a plateau (Lord, Shulman, et al., 2004). What is particularly striking is that many children then regain “lost” language skills but may never attain the easy social reciprocity on a simple level that they had as infants. In one prospective study a subgroup of infants who did not differ significantly from typically developing infants in 14-month assessments exhibited a decrease in the rate of vocabulary development, plateaus in joint attention, and decreases in gestures and shared positive affect (Landa et al., 2007). Though many parents and parent advocacy groups purport an association between the measles–mumps–­rubella (MMR) or thimerisol-­containing vaccines (DeStefano, 2007), numerous research studies have failed to find such a link (Chen, Landau, Sham, & Fombonne, 2004; Richler, Bishop, Kleinke, & Lord, 2006) As more thorough assessments have been possible, in general, most children who experience regression in ASD have shown subtle differences from other children before “the regression” occurred (Lord, Shulman, et al., 2004; Luyster et al., 2005; Siperstein & Volkmar, 2004;

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Werner, Dawson, Munson, & Osterling, 2005). However, decreases in skills and engagement in the second year of life do occur (even though they do not mean that the child was truly “normal” before then), and these changes are heartbreaking and confusing for parents. They also remain a challenge to neurobiological explanations of development in ASD. Results are mixed as to whether the developmental trajectories for children with a regression differ from those without. Some studies have reported slightly higher levels of impairment in subgroups of children with regression (Luyster et al., 2005), whereas others have reported no differences in outcome (Lord, Shulman, et al., 2004; Werner et al., 2005). Children with autism and regression, as with children with ASD in general, are a heterogeneous group with varying developmental trajectories (Richler et al., 2006). There is much overlap between symptoms of ASD and symptoms of other developmental disorders. Most children with global developmental delay or language disorder display some characteristics of ASD, making differential diagnosis a challenge (Ventola et al., 2007). One of the most common behaviors of concern reported by parents is delayed language development, yet expressive language has been shown to be a weak discriminator between ASD-related and non-ASD-related developmental delay (Kleinman, Robins, et al., 2008). Very poor receptive language (e.g., not understanding any words out of context by 4 months) may be a much better marker of ASD (Abbeduto et al., 2006; Philofsky, Hepburn, Hayes, Hagerman, & Rogers, 2004). Toddlers with autism are distinguished from toddlers with developmental delay by the relative absence of shared enjoyment, directed gaze and attention, varied facial expression, and offers to share (Ventola et al., 2007), and as development progresses, children with autism are more likely to show repetitive and restricted behaviors and unusual sensory behaviors (Lord, 1995). As a core deficit of autism, social impairment has led researchers to question whether children on the spectrum are impeded from developing secure attachment relationships with their caregivers (Rogers, Ozonoff, & Maslin-Cole, 1993; Sigman & Ungerer, 1984). One meta-­analysis (Rutgers,

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Bakermans-­K ranenburg, van IJzendoorn, & Beckelaer-Onnes, 2004) concluded that attachment security is compatible with autism and identified diagnostic classification (i.e., PDD-NOS vs. autism) and cognitive level as important moderators of attachment status. These findings were supported in one of the few studies to investigate attachment in toddlers with autism: Severity of autistic symptoms was predictive of an insecure attachment relationship, whereas mental retardation comorbid with autism was predictive of disorganized attachment (Naber et al., 2007). More research with toddlers is necessary to disentangle the intersections between cognitive level and autistic severity. In summary, a number of behavioral markers are indicative of autism as early as 12 months of age. The trajectories of such behavioral markers, how they relate to manifestations of autism later in life, and more importantly, how early identification and intervention may prevent them from unfolding to a more severe degree are research priorities.

DIAGNOSTIC PROCESS AND ASSESSMENT Despite concerns about diagnostic fluctuation within ASD, most children with ASD can be reliably diagnosed by 2 years of age; “working diagnoses” (Charman, 2005) can be proposed as early as 12 months. Through interdisciplinary assessments carried out by examiners with experience and skill, clinicians can obtain a wealth of information about children’s current developmental levels that will have important implications for intervention strategies and goals, and should help inform parents about their child’s existing skill levels. Here the keywords are experience and skill; these may be available in local public early intervention programs, but they also may not, so professionals cannot rely on offhand referrals to community resources without obtaining information about exactly what is offered and the quality of care available. Psychologists, child psychiatrists, and other professionals who lack experience with very young children with ASD need to make referrals, or at a minimum, seek advice, when working with this population.

Though there are limits to the predictive value of standardized tests administered to very young children, in the hands of a skilled clinician, an accurate assessment of a toddler or preschool child’s cognitive development, language and other means of communication, motor and adaptive skills, and social–­emotional behavior can help parents understand their children’s strengths and difficulties and place this information into a developmental perspective. Such results can also serve as a baseline to measure progress. Establishing this baseline is important because a significant minority of children identified early will change diagnoses or cognitive or language levels quite markedly over the next few years. At these early ages, estimated age equivalents, observations of how children go about different tasks, and the factors that make them easier or harder are more important data than standardized scores on cognitive and language measures (e.g., IQs or their equivalents). The one exception is that children with exceptionally low scores (e.g., overall IQs or DQs below 50) are more at risk for long-term delays than children who score closer to average, although even then, care must be taken to rule out other factors (e.g., hearing or motor impairments) that may affect a child’s development. In general, scores that are close to average on complete tests are usually stable or even improve, whereas there is much more variability in scores between 50 and 100 (Anderson et al., 2007; Venter, Lord, & Schopler, 1992). One caveat: It is very important not to overinterpret a good score on a single task or subtest (e.g., rapid completion of inset puzzles; naming pictures or colors; counting) because this may not indicate a child’s range of ability or disability (Tager-­Flusberg et al., in press). If a child does well on only a few tasks from a standardized assessment and cannot (or will not) complete most others, using the highest scores may overestimate his or her general level of functioning. A diagnostic evaluation for possible ASD in a toddler or preschool child must include information from parents and an observation of the child. Several measures are available for parent interviews, including the Parent Interview for Autism—­Clinical Version (PIA-CV; Stone, Coonrod, Pozdol, & Turner, 2003) and a toddler version of



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the Autism Diagnostic Interview—­Revised (ADI-R), available at this point for research purposes only (Lord, Risi, & Pickles, 2004). Well-­validated diagnostic algorithms are not available yet for young children, and it is clear that algorithms for the most commonly used research interview, the standard ADI-R (Lord, Rutter, & LeCouteur, 1994), do not discriminate children with severe nonautism delays from children with ASD when the children have nonverbal mental ages below 18 months (Rutter, LeCouteur, & Lord, 2003). Nevertheless, questions from these interviews may be valuable for clinicians in gaining a picture of the child’s social skills and play, as well as about his or her course of very early development (Chawarska, Paul, et al., 2007; Lord et al., 2006), and by age 3, for most children with ASD, the ADI-R algorithms should work quite well (LeCouteur, Haden, Hammal, & McConachie, 2008). Standard screening measures, such as the Social Responsiveness Scale (SRS; Constantino et al., 2003) or the Social Communication Questionnaire (SCQ; Rutter, Bailey, Berument, Lord, & Pickles, 2001), may be useful for diagnosis when used in conjunction with structured observations with older preschool children, but not currently with children 3 years old or younger. Consequently, standardized diagnoses have focused most on observational instruments. The Screening Test for Autism in Two-Year-Olds (STAT) offers a brief, easyto-use set of observations that have been shown to discriminate children with autism from children with other disorders at age 2 (Stone, Coonrod, & Ousley, 2000). The Autism Observational Scale for Infants (AOSI) is a similarly brief set of tasks intended to discriminate children with ASD from other children in infancy (Bryson et al., 2008). It has been used primarily in studies of subsequent siblings of children with autism and has shown promising results as low as 12 months. The Communication and Symbolic Behavior Scales—­Developmental Profile (CSBS-DP; Wetherby & Prizant, 2002) is another brief, easy-to-use screening observation intended for children under 24 months. Standard scores do not differentiate children with ASD from children with other communication disorders, but additional items (Wetherby et al., 2004) and scoring of videotapes offer important clues about behav-

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iors that differentiate infants and toddlers with ASD. A new module of the Autism Diagnostic Observation Schedule (ADOS), intended for toddlers (from about 12 months, or when children can walk independently, to 30 months), is available (Lord, Luyster, Gotham, & Guthrie, in press) and has been shown to distinguish children with clinical diagnoses of ASD from children with other disorders or typical development. As with other modules of the ADOS, the Toddler Module requires training and more experience than many of the other methods. Because it has a wider range of tasks and codes, it provides broader information, but it takes longer and is more difficult to administer and score. In terms of information about cognitive skills, the Mullen Scales of Early Learning (Mullen, 1995) have comprised the most useful developmental test to date for very young children with ASD because it yields separate age equivalents in receptive and expressive language, fine motor skills, nonverbal problem solving, and gross motor milestones. The Bayley Scales of Infant Development (Bayley, 2006) have recently been modified to provide more discrete information about different areas, and the Stanford–Binet Intelligence Scales (5th ed.; Roid, 2005) are appealing because they span a wide age range, but interpretation is complicated because of early decisions required about “routing” a child based on one task. Standardized language tests may not be very useful for infants and toddlers until their skills approximate those of a typical 18-monthold, when tests such as the Reynell Developmental Language Scales (Reynell & Gruber, 1990) and the Sequenced Inventory of Communicative Development—­Revised (SICDR; Hedrick, Prather, & Tobin, 1984) may be helpful. Standardized tests of language cannot replace the input of an experienced speech–­language pathologist or well-­trained child psychologist for very young children (Tager-­Flusberg et al., in press). The MacArthur Communicative Development Inventories (Fenson, 1989), a parent-­report form for both words and gestures, can provide important information. In addition, the Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984), a parent interview that elicits information about a child’s independent skills, from walking to feeding to engaging

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in play, can also provide a good description of developmental functioning even for very young children.

TREATMENT AND INTERVENTION General recommendations for treatment of children with autism were specified in the National Research Council’s (2001) report and are summarized in Table 18.1. The primary interventions for children with ASD are education and support: (1) education for the children (which includes specialized therapies such as speech therapy and Applied Behavior Analysis [ABA]); (2) support through the provision of individually tailored environments for the child that build on strengths and compensate for deficits (both in “natural settings” such as the home and preschool, as well as in more therapeutic environments); and (3) education and support for caregivers. At this point, there are no medications that treat “core symptoms” of ASD, so medication is relevant only to the degree that it would be used to treat comorbid conditions, such as attentional deficits or epilepsy. Alternative treatments such as diets and supplements (Levy & Hyman, 2003) are widely promoted and often used by families, but so far have not been shown to have any value and sometimes can be harmful.

TABLE 18.1.  Summary of National Research Council Treatment Recommendations (NRC, 2001) 1.  Entry into treatment immediately upon diagnosis or identification as very high risk 2.  Active engagement for a substantial part of the day, most days of the week (suggested for older children 5 hours a day, 5 days a week, comparable to a school day) a.  At young ages, learning should occur in a natural environment as much as possible. 3.  Repeated presentation of brief, planned teaching opportunities aimed at the specific needs and developmental levels of the individual child a.  Targeted skills should be functional and meaningful to the child. 4.  Individual adult attention sufficient to meet the child’s goals and to ensure engagement and learning in the targeted activities a.  Learning must involve the caregivers.

There are almost no randomized controlled trials of comprehensive interventions with preschool children with ASD and none with infants. The dominant literature for comprehensive (e.g., “all-­encompassing”) treatments is behavioral and indicates that intensive, individualized behavioral treatment can result in significant improvements in cognitive skills in preschool children with ASD. These gains seem to occur more often in children with milder diagnoses (e.g., PDD-NOS) and higher IQs (Smith, Groen, & Wynn, 2000). In the literature to date, some children made quite large gains; a substantial minority gained very little. The average gain was about 5 IQ points for children with autism and 20–25 points for children with PDD-NOS—meaningful differences, but decidedly higher in children with fewer difficulties at the start. The strongest evidence supports the effectiveness of behavioral techniques. However, there are no systematic studies that contrast two well-known treatments, so it is not known if one kind of treatment is really better than another, especially when individual differences among children and families are considered (McConachie, 2002; National Research Council, 2001). A number of studies using less well-­controlled designs, such as those that rely on pre–post comparisons, have shown changes in preschool children with ASD during nonbehavioral interventions, such as the Denver model (Rogers, Hall, Osaki, Reaven, & Herbison, 2000) and Floortime (Greenspan & Wieder, 2006), two treatments that emphasize social–­emotional growth as well as other areas. Many smallscale studies also have addressed the use of visual and various other supports (e.g., using pictures and materials to make goals and expectations clearer to children), as originated in the TEACCH program (Mesibov, Shea, & Schopler, 2004; Ozonoff & Cathcart, 2004) and further developed by many educators (Cohen & Sloan, 2007). Much single-case research has shown effects of specific techniques for improving communication (see National Research Council, 2001) in preschool children. Harris and Handleman (2000) have a very informative edited volume that describes different preschool programs in ASD that are considered “state of the art.” Most recently, there have been several studies of complementary treatments that



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are carried out a few hours a week or month in addition to nursery or ABA services for preschool children (Aldred, Green, & Adams, 2004). Despite their low intensity, these interventions seem to have had meaningful effects on behavior. Subtle differences were found in the effects of programs that emphasized symbolic play versus joint attention (Kasari, Freeman, & Paparella, 2006) or that focused on responding to a child’s overtures versus other strategies (Yoder & Warren, 2001), such that social interaction improved more in response to joint attention training, and “responsive” strategies were most effective with families who were more directive. Other approaches have emphasized teaching imitation (Ingersoll, 2008), supporting other “pivotal” behaviors related to language, play, and social interaction (Koegel & Koegel, 2006; Sherer & Schreibman, 2005), or parent training and support (Stahmer, 2001). Various modifications of applied behavior analysis, including a focus on verbal behavior (Barbera, Rasmussen, & Sundberg, 2007; Carbone et al., 2006) and other early intensive behavioral approaches (Eikeseth, Tristam, Jahr, & Eldevik, 2007) also have been proposed. Very few approaches have specifically targeted children under 2 years of age. One of the most creative, well-known interventions for toddlers is the Walden Program (McGee, 1999). This program places toddlers with ASD into a highly structured, well-­supervised day care/preschool with typically developing children and carries out individually planned programs for the children with ASD within the context of small peer groups. The Hanen program, More Than Words (Sussman, 1999), is another approach specifically targeted for parents of children suspected of having ASD. Both approaches have had broad impact, though they have not yet been studied in standard randomized controlled trials. Much thought has gone into considering how approaches should be modified specifically for the needs of families with affected children under 2 years of age. Research showing that maternal synchrony with young children is associated with better outcomes (Siller & Sigman, 2004) and that receptive language and gestures are particularly important predictors of language acquisition (Thurm, Lord, Lee, & Newschaffer,

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2007) has influenced the conceptualization of these approaches. Parent-­implemented strategies have been most popular, in accordance with the National Research Council recommendation that treatments needed to occur in “natural environments” aimed at “meaningful behaviors . . . involving caregivers.” Two interventions for which data have been presented are the Early Social Interaction Model (Wetherby & Woods, 2006) and the Denver Early Start Model (Vismara, Colombi, & Rogers, 2009). Both involve teaching parents general principles related to the factors that we think influence how children with ASD learn and then providing support and ideas for planning ways to maintain social engagement and active communication. Both present intriguing results, with randomized controlled trials in process now (see www.autismspeaks.org). In the meantime, many issues remain open. How much treatment is enough? How can we help families balance the assumed need for intensive, active engagement and “planned opportunities for learning” with all the other needs of a family and the desire of many caregivers to retain their roles as parents (of the child with ASD and often of other children) rather than take on the responsibilities of a therapist? Parents experience many complex emotions as a child with ASD is identified, and they face years of negotiation and unavoidable demands for advocacy to get services for their children (Bailey, 2008). It is critical to individualize services around not just the characteristics of the child but also the needs and desires of families.

COURSE AND PROGNOSIS Questions about the long-term implications of early diagnoses of ASD are complex, and research has led clinicians and researchers in very different directions. On the one hand, autism and ASD are significant disorders that, as diagnosed by experts in children as early as 3 years of age, generally have lifelong effects on the functioning of affected individuals and their families. This is the case even in the majority of milder, “higher­functioning” persons and those with diagnoses of Asperger syndrome or PDD-NOS as well as autism (Howlin & Goode, 2004).

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Even in individuals who are employed and live independently, the social and interpersonal consequences of having ASD remain real, throughout development, though not necessarily as handicapping as 20 or 30 years ago. On the other hand, though it appears as if most diagnoses of autism made by expert clinicians are stable even as early as 2 years of age, diagnoses of PDD-NOS or atypical autism at age 2 are much less stable into preschool and later (Lord et al., 2006; Turner & Stone, 2007). At the same time, with growing public awareness of ASD, milder cases are being referred, and less experienced, less well-­trained clinicians are willing to take them on, so the likelihood that such diagnoses will be even less meaningful over the long run is high. Real changes in trajectories, particularly in social skills and language development, are also apparent for a subset of children identified in preschool years as they become school age, as documented in longitudinal studies (Lord, Risi, et al., 2004). Some of these changes appear to be related to treatments, and some not (Anderson et al., 2007). We also do not know yet whether even earlier, more targeted and sustained interventions are changing outcomes for children who are preschoolers now, but there is much hope that this is the case. In short, the clinician is left with the responsibility of communicating that ASD is a potentially serious condition that warrants immediate treatment and intervention, while still indicating the limits of our current knowledge about predictors of impairment, long-term outcomes, and the possibility of very significant change. In toddlers and preschool children the strongest long-term predictors of later outcome are nonverbal cognitive skills, motor skills, and receptive language a combination that points to the importance of multidisciplinary consultations and thorough developmental evaluations beyond a psychiatric evaluation for ASD (Anderson et al., 2007; Chawarska, Klin, et al., 2007; Lord, 1995; Turner & Stone, 2007). The presence of repetitive behaviors, either observed or reported by parents, and severe deficits in social communication also contribute to longer-term prediction of diagnosis at later ages (Lord et al., 2006). Children with very obvious autism symptoms

(as described earlier), severe developmental delays affecting nonverbal problem solving (who are functioning at less than half their chronological age), delayed motor skills, and very limited receptive language (understands no words out of context by 2 years of age) are most at risk for higher levels of impairment (Thurm, 2007). These developmental factors are more important in many ways than diagnostic distinctions between autism and PDD-NOS at very young ages. Clinicians must beware of overstating either that a particular child has a PDD-NOS and not autism, or the reverse. Feedback to parents should indicate that the child falls within the range of ASD, which is a potentially serious condition but that also includes a wide range of behaviors and outcomes, particularly when diagnosed and treated at very young ages. Any concerns about hearing, vision, seizures, genetics, or general health must also be pursued vigorously. If the child has very severe delays, parents need to be warned gently. In follow-up, the implications of these delays should be addressed gradually.

AUTISM SCREENERS, EPIDEMIOLOGY, AND PUBLIC POLICY One cannot deny the importance of the research within the past 15 years that has contributed to our knowledge of ASD in infancy. Celebration of such achievements, however, is limited by our effectiveness in disseminating this knowledge to the general public. A significant gap exists between our growing ability to recognize ASD in infants and the rate with which infants in the general population are identified with the disorder. Many parents report feeling concerned about their child’s development by 2 years of age (Howlin & Asgharian, 1999; Samms-­Vaughan & Franklyn-­Banton, 2008), but the average age at which children are diagnosed within the United States is not until 4 or 5 years of age (Centers for Disease Control and Prevention, 2007). One proposed method for identifying infants at risk for developing ASD at an earlier age is through surveillance and the administration of developmental screeners by pediatric health care professionals. The Ameri-



18. Autism Spectrum Disorders

can Academy of Pediatrics recommends that standardized developmental screening tests be administered at the 9-, 18-, and 30month well-baby visits, but recognizes that further research should focus on examining the effectiveness of available screening tools (American Academy of Pediatrics, 2006). Surveillance of development in the general population focuses on sensorimotor aspects of development with less emphasis on social interaction. Two of the most commonly used screeners for global development are the Denver-II (Frankenburg et al., 1990) and the Ages and Stages Questionnaire (ASQ; Squires, Bricker, & Potter, 1997). The Denver–II assesses general areas of development, including gross motor, fine motor, social and personal skills, and language. The instrument can be scored in two different ways, yet neither method has been found to yield acceptable rates of sensitivity or specificity (Glascoe et al., 1992). ASQ assesses similar domains to the Denver–II, but has achieved higher levels of sensitivity and specificity in its detection of general developmental delay. Analyses of a revised version of the ASQ (Squires, et al., 1997) yielded a sensitivity of 75% and a specificity of 86% for general delays. The screener seems useful for correctly identifying typically developing children, though it remains limited in its detection of specific developmental disorders. The limited usefulness of general developmental screeners such as the Denver–II and the ASQ in identifying infants at risk for ASD has led researchers to focus on developing specific screeners for identifying the disorder. One of the first empirically tested screeners targeting the general public, the Checklist for Autism in Toddlers (CHAT; Baird et al., 2000), was designed to prospectively identify ASD at 18 months by assessing for simple pretend play and joint­attention behaviors. Positive predictive value (PPV) of the CHAT was high, but sensitivity was limited, precluding any recommendations for using this screener at the general population level. The Early Screening of Autistic Traits (ESAT; Swinkels et al., 2006) is a 14-item instrument to be administered during wellbaby visits at 14 months. PPV for the ESAT was not strong (25%), with false positives consisting of children with mental retarda-

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tion without ASD, language disorder, and other childhood psychiatric disorders. The Modified Checklist for Autism in Toddlers (M-CHAT; Robins, Fein, Barton, & Green, 2001) is a 23-item yes–no parent­report checklist that incorporates several items from the original CHAT. The MCHAT was recently examined in a prospective population study (Kleinman, Robins, et al., 2008). Positive predictive value, or the proportion of children with later ASD diagnoses failing the M-CHAT and failing a telephone follow-up, was 74%. Follow-up several years later yielded a PPV of 59%. There were significant differences in the acceptability of the PPV between the M-CHAT alone and the M-CHAT plus the telephone followup, suggesting that the use of checklists in a pediatrician’s office may not be effective unless a subsequent follow-up is included. This was truer for the low-risk sample of children from the general population (i.e., children who were not already suspected of developmental delay). Overall, use of the M-CHAT with a follow-up interview is a promising technique to detect ASD in children 16–30 months, but it requires more time and effort than most screening procedures, and more data about its use in the general population are needed. A broadband screener that is not specifically designed to detect autism but has shown success at identifying children for future follow-up evaluations is the Infant–­ Toddler Checklist (ITC; Wetherby & Prizant, 2002), a component of the CSBS-DP. The ITC includes 24 items assessing developmental milestones of social communication; the results map onto three composites for social, symbolic, and speech skills. Infants with scores in the lowest 10th percentile of the social composite, symbolic composite, or total score, or infants who score in the lowest 10th percentile of the speech composite on two consecutive ITCs, are referred for follow-up evaluation. Wetherby, Brosnan­Maddox, Pearce, and Newton (2008) have recently completed a study examining the validity of the ITC as a broadband screener to identify infants and toddlers with communication delays from a general population sample. Infants who screened positive for communication delay on the ITC were administered a CSBS-DP Behavior Sample, from which red flags for ASD were rated. Of

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the 60 children later diagnosed with ASD, 56 received a positive broadband screen on the ITC (sensitivity of 93%). Sensitivity was low at 6–8 months of age but increased to over 90% at 12–21 months. In comparison to children diagnosed with communication delay without autism, more children diagnosed with autism performed in the lowest 10th percentile on the social composite than the speech or symbolic composite, supporting evidence that infants with autism are most distinguished from infants with developmental or communication delay based on variables related to social interaction (Lord, 1995; Ventola et al., 2007). The use of the ITC as a broadband screener, followed by an autism-­specific screener such as the M-CHAT, may be one possible efficient means of identifying children at risk for ASD before they visit a diagnostic professional. The continuation of prospective studies of both high-risk and low-risk infants will be invaluable not only to our understanding of the early onset of autism, but also to our ability to identify and predict developmental trajectories of children on the spectrum. In conjunction with research to improve autism screeners, it is important to study the factors that influence parents’ ability to recognize the early symptoms of autism and to communicate such symptoms to health care professionals. The Centers for Disease Control and Prevention (CDC) and other nationally recognized autism awareness organizations have made available to parents descriptions of the most predictive early signs of ASD. The efforts of these organizations may continue to help raise public awareness and encourage parents concerned about their infant’s development to seek the opinion of a health care professional. Another issue related to raising public awareness is ensuring that information regarding early signs of autism is available to families across a range of cultural and socioeconomic backgrounds. This issue is of particular concern because accessibility and use of autism services has been found to be related to socioeconomic factors. In a sample of Medicaid-­eligible families, the age of first ASD diagnosis was 6.3 years for white children whereas it was 7.9 and 8.8 years for African American and Latino children, re-

spectively (Mandell, Listerud, Levy, & Pinto­Martin, 2002). Families of racial/ethnic minorities, lower levels of education, and those who live in nonmetropolitan areas experience greater limitations in accessing services for ASD (Thomas, Ellis, McLurin, Daniels, & Morrissey, 2007). Prevalence has been reported to be higher among non-­H ispanic white children than in non-­H ispanic African American or Latino children in several regions across the United States. It is very possible that these differences are the result of the influence of sociodemographic factors on service use rather than a true difference in occurrence of the disorder (Centers for Disease Control and Prevention, 2007). For many parents, the advantage of early screening is not applicable because diagnostic resources are not available until their children are eligible for services through programs that begin at 3 years of age or even later. The percentage of children identified exclusively at educational sources is significantly higher than the percentage of children identified exclusively at health sources (Centers for Disease Control and Prevention, 2007). Source of diagnosis has also been found to vary by race; in one study, African American children were more likely to be identified at school sources rather than health sources (Yeargin-­A llsop et al., 2003). Sociodemographic factors may also relate to parents’ knowledge of developmental milestones and recognition of early developmental delay. In a study of Jamaican mothers of children with autism, mean age of concern was significantly higher in mothers of lower socioeconomic status (as determined by maternal profession) and the period of time between mothers’ initial concern and the time of the child’s diagnoses was greater (Samms­Vaughn & Franklyn-­Banton, 2008). Of utmost importance to public policy related to ASD is the inclusion of underrepresented families in research. Families who have the most trouble accessing ASD services are not often included in research. It is imperative that the field include families from diverse cultural, ethnic, and social class populations so that the interactions between culture and socioeconomic status and their influence on the early identification of autism may be evaluated.



18. Autism Spectrum Disorders

CONCLUSIONS Overall, enormous progress has been made in the last 5–10 years in recognizing, understanding, and beginning to treat children with ASD under 3 years of age. With this progress comes the recognition that there is clearly much more about the disorder to understand. Research into neurobiological causes is proceeding at a fast pace, as are expansions to international studies and development of treatment and assessment techniques appropriate for very young children with ASD. However, three areas remain a challenge: (1) how to direct attention to the needs of different families in this very complex experience of early identification and treatment, (2) determining how individual differences in children and families can help in the selection of goals and strategies, and (3) determining how to ensure that all children and families have access to appropriate services. References Abbeduto, L., Murphy, M., Richmond, E., Giles, N., Bruno, L., & Schroeder, S. (2006). Cognitive, language, and social–­cognitive skills of individuals with fragile X syndrome with and without autism. Journal of Intellectual Disability Research, 50, 532–545. Adrien, J. L., Faure, M., Perrot, A., Hameury, L., Garreau, B., Barthelemy, C., et al. (1991). Autism and family home movies: Preliminary findings. Journal of Autism and Developmental Disorders, 21, 43–49. Aldred, C., Green, J., & Adams, C. (2004) A new social communication intervention for children with autism: A pilot randomised controlled treatment study suggesting effectiveness. Journal of Child Psychology and Psychiatry and Allied Disciplines, 45, 1420–1430. American Academy of Pediatrics. (2006). Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening. Pediatrics, 118, 405–420. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Anderson, D. K., Lord, C., Risi, S., DiLavore, P. S., Shulman, C., Thurm, A., et al. (2007). Patterns of growth in verbal abilities among children with

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C h a p t e r 19

Communication Disorders Jennifer Windsor Joe Reichle Megan C. Mahowald

C

COMMUNICATION AND LANGUAGE DEVELOPMENT

ommunication is a complex cognitive and social behavior that develops over an extended period of time. However, by the age of 3 years many children have mastered the basic vocabulary (semantics), grammar (morphology and syntax), and sound system (phonology) of language and can communicate in a variety of social contexts (pragmatics). Young children at risk for communication difficulties and those with persistent communication disorders may experience substantial negative academic and social outcomes. Communication disorders in childhood cover a range of conditions, including disorders of fluency and voice production. Language disorders, including phonological disorders, are the most prevalent type of communication disorder. This chapter first overviews typical language development and then outlines the prevalence, comorbidity, and potential risk factors for language disorders. This is followed by an overview of language disorders as they present in early communication, with reference to pragmatics, early vocabulary, and grammar. Assessment and intervention strategies and efficacy are discussed.

Language development begins well before children to use conventional words and sentences. Children’s emerging language is linked closely to their prelinguistic behavior and to their social environments. Infants are aware of their environment as young as the first month or two of life. For example, at about 2 months of age, young children will follow an adult’s eye gaze to a referent of interest. By around 4 months, infants show a propensity to fuss just prior to scheduled feedings and begin to anticipate aspects of familiar routines such as clean-up after mealtimes. These infant behaviors provide salient opportunities for adults to begin to consistently respond to the infant. Adults often do respond, and they tend to interpret infants’ behaviors as intentional communication (Wetherby, Reichle, & Pierce, 1998). Over time, consistent and predictable responses by adults likely facilitate infants’ movement toward early intentional communicative overtures, including vocalizations by about 9 months of age (Crais, Douglas, 318



19. Communication Disorders

& Campbell, 2004). Wetherby and Prizant (1993) described a number of features of early infant–adult exchanges that have been used collectively to infer that a young child’s behavior is intentional communication. These include continuing to produce communicative behavior and changing the form of the behavior until the goal is met, alternating eye gaze between the goal and a listener, waiting for a listener to respond, ceasing the behavior when the goal is met or displaying dissatisfaction if it is not met, and ritualizing or conventionalizing the behavior. The greater the number of these features that are observed, the stronger the case that the behavior was produced intentionally. Once children are communicating intentionally, both the early functions intended and the means used to produce them can be described. Infants’ intention-­deciphering skills or social cognition in conjunction with their ability to abstract patterns from the environment are thought to be fundamental to language development (Tomasello, 2003). Early intentional communication often is characterized as serving three general functions that emerge before intelligible spoken words (Wetherby & Prizant, 1993). These include behavior regulation, joint attention, and social interaction. As shown in Table 19.1, common examples of behavior regulation include requests for objects or activities and protests. Examples of joint attention acts include providing information and commenting. Social interaction acts include intentions such as greetings (see also Wetherby & Prizant, 1993, p. 32).

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Joint attention initiations and responses have been of particular interest to researchers. These communicative functions may be served by different functional brain systems (Mundy, Card, & Fox, 2000). Responses to joint attention occur when a child reacts to an adult’s glancing or pointing to an object or event after the adult first attracts the child’s attention. Responses to adult-­initiated joint attention bids in the form of following an adult’s gaze shift occurs within the first several months. Children’s ability to follow an adult-­initiated pointing gesture emerges between 9 months and 2 years, depending on the location of the referent and communicative partner. Child’s initiation of joint attention bids, in which the child directs a listener’s attention to a referent through eye gaze, gestures, and vocalizations, begins to emerge at about, or slightly before, 12 months of age. Early intentional communication has two major means: gestures (e.g., pointing, reaching) and vocalizations (babbling and nonspeech sounds). Canonical babbling, with well-­formed consonant–vowel syllable shapes, emerges at about the same time as intentional communication, and the presence and frequency of canonical babbling predicts later development (Oller, Eilers, Neal, & Cobo-Lewis, 1998). However, gestures tend to be the primary communicative form until about 14–16 months of age. Gestures decrease during the second year of life as combinations of gestures and vocalizations or early words increase, as do words used alone. By a child’s second birthday, vocaliza-

TABLE 19.1.  Communicative Functions Expressed by Intentional Communicative Acts Function

Definition

Example classifications

Behavior regulation

Communicative acts used to regulate the behavior of another person to obtain a particular outcome

Request: Demands an object or activity Rejection: Refuses an object or event

Joint attention

Communicative acts used to direct another’s attention to an object, event, or focal point of a communicative utterance

Comment: Directs attention to an object Request for information: Seeks information Clarification: Clarifies a prior utterance production

Social interaction

Communicative acts used to obtain or maintain another’s attention to oneself

Greeting: Notices or signals Calling: Draws attention to self Personal: Expresses moods or feelings

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IV. PSYCHOPATHOLOGY

tions alone account for approximately 40% of his or her communication, and gesture–­ vocalization combinations account for about 50% (Iverson & Thal, 1998). By 30 months of age speech alone is the primary form of communication for children acquiring a spoken language (Carpenter, Mastergeorge, & Coggins, 1983). There are strong links between prelinguistic communication and language production and comprehension, although there may be different patterns of association for children with and without developmental disabilities. These links have been shown for a range of early communicative behaviors, including joint attention, gesture, and consonant production (Bruinsma, Koegel, & Koegel, 2004; Camaioni, Aureli, Bellagamba, & Fogel, 2003; Yoder & Warren, 2004). Children’s first spoken word productions tend to emerge around 1 year of age, and many children comprehend a much larger number of words than they produce. There is wide variability in toddlers’ produced and comprehended vocabulary. Sixteen-monthold English-­speaking children comprehend a median number of 50 words. However, children at the 10th percentile produce very few words, and children at the 90th percentile use over 150 words. By age 2 years, the median number of words produced is about 300. The continuum ranges from fewer than 60 words at the 10th percentile to over 500 words at the 90th percentile (Fenson et al., 1994). Although spoken language is the most familiar communicative means, sign languages, such as American Sign Language, may be a child’s native language. Individuals with severe hearing impairment may also use sign systems that represent language. Hearing infants taught by caregivers to use symbolic gestures for concepts such as more and all gone appear to use the gestures slightly earlier than they use spoken words for the same concepts, possibly because gestures are more visible than words (Goodwyn & Acredolo, 1993). Across languages, the emergence of word combinations and grammatical affixes correlates robustly with toddlers’ vocabulary development (Devescovi et al., 2005). Acquisition of a critical mass of different words may be necessary for grammatical skill to emerge (although see Dixon & Marchman, 2007). It is common for children to show over-

regularization errors (e.g., runned, thowed). The order in which grammatical inflections emerge is predictable within a language and reflects the native language being learned. For instance, the regular past tense marker (-ed) appears to be mastered later in English than the Spanish equivalent, whereas the preposition marking in/on is mastered later in Spanish than in English (Kvaal, Shipstead-Cox, Nevitt, Hodson, & Launer, 1987). Between 2 and 4 years of age, children’s sentence length, measured either in words or in ways that account more directly for grammatical complexity, is highly correlated with chronological age (Miller, 1981). Children start to combine two words in the first half of their second year and three words toward the end of the second year. English grammatical markers such as the present progressive -ing and plural -s begin to be used consistently when children create two- to three-word sentences (e.g., me going now, those dogs). Verb forms such as is, am, are, has, and does appear later. For children learning more than one language, there are individual differences in language development related to the age of second-­language exposure and the social and affective contexts of language learning. For young children learning two languages sequentially, there likely is a shift in proficiency across the languages over time (Kan & Kohnert, 2005). However, there is no strong evidence that children who are learning two languages simultaneously or sequentially are at greater risk for language disorders (Kohnert, Yim, Nett, Kan, & Duran, 2005). Children’s phonological development often is characterized in terms of consistent processes, such as consonant cluster reduction, syllable reduction, and final consonant omission. Typical 1- to 2-year-olds may reduce clusters (e.g., pronouncing tair for stair), omit unstressed syllables (e.g., nana for banana), and omit final consonants (e.g., da for dad). Even for children with hearing and speech–motor difficulties, as occur in Down syndrome, these developmental phonological processes may be present (Stoel­Gammon, 1997). Glide (y and w) and liquid (l and r) consonants where the articulators are in close approximation may present particular difficulty (Preisser, Hodson, & Paden, 1988). Coplan and Gleason (1988) proposed a general guideline: 2-year-olds



19. Communication Disorders

with typical speech development are intelligible to strangers in about 50% of their conversation, and 4-year-olds are completely intelligible. In tandem with the development of language structure, children develop conversational and social uses of language. Although there is no uniform agreement about taxonomies of children’s early conversational functions, commonly accepted categories include conversational initiation, maintenance, and termination. Conversational functions to maintain social interactions, including the ability to repair communicative exchanges that break down, have the greatest depth of empirical scrutiny. Children attempt to repair as much as 88% of their original communicative acts by about 1 year of age. During the first several years, children increase the range of repair strategies that they use. By the time children are producing twoword sentences, a sizable proportion of their communicative repairs are modifications of the original message, achieved by increasing loudness and adding gestures, adding different words, and reducing the original message for emphasis (Wetherby, Alexander, & Prizant, 1998).

PRIMARY AND SECONDARY LANGUAGE DISORDERS Language difficulties present as a primary disorder (often called “specific language impairment”) or as secondary to other conditions, such as hearing loss, neurological insult, developmental delays, and environmental deprivation. Different subtypes of primary disorders have been proposed, including expressive (production) language disorder, mixed receptive (comprehension) and expressive language disorder, and phonological disorder (American Psychiatric Association, 1994). As in research on dyslexia, a primary language disorder conventionally is defined by a discrepancy between expressive and/or receptive language performance and nonverbal IQ or, in the case of phonological disorder, developmental expectations. However, it remains open to debate whether primary language disorder is a discrete diagnostic category or represents the tail end of the normal distribution in language performance. Despite the diagnostic issue, it

321

is clear that young children with language disorders are at risk for later behavioral and academic difficulties and negative peer perceptions (Beitchman et al., 1996). Language disorders are a common feature associated with a range of neurodevelopmental conditions. When language disorders are secondary to other conditions, the communication skills often, but not always, reflect the broader cognitive profile of the primary condition (Rice & Warren, 2004). Language disorders are present in many clinical populations with a known genetic basis, such as Down syndrome (Chapman & Hesketh, 2000). Disorders also are present in, for example, populations with focal brain injuries and hearing impairment (Kennedy et al., 2006; Vicari et al., 2000). Language skills may be dissociated from other cognitive skills in some instances, such as with Williams syndrome. Different clinical groups do show differences on close examination of profiles across language domains (Rice, Warren, & Betz, 2005). However, there are some broad similarities across primary and secondary language disorders. For instance, although rates of development across language domains may be different, grammar is a particular weakness for several clinical groups (Bates, 2004; Müllen, 2005).

Prevalence By any measure, language disorders are common childhood conditions distributed across the general population. The U.S. Department of Education (2004) reported that 18.7% of children between 6 and 21 years of age, served in public schools under the Individuals with Disabilities Education Act, received services for primary language and speech-sound disorders. A recent epidemiological study indicated that 13.4% of 24-month-olds without known medical conditions are late to reach early language milestones (Zubrick, Taylor, Rice, & Slegers, 2007). Estimates of the prevalence of primary language and/or speech disorders range from about 5–7% for 2- to 3-year-olds. Estimates of receptive-only and expressiveonly language delays (without concomitant speech delays) are comparable to each other, with about 2–4% of young children affected in each case. More males than females are affected, although it is not clear whether this

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IV. PSYCHOPATHOLOGY

discrepancy reflects biological or reporting differences (Law, Boyle, Harris, Harkness, & Nye, 2000a).

Course Although there is marked heterogeneity, primary delays tend to be persistent, especially for grammatical difficulties (Rice, Taylor, & Zubrick, 2008). Law et al. (2000a) reported that about 70% of children up to the age of 7 years showed persistent language disorders, with higher persistence for mixed expressive–­receptive disorders. Although there are few studies of speech-only delays, these delays appear to be less persistent than language delays. Most prevalence estimates of primary speech delays are for children beyond early childhood, with one estimate of 3.8% for 6-year-old children, with boys affected more often than girls (Shriberg, Tomblin, & McSweeny, 1999).

Comorbidity There is limited reliable information about comorbidity of primary language disorder with other conditions in early development and also little information about reliability of subtypes and profiles across language domains (Tombin & Zhang, 1999). Different clinical subgroups often are comorbid or show overlapping language, social, and/ or subclinical nonlinguistic performance at later points in development (Bishop & Snowling, 2004; Conti-­Ramsden, Simkin, & Botting, 2006; Pickles et al., 2000). For example, there is substantial overlap between primary language/learning disabilities and attention-­deficit and disruptive behavior disorders during the preschool and school years (American Academy of Child and Adolescent Psychiatry, 1998). The current emphasis on cross-­population studies and longitudinal investigations of developmental trajectories may yield very different insights than we have now regarding commonalities and differences across clinical groups (see Beeghly, 2006; Mervis, 2004).

Etiology and Risk Factors Nonshared environmental and genetic factors influence variation in language development. Environmental factors may play a

larger role for young children’s vocabulary development (Bishop, Price, Dale, & Plomin, 2003). There is increasing documentation of a familial and heritable component to primary language disorder (Choudhury & Benasich, 2003; SLI Consortium, 2002). While this raises the issue that there may be particular genes involved in language disorders, there is no clear understanding of the genetic basis of language difficulties at this point. Given the phenotypic overlap with other groups, it is reasonable to assume that multiple genes underlie variation in language performance (Tomblin & Zhang, 1999). It has been suggested that primary language disorder may be an instance of neuromaturational delay (Powell & Bishop, 1992), but there has been relatively little investigation of the underlying neurobiology. A variety of psychological constructs, including deficits in phonological working memory, processing speed, rapid auditory processing, and attention have been invoked to describe primary and secondary language disorders (Leonard, 1998). Although biological factors clearly are important, children’s language also reflects their life experiences, social interaction opportunities, and frequency of exposure to different language forms as well as integrity of the underlying cognitive system. For example, children from lower socioeconomic groups are more likely to be identified as having a primary language disorder or learning disability (Tomblin et al., 1997). Overall, the frequency and responsivity of child–adult social interaction appears to be a central framework for language development (Hart & Risley, 1995; Huttenlocher, Haight, Bryk, Seltzer, & Lyons, 1991). Hart and Risley (1995) found that children of parents who produced the greatest cumulative number of spoken utterances to their children in the first 3 years of life had the most extensive vocabulary skills. Parents of children with superior language skills were far more responsive than other parents to their child’s communicative initiations. Other style aspects may differ between caregivers of children with and without disabilities, such as degree of directiveness and variation in intonation. However, these style differences seem to be adaptations to the child’s communication, not a major cause of language difficulties (Leonard, 1998).



19. Communication Disorders

Phenomenology of Language Disorders For primary and secondary language disorders the communication difficulty likely will include deficits in vocabulary and grammar, pragmatics, and speech-sound production, with varying severity across these domains. Like other developmental phenomena, language may break down in different ways because there is no single pathway to the same developmental outcome (Shonkoff & Phillips, 2000). However, there are identifiable patterns of language breakdown, with the overall trajectory in early development appearing to be delayed onset rather than deviance. Early pragmatic, vocabulary, and grammatical delays are described below.

Prelinguistic and Early Pragmatic Delays In early development, deficits in joint attention and the ability to generalize and use language productively have been of particular interest across clinical groups. Some children with developmental disabilities, notably children with autism, show marked differences compared to typical populations in joint attention initiations and responses. Children with developmental delays may initiate communication less frequently, produce a smaller range of communicative functions, and attempt fewer and less sophisticated communicative repairs than typical peers. Children with disabilities may need clearer and increased numbers of teaching opportunities than typical children to generalize across communicative means. Also, they may have difficulty using new vocabulary conditionally, that is, discriminating when to use and not use a newly acquired communicative form (Drasgow, Halle, & Ostrosky, 1998; Reichle & McComas, 2004).

Early Vocabulary Delays The high variability in vocabulary size for typical children presents a challenge for identifying early delays. A central clinical question has focused on whether children with slow expressive vocabulary development (often defined as below the 10th percentile) but who otherwise show typical development catch up to age peers with continued development. It is not clear what characteristics predispose some children to resolve

323

early language delays, presenting a challenge for appropriate intervention services. Several risk factors have been suggested for persistent delays, especially the presence of a receptive language delay in addition to the expressive delay, more restricted consonant and syllable inventories, and lower nonverbal cognitive abilities (Oliver, Dale, & Plomin, 2004; Thal, Reilly, Seibert, Jeffries, & Fenson, 2004). Toddlers’ “fast mapping” (i.e., the ability to comprehend and produce new words after few exposures) has received particular attention as a predictor of vocabulary learning. For example, when an older brother talks about a new toy, a child can learn that new word by comparing the new object with the novel word and realizing that he or she already understands the names associated with other objects. Children with a primary language disorder may perform similarly to typical children in fast-­mapping comprehension, but have lower production proficiency (Dollaghan, 1987). As a group, late talkers resolve some of their language delay, but the clinical significance of the change is open to debate. Dale, Price, Bishop, and Plomin (2003) showed that 40% of children who were below the 10th percentile in vocabulary size at 2 years of age performed below the 15th percentile at 4 years of age. There are findings that many toddlers with small expressive vocabularies perform at or near age expectations on standardized language tests by 5 years of age; however, the children continue to show noticeable weaknesses in higher-level language use and reading (Rescorla, 2005). Caregiver education and monitoring, without intervention, has been suggested for early vocabulary delays; others have advocated for early intervention (Paul, 2007). Differentiating Late Talkers and Toddlers with Autism Spectrum Disorders.  Separating late talkers from young children at risk for autism spectrum disorders presents a particular diagnostic difficulty. As language skills become more established in the preschool and school ages, the cognitive–­ linguistic profile of children with a primary language disorder is separable from children with autism spectrum disorders. Although there may be overlapping profiles at certain points in development (Tager-­Flusberg, 2004), there are core distinctions in non-

324

IV. PSYCHOPATHOLOGY

verbal intelligence and quality of language performance. By convention, children with a primary language disorder have nonverbal IQs within the normal range. This is not the case in autism spectrum disorders, where about 75% of school-age children have developmental delays (Lord & Risi, 2000) and up to about 35% may have no or severely limited language skills (Lord, Risi, & Pickles, 2004). School-age children with a primary language disorder show subtler grammatical and conversational difficulties. The frequent echolalia (i.e., excessive immediate or delayed imitation) and the characteristic stereotyped behaviors found in children with autism spectrum disorders also are absent for children with a primary language disorder. For infants and toddlers, the distinction between late talkers and children at risk for autism spectrum disorders is less clear. Toddlers with autism spectrum disorders may show differences in social communication, including less frequent imitation and joint attention bids, but may not show the stereotyped behaviors of older children (Crais, Watson, Baranek, & Reznick, 2006). Toddlers identified as late talkers may show low social competence, especially related to shyness and internalizing behaviors (Irwin, Carter, & Briggs-Gowan, 2002). However, in this, as in several other studies, it is difficult to separate the two groups because screening measures for autism were not administered to the assumed late talkers (Fitzgerald, 2003).

Early Grammatical Delays Difficulty with grammar is the hallmark of preschoolers with a primary language disorder. English-­speaking children with language disorders omit verb markers more often than typical children who have the same average sentence length. The verb markers include the regular past-tense marker -ed (walked, kicked), the third-­person singular marker -s (she sleeps, he runs), and the verbs is, are, and am. A 4-year-old child with a language disorder might say he play and she happy, whereas typical age peers say he plays and she is happy. Although grammar appears to be a difficulty across several languages, language-­specific features lead to somewhat different grammatical profiles for chil-

dren with language disorders. For instance, Italian-­speaking children may not show as much difficulty as English-­speaking children with verb markers, probably because Italian has a richer inflectional system (Leonard, 2000). There are two main explanations of the particular difficulty with verb markers. Children may have difficulty with these inflections because they are relatively short in duration and are unstressed, making them difficult to perceive as distinct grammatical forms. Also, children may be very slow in acquiring linguistic tense marking. Although neither explanation has universal support, the grammatical difficulty may have sufficient sensitivity and specificity to act as a clinical marker of primary language disorder (Rice, 2000).

ASSESSMENT OF LANGUAGE DISORDERS Recent language assessments and interventions for young children are framed within family-­centered practices that promote families’ ability to provide appropriate care in addition to a focus on children’s language (Paul, 2007). There is no one broadly accepted screening measure for language disorders, and systematic reviews have concluded that universal language screening is not yet appropriate (Law, Boyle, Harris, Harkness, & Nye, 2000b; Nelson, Nygren, Walker, & Panoscha, 2006). Rather, increasing attention has been focused on identifying factors that place young children at risk for communication and later academic difficulties instead of identifying discrete clinical categories of speech–­language delays (Law et al., 2000a). These risk factors include comorbidity and medical factors, such as prematurity, prenatal care, and the presence of recurrent otitis media (middle ear infections), as well as familial and socioeconomic factors. Behavioral observation, parent or other caregiver report, environmental manipulations to promote use of targeted behaviors, and medical and family history remain core features of assessment for infants and toddlers. General developmental guidelines are available for early language (American Speech–­Language–­Hearing Association, 2007). Most attention has been paid to whether infants are intentional communi-



19. Communication Disorders

cators and to their range of communicative functions and means. Early identification of how young children respond to environmental events is important because it provides the basis for predictable adult responses. Caregiver report and systematic observational measures such as the Early Social Communication Scales (Seibert, Hogan, & Mundy, 1982) and the Communication and Symbolic Behavior Scales (Wetherby & Prizant, 1993) have served as valuable ways to identify early communication skills. Vocabulary growth and the emergence of two-word combinations also are conventional markers of language development. Caregiver reports of vocabulary size, as in the MacArthur–Bates Communicative Development Inventories (Fenson et al., 2006) and the Language Development Survey (Rescorla, 1989), have been used extensively. For example, high sensitivity and specificity to language delay has been shown for the Language Development Survey. A positive screen was identified for monolingual English-­speaking children with either fewer than 50 words or no word combinations at 24 months in conjunction with parental concern or six or more ear infections (Klee, Pearce, & Carson, 2000). Sentence length and presence of inflections typically have served as key grammatical measures (Miller, 1981). Verb inflection probes may serve as efficient grammatical assessments for preschoolers (Goffman & Leonard, 2000). Traditionally, little attention was paid to norm-­referenced assessment measures that are valid and reliable across children from diverse economic, cultural, and linguistic backgrounds. However, the role that experience plays in language is now emphasized in developing less biased assessments. Even during the school years the second-­language performance of typical sequential bilingual children may resemble the language of monolingual children with a primary language disorder (Windsor & Kohnert, 2004). In screening younger children, it remains important not to overidentify language disorders in second-­language learners. Several criterion-­referenced approaches have been proposed to help resolve the issue that speech–­language pathologists and other professionals may not be familiar with the dialect or language of the young children whose language skills they are assessing.

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One approach is the use of a minimal competency core (Stockman, 1996)—that is, a set of guidelines representing the lowest level of semantic, grammatical, pragmatic, and phonological knowledge expected at a given chronological age. For example, a minimal competency core for a 3-year-old child who uses African American English identifies the types of meanings and the proportion of complex sentences minimally expected at age 3 years, the consonants expected to be produced correctly, and the type of conversational repairs likely to be used. Some recent screening measures for young children are cognitive–­linguistic measures that deemphasize language ability but correlate with higher-level language performance. These measures include nonword repetition, rapid naming, and digit recall (Graf Estes, Evans, & Else-Quest, 2007; Windsor & Kohnert, 2008). Dynamic assessment procedures, designed to identify areas of greatest readiness for immediate language growth through mediated learning opportunities, also are used to identify likely intervention targets (Olswang & Bain, 1996).

INTERVENTION AND EFFICACY There is fairly limited information from randomized control trials about intervention efficacy for young children with language disorders. It has been argued that random assignment can present ethical and practical concerns, so quasi-­experimental and singlecase experimental designs often have been used to investigate efficacy. Law, Boyle, Harris, Harkness, and Nye (1998) carried out a systematic literature review of intervention for children up to 7 years of age with a primary language disorder. From the 48 studies meeting review criteria, effect sizes for expressive language from direct (clinician­administered) and indirect intervention (by trained parents or teachers) were clinically significant. Average gains were equivalent to children moving from about the 5th to the 25th percentile in language skills. Indirect intervention results for receptive language were similar; there were little data available for direct receptive intervention. More recently, Law, Garrett, and Nye (2003, 2004) carried out a meta-­analysis of 13 randomized control trials that were suf-

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IV. PSYCHOPATHOLOGY

ficiently similar in intervention approach to be combined. The studies focused mainly on 2- to 3-year-olds with a primary language disorder. Intervention for expressive phonology had substantive positive effects, with larger effect sizes for direct intervention and for intervention lasting at least 8 weeks. Excluding children with severe receptive delays, there were positive effects for expressive vocabulary and syntax in both direct and indirect interventions. Longer interventions were associated with better expressive syntax outcomes. There was no evidence of intervention efficacy for receptive phonology or syntax. Law et al. (2004) concluded that intervention length is a key factor to consider and that systematic intervention by trained parents is a viable option for young children. It is difficult to draw more detailed conclusions from the small sample, and the findings may not be consistent for young children with a language disorder secondary to other conditions (see Johnston, 2005).

Discrete Trial and Social–­Pragmatic Approaches Several experimental studies have examined the role of adult responsivity in intervention outcomes. Generally, intervention strategies lie on a continuum that ranges between behavioral (discrete trial) and more developmentally guided (social–­pragmatic) approaches. Prizant, Weatherby, Rubin, Laurent, and Rydell (2006) characterized core attributes of each approach (see Table 19.2). Some of the strongest evidence supporting intervention efficacy is found in the discrete trial literature, and much of this literature has resulted from intervention for

individuals with autism spectrum disorders. For example, Lovaas (1977) created one of the early manualized intervention protocols with empirical validation demonstrating that an intensive discrete-trial approach resulted in significant communicative gains for children with autism. Recent research has, to a substantial degree, replicated the original outcomes, typically using approaches of lower intensity and shorter duration (Eikeseth, Smith, Jahr, & Eldevik, 2002; Smith, Groen, & Wynn, 2000). Overall, these replications have shown substantial gains in communication, with a smaller subset of children showing improvement in IQ. Whereas discrete-trial approaches attempt to isolate the child from distracters, social–­ pragmatic approaches emphasize following child-­initiated instructional opportunities in the natural environment and providing extensive opportunities for adult responses to children’s initiations. The sequence of instructional objectives is guided by typical development. Social–­pragmatic approaches often involve instruction using sentences that are slightly more advanced than the child’s sentences. Additionally, interventionists attempt to maximize responsivity to child social–­communicative initiations. Finally, social–­pragmatic approaches use familiar social routines as an intervention context (Prizant et al., 2006). These variables have good face validity as intervention strategies, but few have been systematically investigated.

Milieu Language Intervention Milieu language intervention is a hybrid intervention approach that combines some

TABLE 19.2.  Components of Discrete Trial and Social–Pragmatic Intervention Approaches Discrete trial

Social–pragmatic

May or may not be based on developmental expectations

Based on developmental expectations

One-to-one teaching strategies with structure controlled by the interventionist

Interactive–facilitative strategies, with a high degree of acceptance of early communicative forms

Prescribed, objectively defined goals and procedures to promote learning

Adjustment of language and social input to promote learning

Minimal use of contextual support

Based on learning in functional communication and affective contexts



19. Communication Disorders

components of discrete-trial and social–­ pragmatic approaches. This approach, originally described as incidental teaching, has been adapted over time (Hart & Risley, 1986). The adult prompts the child to produce communicative targets (e.g., by asking “What do you want?” or “What is that?” to prompt the child to produce a new object label) and provides a model to imitate if the child does not respond. Once the child responds consistently, the adult implements a time delay (to provide an opportunity for the production of an anticipatory communicative act) before giving a more intrusive spoken model. Once the child is participating consistently at this level, the adult proceeds to incidental teaching in child-­initiated contexts. For example, the child might initiate by saying doggy as she points to a dog. The parent may then expand responsively by saying big white dog. With children who are not yet under good instructional control and who have fewer than about 10 spoken words, prelinguistic milieu teaching can be implemented by professionals or parents and other caregivers. Prelinguistic milieu teaching to facilitate intentional communication has received increasing experimental attention. Warren, Yoder, Gazdag, Kim, and Jones (1993) examined the short-term effects of milieu teaching with toddlers with developmental delays. Milieu teaching resulted in substantial increases in children’s request behavior. The intervention also influenced the communicative behavior of mothers and teachers, who were unaware of the intervention focus, by increasing/expanding their communication bids to the children. Yoder and Warren (1998, 2001) compared prelinguistic milieu teaching with a parallel play treatment. Treatment effectiveness varied as a function of pretreatment maternal responsivity; children with highly responsive mothers performed better with milieu teaching. The interaction between mothers’ amount of formal education and treatment group predicted language outcomes. Fey et al. (2006) found a higher frequency of communicative acts for children with developmental delays in milieu teaching compared to a responsivity-­focused treatment in which intervention opportunities were predicated on the child producing communication before an adult expansion. Warren et al. (2008)

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found no evidence of long-term effects of low-­intensity responsivity-­focused treatment. Yoder and Stone (2006) compared milieu teaching with the picture exchange communication system (a discrete-trial approach in which children use graphic symbols). The visual intervention led to a greater number and variety of nonimitative spoken acts by children with autism; however, children who had low rates of object exploration benefited more from prelinguistic milieu intervention.

Intervention for Children Who Require an Augmentation of Spoken Communication Many children with severe language disorders are not able to effectively produce spoken language. In the United States there are approximately 470,000 children with developmental disabilities served in public schools who could benefit from augmentative communication systems (National Institute on Disability and Rehabilitation Research, 1992). Gestural symbols (conventional gestures, sign languages and systems) and graphic symbols (pictures, line drawings, and orthography) housed in a small wallet or notebook can be implemented to supplement vocal/verbal utterances. Graphic symbols displayed via an electronic communication aid (a speech-­generating device) allow a toddler to retrieve prestored messages with one or more keystrokes that can be produced using synthesized and/or digitized speech. A graphic symbol display can concurrently offer symbol options, lowering the recall demands to retrieve vocabulary. There is increasing research suggesting that augmentative communication systems can have at least a modest positive impact on the emergence of oral/aural communication. Both graphic and gestural symbols may be advantageous in promoting speech production when the child is successful in vocal imitation (Millar, Light, & Schlosser, 2006; Yoder & Layton, 1988).

CONCLUSIONS Communication and language develop in the context of social interaction. However, despite sufficient exposure and experiences, some infants and toddlers do not demon-

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strate robust language growth. Given the likelihood of cumulative effects of language delays over time, early identification of children at risk for delays is critical. Current language screening measures are viable but need refinement and validation, especially for children from diverse cultural and linguistic backgrounds. Language interventions for older children show a range of effectiveness and may be hampered by scheduling and other constraints that reduce the amount of time a child typically receives dedicated intervention services. Frequency and responsivity of interaction may be highly influential in language outcomes. Thus, parents and other familiar caregivers who interact daily with young children and who are taught sustainable, systematic ways to facilitate communication can be key partners with professionals in furthering children’s language development. References American Academy of Child and Adolescent Psychiatry. (1998). Practice parameters for the assessment and treatment of children and adolescents with language disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 37(Suppl.), 49–62. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Speech–­Language–­Hearing Association. (2007). How does your child hear and talk? Retrieved March 30, 2007, from www.asha.org/ public/speech/development/child_ hear_ talk. htm. Bates, E. (2004). Explaining and interpreting deficits in language development across clinical groups: Where do we go from here? Brain and Language, 88, 248–253. Beeghly, M. (2006). Translational research on early language development: Current challenges and future directions. Development and Psychopathology, 18, 737–757. Beitchman, J. H., Wilson, B., Brownlie, E. B., Walters, H., Inglis, A., & Lancee, W. (1996). Longterm consistency in speech/language profiles: II. Behavioral, emotional, and social outcomes. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 815–825. Bishop, D. V. M., Price, T. S., Dale, P. S., & Plomin, R. (2003). Outcomes of early language delay: II. Etiology of transient and persistent language difficulties. Journal of Speech, Language, and Hearing Research, 46, 561–575. Bishop, D. V. M., & Snowling, M. J. (2004). Developmental dyslexia and specific language impair-

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C h a p t e r 20

Intellectual Disabilities Robert M. Hodapp Tricia A. Thornton-Wells Elisabeth M. Dykens

I

n recent editions of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000), mental retardation has been the first disorder described among the “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” In spite of this prominent position, however, the study of children and adults with intellectual disabilities–­mental retardation generally lags behind interest in other psychiatric conditions. Few mental health professionals—child or adult psychiatrists, clinical psychologists, social workers, or other mental health workers—have been specifically trained in intellectual disabilities, and most have only a passing familiarity with these conditions. And yet, within psychiatry proper, there has long been the sense that interest in intellectual disabilities is increasing. Over 80 years ago—in 1927—Howard W. Potter described intellectual disabilities as the neglected child of psychiatry, which he considered the Cinderella of medicine, and (like Cinderella) would soon take its rightful, prominent place at the mental health ball. This Cinderella metaphor has returned repeatedly, with Tarjan (1966) and King, State, Shah, Davanzo, and Dykens (1997) predicting that, in the not-too-­distant future, intellectual disabilities would soon gain in prominence within the mental health field.



Although one might be skeptical of a subfield whose emergence is repeatedly promised over an 80-year span, it is our sense that the study of intellectual disabilities has arrived. The field is increasingly vibrant, prominent, and of interest to a wide variety of professions. Developmental psychologists are intrigued by how children with some syndromes show wide discrepancies in their abilities in certain areas compared to others; geneticists, by the ways that newly discovered genetic mechanisms show themselves in specific genetic syndromes; mental health professionals, by how some mothers, fathers, and siblings cope well, whereas others have difficulties. Nurses, pediatricians, early interventionists, special educators, developmental neurologists and neuropsychologists—all have their profession-­specific reasons for being interested in intellectual disabilities. For infant mental health professionals as well, intellectual disabilities present many interesting issues. In this chapter we consider four of these issues. First, we briefly describe the definition, classification, assessment, and diagnosis of infants and young children with disabilities. Second, we describe what has been called an “etiology-based” approach, using as examples the early development of young children with Down syndrome and Williams syndrome. Third, we address is332



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sues of family functioning, including new work that examines functioning in families of children with different genetic conditions. Fourth, we review issues involved in early intervention services and systems.

DEFINITION Although controversies have arisen repeatedly about the definition of intellectual disabilities, this definition has remained substantially unchanged for over 40 years. Three constant, core features of intellectual disabilities (formerly called “mental retardation”) include (1) significantly subaverage general intellectual functioning, (2) concurrent deficits in adaptive behavior, and (3) an onset of problems during the childhood years (before 18–21 years of age) (American Psychiatric Association, 2000). Although the age criterion is relatively straightforward, the first two of these diagnostic criteria have been trickier to operationalize. Intellectual deficits generally refer to a child’s performance on individually administered, recent, and well-­standardized IQ tests. Given the error band of most IQ tests, “it is possible to diagnose Mental Retardation in individuals with IQs between 70 and 75 who exhibit significant deficits in adaptive behavior” (American Psychiatric Association, 2000, pp.  41–42). In general, though, intellectual disabilities occur when the person’s IQ is below 70. The second criterion relates to deficits in adaptive functioning. Although details of the adaptive behavior criterion have also proven controversial, most professionals view adaptive behavior as one’s ability to perform everyday activities of daily living (e.g., eating, grooming, toileting), to communicate and socialize with others, and to understand social rules (Carter, Marakovitz, & Sparrow, 2006). Although IQ has historically been emphasized, only those children with both IQ and adaptive deficits should be diagnosed with intellectual disabilities.

CLASSIFICATION Traditionally, children have been classified as having mild (IQ 55–69), moderate (IQ 40–54), severe (IQ 25–39), and profound (IQ

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< 25) intellectual disabilities, with each successive level referring to children with progressively lower IQ scores. This “degree of impairment” approach to classification has been somewhat supplanted by a more functional approach that is based on the idea that some individuals may require only intermittent environmental supports, whereas others require limited, extensive, or pervasive supports (American Association on Mental Retardation, 2002). In general, then, professionals differentiate children with intellectual disabilities on the basis of the severity of their impairment, measurable by their IQ level, functional and adaptive behavior, or by their need for environmental supports. In recent years, however, another approach to classification has become prominent. This approach classifies individuals based on the specific cause or etiology of their intellectual disabilities. An early version of this etiology-based approach can be seen in Zigler’s (1967) “two-group approach” to intellectual disabilities, which divided persons with intellectual disabilities into those with one or more clear organic causes (“organic” mental retardation) versus those showing no clear organic cause (nonspecific or familial mental retardation). Given recent advances in molecular and clinical genetics, we are now able to diagnose many more children with a clear organic—­usually genetic—cause. Many of the most exciting discoveries of the past two decades have related to children with genetic conditions of intellectual disabilities.

ASSESSMENT Assessment of intellectual disabilities traditionally has relied on standardized instruments of both intelligence and of adaptive behavior. Most clinicians rely on the Stanford–Binet or the Wechsler-based tests to assess intellectual abilities, and the global IQ score serves as the criterion against which the child is evaluated. Adaptive behavior is similarly examined with the Vineland Adaptive Behavior Scales or other such scales, although clinician judgment is more often allowed in this area. In both cases, the “gold standard” relates to psychometric instruments that are well standardized, of recent vintage, and that provide overall standard scores.

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Although reliance on overall IQ scores derived from standardized tests continues to predominate, the testing world has increasingly moved toward a more multifaceted view of intelligence (Sparrow & Davis, 2000). Most newly designed tests differentiate IQ into multiple domains, and such domains are thought to better reflect the true nature of intellectual functioning. Even in infancy, the Bayley Scales of Infant Development— Third Edition (BSID-III) divides intelligence into five separate domains. Similarly, most tests for toddlers and young children differentiate intelligence into multiple domains (Lichtenberger, 2005). Although this more differentiated view of intelligence has not always influenced diagnosis or intervention, it does relate to many of the major advances within the intellectual disabilities field.

Diagnostic Challenges Even with recent advances in intellectual and adaptive testing, accurate diagnosis of intellectual disabilities during the infancy or early childhood period remains challenging. Many infants simply do not come to the attention of early interventionists, infant mental health, or other professionals, and parents do not always know what is “normal” for young children of different ages. Partly for this reason, the prevalence rates of children with intellectual disabilities rise from the preschool into the school years (Roeleveld, Zielhuis, & Gabreels, 1997), when children are identified though the educational system. Additionally, clinicians may be more apt to consider such diagnoses as specific language impairments or autism spectrum disorder, which may or may not ultimately be associated with intellectual disabilities. Developmental screeners administered by pediatricians or nurses and public health campaigns such as “know the signs” for autism can identify children showing delays in motor, language, or social development, but the diagnosis of a full-blown intellectual disability is complicated by several factors. The primary, inherent difficulty in diagnosing intellectual disability during infancy is the instability of IQ scores from one time point to the next. Bayley Developmental Quotient (DQ) scores taken at 1 year of age generally show relatively little stability with scores on Stanford–Binet or other childhood IQ tests

when the same children are 3–5 years old; test–­retest correlations are as low as 0–.15 (Molfese & Acheson, 1997). This lack of predictive validity occurs because “development occurs so rapidly and because test items may measure different constructs at different ages” (Lichtenberger, 2005, p. 198). Instability of IQ scores, however, may not hold for infants and young children with more severe levels of impairment. Maisto and German (1986) noted that correlations between DQ and IQ scores from an average age of 11 months until retestings up to 4 years later were moderately high, with most test–­retest correlations ranging from .40 to .60 (see also Niccols & Latchman, 2002). Children with IQs below 50 may be more stable in their IQ scores over time. In addition to issues related to infants with disabilities, other issues relate to the tests themselves. Although calls for improved IQ tests during infancy and early childhood have been made repeatedly, certain problems remain. For instance, historically the Bayley scales have provided DQ scores only down to DQ 50 (although the Bayley–III does go down to DQ = 40), with lower functioning simply denoted as “DQ less than” this lowest value. Partly as a result, over the years several attempts have been made to “extend the curve” to lower DQs, but the psychometrics of such downward extensions remain unknown. Thus, the instability of IQ and the difficulties in assessing rapid development in very young children both serve to complicate the diagnosis of intellectual disabilities in infants and young children. These complexities seem particularly striking in young children with mild delays; these children often are from lower socioeconomic status (SES) or minority groups, and may or may not show concurrent deficits in adaptive behavior (Gresham, MacMillan, & Bocian, 1996). Increasingly, these more mildly affected children are diagnosed with learning disabilities, especially as they get older (MacMillan, Gresham, & Bocian, 1998). Much less diagnostic controversy occurs when infants show more severe impairments. In the same way, fewer controversies relate to children who show clear causes for their intellectual disabilities. Children with Down syndrome, Williams syndrome, fragile X syndrome, and even nongenetic disor-



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ders such as fetal alcohol syndrome all show deficits that are easier to identify and whose developmental course is easier to track. Many of the field’s most intriguing findings concern the early development of these children.

ETIOLOGY From 750 to 1,000 genetic disorders have now been associated with intellectual disability (Opitz, 1996), and individuals with genetic syndromes constitute a substantial percentage of those with intellectual disabilities (probably about 40%), with higher percentages at the lower IQ levels (Heikura et al., 2005). Most of these etiologies involve such chromosomal abnormalities as trisomies (i.e., having three copies of the same chromosome), deletions (i.e., part of a chromosome absent), translocations (i.e., part of a chromosome out of place), or uniparental disomies (two copies of the same chromosome from one parent and no copy from the other parent) (Biringen, Fidler, Barrett, & Kubicek, 2005). Researchers are increasingly performing molecular and mouse-model studies to examine the function of genes associated with a specific genetic condition; these studies shed light on biological mechanisms operating along the pathways from genes to brain to behavior. Neuroimaging studies have implicated particular brain regions as being involved in some disorders (Schaer & Eliez, 2007). Such advances are reflected in increased medical scrutiny of infants suspected of having a genetic disorder. Infants with genetic diagnoses may show obvious or subtle physical, facial, or behavioral signs, or may have demonstrable impairments in cardiac, muscular, neurological, motor, or sensory systems. Guidelines have been developed that assist clinicians in knowing when to send infants for genetic testing (Curry et al., 1997), as have syndrome-­specific recommendations for medical best practices in infants, children, and adults. Because genetic disorders often make infants more prone to specific health conditions, knowing about such conditions and medical best practices allow for ongoing vigilance and prompt care of the child’s variable health needs (Roizen, 2003). Knowing the genetic etiology is also im-

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portant because infants with different genetic disorders are prone to show specific strengths and weaknesses in social, cognitive, linguistic, emotional, and motor domains; many also show particular maladaptive behaviors (Dykens, Hodapp, & Finucane, 2000). In addition to profiles, children with a particular disorder may show periods when development is faster or slower. Such developmental information is increasingly being used to develop effective early intervention efforts (Fidler, Philofsky, & Hepburn, 2007; Hodapp & Fidler, 1999). In addition, etiology-based information can help couples in their reproductive and family planning. The presence of certain genetic disorders (e.g., fragile X syndrome) indicates increased risk for future children in the family or, in some cases, for other relatives who may not know that they or their children are at risk. In contrast, other abnormalities are not likely to recur within the same family (e.g., most cases of Prader–Willi syndrome). In these cases, families have no greater risks of having a second child with a specific disorder than do others in the general population.

GENETIC DISORDERS Although a comprehensive review of different genetic disorders is beyond the scope of this chapter, we briefly describe two disorders, Down syndrome and Williams syndrome. Both are noteworthy in that they are fairly common, show distinct behavioral profiles, and feature a fair amount of developmental and behavioral research. In these ways, they demonstrate the promise of research on infants and young children with genetic etiologies.

Down Syndrome Occurring in approximately 1 per 800–1,000 live births, Down syndrome is the most common chromosomal disorder involving intellectual disability. However, numbers differ based on maternal age, with the risk of having a child with trisomy 21 increasing from 1 in 1,000 at maternal age of 30 to 9 in 1,000 at maternal age of 40 (Hook, 1981). In the large majority of cases, Down syndrome is caused by three copies of chromosome 21

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(so-­called trisomy 21). Children and adults with this disorder have several physical characteristics, including short stature, short, broad hands, and distinctive facial features such as a flat nasal bridge and a protruding tongue. Congenital heart defects (particularly of the atrioventricular canal) appear in approximately 50% of these infants. Significant hearing loss is present in approximately 90% of individuals with Down syndrome and may contribute to learning deficits and lower IQ (Mazzoni, Ackley, & Nash, 1994). Within infancy, recent studies have noted that up to half of these children show one or more hospitalizations following birth, often for pneumonia, bronchitis, and other respiratory problems (So, Urbano, & Hodapp, 2007). Over the past decade, geneticists have identified a “critical region” of chromosome 21 that appears to be responsible for the intellectual disabilities and most of the facial features associated with Down syndrome (Korenberg, 1993). The Down Syndrome Critical Region Gene 1 (DSCR1) has also been implicated in cardiac defects and intellectual disabilities. An increased risk of leukemia in patients with Down syndrome has been linked to an interaction between a gene in the critical region (FMS-related tyrosine kinase 3, or FLT3) and a gene located on chromosome 3 (GATA-binding protein 1) (Look, 2002; Wechsler et al., 2002). Although prenatal screening has become an established part of obstetric practice, the most common screening method for Down syndrome is not based on a genetic test. Instead, screening involves measuring several biochemical factors and incorporating risk due to maternal age. The result is a test with a false-­positive rate of 5% and a detection rate of between 63% and 72% (Spencer, 2007). In many cases, genetic testing (which makes the diagnosis definitive) is requested due to the presence of hypotonia, cardiac defects, hearing deficits, and craniofacial abnormalities at birth or in early infancy. Although in psychological research Down syndrome is often used as the “control” or “contrast” condition for children with Williams syndrome or autism, children with Down syndrome do have their own characteristic behavioral features. Behaviorally, most children with Down syndrome score in the moderate range of intelligence (IQ 40–

54), although IQ scores vary widely from one child to another. Most studies show that these children display their highest IQ scores in the earliest years, with gradually decreasing IQs as they age (Hodapp, Evans, & Gray, 1999). Even during those earliest years, though, infants and young children with Down syndrome show slowing in their development (Dunst, 1990). Young children with Down syndrome also show an etiology-­related profile of strengths and weaknesses. Miller (1999) noted that, across the preschool period, most children with Down syndrome showed a profile in which abilities in receptive language were advanced over expressive abilities (and over the child’s overall levels of mental abilities [MA]). Such discrepancies became more pronounced—for increasing numbers of children—as the study examined children over the preschool period. This pattern of receptive over expressive language abilities may also relate to the high rates of articulation problems among children with Down syndrome, as well as specific problems in linguistic grammar (Chapman & Hesketh, 2000). As a group, children with Down syndrome are considered by others to have strengths in social skills. These toddlers look to others (as opposed to objects) more often (Kasari, Mundy, Yirmiya, & Sigman, 1990) and, while performing problem-­solving tasks at later ages, these children tend to look to adults and engage in social behaviors (Kasari & Freeman, 2001; Pitcairn & Wishart, 1994). At the same time, however, children with Down syndrome do not perform well on higher-level social tasks. For example, these children perform poorly on tasks of emotion recognition (Kasari, Freeman, & Hughes, 2001), and the levels they reach on theoryof-mind tasks are no better than their overall mental abilities (Abbeduto et al., 2006; Easterbrooks & Biringen, 2005). In short, although infants and young children with Down syndrome are oriented toward others, their “sociability” is confined mostly to the lowest levels of social skills. Recent work has combined cognitive–­ linguistic weaknesses with infant–­toddler sociability. By examining the early development of infant cognitive skills and behaviors during mother–child interactions, Fidler, Philofsky, Hepburn, and Rogers (2005)



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found that infants with Down syndrome showed particular difficulties in means–ends (i.e., instrumental) thinking, or tasks that involve the idea that objects (e.g., stick, stool) can be used as a means for obtaining desired objects. Such deficits seem to relate to these children’s increased amounts of looking to others for solutions to difficult problems. Eventually, “the coupling of poor strategic thinking [i.e., poor means–ends thinking] and strengths in social relatedness is hypothesized to lead to the less persistent and overly social personality-­motivational orientation observed in this population” (Fidler, 2006, p. 147). Although much remains to be discovered, early developments may hold the key to understanding many etiology-­related behaviors in Down syndrome.

Williams Syndrome Occurring in approximately 1 per 10,000 live births, Williams syndrome is caused by a microdeletion on chromosome 7 that contains approximately 25 genes. Children and adults with this disorder have a particular facial appearance, with a small “pug” nose (what used to be called an “elfin-like” appearance). Cardiac abnormalities (especially supravalvular aortic stenosis) are present in about 80% of children with Williams syndrome. Behaviorally, most children with Williams syndrome score in the mild range of intellectual disabilities (IQ = 55–69; Howlin, Davies, & Udwin, 1998), and these scores remain stable throughout adulthood (Searcy et al., 2004). Most children with this syndrome show relative strengths in language; in fact, early researchers argued that children with Williams syndrome might have near-­normal or “spared” levels of language. Although such spared language is now known to occur in only a few persons with Williams syndrome (Bishop, 1999), these children’s levels in language and communication do appear higher than their overall mental abilities. Conversely, visuospatial processing skills appear particularly weak, such that children with Williams syndrome have extreme difficulty in drawing pictures, in distinguishing left from right, and in performing other visuospatial tasks (Bellugi, Wang, & Jernigan, 1994; Dykens, Rosner, & Ly, 2000). Finally, in addition to friendly—even overly

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friendly—­personalities, most children with Williams syndrome are extremely fearful and anxious (Dykens, 2003; Einfeld, Tonge, & Florio, 1997). From an early age, many of these children display a strong attraction to music, which they seem to instinctively use in a therapeutic manner to reduce anxiety and to increase positive affect (Dykens, 2003). In addition to such behavioral profiles, three aspects of Williams syndrome are particularly noteworthy. First, researchers have begun to tie specific gene regions to particular physical and behavioral characteristics. The gene for elastin (ELN), for example, is known to be responsible for the cardiac defects and some craniofacial abnormalities. Deficits in visuospatial construction, learning, and memory have been associated with lim domain kinase 1 gene (LIMK1; Frangiskakis, et al., 1996), and general transcription factor genes (GTF2I; GTF2IRDI) have been associated with general mental retardation and visuospatial deficits in Williams syndrome (Morris et al., 2003). Second, early diagnosis of Williams syndrome now seems possible based on both physical and medical characteristics. Until now, diagnosis during early childhood was difficult due to phenotypic variability and the subtle nature of the syndrome’s physical characteristics. Indeed, most infants with Williams syndrome first present with cardiovascular abnormalities or with prolonged colic (sometimes lasting a year). Huang, Sadler, O’Riordan, and Robin (2002) showed that, although on average parents reported first being concerned about their child’s health or behavior at a median age of 12 months, the diagnosis of Williams syndrome was not made until 3.66 years. But by including a clinical geneticist in the evaluation process, the mean delay in diagnosis was reduced almost in half, and the number of diagnostic tests performed dropped from 8.2 to 5.2. A third advance relates to early development within Williams syndrome and to some glimmerings of the later-­emerging phenotype. In addition to work documenting infants’ delays in pointing, showing, and other communicative gestures that typically precede early verbal language development (Mervis & Becerra, 2007), studies also document keen interests in faces and aber-

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rant facial gaze in toddlers with Williams syndrome (Laing et al., 2002). Future years promise even greater understandings of early development for children with Williams syndrome and other genetic intellectual disability syndromes.

FAMILY ADAPTATION The field of infant mental health has long been concerned with infants in the context of caregiving relationships, recognizing that infant and context reciprocally transact over time. Before describing some of the field’s recent findings regarding families’ adaptations, we provide a brief overview of the past, present, and emerging trends in this area.

Changing Perspectives Research on families of children with disabilities features a clear change over time (Hodapp, 2002). Prior to the mid-1980s, the dominant perspective could be characterized as pathological or negative. Beginning with the seminal work of Solnit and Stark (1961), mothers were considered to mourn, as in a death, the birth of the newborn with disabilities. Mothers were thought to traverse a set of stages from shock, denial, and disbelief, to anger or depression, to emotional reorganization. Although various theorists modified this stage-like process, and the stages did not always work as predicted (Blacher, 1984), the model was thought to characterize maternal reactions. Most early studies focused on mothers, although a few examined maladaptive behaviors and emotional problems of fathers (Friedrich & Friedrich, 1981) and siblings (Lobato, 1983). Families overall were conceptualized as being at risk, with various studies focusing on economic immobility, marital conflict and divorce, and the inability of families to “grow up” with their children (particularly those with children who had severe–­profound intellectual disabilities; Farber, 1960). Even though this exclusive focus on negative family outcomes predominated, most researchers appreciated that, although some families experienced difficulties, others did not. But how did such “nonpathological” mothers, fathers, siblings, and families fit within what was mostly a negative and pathological view?

In 1983 Crnic, Friedrich, and Greenberg (1983) proposed a different way to conceptualize these families. According to these theorists, the child with disabilities was most appropriately considered as an added stressor in the family. Like the family’s moving from one town to another, or the illnesses, promotions, or other changes that naturally occur in the lives of individual family members, so too could the birth, diagnosis, and raising of the child with disabilities be considered as an added stressor. The experience of dealing with added stress, in turn, could be either detrimental or helpful to the family. This changing perspective led to changes in both theory and practice. Theoretically, the stress-and-­coping perspective led to interest in models that considered the correlates of family success. One such model was the Double ABCX, a revision of a family model originally employed by McCubbin and Patterson (1983). According to this model, the “crisis” (or “X” term) of raising a child with disabilities was dependent on the characteristics of the child (“A”), the family’s internal and external resources (“B”), and the family’s perceptions of the child and the child’s role in the family (“C”). The “Double” conveyed the notion that child characteristics, family resources, and family perceptions of the child can all change over time. Although general, this type of model has been used successfully in understanding coping processes in families of children with disabilities (Minnes, 1988). In practical terms, the stress-and-­coping perspective and Double ABCX model have changed the focus of interventions. First, not all parents and families even need intervention. Many—even most—are coping well. In addition, by considering child and family factors that may lead to better versus worse coping, interventionists can both screen and intervene more effectively. Emphasis also changes from considering families of children with versus without disabilities (betweengroup focus) to one that considers both between-group and within-group issues. By identifying which variables affect family functioning, within-group examinations can help identify which families are most likely to cope well, which are not, and why. Stressand-­coping theories provide a more nuanced, balanced account of these families. Although an improvement on more negative conceptualizations of families, over the



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past 5 years such stress-and-­coping perspectives also have received criticism. Some of the following criticisms are not, by themselves, incompatible with stress-and-­coping models, but all will likely receive increased attention in the years to come.

New Directions Positive Effects Many researchers feel that stress-and-­coping models unduly focus on either negative effects or, at best, familial coping or “getting by.” In many cases, however, families feel that they have benefited from raising a child with disabilities. Such benefits include appreciating life more, understanding life’s deeper meanings, being more empathic and understanding of differences, feeling more committed to social justice, and helping those less fortunate than themselves (Dykens, 2006). Although such benefits have only begun to be examined in families of children with disabilities (Taunt & Hastings, 2002), studies of such positive effects balance the existing body of negative (or at least neutral) studies.

Increased Attention to Other Family Members Although stress-and-­coping models have been less “mother-­centric” than earlier studies, to this day few studies examine other family members or families overall. We need sustained, long-term studies of siblings (Hodapp, Glidden, & Kaiser, 2005); fathers (Krauss, 1993); families’ economic mobility (Farber, 1960); and the amount, timing, and correlates of parental divorce (Risdal & Singer, 2004).

Focus on Etiology and Etiology-­Related Family Outcomes The cause or etiology of the child’s intellectual disabilities may relate to family functioning. As compared to same-age children with other intellectual disabilities, for example, families of children with Down syndrome may cope better (Hodapp, Ly, Fidler, & Ricci, 2001; Seltzer & Ryff, 1994). Yet why such a “Down syndrome advantage” exists remains unclear. Parents may react positively to children who are more often socially oriented and who generally have

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lesser (albeit not absent) degrees of maladaptive behavior (Hodapp, 1999), but Down syndrome may also be a disorder that is more accepted and features more support groups. More generally, specific genetic conditions predispose children to show different cognitive–­linguistic–­adaptive profiles, to become prone to different behavior problems, and to show both profiles and maladaptive behaviors at different times during development. Some disorders (e.g., Down syndrome, spina bifida) also lead to co-­occurring medical problems, and others (e.g., autism) are only diagnosed at later ages. It remains unclear how any of these child characteristics influence parents, siblings, or families overall.

Increased Focus on Real-World Outcomes Most recent family studies have focused on maternal stress, and few examine more real-world outcomes. For example, few studies examine how often or when mothers or fathers get sick or are hospitalized, or how or when they decide to have more children, accept a promotion, go back for further schooling, change their life’s work, or move to another house, town, or state. We know little about the brothers or sisters of children with disabilities, and whether being a sibling to a brother or sister with intellectual disabilities might influence such siblings in their academic, social, marital, or occupational choices and successes. Thus far focused on stress, the field now needs to focus on realworld outcomes for parents and siblings of a child with disabilities.

Summary of Family Findings Overall, families of children with disabilities show only slight negative effects. In contrast to popular thinking, meta-­analyses of several decades of studies show that, as a group, mothers suffer from only slightly to moderately more depression than do mothers of same-age nondisabled children (Singer, 2006). Similarly, couples of children with disabilities show only small increases in their divorce rates—only 6% higher compared to control couples (Risdal & Singer, 2004). Similarly for siblings, Rossiter and Sharpe (2001) found slight negative effects overall, with the largest negative effects arising when siblings of children with (vs. with-

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out) disabilities were examined using direct observation and when outcomes related to anxiety and depression. Siblings of children with disabilities may also show slightly better social functioning. Beyond these more general findings, correlates of coping are found both among mothers and their children with disabilities. Among mothers, the main correlate concerns the mother’s coping style. In contrast to “palliative” coping, in which the mother either denies or perseverates on her negative emotions, mothers who engage in active, problem-­solving coping do better (Essex, Seltzer, & Krauss, 1999). From the child’s perspective, those children who show more behavior problems, particularly acting-out behaviors, appear to be more difficult for parents to handle (Glidden & Schoolcraft, 2007). Compared to parents of same-age children with other disabilities, parents of children with autism may show more depression (Singer, 2006). Parents also experience more depression and higher stress levels after the birth (or early diagnosis) of the child with disabilities. In Glidden and Schoolcraft’s (2003) studies of adoptive versus birth parents of children with disabilities, the birth mothers experienced high levels of depression during the child’s earliest years, but the two groups were indistinguishable when children became older. The adverse effects of having a child with disabilities seem most pronounced during the infancy and early childhood period. In addition, compared to mothers of children with other types of intellectual disability, mothers experienced less parental stress when their children have Down syndrome (Hodapp, Ricci, Ly, & Fidler, 2003). In a recent study examining administrative records of an entire state over a multiyear period, parents of children with Down syndrome divorced at slightly lower rates compared to either parents of (nondisabled) children from the entire state population or to parents of newborns with congenital anomalies other than Down syndrome. When divorce did occur among parents of children with Down syndrome, however, it more often occurred in the baby’s first 2 years of life. Especially among the families of children with Down syndrome, couples who married at younger ages, were less educated, and were both rural and less educated were all particularly prone to divorce (Urbano & Hodapp, 2007).

Taken together, family studies have changed greatly over the past several decades. In addition to changing theoretical perspectives, recent studies have produced more precise findings that might directly lead to better screening and intervention, when needed. Granted, parents and families still experience periods of sadness and increased stress (possibly more often during the early years), but most families cope well, negative effects are (on average) small, and many families find many positives in raising children with disabilities. Still, our knowledge of such families remains incomplete, even as we acknowledge the importance of families to the well-being and development of young children with disabilities.

SERVICE DELIVERY Within the U.S. system of special education services, services to infants and young children are a later-­arriving offshoot. After a series of court decisions and legislative achievements during the 1960s and early 1970s, Public Law 94-142 (PL 94-142), the Education for All Handicapped Children Act, was passed in 1975. PL 94-142 codified the right of all U.S. children to a free, appropriate, public education within the least restrictive educational setting. No longer could any school-age child, whatever his or her disability, be denied access to public education. Today known as the Individuals with Disabilities Education Act (IDEA), this law has been reenacted (with slight modifications) in 1997 and 2004 (Hallahan & Kaufman, 2006). PL 94-142 and IDEA mandated services for school-age children but not for children below 3 years of age. Concern about such younger children led to the passage of PL 99-457 in 1986, mandating special education for children ages 3–5 years and a voluntary grant program for infants–­toddlers below 3 years of age. Although similar to IDEA, the early intervention services for infants and toddlers differ in ways other than simply serving younger children (Krauss & Hauser-Cram, 1992). A first major difference involves who runs the services. Although school-age services are under the direction of children’s local school districts, early intervention services are administered through the states. In each



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state, a state-­designated “lead agency” directs early intervention services. This agency might be the state’s department of education, health, or mental retardation/developmental disabilities. All early intervention services are then coordinated by that lead agency. A second difference relates to which children are eligible for services and the areas of intervention provided to each child. For school-age children, eligibility for special education services occurs when children have established disorders or diagnoses (as determined by appropriate tests and diagnostic procedures). In early intervention, infants–­ toddlers are eligible for services if they have developmental delays or if they have conditions that involve established risks (e.g., Down syndrome, fragile X syndrome), biological risks (prematurity, low birthweight), or environmental risks (extreme poverty, homelessness, suffering from abuse or neglect). Such differences in eligibility criteria constitute a major change from later, schoolbased services (Buysse, Bernier, & McWilliam, 2002). A third and striking difference concerns the family focus of early intervention services. With the exception of needing their agreement concerning their child’s Individualized Education Plan (IEP), parents (and families) receive little attention in special education law and services. But reflecting the long-held view that infants and their families are inextricably linked, early intervention services strive to be family-­centered. For example, early intervention services are based on the Individualized Family Service Plan (IFSP). This document, in addition to its descriptions of the young child’s levels and needs, also includes a statement of the resources, priorities, and concerns of the child’s family, along with statements about how early intervention services will meet the family’s needs. Going beyond the IFSP document per se, early interventionists attempt to include parents and other family members in conceptualizing and intervening with young children who have disabilities (Bruder, 2000). Trivette, Dunst, Boyd, and Hamby (1996) have even developed a typology of program types, ranging from “professionally centered” on one end to “family-­focused” on the other. Differences relate to the degree to which professionals help parents achieve the parents’ own goals and to become full participants in the early intervention process. Still,

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the goal of fully including parents in early intervention is not always met. Despite what program practitioners say they do, parents generally report that most early intervention programs are not fully “family-­centered” (Dunst, 2002). Although programs for infants (vs. preschoolers) more closely achieve family-­centeredness (Dunst, 2002), the goal that parents should be full participants in early intervention continues to be realized only sporadically. In addition to these early intervention services and programs per se, most mental health professionals have come to appreciate the importance of early screening and intervention at the earliest age possible. As a result, early screening, diagnosis, and intervention have become routine for infants and young children who either have, or are at risk of having, intellectual disabilities and/ or other psychiatric conditions. Whether parents and their young children arrive at a child guidance clinic, a pediatric or child psychiatry department in a large hospital, or a community mental health clinic, professionals agree that “the earlier, the better” in terms of diagnosis and intervention. These early-­diagnosed children and their families can then benefit from the entire gamut of early intervention services.

CONCLUDING THOUGHTS In considering the status of intellectual disabilities within the field of infant mental health, we see a field that is itself in its infancy. Many issues continue to be difficult to solve, for example, the basic issue of how to accurately test and diagnose infants or toddlers with intellectual disabilities. On other questions, more progress seems evident. Even compared to 20 years ago, we now know much more about many genetic causes of intellectual disabilities, including how infants with several of these disorders evolve in their behavioral profiles and how genetic anomalies relate to brain and behavior. Our knowledge has similarly advanced concerning how families who have young children with intellectual disabilities cope. In future years we can reasonably hope that our knowledge concerning such families will better inform early intervention services, thereby leading to more optimal outcomes for infants with disabilities and their families.

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C h a p t e r 21

Posttraumatic Stress Disorder Michael S. Scheeringa

D

espite case reports published in the past 25 years describing serious symptomatology in young, traumatized children, only in the past 15 years has posttraumatic stress disorder (PTSD) been studied systematically. In this chapter I begin by reviewing developmental issues relevant for the study of trauma, including the development of memory and the neurobiological substrate of PTSD. Next, I review what is known about the diagnostic validity of PTSD in young children, as well as comorbidity and associated conditions. Then, I consider the relationship context of PTSD in early childhood. Finally, I conclude by reviewing methods of assessment and what is known about the treatment of young children with posttraumatic symptomatology.

DEVELOPMENTAL CONSIDERATIONS Memory Development Memory is a critical issue in PTSD. One must have some form of memory of a past event in order to demonstrate key signs of the disorder: distress at reminders of the event, intrusive recollections of the event, avoidance of the event, and/or flashbacks of the event.

Many types of memory have been studied. Here I focus on two major types most useful for our practical and clinical questions: What do infants remember of their past events? How accessible are those memories to evaluators and therapists of young, traumatized children? The first type of memory, behavioral memory (also called nondeclarative or implicit), is the earliest. It is essentially unconscious to the individual, cannot be verbally recalled, but may be enacted behaviorally. Tests have shown that infants as young as 6 months of age show recall by manipulating toys correctly, which were demonstrated to them 24 hours earlier, and more frequently than toys that were not demonstrated to them (Collie & Hayne, 1999). Nelson (1995) has hypothesized that the brain structures responsible for long-term memory are in place and functional by at least 8 or 9 months (Nelson, 1995). These types of memories may be what are observed when preverbal children repetitively reenact traumatic experiences (Terr, 1981). That is, one can have behavioral memories such as automatic distress reactions to situations that resemble their past events. The second type of memory, autobiographical memory (also called declarative or 345

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explicit), is verbal recall of discrete personally experienced events. This type of memory appears with the emergence of language around 18 months, increases between 18 to 36 months, and manifests in a coherent narrative form after 36 months. This timeline shows convergence from both normal developmental studies (Fivush, 1999) and from clinical settings (Terr, 1988). Overall, memory research suggests that children who are traumatized prior to 6 months of age, and perhaps even prior to 18 months of age, will not have retrievable autobiographical narratives of those events. If children describe memories of events before these ages, the odds are that they overheard discussions of the events from adults and have come to believe that these were, in fact, their own memories. For example, Terr reported a striking case of a girl who was 2 years, 1 month old when her 5-year-old sister was seriously injured when eviscerated by the suction of a swimming pool drain (Terr, 1990). The younger sister was at the pool but never saw her sister in any state of injury. Several years later, after the older sister unexpectedly died, the girl insisted for the first time that she had seen the accident happen originally, and gave several detailed descriptions of the traumatic scene. It was concluded that these were the exact family tales she had heard at home.

Memory for Stressful Events Memory for autobiographical events is an extremely important factor, if not the rate­limiting factor, for determining whether or not children develop PTSD. There is an informative body of literature on children’s memory about how much we can expect young children to remember of their personal stressful experiences, which may or may not be different from how much they remember of everyday events. Merritt et al. systematically asked 24 3- to 7-year-old children about 21 component parts of a voiding cystourethrogram procedure (a catheter is inserted in the urethra, the bladder is filled with contrast fluid, and then the child urinates while being X-rayed) (Merritt, Ornstein, & Spicker, 1994). Six weeks later, children remembered, on average, 83% of the components. Videotaped observational ratings of the degree of children’s distress

during the procedures negatively correlated with the amount of recall. They concluded that young children remember quite accurately, but children for whom the procedure was more distressing actually seemed to remember significantly less. Other studies have parsed out the age effects more systematically. Researchers asked 140 3- to 7-year-old children to remember, on average 18.6, components of a well-child visit to a pediatrician (Baker-Ward, Gordon, Ornstein, Larus, & Clubb, 1993). There was a predictable gradient of memory accuracy increasing with age: the 3-year-olds remembered 75% immediately after the event, the 5-year-olds remembered 82%, and the 7-year-olds remembered 92%. Furthermore, the 7-year-olds showed essentially no forgetting weeks later, but the 3-year-olds’ accuracy had dipped significantly to 70%. A study by Chen et al. of 3- to 18-yearold children also empirically quantified the age gradient for the amount of accurate recall. These children were interviewed for their recall of a lumbar puncture procedure (spinal tap) as part of their cancer treatment protocols (Chen, Zeltzer, Craske, & Katz, 2000). Based on systematic interviews for 20 component parts of the procedure, the 3- to 4-year-olds remembered significantly less (42%) compared to the older age groups; 5- to 7-year-olds, 69%; 8- to 10-year-olds, 78%; and 11- to 18-year-olds, 87%. The 3to 4-year-olds also endorsed purposefully misleading questions significantly more often (61%) compared to the older age groups (18%, 16%, and 0%, respectively). Children’s self-­report of more anxiety during the procedure was associated with poorer recall, replicating the relationship between distress and recall shown by Merritt et al. (1994). Terr’s pioneering qualitative studies of traumatized clinically referred children concluded that generally only those children who were 3 years of age or older at the time of the experiences were capable of producing coherent autobiographical narrative recall of the events years later (Terr, 1988). This timeline concurs generally with nonclinical research conducted by Peterson and colleagues on children who received emergency room treatments. In one study the researchers interviewed 25 children who ranged from 17 to 66 months of age (Howe, Courage, & Peterson, 1994). They concluded that



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children under 24 months of age, in general, failed to provide a coherent narrative of the traumatic event. In another emergency room study, children who were 1 and 2 years old at the time of emergency room treatment did not produce accurate recall later, but children who were 2.5 years or older at the time produced accurate recall, with little forgetting, even 5 years later (Peterson & Whalen, 2001). Lastly, Fivush et al. reinterviewed 42 9to 10-year-old children who had been 3- to 4-years old at the time that they experienced Hurricane Andrew (Fivush, McDermottSales, Goldberg, Bahrick, & Parker, 2004). Their first aim was to determine how much children could recall of a life-­threatening experience 6 years later? Using the same interview techniques at both time points, they found that children recalled almost twice as much detail 6 years later as they did 2–6 months after the hurricane. There was no effect of high or low stress on recall, in contrast to Merritt’s and Chen’s work. Overall, these data suggest that children as young as 2.5–3 years of age clearly recall stressful experiences years later, and these recollections are at least as detailed as normative experiences (Fivush, 1999). There is some evidence that those who experienced more stress at the time of the events recalled less, but this finding is less clear. The implications for infancy (i.e., 12 months and younger) are that children may show behavioral evidence of recalling previously learned experiences but generally are not able to express memories of these events in verbal narrative form even when older (Fivush, 1999).

The Salience of Memory for Psychopathology Despite the obvious importance of memory for the development of PTSD, only a few attempts have been made to explore how assessments of memory correlate with actual psychological outcome. The only known prospective study with children was a 6-year follow-up of 35 children who were 3–4 years old at the time of experiencing Hurricane Andrew at the first assessment (McDermottSales, Fivush, Parker, & Bahrick, 2005). At Time 1, children who recalled more information about the hurricane events showed less severe PTSD symptomatology. In contrast, amount of recall was not correlated

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to severity of PTSD at Time 2, consistent with an adult study (Kangas, Henry, & Bryant, 2005). However, children who simply talked more (but not recalled more amounts of different content) and used more positive emotion words at Time 1 showed less severe PTSD scores at Time 2, with post hoc evidence suggesting that it was primarily the positive emotion words rather than total amount of talking that was associated with better Time 2 PTSD outcome. This finding suggests that the valence of memories, as opposed to the number of memories, may be related to the development of PTSD. One limitation shared with the Kangas et al. (2005) study is that this study did not assess the accuracy of the children’s memories. These findings are important because of the commonly encountered clinical scenario in which caregivers do not want to discuss traumatic events with children because they want children to forget. First, once an event is remembered (after approximately 2.5 years of age), children do not forget it. As time passes beyond the events, children may forget details, and younger children forget more details, but they do not forget generally what happened. Second, although remembering more details does not appear to protect the child from developing PTSD, neither does remembering less. Thus, the advice for caregivers of children 2.5 years old and older would be to encourage conversation about past traumatic events. However, for children younger than 2.5 years, the advice for caregivers may be not to talk about the events. Discussions may create memories in children who lack memories of their own. But if children ask about the past events and seem to recall them, then the advice for older children would apply.

The Moment of Panic PTSD is defined as beginning with an initial moment of panic or sense of being suddenly overwhelmed by a temporarily uncontrollable sense of desperation. Consistent with this definition, epidemiological research on risk factors for PTSD has shown that perceived threat to life and fear at the time of the traumatic events are two of the most consistent predictors of PTSD (Ehlers, Mayou, & Bryant, 1998). The capacity to show fear emerges around 9 months of age

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(Lewis, 2000) but may be present earlier in precocious individuals. The challenge is to ascertain what is and is not frightening for infants and young children. The clearer our understanding of this area, the more effective will be our efforts to help adult caregivers understand how symptoms start and how best to soothe traumatized young children. For physical abuse, sexual abuse, auto accidents, accidental injuries, and animal bites, it is usually straightforward to precisely identify the past events that caused the present triggered fear responses. However, in cases involving the witnessing of domestic violence, determining cause-and-­effect links can be more confusing. For example, children may be more frightened when the mother fights back or when they flee the house, or, if they are in the next room, when they hear yelling without being able to see what’s going on. For invasive medical procedures, oxygen masks or being left alone on a gurney in a hallway may be more frightening than any actual procedure. For more complicated types of events, such as natural or human-made disasters, there are often secondary events connected that may have been equally or more frightening, and it’s not obvious which events were the scariest to children. In a study of 70 young children victimized by Hurricane Katrina, the prevalence of PTSD was 50%. Twenty-four of these children stayed in the city through the storm and the subsequent flood, and their rate of PTSD was 62.5%. The remaining 46 children were evacuated prior to the storm and therefore were never clearly in harm’s way, yet their rate of PTSD was unexpectedly high at 43.5% (Scheeringa & Zeanah, 2008). For most evacuated children, the moment of panic occurred when they returned for the first time to see their flooded homes; this experience was repeatedly and clearly described to us in standardized interviews. All of their toys and clothes were ruined, and all the houses around them had suffered the same fates. It’s likely that children realized at this moment that they had nearly been in harm’s way, more than they had ever imagined, or perhaps they believed that now they were in harm’s way. Most parents of evacuated children that we interviewed were able to clearly pinpoint the onset of their children’s symptoms to the day they returned to see their damaged homes.

The moment of panic for one of these evacuated children was when she and her mother evacuated late at night when it was dark, they were tired, and traffic was heavy. The father was out of the country on business, and the child feared the father wouldn’t be able to find them. A moment of panic for another evacuated child occurred when the mother was pulling out of their driveway and the father refused to go with them. The father finally relented and got in the car, but not until after a standoff that was frightening for the child. All of these examples took place with preschool children rather than infants, but the main point is that a careful history must be taken to track when events in the present trigger distress and then thoughtfully connect back to past events to empirically derive what caused the fear, rather than rely solely on caregiver intuition.

Neurobiology Research with adults has converged to show a number of neurobiological differences associated with PTSD (Kaufman & Charney, 2001; Vermetten & Bremner, 2002); however, few studies have been conducted with young children to confirm whether findings from adults apply to children. For example, morphometric brain imaging of adults has shown consistently a reduced size of the hippocampal structures in subjects with PTSD, but studies with school-age children have failed to replicate this finding, instead suggesting that global brain volume may be reduced (DeBellis et al., 2002). The first year of life is a very active time of emergence and consolidation of capacities. In addition to the more well-known developments in visual acuity, increasing ability to discriminate facial expressions in others, crawling and walking, babbling, and the emergence of discrete emotions, two major advances in socioemotional capacities occur over the 2- to 9-month span (Zeanah, Stafford, Boris, & Scheeringa, 2003). Neurobiological studies in infancy are beginning to map the underlying neural mechanisms of these emerging developmental capacities (Bell & Fox, 1992; Marshall, Bar-Haim, & Fox, 2002). Clearly, the cognitive capacities and the underlying neural networks that are needed for the appreciation of external events are evolving relatively rapidly in



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infancy, making extrapolation from adult studies risky. Nevertheless, to summarize and simplify research on traumatized adults, mapping of the main neural network has shown increased activity of the amygdala and diminished activity of the prefrontal cortex (Shin et al., 2004). Trauma-­related stimuli are associated with increased heart rate and decreased autonomic flexibility of heart rate control (diminished heart rate variability) (Cohen et al., 2000). Findings on baseline levels and reactivity of cortisol regulation have been conflicting (Kaufman & Charney, 2001). The few studies in young children have included a demonstration that autonomic control of heart rate reactivity is diminished in association with PTSD in preschool children only in an interaction with rearing quality that involves harsher and less responsive discipline (Scheeringa, Zeanah, Myers, & Putnam, 2004). There have been substantial studies on cortisol in stressed and maltreated children, but the absence of concurrent measures of PTSD has limited the ability to generalize that research to clinical-level disturbed children (Cicchetti & Rogosch, 2006; Gunnar & Vazquez, 2001). Despite the paucity of data for young children, the potential implications of trauma­induced neurobiological disruptions are ominous. Perry invoked the concept of use­dependent consolidation of neural networks to suggest that the repetitive triggering of fear networks in the context of PTSD will selectively retain maladaptive neural circuits at the expense of more adaptive circuits during the normal course of pruning synapses and networks in the early years of life (Perry, Pollard, Blakley, Baker, & Vigilante, 1995). This retention of maladaptive circuits would theoretically lead to more permanent alterations in the developing brain structure and perhaps maladaptive personality traits and greater chronicity of symptomatology. The only prospective longitudinal study of PTSD in preschool children, to date, does suggest a more chronic course of PTSD compared to the course reported in typical adult studies (Scheeringa et al., 2005). In addition, Schore (2002) has speculated at length that abuse or neglect in infancy (between an infant and caregiver) causes damage to the developing orbitofrontal cortex and is implicated in the development of

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PTSD. However, none of the extensive research cited has been conducted with children with PTSD, and the theory remains speculative.

DIAGNOSTIC VALIDITY OF PTSD Nine studies have systematically examined the diagnostic criteria for PTSD in preschool children (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006; Ghosh Ippen, Briscoe-Smith, & Lieberman, 2004; Levendosky, Huth-Bocks, Semel, & Shapiro, 2002; Ohmi et al., 2002; Scheeringa, Peebles, Cook, & Zeanah, 2001; Scheeringa & Zeanah, 2008; Scheeringa, Zeanah, Drell, & Larrieu, 1995; Scheeringa, Zeanah, Myers, & Putnam, 2003; Stoddard et al., 2006). The consistent findings are that (1) PTSD can be reliably detected in young children; (2) they manifest most (but not all) of the items; and (3) most importantly, an alternative criteria algorithm appears more developmentally sensitive and valid than the DSM-IV algorithm. However, none of these studies analyzed children less than 12 months of age separately from older children. The alternative algorithm for PTSD in young children (Scheeringa et al., 2003) includes modifications in wording for several items to make them more developmentally sensitive to this population. For example, the DSM-IV item for irritability and outbursts of anger was modified to include extreme temper tantrums. The major change, though, is a modification to lower the requirement for the C criterion (numbing and avoidance items) from three out of seven items to just one out of seven items. While this modification was empirically driven, replicated in multiple studies, the rationale behind it was that many of the C-criterion items reflect highly internalized phenomena that appear to be either developmentally impossible in young children (e.g., sense of a foreshortened future) or extremely difficult to detect even when present (e.g., avoidance of thoughts or feelings related to the traumatic event, and inability to recall an important aspect of the event). When this alternative algorithm was applied to samples and compared head-to-head to the DSM-IV algorithm, significantly higher rates of PTSD were consistently found. The rate of PTSD in nonclinical (i.e., non-

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help-­seeking) samples from a gas explosion in Japan was 25% (Ohmi et al., 2002) and from a variety of traumatic events (mainly auto accidents and witnessing domestic violence) was 26% (Scheeringa et al., 2003), whereas the rates of PTSD using the DSMIV criteria in both of those studies were 0%. The rate of PTSD in clinic-­referred children who witnessed domestic violence was over 40% (Ghosh Ippen et al., 2004) and from a variety of traumas in two small clinic studies was 69% (Scheeringa et al., 1995) and 60% (Scheeringa et al., 2001), but the rates by the DSM-IV criteria were approximately 2%, 13%, and 20%, respectively. Rates of PTSD in young children are consistent with rates found in older populations when developmentally sensitive measures and criteria are used.

What Is the Youngest Age Possible to Develop PTSD? Gaensbauer (1982) evaluated a 3-month-old girl who had been physically abused; she was treated for a broken arm at 2 weeks of age, a bruise on her back was discovered at a wellbaby visit at 7 weeks, and a nondepressed skull fracture and another broken arm were reported at 3 months. Gaensbauer did not put forth a diagnosis, as his purpose was to describe emotion development, but there were enough details to ascertain much of the PTSD symptomatology. Her symptomatology was apparent immediately in the hospital, but whether the enduring symptoms were all due to the traumas or confounded by the new stressors and attachment-­related difficulties is difficult to parse apart. Her fear of men and her affect improved naturalistically approximately 2 weeks after the last injury, during which time she had been in a foster home, suggesting that these were not enduring PTSD symptoms. The girl’s father was implicated in all of these injuries. She was described as differentially distressed by the approach of men but not women, tried to avoid interactions with men, lost interest in usual activities, had reduced positive affect, and was excessively irritable and hypervigilant. This case was complicated by the pain of her physical injuries, being hospitalized, undergoing medical procedures, and then separation from her parents and placement in a foster home. Therefore, it’s not clear that

her symptomatology can rightly be called PTSD symptomatology. It may have been more akin to adjustment disorder problems that existed as long as the noxious events were still ongoing (abuse, pain, procedures, separations), but disappeared soon after the noxious events ceased. Solter (2007) described a 5-month-old boy who underwent cranial surgery to correct a congenital defect. He showed three PTSD items, including distress at being placed in the supine position (a possible reminder of his surgery and/or hospitalization experience), new night waking, and irritability. He also showed new night terrors, regression in motor skills, and fear of strangers, but these are not used in the PTSD criteria. The presence or absence of the items that constitute the avoidance and numbing criterion of PTSD were not specifically described as either present or absent. This infant also had extreme emotional distress and newly impaired routine functioning (sleep, feeding, and socializing). Treatment was conducted using a flooding technique within the first month, which consisted of placing the infant in the supine position for successively longer periods until the crying and distress abated. It’s problematic to conclude that this was a case of PTSD because there were “no remaining symptoms” at the 2-month followup. The literature on the course of PTSD has been clear that most, if not all, individuals show some symptomatology consistent with PTSD in the first month following life­threatening events (Davidson, Hughes, Blazer, & George, 1991), but only approximately 30% show symptomatology after the first month and are eligible for the diagnosis for PTSD (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). The symptomatology of this infant may have disappeared due to the flooding treatment in the first month, or it may have remitted spontaneously after he adapted to the helmet or the residual irritants (movement restriction, incision pain, and sore throat) were removed. A more convincing possibility of the youngest child with PTSD is a girl who had been in a terrifying car accident at 9 months of age (Gaensbauer, 1995) and was evaluated at 22 months of age. She showed distinct trauma-­related symptomatology, as she was frightened of being in cars in ways that represented both distress at, and avoidance



21. Posttraumatic Stress Disorder

of, reminders. She also showed new sleep difficulty, irritability, and restricted range of affect. It may not be a coincidence that this earliest known published case of PTSD (diagnosed by the alternative algorithm) is around 9 months of age, which is also the time when behavioral memory capacities are known to emerge (described earlier). In contrast, the youngest known case to qualify for full DSM-IV criteria of PTSD was 34 months old (Gaensbauer, 1997), highlighting the problematic issue of including highly internalized items in a diagnostic nosology for young children. Other noteworthy published cases include a girl who was sexually abused from 0 to 6 months of age and evaluated at 35 months (Terr, 1988); a boy who was likely sexually and physically abused at 7 months of age and had a dissociative flashback at 7 years of age (Gaensbauer, 1995); a girl who witnessed the violent death of her mother at 12 months of age and was first treated at 4 years of age (Gaensbauer, Chatoor, Drell, Siegel, & Zeanah, 1995); a boy who took an accidental overdose of pills and required hospitalization at 13 months of age and was assessed at 25 months of age (Gaensbauer, 1995); a girl who broke her leg under somewhat mysterious circumstances at 15 months and was treated at 19 months (Gaensbauer, 1995); a child who suffered complications of an intravenous needle insertion in a hospital at 16 months of age (Gaensbauer, 1997); a girl who witnessed domestic violence throughout her first year of life and probable physical abuse at 17 months of age and was evaluated at 18 months of age (Zeanah & Scheeringa, 1997); and a girl who was sexually abused from 15 through 17 months of age and assessed at 5 years of age (Terr, 1988). In addition, Coates and Schechter (2004) published two cases from the World Trade Center disaster: a 3-year-old girl and a 2-year-4month-old girl. For clinical guidance about individual cases, readers may wish to consult the cases noted above for more detail if they are close in type of trauma and age to the case of interest. Nearly all of these reports are problematic for a lack of comprehensiveness in assessing PTSD symptomatology. It would be helpful for future published case reports to systematically describe the presence and absence of all PTSD items, and to make more comprehensive efforts to try to

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establish whether distress and avoidance behaviors are truly trauma specific as opposed to generalized negative reactivity to current pain. In summary, there have been no cases of infants (under 12 months) published in the literature that clearly meet criteria for PTSD, even by the alternative algorithm. That doesn’t mean the diagnosis is impossible. The conservative conclusion at this point is that cases have not been described completely enough with this goal in mind. It still appears plausible that infants (particularly those in the 9- to 12-month range) can develop PTSD, but such a case has yet to be published. The evidence has not been overwhelmingly convincing yet that children under 9 months of age can manifest the critical items of PTSD symptomatology, even if cases were to be assessed and described more systematically. Below 9 months of age children can certainly show distress from painful circumstances, but it’s not clear that there are the cognitive meta-­associations of connections between various stimuli and threat reminders. Symptoms in this age may be more akin to conditioning, which disappears relatively quickly with the removal of the painful stimulus.

PARENT–CHILD RELATIONAL ISSUES Over 17 studies are nearly unanimous in showing that children with more severe psychopathology following traumas have parents with more severe psychopathology and/ or family problems (reviewed in Scheeringa & Zeanah, 2001). None of these studies involved infants, and only a few involved preschool children, but the implications for the importance of the caregiving context are so relevant that they deserve our attention in this chapter on infancy. There are several plausible explanations for these data that are not mutually exclusive: 1.  Parenting models explain these data by saying that children have severer reactions because their caregivers are disabled in their rearing skills by their own psychopathology. 2.  Bidirectional models explain these data by saying that when children are emotionally

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disturbed, the (normal?) empathic response of many parents is to also be distressed. The key difference in these models from parenting models is that children are seen as becoming disturbed first, and parenting does not influence their psychopathology. 3.  Shared genetic vulnerability models contend that parents who are vulnerable to developing emotional disorders pass on those vulnerability genes to their children. These models don’t depend on who became disturbed first or on parenting. In clinical practice it is tempting to rely most heavily on parenting models because we are used to believing in the importance of rearing. Within parenting models, there are additional potential sets of assumptions to consider: (1) Parenting completely causes children’s PTSD, and children only get PTSD because their parents aren’t doing well (full mediation model); (2) children develop PTSD on their own, but it is intensified by parents’ less than optimal functioning (partial mediation or moderation model); and (3) less than optimal parenting doesn’t cause PTSD or make it worse, but it can prevent it from getting better when it is an additive burden on the children (partial moderation model). However, the studies that could prove or disprove these models have yet to be conducted. In fact, the early studies described next, which analyze parenting models with cross­sectional data, do not consistently support a parenting model. A study involving 95 7- to 12-year-old children—the first to use an observational rating of parenting in relation to domestic violence (DV)—showed no simple association between severity of domestic violence and parental warmth. But after statistically “controlling” for observed child behaviors, negative life events, social support, maternal depression, and maternal trauma symptoms, then exposure to DV accounted for 17% of the variance in maternal warmth (Levendosky & Graham-­B ermann, 2000). However, severity of DV did not predict observed authoritycontrol, as it should have if DV effects operate through parenting. The authors acknowledged that the chicken-orthe-egg question could not be answered by this study design, and it was plausible that children were not reacting to their parents’ rearing style, but that the parents’ rearing

style was a reaction to their children’s symptoms. Furthermore, severity of DV was not directly related to observed child’s behavior either prosocial or antisocial, contrary to expectations. This study was limited in that it did not assess children’s psychiatric symptomatology as an outcome. However, children’s outcome was assessed in a later study (Levendosky, HuthBocks, Shapiro, & Semel, 2003) that tested an ecological model of the parent–child relationship as a mediator. These researchers studied 103 3- to 5-year-old children, 70% of whose mothers reported physically abusive DV during their children’s lifetime. PTSD was not measured, but the design and analysis are useful for shedding light on how violence is related to quality of parenting and how that, in turn, may be related to child outcome in more general terms. Severity of DV was associated with self-­reported higher parenting effectiveness, contrary to expectations. However, severity of maternal psychological problems appeared to mediate parenting quality; that is, mothers with severer psychological problems had lower self-­reported parenting effectiveness, suggesting, somewhat obviously, that mothers with psychological problems, not those who experience DV, per se, exhibit diminished parenting effectiveness. The model suggested that mothers with severe psychological problems and lower parenting effectiveness had children with higher scores of externalizing behavior—but overall this group of children did not show severe externalizing problems: The group mean on the Child Behavior Checklist (CBCL) Externalizing scale was only 55.78, with a standard deviation of 10.74, and the “clinically significant” accepted cutoff is 63. This group of researchers also used the Working Model of the Child Interview (Zeanah & Benoit, 1995) and found that mothers who experienced DV had more negative representations of their infants and themselves as mothers compared to mothers who had not experienced DV (Huth-Bocks, Levendosky, Theran, & Bogat, 2004). This finding suggests that trauma to a mother impacts the quality of her rearing skills, and by extension, has an impact on her children. However, this study did not measure actual rearing quality or any child outcomes. Furthermore, this study is limited by the fact



21. Posttraumatic Stress Disorder

that DV does not happen at random in the population, and mothers who suffer violence also may possess different working models prior to their involvement in abusive relationships. A clue that infants are influenced by violent rearing environments was provided by DeJonghe and colleagues, who studied 30 DV-exposed and 59 non-­exposed 12-monthold infants. The exposed group showed more facial distress in response to a staged angry phone call by a female experimenter (DeJonghe, Bogat, Levendosky, von Eye, & Davidson, 2005). Although not surprising that these findings were consistent with research that has shown that infants can be affected by violence at this age, and there was no concurrent measure to indicate if facial distress co-­occurred with increased symptomatology or impairment, this study does provide a more standardized and observational laboratory confirmation that 12-month-old infants have the capacities to scan, process, and react to their environments for these types of salient events, and these capacities were generalized because they were shown in the absence of cues from their mothers. In another study by this group, 48 twelvemonth-old infants were assessed for the impact of witnessing DV (Bogat et al., 2006). A strict assessment of PTSD was not conducted, but infants showed a mean of 1.04 posttraumatic symptoms (range 0–7). In addition, the time frame was within 2 weeks of the traumatic events, so it’s problematic to consider these true PTSD symptoms, which must be present for a minimum of 1 month. Nevertheless, a moderating relationship was shown for level of maternal posttraumatic distress. That is, those infants who had witnessed relatively more violence showed more trauma symptoms only if their mothers had higher levels of trauma symptoms, and this relationship was not present for those who had witnessed relatively less violence. The author’s interpretation was that the severer violence led to severer maternal symptoms which led to changes in parenting, consistent with a relational PTSD model in which maternal symptoms may worsen children’s symptoms (Scheeringa & Zeanah, 2001). Stoddard and colleagues (2006) collected data from 52 children with burns, ages 12–48 months, and their caregivers (Stoddard et al., 2006). They found that 29% met

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criteria for PTSD by the alternative criteria (Scheeringa et al., 2003). Parents’ symptomatology partially mediated the relationship between children’s levels of pain and acute stress symptoms.

ASSESSMENT Children with PTSD may not appear symptomatic to most observers. This leads to a public health challenge because professionals and caregivers do not recognize PTSD or provide appropriate treatment. For example, the 3-month-old girl described earlier, “was described by observers in the hospital as a ‘lovable baby’—happy, cute, and highly sociable”—despite her multiple injuries and list of problems (Gaensbauer, 1982, p.  35). In one study of preschool children, only 12% of their actual PTSD symptomatology was observed and/or elicited by a clinician in the office (Scheeringa et al., 2001). Therefore, the most efficient assessment method is to interview the caregiver. An additional problem, however, is that parents may endorse many items reflecting symptomatology but then reject a referral to treatment because they think their child doesn’t need it. Contrast this situation to that involving children with severe externalizing disorders, whose annoying and disruptive behaviors can be spotted across a room, and who, as a group, are disproportionately represented in preschool clinic populations (Peebles, 1997). Complicating this issue is that PTSD is not in the normal lexicon describing observable phenomenon for most people. We all know what depression and hyperactivity look like. But most people, in their ordinary experiences, do not know what it’s like to have overgeneralized fear responses to nonthreatening stimuli or a constant state of hyperarousal in the absence of a present stressor. Once a pediatrician asked me how to recognize PTSD in children in the pediatric clinic. Before I could answer, he described an anecdote of a child who had been struck by a car. The child’s mother told the pediatrician that the child was now afraid to cross the street with her. The pediatrician had told her that that was normal and to basically ignore it. Unfortunately, PTSD may be missed even by motivated professionals—and this oversight constitutes one source of false

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negatives in assessment. Another source of false negatives arises from caregivers who minimize, deny, or are simply unaware of their children’s symptoms, perhaps because of their own symptomatology. False positives, also a challenge, may arise when clinicians equate the young child’s experience of a traumatic event or subthreshold symptomatology with a diagnosis of PTSD. In fact, most traumatized young children do not develop PTSD. In addition, caregivers may overreport signs of PTSD in their children, perhaps projecting their own symptoms onto the children. Although the accuracy of parental reports of young children’s posttraumatic symptoms has not been studied carefully, there are relevant data to consider. Many studies have been conducted with simultaneous assessments of both caregivers and children, and they generally report moderate to strong convergence of symptomatology (Scheeringa & Zeanah, 2001). These data are most compatible with the false-­positive problem, though a reasonable rival hypothesis is that parents and young children are both traumatized, and the parent reports are accurate.

Interviewing To minimize false positives and false negatives and to assess for PTSD in young children, one must conduct a comprehensive, standardized, and rigorous interview of the caregiver. Such an interview involves systematically inquiring about all 17 signs of PTSD, as well as the associated signs in young children. Specifically, one must ask, from a menu of probes, about possible signs and symptoms until the caregiver answers “yes,” or the interviewer runs out of probes. Further, in our interviewing technique, before we endorse an item as being present, we typically require an example, a date of onset, duration, and frequency. For example, for an infant who was physically abused by the father, the initial probe question for the item “psychological distress at reminders to the traumatic experience” would be to ask, “Does your child show distress when exposed to things that could remind him/her about the (traumatic event)?” If the caregiver replies “No,” then the interviewer is obligated to ask more specific probes. “What about if something hap-

pens that might be close to what happened, like you tell her to stop doing something?” If the answer is no, continue. “What about if somebody raises their voice and yells at him/ her or around him/her?” If the answer is no, continue. “What about being spanked?” If the answer is no, continue. “What about being in certain positions, or being handled roughly?” If the answer is no, continue. “What about being around the man who abused him/her, or being around any man that might remind him/her of that man?” If the answer is no, continue. Continue until the interviewer has exhausted all possible triggers applicable to that particular situation. Clinicians may have reservations about this technique because they were trained not to “lead the witness.” This is not leading the witness, however. Instead, this is being clear about the meaning of probes. Most caregivers have no frame of reference for the internalized and abstract items comprising signs of PTSD, so they need education about how these signs appear in young children. These signs are in contrast to other types of symptomatology, as already noted, such as hyperactivity or depression, which are readily observable and intuitively obvious to most people. If clinicians follow up every endorsement by asking for specific examples, frequency, duration, and onset, there is very little chance that caregivers will overreport symptomatology.

PTSD if the Trauma Is Unknown If it is suspected that infants or older preverbal children have been traumatized but no adult witness is available who can describe what happened, this presents a challenge to diagnosing PTSD. In one common scenario, it may be known that something happened, but the details are unclear. For example, the caregiver is a grandparent or foster parent who knows that some type of maltreatment is alleged as a reason to remove a child from the parents’ care. In another common scenario, it is unknown if a trauma has occurred, but the child’s behaviors are abnormal. For example, new onset of sexualized behavior following a visitation with another parent or after a babysitting episode, but no adult has confirmed that anything traumatic happened, and there is no physical evidence.



21. Posttraumatic Stress Disorder

In both of these cases, it is useful to remember that 5 of the 17 PTSD items represent triggered phenomenon (the other 12 items are more nonspecific). These five items are psychological distress at reminders, physiological distress at reminders, intrusive recollections of the event (or play reenactments), avoidance of external reminders, and avoidance of internal reminders. If the infant or young child has PTSD, the caregiver ought to be able to report that there are certain situations that trigger distress or avoidance in him or her. From our example earlier, if a caregiver notices that a child shows wideeyed terror and cries when her husband raises his voice, this reaction is not normative childhood behavior and is an indicator that the child is being triggered by a reminder of something similar to past maltreatment. Short of verbal confirmation from an adult who witnessed the child’s original trauma, these types of clues are the best for which we can hope. These are reasonably reliable, since they involve both non-­normative behavior and triggered fear responses.

Specific Measures As noted earlier, the only proper assessment of PTSD in young children is to conduct a comprehensive, standardized, and rigorous interview of the caregiver. Two standardized diagnostic interviews are available that have been developmentally adapted for caregivers of young children. The Posttraumatic Stress Disorder Semi­Structured Interview and Observational Record for Infants and Young Children (PTSDSSI) has been the most widely used in multiple studies of very young children (Scheeringa et al., 2001; Scheeringa et al., 2003; Stoddard et al., 2006). A traumatic events screen at the beginning includes a menu of 11 different types of traumatic events. The interview inquires about the 17 items of PTSD from the DSM-IV, and alternative developmentally sensitive wordings are provided for 5 of the items. In addition, the interview includes questions about four associated symptoms that are not part of the DSM-IV criteria but empirically have been found to be common in young children. There are five questions at the end to establish whether functional impairment or significant distress is associated with the symptomatology. Interrater

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reliability in which a second rater coded the measure from a videotape of an interviewer using this interview for 11 cases from a psychiatric clinic was good (mean Cohen’s kappa 0.75 for all 17 items) and was excellent for agreement on the full diagnosis by the alternative algorithm (Cohen’s kappa 0.79). This measure has been translated into Dutch, German, Spanish, and Hebrew. The Preschool Age Psychiatric Assessment (PAPA) is a structured diagnostic interview of 2- to 5-year-old children that includes detailed probes about PTSD symptomatology plus a traumatic events screen for 21 different events and a functional impairment section. The symptomatology section includes 15 of the 17 DSM-IV items; sense of a foreshortened future and loss of interest in usual activities have to be extracted from the depression module. It also includes five associated symptoms that are not part of the DSM-IV criteria but are common in young children. In one study, the 1-week test–­retest reliability of a large number of preschool children (N = 307) was good to excellent (Egger et al., 2006). Retest agreement was not reported for individual items. It was noted earlier that a study of observational assessments of infant and preschool children in the office detected only about 12% of their actual PTSD symptomatology (Scheeringa et al., 2001). Since nearly all of this 12% of symptomatology also was reported in caregiver interviews, it is neither time efficient nor useful to try to elicit diagnostic information directly from young children. Clinical interaction and observational assessments may, of course, be valuable for other purposes, but not for making diagnoses of PTSD. Self-­administered checklists (completed by caregivers about their children) for PTSD symptomatology should not be used in routine clinical practice. Because of the issues noted earlier—most persons have no frame of reference for these types of internalized and abstract items—self-­administered checklists are almost certain to be less accurate than responses elicited by a well-­trained interviewer. This will be true particularly for the critical items regarding triggered events involving reexperiencing and avoidance. Checklists can be useful for screening large numbers of children in schools or for very large surveys where time-­consuming in-

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terviews are not used, but they always carry the limitations noted above.

COMORBIDITY AND ASSOCIATED SYMPTOMATOLOGY Young children with PTSD are often first noticed by adults as having something wrong with them due to associated problem behaviors (usually of the externalizing sort) rather than due to the internalized and/or triggered symptomatology of PTSD. The first study of comorbid disorders in very young children with PTSD studied 62 1- to 6-year-old children who had all experienced one or more traumatic events. Of the 16 children who met criteria for a diagnosis of PTSD, 75% also met criteria for oppositional defiant disorder (ODD), 63% had separation anxiety disorder (SAD), 38% had attention-­deficit/ hyperactivity disorder (ADHD), and 6% had major depressive disorder (MDD) (Scheeringa et al., 2003). This high rate of ODD was replicated in a recent study of 70 three- to six-year-old children who experienced Hurricane Katrina. Of the 35 children diagnosed with PTSD, 61% also had ODD, 21% had SAD, 33% had ADHD, and 43% had MDD (Scheeringa & Zeanah, 2008). Over half (57%) of the ODD disorders started immediately after the hurricane experiences. Thus, in both of these studies over three­fourths of children with PTSD also had at least one other comorbid disorder, and we can surmise that over half of these comorbid disorders started after their traumatic experiences. Furthermore, and perhaps most importantly, the latter study also found that none of the new-onset comorbid disorders existed in the absence of PTSD symptoms. In other words, non-PTSD disorders that arose following traumatic events were always accompanied by PTSD symptomatology. This finding is consistent with findings from the only other known study to track onsets of disorders in this fashion, a study of adult flood survivors, and also found that no nonPTSD disorders developed in the absence of PTSD symptomatology (McMillen, North, Mosley, & Smith, 2002). The take-home lessons from this type of research: Assessments of young children who are brought in for new problems (of whatever type) that begin following trau-

matic events need to include assessments of PTSD. The most parsimonious and efficient treatment approach is to be to treat the posttraumatic symptomatology first, as that is likely to have a ripple effect for improving the comorbid disorders.

COURSE Studies of adult trauma survivors have shown consistently that although there is usually a statistically significant decrease in the group mean for the number of PTSD items over long follow-ups, PTSD fails to remit in more than one-third of cases (Norris & Slone, 2007). Furthermore, the disorder can persist for decades (Lee, Vaillant, Torrey, & Elder, 1995). This prospect of chronic and unremitting PTSD takes on new salience in early childhood during a time of uniquely rapid brain development. Given the speculation noted earlier about potentially permanent alterations in the developing brain, maladaptive personality traits, and greater chronicity of symptomatology (Perry et al., 1995; Schore, 2002), it seems reasonable to ask, What is known about the course and prognosis of PTSD in young children? Preliminary data are sparse but worrisome. Only one study has prospectively followed PTSD in young children. We followed 35 children for 2 years who were 1–6 years old at the first assessment (Scheeringa et al., 2005). There was no statistically significant decrease in the number of PTSD items over these 2 years. This finding contrasts with the findings from adult studies of improvement for most patients over time (Norris & Slone, 2007). Other studies have also shown lack of remittance in samples of older children. Thirty months after preschool Israeli children experienced Scud missile attacks Laor, Wolmer, Mayes, and Gershon (1997) reassessed their posttraumatic symptoms. The subset of children who were not displaced (as opposed to the subset that was displaced by home damage) did not show significant improvement over this time. The children in the displaced group may have shown statistical improvement because they were so symptomatic at the first assessment that the follow-up assessment found them somewhat improved but still highly symptomatic. McFarlane’s study of 808 school-age children exposed



21. Posttraumatic Stress Disorder

to an Australian bush fire showed no significant improvement in posttraumatic phenomena after 18 months (McFarlane, 1987). In a study of children exposed to Hurricane Andrew, 53% showed no change and 17% had actually worsened in PTSD symptoms after 21 months (Shaw, Applegate, & Schorr, 1995).

TREATMENT There are no controlled psychotherapy studies of infants with PTSD. The few controlled studies that have included older preschool children have used cognitive-­behavioral therapy (CBT; Cohen & Mannarino, 1996a, 1996b; Deblinger, Steer, & Lipmann, 1999; Scheeringa et al., 2007) or child–­parent psychotherapy (CPP; Lieberman, Van Horn, & Ghosh Ippen, 2005). CBT cannot be used with infants and younger toddlers because they lack the cognitive and verbal capacities to engage in the therapy, but other treatments are available.

Acute (Less Than 1-Month) Reactions Research on the course of PTSD has been clear that, following life-­threatening events, most individuals show some PTSD-like symptomatology in the first month (Davidson et al., 1991), but only approximately 30% show enduring symptomatology after the first month (Kessler et al., 1995). Recognition of these findings has been codified in a National Institute for Clinical Excellence report, which recommends watchful waiting for mild symptoms within the first month (National Institute for Clinical Excellence [NICE], 2005). However, if symptomatology is severe and impairing within the first month, treatment probably ought to start immediately.

Work with Caregivers The first approach probably ought to focus on teaching caregivers to (1) recognize what situations trigger the overgeneralized fear reactions of PTSD in their infants, (2) protect their infants from those triggers, and (3) rapidly and effectively soothe them when they become distressed. Situational triggers stem directly from children’s traumatic experiences but are not

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always intuitively obvious. A preschool child was in an automobile accident in which the car was rear-ended by a speeding truck. The gas tank ruptured, and the smell of gas was strong. The child’s cognitive distortion of the event produced a narrative in which the accident had occurred because his family had run out of gas, and his PTSD reaction was triggered whenever the car came to a stop (Scheeringa et al., 2007). Another young child was trapped in his home through the Hurricane Katrina disaster and experienced a series of stressful events over days. Initially, his mother believed that his most terrifying moment had been when he had to evacuate in a boat without her. However, during the course of therapy it became clear that he was triggered by the dark, and his most salient fear actually stemmed from spending 2 nights in their dark, suffocatingly hot attic waiting to be rescued (Scheeringa et al., 2007). If sensitive responding by parents does not lead to improvement within a month, then more systematic approaches in office-based therapy ought to be tried. CPP may be useful for younger children because of the focus on enhancing emotional communication during parent–child interaction. Lieberman et al. (2005) assessed 75 three- to five-year-old children who had witnessed marital violence and randomly assigned them to either a 50-week CPP protocol or to case management plus standard community treatment. CPP was significantly more effective than community treatment for reducing posttraumatic stress symptomatology. Interestingly, CPP also showed significant reductions in total maternal PTSD severity scores, driven mostly by reductions in the avoidance cluster. CPP, with its heavy emphasis on joint mother–child free play interspersed with individual sessions for the mothers, emphasizes the value of including caregivers in the treatment. Limitations include the practical problem of retaining families in treatment for 50 weeks. In a novel study (Schechter et al., 2006), a sample of 32 mothers with 8- to 50-monthold children were videotaped in a structured laboratory interaction that included free play, separation, and reunion. The clinician then chose four 30-second excerpts to show to the mothers at their next visit. The excerpts were chosen to show both positive and negative moments. As the video excerpts were

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shown to the mothers, the clinician probed with a series of scripted questions to lead the mothers to think about what both they and their children were feeling at those moments, and also commented on the positive qualities the parents showed while interacting with their children. Serial measurements of how negatively mothers described their children (maternal attributions) showed that mothers described their children more positively following the clinician-led video­feedback session. This type of emerging research suggests the potential value of working with caregivers to alter their parenting amid issues of violence and trauma. Parent–child interaction therapy (PCIT) was developed as a treatment for oppositional behavior but has been proposed as a potential treatment for maltreated toddlers because of the focus on the parent–child relationship in the first phase (Timmer, Urquiza, & Zebell, 2005; Urquiza & McNeil, 1996). An adaptation of PCIT, called parent–child attunement therapy, was described as improving behavioral problems of a 23-monthold child (Dombrowski, Timmer, Blacker, & Urquiza, 2005). There have been no controlled studies of this approach with PTSD and no known case reports with traumatized infants. Theoretically, PCIT could be effective for relational issues, particularly in cases of maltreatment, but it does not include techniques for addressing past traumatic events or triggered fear reactions. If efforts with caregivers are still not effective in eliminating children’s symptoms or impairment, consideration should then be given to a procedure to help extinguish the children’s overgeneralized fear reactions.

Play Therapy There are no controlled trials and no known published case reports of using play therapy for PTSD with 12-month-old or younger infants. Due to their cognitive developmental limitations it is difficult, if not impossible, for infants to abstractly connect current office maneuvers to past events. Play therapy becomes more feasible as children turn 2, or more generally 3, years old. Excellent case­centered descriptions of how to conduct play therapy with these older toddlers are available (Gaensbauer, 1995, 1997; Gaensbauer et al., 1995).

Prolonged Exposure Prolonged exposure therapy teaches patients to implement positive coping skills while maintaining exposure to the feared stimulus. Since infants cannot implement self-­soothing skills on command, using prolonged exposure with infants would appear as more of an involuntary flooding experience. Solter’s (2007) case of treating a 5-month-old boy with flooding was described earlier. Caution must be urged, given the involuntary nature of the procedure and potential for extreme distress, and, of course, any procedure that could exacerbate a child’s symptoms urges considerable caution.

Eye Movement Desensitization and Reprocessing Including a review of at least 10 well­conducted randomized clinical trials, eye movement desensitization and reprocessing (EMDR) has been found to be as effective as other less controversial treatments for PTSD, (Bradley, Greene, Russ, Dutra, & Westen, 2005), but none of these studies included young children. There have been several individual case reports of successful use of EMDR with 4- and 5-year-old children (Cocco & Sharpe, 1993; Greenwald, 1994; Tufnell, 2005), and less rigorous anecdotal reports of treatment of younger children (Lovett, 1999; Tinker & Wilson, 1999). The potential advantages of using EMDR with young children are enormous. EMDR does not require patients to verbalize their thoughts. The bilateral processing does not have to involve eye movements and can be effective with bilateral auditory or tactile stimuli. Treatment effects are often seen relatively quickly compared to other treatment modalities. Preliminary work needs to be conducted with controlled trials in young children.

CONCLUSIONS The first few years of life are important because the brain is developing and refining circuitry that may be lasting. It is not yet clear if this period provides protective plasticity or greater vulnerability to extreme stress. The case studies of disturbed infants and the



21. Posttraumatic Stress Disorder

controlled investigations of preschool children suggest that older infants are at least equally vulnerable as other age groups and leave open the possibility that they are at greater vulnerability. The gaps of knowledge identified possess pressing salience. These gaps include identifying earliest possible ages for PTSD, earliest memory capacities, the bidirectional influences of parent–child relationships, and the lack of controlled treatment studies. A major issue is underdetection, and hence, undertreatment of young children. Only by ensuring that health and mental health professionals understand the subtleties of PTSD in young children will we be able to meet the challenge that confronts us. References Baker-Ward, L., Gordon, B., Ornstein, P., Larus, D., & Clubb, P. (1993). Young children’s longterm retention of a pediatric examination. Child Development, 64, 1519–1533. Bell, M., & Fox, N. (1992). The relations between frontal brain electrical activity and cognitive development during infancy. Child Development, 63, 1142–1163. Bogat, G., DeJonghe, E., Levendosky, A., Davidson, W., & von Eye, A. (2006). Trauma symptoms among infants exposed to intimate partner violence. Child Abuse and Neglect, 30, 109–125. Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-­analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214–227. Chen, E., Zeltzer, L., Craske, M., & Katz, E. (2000). Children’s memories for painful cancer treatment procedures: Implications for distress. Child Development, 71, 933–947. Cicchetti, D., & Rogosch, F. (2006). Personality, adrenal steroid hormones, and resilience in maltreated children: A multilevel perspective. Development and Psychopathology, 19, 787–809. Coates, S., & Schechter, D. (2004). Preschoolers’ traumatic stress post-9/11: Relational and developmental perspectives. Psychiatric Clinics of North America, 27, 473–489. Cocco, N., & Sharpe, L. (1993). An auditory variant of eye movement desensitization in a case of childhood post-­traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 24, 373–377. Cohen, H., Benjamin, J., Geva, A. B., Matar, M. A., Kaplan, Z., & Kotler, M. (2000). Autonomic dysregulation in panic disorder and in posttraumatic stress disorder: Application of power spectrum analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks. Psychiatry Research, 96, 1–13.

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Gaensbauer, T., Chatoor, I., Drell, M., Siegel, D., & Zeanah, C. (1995). Traumatic loss in a one-yearold girl. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 520–528. Ghosh Ippen, C. G., Briscoe-Smith, A., & Lieberman, A. F. (2004, November). PTSD symptomatology in young children. Paper presented at the International Society for Traumatic Stress Studies 20th annual meeting, New Orleans. Greenwald, R. (1994). Applying eye movement desensitization and reprocessing (EMDR) to the treatment of traumatized children: Five case studies. Anxiety Disorders Practice Journal, 1, 83–97. Gunnar, M., & Vazquez, D. (2001). Low cortisol and a flattening of expected daytime rhythm: Potential indices of risk in human development. Development and Psychopathology, 13, 515–538. Howe, M., Courage, M., & Peterson, C. (1994). How can I remember when “I” wasn’t there: Long-term retention of traumatic experiences and emergence of the cognitive self. Consciousness and Cognition, 3, 327–355. Huth-Bocks, A., Levendosky, A., Theran, S., & Bogat, G. (2004). The impact of domestic violence on mothers’ prenatal representations of their infants. Infant Mental Health Journal, 25, 79–98. Kangas, M., Henry, J., & Bryant, R. (2005). A prospective study of autobiographical memory and posttraumatic stress disorder following cancer. Journal of Consulting and Clinical Psychology, 73, 293–299. Kaufman, J., & Charney, D. (2001). Effects of early stress on brain structure and function: Implications for understanding the relationship between child maltreatment and depression. Developmental Psychopathology, 13, 451–471. Kessler, R., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060. Laor, N., Wolmer, L., Mayes, L. C., & Gershon, A. (1997). Israeli preschool children under Scuds: A 30-month follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 349–356. Lee, K., Vaillant, G., Torrey, W., & Elder, G. (1995). A 50-year prospective study of the psychological sequelae of World War II combat. American Journal of Psychiatry, 152, 516–522. Levendosky, A., & Graham-­B ermann, S. (2000). Behavioral observations of parenting in battered women. Journal of Family Psychology, 14, 80–94. Levendosky, A. A., Huth-Bocks, A. C., Semel, M. A., & Shapiro, D. L. (2002). Trauma symptoms in preschool-age children exposed to domestic violence. Journal of Interpersonal Violence, 17, 150–164. Levendosky, A., Huth-Bocks, A. C., Shapiro, D., & Semel, M. (2003). The impact of domestic violence on the maternal–child relationship and

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Peterson, C., & Whalen, N. (2001). Five years later: Children’s memories of medical emergencies. Applied Cognitive Psychology, 15, S7–S24. Schechter, D. S., Myers, M. M., Brunelli, S. A., Coates, S. W., Zeanah, C. H., Davies, M., et al. (2006). Traumatized mothers can change their minds about their toddles: Understanding how a novel use of videofeedback supports positive change of maternal attributions. Infant Mental Health Journal, 27, 429–447. Scheeringa, M., Salloum, A., Arnberger, R., Weems, C., Amaya-­Jackson, L., & Cohen, J. (2007). Feasibility and effectiveness of cognitive-­behavioral therapy for posttraumatic stress disorder in preschool children: Two case reports. Journal of Traumatic Stress, 20, 631–636. Scheeringa, M., & Zeanah, C. H., Jr. (2008). Reconsideration of harm’s way: Onsets and comorbidity patterns in preschool children and their caregivers following Hurricane Katrina. Journal of Clinical Child and Adolescent Psychology, 37, 508–518. Scheeringa, M., Zeanah, C. H., Jr., Myers, L., & Putnam, F. (2005). Predictive validity in a prospective follow-up of PTSD in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 899–906. Scheeringa, M. S., Peebles, C. D., Cook, C. A., & Zeanah, C. H., Jr. (2001). Toward establishing procedural, criterion, and discriminant validity for PTSD in early childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 52–60. Scheeringa, M. S., & Zeanah, C. H., Jr. (2001). A relational perspective on PTSD in early childhood. Journal of Traumatic Stress, 14, 799–815. Scheeringa, M. S., Zeanah, C. H., Jr., Drell, M. J., & Larrieu, J. A. (1995). Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 191–200. Scheeringa, M. S., Zeanah, C. H., Jr., Myers, L., & Putnam, F. W. (2003). New findings on alternative criteria for PTSD in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 561–570. Scheeringa, M. S., Zeanah, C. H., Jr., Myers, L., & Putnam, F. W. (2004). Heart period and variability findings in preschool children with posttraumatic stress symptoms. Biological Psychiatry, 55, 685–691. Schore, A. N. (2002). Dysregulation of the right brain: A fundamental mechanism of traumatic attachment and the psychogenesis of posttraumatic stress disorder. Australian and New Zealand Journal of Psychiatry, 36, 9–30. Shaw, J., Applegate, B., & Schorr, C. (1995). Twenty-one-month follow-up study of school-age children exposed to Hurricane Andrew. Journal of

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C h a p t e r 22

Sleep Disorders Judith Owens Melissa M. Burnham

A

lthough the phrase “sleeping like a baby” conventionally implies certain characteristics, such as sleeping deeply and for long uninterrupted bouts, developmental sleep researchers—and anyone who has ever lived with an infant—have long understood that “typical” infant sleep is characterized by a variety of different behaviors and patterns, as well as by a number of structural features (“sleep architecture”) unique to sleep in early life. Furthermore, both the regulation and timing (i.e., “chronobiology”) of sleep undergo substantial developmental changes across the first 3 years of life, and infants often experience either transitory or longer-­lasting disturbances in their sleep during this period. In this chapter we review the typical course of sleep–wake state development across the first 3 years of life, discuss the most common sleep disturbances seen during this period, describe sleep disturbances in the context of other disorders, and provide an overview of common interventions used to treat infant–­toddler sleep problems.

ONTOGENETIC COURSE OF SLEEP ACROSS THE FIRST 3 YEARS Although the focus of this chapter is on postnatal development, it should be noted that researchers generally agree that sleep states are evident in the last trimester of the prenatal period. Mirmiran, Maas, and Ariagno (2003), in a review of this work, reported that both active and quiet sleep can be differentiated as early as 32 weeks gestation and that quiet sleep increases from 32 to 40 weeks gestation with a concomitant decrease in indeterminate sleep. Active sleep, however, appears to remain relatively constant during the last weeks of gestation. Similar results are found in preterm infants of the same postconceptional age. The high proportion of active sleep during late gestation parallels rapid brain maturation that is occurring at this time, implicating active sleep as potentially playing a role in brain development (Mirmiran et al., 2003). In addition to these changes in sleep architecture 362



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during the prenatal period of life, circadian rhythms also are evident in the last trimester of gestation. Mirmiran (1996) Lunshoff and colleagues (1998) have reported a circadian fetal heart rate rhythm that is entrained to maternal rest–­activity, cortisol, melatonin, body temperature, and heart rate rhythms. Thus, even during prenatal life, the circadian clock appears to be functional. Following the prenatal period, dramatic changes in sleep occur during the first 3 years of life, including the average sleep duration, sleep architecture, and the timing of sleep and wakefulness across the 24hour day. At birth, the typical infant spends significantly more time asleep than awake, has a disproportionately higher percentage of active versus quiet sleep, and sleeps about the same amount during the day and night (Kleitman & Englemann, 1953; Roffwarg, Dement, & Fisher, 1964). By age 3, all of this has changed such that the average 3-year-old now has consolidated sleep into one lengthy nighttime bout and one daytime nap, is starting to exhibit adult proportions of active and quiet sleep, and sleeps for an average of about 12 hours per 24-hour day (Jacklin, Snow, Gahart, & Maccoby, 1980). These transformations are discussed in turn. Detailed studies of infant sleep from the middle of the previous century served to inform some general misperceptions that existed at the time. For example, it was discovered that during the newborn period, the average child sleeps approximately 16–17 hours per day, in sharp contrast to the 20–22 hours that was reported in pediatric textbooks prior to the 1950s (Kleitman & Englemann, 1953; Parmelee, Schulz, & Disbrow, 1961). Also, it had been generally accepted that the total amount of sleep declines early in infancy. The seminal longitudinal work of Kleitman and Engelmann (1953), however, showed that the total duration of sleep did not differ over the first 3 months of life; rather, it is the distribution of sleep across the 24-hour day that changes, so that more sleep becomes prominent (or “consolidated”) during the nighttime hours. This finding has been substantiated in subsequent investigations (e.g., Anders & Keener, 1985; Coons & Guilleminault, 1984). Total sleep time across 24 hours does decline some-

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what beyond the 3-month mark, but most infants continue to sleep between 12 and 14 hours per day through the age of 2 years. The longest uninterrupted sleep period at night continues to increase until leveling off sometime between 3 and 6 months of age for the remainder of the first year of life (Anders & Keener, 1985; Burnham, Goodlin-Jones, Gaylor, & Anders, 2002). Notwithstanding these changes, it should be noted that “sleeping through the night” is a misnomer for most infants and toddlers across the first 3 years of life. Most young children continue to wake up during the night; a substantial proportion, however, learn to self-­soothe (sleep “regulation”) and put themselves back to sleep independently upon such awakenings (e.g., Burnham et al., 2002). In addition to changes in the total amount of sleep, substantial changes occur in the nighttime architecture of sleep as well. For instance, although the typical adult enters sleep at the beginning of the night through (non-rapid-eye-­movement non-REM) sleep stages (progressing through stages 1–4), very young infants enter sleep in an active (or “REM-like”) sleep state. Active sleep (AS) onset occurs during the early months of life and generally declines with age. Coons and Guilleminault (1984) reported a significant decrease in AS-onset sleep periods between 3 and 6 weeks of age, and again between 4 and 6 months of age. In addition to the entry into active sleep, young infants also experience much higher proportions of total sleep time in active sleep, compared to adults and older children (Ficca, Fagioli, & Salzarulo, 2000; Jenni, Borbély, & Achermann, 2004). The decline in the percent of the night spent in active sleep across the first year of life is accompanied by a concomitant increase in quiet (or “slow wave-like”) sleep (Anders & Keener, 1985; Burnham et al., 2002; Dittrichová, 1966; Louis, Cannard, Bastuji, & Challamel, 1997). For instance, Jenni and colleagues (2004) report that 2-weekolds spend approximately 51% of the night in active sleep and 39% of the night in quiet sleep; these percentages gradually change to 30% and 70%, respectively, by 9 months of age. As mentioned in the section on prenatal development, the proclivity for active sleep during early development is thought to play a role in brain development (Peirano, Algar-

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ín, & Uauy, 2003). The cycle length of each active–quiet sleep bout is also shorter in infancy and early childhood compared to the 90-minute cycle characteristic of adult sleep architecture. This so-­called ultradian cycle is closer to 60 minutes in infancy (Aserinsky & Kleitman, 1955; Dittrichová, 1966; Harper et al., 1981), with the adult cycle pattern thought to emerge sometime during middle childhood (Roffwarg et al., 1964). Perhaps the most striking developmental sleep change that occurs during early infancy is the maturation of the circadian system and the infant’s gradual synchronization (or “entrainment”) to the 24-hour light–dark cycle. The bulk of research to date suggests that infants are not born with a clear relationship between sleep and wakefulness and time of day. Rather sleep patterns are largely dependent on hunger, satiety, and feeding schedules. Thus, sleep is distributed for the young infant almost equally between night and day. Young infants typically sleep for 3- to 4-hour periods (which may be shorter in breastfed infants) separated by 1–2 hours of wakefulness. Remarkably, by about 3 months of age, most infants have established consolidated sleep periods that occur during the nighttime hours (Bamford et al., 1990; Burnham, 2007; McMillen, Kok, Adamson, Deayton, & Nowak, 1991). Although largely ignored in discussions of “average” or “typical” sleep, it is essential to note that there appears to be individual variability in total sleep amount, in the timing of sleep–wake rhythmicity, in the proportion of time spent in each sleep state during sleep itself, and in the longest period of consolidated sleep, among other sleep–wake variables (e.g., Anders, Halpern, & Hua, 1992; Emde & Walker, 1976; Fazzi et al., 2006; Navelet, Benoit, & Bouard, 1982; Sadeh, Hauri, Kripke, & Lavie, 1995; St. James-­Roberts & Plewis, 2006). For example, an epidemiological study of 493 children studied from 1 month to 16 years of age in Switzerland revealed significant variability in total sleep duration, nighttime sleep duration, and daytime sleep duration (Iglowstein, Jenni, Molinari, & Largo, 2003). Although researchers are beginning to recognize and examine these individual differences and possible etiological factors in older children (e.g., Buckhalt, El-­Sheikh, & Keller, 2007) and adults (Tucker, Dinges, & Von Dongen, 2007),

more research into individual differences at earlier ages is needed. These interindividual differences are important partly because they illuminate the complexity involved in clearly defining the boundary between normal and pathological sleep in young children, and thus in recognizing and evaluating sleep disturbances in this population.

SLEEP DISTURBANCES Definition As described above, the definition of a sleep “problem” in infants and toddlers is complicated by the existence of strong variability in individuals’ “normal” sleep. There are additional complicating factors as well. Before describing the prevalence and types of sleep disturbances that are commonly diagnosed in infants and toddlers, these definitional issues are mentioned in an effort to elucidate the complexity in diagnosing and treating such disturbances in this population. Factors such as inter- and intracultural variation in what is considered “normal,” extreme developmental changes that occur during this age period, the fact that sleep disturbances occur in the context of parent–child relationships, and the existence of various systems for clinically classifying sleep “disorders” are all involved in complicating the definition of sleep problems in this age group. For example, culturally based values and beliefs regarding the meaning, importance, and role of sleep in daily life, as well as culturally based differences in sleep practices (e.g., sleeping space and environment, solitary sleep vs. cosleeping, use of transitional objects) have a profound effect not only on how a parent defines a sleep “problem” but on the relative acceptability of various treatment strategies. Furthermore, the patient is rarely the one who presents with a chief complaint of sleeplessness. Thus, parental concerns and subjective observations regarding their child’s sleep patterns and behaviors often define what constitutes a sleep “disturbance” in the clinical context. Parental recognition and reporting of sleep problems in children also vary across childhood, with parents of infants and toddlers more likely to be aware of sleep concerns than those of school-age children, for example. Finally, the daytime se-



22. Sleep Disorders

quelae of inadequate or disrupted sleep may also be less easily recognized, as excessive daytime sleepiness in children is frequently manifested as behavioral and/or neurocognitive dysfunction. Clinicians, then, need to be careful in diagnosing and treating such problems and must consider contextual and developmental factors that may be contributing to what is perceived as a sleeping disturbance.

Prevalence Despite the difficulty in delineating a clear, universally accepted definition of “problem sleep” in the infant–­toddler population, concerns with sleep are among the most common complaints of parents during well-baby visits (Thiedke, 2001). During infancy, the most frequent of these complaints has to do with excessive night waking, which affects as many as 15–20% of children under the age of 3 (Mindell, 1993). In toddlerhood, the concern often shifts to settling difficulties at bedtime. Settling problems are typically seen in 5–10% of children ages 2 and above (Mindell, 1993). These prevalence rates are largely determined by parental report, although some studies have shown similar rates using objective measures of sleep and a priori established research criteria (e.g., sleep onset ≥ 30 minutes, occurring ≥ 5 nights/week for ≥ 3 weeks; Gaylor, Goodlin-Jones, & Anders, 2001). The most commonly reported overall prevalence rate of any type of sleep problem in the infant–­toddler population is around 25% (Lozoff, Wolf, & Davis, 1985; Richman, 1981). However, a recent poll conducted by the National Sleep Foundation (2004) found that only 6% of parents of infants and 11% of parents of toddlers reported a sleep problem in their child. Thus, it is important for more community-based, randomized studies to be conducted in order to determine clear and accurate prevalence rates. Clinicians often rely exclusively on parent report of a problem in order to diagnose and treat a sleep disturbance in an infant or toddler. Indeed, sleep problems in infants and toddlers have been found to be correlated with maternal depression, parental fatigue, general disruptions to family life, poor maternal mental and physical health, and less parental well-being (e.g., Bayer, Hiscock, Hampton, & Wake, 2007). Some parents

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clearly do find disruptions in their child’s sleep to be problematic, yet individual tolerance levels and expectations differ greatly. Thus, one job of the clinician is to disseminate information on what is considered “typical” sleep in the infant–­toddler age period.

Problematic Night Waking As discussed above, the most common sleep complaint in the infant–­toddler parent population is night waking. The most common etiology for problematic night wakings is termed “behavioral insomnia of childhood, sleep-onset association subtype,” in the most commonly used classification scheme in pediatric sleep medicine, the International Classification of Sleep Disorders–2 (ICSD2; American Academy of Sleep Medicine, 2005). The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) classifies this type of sleep problem as a “dysomnia,” or difficulty initiating or maintaining sleep. The DSM-IV classification has limited usefulness in the infancy period, however, because specific criteria for young children are not distinguished, and young children rarely meet the impairment and/or severity criteria for the adult diagnosis. Most night waking during infancy is thought to occur because the infant has learned to depend upon or need specific circumstances or objects (“sleep-onset associations”) introduced by a caregiver (e.g., rocking, nursing, or a pacifier) in order to fall asleep. These are typically available to the child at bedtime; however, these same sleeponset associations are also often needed by the child in order to fall back to sleep after normal arousals or awakenings during the night. Thus, when the child wakes at night and these circumstances or objects are not present, the parent must reintroduce them in order for the child to reinitiate sleep. As infants and children typically arouse briefly on average four to six times throughout the night as a result of the normal ultradian rhythm of sleep cycles, these night wakings (or, more accurately, these failures to fall back to sleep) may occur as often as every 90–120 minutes. Night waking is only considered a disorder in the presence of “a specific constellation of symptoms of a defined severity level to be

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present for a specified time and to result in some significant impairment in functioning either in the child or in the parent(s) or family” (Mindell, Kuhn, Lewin, Meltzer, Sadeh, & American Academy of Sleep Medicine, 2006). In the absence of these criteria, a disorder is not diagnosed. Not all parents find it disturbing that their infants or toddlers need their assistance to fall asleep. Thus, two children may present with the exact same symptoms, but only the child whose parents find the pattern problematic, or who is experiencing impairment in daytime functioning, is diagnosed with a disorder. Excessive night waking is thought to be exacerbated by parents’ providing a bedtime environment that cannot be reproduced by the infant after waking up in the middle of the night. Fehlings, Weiss, and Stephens (2001) found that 6-month to 4-year-old children, referred from a sleep clinic, who experienced these types of “nonadaptive sleep associations” had significantly higher odds of night waking compared to a matched control group. In particular, the ability to self-­soothe has been clearly shown to be associated with the practice of putting the infant to bed while drowsy but still awake (i.e., avoiding associating sleep onset with parental intervention). In addition, parental responses to night wakings may, in and of themselves, be reinforcing (feeding, prolonged interactions). Although sleep associations are certainly part of the cause of night waking, there are apparently other reasons that night waking develops. Interestingly, active physical comforting at bedtime only explained 3% of the variance in infant sleep problems at 1 year when examined with other variables such as maternal cognitions, temperament, and maternal anxiety/depression, but it did explain more variance in the continuity of problematic sleep from the first to the second year of life (Morrell & Steele, 2003). Clearly, more research is needed to fully explain the reasons behind night waking in the infant–­toddler period.

Settling Difficulties The second most common sleep disorder found in the infant/toddler population is termed “behavioral insomnia of childhood, limit setting subtype” in the ICSD-2, and is defined as delaying or resisting bedtime. It

generally develops in children ages two and above, as children gain more independence and experience more fears, and is manifested by prolonged bedtime routines and strong resistance to going to bed (Crowell, Keener, Ginsburg, & Anders, 1987; Jenkins, Owen, Bax, & Hart, 1984; Salzarulo & Chevalier, 1983). Settling difficulties are thought to be exacerbated by parents’ inadequate enforcement of bedtime and/or responding to (and thus reinforcing) children’s “curtain calls” (requests, after bedtime, for one more story, one more drink of water, one more hug, 5 more minutes, and the like). The most robust research in this area comes from older children but demonstrates a significant correlation between bedtime resistance and daytime resistance to parental behaviors (Bates, Viken, Alexander, Beyers, & Stockton, 2002). Both daytime and bedtime resistance are considered the result of parents’ inability to set clear limits. Many children, of course, have symptoms of both the sleep-onset association type (night wakings) and limit-­setting type (bedtime resistance) of behavioral insomnia, and thus a clear distinction between subtypes is not always feasible. From a practical standpoint, the appropriate subtype should be based on the predominant symptom pattern for the previous 3 months, whenever possible. There are also a number of precipitating and perpetuating factors associated with night wakings and settling difficulties in infants and toddlers, which include both extrinsic (e.g., environmental situations, parental issues) and intrinsic (e.g., temperament, medical issues) factors and often represent a combination of these issues. Bedtime problems are often associated with child temperament (Carey, 1974; Keener, Zeanah, & Anders, 1988; Sadeh, Lavie, & Scher, 1994; Van Tassel, 1985). For example, “fussy” children may insist on a particular type of soothing/ sleep-­inducing technique, resisting any alternative that is less dependent on the caregiver. Some caregivers may have their own issues (e.g., mental illness, long work hours) that interfere with their ability to set clear limits both during the day and at bedtime. In other cases, there is a mismatch between parental expectations regarding sleep behaviors and the normal developmental trajectory (Mindell, 2006). Finally, environmental factors,



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such as living accommodations that require a child to share a bedroom with a sibling, parent, or additional family members (e.g., grandparents), may also contribute to poor limit setting or negative sleep-onset associations. Other sleep disorders, such as obstructive sleep apnea and restless legs syndrome/ periodic limb movement disorder, may also delay sleep onset and trigger night wakings, and should be considered in the differential diagnosis if symptoms and risk factors are present (e.g., snoring, adenotonsillar hypertrophy, positive family history). Primary sleep disorders may also coexist with the more behaviorally based insomnias, potentially exacerbating daytime sequelae. For example, sleep terrors may be a cause of nocturnal awakenings characterized by agitation and high levels of arousal in young children, but are much less common (prevalence of about 1–3%) than problematic sleep-onset associations. They typically first present in the preschool age range, and there is frequently a family history of sleep terrors or sleepwalking. Sleep terrors are characterized by extreme levels of agitation, a high arousal threshold, resistance to comforting, and a rapid return to quiet sleep; they generally occur in the first third of the night, when slow-wave sleep predominates. The child has no memory of the event, and daytime sequelae are extremely rare. Transient sleep disturbances, also called “adjustment sleep disorders,” usually occur in a child with prior normal sleep. Transient night wakings can be the result of a stressful life event, disruption of sleep schedule (e.g., trip, jet lag), or an illness. Short-term sleep disturbances, however, can become chronic if parents respond in a way (reinforcement of the night wakings) that fosters poor sleep habits.

Impairment It is clear that two main sleep problems exist during the infant–­toddler period, that some parents find these problems disturbing whereas others do not, and that sleep problems occur within a rich context of factors that impact their definition and diagnosis. There is also evidence that sleep problems can have a significant impact on some families, and there is some research to suggest that they can have an impact on the children

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who experience them, as well. However, due to the fact that research in this area is relatively new and generally has not used causal research designs or data analysis techniques, we use the term “correlate” to discuss purported impacts of sleep problems on children and families.

Family Some of the correlates of infant–­toddler sleep problems in families include maternal depression, parental fatigue, general disruptions to family life, poor maternal mental and physical health, and less parental wellbeing (Bayer et al., 2007; Eckerberg, 2004; Hall, Clauson, Carty, Janssen, & Saunders, 2006; Lam, Hiscock, & Wake, 2003; Meijer & van den Wittenboer, 2007; Meltzer & Mindell, 2007; Wake et al., 2006). Hall and colleagues (2006) reported that resolving the sleep problems of 6- to 12-month-old infants resulted in significant improvement in parents’ sleep quality, cognitions about infant sleep, depression, and increased marital harmony. It is important to keep in mind that it is difficult to tease apart the potential direction of effect in these investigations. It is entirely possible that some of these correlates preceded the child’s sleep disruption, or the two are related to a completely different, unstudied factor. One prospective study did find that persistent sleep disruptions across the first 2–24 months of life were uncommon (6%) but were associated with maternal depression and parenting stress at 24 months (Wake et al., 2006). In contrast, at least one investigation has reported that once maternal sleep quality was controlled for, the relationship between infant sleep problems and maternal mental health was eliminated (Bayer et al., 2007). In most of these investigations, both child sleep and parental well-being were measured by parent report, which potentially confounds any reported relationships.

Child As discussed above, infant–­toddler sleep disruptions are correlated with, and indeed may cause, several negative family outcomes. Less clear is whether or not there is a negative impact on the child him- or herself. Whereas studies on older children and ado-

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lescents have found relationships between sleep problems and daytime behavior (e.g., Owens-­Stively et al., 1997; Smedje, Broman, & Hetta, 2001; Wolfson & Carskadon, 1998), data are virtually nonexistent for the infant–­toddler population. Studying the potential impact of sleep problems on very young children is particularly challenging because these children take regular naps during the day. Daytime behavioral effects of a nighttime sleep problem may be diminished by the child’s use of daytime sleep to “make up for” a restless or short night. Although there is little research to support the presence of objective daytime behavioral sequelae for infants and toddlers who experience sleep problems, animal research has found a relationship between sleep and development of the brain. For example, there is some evidence that REM sleep helps consolidate memory and promotes advanced cognitive functioning (Stickgold, 2005); sleep also may be involved in promoting brain plasticity (Frank, Issa, & Stryker, 2001). These lines of evidence point to the possibility that sleep provides the foundation for neurocognitive development and growth (Cheour et al., 2002; Stickgold, Whidbee, Schirmer, Patel, & Hobson, 2000). Thus, it would follow that any problem that results in significant sleep loss during development may impact cognitive functioning. However, there are thus far no developmental human research studies to support this hypothesis. There is research, however, showing associations between the quality of older children’s sleep and their cognitive and emotional functioning and physical well-being. Sleep loss and sleep fragmentation are known to directly impact mood (increased irritability, decreased positive mood, poor affect modulation). Behavioral manifestations of sleepiness in children are varied and range from externalizing behaviors such as increased impulsivity, hyperactivity, and aggressiveness to mood lability and inattentiveness (Smedje et al., 2001). For instance, sleep loss has been found to be related to maladjustment in preschoolers (Bates et al., 2002) and in impaired daytime cognitive and behavioral functioning in school-age children (Sadeh, Gruber, & Raviv, 2003). Sleepiness may also result in observable neurocognitive performance deficits, including decreased cognitive flexibility and verbal creativity, poor

abstract reasoning, impaired motor skills, decreased attention and vigilance, and memory impairments (Dahl, 1996; Randazzo, Muehlbach, Schweitzer, & Walsh, 1998). Although some of the above studies were confounded by the fact that parents provided information on both sleep and behavior, others (e.g., Randazzo et al., 1998) have used objective measures. Unfortunately, most evidence for a link between poor sleep and daytime behavioral impairment comes from studies with older children. Finally, it should be emphasized that other postulated health outcomes of inadequate sleep in children include potential deleterious effects on the cardiovascular, immune, and various metabolic systems, including glucose metabolism and endocrine function, and an increase in accidental injuries. For example, shorter periods of nighttime sleep at 3 years of age have been linked to obesity during middle childhood (Reilly et al., 2005). Some studies have reported modest relationships between disturbed sleep and later behavior problems in very young children (e.g., Dearing, McCartney, Marshall, & Warner, 2001; Gregory, Eley, O’Connor, & Plomin, 2004), although factors other than disturbed sleep clearly contribute to the appearance of later behavior problems as well. Scher, Zukerman, and Epstein (2005), for example, found that night waking in infancy predicted only 3% of the variance in behavioral scores at 42 months. Persistent night waking and/or settling problems were better predictors of later negative behavior than was night waking during the infancy period. Wake and colleagues (2006) also found that persistent, rather than transient, problems during the infant–­toddler period related to subsequent child behavior problems. Thus, it appears likely that severe, persistent sleep problems during the infant–­toddler period can impact daytime behavior; less clear is the potential impact of less severe problems.

SLEEP DISTURBANCES IN THE CONTEXT OF OTHER DISORDERS The high prevalence rates for sleep problems found in children with neurodevelopmental disorders, ranging from 13 to 85%, may be related to any number of factors, including



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intrinsic abnormalities in sleep regulation and circadian rhythms, sensory deficits, and medications used to treat associated symptoms (Johnson, 1996; Wiggs, 2001). In children with special needs, sleep problems are often chronic in nature and unlikely to resolve without aggressive treatment. In addition, sleep disturbances in these children often have a profound effect on the quality of life of the entire family. These children also frequently have multiple sleep disorders occurring simultaneously or in succession. Higher degrees of cognitive impairment tend to be associated with more frequent and severer sleep problems. It has been estimated that significant sleep problems occur in 30–80% of children with severe mental retardation and in at least half of children with less severe cognitive impairment. Estimates of sleep problems in children with autism/pervasive developmental disorder are similarly in the 50–70% range. The types of sleep disorders that occur in these children are generally not unique but more frequent and severe than in the general population, and they typically reflect children’s developmental level rather than chronological age. Significant problems with initiation and maintenance of sleep, shortened sleep duration, irregular sleeping patterns, and early morning waking, for example, have been reported in children with a variety of different neurodevelopmental disorders (including Asperger syndrome, Angelman syndrome, Rett syndrome, Smith–­Magenis syndrome, and Williams syndrome). Basic principles of sleep hygiene are particularly important to consider in preventing and treating sleep problems in children with developmental delays (Didden, Curfs, van Driel, & de Moor, 2002). Ensuring the safety of these children, especially if night waking is a problem or there is a history of self-­injurious behavior, is also a key consideration in management. A range of behavioral management strategies used in normal children for night wakings and bedtime resistance, such as graduated extinction procedures and positive reinforcement, may also be applied effectively in children with developmental delays. Collaboration with a behavioral therapist may be needed if there are complex, chronic, or multiple sleep problems, or if initial behavioral strategies have failed. Finally, the use of pharmacological

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intervention, including melatonin in conjunction with behavioral techniques, has also been shown to be effective in selected cases (Weiss, Wasdall, Bomben, Rea, & Freeman, 2006). Parents of children with attention-­deficit/ hyperactivity disorder (ADHD) frequently report sleep disturbances, especially difficulty initiating sleep and restless and disturbed sleep. Surveys of parents and children with ADHD consistently report an increased prevalence of sleep problems, including delayed sleep onset, poor sleep quality, frequent night wakings, and shortened sleep duration. It should be pointed out that more objective methods of examining sleep and sleep architecture (e.g., polysomnography [PSG], actigraphy) have, overall, disclosed minimal or inconsistent differences between children with ADHD and controls, except for more restless sleep and increased nightto-night variability in sleep patterns. Sleep problems in children with ADHD are likely to be multifactorial in nature, with potential etiologies ranging from psychostimulant­mediated sleep-onset delay in some children to bedtime resistance related to a comorbid anxiety or oppositional defiant disorder in others. In some children, settling difficulties at bedtime may be related to deficits in sensory integration associated with ADHD, whereas in others, a circadian phase delay may be the primary etiological factor in bedtime resistance. Underlying medical conditions can also account for difficulties falling asleep and staying asleep, including gastroesophageal reflux, allergies and atopic dermatitis, asthma, milk intolerance, chronic gastrointestinal disorders, seizures, and pain (e.g., otitis media). In addition, in those conditions that typically require nighttime parental intervention (e.g., colic), it may be difficult for parents to differentiate between night wakings due to ongoing physical symptoms and those that are related to learned behaviors (e.g., due to parental attention to crying). Parents of a child with a current or past history of medical problems may also have difficulty setting limits, whether because of guilt, a sense that the child is “vulnerable,” or concerns about doing psychological harm. Medication effects may also lead to disrupted sleep and night wakings. A number of patient and environmental factors, such as

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the impact of repeated hospitalization, family dynamics, underlying disease processes, comorbid mood and anxiety disorders, and concurrent medications are clearly important to consider in assessing the bidirectional relationship of sleep problems and chronic illness in children.

INTERVENTIONS FOR SLEEP-RELATED DISTURBANCES Behavioral interventions are the mainstay of treatment of bedtime struggles and night wakings in infants and toddlers. Consistent with the conclusions of two previous reviews (Kuhn & Elliott, 2003; Mindell, 1999), a recent review of 52 treatment studies indicated that behavioral therapies produce reliable and durable changes for both bedtime resistance and night wakings in young children (Mindell et al., 2006). Ninety-four percent of the studies reported that behavioral interventions were efficacious, with over 80% of children demonstrating clinically significant improvement maintained for up to 3–6 months. No study reported detrimental effects, although it is important to note that most studies did not examine the efficacy or effect of treatment in very young infants (i.e., those less than 6 months of age). Thus, clinicians should use caution in recommending aggressive forms of sleep training in very young infants. These studies do demonstrate that treatment-­related changes across most types of interventions were maintained at short (< 6 months), intermediate (6–12 months), and long-range follow-up (> 12 months) (Mindell et al., 2006). A number of studies also found positive effects of sleep interventions on secondary child-­related outcome variables, such as parent-­reported daytime behavior (e.g., crying, irritability, detachment, self-­esteem, or emotional wellbeing). Sleep-­related behavioral intervention also led to improvement in the well-being of the parents (effects on mood, stress, or marital satisfaction) in a number of studies. Most of the interventions described in behavioral treatment studies could be placed into the following categories: extinction and its variants, positive bedtime routines, scheduled awakenings, bedtime fading with response cost, positive reinforcement, and parent education/prevention. Some of the

interventions described below are tailored more specifically toward either bedtime problems or night wakings, but since these two issues often coexist, all treatment modalities are included. Unmodified extinction and parent education/prevention are the two behavioral interventions that have the strongest empirical support. “Extinction” procedures in general involve the elimination of parental attention as a reinforcer for undesired behaviors (e.g., crying, screaming). The goal of extinction in the case of problematic night wakings is to enable a child to develop “self-­soothing” skills in order to fall asleep independently without continued need for parental presence.

Extinction Procedures Unmodified Extinction In the “cry it out” approach, parents put the child to bed at a designated bedtime and then ignore protest behaviors such as crying, tantrums, and calling for the parents (with the exception of illness, injury, etc.) until a preset time the next morning. The biggest obstacles associated with extinction are (1)   the requirement for strict parental consistency with the intervention, since inconsistent caregiver response provides intermittent reinforcement and maintains the awakenings and (2) the likelihood of postextinction “response bursts” (temporary intensification of protest behavior immediately after the intervention is instituted). From a clinical standpoint, the major drawbacks of unmodified extinction procedures are that it is stressful for parents and that many parents are unable to ignore crying long enough for the procedure to be effective.

Extinction with Parental Presence In a modification of the extinction approach the parents stay in the child’s room at bedtime but ignore the child and his or her protest behavior.

Graduated Extinction “Sleep training” refers to a variety of techniques. Typically, parents are instructed to ignore bedtime crying and tantrums for



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specified periods of time, tailored to the child’s age and temperament, as well as the parents’ judgment of how long they can tolerate the child’s crying. Parents employ a fixed schedule (e.g., 5 minutes) or one that involves progressively longer intervals (e.g., 5 minutes, 10 minutes, 15 minutes, etc.) of waiting before checking on their child. With incremental graduated extinction, the intervals increase across successive checks within the same night or across successive nights. During the checking procedure the parents comfort their child for a brief period, usually 15 seconds to a minute. The parents are instructed to minimize any interactions during check-ins that may reinforce their child’s attention-­seeking behavior.

Positive Routines and Bedtime Fading with Response Cost Similar to extinction techniques, these approaches match the child’s bedtime with his or her natural sleep-onset time and rely heavily on stimulus control techniques as the primary agent of behavior change. In contrast to extinction strategies, both of these treatments aim to increase appropriate behaviors and control of affective and physiological arousal, rather than focusing on reduction of inappropriate behaviors. In this approach parents develop a set bedtime routines characterized by quiet and calming activities that the child enjoys. “Bedtime fading with response cost” involves taking the child out of bed for prescribed periods of time when the child does not fall asleep. Bedtime is also temporarily delayed to ensure rapid sleep initiation. Once the behavioral chain is well established and the child is falling asleep quickly, the bedtime is moved earlier by 15–30 minutes over successive nights (“fading”) until a preestablished bedtime goal is achieved.

Scheduled Awakenings Technique This approach focuses on increasing the duration of consolidated sleep. In this intervention parents awaken and console their child approximately 15–30 minutes before a typical spontaneous awakening. Caregivers must first establish a baseline of the usual number and timing of spontaneous nighttime awakenings, and then schedule preemptive awak-

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enings. Scheduled awakenings are then gradually faded out by systematically increasing the time span between awakenings. Of course, all of the behavioral interventions described above, especially when used with children preschool age and above, can be combined with positive reinforcement strategies (e.g., sticker charts) to increase the likelihood of desired behaviors (e.g., staying in bed).

Parent Education Programs These approaches generally focus on early establishment of positive sleep habits and are often preventive rather than intervention strategies per se. Strategies typically target bedtime routines, developing a consistent sleep schedule, parental behavior during sleep initiation, and parental response to nighttime awakenings. Almost all programs include the recommendation that infants be put to bed “drowsy but awake,” starting at around 3–4 months of age, to help them develop independent sleep initiation skills at bedtime. Other features of parent sleep education programs often include the following: •• Institution of a set bedtime and regular sleep schedule that ensures adequate sleep, as sleep deprivation will result in increased nighttime arousals. A bedtime should be set that is appropriate for the child’s age and provides adequate sleep at night. A consistent nightly bedtime will also help reinforce the circadian clock and enable the child to fall asleep more easily. •• Establishment of a consistent bedtime routine that is approximately 20–45 minutes and includes three to four soothing activities (e.g., bath, pajamas, stories) but does not include stimulating activities such as television viewing. •• Maintenance of daytime sleep (naps), at least through the age of 3–3½ years, to avoid sleep deprivation. •• Use of transitional objects, such as a blanket, doll, or stuffed animal, which is readily available to the child during the night. It is critical that parents are consistent in applying any of these behavioral programs to avoid inadvertent intermittent reinforcement of night wakings. They also should be

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forewarned that protest behavior frequently escalates temporarily at the beginning of treatment (“postextinction burst”).

Restricted Pharmacological Interventions Only a few studies have examined the effect of pharmacological treatment, usually in combination with behavioral treatments, of bedtime problems and night wakings in young children. Despite this paucity of research, pharmacological interventions such as nonprescription sedating antihistamines are commonly used in clinical practice for sleep problems, even in young children (Owens, Rosen, & Mindell, 2003). However, at least one study suggests that this practice is ineffective and can be associated with drug-­related side effects (Merenstein, Diener-West, Halbower, Krist, & Rubin, 2006). In addition, pharmacological strategies are not necessarily helpful in improving parental adherence to a concurrent behavioral treatment and thus may not have long-­lasting effects. Overall, the evidence suggests that behavioral strategies are equally or more effective, are more acceptable to both parents and practitioners, and avoid potentially harmful side effects associated with medication use. Behavioral sleep management strategies have the further advantage of potentially generalizing to the management of daytime issues. Nonetheless, there may be a role for judicious use of medication combined with behavioral therapy in very selected clinical circumstances (e.g., inpatient hospitalization, special needs populations). For clinicians, an important treatment goal in managing individual children with special needs, such as ADHD or other neuropsychiatric conditions such as autism, should be evaluation of any comorbid sleep problems, followed by diagnostically driven behavioral and/or pharmacological intervention. For example, children with ADHD who have difficulty falling asleep due to psychostimulant use may respond to adjustments in the dosing schedule; in some children the sleep-onset delay is due to a “rebound” effect of the medication wearing off coincident with bedtime, rather than a direct stimulatory effect of the medication itself. Melatonin use has demonstrated reductions in sleep latency when given at bedtime

in children with ADHD and in those with other neurodevelopmental disorders (Smits et al., 2003; Weiss, Wasdell, Bomben, Rea, & Freeman, 2006), and appears to have relatively few side effects. Alpha-­agonists such as clonidine (at bedtime) are commonly used in clinical practice to manage prolonged sleep-onset delay in children with ADHD (Klein-­Schwartz, 2002; Prince, Wilens, Biederman, Spencer, & Wozniak, 1996); however, it should be pointed out that little empirical evidence exists regarding efficacy and safety, particularly in younger children.

Other Approaches Alternative treatments such as infant massage may be safe and simple when used adjunctively in the treatment of infant sleep problems. Infant massage is commonly used in many areas of the world, especially Africa, India, and Asia. Although the effects of infant massage on pediatric sleep have not been studied extensively, recent studies have shown that massage in the newborn period may have a long-term effect on melatonin synthesis and the development of normal circadian rhythms (Ferber, Laudon, Kuint, Weller, & Zisapel, 2002). The positive effects of massage may also target many of the problems associated with prolonged bedtime struggles, including high infant arousal, parent tension, and negative parent–child interactions. The few studies that have investigated massage as an intervention for pediatric sleep problems have reported shortened sleep-onset latency, fewer night wakings, and improved daytime alertness/ behavior following regular bedtime massage (Field & Hernandez-Reif, 2001; Field, Kilmer, Hernandez-Reif, & Burman, 1996).

CONCLUSIONS Our basic understanding of the normal trajectory of sleep development in the first few years of life, and of the etiology and treatment of disordered sleep in infancy, is evolving rapidly. The recognition that sleep is a fundamental human function that both mirrors and impacts other important areas of maturation (e.g., social, emotional, cognitive) in the young child has led to an increasing and sound body of research exploring the



22. Sleep Disorders

bidirectional relationship between sleep and development. There is much to learn about the nature and impact of sleep disorders in young children, particularly because further elucidation of these fundamental questions are likely to contribute significantly to our understanding of the relationship between specific brain functions, neuromodulator systems, sleep, and daytime behavior. Key areas for future research include: •• Neuroanatomical and neurophysiological basis of both normal and abnormal sleep development •• Elucidation of the scope, magnitude, natural history, and impact on morbidity of sleep disorders in young children in the general population as well as those children with behavioral and developmental disorders •• Relative risk and protective factors (e.g., temperament, parenting styles, psychosocial adversity) influencing the development of sleep problems •• The efficacy of various prevention strategies and treatment modalities in infants, toddlers, and children, and the impact of treatment on the natural history of sleep disorders into later childhood and adulthood •• The potential utility of sleep problems in predicting the eventual emergence of other psychiatric disorders. Particularly important is development of a more comprehensive nosology to describe and classify infant sleep disorders; these systems must accurately capture both the similarities and distinctions between adult and pediatric sleep disorders, as well as differentiate normal developmental variation from “pathology” across the age spectrum. Evidence-based clinical screening and evaluation tools for sleep problems in young children, which are easily adapted to primary care and outpatient mental health settings, need to be developed, systematically evaluated, and disseminated, coupled with educational interventions for caregivers and providers targeted at raising awareness of the significance of these issues. Finally, the substantial impact of disordered sleep deserves further study, ranging from effects on neuroendocrine systems and metabolic pathways related to the development of obesity;

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Chapter 23

Feeding Disorders, Failure to Thrive, and Obesity Diane Benoit

F

eeding disorders (FDs) and failure to thrive (FTT) are common problems of infancy and early childhood in industrialized countries. FDs affect up to 25–40% of infants and young children developing normally and up to 80% of those with developmental handicaps (Kerwin, 1999; Manikam & Perman, 2000). In the United States, FTT affects up to 30% of infants seen in ambulatory care and inner-city emergency room settings, 22% of those born prematurely with low birthweight, 1–5% of those hospitalized, and as many as 57% of those living in low-­income areas or below the poverty level in rural and urban areas (Benoit, 2000a; Mackner, Black, & Starr, 2003). In the United Kingdom, the prevalence rates in population-based cohorts vary from 1.8 to 4.8% for full-term infants born at a time appropriate for their gestational age (Blair et al., 2004; Drewett, Corbett, & Wright, 1999; Wright, Parkinson, & Drewett, 2006b). In Israel, 3.9% of full-term infants in the community develop FTT (Wilensky et al., 1996). Although FTT and FD may coexist in 47% of cases in the United Kingdom (Drewett et al., 1999), the frequency of association is not yet firmly determined. In the first study published on the topic from India, 17–18% of 171 full-term infants born in a

public hospital servicing families from the lower socioeconomic strata showed FTT at 7 weeks and 6 months (Patel, DeSouza, & Rodrigues, 2003). Obesity has reached epidemic proportions in most developed countries. In England, the United States, and Australia, more than half of all adults are overweight or obese, and trend data show a dramatic increase in prevalence over the past two decades (Crawford, 2002). Obesity affects about 10% of infants in the United States (Whitaker, Wright, Pepe, Seidel, & Dietz, 1997), with ever-­increasing rates. Data from the United Kingdom show that from 1993 to 2005 the rate of obesity in children ages 2–10 increased from 9.6 to 16.6% for boys and 10.3 to 16.7% for girls (East Midlands Public Health Observatory, 2006). FDs, FTT, and obesity are reviewed in this chapter, with an emphasis on research since 1997.

FEEDING DISORDERS Definition, Classification, and Etiology There is no universally accepted definition or validated classification of FDs in infancy. Some rare FDs are listed in the Diagnostic and Statistical Manual of Mental Disorders 377

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(4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000). These include rumination disorder, which consists of the repeated regurgitation and rechewing of food, and pica, which consists of the ingestion of a non-­nutritive substance that is inappropriate to the individual’s developmental level and is not part of a culturally sanctioned practice. DSM-IV-TR also has a diagnostic category for “feeding disorder of infancy or early childhood,” which requires that affected children present with a persistent failure to eat adequately, with significant failure to gain weight or significant loss of weight over at least 1 month. It appears that this latter DSM-IV-TR diagnosis may be synonymous with FTT, although without using anthropometric measurements for the diagnosis. Another classification system, the DC:0– 3R (Zero to Three, 2005), lists six subcategories of “feeding behavior disorder”: 1. Feeding disorder of state regulation, which requires difficulty reaching and maintaining a calm state during feeding, starting in the newborn period. 2. Feeding disorder of caregiver–­infant reciprocity, which requires the lack of social reciprocity during feeding that is not due solely to a physical disorder or a pervasive developmental disorder. 3. Infantile anorexia, which is characterized by refusal to eat adequate amounts of food, lack of interest in food, but strong interest in exploration and interaction, and apparent lack of hunger (Chatoor, Ganiban, Colin, Plummer, & Harmon, 1998; Chatoor, Ganiban, Hirsch, Borman-­Spurrell, & Mzarek, 2000; Chatoor et al., 2004). 4. Sensory food aversion, which requires persistent refusal to eat specific foods but no difficulty with preferred foods, associated with specific nutritional deficiencies or delay of oral–motor development. 5. Feeding disorder associated with concurrent medical condition, which is characterized by initial acceptance of feeding, followed by progressive distress, then refusal over the course of feeding—all caused by a concurrent medical condition and associated with improvement but not complete alleviation after medical management.

6. Feeding disorder associated with insults to the gastrointestinal tract, which requires that the food refusal be persistent and follow a major aversive event or repeated noxious insults to the oropharynx or gastroinstestinal tract, and that distress be present at exposure to reminders of the traumatic event(s). Most subcategories (except for 4 and 6) require the presence of “growth deficiency,” or failure to gain weight or weight loss, and thus these diagnostic labels may overlap with FTT. Some have reported on the usefulness of the DC:0–3 for assessment and treatment of FD in a hospital pediatric liaison service (Scheer, Dunitz-­Scheer, Schein, & Wilken, 2003). Also, some empirical evidence documents the validity of some of these diagnostic categories (Chatoor et al., 2000; Chatoor, Hirsch, Ganiban, Persinger, & Hamburger, 1998). The etiology of FD is not well understood and is likely to be multifactorial (Winters, 2003), with physiological, behavioral, and environmental factors interacting. Such factors may include anatomical or sensory–­perceptual abnormalities, motor dysfunction, temperamental and regulatory characteristics, health problems, traumatic experiences, mealtime behaviors, and characteristics of the caregiver, caregiver–­infant relationship, and family and social environment (Benoit, Wang, & Zlotkin, 2000; Chatoor et al., 2000; Chatoor et al., 1997; Cooper, Whelan, Woolgar, Morrell, & Murray, 2004; Kerwin, 1999).

Associated Features and Outcome There is evidence for comorbidity, particularly with FTT, sleep problems, and various regulatory difficulties and health problems (Benoit, 2000a, 2000b; Benoit & Coolbear, 1998; Benoit et al., 2000; Drewett et al., 1999; Kerwin, 1999; Manikam & Perman, 2000). Severe and persistent feeding problems, which are experienced by 3–10% of children, tend to persist and worsen over time, and are more prevalent in children with physical disabilities (26–90%), mental retardation (23–43%), and medical illness, prematurity, or low birthweight (10–49%) (Kerwin, 1999). Consequences of severe



23. Feeding Disorders, Failure to Thrive, and Obesity

feeding disorders are believed to be potentially serious and include FTT, susceptibility to chronic illness, and even death (Manikam & Perman, 2000).

Assessment Manikam and Perman (2000) advocate that FD should be assessed by an interdisciplinary team of professionals that includes, at a minimum, a gastroenterologist, nutritionist, behavioral psychologist, and occupational and/or speech therapist. A comprehensive assessment should include a review of the child’s health; developmental, feeding, regulatory, and growth history; growth parameters; parental reports of mealtime behaviors and nutrient intake; and observation of meals with primary feeders (ideally both at the office and in the home, e.g., via videotapes; Arts-Rodas & Benoit, 1998). An assessment of an infant with FD should answer questions about whether or not (1) the child has FTT; (2) the child is safe to feed (if so, is the child anatomically and developmentally able to feed? If so, then is the child willing to eat?); and (3) there are feeder–­infant relationship problems or other environmental problems.

Intervention Based on answers to the questions posed during the assessment, the type of intervention can then be determined; for example, (1) no oral feeding because it is unsafe to feed; (2) occupational and/or speech and language therapy when oral–motor, oropharyngeal, oral–­sensory dysfunction or neurologically based swallowing difficulties are present; (3) nutrition and/or pediatrics when FTT or other medical condition is present; (4) parent–­infant therapy when parent–­ infant relationship problems are present; (5) behavior therapy to alter problem feeding behaviors; and (6) combined treatment modalities when multiple problems are present (Arts-Rodas & Benoit, 1998). In part because the assessment of severer FD is often done by interdisciplinary feeding teams, interventions typically consist of multicomponent packages tailored to the needs of the infant. The use of exclusive tube feedings should be avoided if possible (Manikam & Perman, 2000).

379

Kerwin (1999) reviewed the literature on severe feeding problems, not FTT, and found that various treatment modalities have been used (behavioral, individual child psychotherapy, cognitive-­behavioral intervention for food phobia, interactional therapy, and family-­oriented interventions). She points out that her evaluation of the effectiveness of these interventions was hampered by methodological problems, including inconsistent definitions of feeding problems, inferior experimental designs, small sample size, inadequate or missing control groups or conditions, absence of standardized outcome measures, and incomplete descriptions of intervention. Despite these problems, empirical evidence shows that effective interventions for children with severe FD are contingency management treatments that include positive reinforcement of appropriate feeding responses and ignoring or guiding inappropriate responses. Promising interventions include positive reinforcement for acceptance and extinction (not removing the spoon for refusal) and swallow induction training. None of the nonbehavioral interventions was methodologically rigorous enough to be considered an empirically proven treatment. Most published reports of behavioral interventions, however, include case reports or small sample sizes. The largest published study is a randomized controlled trial of 64 infants under age 36 months, which demonstrated that behavior therapy using extinction and positive reinforcement was more efficacious in eliminating the need for tube feeding than nutritional counseling alone in children who had severe feeding problems in addition to serious underlying health problems and a dependence on tube feedings (Benoit et al., 2000a). Although Scheer et al. (2003) reported that 93 tube-fed infants were referred to their service between 1997 and 2001 and successfully treated in an inpatient setting, the intervention is not well described, does not appear to have been manualized, and no empirical evidence has documented its efficacy. Although the effectiveness of behavioral interventions for pediatric feeding problems has been well documented, the application of these procedures in practice is often more complex and difficult than research reports reveal (Linscheid, 2006).

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FAILURE TO THRIVE Definition and Classification There are still problems with the definition of FTT, despite consensus that the fundamental cause of FTT is nutritional deficiency (Gahagan, 2006). A recent review of the literature between January 2003 and June 2004, shows that although most researchers broadly define FTT as inadequate growth, and there is total agreement to define FTT based solely on anthropometric measures, there are large differences regarding which growth parameters to use and whether to use attained values or velocities (Olsen, 2006). For example, many British studies now report weight gain using change in weight standard deviation score, conditional on birth weight (or the “thrive index”), which provides a linear measure of weight gain, comparing a child’s actual weight standard deviation score to his or her expected weight standard deviation score, adjusted for regression to the mean. Most British researchers define FTT as conditional weight gain below the 5th percentile (Wright, Avery, Epstein, Birks, & Croft, 1998). Since the early 2000s, most of the British literature on FTT has referred to the condition as “weight faltering.” Researchers in other countries often define FTT as (1) weight below the 5th percentile for age and gender on standardized growth charts, and/or (2) deceleration in the rate of weight gain from birth to the present (downward crossing of at least two major percentiles on standardized growth charts), and/or (3) weight for height age less than 80% (or 90% in some cases; Block, Krebs, Committee on Child Abuse and Neglect, & Committee on Nutrition, 2005). Raynor and Rudolf (2000) compared five anthropometric methods used to assess weight parameters in 83 children with FTT: (1) median weight for age, (2) median weight for height, (3) median weight divided by median height for age, (4) body mass index (BMI) or weight in kg divided by height in m2 , or (5) thrive index (later weight standard deviation (SD) minus [birthweight SD × 0.4]). They found that the degree of FTT varied greatly according to the index used. The varying definitions of FTT and varying anthropometric methods used to assess it hamper studies in the field and make comparisons of findings across studies difficult.

Although all infants with FTT have a serious underlying medical problem of malnutrition, FTT continues to be referred to in some clinical settings as “organic” (when an underlying medical problem contributing to FTT is present), “nonorganic” (when no contributing medical problem is present), and “mixed” (when both organic and nonorganic factors are present). Since 1997, two British population-based studies have found that 5% or less of children with FTT have a major organic disease (Drewett et al., 1999; Wright, Callum, Birks, & Jarvis, 1998).

Associated Features and Outcome FTT is a multifactorial problem involving a combination of biological and environmental factors (Block et al., 2005). Such factors include (1) characteristics of infants, such as subtle neurodevelopmental impairments and oral–motor dysfunction (Ramsay, Gisel, McCusker, Bellavance, & Platt, 2002), prematurity (Drewett, Blair, Emmett, Emond, & ALSPAC Study Team, 2004), organic disease, temperamental/behavioral/regulatory characteristics (Benoit, 2000b; Chatoor et al., 2000; Steward, 2001), feeding problems, appetite control; (2) characteristics of caregivers, such as maternal depression (Drewett et al., 2004; O’Brien, Heycock, Hanna, Jones, & Cox, 2004; Patel et al., 2003) and poor problem-­solving abilities (Robinson, Drotar & Boutry, 2001); (3) caregiver–­infant relationship problems, such as infant and adult insecure attachment or disturbances in parental perceptions of child and interactions with the child (Benoit, Zeanah, Parker, Nicholson, & Coolbear, 1997; Chatoor et al., 2000, 2004; Chatoor, Ganiban, et al., 1998; Coolbear & Benoit, 1999; Ward, Lee, & Lipper, 2000); and (4) family and social environment characteristics, such as poverty, abuse, or neglect (Kerr, Black, & Krishnakumar, 2000; Mackner et al., 2003; Mackner, Starr, & Black, 1997). Two American studies have used a cumulative risk model to examine the impact of FTT and maltreatment on cognitive outcome (Mackner et al., 1997) and the relationship among FTT, maltreatment, and four aspects of children’s development, including cognitive performance (standardized testing), adaptive functioning at school (from teacher report), classroom behavior



23. Feeding Disorders, Failure to Thrive, and Obesity

(from teacher report), and behavior at home (maternal report; Kerr et al., 2000). Findings suggest that the accumulation of risk factors is detrimental to cognitive functioning: 6-year-old children with both FTT and maltreatment had more behavior problems and worse cognitive performance and school functioning than children with neither risk factor, and children with only one risk factor (either FTT or maltreatment) had intermediate scores. Findings support a cumulative risk model as being more detrimental to children’s development than the presence of a single risk factor alone. As seen in Table 23.1, British populationbased studies document a low rate of families of children with FTT who are “registered” for abuse and neglect (Wright & Birks, 2000), although children with FTT are four times more likely to be abused than controls (Wright, 2000). Thus, in some cases FTT may be a manifestation of child neglect (Block et al., 2005), albeit not synonymous with it (Black et al., 2006). In most British population-based cohorts, which are comprised of predominantly white British infants born at term (typically with birthweights ≥ 2,500 grams, parental and environmental factors seem to explain only a minority of cases, as does underlying organic disease. In the United Kingdom, FTT is more common not in poorer families but in larger families (Wright et al., 2006b), possibly because of the relative cheapness of food and of a reasonable system of benefits for families with young children (Blair et al., 2004). Population-based studies from the United Kingdom (Table 23.1) suggest that the natural history of FTT involves gradual improvement over the preschool years, but with a lasting deficit with respect to growth (Wright, 2000). With respect to cognition, the evidence shows that significant developmental deficits between 7 and 10 Developmental Quotient (DQ) points can be found at the age of 1 year in two population-based studies conducted before 1997 in the United Kingdom and Israel, each including approximately 50 children with FTT (Wilensky et al., 1996; Wright, 2000). However, when followed up to the age of 6 years (in the British study), no significant difference in IQ was found. An American study showed similar findings in a prospective study of 128 (57%; N = 226) low-­income infants who developed

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FTT and were treated in a multidisciplinary clinic and then compared to 98 subjects with normal growth at ages 4–6 (Mackner et al., 2003). Mackner et al. (2003) found that although cognitive development declined in both groups over time, and children with FTT had lower cognitive scores through age 4, by ages 5 and 6 there were no differences in cognitive scores based on children’s growth history. Further, in an Ethiopian birth cohort (N = 1,563) of infants born at term with birthweights ≥   2,500 grams, Drewett, Wolke, Asefa, Kaba, and Tessema (2001) compared 40 children with “growth faltering” in the first 4 months, 70 children with “growth faltering” at 10 and 12 months old, and 100 controls with no history of “growth faltering.” Early malnutrition was not found to have specific adverse effects on development beyond the contribution that it makes to enduring malnutrition over the first 2 years of life. Thus, the evidence suggests that although FTT influences development in the short term, early developmental delays appear to diminish over time (Boddy, Skuse, & Andrews, 2000; Drewett et al., 1999), suggesting that a permanent effect on brain growth is not likely (Wright, 2000). In their systematic review of cohort studies and randomized clinical trials examining the long-term outcome for infants with FTT (including studies prior to 1997), irrespective of whether interventions were used, Rudolf and Logan (2005) identified 13 studies (eight cohort studies and five randomized controlled trials), eight of which included a comparison group (and five of these included children identified in community settings). All studies without a comparison group reported results suggesting that children with FTT were shorter, lighter, and scored lower on measures of psychomotor development than population norms, with those recruited as clinical samples generally doing worse. The height and weight differences between groups were larger and statistically significant, but few children were below the 3rd percentile at follow-up. Four studies reported an IQ difference between groups equivalent to ~ 3 IQ points, which they found to be of questionable clinical significance. However, the authors pointed out methodological problems, including paucity of high-­quality follow-up studies and the fact that the population-based studies that included com-



382

RCT; 42 FTT (to “conventional care” + home intervention by specialist

Raynor, Rudolf, Cooper, Marchant, & Cottrell (1999)

RCT; 229 FTT

Wright, Callum, Birks, & Jarvis (1998)

107 FTT from Wright et al. (1998), 136/2,812 (4.8%) FTT at 1 year + 136 controls from same GP practice and neighborhood

23 stunted 4-yearolds

Dowdney, Skuse, Morris, & Pickles (1998)

Drewett, Corbett, & Wright (1999)

Subjects

Study

7–9 years

3–4 years

11 years

Age at assessment/ follow-up

•• Small, nonsignificant difference in IQ •• No group difference in reading, spelling, or reading comprehension •• Adjusted for both parents’ heights, the case–control difference in children’s heights is small but statistically significant •• Child IQ strongly related to mother’s •• Children with a history of an organic condition affecting growth had significantly lower IQ than those with no such history •• Both groups improved in developmental score •• No significant difference in Bayley scores

•• Good weight gain in both groups after 1-year trial •• Both groups improved in energy intake

•• Deficit of 12 IQ points at age 11 (had a 20-point DQ difference at age 4)

Developmental/cognitive outcome

•• FTT significantly shorter (3/4 of a centile space or 5 cm) and lighter (average BMI > 1 centile space lower) than controls (also reduced head circumference) •• < 5% of infants with FTT have organic disease •• 9/136 (6.6%) of infants with FTT referred to inpatient or outpatient hospitals because of their FTT

•• Children in community-based intervention ½ centile space higher, significantly heavier, and had better appetite •• < 5% of FTT have organic disease

Health/nutritional/growth outcome

•• No significant difference between groups in behavioral scales, hospital anxiety and depression, or use of health care resources

•• 47% of infants with FTT have feeding problems (vs. 25% for controls; statistically significant difference) •• With community-based intervention, reported appetites and growth of children with FTT improved significantly •• 2/136 (1.5%) of infants with FTT referred to inpatient or outpatient hospitals because of feeding problems

Psychosocial characteristic or outcome

TABLE 23.1. Outcomes of Some FTT Research from British Population-Based Studies/Surveys and Controlled Studies Since 1997



383

Wright & Birks (2000)

Boddy, Skuse, & Andrews (2000)

97 FTT, 28 controls

42 FTT originally studied at 15 months + 42 controls

health visitor) + 42 controls (to “conventional care”) 4–30 months

16–18 months

6 years

•• FTT considerably smaller than comparisons in terms of BMI and height and weight for age Z scores •• A history of FTT in infancy explained substantial variance in weight and BMI at 6 years

•• Children < 12 months in intervention group showed a higher mean (SD) increase in weight SD score compared to controls

•• FTT in infancy (presence and timing of it) did not predict any aspect of cognitive performance at 6 years (in contrast to findings at 15 months), although children with history of FTT in infancy performed significantly worse than matched counterparts on test items related to quantitative and memory skills •• Maternal IQ was sole significant predictor of performance on all indices of cognitive performance at 6 years

(continued)

•• 4/97 (4%) showed “evidence of major neglect” •• Per parental report, and compared to controls, FTT had (significantly) —poorer appetites —narrower range of foods ingested —more undemanding and shy behavior —less hunger expressed —less enjoyment of food —delay in progression to solid foods

•• No significant difference in growth and diet, but controls had significantly more dietary referrals, social service involvement, hospital admissions, and were less compliant with appointments



384

30 FTT, 57 controls from cohort of 961

11,718

Blair et al. (2004)

Parkinson, Wright, & Drewett (2004)

Subjects

Study

TABLE 23.1.  (continued)

13–21 months

6–8 weeks; 9 months

Age at assessment/ follow-up •• 30/11,718 (0.3%) with slow weight gain from birth to 6–8 weeks persisted in slow weight gain from 6 to 8 weeks to 9 months •• 8× as many infants born to shorter parents showed slow weight gain as infants born to taller parents

Health/nutritional/growth outcome Developmental/cognitive outcome

•• Nested case–control study with direct observation of feeding behavior found that compared with control group: —Mothers in FTT group fed child spoon foods more often at meals —Infants in FTT group self-fed finger foods more often at meals —Infants with FTT ingested less energy, were less likely to stay in high chair throughout meal —More food consumed at “spoon food” meals, but energy intake not higher (for two groups)

•• Maternal age, alcohol consumption, smoking, low education/occupational status: all not associated with FTT •• Maternal short stature, parity, and low BMI = strongest predictors of slow weight gain from birth to 9 months •• Birth in fourth or subsequent pregnancy = 2× as likely to fail to thrive from birth to 9 months as firstborns

Psychosocial characteristic or outcome



385

Variable number at various times and for different measures out of 923 potential subjects from birth cohort

Wright, Parkinson, & Drewett (2006a)

6 weeks; 4 months; 8 months; 12 months

12 years

•• Children with history of FTT: —significantly more likely to rate their appetite as lower than their best friend’s —significantly lower scores related to restriction of food intake —no significant difference on anxiety, depression, self-esteem •• FTT unrelated to SES, maternal deprivation, educational level, or markers of eating disorder •• Mothers from low SES and depressed = infants with poorer weight gain—transient, up to 4 months •• By maternal report using questionnaire not validated: —appetite at 6 weeks and 12 months independently predict 12 months’ weight —avoidant eating behavior seen in most children at 12 months, but no relationship with weight gain or faltering after adjustment for appetite

•• Children with history of FTT = significantly shorter and lighter at 12 years + had significantly lower BMIs •• Children with history of FTT did not go into puberty later

•• 92/923 (10%) of infants showed weight faltering at some time, and 36/923 (4%) showed sustained weight faltering in two or more of the four age bands •• Extent to which caregiver responded to food refusal (by maternal report): significant inverse predictor of weight gain, even after adjusting for appetite •• Weight gain at 6 weeks independently related to appetite and oral–motor dysfunction at 6 weeks

Note. FTT, failure to thrive; BMI, body mass index; SES, socioeconomic status; RCT, randomized controlled trial; GP, general practice.

89 FTT, 91 controls

Drewett, Corbett, & Wright (2006)

—No clear difference between groups on actual feeding behaviors

386

IV. PSYCHOPATHOLOGY

parison groups were small, none adjusted adequately for potential confounders, and few reported data in a form that allowed inclusion in the meta-­analysis. Further, the relative lack of usable data reduced the precision of their estimates of the magnitude of the association between a diagnosis of FTT and long-term growth and cognitive development, which meant that they could not entirely exclude quite substantial effects. These findings from Rudolf and Logan (2005) contradict Corbett and Drewett’s 2004 review and meta-­analysis of controlled studies, which showed evidence that FTT in infancy is associated with adverse intellectual outcomes sufficiently large (equivalent to 4.1 IQ points) to be of importance at a population level. Overall, many risk or associated factors that have been identified in clinical case series usually prove less clearcut in controlled studies and can disappear completely in population-based studies.

Management/Treatment Interventions have been conducted at various levels (psychological, medical, home visiting, multidisciplinary) and in various settings (hospital admissions, outpatient clinics, home/community). Krugman and Dubowitz (2003) advocate that all children with FTT need additional calories to catch up, and a multidisciplinary approach should be used when FTT persists despite intervention or when it is severe. Currently, there is little good evidence from randomized controlled trials that interventions are markedly beneficial in FTT (Hutcheson et al., 1997; Reifsnider, 1998; Rudolf & Logan, 2005; Wright, Callum, et al., 1998).

OBESITY Definition and Etiology The definition of infant obesity is controversial (Baird et al., 2005); some definitions are based on BMI, weight, weight for height, or skinfold thickness. However, BMI is increasingly used as an indicator of obesity (Sowan & Stember, 2000), and obesity is often defined as body weight ≥ 85th percentile of gender-­specific and age-­specific BMI. Obesity is considered a multifactorial problem and the phenotypic expression of

complex interactions between a variety of genetic (Maes, Neale, & Eaves, 1997) and environmental (e.g., diet, exercise) influences. Since the discovery in 1994 of the ob gene, believed to play an important role in obesity, research into the physiological mechanisms controlling body weight and appetite regulation has grown exponentially (for details about this research, see Jebb, Kopelman, & Butland, 2007). In addition, although some medical conditions may be associated with infant obesity (Barlow & Dietz, 1998), this is rarely the case. Over the last decade, research on obesity has exploded, reflecting the finding that obesity has reached epidemic proportions in many industrialized countries.

Associated Features and Outcome It is now recognized that obese infants can become obese children, and obese children can become obese adults. Persistence of obesity during infancy and childhood increases the risk of obesity during adolescence and adulthood and links infant obesity to the potential development of serious adult health problems, such as cardiovascular disease, atherosclerosis, hypertension, diabetes, cancer, arthritis, diminished physical abilities, and psychological problems. Despite large-scale, population-based cohort studies and controlled trials, research on infant obesity is replete with contradictory findings (Sowan & Stember, 2000). For example, in examining the contribution of socioeconomic status, some findings suggest that decreasing socioeconomic status is associated with increasing infant and childhood obesity, whereas others show higher socioeconomic levels are associated with obesity in infants and young children, and still others show no relationship (Hernandez, Uphold, Graham, & Singer, 1998; Sowan & Stember, 2000; Stunkard, Berkowitz, Schoeller, Maislin, & Stallings, 2004). Similar contradictory findings relate to the role of maternal smoking (Sowan & Stember, 2000). Several antenatal factors have been studied as they relate to infant obesity. For example, longitudinal or controlled studies on mothers with gestational diabetes mellitus show that their offspring have a high rate of overweight that is associated both with intrauterine growth and parental obesity (Schaefer-



23. Feeding Disorders, Failure to Thrive, and Obesity

Graf et al., 2005; Vohr & McGarvey, 1997). Population-based and longitudinal studies of nondiabetic mothers show that maternal prepregnancy BMI is significantly correlated with offspring weight, length, and BMI at birth, and remained correlated with offspring weight and BMI during the first 2 years (Knight et al., 2007). Other parental risk factors for infant obesity include (1) maternal variables of prepregnancy weight (the odds of infant obesity at 7 months increased 20–30% with each 25-pound increase in the mother’s usual weight); (2) pregnancy weight gain (the odds of infant obesity at 1 month increased 10% with every 5-pound increase in mother’s weight, but at 14 months the odds of infant obesity were approximately 20% less with each 5-pound increase in weight gained during pregnancy); and (3) maternal age (the odds of infant obesity at 10 months increased 20–40% with each 5-year increase in mother’s age) (Sowan & Stember, 2000). Possible postnatal factors associated with infant (and later) obesity include paternal BMI, which has been correlated with offspring weight from 12 weeks onward, length and BMI from 1 year onward (Knight et al., 2007); and infant birthweight, which has been positively associated with adult BMI (Baird et al., 2005; Monteiro & Victora, 2005). BMI at birth (or abdominal circumference in infants of mothers with gestational diabetes) has been related to later BMI, and the rate of overweight at follow-up increased with increasing birthweight (Schaefer-Graf et al., 2005, 2006). In children of diabetic mothers with high BMI at birth, when both parents had a BMI < 30 kg/m2 , 20% of the infants were overweight; the rate increased to 34% with one parent and to 69% when both parents were obese (Schaefer-Graf et al., 2005). In their systematic review of 24 published studies (including 22 cohort and two case–­ control studies) that examined the question of whether infant size or rate of weight gain were linked to subsequent obesity, Baird et al. (2005) found considerable consistency in findings among 11 studies (including 25,499 subjects from the United States, Finland, France, Brazil, and the United Kingdom): Infants who were heavier during infancy or were defined as obese were more likely to develop obesity in childhood, adolescence,

387

and adulthood. Compared with nonobese infants, odds ratios or relative risks for subsequent obesity in those who had been obese ranged from 1.35 to 9.38. Ten studies assessed the relation of infant growth with subsequent obesity, and most showed that infants who grew more rapidly were at increased risk of obesity. Compared with other infants, infants with rapid growth had odds ratios and relative risks of obesity at ages 4.5–20 years that ranged from 1.17 to 5.70. Associations were consistent for obesity at different ages and for people born over a period from 1927 to 1994. Further, there was no evidence to suggest that exposure at a particular time during infancy was critical: large size or a rapid phase of growth at a range of intervals during the first and second year of life predisposed to later obesity. In a prospective, longitudinal study of 40 infants of obese mothers and 38 infants of lean mothers, Stunkard et al. (2004) found that energy intake, and not energy expenditure, was the determinant of body size in infants at 1 and 2 years of age. Another recent example of contradictory research finding pertains to the impact of breastfeeding on the prevention of obesity. Specifically, there is empirical evidence suggesting that breastfeeding might protect against the development of obesity in infancy (Scholtens et al., 2007), including in infants of mothers with diabetes (MayerDavis et al., 2006) and gestational diabetes mellitus (Schaefer-Graf et al., 2006). In addition, Scholtens et al. (2007) examined the longitudinal data collected on 2,347 Dutch children born in 1996–1997 and found that compared with nonbreastfed children, children breastfed for > 16 weeks tended to have a lower BMI at about 1 year of age but that the association between breastfeeding and BMI between 1 and 7 years of age was negligible, whereas a high BMI at 1 year was strongly associated with a high BMI between 1 and 7 years. This finding suggests that the lower BMI and lower risk of overweight among breastfed children later in life are already achieved at 1 year of age. Evidence from one meta-­analysis that reviewed 17 studies with more than 100,000 children (Harder, Bergmann, Kallischnigg, & Plagemann, 2005) strongly supports a dose-­dependent association between longer duration of breastfeeding and decrease in risk

388

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of overweight or obesity. However, Quigley (2006) described methodological problems with the Harder et al. meta-­analysis. Another meta-­analysis of 70 studies with 355,301 children (Owen, Martin, Whincup, Davey Smith, & Cook, 2005b) showed that mean BMI was lower among breastfed children, but the difference was small and likely to be strongly influenced by publication bias and confounding factors, and concluded that promotion of breastfeeding, although important for other reasons, is not likely to reduce mean BMI. In another meta-­analysis of 28 studies with 298,900 subjects, Owen, Martin, Whincup, Davey-Smith, and Cook (2005a) found that initial breastfeeding protected against later obesity, but cautioned that a review including large unpublished studies exploring the effect of confounding factors (e.g., parental obesity, maternal smoking, and social class) was needed. Recently published findings from a large longitudinal study of 35,526 female registered nurses aged 25–42 years in 1989 and followed prospectively between 1989 and 2001 show that, having been breastfed as infants (based on the reports of the subjects’ mothers) did not prevent women from becoming overweight or obese throughout the life course (Michels et al., 2007).

Treatment/Prevention Barlow and Dietz (1998) described the recommended pediatric practice for assessment and treatment of children and adolescents with obesity. However, no specific recommendations for infants are provided, other than evaluation in a pediatric obesity clinic in the rare cases of severely overweight children younger than 2 years of age. In fact, there appears to be no universally accepted or proven intervention to either prevent or treat infant obesity, much like what is seen in adult obesity. Although the emphasis has been on prevention, for example, by promoting breastfeeding, recent evidence from research questions the efficacy of breastfeeding in preventing childhood, adolescent, and adult overweight and obesity. It appears that general principles such as trying to control the rate of weight gain in the infant, both during pregnancy and the first year of life, in addition to increasing physical activity, might be promising directions. Other pos-

sible foci of intervention might relate to control of parental weight, BMI, and possibly lifestyles issues such as diet (energy intake) and level of physical activity (energy expenditure), until physiological and genetic research can provide other means to prevent, control, or treat overweight and obesity in all age groups, including infancy.

CONCLUSION FD, FTT, and obesity continue to be viewed as common but complex, multifactorial problems, often with inconsistent definitions and controversies. Despite many problems in research methodology, inconsistent findings, and disappointing results from intervention studies, there has been an overall improvement in the quality of research over the last decade or so. Although the next decade is not likely to provide definite answers and solutions to all aspects of FD, FTT, and obesity, the recent improvements in the quality of research are inspiring and bode well for the upcoming decade. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Arts-Rodas, D., & Benoit, D. (1998). Feeding problems in infancy and early childhood: Identification and management. Paediatrics and Child Health, 3, 21–27. Baird, J., Fisher, D., Lucas, P., Kleijnen, J., Roberts, H., & Law, C. (2005). Being big or growing fast: Systematic review of size and growth in infancy and later obesity. British Medical Journal, 331, 929–934. Barlow, S. E., & Dietz, W. H. (1998). Obesity evaluation and treatment: Expert Committee Recommendations. Pediatrics, 102, E29. Benoit, D. (2000a). Feeding disorders, failure to thrive, and obesity. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 339–352). New York: Guilford Press. Benoit, D. (2000b). Regulation and its disorders. In C. Violato, E. Oddone-­Paolucci, & M. Genuis (Eds.), The changing family and child development (pp. 149–161). Aldershot, UK: Ashgate. Benoit, D., & Coolbear, J. (1998). Post-­traumatic feeding disorders in infancy: Behaviors predicting treatment outcome. Infant Mental Health Journal, 19(4), 409–421. Benoit, D., Wang, E. E. L., & Zlotkin, S. H. (2000). Discontinuation of enterostomy tube feeding by



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Kerwin, M. E. (1999). Empirically supported treatments in pediatric psychology: Severe feeding problems. Journal of Pediatric Psychology, 24(3), 193–214. Knight, B., Shields, B. M., Hill, A., Powell, R. J., Wright, D., & Hattersley, A. T. (2007). The impact of maternal glycemia and obesity on early postnatal growth in a nondiabetic Caucasian population. Diabetes Care, 30, 777–783. Krugman, S. D., & Dubowitz, H. (2003). Failure to thrive. American Family Physician, 68(5), 879–884. Linscheid, T. R. (2006). Behavioral treatments of pediatric feeding disorders. Behavior Modification, 30(1), 6–23. Mackner, L. M., Black, M. M., & Starr, R. H. (2003). Cognitive development of children in poverty with failure to thrive: A prospective study through age 6. Journal of Child Psychology and Psychiatry and Allied Disciplines, 44(5), 743–751. Mackner, L. M., Starr, R. H., & Black, M. M. (1997). The cumulative effect of neglect and failure to thrive on cognitive functioning. Child Abuse and Neglect, 21(7), 691–700. Maes, H. H. M., Neale, M. C., & Eaves, L. J. (1997). Genetic and environmental factors in relative body weight and human adiposity. Behavior Genetics, 27(4), 325–351. Manikam, R., & Perman, J. A. (2000). Pediatric feeding disorders. Journal of Clinical Gastroenterology, 30(1), 34–46. Mayer-Davis, E. J., Rifas-­Shiman, S. L., Zhou, L., Hu, F. B., Colditz, G. A., & Gillman, M. W. (2006). Breast-­feeding and risk for childhood obesity. Diabetes Care, 29, 2231–2237. Michels, K. B., Willett, W. C., Graubard, R. L., Vaidya, R. L., Cantwell, M. M., Sansbury, L. B., et al. (2007). A longitudinal study of infant feeding and obesity throughout life course. International Journal of Obesity, 31, 1078–1085. Monteiro, P. O. A., & Victora, C. G. (2005). Rapid growth in infancy and childhood and obesity in later life: A systematic review. Obesity Review, 6, 143–154. O’Brien, L. M., Heycock, E. G., Hanna, M., Jones, P. W., & Cox, J. L. (2004). Postnatal depression and faltering growth: A community study. Pediatrics, 113(5), 1242–1247. Olsen, E. M. (2006). Failure to thrive: Still a problem of definition. Clinical Pediatrics, 45(1), 1–6. Owen, C. G., Martin, M. M., Whincup, P. H., Davey-Smith, G., & Cook, D. G. (2005a). The effect of breastfeeding on mean body mass index throughout life: A quantitative review of published and unpublished observational evidence. American Journal of Clinical Nutrition, 82(6), 1298–1307. Owen, C. G., Martin, M. M., Whincup, P. H., Davey Smith, G., & Cook, D. G. (2005b). Effect of infant feeding on the risk of obesity across the life course: A quantitative review of published evidence. Pediatrics, 115, 1367–1377. Parkinson, K. N., Wright, C. M., & Drewett, R.

W. (2004). Mealtime energy intake and feeding ­behaviour in children who fail to thrive: A population-based case–­control study. Journal of Child Psychology and Psychiatry, 45(5), 1030– 1035. Patel, V., DeSouza, N., & Rodrigues, M. (2003). Postnatal depression and infant growth and development in low income countries: A cohort study from Goa, India. Archives of Disease in Childhood, 88, 34–37. Quigley, M. A. (2006). Letter to the Editor, re: “Duration of breastfeeding and risk of overweight: A meta-­analysis.” American Journal of Epidemiology, 163(9), 870–872. Ramsay, M., Gisel, E. G., McCusker, J., Bellavance, F., & Platt, R. (2002). Infant sucking ability, non-­organic failure to thrive, maternal characteristics, and feeding practices: A prospective cohort study. Developmental Medicine and Child Neurology, 44, 405–414. Raynor, P., & Rudolf, M. C. J. (2000). Anthropometric indices of failure to thrive. Archives of Disease in Childhood, 82, 364–365. Raynor, P., Rudolf, M. C. J., Cooper, K., Marchant, P., & Cottrell, D. (1999). A randomized controlled trial of specialist health visitor intervention for failure to thrive. Archives of Disease in Childhood, 80, 500–505. Reifsnider, E. (1998). Reversing growth deficiency in children: The effect of a community based intervention. Journal of Pediatric Health, 12, 305–312. Robinson, J. R., Drotar, D., & Boutry, M. (2001). Problem-­solving abilities among mothers of infants with failure to thrive. Journal of Pediatric Psychology, 26(1), 21–32. Rudolf, M. C. J., & Logan, S. (2005). What is the long-term outcome for children who fail to thrive?: A systematic review. Archives of Disease in Childhood, 90, 925–931. Schaefer-Graf, U. M., Hartmann, R., Pawliczak, J., Passow, D., About-Dakn, M., Vetter, K., et al. (2006). Association of breast-­feeding and early childhood overweight in children from mothers with gestational diabetes mellitus. Diabetes Care, 29, 1105–1107. Schaefer-Graf, U. M., Pawliczak, J., Passow, D., Hartmann, R., Rossi, R., Bührer, C., et al. (2005). Birth weight and parental BMI predict overweight in children from mothers with gestational diabetes. Diabetes Care, 28(7), 1745– 1750. Scheer, P., Dunitz-­S cheer, M., Schein, A., & Wilken, M. (2003). DC:0–3 in pediatric liaison work with early eating behavior disorders. Infant Mental Health Journal, 24(4), 428–436. Scholtens, S., Gehring, U., Brunekreef, B., Smit, H. A., de Jongste, J. C., Kerkhof, M., et al. (2007). Breastfeeding, weight gain in infancy, and overweight at seven years of age. American Journal of Epidemiology, 165, 919–926. Sowan, N. A., & Stember, M. L. (2000). Parental risk factors for infant obesity. American Journal of Maternal/Child Nursing, 25(5), 234–241.



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Steward, D. K. (2001). Behavioral characteristics of infants with nonorganic failure to thrive during a play interaction. Journal of American Maternal/ Child Nursing, 26(2), 79–85. Stunkard, A. J., Berkowitz, R. I., Schoeller, D., Maislin, G., & Stallings, V. A. (2004). Predictors of body size in the first 2 years of life: A high-risk study of human obesity. International Journal of Obesity, 28(4), 503–513. Vohr, B. R., & McGarvey, S. T. (1997). Growth patterns of large-for-­gestational-age and appropriate-for-­gestational-age infants of gestational diabetic mothers and control mothers at age 1 year. Diabetes Care, 20(7), 1066–1072. Ward, M. J., Lee, S. S., & Lipper, E. G. (2000). Failure-to-­thrive is associated with disorganized infant–­mother attachment and unresolved maternal attachment. Infant Mental Health Journal, 21(6), 428–442. Whitaker, R. C., Wright, J. A., Pepe, M. S., Seidel, K. D.,& Dietz, W. H. (1997). Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine, 337, 869–873. Wilensky, D., Ginsberg, G., Altman, M., Tulchinsky, T., Ben Yishay, F., & Auerbach, J. (1996). A community based study of failure to thrive in Israel. Archives of Disease in Childhood, 75, 145–148. Winters, N. C. (2003). Feeding problems in infancy

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and early childhood. Primary Psychiatry, 10(6), 30–34. Wright, C., Avery, A., Epstein, M., Birks, E., & Croft, D. (1998). New chart to evaluate weight faltering. Archives of Disease in Childhood, 78, 40–43. Wright, C., & Birks, E. (2000). Risk factors for failure to thrive: A population-based survey. Child: Care, Health and Development, 26(1), 5–16. Wright, C., Callum, J., Birks, E., & Jarvis, S. (1998). Community based management of failure to thrive: A randomized control trial. British Medical Journal, 317, 571–574. Wright, C. M. (2000). Identification and management of failure to thrive: A community perspective. Archives of Disease in Childhood, 82, 5–9. Wright, C. M., Parkinson, K. N., & Drewett, R. F. (2006a). How does maternal and child feeding behavior relate to weight gain and failure to thrive?: Data from a prospective birth cohort. Pediatrics, 117, 1262–1269. Wright, C. M., Parkinson, K. N., & Drewett, R. F. (2006b). The influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive): Data from a prospective birth cohort. Archives of Disease in Childhood, 91, 312–317. Zero to Three. (2005). Diagnostic classification of mental health and developmental disorders of infancy and early childhood: Revised edition (DC:0–3R). Washington, DC: Author.

C h a p t e r 24

Characterizing Early Childhood Disruptive Behavior Enhancing Developmental Sensitivity Lauren S. Wakschlag Barbara Danis

A

lthough it has long been evident that disruptive behavior has origins in early life (Shaw, Bell, & Gilliom, 2000), substantial strides have been made over the past decade in the identification of clinically salient patterns of disruptive behavior in early childhood. In large part, this progress has been due to the convergence of four scientific advances during this period: (1) innovations in measurement that enable assessment of clinical patterns in a developmentally sensitive manner (DelCarmen-­Wiggins & Carter, 2004); (2) advances in statistical modeling of developmental trajectories (Nagin & Tremblay, 1999); (3) the maturation of many of the early studies of disruptive behavior in young children, which provide longitudinal data to elucidate the predictive meaning of these early patterns (Campbell et al., 2006; Shaw, Gilliom, Ingoldsby, & Nagin, 2003); and (4) empirical testing of the validity of clinical nosology in early childhood (Egger & Angold, 2006; Task Force, 2003). The notion that psychopathology emerges in early childhood has been disturbing to many because it seems overly deterministic (Zeanah, 2000). This view is amplified in the case of disruptive behavior because of its overlap with the normative misbehaviors of early childhood and the resultant diffi

culty in distinguishing normative variation from behaviors indicative of clinical concern (Wakschlag, Briggs-Gowan, et al., 2007). Although there has been extensive debate in the field about the virtue of early identification versus the dangers of overidentification (Keenan & Wakschlag, 2003; McClellan & Speltz, 2003; Wilens, Biederman, & Spencer, 2003; Zeanah, 2000), clinicians, teachers, and parents have long recognized that disruptive behavior problems in young children are real and impairing—­disruptive behavior is the most common reason for mental health referral of young children (Wakschlag & Danis, 2004). And while philosophical debates about the merits of early childhood psychopathology continue, the increasing use of psychopharmacological treatments in young children, much of it to manage behavior problems, attests to the need for a stronger empirical basis for properly identifying clinically significant disruptive behavior in a manner that can more specifically direct treatments (Barbaresi, 2003; Zito et al., 2000). Taken together with recent scientific advances, there is now little doubt that clinical patterns are evident as early as the first years of life. Here the term “clinical” does not refer to the ongoing debate about whether psycho392



24. Early Childhood Disruptive Behavior

pathology is best conceptualized from within a dimensional or categorical perspective, as recent scientific advances have moved the field well beyond an “either–or” approach to these questions (Pickles & Angold, 2003; Rutter, 2003). Rather, we use the term clinical to connote a framework for determining the atypicality of individual behavior patterns within a developmental context. The question is no longer whether psychopathology exists in early childhood but how. That is, how can clinical patterns in young children be conceptualized and assessed so that they are both developmentally specified and coherent with clinical phenomenology over time? Pragmatically, this question translates into, How can we tell “when to worry” in assessing disruptive behaviors in young children? Addressing this question in regard to early childhood disruptive behavior (from ages 18 months to 5 years) is the topic of the present chapter. In response to this clinical imperative, much of our recent work has focused on formulating a developmentally sensitive conceptualization of disruptive behavior in young children (Wakschlag, Leventhal, & Thomas, 2007). In particular, we have focused on integrating clinical, theoretical, and empirical knowledge to operationalize developmental manifestations of disruptive behavior—with the goal of developing testable hypotheses that can lead to the generation of systematic and empirically validated guidelines for clinical decision making regarding young children.

DISRUPTIVE BEHAVIOR IN A DEVELOPMENTAL CONTEXT The achievement of autonomously regulated emotions and behavior is a central developmental task of early childhood (Kochanska, Coy, & Murray, 2001). These skills emerge and are consolidated via the child’s acquisition of increasingly sophisticated cognitive, linguistic, and inhibitory skills and increasing socialization emphasis on maturity demands and limit setting. As these processes become consolidated and internalized during early childhood, the developmental thrust to autonomy results in heightened frustration and angry outbursts manifesting as noncompliance, aggression, and temper tantrums.

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We have termed this triad of expectable early childhood behaviors “normative misbehaviors” (Wakschlag, Briggs-Gowan, et al., 2007). In fact, approximately 75% of children exhibit aggression and tantrums by age 2 (Potegal & Davidson, 2003; Tremblay et al., 1999). Normative misbehaviors typically emerge after the first birthday when developmental progression enables autonomous function motorically and communicatively and when differentiated thought processes enable comprehension of intentionality of action and means–ends relationships (Hay, 2005). The intentionality and directedness of these misbehaviors represent developmental progression from the more diffuse reactivity of early infancy (Hay, 2005).

Normative Misbehaviors Aggression appears during infancy as a natural way of expressing anger. Thus, aggression per se is not pathognomonic. Instead, the gradual attainment of “aggressive competence” is a normative developmental event (Hay, 2005, p.  125). Typically, normative aggression emerges as an instrumental response to frustration or blocked goals (e.g., toy disputes) (Tremblay, 2003). It also occurs normatively in rough-and-­tumble play, a context that provides young children with opportunities to learn to modulate their behavior with peers (Peterson & Flanders, 2005). Noncompliance reflects resistance to, and failure to comply with, rules, directives, and social norms. It has multiple manifestations, including simple refusal, negotiation, active defiance, rule breaking, and ignoring. Because the ability to say “no” is considered a major milestone in the development of autonomy (Crockenberg & Litman, 1990), some noncompliance is considered developmentally adaptive (Dix, Stewart, Gershoff, & Day, 2007). Tantrums have been defined as discrete temper outbursts (that include stomping, yelling, crying, and/or destructive behavior) that communicate frustration, anger, and distress (Einon & Potegal, 1994). The overlap of these normative misbehaviors with the core features of DSM-IV disruptive behavior disorders (DBDs) has made determination of the clinical significance of disruptive behavior in early childhood espe-

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cially challenging (Campbell, 2002). For example, the defining features of oppositional defiant disorder (ODD) are temper loss and noncompliance. Although DSM-IV conduct disorder (CD) symptoms reflect manifestations of antisocial behavior in older youths (e.g., illegal activities, rape), the latent features of CD are salient across developmental periods—that is, problems in modulating aggression and lack of concern for others (Wakschlag, Tolan, & Leventhal, 2009). Thus, a developmental approach to understanding clinical phenomenology in young children is critical. In the discussion that follows, we review recent evidence of the validity of applying DSM DBD clinical constructs to young children. We then examine findings from developmental science that are fundamental to advancing our understanding of disruptive behavior in young children. In addition, we examine new observational methodology that reflects an initial attempt to bridge clinical and developmental approaches. Finally, we outline an integrated developmental/clinical approach as a framework for future research.

Validity of DSM DBD Constructs for Young Children Over the past decade, much research has focused on DBDs in children from ages 2–5 years, although many samples have focused exclusively on preschoolers. The application of clinical constructs to this age period followed earlier studies that focused on “preschool behavior problems” (Campbell, 2002). Disruptive behavior in earlier studies was generally assessed with dimensional measures, either in terms of specific behaviors (e.g., “noncompliance,” “aggression”) or as aggregated attentional, oppositional, and conduct problems under the rubric of “externalizing behaviors” (Shaw, Keenan, & Vondra, 1994). This work demonstrated that “preschool behavior problems” are moderately stable, heritable, and often presage a chronic trajectory of impairing disruptive behavior (Bates, Bayles, Bennett, Ridge, & Brown, 1991; van den Oord, Verhulst, & Boomsma, 1996). With evidence that preschool behavior problems are real and measurable and are often the initial phase of a chronic disruptive behavior trajectory, the second genera-

tion of studies has focused on attempting to achieve greater clinical specificity by testing the application of diagnostic constructs to this age group. The goal of this work has been early detection and charting the course of clinical disorders at their emergence in a manner that is consistent with lifespan concepts of disruptive behavior. In the absence of developmentally validated instruments, a guiding principle of this work has been to “adhere as closely as possible to DSM-IV,” with only minor developmental modifications (Task Force, 2003). Thus, for example, some CD symptoms that were developmentally impossible for preschoolers to exhibit (e.g., truancy) were dropped, and examples of symptomatic behavior were developmentally modified (see Keenan et al., 2007). Within this framework multiple research groups have independently demonstrated that patterns of behavior consistent with DSM-IV DBD symptoms are present and detectable in children during early childhood (e.g., Keenan & Wakschlag, 2004; Kim-Cohen et al., 2005; Lavigne et al., 1998; Speltz, McLellan, DeKlyen, & Jones, 1999). The introduction of diagnostic interviews specifically developed for use with young children, such as the Preschool Age Psychiatric Assessment (PAPA) and the Kiddie Disruptive Behavior Disorders Schedule (K-DBDS), in two more recent studies provides additional validation (Egger et al., 2006; Keenan et al., 2007). These studies demonstrate that disruptive behavior symptoms distinguish clinically referred and nonreferred children as well as impaired and nonimpaired children in community samples. In addition, they provide evidence that (1) preschoolers meeting DBD symptom criteria are more than 20 times as likely to be impaired by parent report and more than twice as likely to be impaired by teacher report (Keenan et al., 2007); (2) DBD symptoms are associated with developmentally based assessments of disruptive behavior, including observed disruptive behavior (Wakschlag, BriggsGowan, 2007) and self-­reported antisocial behaviors on the Berkeley Puppet Interview (Kim-Cohen et al., 2005); (3) DBD symptoms demonstrate moderate stability (Lavigne et al., 2001; Speltz et al., 1999); and (4) preschool DBDs are responsive to empirically validated interventions for disruptive behavior (Webster-­Stratton & Reid, 2007).



24. Early Childhood Disruptive Behavior

As it has become increasingly clear that disruptive behavior patterns are evident, relate to current functioning and later diagnosis, and impair subsequent development, there has also been increasing concern that DSM DBD nosology is misspecified for early childhood (Wakschlag, Leventhal, et al., 2007). This concern arises because (1) manifestations of disruptive behavior at different developmental periods have not been carefully characterized within a framework of heterotypic continuity; (2) the implications of possible misspecification for accurate identification have not been examined; and (3) the changing developmental capacities of children within the early childhood period have not been incorporated into symptom definitions or clinical cutpoints. Heterotypic continuity assumes that there is continuity of latent traits across developmental periods but that there is discontinuity in their developmental expression (Rutter & Sroufe, 2000). With the wholesale application of DSM DBD symptoms associated with older children to early childhood, very little attention has been paid to the “fit” of these symptoms to the developmental expression of disruptive behaviors in young children. This question of fit is multifaceted. First, are young children capable of the behaviors being assessed in these symptoms, and if so, how well do these behaviors capture early childhood expression? Many CD symptoms are developmentally impossible, and dropping them without replacing them results in a restricted symptom pool. Others are improbable, representing extreme forms of behavior that occur rarely in young children and are not likely to capture the phenomenology of these behaviors at this age period (Wakschlag, Leventhal, et al., 2007). Second, how well do the symptoms capture critical clinical distinctions in this age period? Many ODD symptoms are developmentally imprecise because they are worded in a manner that entails substantial overlap with the normative misbehaviors of early childhood (e.g., losing temper, defying adults) (Wakschlag, Leventhal, et al., 2007). There is no specification of how frequently these common misbehaviors must occur in order to be considered symptoms. Using data from the PAPA, Egger and Angold (2006) have demonstrated that applying frequency cutpoints for ODD developed for school-age children

395

to preschool children results in substantial overidentification, identifying as many as 57% of children ages 2–5 years. Current symptom definitions do not incorporate behavioral features beyond frequency that are necessary for identifying atypicality during this age period. Many behaviors are defined in gross terms that may not capture clinically salient features during this developmental period or be precise enough to capture important individual differences. For example, Baillargeon and colleagues (Baillargeon, Normand, et al., 2007; Baillargeon, Zoccolillo, et al., 2007) have recently demonstrated that at 17 months, boys are significantly more likely than girls to “hit, kick or bite,” but such sex differences are not found in the severer behavior “physically attacks.” Finally, the possibility of unique criterial features for this age period has not been systematically considered. In clinical research to date, accuracy of identification, particularly in terms of developmental adaptation over time and differential diagnosis, has received scant attention. Although impairing behaviors in early childhood are of concern regardless of whether they persist over time, examining the predictive meaning of these behaviors is critically important for elucidating their clinical significance. Poor specification in clinical nosologies may contribute to overidentification. Little is known about the characteristics of young children who have high levels of disruptive behavior that do not persist beyond early childhood. For example, much has been made of the stability of disruptive behavior in young children. Fairly consistent evidence across studies has indicated that approximately 50% of children will continue to exhibit disruptive behavior (Campbell, 2002; Kim-Cohen et al., 2005; Lavigne et al., 2001), with somewhat higher rates in referred samples (Speltz et al., 1999). However, these data also indicate that approximately 50% of early-­childhood-­identified disruptive preschoolers will not persist in this behavior. Kim-Cohen, Arseneault, and colleagues (2005) have begun to explore the question of continuity and discontinuity by examining developmental outcomes for children within their community sample identified as meeting criteria for CD at ages 4½–5 years. Nearly half of these preschoolers did

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not meet criteria for CD 2 years later at age 7. This “discontinuous” group was significantly more behaviorally and academically impaired at early school age compared to the group of children who did not meet CD criteria as preschoolers. While these findings might suggest subsyndromal patterns at age 7, they also suggest the possibility that other developmental difficulties (e.g., learning problems and social skills deficits) may manifest as disruptive behavior in young children. Along these lines, Briggs-Gowan et al. have recently shown that high levels of adaptive social behavior in toddlers reduce the risk of persistence of disruptive behavior from early childhood to early school age (Briggs-Gowan & Carter, 2007; BriggsGowan, Jones, Wakschlag, & Carter, 2007). Taken together, these studies underscore the importance of evaluating the clinical significance of young children’s behavior problems within the context of their broader developmental functioning and also highlight the substantial discontinuities, as well as continuities, in disruptive behavior patterns over time. Because the risk of overidentification has been at the center of debates about early childhood psychopathology (Zeanah, 2000), insufficient attention has been paid to the risk of underidentification. For example, there has been no systematic examination of the extent to which the application of DSM DBD nosology (which encompasses many extreme antisocial behaviors as they manifest in older youths) may contribute to “overlooking” young children with clinically concerning patterns that manifest differently during early childhood than at older ages. A more developmentally based nosology is likely to enhance accurate identification (Kim-Cohen et al., 2005). Because so much emphasis has been placed on establishing the validity of the existence of disruptive behavior across developmental periods (e.g., Are prevalence rates similar in preschool and school-age periods?), there has been little examination of the validity of disruptive behavior symptoms within the early childhood period. The developmental period from 18 months to 5 years encompasses rapid developmental changes in language and cognitive skills, moral development, and self-­regulation capacities (Espy &

Bull, 2005; Kochanska et al., 2001; Shaw, Bell, & Gilliom, 2000). These developmental changes have substantial implications for the meaning and normative occurrence of the range of disruptive behaviors, many of which assume intent, verbal comprehension, and the ability to purposefully inhibit behavior. Further, these changes in inhibitory capacities, internalization of rules, linguistic skill, intentionality, and perspective-­taking skills may substantially affect the manifestation and frequency of behavior within the early childhood period. For example, frequency of aggression is likely to decrease as young children’s verbal negotiation skills and capacity to anticipate consequences become increasingly sophisticated between ages 2 and 5 years. Thus, developmental research has much to offer in informing our understanding of the boundaries between typical and atypical behavior in early childhood. This is the focus of the section that follows.

Developmental Patterns of Precursor Behaviors To a large extent, studies of toddlers (12–36 months) have focused on specific precursor behaviors whose manifestations and course indicate deviation from normative developmental patterns (Baillargeon, Normand, et al., 2007; Hay, Castle, & Davies, 2000; NICHD, 2004). Precursors have been conceptualized as specific behavioral perturbations that reflect early clinical patterns (Hay & Angold, 1993; Wakschlag, Leventhal, Pine, Pickett, & Carter, 2006). Whereas a risk factor generically increases the probability of maladaptation, precursors indicate progression toward a specific clinical problem (Pickles, 1993). Although the popular notion of “the terrible twos” suggests that normative misbehavior occurs in a chaotic and unpredictable fashion, there is ample evidence from developmental research that these behaviors unfold in a relatively expectable developmental pattern. Precursors reflect behavioral patterns or qualities that deviate from this expectable course and expression. One of the challenges of delineating when behaviors are of clinical concern in early childhood is that doing so requires identifying “deviation from the norm,” yet there are very few empirical data on the



24. Early Childhood Disruptive Behavior

actual frequency of aggression, noncompliance, and tantrums in normative samples of young children. By far the greatest emphasis in developmental research has been on patterns of early aggression (Shaw, Gilliom, & Giovannelli, 2000). Importantly, even though it is typical for young children to exhibit aggression some of the time, such behaviors are not characteristic (Hay, 2005). Thus, even when aggression is at its peak, prosocial or neutral interactions predominate (Hay, 2005; Tremblay & Nagin, 2005). Empirical support for this point is found in multiple community samples. Table 24.1 lists prevalence of aggressive behavior in three community samples at ages 2–3 years (Baillargeon, Tremblay, & Willms, 2005; Carter, Briggs-Gowan, Jones, & Little, 2003; NICHD, 2004). Although rates of engaging in occasional aggression vary somewhat across these samples, what is striking from these data is that less than 10% of children as young as 2 years of age are reported to “often” hit others. This finding suggests that even though the occurrence of misbehaviors such as hitting is normative, their frequent occurrence is not. Although the NLSCY and NICHD studies focused on aggression only, similar patterns are found for tantrums and noncompliance in the data from the Infant–­Toddler Social and Emotional Assessment (ITSEA; Carter et al., 2003). On the ITSEA, 10% of 2-yearolds and 8% of 3-year-olds are reported to “often have temper tantrums” and 6% of 2-year-olds and 7% of 3-year-olds are re-

397

ported to be “often defiant” (Carter, BriggsGowan, McCarthy, & Wakschlag, 2009). The consistency of these data across diverse samples is quite striking in belying the myth of the “terrible twos.” Thus, despite increases in normative misbehaviors during this developmental period, these behaviors actually do not characterize the majority of young children’s interactions. These epidemiological findings are consistent with findings from observational studies as well (Hay, 2005). Whereas these data based on subjective frequency (e.g., “often”) are important for broadly establishing that it is not normative for these misbehaviors to occur at high frequency, data on objective frequency (e.g., times per day) of aggression, noncompliance, and tantrums in young children of different ages are critical to the task of providing clinically meaningful information. Empirically establishing the actual frequency of behaviors at different ages within early childhood will enable us to generate empirically grounded clinical cutpoints that can be applied systematically. The other major advance in elucidating precursors to disruptive behavior has been the robust identification of atypical patterns across early childhood. This work was pioneered by Tremblay and colleagues, who theorized that aggression is not “learned” over time—­rather, it is “unlearned,” resulting in a normative decline of aggression over time—as self-­control, language, and adaptive problem-­solving skills are acquired with maturation (Cote, Vaillancourt, LeBlanc,

TABLE 24.1.  Rates of “Hits Others” in Early Childhood from Three Community Samples 2 years Never/ rarely

Sometimes

28%

NLSCYb: “Hits, kicks, bites other children” CEDPc: “Hits, shoves, kicks, bites other children”

NICHDa:

“Hits others”

3 years Often

Never/ rarely

Sometimes

Often

66%

6%

35%

61%

5%

61%

35%

4%

67%

31%

2%

71%

26%

3%

77%

20%

3%

Note. Findings from these studies have been reported in multiple publications. Data reported here are from survey questions in the aNICHD Early Child Care Research Network sample, n = 1,100; and b National Longitudinal Survey of Children and Youth, n = 1,962, and Canadian household survey (Baillargeon, Tremblay, & Willms, 2005); c data from the ITSEA within the Connecticut Early Developmental Project, n = 1,279, representative birth cohort (Carter et al., 2003, 2009).

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IV. PSYCHOPATHOLOGY

Nagin, & Tremblay, 2006). Thus, within this framework, it is not the presence of aggression in young children but the failure to inhibit it that is an indicator of clinical concern. To test this theory, Tremblay examined trajectories of aggression in a community sample of Canadian children from ages 17 to 42 months (Tremblay et al., 2004). Three trajectories were identified—the most common was a rising pattern of modest aggression from ages 17 to 42 months (58% of children). Slightly more than a quarter of the children (28%) showed a stable low pattern of aggression, and 14% of the sample demonstrated a rising trajectory of high aggression. Using diverse samples and methods, these findings have now been replicated and robustly demonstrate that (1) a pattern of stable high aggression in early childhood is atypical and (2) that it marks the early phase of a chronically high pattern of aggression extending through preadolescence (Cote et al., 2006: NICHD, 2004; Shaw et al., 2003). Further evidence for the clinical significance of this pattern is found in the fact that such atypical trajectories are associated with well-­established early risk processes for disruptive behavior, including young maternal age at first birth, prenatal smoking, and parenting that is harsh and unresponsive or marked by coercive interactional cycles (Granic & Patterson, 2006; NICHD, 2004; Shaw et al., 2003; Tremblay et al., 2004; Wakschlag et al., 2006). In contrast to aggression, studies of tantrums in normative populations of young children are limited. Much of what is known about the developmental course of tantrums is derived from small, observational studies conducted between the 1920s and the 1960s. The most frequently cited study is one conducted by Goodenough in the 1920s, in which 45 mothers recorded the frequency of their children’s tantrums on a daily basis for 1 month, with more than 1,000 tantrums observed (Goodenough, 1931). Data on tantrum frequency is also reported from several birth cohort studies (Earls, 1983; Jenkins, Owen, Bax, & Hart, 1984; MacFarlane, Allen, & Honzik, 1962). Despite limitations of measurement, data from these studies parallel findings from the aggression studies, suggesting that tantrums peak between 17

and 24 months of age and begin to decline by around 3 years of age (Goodenough, 1931; MacFarlane et al., 1962; Potegal & Davidson, 2003). More than 80% of toddlers exhibit tantrums by the age of 2 (Einon & Potegal, 1994). However, as with aggression, although tantrums are common they are not characteristic. Even at the age of 2, less than 20% of children have tantrums daily or nearly every day. By the age of 3, less than 10% of parents report frequent tantrums (Carter et al., 2009; Earls, 1980; Jenkins et al., 1984). There is also some evidence suggesting that stable high rates of tantrums across the preschool period are associated with problems over time (Jenkins et al., 1984; Stevenson & Goodman, 2001). To our knowledge, there are no studies of normative rates of noncompliance in early childhood.

Quality of Behavior as a Clinical Indicator DSM-IV nosology defines disruptive symptoms in terms of frequency (e.g., “often loses temper”) (American Psychiatric Association, 1994). Based on the evidence described above, high frequency of disruptive behavior is, indeed, atypical even in young children. However, it is unlikely that frequency alone will be adequate to identify clinically significant disruptive behavior in young children due to the high rates of behavioral variability during this age period and the difficulty of distinguishing transient perturbations from behaviors of concern. Defining features beyond frequency that mark the presence of disruptive behavior in young children has been a central focus of our recent work (Wakschlag et al., 2007a, 2008b). Following the suggestion of Catherine Lord, based on her seminal work on the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 2000), we first drew on our extensive clinical experience to operationalize the basis by which we made clinical judgments—“What tells us that a young child’s behavior is cause for concern?” For example, when clinicians observe a child whose tantrums are intense, destructive, and unresponsive to adult support, they know it is “time to worry,” whereas a brief tantrum that is easily ameliorated with parental reassurance is not. Similarly, observation of sneaky pinching that is unprovoked is a “red



24. Early Childhood Disruptive Behavior

flag” for clinicians, whereas smacking a peer in the midst of a toy dispute is not. Finally, a “reflexive no” that is elicited in response to virtually any request is clinically concerning, whereas refusing to clean up is not. Melding this clinical knowledge with theory and empirical evidence from a large body of research on preschool behavior problems (Campbell, 2002; Shaw, Keenan, et al., 2000), developmental research (Hay, 2005; Kuczynski & Kochanska, 1990), and the perspective of developmental psychopathology (Cicchetti & Richters, 1997), we conceptualized quality of behavior as a critical element of clinical decision making with young children. We defined quality of behavior as the extent to which behavior is modulated and expectable in context (Wakschlag, BriggsGowan, et al., 2007). Modulation refers to the intensity, flexibility, and organization of behavior. Expectability in context assesses whether a context typically elicits particular types of responses (Cole, Martin, & Dennis, 2004; Goldsmith & Davidson, 2004). Although quality of behavior has not been systematically operationalized and tested as a central feature of early childhood disruptive behavior or as long-term predictor, there is substantial support for this concept in developmental research. Seminal work by Kochanska and colleagues on developmental patterns of compliance has elegantly demonstrated the development of internalization processes and the implications of systematic differences in quality of young children’s compliance for adaptation over time. Though the first years of life involve multiple developmental shifts resulting in marked developmental changes in children’s capacity for compliance, this capacity is firmly established in toddlerhood (Kuczynski & Kochanska, 1990). For example, toddlers (ages 18–24 months) demonstrate the capacity to obey rules even when unsupervised and exhibit spontaneous remorse after misbehavior (Kochanska, Aksan, & Koenig, 1995). There is also evidence that developmental patterns of compliance vary depending on the demand context—for example, whereas compliance to parental requests (compliance “do”) is fairly stable from ages 14–45 months, compliance with prohibitions in the absence of parental supervision (compliance “don’t”) sharply increases across this age period (Kochanska et al., 2001).

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The fundamental distinction that must be made in early childhood in terms of normative versus problematic manifestations of noncompliance is one of quality. Crockenberg suggested that this distinction can be made in terms of the motivational elements of behavior. The primary goal of adaptive forms of noncompliance is to assert autonomy, whereas the goal of defiance is to resist adult requests (Crockenberg & Litman, 1990)—a response pattern reflecting “resistance to control” (Bates, Petit, Dodge, & Ridge, 1998). Along these lines, Kochanska et al. (1995) identified multiple forms of skillful (e.g., negotiation, simple refusals) and unskillful (e.g., passive noncompliance/ ignoring, direct defiance and whining) noncompliance and assessed the association of these variations in quality of noncompliance during early childhood to adaptation across time. Findings from this and other studies indicate that whether or not early observed noncompliance increases, risk of disruptive behavior is contingent on the quality of the noncompliance. Toddler unskilled noncompliance strategies predict elevated risk of preschool disruptive behavior, whereas skillful noncompliance does not (Drabick, Strassberg, & Kees, 2001; Kuczynski & Kochanska, 1990). Quality of early aggression also has been studied as a marker of clinical concern. One major line of work in this area has been the distinction between reactive and proactive aggression. Reactive aggression reflects affectively driven aggressive outbursts that are “reactive” to frustration or provocation (Dodge, 1991; Vitaro, Gendreau, Tremblay, & Oligny, 1998). Reactive aggression may be viewed as “unconditioned temperamentally based reactions” (Vitaro & Brendgen, 2005). In young children, in particular, reactive aggression may reflect immature self-­regulatory skills and is thus conceptualized as a normative misbehavior. Examples of normative aggression include aggression that may occur in the context of rough-and­tumble play and struggles over possessions (Zahn-­Waxler, Iannotti, Cummings, & Denham, 1990). In contrast, proactive aggression is regulated and planful and is not the result of provocation or anger; that is, it is aggression “for its own sake,” making it more antisocial in nature (Hay et al., 2000; Vitaro et al., 1998). The reactive–­proactive

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distinction has been demonstrated in toddlers as young as 18 months of age (Hay et al., 2000). Reactive aggression occurs more frequently in normative populations of young children. For example, parent report on the ITSEA indicates that 19% of 2-yearolds and 15% of 3-year-olds are often “aggressive when frustrated,” whereas only 1% of children at either age are reported to “hurt others on purpose” (Carter et al., 2009). Further, observed reactive aggression with peers (e.g., in toy dispute) is not significantly associated with high maternal ratings of aggressiveness, whereas forceful, proactive aggression is (Hay et al., 2000). Other qualities of aggression that may be clinical indicators include intense, driven aggression; dysregulated, destructive aggression; and aggression directed toward adults (Hay, 2005; Zahn-­Waxler et al., 1990). There is scant research on tantrum quality as a clinical indicator. Recent work by Egger and colleagues (Egger, Erkanli, Wakschlag, & Angold, 2007) in an early childhood community sample indicates that “destructive tantrums” (i.e., tantrums that include directed violence against self or others) are clinically discriminating, whereas nondestructive tantrums are not. In addition, “severe” tantrums that are intense and dysregulated are associated with impairment (Needleman, Stevenson, & Zuckerman, 1991). In summary, a diverse set of developmental studies suggests that quality of misbehaviors is informative for discriminating typical from atypical patterns in young children. Unfortunately, however, these studies have generally proceeded along separate lines (e.g., studies of aggression vs. studies of noncompliance) and have not been integrated into a comprehensive clinical conceptualization of disruptive behavior in young children. In order to test whether assessing quality of behavior has incremental clinical utility, these features must be systematically identified and operationalized within a coherent clinical framework and empirically tested. Accomplishing this task will require a multifaceted integrated clinical/developmental approach including large-scale studies that examine developmental patterns over time in relation to clinical symptomatology and impairment and standardized methods that operationalize these behaviors into observable form. To illustrate this integrated ap-

proach, we describe a new diagnostic observation method we have developed to provide a developmentally sensitive direct assessment method for distinguishing normative misbehavior from clinically significant disruptive behavior during early childhood.

THE DISRUPTIVE BEHAVIOR DIAGNOSTIC OBSERVATION SCHEDULE Diagnostic observation provides a standardized method that serves as an additional “informant” about child behavior in conjunction with parent interviews and also generates essential information for phenotypic characterization (Wakschlag, Briggs-Gowan, et al., 2008; Wakschlag, Hill, et al., 2008). As a case in point, diagnostic observation has played a critical role in establishing the developmental validity and phenotype of another early childhood disorder, autism (Lord et al., 2000). Direct observation of young children’s behavior has long been considered central to developmentally sensitive assessment of young children (American Academy of Child and Adolescent Psychiatry, 1997; Zeanah, Larrieu, Heller, & Valliere, 2000) because observation provides developmentally contextualized information about child behavior. Assessing these behaviors within the family context, while in a laboratory setting, also provides a relatively naturalistic way in which to capture child behavior patterns. Many studies of preschool behavior problems have incorporated observational assessments of parent–child interaction (Campbell, Breaux, Ewing, Szumowski, & Pierce, 1986; Webster-­Stratton, 1985). However, because these paradigms were not designed to be diagnostically informative, they are of limited clinical utility (Mash & Foster, 2001). In contrast, examiner-based assessments are designed to be clinically sensitive by standardizing adult responses in a manner that “presses” for a range of clinically salient behaviors in the child—but, as a result, they lack the ecological validity of parent–child assessment. Thus, examinerand parent-based behavioral observations, taken together, provide complementary methods for incorporating the interactive nature of social behavior into the assessment of clinical significance.



24. Early Childhood Disruptive Behavior

To this end, we developed the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS; Wakschlag, Briggs-Gowan, et al., 2008; Wakschlag, Hill, et al., 2008). A central aspect of this process was defining clinical patterns at this age period in a manner that distinguished them from the “normative misbehaviors” of early childhood (Wakschlag, Briggs-Gowan, et al., 2007). This required an intensive process in which we drew on our extensive clinical experience with young children, developmental research, and clinical literature to develop a developmentally sensitive paradigm. The result was a DB-DOS coding system with a central focus on characterizing the quality of behavior and a DB-DOS paradigm that assessed the pervasiveness of behaviors across interactional contexts. Behavioral qualities were operationalized on the DB-DOS as 21 behaviors within two broad domains conceptualized as the “prototypical elements” (Weems & Stickle, 2005) of disruptive behavior: Problems in Behavioral Regulation and Problems in Anger Modulation. This multidomain approach was designed to conceptualize disruptive behavior problems within the framework of developmental domains rather than as a descriptive list of symptoms. Codes on the DBDOS were defined along a continuum from normative variation to clearly atypical (see

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Table 24.2). Thus, the DB-DOS Behavioral Regulation Domain captures qualitative differences in noncompliance and aggression that distinguish behaviors of clinical concern from normative misbehaviors in a developmentally sensitive manner. For example, noncompliance codes on the DBDOS are designed to distinguish assertions of autonomy from the clinically concerning active defiance or entrenched resistance to social demands that are prototypical of ODD. These distinctions rest on behavioral qualities such as the expectability of the behavior (e.g., resistance to a transition vs. “reflexive no”) and responsiveness to environmental scaffolding (e.g., defiance that persists even with adult support). Similarly, the DB-DOS Problems in Anger Modulation Domain assesses multiple dimensions of anger expression, including its intensity, ease of elicitation and expectability, in a manner designed to distinguish “anger dyscontrol” from the normative tantrumming and low frustration tolerance that are typical in early childhood. Because we hypothesized that pervasiveness of disruptive behavior across relationships was also of relevance in determining whether such behaviors were clinically significant in early childhood, the DB-DOS paradigm is comprised of three interactional contexts that vary by partner (parent vs. ex-

TABLE 24.2.  Illustrative DB-DOS Codes Normative variation Normative behavior (0)

Normative misbehavior (1)

Behavioral Regulation Domain: Behavioral Inflexibility

None or fleeting. Child is flexible, takes turns, and “goes with the flow.”

Anger Modulation Domain: Easy to Elicit

Anger is not easily elicited. Only low levels displayed, even when frustrated.

Clinically concerning Of concern (2)

Atypical (3)

Mild evidence of inflexibility, such as occasional difficulty with transitions.

Child is fairly inflexible and somewhat resistant to adult directions, but may shift grudgingly in response to adult input.

Child is highly inflexible and/or controlling. Insists on doing things his or her own way and is unresponsive to adult input. Inflexibility is pervasive across task demands.

Anger is elicited a few times in response to frustration, limits, or demands.

Anger is elicited several times in response to even low-level frustrations, limits, or demands, but not in response to social interactions.

Anger is frequently and quickly elicited in response to low-level frustrations, limits, demands, and social interactions.

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aminer) and demand characteristics (active engagement vs. withdrawal of attention). Each interactional context includes parallel sets of “presses” designed to elicit a range of clinically salient behaviors. This design enables examination of the pervasiveness of these behaviors across contexts and provides data about the interactional contexts in which the behaviors occur. The DB-DOS also includes the Parenting Clinical Observation Schedule (P-COS), a clinically informative system for coding parenting behavior during the DB-DOS (Hill et al., 2008). Psychometric properties of the DB-DOS have recently been reported (Wakschlag, Briggs-Gowan, et al., 2008; Wakschlag, Hill, et al., 2008). The DB-DOS has demonstrated good interrater and test–­retest reliability and a sound factor structure (Wakschlag, Hill, et al., 2008). There is also evidence of construct, convergent, divergent, discriminative, and predictive validity (Wakschlag, Briggs-Gowan, et al., 2008). Initial results indicate good sensitivity and specificity for discriminating DBDs, with approximately 75% of preschoolers correctly classified based on DB-DOS scores. In addition, DBDOS scores significantly increase the ability to predict impairment over time, above and beyond parent-­reported symptoms (Wakschlag, Briggs-Gowan, et al., 2008). Psychometric work is now underway to develop an algorithm that weights clinical salience of each behavior and incorporates pervasiveness of these behaviors across DB-DOS interactional contexts as well as taking age and sex differences into account. A key goal of this work is to provide a developmentally sensitive direct assessment tool that will enable early childhood clinicians to use standardized methods to incorporate clinical judgment into diagnostic decision making with young children. Child disruptive behavior is assessed with both parent and examiner on the DB-DOS, and quality of parenting is also directly assessed. As a result, the DB-DOS provides an intriguing opportunity to begin to examine early childhood disruptive behavior within relational context—an issue of longstanding concern within the field of infant mental health (Sameroff & Emde, 1989). One question is whether preschoolers with parent- and/or teacher-­identified DBDs manifest observed disruptive behaviors exclusive-

ly or predominantly with their parents during the DB-DOS. Of the children with DBDs exhibiting problems in the Anger Modulation and Behavioral Regulation Domains on the DB-DOS, an average of 24% exhibited disruptive behavior with their parent only, 34% with the examiner only, and 42% with both parent and examiner. As would be expected, pervasiveness across parent and examiner contexts for both Anger Modulation and Behavioral Regulation Domains was associated with clinically significant problems (c2 = 21.5 and 26.8, respectively; p < .001). A second question of interest is whether observed disruptive behavior occurs only in the context of problematic parenting. To explore this issue, we classified mothers as problematic or competent based on the pattern of their observed parenting. Comparisons across problematic and competent groups provide evidence for the expectable finding that preschoolers with DBDs were significantly more likely to have a mother who exhibited problematic parenting (c2 = 11.15, p < .05). However, interestingly, the proportion of mothers within each group who had a child with disruptive behavior was roughly comparable (25% in the problematic group, 20% in the competent group) (Hill et al., 2008). Finally, we can examine whether observed disruptive behavior predicts impairment when parenting is taken into account. In fact, high levels of observed problems in Behavioral Regulation and Anger Modulation Domains on the DBDOS significantly increase risk of child impairment even with observed parenting controlled (adjusted odds ratios = 4.5 and 2.8, respectively; Wakschlag, Briggs-Gowan, et al., 2008). These initial glimpses from the DB-DOS suggest that examining this issue cannot be approached from an “either–or” perspective—­rather, it requires a more nuanced approach. That family context can play an etiological role in the development and early emergence of disruptive behavior is clear (Tolan, Guerra, & Kendall, 1995). But it is also increasingly clear that some young children are born with biologically determined susceptibilities to problems in regulating emotion and behavior (Stieben et al., 2007), and that these susceptibilities increase their risk of disruptive behavior, which in turn, increases the likelihood of



24. Early Childhood Disruptive Behavior

receiving problematic parenting (Dishion, Patterson, & Kavanagh, 1992) and amplifies their vulnerability to contextual risks (Van Lier et al., 2007). Perhaps most importantly, these data suggest the heterogeneity of manifestations of child disruptive behavior and the contexts in which they occur and underscores the need for systematic study of meaningful individual differences in these patterns. For example, one could test the hypothesis that early childhood disruptive behavior, with and without parent–child relationship dysfunction, reflects distinct subtypes with distinct etiologies and developmental courses. If this hypothesis were supported, these patterns would have clear implications for early intervention.

SUMMARY AND CONCLUSIONS We propose that integration of clinical and developmental science, with an emphasis on heterotypic continuity and identifying meaningful subgroups, is the next fundamental step for advancing understanding of disruptive behavior in young children, generating a more developmentally appropriate classification system for young children, and, ultimately, enhancing accurate identification. While we clearly know much more than we did a decade ago about the emergence of clinical phenomena in early childhood, substantial work is necessary to generate a truly developmentally informed characterization of disruptive behavior in early life. A central aspect of this work must be to synthesize knowledge about the developmental progression of the capacities that underlie the regulation of emotions and behavior and their deviations into clinical conceptualizations and nosology. For example, what is the normative developmental course of tantrums (their frequency, duration, and patterns over time) and what tantrum features are indicators of clinical concern? At what age does the ability to self-­regulate in the face of frustration emerge, and how does this capacity change and consolidate across the early childhood period? With a developmentally specific knowledge base like this in hand, we would be able to generate empirically defined parameters for identifying disruptive behavior that are sensitive and specific to early childhood.

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Conceptualization of early childhood clinical phenomenology in a manner that is both developmentally sensitive and coherent with disruptive behavior constructs across the lifespan is critical for identifying the emergence of patterns that have their origins in the first years of life. This requires combining a “top-down” approach (i.e., testing the fit of clinical constructs developed for older children) with a “bottom-up” approach (i.e., developing and testing criteria for this age group in reference to core developmental processes). Striking a balance between lifespan coherence and developmental sensitivity requires delineation of the “latent constructs” that underlie the core features of disruptive behavior, such that developmentally specific indicators are just varying manifestations of these core underlying features. We have recently suggested a developmentally sensitive multidimensional framework for applying this concept to preschool disruptive behavior (Wakschlag, Henry, et al., 2008) with four distinct behavioral dimensions: temper loss, aggression, noncompliance, and low concern for others (see Table 24.3). Empirical testing of the validity of this preschool multidimensional approach, including identifying those behaviors that are maximally discriminative for distinguishing disruptive behaviors and normative misbehaviors, and testing the usefulness of this approach compared to the traditional DSM nosology, is a critical next step for research. We began this chapter by asking “How can we tell ‘when to worry’ in assessing disruptive behaviors in young children?” We have suggested a framework within which to conceptualize clinical concern in early childhood. That is, the time to worry is when young children’s disruptive behaviors are frequent, persistent, or qualitatively distinct from the typically brief, contextualized, and flexible normative misbehaviors of early childhood. This framework draws on clinical experience, preliminary evidence from clinical research, and consonant themes within developmental science. However, to generate definitive, empirically derived parameters for making such distinctions that can be broadly applied by practitioners and researchers alike, this framework must be operationalized and systematically tested in studies of representative samples of young children. With an empirically grounded, de-

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TABLE 24.3.  Illustration of Developmentally Sensitive Multidimensional Framework for Preschool Disruptive Behavior Illustrative behaviors DSM-IV

Early childhood manifestations

Temper loss

•• “Often loses temper” •• “Often angry/resentful”

•• “Has tantrums many times per day” •• “Has trouble calming down when angry”

Noncompliance

•• “Often defies or refuses to comply with adult requests” •• “Stays out past curfew”

•• “Says ‘no’ before hearing what is being asked” •• Persists in disobedience even with warnings

Aggression

•• “Often starts fights” •• “Bullies/intimidates”

•• “Is aggressive for ‘no reason’ or ‘out of the blue’ •• “Pinches/hurts children when you are not looking”

Low concern for others

•• “Is physically cruel to others” •• “Has engaged in forcible sexual activity”

•• “Does not seem to care about others’ feelings” •• “Seems to enjoy making others upset, angry, or sad”

velopmentally sensitive phenomenology for understanding disruptive behavior in early childhood, based on measurement tools specifically developed for the preschool period and to provide careful delineation of developmental atypicalities, the question of where normative misbehavior ends and disruptive behavior problems begin can be put to rest. Such developmentally informed specification of the major features of disruptive behavior in preschool children is vital for accurate identification, ­capturing meaningful clinical heterogeneity and informing targeted intervention. Acknowledgments Work on this chapter has been supported by National Institute of Mental Health Grant No. MH068455 as well as ongoing support from the Walden and Jean Young Shaw and Children’s Brain Research Foundations. Ideas put forth have been importantly shaped by critical discussions with our collaborators: Alice Carter, Anil Chacko, Carri Hill, Helen Egger, Kimberly Espy, Kate Keenan, Bennett Leventhal, Catherine Lord, Margaret Briggs-Gowan, Daniel Pine, Chaya Roth, and Patrick Tolan.

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C h a p t e r 25

Depression Joan L. Luby

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cceptance of the idea of very-earlyonset depression by the mental health and developmental communities has been in flux over the last six decades. As early as the 1940s, clinical depression was observed and described in infants deprived of primary caregiving relationships (Spitz, 1946). However, in subsequent years prevailing theory suggested that young children were too immature to experience the core emotions of depression, thereby ruling out the possibility of clinical depression before school age (Rie, 1966). Recent advances in studies of basic emotion development have now clearly refuted this claim, demonstrating the previously unrecognized emotional sophistication of infants and toddlers (Denham, 1998; Shonkoff & Phillips, 2000). Despite this advancement, empirical data to validate and describe a clinical depressive syndrome in infants and toddlers under the age of 3 remains unavailable. In order to understand whether depression can arise early in life and how it might manifest, it is essential to understand the normative trajectory of early emotional development. Normative emotional development provides a framework against which alterations in early emotional experiences

and expressions can be assessed. In the early 1900s, Darwin theorized, based on the observation of facial expressions, that several core emotions were present at birth in the human infant. Subsequently, empirical studies provided support for this hypothesis (e.g., Izard, Huebner, Risser, McGinness, & Dougherty, 1980). Despite these early insights, a significant body of empirical data that began to outline the trajectory of early emotion development did not become available until the late 1980s. Over the last two decades, data informing how children recognize and express discrete emotions, develop the ability to regulate emotional responses, understand the causes and consequences of emotions, as well as experience more complex emotions have become available (for review, see Denham, 1998; Saarni, 1999). Although these data have provided a broad framework illustrating that emotional competence develops earlier in life than previously recognized, many details about when and how emotional development unfolds in the infancy and preschool period remain under studied. Further investigation of this early trajectory may be key to understanding the earliest possible onset of depression and its developmental characteristics. 409

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From a public health perspective, the identification of depression at the earliest possible point in development may be a very important goal, not only because relieving the suffering of young children is a necessary and worthy cause, but also because earlier intervention may provide a window of opportunity for greater therapeutic change. The unique efficacy of early intervention during the preschool period has been demonstrated for several specific childhood mental disorders, such as autistic spectrum disorders and some disruptive behavior disorders (e.g., Eyberg et al., 2001; Faja & Dawson, 2006). Early intervention may be of particular importance in depression, given the suboptimal treatment responses and high rates of treatment resistance shown in older depressed children (Kennard et al., 2006). For these reasons, as well as the compelling accounts of clinical observation of depressive affect very early in life, depression is a disorder for which the earliest possible identification may hold promise to advance the public health and is therefore worthy of scientific exploration. This chapter explores the empirical and theoretical literature on depression in infants, toddlers, and preschool-age children. The discussion begins with the preschool period, for which the largest body of available empirical data is now available. Then the relevant literature and available data pertaining to toddlers and infants are explored. In these younger age groups, there are no available empirical data on clinical symptoms or syndromes. However, related literature on early alterations in emotion expression in high-risk groups and clinical observations are reviewed. Further, designs of future studies of depressive symptoms in these younger populations are explored.

EMOTION DEVELOPMENT IN EARLY-ONSET DEPRESSION A developmental issue of interest in the study of early-onset depression, as well as mood disorders more generally, is the question of whether alterations in patterns of emotion development can be identified. This area of inquiry is important not only for the purpose of identifying developmental manifestations

of early-onset mood disorders, but perhaps more clinically relevant, to find potential developmental targets for early intervention. The recognition that emotional competence develops earlier than previously thought and is on a rapid trajectory during the infancy and preschool period suggests that impairments or alterations in this domain are likely to be associated with early-onset mood disorders and thus should be explored. Charles Darwin was the first to suggest that human infants were born with the ability to express a limited repetoire of discrete emotions. Subsequently, developmental psychologist Carroll Izard and colleagues provided empirical data demonstrating that human infants displayed specific and discrete facial expressions that were consistent with incentive events designed to evoke these emotional states (1980). Pertinent to the development of depression in infancy is the normative development of sadness and joy. Izard, Hembree, and Huebner (1987) have shown that facial expressions of sadness can be clearly and reliably distinguished from other negative emotions by the age of 2 months in human infants. Further, by 6 months of age sad facial expressions arise in response to, or concurrent with, sadness-­provoking incentive events (Izard et al., 1995). Similarly, studies have also shown that human infants display discrete facial expressions of joy as early as 6–8 months of life. The greater differentiation of emotional expression, in which subtler and more complex expressions are observed, occur after the first year of life (Demos, 1986). These findings demonstrating that the experiences of sadness and joy appear to arise in human infants during the first 6 months of life, suggesting that depressive affects may also be possible at this very early stage of development. However, as outlined below, apart from compelling clinical observations, there are no empirical data to inform the issue of whether depression arises in infancy to date. Studying the emotional expression of joy and sadness, as well as recognition of these emotions and those that are more complex such as guilt, has received more empirical attention in older preschool children for obvious reasons. One area of interest is determining whether depressed preschoolers demonstrate an earlier ability to recognize



25. Depression

and label negative emotions compared to nondepressed preschoolers. Previous findings demonstrated that depressed preschoolers recognized sad female faces more readily than disruptive comparison children (Mrakotsky, 2001). These findings suggest that the ability to recognize and label negative emotions, specifically sadness, may develop more rapidly in preschoolers who experience depression. Further focused investigations of this issue are important. An investigation of the development of more complex emotions, particularly guilt and shame, were of special interest in our ongoing study of preschool depression. Kochanska, Gross, Lin, and Nichols (2002) have previously shown that children understand the experience of guilt as early as 3 years of age. In light of this finding, we hypothesized that depressed preschoolers, like older depressed individuals, would experience higher levels of guilt than nondepressed preschoolers. Two qualitatively different measures were used to assess guilt within the preschool sample. One measure, the “My Child,” is a parent report of the child’s tendency to display guilt and to take actions to repair the situation in the aftermath of the guilt (Kochanska, 1992). In addition, MacArthur Emotion Story Stems were used to tap guilt emotions (Bretherton, Oppenheim, Buchsbaum, Emde, & the MacArthur Transition Network Narrative Group, 2001). In this latter technique, preschoolers were given a story stem that sets up a conflict that may evoke guilt. Their completion of the story is coded for guilt (and other) themes and content. Findings demonstrated that depressed children experienced higher levels of guilt than younger children in several nondepressed comparison groups, including those with DSM-IV disruptive disorders (attention-­deficit/hyperactivity disorder [ADHD], oppositional defiant disorder [ODD], and conduct disorder [CD]) and anxiety disorders on both of these measures (Luby et al., in press). Also notable was that depressed preschoolers had less of a tendency to take actions to repair feelings of guilt. These findings suggest that the experience of excessive guilt is a central feature of depression as early as the preschool period and therefore should be a focus of early intervention strategies.

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DEPRESSION IN INFANCY Despite significant amounts of public and media attention to the issue of infant depression, there are no systematic data available at this time to inform the question of whether a true depressive syndrome can arise before 3 years of age. Nevertheless, the first observations of depressed affect in infants date back to the mid 1940s, when psychoanalyst Rene Spitz provided compelling reports of withdrawal, apathy, depressed mood, and failure to thrive among institutionalized infants (Spitz, 1946). Spitz described this syndrome as “anaclitic depression,” and he speculated that it was based on the infant’s reaction to separation from a primary caregiver. Underscoring the life-­sustaining importance of the emotional elements of the early caregiving relationship, these infants deprived of primary caregivers displayed a failure to thrive even in the presence of adequate nutrition and physical care. Despite this compelling finding of depressed affect and physical growth retardation apparently arising from psychosocial deprivation, Spitz’s observations, although now recognized as pioneering, had little impact on enhancing the recognition of very-early-onset depression among mainstream mental health practitioners.

Infants of Depressed Mothers Several decades after Spitz’s compelling descriptions of depressed affect in infants, developmental psychologists developed new and systematic methodology to investigate mood and affect in infants of depressed mothers, a group hypothesized to be at high risk for depression, based on both genetic and psychosocial factors (Cohn & Tronick, 1989; Field, 1984; Murray, 1992). This group was also of particular interest because maternal depression is a well-known risk factor for a range of poor developmental outcomes in children (Diego et al., 2004; Murray, Sinclair, Cooper, Ducournau, & Turner, 1999). Maternal depression that extends beyond the transient experience of “baby blues” and crosses the threshold into a clinical postpartum depression, or a more chronic major depressive syndrome, has been shown to be associated with less supportive and less sensitive caregiving (Downey & Coyle, 1990; Goodman

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& Gotlib, 1999). Depressed mothers have been observed to be less responsive, to display less positive affect, and to gaze less frequently at their infants than nondepressed mothers. Mothers experiencing chronic depression were also observed to provide less social stimulation to their babies, including less touching, fewer games, and less talking to their infants than nondepressed mothers. These deficits in parenting skills have been associated with a range of negative emotional developmental outcomes and represent important risk conditions for infants (Field, Healy, Goldstein, Perry, & Bendell, 1988; Hernandez-Reif, Field, Diego, Vera, & Pickens, 2005; Murray et al., 1999). Numerous studies have now provided converging evidence demonstrating that maternal depression occurring during the infancy and preschool period may have adverse effects on the child’s emotional development (for review, see Downey & Coyle, 1990). Observational paradigms, in which infants’ facial expressions and motor activity in response to evocative events are observed and systematically rated, have been designed so that inferences about infant emotional states can be made. The “Still-Face Paradigm” (Cohn & Tronick, 1989), a laboratory task in which mothers are asked to maintain a flat facial expression in response to their infant’s cues, has been used by a variety of research groups and has been shown to differentiate high-risk from control infants. Infants of depressed mothers have been observed to be less active, more withdrawn, and display less positive affect than infants of nondepressed mothers during face-toface interactions with their mothers. Importantly, during the still-face paradigm these infants displayed less protest than infants of nondepressed mothers, suggesting that they were accustomed to limited maternal responsiveness. These findings were among the first to demonstrate the sensitivity of very young infants to the emotional states of their caregivers. This research confirmed that early interpersonal and environmental factors may have a material impact on emotion development in the infant and very young child and therefore may be of importance in the developmental psychopathology of mood disorders. Field et al. (1988) demonstrated that negative infant affect generalized to interactions

with other adults (strangers). However, further investigations subsequently showed that infants of depressed mothers displayed less depressed behavior with other important caregivers such as nursery school teachers as well as their nondepressed fathers (Hossain et al., 1994; Pelaez-­Nogueras, Field, Cigales, Gonzalez, & Clasky, 1994). In other words, although there was a tendency for infants’ depressed behavior with mother to generalize to interactions with unfamiliar adults, if the infant had a relationship with a nondepressed adult caregiver, the relationship buffered the infant from the effects of his or her mother’s depression. These findings also emphasize the need to maintain additional supportive relationships with nondepressed caregivers in the life of the high-risk infant.

Maternal Depression and Infants Psychobiological Processes In addition to inferring differences in infants’ emotional responses based on their facial expression or bodily movements, other physiological markers of reactivity, such as brain activity and heart rate variability, also have informed our understanding of factors that impact emotion development during the infancy period. Electroencephalographic (EEG) asymmetry, specifically, decreases in left frontal lobe activity, has been demonstrated in depressed adults (Davidson & Fox, 1983). Numerous studies using both adults and very young infants have found that asymmetries in frontal lobe activation and function are related to discrete emotions. That is, results indicate that right frontal lobe activations are more likely to occur during crying and sadness, whereas relatively stronger left frontal lobe activations occur during happiness. These findings point to potentially important neurophysiological changes associated with the emotions of depression. Dawson and colleagues have hypothesized that differences in individual children’s frontal lobe activation might be a result of life experience as opposed to innate biological factors. The significant role that parents play in infants’ emotional development capacities (e.g., regulation, expression, and understanding) may account for some of the differences in children’s frontal brain activity. Empirical findings indicate that during plea-



25. Depression

surable and playful interactions with their primary caregivers, infants typically show greater activation in the left frontal area. Dawson and colleagues found that infants of depressed mothers show no difference in left and right activation of the frontal area, indicating that these infants may not find mother–child interactions highly pleasurable (Dawson, Klinger, Panagiotides, Hill, & Spieker, 1992). Whether these changes would generalize to interactions with other caregivers remains unknown. These results support the notion that caregiver socialization can influence frontal asymmetries. Findings also support the role of relationship dynamics as factors that shape early biological processes. One of the critical questions to be answered by future longitudinal studies is whether measures of frontal lobe activity and asymmetry can predict vulnerability for emotional disorders both concurrently as well as later in life.

Depression in Infants and Toddlers To date, there have been no large-scale systematic empirical investigations of clinical depression in infants and toddlers. Despite this lacuna, the collective experience of clinicians and compelling case descriptions strongly suggest that the syndrome can arise in infants and toddlers. Based on these observations, diagnostic criteria and symptom descriptions of depression as it applies to infants and toddlers have been outlined in an alternative developmentally sensitive diagnostic system entitled Diagnostic Classification of Mental Health and Developmental Disorders in Infancy and Early Childhood—­Revised (DC:0–3R; Zero to Three, 2005). The DC:0–3R is based on the experience of a multidisciplinary group of infant mental health clinicians and has also been informed by the available empirical database. A section on depression in infancy and early childhood proposes developmental translations of depressive symptoms that encompass two diagnostic categories: major depression and depressive disorder not otherwise specified (NOS). The DC:0–3R also includes a unique category, “prolonged bereavement/grief reaction,” that addresses the more transient depressed affect that may arise after the loss of a primary caregiver. These categories may provide a useful

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framework which clinicians can use to identify the disorder as well as guidelines for future empirical investigations. Unfortunately, no studies of these putative disorders have been reported.

DEPRESSION IN PRESCHOOL CHILDREN The first empirical investigations of clinical symptoms of depression in preschool-age children were conducted by Kashani and colleagues in the 1980s. These researchers were interested in whether preschool-age children could manifest symptoms of depression as described in the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III; American Psychiatric Association, 1981), previously unexplored in empirical research. This group provided case reports of preschoolers in clinical settings who met criteria for DSM-III major depressive disorder (MDD; Kashani & Carlson, 1985). In addition, they investigated whether preschoolers in a general population sample could be identified with the disorder. They concluded, based on finding a number of preschoolers with concerning symptoms but who did not meet full or formal criteria for DSM-III MDD, that developmental modifications to the criteria might be needed (Kashani, Holcomb, & Orvaschel, 1986; Kashani, Ray, & Carlson, 1984). The findings of Kashani and colleagues, in addition to the finding of affective alterations in the offspring of depressed mothers, led to a larger-scale investigation of depression in preschoolers at the Washington University School of Medicine Early Emotion Development Program. This investigation represented an advance of earlier methodologies in several important ways. First, it used an age-­appropriate structured diagnostic interview in which developmental translations of symptom states were assessed. Anhedonia, for example, was described as the inability to enjoy activities and play (as opposed to lack of libido, as might be evident in an adult). In addition, subjects from both healthy and psychiatric comparison groups were ascertained so that the specificity of symptoms to depression could be determined. Findings from this study provided evidence for a specific and stable depressive symptom

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constellation arising in preschool children ages 3 years to 5 years, 6 months (Luby et al., 2002). In addition, based on data regarding the psychiatric status of the first- and second-­degree relatives of the preschool subject, the finding that depressed preschoolers came from families with greater histories of related affective disorders, compared to families of healthy controls, also emerged. Based on these parent-­report data, these results suggested that familial transmission of depression was also evident in the preschool period, as had been previously demonstrated in older child and adult populations (e.g., Jaffee et al., 2002; Neuman, Geller, Rice, & Todd, 1997). Familial transmission, whether genetic or psychosocially transmitted, in addition to a specific and stable symptom constellation are key elements in the validation of psychiatric disorders as described by Robins and Guze (1970). The question of whether these very young depressed children displayed “masked” symptoms of the disorder, such as somatic complaints or regression in development, also was examined. This area was of interest because the idea that young children could not manifest the core symptoms of depression but would instead display masked symptoms was a widely accepted but empirically unexplored clinical adage. Notably, depressed preschoolers displayed age-­appropriate manifestations of “typical” DSM symptoms of depression more frequently than masked symptoms (Luby et al., 2003a). However, masked symptoms also occurred at higher rates in the depressed group than the comparison groups. This finding was remarkably similar to earlier findings regarding older school-age children with depression (Carlson & Cantwell, 1980). The finding that young children can display core depressive symptoms and that these arise at a higher frequency than masked symptoms is important because it suggests that clinicians should look for typical age-­adjusted symptoms of depression as the most specific and sensitive markers of the disorder, even in preschool-age children. Several additional markers of the validity of preschool-onset depression also emerged from this study. Evidence of impairment, key to determination of “caseness” in the DSM system, was also detected in depressed

preschoolers. Impairment is a difficult construct to capture in a preschool-age child due to the reduced demand to function in structured settings and the resulting greater ambiguity in its measurement (Carter, Briggs-Gowan, & Davis, 2004). Therefore, we focused on measures of social development because this factor was determined to be a key element of competence and adaptive functioning during this developmental period. Of note was that depressed preschoolers, similar to those with Axis I disruptive disorders, demonstrated delays in social development as evidenced by lower scores on the Socialization subscale of the Vineland Scales of Adaptive Functioning, compared to healthy controls, suggesting that they are impaired in this key area of development (Luby et al., 2002). Although a specific and stable symptom constellation, family history of related disorders, and evidence of social impairment are key markers of the validity of a psychiatric disorder and of preschool depression, objective evidence offers a higher level of scientific validity. For this reason, biological measures are of interest as valid markers of preschool depression. Alterations in the physiological response to stress, measured along the  hypothalamic–­pituitary–­adrenal (HPA) axis, are well established in depressed adults (Plotsky, Owens, & Nemeroff, 1998; Rubin, Poland, Lesser, & Martin, 1987). Based on these findings, Nemeroff (2004) has argued that a core element of the developmental psychopathology and etiology of depression is a stress response that has become dysfunctional. Following this model, an investigation of the stress response of preschoolers with symptoms of depression, compared to nondepressed psychiatric and healthy comparison groups, were of interest.

Biological Correlates of Preschool Depression We measured salivary cortisol before, during, and after a mildly stressful laboratory task (Luby et al., 2003b). The task represented an experimental paradigm designed to induce mild psychosocial stress to investigate the reactivity of the HPA axis of depressed children compared to those with other psychiatric disorders (i.e., DSM-IV



25. Depression

Axis I disruptive disorders) and to healthy children. Depressed preschoolers displayed different patterns of stress cortisol reactivity in response to stress, compared to healthy and psychiatric comparison groups. Notably, consistent with patterns of elevated cortisol shown in depressed older children and adults, depressed preschoolers demonstrated a unique pattern of increasing cortisol levels throughout the duration of the assessment. This pattern was in contrast to the more typical and presumed adaptive pattern evident in the two comparison groups, in which cortisol levels dropped after entry into the laboratory, compatible with acclimation to the situation. These findings represented an important advance in the validation of preschool depression because they provided objective evidence of physiological alterations, similar to those previously demonstrated in the adult form of the disorder, associated with preschool-onset depression. Further, similar alterations in HPA axis reactivity in response to stress have also been detected in the offspring of depressed mothers (Ashman, Dawson, Panagiotides, Yamada, & Wilkinson, 2002). The finding that similar changes are also evident in this disorder in older individuals suggests some continuity in the underlying pathophysiology of depression across the age span. Along these lines, further evidence of this continuity could provide clues to the developmental psychopathology of depressive disorders.

Melancholic Subtype Evidence for a more severe melancholic subtype of depression, characterized by the presence of anhedonia, has also been detected in preschool-age children. Preschoolers who met all DSM-IV symptom criteria for MDD (when symptoms were translated for developmental appropriateness, as described above) and who also had the symptom of anhedonia had significantly higher depression severity scores than a depressed nonanhedonic group (Luby, Mrakotsky, Heffelfinger, Brown, & Spitznagel, 2004). In addition, melancholically depressed preschoolers had a number of features similar to melancholically depressed adults, such as lack of brightening in response to positive events as well as higher rates of neurovegeta-

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tive signs, including sleep disturbances and changes in appetite. These findings suggest that a subtype of severe depression that has clear biological correlates known in adults can also arise during the preschool period. This melancholic subgroup should be a focus of future longitudinal investigations that address outcome and course as well as other biological markers, such as structural and functional changes in the brain. Neuroimaging of young children with a history of melancholic depression could be illuminating.

Observational Evidence of Preschool Depression In addition to the markers of validity noted above, blindly rated observations of the behaviors of depressed preschoolers during dyadic interactions with their caregivers have also been examined and provide more objective evidence for the validity of a preschool depressive disorder (Luby, Sullivan, et al., 2006a). Preschoolers’ affective and behavioral responses during semistructured dyadic interactions with their primary caregivers were systematically coded by raters who remained blind to the preschoolers’ diagnoses. In these dyadic interactions, melancholically depressed preschoolers demonstrated less enthusiasm, more avoidance, and more noncompliance than healthy preschoolers. They also appeared to have a more negative overall experience with the dyadic task than those who were healthy. These findings provided objective evidence for the symptom of anhedonia, previously described and known to be a specific marker of depression in young children. Additionally, these findings provided evidence of greater overall behavioral and emotional negativity in preschool depression. In an independent investigation, Mol Lous and colleagues detected differences in observed play (both peer and solitary) behaviors among preschool children who received a clinical diagnosis of depression, compared to healthy control subjects (Mol Lous, de Wit, De Bruyn, & Riksen-­Walraven, 2000). Observational studies and clinical observations of play provide an important method of assessing symptoms of depression in young children, for whom self-­reports are more difficult to access and often less reliable.

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An Independent Sample, Validation of Preschool Depression Most of the findings described above were derived from a single study sample in the St. Louis metropolitan area. Replication of these findings in independent samples is critical to validating clinically useful understanding and approaches. More recently, findings from an independent sample, ascertained using a screening checklist from community sites in the metropolitan St. Louis area, have replicated and extended the previously discussed findings about preschool depression. In this larger sample, every age-­adjusted DSM-IV symptom of depression, with the exception of irritability, occurred significantly more frequently in preschoolers meeting criteria for depression, compared to those who met DSM-IV criteria for disruptive behavior disorders and those from a healthy control group. Further, symptoms of depression also differentiated depressed preschoolers from those with anxiety disorders, providing the first discriminant validity, to our knowledge, between depression and another internalizing affective disorder (Luby et al., 2009). In addition, a statistically significant hierarchy in depression severity was also found, with the melancholic group demonstrating the highest depression severity scores in this depressed sample, replicating previous findings (Luby et al., 2004). These findings demonstrate that a specific depressive syndrome can be identified in preschool children. The specificity of this disorder is evidenced by the finding that symptoms distinguished depressed preschoolers from those with disruptive disorders. In addition, findings from this study also demonstrated that preschool depression is associated with impairment in functioning. This is an important issue as impairment is a necessary precondition for “caseness,” according to the DSM-IV criteria. As previously discussed, the measurement of impairment in preschool-age is more difficult to capture and requires developmentally sensitive measures. Impairment was measured using several methods, including the Vineland Scales of Adaptive Functioning (Sparrow, Balla, & Cicchetti, 1984), the Preschool and Early Childhood Functioning Assessment Scales (PECFAS; Hodges, 1994), and the Health and Behavior Questionnaire (HBQ; Arm-

strong, Goldstein, & MacArthur Working Group on Outcome Assessments, 2003). Depressed preschoolers were impaired compared to healthy comparison groups on all of the scales mentioned above (Luby et al., 2009). Notably, the HBQ revealed teacherrated impairment among depressed preschoolers in several domains, compared to nondepressed preschoolers, though there were no differences between the depressed and disruptive groups.

Treatment of Preschool Depression Given that preschool depression has only recently become widely recognized, there have been no systematic treatment studies conducted to date. The literature contains case reports as well as descriptions of treatments of various types. However, large-scale empirical studies that use standardized methodologies and controlled assessments are needed to inform clinical practice. In younger and more vulnerable populations, greater uncertainties about safety and more immature nervous systems make psychotherapeutic interventions preferred treatments over psychopharmacological options. Psychotherapeutic approaches, including cognitive-­behavioral and interpersonal psychotherapies, have demonstrated efficacy for the treatment of depression in older children and adolescents. Still, age-­appropriate psychotherapeutic strategies are needed for application to this younger age group. Numerous dyadic psychotherapeutic strategies have been developed, and several have been tested for the treatment of a variety of disorders arising in the preschool period. Related to the risk for early-onset depression, treatment for depressed mothers, designed to ameliorate negative effects on infants and toddlers, has also been developed and tested (Cicchetti, Rogosch, & Toth, 2000). These investigators have shown that declines in cognitive development that are apparent in the infants of depressed mothers can be prevented when depressed mothers undergo preventive toddler–­parent psychotherapeutic (TPP) interventions. However, to date no age-­appropriate psychotherapies designed for the treatment of preschool depression have been tested. We have recently adapted parent–child interaction therapy (PCIT) for the treatment of



25. Depression

preschool depression by adding an emotion development (ED) component (Luby, Stalets, Blankenship, Pautsch, & McGrath, 2008). PCIT was originally designed and proven effective for the treatment of preschool disruptive disorders (Eyberg, 1974). PCIT-ED has an additional component that specifically addresses emotion regulation and emotional repertoire and is designed to address the absence of joy and excess of guilt and sadness experienced by the depressed preschooler. As in the original form of PCIT, the focus on strengthening the parent–child relationship and using the parent as the “arm of the therapist” is central to the treatment. The revised form designed for the treatment of preschool depression, so called PCIT-ED, has not yet been tested in large populations of depressed preschoolers but has been administered successfully to pilot subjects who have shown symptomatic improvement. Questions often arise about the use of pharmacological agents, particularly antidepressants, for the treatment of preschool depression. It is important to note that there are no studies available to inform the safety or efficacy of antidepressants for preschoolage children. Concerns about the activating side effects of selective serotonin reuptake inhibitor (SSRI) antidepressants, which may occur at higher rates in younger children, as well as unresolved reports of possible increases in suicidality, make this treatment option more complicated and unfeasible for use in preschool-age children at this time (Zuckerman et al., 2007).

Future Research: Next Steps Replication of these findings by independent research groups in other geographical sites as well as cross-­culturally would be an important next step in the validation of preschool depression. Further, longitudinal follow-up of preschool children with a depressive syndrome into school age and early adolescence is also critical to determine whether there is continuity of the early-onset form with later life forms. If longitudinal continuity in depressive disorders from the preschool period to later life periods could be shown, it would support the need for early interventions. Heterotypic continuity also needs to be explored, given the relatively less differentiated nature of psychopathology in younger indi-

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viduals. The search for biological correlates that might give clues to the developmental pathophysiology of childhood depression, too, remains critical to understanding, preventing, and treating this disorder.

CASE EXAMPLE A. B. is a 3-year, 6-month-old female who was referred to the infant and preschool mental health clinic by her pediatrician after a medical work-up for gastrointestinal symptoms was negative. She presented to the pediatrician with a new onset of persistent stomachaches, associated with periodic vomiting and regression in toilet training that had begun after the birth of a sibling. Also notable was that she displayed a decreased interest in food (without weight loss) and some sleep disturbance. In addition, psychiatric history obtained from parents also revealed social withdrawal in the school setting, periods of extended sadness evident at home, and recurrent episodes of irritability and social withdrawal at home when needs are not immediately met. Her parents also reported that she did not seem to enjoy previously desirable play activities. Of note is that the child seemed to be interested in her infant sibling and engaged with the baby in a positive way, but the mother described a great deal of anticipatory anxiety in the child prior to the sibling’s birth. The parents denied any signs separation anxiety or school refusal in their daughter, but they did note that she had always been shy and slow to warm. The child’s teacher stated that she played on her own on the playground and did not spontaneously engage peers, although she displayed age-­appropriate symbolic play and engaged in reciprocal play interaction with an older sibling. Her parents also indicated that she was an extremely fussy and difficult-to-­soothe infant. There was an extensive family history of depression, including maternal depression arising during the pregnancy with the patient. On clinical observation, the child was slow to warm, appeared shy, and displayed a muted affect during play overall. She did not appear persistently sad and did brighten at times in the course of observational play. During a dyadic interaction, she displayed age-­appropriate symbolic play with her

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mother, during which the mother appeared positive but fatigued and lacking in enthusiasm. Of note, the child became tearful when the toys were put away and expressed that she felt hurt and “left out,” since this had occurred while she was briefly out of the playroom. In addition, during a brief separation from her mother, she became immediately withdrawn, stopped playing, and sat, appearing sad and making no attempt to find her mother. This case illustrates both typical and masked symptoms of depression in a preschool-age child. Notably, the masked symptoms in the form of somatic complaints came to the attention of the parents as the first concerning symptoms. However, upon further interview the typical symptoms of depression, such as sadness, irritability, anhedonia, social withdrawal, and neurovegetative signs, were also present. Of further note was that the child did not appear obviously depressed through the entire observation and had periods of brightening and joyful play. Her response to disappointments with intense sadness and withdrawal, however, in circumstances where nondepressed peers would have been assertive or angry, was clinically relevant. In addition, the case represents a child with several key risk factors known in depressive disorders. There is a strong family history of depression, the child displays a shy and slow-to-warm temperament, and she experienced a stressful life event (the birth of a younger sibling), which appeared to serve as a precipitant of the depressive episode. This confluence of risk factors is very similar to that described in samples of older subjects studied longitudinally as well as to the risk trajectory of preschool depression (Caspi et al., 2003; Luby, Belden, & Spitznagel, 2006b).

CONCLUSIONS A growing body of research is now available validating and describing clinical depression in preschool children. Convergent findings from two independent samples as well as physiological and observational evidence support the clinical importance of this earlyonset syndrome. Although there are no available data to inform treatment at this point, an age-­appropriate PCIT has been modified

for depression and awaits empirical testing. Despite these advances for preschool-age children, at the current time there are no data to inform a diagnosis of a valid clinical depressive syndrome earlier than age 3 years, although compelling clinical experience suggests that the syndrome does arise earlier, in toddler and even in family periods. Future studies should focus on this younger age group so that the earliest identification of, and intervention in, depressive disorders can become possible. References American Psychiatric Association. (1981). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. Armstrong, J. M., Goldstein, L. H., & MacArthur Working Group on Outcome Assessments. (2003). Health and Behavior Questionnaire. In D. J. Kupfer (Ed.), Manual for the MacArthur Health and Behavior Questionnaire (HBQ 1.0). Pittsburgh: University of Pittsburgh. Ashman, S. B., Dawson, G., Panagiotides, H., Yamada, E., & Wilkinson, C. (2002). Stress hormone levels of children of depressed mothers. Development and Psychopathology, 14, 333–349. Bretherton, I., Oppenheim, D., Buchsbaum, H., Emde, R., & MacArthur Transition Network Narrative Group. (2001). MacArthur Story Stem Battery Manual (MSSB). Unpublished manuscript, Denver, CO. Carlson, G. A., & Cantwell, D. P. (1980). Unmasking masked depression from childhood through adulthood: Analysis of three studies. American Journal of Psychiatry, 145, 1222–1225. Carter, A. S., Briggs-Gowan, M. J., & Davis, N. (2004). Assessment of young children’s social–­ emotional development and psychopathology: Recent advances and recommendations for practice. Journal of Child Psychology and Psychiatry, 45, 109–134. Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I., Harrington, H., et al. (2003). Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science, 18(301), 291–293. Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2000). The efficacy of toddler–­parent psychotherapy for fostering cognitive development in offspring of depressed mothers. Journal of Abnormal Child Psychology, 28(2), 135–148. Cohn, J. F., & Tronick, E. (1989). Specificity of infants’ response to mothers’ affective behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 242–248. Davidson, R. J., & Fox, N. (1983). Asymmetrical brain activity discriminates between positive ver-



25. Depression

sus negative affective stimuli in human infants. Science, 218, 1235–1237. Dawson, G., Klinger, L. G., Panagiotides, H., Hill, D., & Spieker, S. (1992). Frontal lobe activity and affective behavior of infants of mothers with depressive symptoms. Child Development, 63(3), 725–737. Demos, V. (1986). Crying in early infancy: Affect, cognition, and communication. In T. B. Brazelton & M. Yogman (Eds.), Affect and early infancy (pp. 39–73). New York: Ablex. Denham, S. A. (1998). Emotional development in young children. New York: Guilford Press. Diego, M. A., Field, T., Hernandez-Reif, M., Cullen, C., Schanberg, S., & Kuhn, C. (2004). Prepartum, postpartum, and chronic depression effects on newborns. Psychiatry, 67, 63–80. Downey, G., & Coyle, J. C. (1990). Children of depressed parents: an integrative review. Psychological Bulletin, 108(1), 50–76. Emslie, G., Rush, J., Weinberg, W., Kowatch, R., Hughes, C., & Carmody, T. (1997). A doubleblind, randomized, placebo-­controlled trial of fluoxetine in children and adolescents with depression. Archives of General Psychiatry, 54(11), 1031–1037. Eyberg, S. M. (1974). Manual for the coding of parent–child interactions of children with behavior problems. Unpublished manuscript, Oregon Health Sciences University, Portland, OR. Eyberg, S. M., Funderburk, B. W., Hembree-Kigin, T. L., McNeil, C. B., Querido, J. G., & Hood, K. K. (2001). Parent–child interaction therapy with behavior problem children: One and two year maintenance of treatment effects in the family. Child and Family Behavior Therapy, 23, 1–20. Faja, S., & Dawson, G. (2006). Early intervention for autism. In J. Luby (Ed.), Handbook of preschool mental health (pp. 388–416). New York: Guilford Press. Field, T. (1984). Early interactions between infants and their post-­partum depressed mothers. Infant Behavior and Development, 7, 537–542. Field, T., Healy, B., Goldstein, S., Perry, S., & Bendell, D. (1988). Infants of depressed mothers show “depressed” behavior even with non­depressed adults. Child Development, 59, 1569– 1579. Goodman, S. H., & Gotlib, I. H. (1999). Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychological Review, 106, 458–490. Hernandez-Reif, M., Field, T., Diego, M., Vera, Y., & Pickens, J. (2005). Happy faces are habituated more slowly by infants of depressed mothers. Infant Behavior and Development, 29(1), 131–135. Hodges, K. (1994). The Preschool and Early Childhood Functional Assessment Scale (PECFAS). Eastern Michigan University, Ypsilanti, MI. Hossain, Z., Field, T., Gonzalez, J., Malphurs, J., del Valle, C., & Pickens, J. (1994). Infants of “depressed” mothers interact better with their non-

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depressed fathers. Infant Mental Health Journal, 15(4), 348–357. Izard, C. E., Fantauzzo, C., Castle, J., Haynes, O., Rayais, M., & Putnam, P. (1995). The ontogeny and significance of infants’ facial expression in the first 9 months of life. Developmental Psychology, 31, 997–1013. Izard, C. E., Hembree, E., & Huebner, R. (1987). Infants’ emotional expressions to acute pain: Developmental change and stability of individual differences. Developmental Psychology, 23, 105–113. Izard, C. E., Huebner, R. R., Risser, D., McGinness, G., & Dougherty, L. (1980). The young infant’s ability to produce discrete emotional expression. Developmental Psychology, 16, 132–140. Jaffee, S. R., Moffitt, T. E., Caspi, A., Fombonne, E., Poulton, R., & Martin, J. (2002). Differences in early childhood risk factors for juvenile-onset and adult-onset depression. Archives of General Psychiatry, 59(3), 215–222. Kashani, J. H., & Carlson, G. A. (1985). Major depressive disorder in a preschooler. Journal of the American Academy of Child and Adolescent Psychiatry, 24(4), 490–494. Kashani, J. H., Holcomb, W. R., & Orvaschel, H. (1986). Depression and depressive symptoms in preschool children from the general population. American Journal of Psychiatry, 143(9), 1138– 1143. Kashani, J. H., Ray, J. S., & Carlson, G. A. (1984). Depression and depressive-like states in preschool-age children in a child development unit. American Journal of Psychiatry, 141(11), 1397– 1402. Kennard, B., Silva, S., Vitiello, B., Curry, J., Kratochvil, C., Simons, A., et al. (2006). Remission and residual symptoms after short-term treatment in the treatment of adolescents with depression study (TADS). Journal of the American Academy of Child and Adolescent Psychiatry, 45(12), 1404–1411. Kochanska, G. (1992). My child. University of Iowa, Iowa City, IA. Kochanska, G., Gross, J., Lin, M., & Nichols, K. (2002). Guilt in young children: Development, determinants, and relations with a broader system of standards. Child Development, 72(2), 461–482. Luby, J. L., Belden, A., & Spitznagel, E. (2006). Risk factors for preschool depression: The mediating role of early stressful life events. Journal of Child Psychology and Psychiatry, 47(12), 1292–1298. Luby, J. L., Belden, A., Sullivan, J., Hayin, R., et al. (in press). Shame and guilt in preschool depression as early as age 3. Journal of Child Psychology and Psychiatry. Luby, J. L., Belden, A. C., Pautsch, J., Yemei, S., & Spitznagel, E. (2009). The clinical significance of preschool depression: Impairment in functioning and clinical markers of the disorder. Journal of Affective Disorders, 112, 111–119. Luby, J. L., Heffelfinger, A., Mrakotsky, C., Brown,

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K., Hessler, M., & Spitznagel, E. (2003b). Alterations in stress cortisol reactivity in depressed preschoolers relative to psychiatric and no-­disorder comparison groups. Archives of General Psychiatry, 60(12), 1248–1255. Luby, J. L., Heffelfinger, A., Mrakotsky, C., Hessler, M., Brown, K., & Hildebrand, T. (2002). Preschool major depressive disorder: Preliminary validation for developmentally modified DSM-IV criteria. Journal of the American Academy of Child and Adolescent Psychiatry, 41(8), 928–937. Luby, J. L., Heffelfinger, A. K., Mrakotsky, C., Brown, K. M., Hessler, M. J., Wallis, J. M., et al. (2003a). The clinical picture of depression in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3), 340–348. Luby, J. L., Mrakotsky, C., Heffelfinger, A., Brown, K., & Spitznagel, E. (2004). Characteristics of depressed preschoolers with and without anhedonia: Evidence for a melancholic depressive subtype in young children. American Journal of Psychiatry, 161(11), 1998–2004. Luby, J. L., Stalets, M., Blankenship, S., Pautsch, J., & McGrath, M. (2008). Treatment of preschool bipolar disorder: A novel parent–child interaction therapy. In B. Geller & M. DuBello (Eds.), Treatment of childhood bipolar disorder (pp. 270–186). New York: Guilford Press. Luby, J. L., Sullivan, J., Belden, A., Stalets, M., Blankenship, S., & Spitznagel, E. (2006). An observational analysis of behavior in depressed preschoolers: Further validation of early onset depression. Journal of the American Academy of Child and Adolescent Psychiatry, 45(2), 203–212. Mol Lous, A., de Wit, C. A. M., De Bruyn, E. J., & Riksen-­Walraven, J. (2000). Depression markers in young children’s play: A comparison between depressed and nondepressed 3- to 6-year-olds in various play situations. Journal of Child Psychology and Psychiatry, 43(8), 1029–1038. Mrakotsky, C. (2001). Visual perception, spatial cognition, and affect recognition in preschool depressive syndromes. Unpublished dissertation, University of Vienna/Washington University, St. Louis. Murray, L. (1992). The impact of postnatal depression on infant development. Journal of Child Psychology and Psychiatry and Allied Disciplines, 33, 543–561. Murray, L., Sinclair, D., Cooper, P. J., Ducournau, P., & Turner, P. (1999). The socioemotional development of 5-year-old children of postnatally depressed mothers. Child Development, 67, 2512–2526. Nemeroff, C. (2004). Neurobiological consequences of childhood trauma. Journal of Clinical Psychiatry, 65, 18–28.

Neuman, R. J., Geller, B., Rice, J. P., & Todd, R. D. (1997). Increased prevalence and earlier onset of mood disorders among relatives of prepubertal versus adult probands. Journal of the American Academy of Child and Adolescent Psychiatry, 36(4), 466–473. NICHD Early Child Care Research Network. (1999). Chronicity of maternal depressive symptoms, maternal sensitivity, and child functioning at 36 months. Developmental Psychology, 35(5), 1297–1310. Pelaez-­Nogueras, M., Field, T., Cigales, M., Gonzalez, A., & Clasky, S. (1994). Infants of depressed mothers show less “depressed” behavior with their nursery teachers. Infant Mental Health Journal, 15(4), 358–367. Plotsky, P. M., Owens, M. J., & Nemeroff, C. B. (1998). Psychoneuroendocrinology of depression. Psychiatric Clinics of North America, 21, 293–307. Rie, H. E. (1966). Depression in childhood: A survey of some pertinent contributions. Journal of the American Academy of Child and Adolescent Psychiatry, 5(4), 653–685. Robins, E., & Guze, S. B. (1970). Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. American Journal of Psychiatry, 126(7), 983–986. Rubin, R. T., Poland, R. E., Lesser, I. M., & Martin, D. J. (1987). Neuroendocrine aspects of primary endogenous depression: IV. Pituitary–­thyroid axis activity in patients and matched control subjects. Psychoneuroendocrinology, 12(5), 333–347. Saarni, C. (1999). The development of emotional competence (Vol. 18). New York: Guilford Press. Shonkoff, J. P., & Phillips, D. A. (2000). From neurons to neighborhoods: The science of early child development. Washington, DC: National Academy Press. Sparrow, S., Balla, D., & Cicchetti, D. (1984). Vineland Adaptive Behavior Scales—­Interview Edition, Survey for Manual. Circle Pines, MN: American Guidance Service. Spitz, R. (1946). Anaclitic depression: An inquiry into the genesis of psychiatric conditions in early childhood. Psychoanalytic Study of the Child, 1, 47–53. Zero to Three. (2005). Diagnostic classification of mental health and developmental disorders of infancy and early childhood—­Revised (DC:0– 3R). Washington, DC: Author. Zuckerman, M., Vaughan, B., Mayfield-­Jorgensen, M., March, J., Kollins, S., Murray, J., et al. (2007). Tolerability of selective serotonin reuptake inhibitors in forty children under age seven: A retrospective chart review. Journal of Child and Adolescent Psychopharmacology, 17(2), 165–174.

C h a p t e r 26

Attachment Disorders Charles H. Zeanah, Jr. Anna T. Smyke

A

ttachment describes the human infant’s tendency to seek comfort, support, nurturance, and protection from a small number of caregivers. Based upon experiences of regular interactions with adult caregivers, infants gradually learn to seek comfort and protection not from just anyone but selectively from caregivers upon whom they have learned they can rely. According to attachment theory, infants’ behaviors with these caregivers is guided by their “internal working models” of relationships, Bowlby’s (1969) heuristic term describing a set of tendencies to experience and behave in intimate relationships in particular ways. That is, as early as the first year of life, infants begin to construct expectations about how they and others with whom they interact will feel and behave. The internal working model is more than a set of expectations, however, because it includes selective attention to incoming social information and salient social cues, feelings elicited during intimate interactions with others, memories of similar feelings in previous interactions and relationships, and the infant’s behavioral responses to others. Attachment is considered a vital component of social and emotional development in the early years, and individual differences in the quality of attachment relationships

are believed to be important early indicators of infant mental health. John Bowlby, who elaborated attachment theory, declared in the mid-20th century that “essential for mental health is that an infant and young child should experience a warm, intimate and continuous relationship with his mother (or mother substitute . . . ) in which both find satisfaction and enjoyment” (1953, p. 13). The propensity for human infants to form selective attachments is believed to be so strong that only in highly unusual and maladaptive caregiving environments do attachments fail to develop. For infants raised in species-­atypical rearing conditions, however, seriously disturbed and developmentally inappropriate ways of relating may evolve. Examples of atypical environments include institutions (i.e., orphanages), frequent changes of caregivers (as sometimes happens in foster care), neglectful or abusive caregiving, or being raised by insensitive or unresponsive caregivers. In these extreme situations, young children may develop clinical disorders of attachment. In this chapter we review the construct of attachment disorders, with an emphasis on reactive attachment disorder (RAD). Although derived from descriptive studies dating back at least to the 1940s, these disorders 421

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have been subjected to systematic study only in the past decade or so, and are still often misunderstood (Chaffin et al., 2006). Therefore, we review developmental perspectives on attachment, as well as the phenomenology, correlates, epidemiology, and course of RAD. Finally, we consider assessment and treatment of RAD.

DEVELOPMENTAL PERSPECTIVES The capacity to form an attachment is not present at birth but develops gradually over the first year of life. For the first 2 months after birth, infants are not well developed socially, and they spend most of their time sleeping, eating, and crying. At around 2 months of age, they become dramatically more social, exhibiting a responsive “social” smile, as well as cooing responsively and making more sustained eye-to-eye contact. They seem more interested in social interaction and are willing to interact readily with adults. Although infants in the first 6 months are able to distinguish among different interactive partners, they do not express an obvious preference for one caregiver over another. This lack of obvious preference changes at around 7–9 months of age. At that point, infants begin to exhibit stranger wariness and separation protest, two behaviors that herald the onset of “focused” or “selective” attachment. Stranger wariness varies from mild reticence to outright distress, and it contrasts with the infant’s comfort in selectively seeking support, nurturance, and protection from a specific caregiver. “Separation protest” describes the infant’s reaction to actual or anticipated separation from an attachment figure. Once infants have developed the cognitive capacity to exhibit separation protest and stranger wariness, they may form new attachments with any caregivers with whom they have significant interactive experiences. It is important to remember that infants are likely to recognize and may even be comfortable with a larger number of caregivers than those to whom they are attached. Bowlby (1969) emphasized that play partners are not necessarily attachment figures. We can think of a continuum of infants’ behavior

with caregivers beginning with recognition/ familiarity, followed by familiarity/comfort, then comfort/pleasure, then pleasure/reliance, and finally reliance/preference. Only at the level of reliance/preference do we say that infants have fully formed attachments to caregivers. Though older children can sustain attachment relationships over time and space, in the first 3 years of life or so, the young child needs actual interaction with caregivers in order to become attached to them. This specific need has important implications both for custody and visitation and for infants in foster care.

Classifications of Attachment Attachment is most often assessed in the early years of life with a method known as the Strange Situation Procedure (SSP). This observational paradigm involves a series of interactions between a young child, an attachment figure, and a stranger (Ainsworth, Blehar, Waters, & Wall, 1978). The procedure was designed to examine the young child’s balance between attachment and exploratory behaviors, primarily through comparing the child’s behavior with the attachment figure and with the unfamiliar adult. Because separation from the attachment figure activates the young child’s need for closeness and comfort, the SSP includes two brief separations and reunions that allow direct observation of the child making use of the caregiver to regulate his or her emotions during this moderately stressful experience. Based on the organization of child’s attachment behaviors and the balance between the child’s tendency to seek proximity to the attachment figure and the tendency to move away from the attachment figure and explore, it is possible to derive an overall classification of attachment between the child and caregiver. Ainsworth and colleagues (Ainsworth et al., 1978) described three major patterns of attachment. Children whose attachments to their caregivers were classified as secure expressed distress directly, sought comfort unhesitatingly, and responded to comfort readily. Children who showed little distress on separation and little need for closeness or comfort on reunion were classified avoidant.



26. Attachment Disorders

Finally, children who showed intense distress but who could not be comforted on reunion were classified resistant (sometimes referred to as ambivalent). Essentially, these patterns represent moderate (secure), diminished (avoidant), and excessive (resistant) activation of the child’s need for comfort when stressed. A fourth classification was later added by Main and colleagues (Main & Hesse, 1990; Main & Solomon, 1990): They described disorganized attachment, a heterogeneous pattern that involves various aberrant behaviors and/or mixed strategies involving incoherent combinations of secure, avoidant, and resistant attachment behaviors. Disorganized attachment is the pattern that is most predictive of concurrent and subsequent psychopathology (Green & Goldwyn, 2002). Important work by Sroufe (2005) and colleagues (see Weinfield, Sroufe, Egeland, & Carlson, 2008) established the construct validity of the SSP for the assessment of the quality of parent–child attachment in young children. The disorganized classification, in particular, extended the value of observing the young child’s behavior in the SSP to clinical populations of young children. Indeed, the SSP is now considered quite useful in attachment-based interventions such as the Circle of Security (see Powell et al., Chapter 28, this volume). The SSP has been used in hundreds of studies of attachment around the world and is still widely considered the gold standard for assessing quality of attachment in the early years. It has been repeatedly emphasized that SSP classifications of secure, avoidant, resistant, and disorganized should be considered risk and protective factors for disorders rather than diagnostic entities themselves. A number of studies have demonstrated increased risk for anxiety disorders, disruptive behavior disorders, dissociative disorders, substance use, delinquency, and personality disorders among children with insecure and especially disorganized attachments to their primary caregivers (Allen, Hauser, & Borman-­Spurrell, 1996; Carlson, 1998; DeKlyen, 1996; Lyons-Ruth, 1996; Rosenstein & Horowitz, 1996; Warren, Huston, Egeland, & Sroufe, 1997). Nevertheless, two important caveats must be mentioned. First, to date, there is no clear association between specific classifications of attachment and

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specific psychiatric disorders. In some instances, this lack of association may be due to a lack of replication attempts rather than to contradictory findings. Second, it seems increasingly clear that taken alone, classifications of attachment have more limited long-term predictive power, whereas when considered with other variables, they appear to be important, if not vital, considerations (Sroufe, 2005). Given the ubiquity of attachment for human infants, an important clinical challenge is to distinguish between typically appearing variants of attachment and actual clinical disorders of attachment. For this distinction, we turn to a consideration of the clinical perspective on attachment disorders.

CLINICAL PERSPECTIVES ON ATTACHMENT RAD is the clinical disorder of attachment that has been best described and studied. It was first described formally in the psychological literature in 1980 with the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980). Since then, the criteria have been revised in both official (DSM-IV-TR [American Psychiatric Association, 1999]; ICD-10 [World Health Organization, 1992]) and unofficial nosologies (DC:0–3R [Zero to Three, 2005]; Research Diagnostic Criteria—­Preschool Age [American Academy of Child and Adolescent Psychiatry, 2003]). Nevertheless, only in the past decade have studies focused explicitly on the diagnostic criteria. The phenomenology of RAD was derived from descriptive studies of young children raised in extreme caregiving environments, such as those who have been maltreated or those who have been reared in institutional settings (Goldfarb, 1945; Main & George, 1979; Spitz, 1945; Wolkind, 1974). Drawing upon these studies, Tizard and Rees (1975) reported that at age 4 years, a majority of young children (18/26) who had been raised in residential nurseries in the United Kingdom since birth exhibited aberrant attachment behaviors. Eight children were described as emotionally withdrawn and unresponsive, and ten children

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were noted to be indiscriminate, attention seeking, and socially superficial. The signs and symptoms of RAD were drawn from these two groups of children, as identified in descriptive studies such as the Tizard and Rees (1975) study. The criteria for RAD in DSM-IV (American Psychiatric Association, 1994) and ICD-10 (World Health Organization, 1992) are notably similar, with both describing an emotionally withdrawn/inhibited type and a socially indiscriminant/disinhibited type. The major difference is, whereas DSM-IV criteria include inhibited/emotionally withdrawn and disinhibited/indiscriminately social subtypes, ICD-10 criteria describe two different disorders, reactive attachment disorder (the emotionally withdrawn/inhibited type) and disinhibited attachment disorder (the indiscriminately social/disinhibited type). In addition to the disturbed social behaviors that form the core of contemporary descriptions of attachment disorders, both the DSM and the ICD specify that the etiology of the disorder is extremes of poor caregiving. The DSM-IV criterion C requires “pathogenic care” (American Psychiatric Association, 1994, p.  130), and the ICD-10 description cautions against making the diagnosis in the absence of maltreatment. Indeed, RAD has been reported only in children with histories of either maltreatment or institutional rearing, but this may be because the pathogenic care criterion is required. A direct assessment of individual differences in quality of the caregiving environment and individual differences in RAD found moderate associations between caregiving quality and signs of emotionally withdrawn/inhibited RAD, but no association between caregiving and signs of indiscriminately social/disinhibited RAD (Zeanah, Smyke, Koga, Carlson, & BEIP Core Group, 2005).

Emotionally Withdrawn/Inhibited RAD Emotionally withdrawn/inhibited RAD is characterized by minimal or no discriminated attachment behavior, even at times when the child’s attachment behaviors should be activated (see Table 26.1). Phenomenologically, it is characterized by the absence of organized attachment behaviors, reduced social engagement and reciprocity, emotion regulation difficulties (i.e., low levels of posi-

tive affect, outbursts of irritability, unexplained fear, and hypervigilance). Children with this pattern do not seek comfort consistently or at all, even when distressed, and are not easily soothed when they do become distressed. The DSM-IV and ICD-10 descriptions of the emotionally withdrawn/inhibited types of RAD have been criticized as diffuse, vague, and not focused on attachment behaviors (O’Connor & Zeanah, 2003a; Zeanah, 1996). An alternative approach to the phenomenology of emotionally withdrawn/ inhibited RAD has emphasized seriously restricted or absent attachment behaviors with any adult caregivers, including comfort seeking and acceptance of comfort. In addition, affected children display a pattern of disturbances in emotion regulation, such as fearfulness/hypervigilance, irritability, and restricted positive affect. This alternative approach has been validated in maltreated children (Oosterman & Schuengel, 2007; Zeanah et al., 2004) and in institutionalized children (Smyke et al., 2002; Zeanah, Smyke, & Dumitrescu, 2002; Zeanah et al., 2005). There have been some attempts to assess convergent validity of caregiver reports of RAD through behavioral observations, as well. For example, Zeanah et al. (2005) found that young children living in institutions who had signs of emotionally withdrawn/inhibited RAD also had attachments to their caregivers that observers rated as incompletely developed. In the same sample of children, however, there was no association between the indiscriminately social/disinhibited RAD and the degree to which an attachment had formed.

Indiscriminate/Disinhibited Pattern of RAD The essence of the indiscriminate/disinhibited type of RAD is the failure to exhibit developmentally expectable reticence around unfamiliar adults (see Table 26.1). This is manifest by the child’s lack of reticence about engaging socially with unfamiliar adults, failure of the child to check back with the caregiver in unfamiliar settings and instead wandering off, and the child’s willingness to approach, interact with, and “go off” with a stranger. Developmentally, stranger wariness appears early in the second half of the



26. Attachment Disorders

first year of life. Though individual differences are evident, some degree of stranger wariness is evident in all typically developing children. In the indiscriminate/disinhibited pattern, wariness around strangers is absent or substantially diminished. There have been three different ways of operationalizing indiscriminate behavior. Chisholm (1998), in a follow-up study of children adopted out of institutions, included wandering off without distress, approaching strangers, going off with strangers, never being shy with new adults, and being friendly with new adults. O’Connor and Rutter (2000), who also studied children adopted out of institutions, included not differentiating among adults, readily going off with a stranger, and not checking back with a parent. We studied children living in institutions as well as maltreated children living in foster care and included not having a preferred caregiver, lack of reticence with a stranger, failure to check back with a parent, and willingness to go off with a stranger (Zeanah et al., 2002, 2004, 2005). Despite some differences in definition, these three different approaches actually showed substantial convergence (intercorrelations ranging from 0.64 to 0.97) when used to assess a group of young children living in institutions. Two reports have described behavioral assessment of indiscriminate behavior. Rutter and colleagues (2007) examined convergence between parent reports and child behavior with parents and strangers at ages 6 and 11 years using the SSP and other standardized procedures in their sample of children adopted out of Romanian institutions. They found marginal convergence between parent report and observer ratings of disinhibited behavior (lack of social reserve) and intimate closeness with a stranger that failed to reach conventional levels of significance. The other study demonstrated substantial convergence between caregiver reports of indiscriminate behavior and observed reactions of the child with an adult stranger (Zeanah, Smyke, Fox, & Nelson, 2008).

EPIDEMIOLOGY RAD is a rare disorder. In a sample of more than 300 2- to 5-year-old children drawn from pediatric clinics in North Carolina,

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there were no cases of RAD (Egger et al., 2006). Even in disadvantaged samples of young children, the disorder seems to be rare. For example, Boris et al. (2004) reported that there were no cases of RAD among impoverished young children attending a Head Start program, and only 2 of 25 homeless young children met ICD-10 criteria for disinhibited attachment disorder. Among samples of maltreated children, the disorder seems to be more common. In one retrospective study, clinicians who were interviewed using a structured interview reported that 35% of young children coming into foster care had met criteria for RAD (Zeanah et al., 2004). Oosterman and Schuengel (2008) showed that signs of both the emotionally withdrawn and indiscriminately social types of RAD were evident in preschool children in foster care. Signs of RAD have been readily identified among young children living in institutions. We reported some signs of both emotionally withdrawn/inhibited and indiscriminately social/disinhibited attachment in almost three-­quarters of young children being raised in a large institution in Bucharest, Romania (Smyke, Dumitrescu, & Zeanah, 2002). In another sample of institutionalized young children, most had incompletely developed attachments and clinically significant signs of both types of RAD (Zeanah et al., 2005).

DIFFERENTIAL DIAGNOSIS Though some of the signs and symptoms of RAD are similar to those of other disorders, the diagnosis is usually clear because of the distinctive clinical subtypes and the history of neglect. Nevertheless, in clinical settings, it may be challenging to know historical details about a particular child, meaning that careful assessments are necessary to distinguish RAD from other disorders. Other clinical problems associated with severe neglect, such as language and cognitive delays, may co-occur and sometimes complicate the clinical picture. The mostly likely clinical entity that can be challenging to distinguish from the emotionally withdrawn/inhibited type of RAD is pervasive developmental disorders (PDDs). DSM-IV-TR (American Psychiatric Associa-

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tion, 2000) and the ICD-10 (World Health Organization, 1992) emphasize the distinction between RAD and PDD. Though children with either disorder share impairments in social responsiveness and in evidence of deprivation (e.g., stereotypies), there are also important differences. Although deprived caregiving conditions characterize RAD, the deprivation in PDD is likely “disorder induced” (M. Sigman, personal communication, September 17, 2000). Thus, whereas PDD usually occurs in adequate caregiving environments, RAD does not. Furthermore, there is no reason to expect selective deficits in imaginative play, deficits in the initiation or response to joint attention, or deviant language development (e.g., echolalia) in RAD, whereas these are common, if not pathognomonic, in PDD. In addition, persistently restricted, repetitive, and stereotyped patterns of behaviors, interests, and activities are more characteristic of PDD than of RAD. Anxiety disorders may include substantial inhibition, but positive affect is apparent with caregivers, and selective attachment behaviors are present. The pathogenic care criterion is particularly important in distinguishing indiscriminate/disinhibited RAD from conditions such as Williams syndrome and fetal alcohol syndrome, both of which have been reported to be associated with indiscriminate social behavior (Jacobson & Jacobson, 2003; Jones et al., 2000). In addition, some children with attention-­deficit/hyperactivity disorder (ADHD) may be socially impulsive. If the child has clear signs of ADHD, including general impulsivity, and also shows indiscriminate behavior with unfamiliar adults, both ADHD and RAD may be present.

COURSE One of the important considerations for disorders in early childhood is their predictive validity, but longitudinal studies of signs of RAD are uncommon. Evidence regarding the predictive validity of RAD comes from the original studies of Tizard and colleagues (Hodges & Tizard, 1989; Tizard & Hodges, 1978; Tizard & Rees, 1975), from studies of children adopted out of institutions, and from one randomized controlled trial of foster care versus care as usual.

The emotionally withdrawn/inhibited type of RAD is not evident in follow-up studies of children adopted out of institutions. In the Bucharest Early Intervention Program (BEIP), however, there was continuity of signs of this type of RAD during the first 4–5 years of life (Zeanah et al., 2008). When children with the emotionally withdrawn/inhibited RAD are placed in more favorable environments, however, signs of the disorder seem to dissipate (Chisholm, 1998; O’Connor, Marvin, Rutter, Olrick, & Britner, 2003; Zeanah et al., 2008). The indiscriminately social/disinhibited type of RAD is more persistent. Tizard and Rees (1975) first described indiscriminate behavior in 4-year-olds with a history of institutional rearing. These signs had persisted when the children were observed at 8 years of age (Tizard & Hodges, 1978). At 16 years of age, adolescents in this sample who had demonstrated indiscriminate behavior with caregivers at ages 4 and 8 years were found to be indiscriminate with peers at 16 years (Hodges & Tizard, 1989). In addition, signs of indiscriminate behavior have been noted to be quite persistent in longitudinal studies of children adopted out of institutions (Chisholm, 1998; O’Connor et al., 2003). Rutter et al. (2007) reported moderately stable signs of indiscriminate behavior in children adopted out of Romanian institutions into the United Kingdom between the ages of 6 and 11 years. In the BEIP, children with a history of institutional rearing continued to show signs of the indiscriminate type of RAD through 54 months of age, even if they had been placed in foster care (Zeanah et al., 2008). Taken together, these results suggest that both types of RAD show stability over time. The difference seems to be that the emotionally withdrawn/inhibited type continues to be evident only if adverse caregiving environments continue, whereas the indiscriminately social/disinhibited type persists in some children even after caregiving environments improve.

ASSESSMENT ISSUES Complicating the assessment of RAD has been controversies over the criteria used to define it (AACAP, 2003; Chaffin et al.,



26. Attachment Disorders

2006; O’Connor & Zeanah, 2003a, 2003b). As with most psychiatric disorders, RAD is most often measured by caregiver report of the child’s behaviors, either as part of a structured psychiatric interview (e.g., Egger et al., 2006) or as a specific interview designed to assess signs of RAD (Smyke et al., 2002; Zeanah et al., 2002). Boris et al. (2004) proposed combining behavioral observation and a structured interview in a structured activity assessment to determine if young children met criteria for RAD. The observational procedure, known as the clinical observation of attachment, was explicitly designed to be useful in clinic settings. It involves a series of episodes designed to compare the child’s behavior with a discriminated attachment figure and a stranger in various moderately stressful situations (e.g., pick up, separation, scary/ novel toy). The structured interview allowed categorical diagnosis of RAD using DSM-IV or ICD-10 criteria. In order to diagnose RAD, the American Academy of Child and Adolescent Psychiatry (2005) Practice Parameters for RAD recommended observing the child serially with all involved caregivers and with an unfamiliar adult, in addition to a obtaining a thorough history of early caregiving environments from collateral sources. The academy also

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recommended using a relatively structured observational paradigm so that comparable observations could be made across the child’s different relationships. Although the SSP has constraints on its use diagnostically (see Boris, Aoki, & Zeanah, 1999), as part of a comprehensive assessment it may have value (see Powell et al., Chapter 28, this volume). As part of a clinical assessment, it is probably best used to inform an understanding of how the child’s attachment behaviors are organized toward the parent or caregiver rather than as a way to derive a classification of attachment.

INTERVENTION Two randomized controlled trials have demonstrated improvements on SSP classifications of attachment in maltreated children following treatment with child–­parent psychotherapy (Cicchetti, Rogosch, & Toth, 2006; Toth et al., 2002). Unfortunately, no interventions attempting to reduce signs of RAD in maltreated children have been studied. This is an area that needs attention. To date, the only intervention studies regarding RAD, per se, have been in samples of children with histories of institutional rearing, either designed to change caregiving

TABLE 26.1.  Similarities and Contrasts between the Two Types of RAD Type of RAD

Inhibited/emotionally withdrawn

Disinhibited/indiscriminately social

Etiology

Linked to social deprivation and neglect

Linked to social deprivation and neglect

Maltreatment

Readily identifiable in maltreated children

Identifiable in maltreated children

Institutional care

Identifiable in children being raised in institutions

Identifiable in children being raised in institutions

Children adopted out of institutions

Not identified

Identifiable in children adopted out of institutions

SSP classifications/ behavior

Related to attachment behavior in the SSP (but not to attachment classifications)

Not related to attachment behavior or classifications in the SSP

Quality of caregiving

Related to quality of caregiving

Not related to quality of caregiving

Intervention

Responsive to enhanced caregiving

Less responsive to enhanced caregiving

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IV. PSYCHOPATHOLOGY

practices within institutional settings, and interventions that removed children from institutions and placed them in families.

Interventions within Institutions McCall and colleagues (St. Petersburg–USA Orphanage Research Team, 2008) conducted an ambitious intervention to change the quality of caregiving within institutions for young children in Russia. Using a quasi­experimental design, this group provided training to promote more sensitive/responsive caregiving, and structural changes to support positive relationships between children and caregivers, predominantly by decreasing the number of caregivers per child. In one institution for young children, both of these changes were implemented; in a second, only training was provided; and in a third, no intervention was implemented. Although the study included no direct assessments of attachment disorders, the investigators found that those children whose institution received training plus structural changes displayed more positive emotions, a greater number of emotions, and more activity during free play and reunions following brief separation, and they showed more negative emotions when their caregiver left and returned. Results for children with disabilities were in the same direction, but not statistically significant. They also found that children whose institutions received training and structural changes displayed substantially more proximity-­seeking and contact­maintaining attachment behavior and less avoidant attachment behavior with their caregivers than did children in the other groups. Smyke et al. (2002) studied young children in a large institution in Romania. They examined signs of RAD in children on a standard care unit and in children on a “pilot” unit. These children then were compared to children who lived with their parents but attended community child care settings. Whereas children on the standard care unit had many different caregivers in a week, children on the pilot unit had caregivers drawn from a pool of four women on the day and evening shifts. That is, without changing the ratio of caregivers to children (roughly 1:12), the investigators were able to evaluate specifically the effect of reducing the number of caregivers for each child.

They found significant differences across the groups, with consistently more signs of both emotionally withdrawn/inhibited and indiscriminately social/disinhibited RAD in children on the standard unit. Anecdotally, the caregivers on the pilot unit seemed to be more psychologically invested in the children in their care, compared to caregivers on the standard care unit. For example, each of the groups of children on the pilot unit had a name (e.g., “puppies,” “kittens,” “cubs,” or “bunnies”), and the caregivers often referred to “my child” during structured interviews. This was in striking contrast to the absence of such references on the standard caregiving unit and suggests that focusing caregivers on a specific group of children may have had effects on both caregivers and children.

International Adoption Studies Two longitudinal studies of children adopted out of Romanian institutions have reported findings regarding RAD. Chisholm (1998) and colleagues (Chisholm, Carter, Ames, & Morison, 1995) reported on two groups of children adopted from Romania into Canada. The first group of 46 children was adopted after 8 or more months of institutional care. The second group of 30 children was adopted after less than 4 months of institutional care. These groups were compared to another group of 46 typically developing Canadian children with no history of adoption. The groups were assessed initially at a median of 11 months and later at a median of 39 months following adoption. Attachment was assessed by parental report. O’Connor and colleagues (O’Connor, Bredenkamp, & Rutter, 1999; O’Connor & Rutter, 2000) assessed 165 children adopted from Romania into the United Kingdom. Of these, 111 were adopted prior to 6 months, and 54 were adopted between 24 and 42 months. They were compared to 52 children without histories of maltreatment who had been adopted within the United Kingdom prior to 6 months of age. Despite design differences, there was a convergence of findings in these two studies. First, there were no reports of children with emotionally withdrawn/inhibited RAD, but a substantial minority in both samples had signs of indiscriminately social/disinhibited RAD. In fact, signs of indiscriminate behav-



26. Attachment Disorders

ior are among the most commonly reported social abnormalities in young children with histories of institutional rearing (Zeanah, 2000). These findings suggest that signs of indiscriminately social/disinhibited RAD persist even after the environment improves. Both studies also suggested that risk for indiscriminate behavior increases with increasing length of time in institutional rearing. For example, O’Connor and Rutter (2000) found that children who exhibited indiscriminate behavior at age 6 years had experienced deprivation for twice as long (22 months) as did children exhibiting no signs of indiscriminate behavior (11 months). Despite these important findings, there are limitations. Adoption studies do not include assessments of individual differences in the preadoptive caregiving environments, nor are they able to determine anything about the children’s possible attachments within the institutions. In addition, they are somewhat less representative of institutionally reared children since those adopted are likely to be selected based on nonrandom factors.

Bucharest Early Intervention Project The most intentional intervention study of RAD conducted to date is the BEIP (Zeanah et al., 2003). This was a randomized controlled trial of foster care as an alternative to institutional care conducted with young children living in Romanian institutions. Children ranged from 6 to 30 months of age at the time of recruitment. They were assessed comprehensively and then randomly assigned to care as usual or foster care. The children were followed longitudinally through 54 months of age. The goal of the BEIP intervention was to test a model of foster care that was effective, affordable, replicable, and culturally sensitive. Furthermore, the foster care was designed to be informed by the latest clinical and research findings (see Nelson et al., 2007, supplemental online material; Zeanah & Smyke, 2005). Foster parents were recruited through newspaper advertisements and word of mouth. They were trained using a manual that had been developed by Romanians and for Romanians, based on models of foster care in France and the United States. Three project social workers were recruited and trained to provide a variety of services

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to foster parents and the children for whom they cared. In addition to initial training, the social workers also received regular weekly consultation/supervision from experienced clinicians in the United States who worked with young, maltreated children. The goal was to have the social workers orchestrate foster care around the needs of the children for stable, consistent, and emotionally available caregivers. The aim was to have the foster parent become emotionally invested in the child and advocate on the child’s behalf as if he or she were the foster parent’s own child. The social workers supported, monitored, and intervened with foster parents as needed. Results of the BEIP indicated that signs of emotionally withdrawn/inhibited RAD were reduced substantially by placement in foster care (Zeanah et al., 2008). In this regard, the response to placement was both early and sustained. In fact, signs of emotionally withdrawn/inhibited RAD in the foster care group became indistinguishable from those in the community group. In contrast, signs of indiscriminately social/disinhibited behavior responded to placement more modestly (Zeanah et al., 2008). Work is ongoing to attempt to identify predictors of both recovery and sustained symptomatology.

Implications for Clinicians Based on results to date, it is clear that the first priority of treatment is to establish a safe and stable caregiving environment with a warm and consistent caregiver. Treatment of RAD begins by carefully assessing the relationship between the primary caregiver and child. The first question is whether the child has an attachment relationship—if not, then treatment means helping the child establish one. Secure attachments are fostered by caregivers who are emotionally available, sensitive, and responsive; value the child as a unique individual; and place the needs of the child ahead of their own needs. These features become the goal for establishing the kind of attachment relationship the child who lacks one needs to have (Zeanah & Smyke, 2008a, 2008b). If the child has an established attachment relationship, then the second question is about the quality of that connection. The goal in this case is to enhance the adaptive

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qualities and reduce the maladapative qualities of the relationship. Treatment can be conducted with the caregiver or with the caregiver and child, but it is essential that the relationship between the child and a primary caregiving adult be the focus. The chief goal of the treatment is helping the child learn, through repeated interactions with the adult caregiver, that the caregiver can be relied upon to provide comfort, support, nurturance, and protection to the child. Associated problems, such as cognitive and language delays, aggression, or posttraumatic symptoms, should also be addressed with appropriate therapeutic interventions. This view is compatible with the findings of Stovall and Dozier (2000), who reported that attachment behaviors of young children in foster care begin to organize around their new primary caregiver within days to weeks of placement, based on diary ratings kept by foster parents. If young children have a strong propensity to form attachments, then in species-­t ypical rearing conditions (i.e., in families), such attachments should form readily. This premise is supported by all studies conducted to date, including studies of children being raised within institutions, studies of internationally adopted children, and studies of young children in foster care. Admittedly, the research base is still thin, but there is nothing extant contradicting the idea that the emotionally withdrawn/inhibited pattern of RAD is analogous to absent or nearly absent preferred attachments. In fact, this pattern has been described only in young children in extremely adverse caregiving environments (Zeanah et al., 2004, 2005) and not in children who have been removed and placed in more optimal caregiving environments (Chisholm, 1998; O’Connor & Rutter, 2000). The thesis is that it is so crucial for children to form and sustain attachments to caregiving adults that they retain the capacity to do so once environments improve. The situation for indiscriminately social/ disinhibited RAD is somewhat different. Measures of indiscriminate behavior clearly diverge from other measures of attachment quality, and in fact, indiscriminate behavior has been identified in children who both lack and do not lack preferred attachment figures (Chisholm, 1998; O’Connor et al., 2003; Zeanah et al., 2005). The disinhibited pattern also is far less responsive than

is the inhibited pattern to enhanced caregiving (Zeanah et al., 2005). Perhaps most troubling is the finding that young children who appear to have established attachments, sometimes even secure ones, to adoptive or foster parents may demonstrate significant levels of indiscriminate behavior (Chisholm, 1998; O’Connor et al., 2003).

RELATIONAL DISORDERS OF ATTACHMENT The preceding discussion of attachment disorders focused exclusively on a withinthe-child disorder. Yet clinically, it has been argued that disturbances between child and caregiver may exist that are relationship specific. In fact, we and others have suggested additional forms of attachment disorder, beyond RAD, intended to capture relationship­specific psychopathology (Lieberman & Pawl, 1988; Lieberman & Zeanah, 1995; Zeanah & Boris, 2000; Zeanah, Mammen, & Lieberman, 1993). The basic premise underlying these forms of attachment disorders is that the child has an attachment relationship with a discriminated caregiver, but that the attachment relationship is seriously disturbed. Lieberman and Pawl (1988) deemed these disturbances “secure base distortions.” Later, several disturbed-­relationship patterns were described, including “self­endangering,” “vigilant/hypercompliant,” and “role reversed” (Zeanah & Boris, 2000). These descriptions defined disorders that existed between, rather than within, individuals. A substantial challenge is apparent for those attempting to validate such relational disorders. That is, we lack a language to describe what Stern (2006) termed a “two person” psychology. The DC:0–3R (Zero to Three, 2005) included an axis of relational disorders, but in more than 15 years since first described, it has inspired no efforts at validation. There are serious efforts underway to study relationship disorders, but these have not yet included young children and their parents (Beach et al., 2006). A lone study has demonstrated interrater reliability of codings of secure base distortions based on chart reviews of clinically referred children (Boris, Zeanah, Larrieu, Scheeringa, & Heller, 1998). In addition to



26. Attachment Disorders

demonstrating adequate interrater reliability, the study also showed that children with secure base distortions also had relationships coded as lower in adaptive qualities than did children with other clinical difficulties, providing preliminary validity for the construct. Obviously, much remains to be done before such relational disorders are considered valid and useful clinical disturbances.

SUMMARY AND FUTURE DIRECTIONS Maltreatment and institutional care increase the risk of serious disturbances of attachment in young children. Further, within institutionalized children, higher ratings of quality of care are related to increased probability of more fully developed attachments as well as reduced likelihood of having the emotionally withdrawn/inhibited type of RAD. There is no evidence, however, that individual differences in signs of indiscriminate/disinhibited attachment are related to individual differences in quality of care, though severe deprivation does seem clearly associated with the ontogenesis of indiscriminate behavior. Placement of institutionalized young children in families seems to reduce signs of RAD, with more pronounced reduction of emotionally withdrawn/inhibited RAD than the indiscriminately social/disinhibited pattern of RAD. Studies of children adopted out of institutions have found virtually no children with significant signs of emotionally withdrawn/inhibited RAD. Taken together, findings to date have suggested that the emotionally withdrawn/inhibited pattern of RAD is quite remediable if children are placed in more appropriate caregiving environments. What remains unclear is how long such a window of opportunity might remain open. Based on available evidence, it does not ever appear to be too late for a child to form an attachment, at least. Additionally, we do not yet know about potential long-term impairments in the quality of attachments that young children who have had RAD in early childhood are subsequently likely to develop. Certainly, results from O’Connor et al. (2003) and Marcovitch et al. (1997) have suggested that these children are at increased risk for unhealthy and atypical attachments

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even after they are placed in enhanced caregiving environments. Other challenges remain for the field. For example, we have little understanding of the reasons that similar conditions of risk give rise to the very different clinical pictures of inhibited and disinhibited RAD. In addition, which aspects of caregiving are most crucial in remediating signs of disturbance remain to be determined. Little also is understood about the neural substrate underlying attachment processes. A clearer understanding might help resolve some of the current dilemmas. Finally, a remaining challenge for research is to determine if it is useful to conceptualize attachment disorders beyond the currently narrow conceptualization of RAD. Some have advocated for inclusion of attachment relationship disorders as disorders between individuals rather than within individuals (Zeanah, 1996; Zeanah & Boris, 2000; Zeanah et al., 1993), but little research has addressed the validity of this framework. Progress in these and related areas will enhance our understanding of the family and social context of attachment disorders and continue to fill in details of Bowlby’s illuminating insights. Acknowledgment This chapter is an updated version of Zeanah and Smyke (2008). Copyright 2008 by the Michigan Association for Infant Mental Health. Reprinted by permission.

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and intergenerational attachment patterns: A comparison of normal and clinic referred preschoolers and their mothers. Journal of Consulting and Clinical Psychology, 64, 357–365. Egger, H. L., Erkanli, A., Keeler, G., Potts, E., Walter, B. K., & Angold, A. (2006). Test–­retest reliability of the Preschool Age Psychiatric Assessment (PAPA). Journal of the American Academy of Child and Adolescent Psychiatry, 45, 538–549. Goldfarb, W. (1945). Psychological privation in infancy and subsequent adjustment. American Journal of Orthopsychiatry, 14, 247–255. Green, J., & Goldwyn, R. (2002). Annotation: Attachment disorganisation and psychopathology: New findings in attachment research and their potential implications for developmental psychopathology in childhood. Journal of Child Psychology and Psychiatry, 43, 835–846. Hodges, J., & Tizard, B. (1989). Social and family relationships of ex-­institutional adolescents. Journal of Child Psychology and Psychiatry and Allied Disciplines, 30, 77–97. Jacobson, S., & Jacobson, J. (2003). FAS/FAE and its impact on psychosocial child development. In R. E Tremblay, R. G. Barr, & R. D. V. Peters (Eds.), Encyclopedia of early childhood development (pp. 1–7). Retrieved April 18, 2008, from www.excellence-­e arlychildhood.ca/documents/ JacobsonANGxp.pdf. Jones, W., Bellugi, U., Lai, Z., Chiles, M., Reilly, J., Lincoln, A., et al. (2000). Hypersociability in Williams syndrome. Journal of Cognitive Neuroscience, 12, 30–46. Lieberman, A., & Pawl, J. (1988). Clinical applications of attachment theory. In J. Belsky & T. Nezworski (Eds.), Clinical implications of attachment (pp. 375–398). Hillsdale, NJ: Erlbaum. Lieberman, A., & Zeanah, C. H. (1995). Disorders of attachment in infancy. In K. Minde (Ed.), Infant psychiatry (pp.  571–588). Philadelphia: Saunders. Lyons-Ruth, K. (1996). Attachment relationships among children with aggressive behavior problems: The role of disorganized early attachment patterns. Development and Psychopathology, 3, 207–226. Main, M., & George, C. (1979). Social interactions of young abused children: Approach, avoidance, and aggression. Child Development, 50, 306– 318. Main, M., & Hesse, E. (1990). Parents’ unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/ or frightening parental behavior the linking mechanism? In M. T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp.  161–182). Chicago: University of Chicago Press. Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/ disoriented during the Ainsworth Strange Situation. In M. T. Greenberg, D. Cicchetti, & E. M. Cummings



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Zeanah, C. H., Mammen, O., & Lieberman, A. (1993). Disorders of attachment. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp. 332–349). New York: Guilford Press. Zeanah, C. H., Nelson, C. A., Fox, N. A., Smyke, A. T., Marshall, P., Parker, S., et al. (2003). Effects of institutionalization on brain and behavioral development: The Bucharest Early Intervention Project. Development and Psychopathology, 15, 885–907. Zeanah, C. H., Scheeringa, M. S., Boris, N. W., Heller, S. S., Smyke, A. T., & Trapani, J. (2004). Reactive attachment disorder in maltreated toddlers. Child Abuse and Neglect: The International Journal, 28, 877–888. Zeanah, C. H., & Smyke, A. T. (2005). Building attachment relationships following maltreatment and severe deprivation. In L. Berlin, Y. Ziv, L. Amaya-­Jackson, & M. Greenberg (Eds.), Enhancing early attachments: Theory, research, intervention, and policy (pp. 195–216). New York: Guilford Press. Zeanah, C. H., & Smyke, A. T. (2008a). Attachment disorders in family and social context. Infant Mental Health Journal, 29, 219–233.

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Pa r t V

INTERVENTION

W ith all of the dramatic advances in the knowledge base of infant mental health highlighted in this volume, perhaps none is as striking as the growing evidence base of effective interventions. In fact, it is a testament to where the field has progressed that the interventions described in this section have evidence of their efficacy, most being supported by one or more randomized controlled trials and others currently being evaluated. What is striking about the psychotherapeutic interventions described is that they are built upon a solid base of two historically important methods of dyadic psychotherapy. Fraiberg and her colleagues (Fraiberg, Adelman, & Shapiro, 1975) described the first dyadic psychotherapy, what has come to be known as infant–­ parent psychotherapy. This approach called attention to the importance of the baby’s actual presence in the session to facilitate treatment. The child’s participation has become an accepted component of all of the treatments described. In addition, the Fraiberg approach included attention to the meaning of the baby to the parent, another underpinning of all of the approaches described. Finally, infant–­parent psychotherapy focuses on emotional communication, yet another central feature of the treatments described. The other historically important dyadic psychotherapy of infant and toddlers, interaction guidance (McDonough, 2000), introduced videotape review of infant and parent as a core feature. This method created opportunities for careful reflection by parents, under therapeutic guidance, about the baby’s behavior and their own reactions. This feature is incorporated into both Circle of Security and triadic family therapy, as well as other early childhood interventions described elsewhere. In Chapter 27 Lieberman and Van Horn describe child–­parent psychotherapy, the latest version of infant–­parent psychotherapy, which they have extended to children older than 36 months. As the oldest and best-­established psychotherapeutic intervention in infant mental health, it is also the best supported, with five randomized controlled trials by two different groups of investigators bolstering its importance. In addition to extending the age of children to whom this intervention can be applied, Lieberman and Van Horn also describe modifications in

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infant–­parent psychotherapy with a central focus more on emotional communication between the parent and young child and less on repetition of past relationship conflicts. Chapter 28, by Powell, Cooper, Hoffman, and Marvin, describes a new and promising intervention, the Circle of Security. This attachment-based intervention relies upon taped review of parent–child interactions framed in terms of the emotional availability of the parent and the balance of exploratory and proximity­seeking behavior in the child. This treatment, which empathically emphasizes the universality of attachment struggles for parents, also uses a variety of visual aids to help parents appreciate their own areas of conflict as they relate to the child’s attachment needs. In Chapter 29 Favez, Frascarolo, Keren, and Fivaz-­Depeursinge make the case for moving beyond the dyadic and understanding the young child’s development at the level of the triad. They cite evidence that psychotherapy at the family level is beneficial, but that data about the early mother–­father–infant family triad are not yet available. They also note the need for studies on the processes responsible for therapeutic change. Based upon observable interactions, the quality of family relationships in terms of alliances is an effective and valid way of making a “diagnosis” of family functioning, which in turn allows therapists to calibrate the intervention according to the difficulty the infant–­mother–father triad presents. Suchman, DeCoste, and Mayes (Chapter 30) note that substance-­abusing mothers’ perspectives about parenting indicate that they have a limited understanding of basic child development issues and ambivalent feelings about having and keeping children. The authors then present an overview and preliminary evidence about the effectiveness of an attachment-based intervention for substance­abusing mothers and their infants that targets the mother’s representation of her child and reflective functioning about her child. Suchman and colleagues make clear that not only is their approach feasible to apply to this challenging treatment population, but it also may be more likely to foster change in dyadic interactions than more traditional behavioral parent training approaches. Chapter 31, by Smyke and Breidenstine, presents an overview of foster care as an intervention for young maltreated children. Highlighting the special challenges of foster care for young children, they argue that foster care for young children must be conceptually differently from foster care for older children, because of the compelling attachment needs of young children. They review model foster care programs, supported by evidence of their efficacy, and also highlight many of the features of the psychotherapies described in Chapters 27–29 that are incorporated into these model programs. Easily the most provocative chapter in the section is the concluding one by Gleason on psychopharmacology in early childhood (Chapter 32). Why include a chapter on medication in the Handbook of Infant Mental Health? The chief reason, as Gleason notes, is that young children are being prescribed medications at alarming rates in the United States, usually without any evidence to support or guide their use. Therefore, a consideration of the pharmacological, physiological, ethical, and regulatory issues in this form of practice deserve attention. Gleason concludes, based on available direct and indirect evidence, that children less than 3



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years old should not be prescribed psychotropic medication and that children 3–5 years old should only rarely be treated with psychotropic medication. She provides clear guidelines designed to guide physicians in the rare situations when medications may be indicated in young children. References Fraiberg, S., Adelman, B., & Shapiro, V. (1975). Ghosts in the nursery. Journal of the American Academy of Child and Adolescent Psychiatry, 14, 387–421. McDonough, S. (2000). Interaction guidance: An approach for difficult to engage families. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 485–493). New York: Guilford Press.

C h a p t e r 27

Child–­Parent Psychotherapy A Developmental Approach to Mental Health Treatment in Infancy and Early Childhood Alicia F. Lieberman Patricia Van Horn

C

hild–­parent psychotherapy (CPP) is a relationship-based treatment for infants, toddlers, and preschoolers who are experiencing mental health problems or who are at risk for such disturbances due to parental mental illness, maladaptive parenting practices, discordant parent–child temperamental styles, and/or adverse life circumstances, including traumatic stressors. The goal of treatment is to promote an emotional partnership in which the child’s regulation and integration of affect, interpersonal skills, readiness to learn, and accurate reality testing are supported by the parent’s increased ability to provide a secure base to meet the child’s developmental and individual needs. CPP promotes child and parent perceptions and behaviors that facilitate mutuality of positive affect, age­appropriate self-­assertion, and constructive conflict resolution. It targets for change frightening, dangerous, and maladaptive parent and child behaviors, including externalizing problems such as excessive control, punitiveness, self-­endangerment, and aggression, and internalizing problems such as

anxiety, somatization, and emotional withdrawal (Lieberman, 2004).

CONCEPTUAL CORE AND DEVELOPMENTAL CONTEXT CPP is based on the premise that nurturance, protection, and culturally and age­appropriate socialization from the attachment figure(s) comprise the cornerstone of mental health in infancy and early childhood and create interactive patterns that are internalized by the child in the forms of stable lifelong psychological “structures.” This premise informs a developmental approach to treatment. CPP is organized around the evolving basic needs of the infant, toddler, and preschooler for care, protection, and acquisition of culturally sanctioned patterns of affect modulation, interpersonal relatedness, and learning. The goal of promoting the healthy unfolding of development is pursued through joint child–­parent sessions, wherein the CPP therapist uses spontaneous behaviors, interactions, and free play as 439

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ports of entry to translate the meaning of the child’s behavior for the parent and to facilitate the child’s age-­appropriate understanding of the parent’s motives.

Children’s Developmental Stage The child’s developmental stage is incorporated into the clinical case formulation following the initial assessment, and ongoing observations are used during treatment to align therapeutic objectives to the child’s changing developmental needs. Across the birth–5 age range encompassed by CPP, the unifying clinical theme is the quality of the child–­ parent relationship. For this reason, the term “child–­parent psychotherapy” represents an overarching construct that encompasses the age-­specific labels of “infant–­parent psychotherapy” (Fraiberg, 1980; Lieberman, Silverman, & Pawl, 2000), “toddler–­parent psychotherapy” (Cicchetti, Toth, & Rogosch, 1999; Lieberman, 1992), and “preschooler–­ parent psychotherapy” (Toth, Maughan, Manly, Spagnola, & Cicchetti, 2002). With preverbal, prelocomotive infants and their parents, CPP relies more extensively than at later ages on the therapeutic techniques first described by Fraiberg (1980) to elucidate how the parent’s psychological difficulties affect his or her capacity to cherish, nurture, and protect the infant. As the growing child becomes an increasingly more active participant in the sessions, the therapeutic focus moves from an exploration of the parent’s subjective experiences to addressing the mutual parent–child perceptions, attributions, and emotional demands of the present moment. When the child is able to use language and symbolic play to articulate feelings, his or her inner world moves to center stage during the sessions, and the parent’s individual subjective experience is incorporated as an adjunct to the intervention rather than as a discrete focus of attention. The CPP developmental framework incorporates the normative developmental anxieties first identified by Freud (1926/1959) and repeatedly elaborated in subsequent decades (see, e.g., Brenner, 1976; Marans, 2005; Pynoos, 1995)—namely, fear of separation and loss, fear of losing the parents’ love, fear of body damage, and fear of not living up to the expectations of one’s social group. Chil-

dren manifest these fears through behaviors that often befuddle parents and evoke rejecting or punitive responses, including inconsolable bouts of crying, prolonged tantrums, adamant refusals to comply, self­endangering behavior, and hitting, biting, and other forms of aggression. Many of the seemingly incomprehensible behaviors of infants and young children become not only understandable but also compellingly eloquent when understood in the context of specific situations or larger life circumstances that trigger or exacerbate these fears. The following guidelines are used to expand parental understanding and empathy for their children’s experience and to guide their search for an emotionally contingent and developmentally appropriate response (Lieberman & Van Horn, 2008).   1. Young children cry and cling in order to communicate an immediate need for parental proximity and care.   2.  Separation distress is an expression of the child’s fear of losing the parent.   3.  Young children want to please their parents and fear their disapproval.   4.  Young children are afraid of being hurt and of losing parts of their body.   5.  Young children imitate their parents’ behavior because they want to be like them and assume that their parents’ behavior is a model to emulate.   6.  Young children feel responsible and blame themselves when the parent is angry or upset for whatever reason.   7. Young children harbor a conviction that parents know everything and are always right.   8. Young children need clear and consistent limits to their dangerous or culturally inappropriate behaviors in order to feel safe and protected.   9.  Young children use the word “no” to establish and practice their autonomy. 10. Memory starts at birth; babies and young children remember experiences before they can speak about them. 11. Young children need their parents’ help and support in learning to express strong emotions without hurting themselves or others. 12.  Child–­parent conflicts are inevitable due to the different developmental needs



27. Child–­Parent Psychotherapy

of each participant, but can be resolved in ways that promote trust and support development. These developmental guidelines are the backdrop for CPP interventions. CPP therapists use them to guide their choice of interventions and may describe a guideline to the parent as a way of expanding parental understanding of child development. The guidelines can also be translated into language that is understandable to young children and used to facilitate the creation of a shared emotional agenda between parent and child. This is done, for example, when the therapist speaks for the child in the child’s presence in order to help the parent understand the child’s experience.

The Role of Play Play is the form of communication that most richly conveys young children’s efforts to make meaning from their experiences. Through play, children experiment with their internal world and external circumstances, rehearsing a range of outcomes in an effort to achieve mastery over their reality (Erikson, 1964). Children’s use of play to enact anxiety-­provoking experiences, to express wishful fantasies, to symbolize, and even to avoid emotionally charged themes make playing a natural vehicle for therapeutic intervention. Like other child psychotherapies, CPP encourages play. CPP differs from other approaches in viewing play not only as an individual child endeavor but also as an opportunity to help the child and the parent to play together, because joint play can become the vehicle to co-­create narratives that address the relevant emotional issues confronting them. In addition to this therapeutic function, play is also used in CPP as an opportunity for child and parent to spend time together and enjoy the pleasures of mutuality and discovery, as captured in Slade’s (1994) concept of “simply playing.”

Parents’ Developmental Stage Because development is a lifelong process, the parents’ developmental stage is also incorporated into the treatment formulation.

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Parents’ ability to integrate the parenting role into their sense of themselves is influenced by the extent to which they have attained the normative developmental milestones that precede parenthood, including a cohesive sense of self, mature intimacy in adult relationships, and satisfying engagement with everyday activities. The developmental guidelines described above are woven into the intervention as ways of promoting not only the parent’s understanding of the child but also the parent’s increasing self­understanding both as an adult and as the child in the past growing up. The ability to function adequately in adult roles is an important component of the parent’s ability to nurture, protect, and socialize the child. Adverse life circumstances, traumatic stressors, and mental health problems are recurrent obstacles to adaptive parenting, both because these factors have a direct impact on the child’s moment-to­moment experience and because they distort the parent’s ability to notice, interpret, and respond to the child’s needs. The focus of treatment may expand or shift in response to urgent material need or family crises in order to bolster the parents’ functioning in their roles as providers and partners in adult relationships. When the parents’ emotional needs are urgent and immediate, the CPP therapist resorts to a range of interventions to maintain or restore their capacity to attend to the child’s experience. These interventions include dividing the therapist’s focus of attention between the child’s and the parent’s individual needs, adding parallel individual sessions with the parent, telephone conversations focused on the parent’s experience, and referral for individual or group psychotherapy when clinically indicated.

Child-­Centered Focus A hallmark of CPP is the child’s presence in the session. Even when not physically present, the child is maintained as the organizing focus of the intervention in the mind of the CPP therapist. Individual sessions with parents aim at helping them function more effectively as adults for the sake of the child, including their becoming increasingly attuned to responses and feelings mobilized

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by their parenting role and to the impact on the child of their behavior and psychological states (Lieberman & Van Horn, 2005).

THEORETICAL INFLUENCES CPP continues to carry the imprint of its psychoanalytic origins in infant–­parent psychotherapy, which became identified with the well known metaphor of “ghosts in the nursery” (Fraiberg, Adelson, & Shapiro, 1975). This expression is used to describe the intergenerational transmission of psychopathology through the parents’ reenactment, with their baby, of unresolved conflicts from their own childhood. The lasting imprint of the “ghosts in the nursery” model is manifested in CPP’s attention to (1) the parent’s and child’s ongoing efforts to adapt to the characteristics of their environment, (2) the psychological and relational origins of present mental health problems, and (3) the parent’s and child’s deployment of coping strategies and unconscious defense mechanisms for the purpose of self-­protection against intolerable internal emotional states and external dangers. These premises, defined by Rapaport and Gill (1959) as the adaptive, genetic, and structural assumptions in the metapsychology of psychoanalysis, were also adopted by Bowlby (1969) as integral components of attachment theory. In addition, CPP incorporates the points of view advanced in attachment theory that (1) the human infant is biologically predisposed to form an affective bond with the mother figure; (2) separation from and loss of the attachment figure are pathogenic events with long-term repercussions on personality structure; (3) maternal sensitivity to the infant’s signals promote healthy adaptation; (4) observation of child behavior in ecologically representative environments is the bedrock for the understanding the etiology of early psychopathology; and (5) a prospective approach is essential to understanding the relationship between risk factors and their manifestations in the course of development (Ainsworth, Blehar, Waters, & Wall, 1979; Bowlby, 1969). In addition to psychoanalytic and attachment theory, CPP encompasses other theoretical perspectives as well. Develop-

mental psychopathology contributes an understanding of developmental outcomes that is informed by the inclusion of biological, psychological, social, and cultural levels of analysis and attention to the transactional processes among risk and protective factors within and between these domains (Cicchetti & Sroufe, 2000). The influence of this cross­disciplinary, integrative perspective is also manifested in CPP’s use of principles from cognitive-­behavioral therapy (CBT), whose aim is to guide cognitive change as a port of entry to effect affective and behavioral change (Cohen, Mannarino, & Deblinger, 2006), and principles from social learning theory about the transmission of coercive family patterns through imitation and learning of family roles (Patterson, 1982). Furthermore, theory and clinical strategies from the field of adult and child trauma are incorporated when the child and/or the parent have experienced traumatic events (Pynoos, Steinberg, & Piacentini, 1999; van der Kolk, 1987). The philosophical outlook encompassing these different perspectives is the conviction that hope and positive engagement with the activities of living are the primary ingredients of any successful therapeutic endeavor. A new model of “angels in the nursery” has been incorporated to CPP as a necessary counterbalance to the “ghosts in the nursery” focus on unresolved conflict and psychopathology (Lieberman, Padron, Van Horn, & Harris, 2005). The pain, anger, and despair generated by adverse relationships and life circumstances in the past and the present need to be countered with an affirmation that change for the better is possible, and that benevolent old memories can be retrieved from the past or new supportive memories can be created in the present to stand as “angels in the nursery” that will guard over the child’s and the parent’s wellbeing.

INTERVENTION MODALITIES CPP makes use of a variety of intervention modalities in response to different clinical needs (Lieberman & Van Horn, 2005). The unifying threads across modalities are (1) the goal of promoting healthy develop-



27. Child–­Parent Psychotherapy

ment in the child and the parent and (2) the simultaneous attention to the child’s and the parent’s experiences for the purpose of supporting their relationship. The cross­disciplinary nature of CPP is reflected in the use of modalities informed by social work along with modalities based on developmental psychology, psychoanalytic/attachment theory, trauma, social learning theory, and CBT. Several of these modalities were first described by Fraiberg (1980) as components of infant–­parent psychotherapy.

Using Play, Physical Contact, and Language Many problems in the child–­parent relationship involve misunderstandings or distortions in the meaning that parent and child give to each other’s behavior. CPP aims to clarify these behavioral meanings by describing the motives and function of specific child behaviors to highlight how the behavior is an effort to cope with the normative anxieties of infancy and early childhood. As the child becomes increasingly attuned to parental motives in the course of development, the intervention also involves age-­appropriate explanations of the parent’s point of view. Putting feelings into words, play, and physical contact are used as vehicles to build up trust and expand empathic understanding. To set the stage for the intervention, the therapist provides toys that are chosen according to the child’s developmental stage and to the goals of treatment, including toys that evoke relationship themes (e.g., a family of dolls that match the child’s and family’s ethnicity, farm animals, wild animals); toys that promote nurturing and self-care (e.g., kitchen and eating utensils, toy food); materials that promote artistic expression (e.g., paper and crayons); toys that reflect the specific stressors endured by the child (e.g., police cars, ambulance); and toys that promote the theme of healing (e.g., medical kit). The selection of toys may change in the course of treatment as some themes are outgrown and new themes emerge. CPP encourages play between the parent and the child, with the clinician taking the role of encouraging play, participating as requested by the child, and serving as a translator of the play to clarify its meaning in ways that enlarge understand-

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ing and provide support for the child and the parent. Putting feelings into words is systematically pursued as an avenue to help children understand and manage intense emotion. Strong feelings are always felt first and foremost through bodily sensations, and young children need to translate these body sensations into words as an important building block in the ability to regulate affect. Describing in words what the child is experiencing helps to correct mutual misperceptions and misattributions. The parents’ own emotional regulation improves when they participate in a therapeutic process where putting feelings into words is an explicit focus of the intervention. The role of touch and affection is woven into the intervention because physical contact is an important vehicle for building trust and conveying love between parent and child. When the child is frightened or upset and the parent does not intervene, for example, the clinician may first describe what the child is feeling and then speak about the reassuring power of picking up and holding a frightened child or letting the child sit on the parent’s lap.

Unstructured Reflective Developmental Guidance The developmental guidelines listed earlier are an example of the kinds of intervention employed in this modality. CPP developmental guidance is unstructured because it responds to the needs of the moment rather than following a prescribed curriculum, and it is reflective because it encourages the parent to integrate thinking and feeling into a new and more empathic understanding of the child’s developmental (Fonagy, Gergely, Jurist, & Target, 2002). Developmental guidance may also incorporate reframing, empathy, and appropriate limit setting in response to the child’s behavior. Toddlers and preschoolers can also profit from developmental guidance that is tailored to their cognitive and emotional resources. Developmental guidance is not restricted to information about normal development. In the aftermath of stressful or traumatic events, providing psychoeducation about expectable responses can be extremely helpful

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both to parents and, to the extent that this is age-­appropriate, to children because it normalizes their reactions and makes them feel understood and accepted.

Modeling Appropriate Protective Behavior In this modality the therapist takes action to stop dangerous or self-­destructive behavior. Modeling protective action is particularly relevant to parents and children whose perceptions of danger and safety are unrealistic or distorted as the result of repeated exposure to family or community violence or other traumatic experiences. Young children’s ability to appraise danger is undermined when their own attachment figures become the agents of fear. When this happens, the therapist’s protective actions are not only important in providing safety but also represent a commitment to help the parents learn or relearn how to protect their child.

Insight-­Oriented Interpretation Insight-­oriented interpretation is used to clarify the unconscious or symbolic meaning of behavior in ways that increase self­understanding. Interpretation can be used with parents as well as with children capable of receptive language. Well-timed interpretations can help parents become aware of motives, negative attributions, and behaviors that interfere with their ability to nurture and protect their children. However, the therapist must exercise good clinical judgment in deciding whether offering an interpretation in the presence of the child may violate the parent’s privacy. Interpretations can also help young children who blame themselves for their parents’ problems by promoting a more accurate understanding of causality and of their own role in the family.

Addressing Traumatic Reminders When the child is referred for treatment following a traumatic event, the treatment must address traumatic play and other manifestations of traumatic stress by enabling the child to narrate the traumatic event through play, drawings, or verbal description and by providing relaxation and reassurance experiences to address somatic reexperiencing and behavioral reenactments. Many events

traumatize the child and the parent simultaneously, such as car accidents or domestic violence. The parent may also experience vicarious trauma from witnessing what happened to the child, as when the child is abused by the other parent or attacked by a dog. Treatment in these cases needs to address the impact of the trauma on the parents as well, including appropriate referrals when necessary.

Retrieving Benevolent Memories Just as it is important to identify and address traumatic cues, it is also therapeutic to bring to conscious awareness what William Harris (personal communication, May 2004) called “beneficial cues”—moments of wellbeing that bolster self-worth because they serve as reminders of experiences in which the individual felt supported and cherished. Linking the past and the present is equally important with benevolent experiences as it is with conflict-laden memories. Remembering episodes of loving care can give parents the impetus to provide such experiences to their child. When these benevolent memories are not available, the treatment must provide a setting for the creation of new memories that offer a sense of trust, pleasure, and selfworth.

Emotional Support The therapist’s emotional availability is a core component of all psychotherapies. It takes the forms of conveying, through words and action, (1) a realistic hope that the treatment goals can be achieved, (2) a sharing in the satisfaction of achieving personal goals and developmental milestones, (3) effective coping strategies, (4) progress, (5) effective self-­expression, (6) and accurate reality testing (Luborsky, 1984; Wallerstein, 1986). In CPP this stance on the part of the therapist has the additional goal of modeling ways of being with one another for both parent and child. Emotional support is particularly important in the treatment of parents and children whose sense of themselves is under assault due to the hardships of poverty and discrimination. In these situations, emotional support becomes an end in itself as well as a therapeutic tool because it affirms the parents’ and the child’s right to dignity and



27. Child–­Parent Psychotherapy

respect and aims at lifting their self-worth as members of society.

Crisis Intervention and Case Management Parents facing acute problems of living can become more receptive to mental health treatment when the therapist is actively involved in alleviating their life circumstances. These activities may include advocacy with different agencies, consultation with the child care provider to prevent expulsion of the child for inappropriate behavior, mediation between the parent and child protective services if questions of abuse or neglect arise, or referral to other needed services. Crisis intervention is often the first intervention offered when the child is referred following a traumatic situation, such as maltreatment, community violence, or an accident. Ensuring safety is the first order of business in these circumstances, and concrete interventions can give the beleaguered parents a sense that change for the better may be possible as the result of treatment.

SELECTING PORTS OF ENTRY Choosing what to address during a session can be daunting for the therapist doing joint child–­parent therapy because he or she is often confused by the multiple stimuli that demand attention. In CPP the concept of “ports of entry,” developed by Stern (1995), is adapted to refer to the variety of elements in the parent–child relationship system that may be used as the starting point for an intervention (Lieberman & Van Horn, 2005). CPP targets negative attributions and maladaptive parent and child behaviors, and the therapist must choose ports of entry on the basis of clinical judgment of what needs attention in the moment. One port might be chosen because the moment is charged with emotional meaning, and another might be selected because it has important long-term implications for the child’s or the parent’s mental health. Once an initial port of entry is chosen, other points of entry can open up in quick succession (although sometimes efforts to pursue a port of entry may seem to lead nowhere). Examples of different ports of entry as opportunities for intervention are provided below.

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Individual Behavior of Child and/or Parent During a home visit that took place in the kitchen, a 3-week-old baby was crying loudly as his mother, still hurting from a cesarean section (C-section) and exhausted by sleepless nights, was describing her anger at her obstetrician, who insisted on the surgery in spite of the mother’s entreaty to wait. The therapist made a sympathetic comment about the fear and pain that the mother went through and then said, using the child’s behavior as an initial portal of entry, “He is crying so hard! He seems to be saying that he also had a hard time.” The mother replied angrily: “He thinks he had a hard time! He didn’t even push well enough to be born normally!” Taken aback by the mother’s blaming of the baby, the therapist turned her attention to the mother’s experience and said, “You sound so disappointed with him!” The mother burst into tears, and for a while mother and baby cried simultaneously. The therapist felt torn between her impulse to pick up the baby, her anger at the mother for having a distorted perception of the child, and pity for the mother’s despair. After a silence during which she struggled to sort out what would be the most helpful intervention, the therapist allied herself with the mother’s experience as a bridge to build empathy for the baby. She said softly: “These first weeks can be so exhausting, and you are still hurting from the incision. Can I do something to help you right now?” The mother and the baby continued crying. The therapist went to the kitchen sink, poured a glass of water, and brought it to the mother. The mother drank the water and thanked the therapist with a weak voice. The therapist asked: “Would you like me to see if I can soothe the baby? You look so tired right now.” The mother nodded wordlessly. The therapist picked up and rocked the baby, humming softly. As the baby’s crying subsided, she said to the baby: “Your mom did not want to have a C-section. She wanted you to be born naturally.” The mother looked coldly at the baby. The therapist continued talking to the baby: “She was hoping that you would be stronger and would push more, but you were too little and did not know how to do it. You tried and tried, but you couldn’t do it.” The mother’s face softened and she looked very sad. She said

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in a whisper: “The doctor told me that my contractions were not strong enough.” The therapist said gently: “Both of you tried so hard.” The mother cried again, and the therapist asked what she was feeling. The mother replied: “I feel like a failure.” The therapist said: “I know you are very sad and upset right now. But you are not a failure. You gave birth to a healthy and beautiful baby.” The mother said in a surprised tone, as if the thought had not occurred to her: “I did, didn’t I?” The therapist smiled at her and said: “You sure did!” She then nuzzled the baby’s head and added: “And he smells so good.” The conversation shifted to baby shampoo and the pleasure of the baby’s father in giving him a bath. The therapist talked about the hormonal changes that the mother was undergoing and the impact of these changes on her mood, and said lightly that the body takes a while to adjust. By the end of the session, the mother’s mood was considerably brighter. In this example, the therapist used the child’s and the mother’s individual behavior as ports of entry into the meaning of their respective experiences. By speaking to the baby’s earnest but unsuccessful efforts to be born vaginally, the therapist facilitated a reframe of the mother’s negative attributions to the baby and enabled her to acknowledge her own sense of failure at not having produced sufficiently strong contractions to prevent the C-section. The therapist also normalized the mother’s feelings by providing developmental guidance about the hormonal changes through which she was going. These interventions, in combination with practical helpfulness in offering water and soothing the baby, led to a more positive frame of mind on the mother’s part by the end of the session.

Interactive Exchanges between Parent and Child Three-year-old Sam pushed his 18-monthold brother when the toddler swiped at the tower of the blocks Sam was building and made it fall. The little boy fell on the floor and started crying frantically. The mother picked him up while screaming at Sam: “You are a murderer! You will kill him!” The child started crying loudly, but his mother ignored

him while consoling the younger son. The therapist turned to Sam and said: “Your mommy got mad when you hit Manny, but you were mad because Manny hit your tower and made it fall down.” She started rebuilding the tower and invited the crying Sam: “Let’s put it back together again.” Sam’s crying subsided and he joined the therapist in rebuilding the tower. While engaged in this activity, the therapist turned to the mother and asked: “What did you mean when you told Sam that he is a murderer?” The mother, still angry, answered that Sam was aggressive toward Manny, and she feared that he would seriously hurt his brother some day. The therapist suppressed her wish to contradict the mother directly by telling her that this is an unrealistic fear. Instead, she made herself remember that this was a mother with a long history of childhood abuse and domestic violence with the children’s father. She answered: “I agree with you that Sam needs to learn not to hit Manny. How have you tried to teach him not to hit?” The mother shrugged her shoulders and said: “I tell him ‘no,’ but he doesn’t listen.” Turning to Sam, the therapist said: ”Your mom doesn’t like it when you hit Manny. She wants to teach you not to hit because hitting hurts.” Sam continued building the tower and did not respond. The mother screamed: “Listen to what she is saying!” The therapist said, speaking to both mother and child: “Learning not to hit is very hard and takes a long time. Even grown-ups are still learning.” The mother’s body relaxed, and sensing that she was less angry and more receptive, the therapist said to her: “I think any time you see any kind of hitting, you get scared that it will get out of control because of everything that you went through.” This statement opened the door for a discussion of the mother’s fear of Sam’s anger. Relieved that the mother could identify the fear underlying her anger at the child, the therapist moved next to make the mother more aware of her attribution to Sam of adult-like destructive aggression. She said: “Maybe you see Sam as bigger and stronger than he actually is and forget that he is also a scared little boy trying to protect himself. I think Sam also thinks that Manny is bigger and stronger than he actually is.” The mother listened attentively. The therapist



27. Child–­Parent Psychotherapy

then turned to Sam and said: “Hitting is too scary. Your mom wants to keep everybody safe.” In this session, which occurred 2 months into treatment, the therapist used the mother’s perception of Sam as a murderer as a port of entry to start exploring the themes of aggression and victimization that were prevalent in this family. The therapist was careful not to address the mother’s perception of Sam as a murderer directly because the mother was still unsure about the value of treatment and became easily defensive when she felt criticized. The therapist affirmed instead the mother’s appropriate desire to teach Sam not to hit, using this shared goal as a platform to explore the larger themes of danger and of appropriate and hurtful responses to danger.

Child Mental Representations A 2½-year-old boy was trying unsuccessfully to put a block into a shape container. He suddenly banged his head against the wall. The mother laughed and said, “Don’t do that.” The boy hit his head again. The mother said to the therapist, “He is so weird.” The therapist addressed both mother and child by speaking to the child: “Your mommy doesn’t want you to hit yourself, but I think you are punishing yourself because you couldn’t put the shape in the box.” The child looked fixedly at the therapist and hit his head again, but this time more slowly. The therapist turned to the mother and said: “I think he needs help to know that it’s OK if he can’t put the shape in.” The mother said, “He’s weird,” but then turned to the child and said: “Come here, baby.” The child went to her, and the mother sat him on her lap and put her arms around him. The therapist commented: “All better now.” She then brought the shape sorter to mother and child and said: “Now you can try again.” This time the mother directed the child on how to put the shape into the container, and the child succeeded in doing so. The beginning of this scene revealed the intricate connection between this child’s mental representation of himself and his perception of how his mother saw him. The mother’s dismissal of the child’s distress at not succeeding reinforced his sense that he deserved punishment. Instead of treating

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the mother’s use of the word weird as an entrenched negative attribution that called for direct intervention, the therapist encouraged instead a concrete maternal response that reassured the child, both by providing reassuring physical contact and by moving on to successful problem solving as a way of dispelling the child’s self-­perception of having failed and showing him that he could achieve his goal with his mother’s help. Each of the examples above illustrates a particular way in which the parents and/or the child convey a view of themselves or the other that detracts from nurturing, protection, and age-­appropriate socialization. The therapists’ interventions began with efforts to understand the motives underlying the child and parent perceptions and behavior, framing them in a supportive, developmental context. As they unfolded, the interventions moved back and forth between individual child and parent behaviors, feelings, and mental representations of themselves and each other. The choice of ports of entry is extensive because relationships affect relationships, and these influences are expressed in a multiplicity of ways that open up many possibilities for intervention (Emde, Everhart, & Wise, 2004; Lieberman & Van Horn, 2005; Sameroff & Emde, 1989). The specific port of entry may be determined by factors such as the child–­parent psychotherapist’s theoretical preferences; the parent’s cultural mores, educational level, and temperamental style; the child’s temperamental style and ability to symbolize; the quality of the working relationship between the parent and the therapist; or the urgency of the clinical issues involved. Some parents are willing to reflect on the child’s thoughts and feelings but become guarded or angry when the therapist addresses their parenting practices. Other parents want to focus on their own situation and fend off efforts to include the child’s experience in the treatment. For these reasons, there are no “typical” CPP cases, and therapeutic strategies are tailored to the specific characteristics of the child and the parents. In general, the match between the therapist’s therapeutic strategies and the parent’s and the child’s receptiveness is the best predictor of treatment outcome. The timing of questions, suggestions, and interpretations is a

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crucial element in fostering treatment motivation. The therapist needs to cultivate a careful balance between addressing the relevant clinical issues and remaining tactfully alert to the parent’s and child’s ability to tolerate and make use of these interventions.

EMPIRICAL EVIDENCE CPP efficacy has been empirically documented in randomized trials with highrisk groups of toddlers and preschoolers. The samples include anxiously attached toddlers of impoverished, unacculturated Latina mothers with trauma histories (Lieberman, Weston, & Pawl, 1991); toddlers of depressed mothers (Cicchetti, Rogosch, & Toth, 2000; Cicchetti et al., 1999); maltreated preschoolers in the child protection system (Toth et al., 2002; Toth, Rogosch, Manly, 7 Cicchetti, 2006); and preschoolers exposed to domestic violence (Lieberman, Van Horn, & Ghosh Ippen, 2005; Lieberman, Ghosh Ippen, & Van Horn, 2006). Findings from these randomized controlled trials have demonstrated that this approach results in improvements in a variety of domains, including reduced child and maternal symptoms, more positive child attributions (of parents, themselves, and relationships), improvements in the mother–child relationship and the child’s attachment security, and improvements in child cognitive functioning. Four of the randomized trials involved predominantly ethnic minority samples, including monolingual Spanish-­speaking dyads, indicating that a relationship-based approach has ecological validity for at least some different cultural groups. These findings provide strong support for a therapeutic focus on the child–­mother relationship for young children whose mental health is impaired by stress, trauma, and the parenting problems associated with these conditions. References Ainsworth, M. D. S., Blehar, M., Waters, E., & Wall, S. (1979). Patterns of attachment: A psychological study of the Strange Situation. Hillsdale, NJ: Erlbaum. Bowlby, J. (1969). Attachment and loss: Vol. I. Attachment. New York: Basic Books.

Brenner, C. (1976). Psychoanalytic technique and psychic conflict. New York: International Universities Press. Cicchetti, D., Rogosh, F. A., & Toth, S. L. (2000). The efficacy of toddler–­parent psychotherapy for fostering cognitive development in offspring of depressed mothers. Journal of Abnormal Child Psychology, 28, 135–148. Cicchetti, D., & Sroufe, L. A. (2000). The past as prologue to the future: The times, they’ve been a-­changing [Editorial]. Development and Psychopathology, 12(3), 255–264. Cicchetti, D., Toth, S. L., & Rogosch, F. A. (1999). The efficacy of toddler–­parent psychotherapy to increase attachment security in offspring of depressed mothers. Attachment and Human Development, 1, 34–66. Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: Guilford Press. Emde, R. N., Everhart, K. D., & Wise, B. K. (2004). Therapeutic relations in infant mental health and the concept of leverage. In A. J. Sameroff, S. C. McDonough, & K. L. Rosenblum (Eds.), Treating parent–­infant relationship problems (pp. 267–292). New York: Basic Books. Erikson, E. (1964). Childhood and society (2nd ed.). New York: Norton. Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of self. New York: Other Press. Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant–­mother relationships. Journal of the American Academy of Child Psychiatry, 14, 387–421. Fraiberg, S. H. (1980). Clinical studies in infant mental health: The first year of life. New York: Basic Books. Freud, S. (1926/1959). Inhibitions, symptoms  and anxiety. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 4, 87–156). London: Hogarth Press. Lieberman, A. F. (1992). Infant–­parent psychotherapy with toddlers. Development and Psychopathology, 4, 559–575. Lieberman, A. F. (2004). Child–­parent psychotherapy: A relationship-based approach to the treatment of mental health disorders in infancy and early childhood. In A. J. Sameroff, S. C. McDonough, & K. L. Rosenblum (Eds.), Treating parent–­infant relationship problems: Strategies for intervention (pp. 97–122). New York: Guilford Press. Lieberman, A. F., Ghosh Ippen, C., & Van Horn, P. (2006). Child–­Parent Psychotherapy: Six month follow-up of a randomized control trial. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 913–918. Lieberman, A. F., Padron, E., Van Horn, P., & Harris, W. (2005). Angels in the nursery: Intergen-



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erational transmission of beneficial parental influences. Journal of Infant Mental Health, 26(6), 504–520. Lieberman, A. F., Silverman, R., & Pawl, J. H. (2000). Infant–­parent psychotherapy: Core concepts and current approaches. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 472–484). New York: Guilford Press. Lieberman, A. F., & Van Horn, P. (2005). Don’t hit my mommy: A manual for child–­parent psychotherapy with young witnesses of family violence. Washington, DC: Zero to Three Press. Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York: Guilford Press. Lieberman, A. F., Van Horn, P., & Ghosh Ippen, C. (2005). Towards evidence-based treatment: Child–­parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1241–1248. Lieberman, A. F., Weston, D., & Pawl, J. H. (1991). Preventive intervention and outcome with anxiously attached dyads. Child Development, 62, 199–209. Luborsky, L. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive–­ expressive treatment. New York: Basic Books. Marans, S. (2005). Listening to fear: Helping kids cope, from nightmares to the mighty news. New York: Holt. Patterson, G. R. (1982). Coercive family process. Eugene, OR: Castalia. Pynoos, R. S. (1995, December). The traumatic moment revisited: Toward developmental psychoanalytic model of internal and external dangers. Paper presented at the American Psychoanalytic Association Vulnerable Child Discussion Group, Los Angeles, CA.

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Pynoos, R. S., Steinberg, A. M., & Piacentini, J. C. (1999). Developmental psychopathology of childhood traumatic stress and implications for associated anxiety disorders. Biological Psychiatry, 46, 1542–1554. Rapaport, D., & Gill, M. M. (1959). The points of view and assumptions of metapsychology. International Journal of Psychoanalysis, 40, 153–162. Sameroff, A. J., & Emde, R. N. (1989). Relationship disturbances in early childhood: A developmental approach. New York: Basic Books. Slade, A. (1994). Making meaning and making believe: Their role in the clinical process. In A. Salde & D. Wolf (Eds.), Children at play: Clinical and developmental approaches to meaning and representation (pp. 81–110). New York: Oxford University Press. Stern, D. N. (1995). The motherhood constellation: A unified view of parent–­infant psychotherapy. New York: Basic Books. Toth, S. L., Maughan, A., Manly, J. T., Spagnola, M., & Cicchetti, D. (2002). The relative efficacy of two interventions in altering maltreated preschool children’s representations models: Implications for attachment theory. Developmental Psychopathology, 14, 877–908. Toth, S. L., Rogosch, F. A., Manly, J. T., & Cicchetti, D. (2006). The efficacy of toddler–­parent psychotherapy to reorganize attachment in the young offspring of mothers with major depressive disorder: A randomized preventive trial. Journal of Consulting and Clinical Psychology, 74, 1006–1016. van der Kolk, B. (1987). Psychological trauma. Washington, DC: American Psychiatric Association. Wallerstein, R. (1986). Forty-two lives in treatment: A study of psychoanalysis and psychotherapy. New York: Guilford Press.

C h a p t e r 28

The Circle of Security Bert Powell Glen Cooper Kent Hoffman Robert S. Marvin

A

s the field of early intervention continues to evolve, new clinical models that are both theoretically sound and empirically validated are being developed. In keeping with what Oliver Wendell Holmes called the “simplicity on the other side of complexity,” those designing models of intervention recognize the need for them to be “user-­friendly” and “intuitively accessible” for both parents and psychotherapists. Having a clinical protocol that is supported by research, clinically sound, easily understood, and equally simple to remember has been central in the treatment design of the Circle of Security (COS) project since its inception. Originally conceived as a means of teaching parents attachment theory, it has evolved into a more comprehensive treatment model that is being used in a variety of clinical settings. The COS protocol is an attachment-based early intervention method that is designed to help caregivers provide a secure base/safe haven for their children (Hoffman, Marvin, Cooper, & Powell, 2006; Marvin, Cooper, Hoffman, & Powell, 2002). The protocol is organized using the COS graphic, which illustrates the secure base/safe haven phenomenon and lists children’s exploratory and at

tachment needs (Ainsworth, Blehar, Waters, & Wall, 1978; see Figure 28.1). The concept of a COS is used throughout the protocol in different ways to facilitate four key aspects of intervention. First, the COS graphic guides the therapist, as he or she creates a secure base and safe haven for the caregiver, by providing an overarching organization for relationship-based treatment and intervention. Second, the COS serves as a learning tool that helps caregivers to see, understand, and support their children’s attachment and exploratory needs. Third, using the COS relationship assessment graphic (Figure 28. 1), the clinician assesses the caregiver–child dyad. Fourth, a treatment plan is tailored to address that particular dyad’s strengths and struggles on the COS. Relationship-based treatment, parent education, assessment, and individualized treatment planning are the cornerstones of the protocol and four facets of how the COS is used in early intervention. In addition to the COS graphic, we use a state-of-mind interview called the Circle of Security Interview (COSI) to gain access to caregivers’ internal working models regarding their relationship with their child. The interview helps to identify the quality 450



28. The Circle of Security Caregiver “Hands” Bigger, Stronger, Wiser, and Kind versus Frightening, Frightened, Disengaged, or Shifting t Strategies Follow Confident presence Fearful compliance Flat/Going through the motions Misattune Intrusive Distracted Pressure to achieve Pressure to be selfsufficient Pressure to stay involved with me Over bright Anxious/hypervigilant Rejecting/neglecting of needs Negative affect/attributions Take charge Confident Presence/expectation Scaffolding/co-organizing Distraction to top or bottom of circle Aggression or threat of Abandonment or threat of Abdicate Helplessness/fearful Dissociation Neglect Conflict avoidance Role distortion (peer to peer) Let’s be little together Be an adult with me Be my companion Don’t need me Role reversal Parent controlled by: Child’s caregiving Child’s aggression Shifting/competing strategies

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Top-Half Moments Child Cueing: Direct—Engaged—Comfortable—Calm—Showing Positive Expectations of Caregiver Child Miscuing: Clinging—Helpless—Overly Focused on the Caregiver— Over Bright—Walking on Egg Shells—Resistant/Argumentative— Controlling—Defiant—Aggressive—Ignoring—Rejecting—Overly Compliant—Flat I need you to . . . Support my exploration

u Watch over me u Delight in me u Help me u Enjoy with me Transition moments Child and/or parent cueing/miscuing

I need you to . . .

Welcome my coming to you

u Protect me u Comfort me u Delight in me u Organize my feelings Bottom Half Moments Child Cueing: Direct—Engaged—Showing Positive Expectations of Caregiver—Affectionate Child Miscueing: Avoiding or Rejecting Care—Distracting from Need—Taking Care of the Caregiver—Controlling—Defiant—Resistant/Argumentative— Aggressive—Overly Compliant—Overly Bright—Vigilant—Flat

FIGURE 28.1.  Circle of Security relationship assessment. Copyright 1999 by G. Cooper, K. Hoffman, R. Marvin, and B. Powell. Reprinted by permission.

of internal representations that caregivers attribute to attachment-based interactions. Caregivers are asked to look at themselves and reflect on numerous aspects of their relationship with their children and their own parents. Having at least minimal capacity for such “reflective functioning” (Fonagy, Steele, Steels, & Target, 1997) is an essential component for caregiver success in COS

therapy. The COSI also helps the therapist discern the caregiver’s internal working model as one of three discrete prototypes, called “core sensitivities.” The protocol becomes more personalized by organizing interventions from the perspective of the caregiver’s core sensitivity. This chapter introduces the reader to the essential features of the COS.

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COS PROTOCOL In the usual COS protocol, caregivers meet for 20 weeks in groups of five or six, each lasting 75 minutes. Weeks 1, 2, and 9 are psychoeducational, dedicated to teaching caregivers how to first see strengths in their relationship and then struggles using COS as a guide. The remaining weeks focus on teaching individual participants about their unique relationship with their own child by watching and dialoguing about selected video vignettes from their preintervention Strange Situation Procedure (SSP; Ainsworth et al., 1978) and a later structured parent– child videotape. The last session in week 20, is a celebration of all the participants have learned.

Providing A Secure Base for Caregivers Many parents seeking assistance to provide better care for their children, especially those parents considered high risk, have few experiences in their own developmental histories that support having trust and confidence in another. How then can such parents be expected to use the support and assurance of a therapist to allow themselves to become vulnerable and to learn? It is for this reason that the essential initial step of all parent– child psychotherapy is the building of a therapeutic alliance, a safe and trustworthy relationship between the parent and the therapist. The foundation of this alliance is the practitioner’s capacity to be sensitive to the unique needs and circumstances of the parent involved in treatment. British pediatrician and psychoanalyst Donald Winnicott (Winnicott, 1965) used the term “holding environment” to describe the central emotional requirement of all children and adults. With these two words, Winnicott clarified that each of us needs the sensitive availability of another someone willing and able to “hold” and “be with” our emotional needs. How can parents give availability and responsiveness to their children if they have never known either? The cornerstone of the COS intervention is therefore centered upon the therapist’s providing a genuine holding environment for each parent. By offering consistency, empathy, and, when possible, genuine belief in the parent, the therapist provides a potential new option. Through-

out the process of providing COS interventions, we have learned that as parents absorb this experience of “being held,” they are in turn better able to provide this same holding environment for their children.

Parent Education The first two weeks of the COS protocol are focused on creating a secure base for the parents and teaching basic attachment theory and observational skills. Essential elements of attachment theory are taught via the COS graphic. The COS is explained in this way: When children feel safe they are “hard-wired” to be interested in their world and to explore it. While exploring, children look to their caregivers to act as a secure base. Sometimes they want their caregivers to be with them by watching, sometimes they need help, and sometimes they want the parents to enjoy or even delight in their play. While exploring, children inevitably need to return to their base, to be closer to their caregiver because they may need comfort, help with their feelings, protection, or an experience of shared delight. Children look to their caregivers to support them when they need to use their caregivers as a safe haven. While viewing videotaped interactions of themselves with their children, parents practice creating behavioral descriptions of these interactions. Once the caregiver is able to describe the child’s behavior free from inference, he or she is encouraged to guess about the primary attachment or exploratory need that is being displayed in the clip. This process is called “seeing and guessing” and becomes the basic procedure for viewing videotapes throughout the group. The second major tenet in the COS is this: “Always be bigger, stronger, wiser and kind. Whenever possible, follow your child’s need. Whenever necessary, take charge.” Sometimes when parents try to take charge and act bigger and stronger, they sacrifice being kind and become mean and harsh. Parents who act this way often believe that they must act aggressively and evoke fear to get the respect of their child. Other parents, when they try to be kind, give up being bigger and stronger, abdicate their leadership, and allow the child to run the relationship. It is an ongoing challenge for all parents to be simultaneously bigger, stronger, and kind



28. The Circle of Security

and to have the wisdom to understand that a child’s need for security rests on their ability to provide this all-­important function. We encourage parents to respond to their child’s cues for any of the COS needs unless there is a clear reason to take charge. Parents learn that children who can use their caregivers all around the COS are more secure in their attachment and will thus have more resilience to life’s challenges. A caregiver who can provide a secure base and safe haven for a child allows the child to develop a “psychological immune system” (LyonsRuth, Bronfman, & Gwendolyn, 1999). Our immune systems do not guarantee that we will never get sick, but they provide the crucial mechanism for healing when we do. Children with secure attachments have caregivers to whom they can turn in times of stress who will help them calm themselves and solve problems. There is ample converging evidence that children who are secure do better across a broad range of developmental outcomes (Carlson & Sroufe, 1995; Kobak, Cassidy, Lyons-Ruth, & Ziv, 2006; Sroufe, Egeland, Carlson, & Collins, 2005). This is a “difference that makes a difference,” and one that caregivers can do something about.

ASSESSMENT This section addresses some of the pragmatics of successful diagnosis and intervention for parents and young children who are currently experiencing relational distress. The theoretical foundation offered by attachment theory and research provides clarity when it comes to understanding how a child and caregiver negotiate specific strengths and struggles within their relationship. Here we describe a process of differential diagnosis designed to identify the linchpin struggle— that is, the core interactional process and caregiver state of mind that sustain the equilibrium of insecure/disorganized relational patterns. The assessment section is divided into two parts. The first is the assessment process we have used in research, which includes formal double-blind coding by certified, reliable coders. The second section represents a less formal and more user-­friendly assessment procedure, designed by us (Cooper, Hoff-

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man, & Powell), and used by clinicians in non-­research-based early intervention applications. The clinical assessment is further subdivided into the interactional assessment and the state-of-mind assessment.

Research Assessment In research designs, prior to the COS intervention, each caregiver–child dyad was assessed using the SSP. If the child were younger than 24 months, the Ainsworth (Ainsworth et al., 1978) coding system was used, and children were classified as B (secure), A (avoidant), or C (resistant/ambivalent). Children were also coded D (disorganization), when applicable, using the Main and Solomon system (1990). For children from 24 to 60 months of age the preschool coding system was used (Cassidy & Marvin, 1992). The preschool system classifies children as B (secure), A (avoidant), C (resistant/ ambivalent), D (disorganized/role-­reversed/ controlling, with subsets of caregiving and/ or punitive) and I/O (disorganized but not controlling patterns that appear as incoherent and shifting). The parent’s caregiving pattern was identified using the Caregiver Behavior Classification System (Britner, Marvin, & Pianta, 2005; Marvin & Britner, 1995). Following the SSP, we added a with a 5-minute episode in which the parent reads an age-­appropriate book to the child and a 3-minute episode in which the parent organizes the child to pick up the toys and place them back into the toy box. The COSI is conducted following completion of the SSP and is used to assess the caregiver’s internal working model. This interview lasts approximately 1 hour and is videotaped. The questions are designed to elicit episodic memories of the caregiver’s present relationship with the child and memories of parent–child interactions from the caregiver’s own developmental history. The questions are also designed to elicit the caregiver’s reflections on those interactions and relationships. The interview consists of five questions about the Strange Situation experience that the caregiver and child had just completed, 20 questions about the parent’s perceptions of the child and the relationship between them (adapted from the Parent Development Interview; Aber, Slade, Berger, Bresgi, & Kaplan, 1985), and six questions

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about the parent’s relationships with his or her own parents during childhood (adapted from the Adult Attachment Interview; George, Kaplan, & Main, 1996). This interview is used to create the individualized intervention goals for each dyad.

Clinical Assessment COS Relationship Assessment Since completion of the first intervention groups in 2002, a system to assist clinicians in formulating treatment has been developed. Coding the SSP for research purposes involves focusing on the child’s behavior, with particular emphasis on the use of the parent as a secure base for exploration and as a safe haven when stressed after a separation. This coding clarifies only one-half of the relationship by omitting the caregiver’s behaviors. The Caregiver Behavior Classification System focuses primarily on the caregiver’s behaviors in the SSP. For clinical use, it takes knowledge from both systems to describe each member’s part of the dyadic “dance.” Because it is the relationship that needs to be assessed to formulate a clear plan for intervention, the COS relationship assessment is designed to teach clinicians a user-­friendly method to evaluate the behavior of both the parent and child The goal is to help clinicians develop skills to gauge the quality of the attachment/caregiving relationship and to organize their observations into a treatment plan specific to the attachment needs of the dyad. In other words, this is an effort to develop a method that is based on, and consistent with, research but is far less time consuming both to learn and to implement. In fact, a core goal of COS has been to organize complex developmental information into user-­friendly formats without sacrificing the essence of the concepts. The basic COS graphic has been successfully used to teach parents as young as 15 to understand the secure base/safe haven concept and to use that information in relationship with their children. The COS relationship assessment is designed for clinicians, especially those who have not been formally trained to score Strange Situations for research purposes, to efficiently grasp and use attachment theory in clinical assessment and treatment plan-

ning. Even though the COS relationship assessment handout is only 1 page (Figure 28.2), the relational dimensions emphasized, we believe, provide the clinician with a sophisticated level of assessment. The COS assessment focuses on three categories of interaction: “top-half” “bottomhalf moments,” and the caregiver’s role, which is termed “hands” (see Figure 28.1). The top half refers to the child’s ability to use the caregiver as a secure base from which to explore; the bottom half refers to the child’s ability to use the caregiver as a safe haven to come to for comfort and protection; and the drawing of the hands refers to the caregiver’s ability to maintain a position of “bigger, stronger, wiser, and kind” both in following the child’s cues and in taking charge when there is a need to do so. Many insecure caregivers seem to take charge when there is no need for them to do so, becoming overly directive and controlling in the play. Conversely, they may fail to take charge when the child clearly needs it. Key questions during the assessment are, When does the parent lead, and when does the parent follow?

COS Needs The COS differentiates four secure base needs, four safe haven needs, and two transitional needs. The assessment clarifies whether or not the dyad can negotiate all of these needs, and if not, which ones represent a struggle? Does the child cue the needs directly or has the child learned to miscue needs because direct cues distress the parent? The COS protocol defines a cue as a direct or indirect signal from the child for a specific need to be met, whereas a miscue is a misleading or contradictory signal used to protect the child from the pain of having a specific need exposed and/or left unmet (Cooper, Hoffman, Powell, & Marvin, 2005). Even though all children miscue, the more insecure the child the more he or she miscues, especially when the attachment behavioral system is activated. For example, a child moving away from the parent to play with a toy when it is clear the child is upset and needs comfort is a miscue. “Delight in me” can be found on both the top and the bottom of the circle. Parents who truly delight in their child, whether the child is exploring or needing to be close, promote



28. The Circle of Security

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I need you to …

I need you to… u u u u

Support my exploration

Watch over me Delight in me Help me Enjoy with me

I need you to…

I need you to…

u u u u

Welcome my coming to you

Protect me Comfort me Delight in me Organize my feelings

FIGURE 28.2.  Limited Circles of Security. Copyright 1999 by G. Cooper, K. Hoffman, R. Marvin, and B. Powell. Reprinted by permission.

such a positive relationship that their children tend to be more secure. In troubled dyads, it can be hard to find moments of shared delight. Delight is simply evoked by who the child is, not by what the child is accomplishing. Although pride in their success is helpful to children, the core of self-­esteem is a sense that someone delights in you for who you are, for your very being. If all you have ever known is being valued for what you accomplish, then you are only as good as your last home run. The self-­esteem of accomplishment needs the self-­esteem of being to adhere to, like Velcro, for an enduring positive sense of self that is available in the good times as well as the bad. Most insecure parents have never experienced being delighted in for who they are and thus know very little about giving this emotional experience to their child. We believe that if a parent learns from an intervention how to

experience more delight in his or her child, then the program was a success. Top Half of the Circle.  “Top-half moments” refer to interactions in which the child is using the parent as a secure base from which to explore. Does the parent support the child as the child is making a transition from proximity to the parent to exploring the environment? Such support can be quite subtle: a facial expression or a tone of voice. As the child moves away from the parent, what emotional tone does the parent communicate? Is the parent calm or anxious? Does the parent become withdrawn, rejecting, or intrusive when the child shows interest in the play environment? How does the child experience the transition from being close to the parent to moving out to explore? Can the child directly signal his or her needs related to an interest in the environment?

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When exploring, sometimes the child simply wants to play without direct involvement by the parent, and all the parent needs to do is “watch over me.” Winnicott (1965, p. 30) wrote that the capacity for autonomy develops in a paradoxical manner: “This experience is that of being alone, as an infant and small child, in the presence of mother.” “The basis of the capacity to be alone is the experience of being alone in the presence of someone” (Winnicott, 1965, p. 36). For some parents, providing a quiet, watchful presence can be difficult. They may feel rejected, unwanted, unimportant, or alone when the child wants to play by him- or herself. They may show their distress by pressuring the child or by withdrawing. When parents pursue the child, the quest can represent a variety of needs that the child is being pressured to fulfill. Sometimes a parent does not want to be alone and pressures the child to stay involved. Alternatively, a parent may pressure a child to accomplish tasks so that the parent can feel and look successful. Sometimes a parent needs the child to show interest only in things that are of interest to the parent, thus reinforcing the notion that the child is “just like me.” All of these instances represent examples in which the parents use their children to help themselves manage uncomfortable emotions and thus place demands on the children to be responsible for their emotional stability. During the SSP, many children cue their parents to share in the enjoyment of the play. When successful, this often takes the form of mutual smiling and laughing. Some parents can be so emotionally flat or distracted, however, that they do not seem to be able to provide this kind of positive interaction. Often the child will seek the parent’s help with a toy. How does the parent provide help? Does the parent provide a supporting framework to scaffold the child’s learning? Some parents are uncomfortable when their child needs them and thus will pressure the child to “do it by yourself.” Other parents will be uncomfortable negotiating with the child, at the child’s level, and get so focused on getting the job done that they will completely take over the task and ignore the fact that their child is no longer having fun. Bottom Half of the Circle.  As children explore, there will inevitably come a time

when they feel the need to seek proximity and closeness and turn to their caregivers as an emotional safe haven. When this happens, how do caregivers respond? As with the transition into exploration, the caregiver’s signals to the child can be quite subtle. Often, it is more of an attitude or a facial expression than an overt behavior. The COS assessment calls negotiating needs for proximity with the caregiver the “bottom half of the circle.” Attachment behaviors are behaviors that increase or maintain a child’s proximity to the caregiver during moments of distress (Bowlby, 1969/1982). By attaining closeness with a responsive caregiver, a child’s distress will diminish, and the child will feel more secure. Of particular interest when assessing the relationship is the child’s ability to use the caregiver for comfort during a reunion when the child’s attachment behavioral system has been activated by a separation. Of all the moments on the circle, this moment can be the most revealing. Some children directly cue the parent for their need for comfort, and the parent responds in a way that helps them soothe and return to exploration. Other children act as if they don’t need comfort even though they are distressed by the separation. These children have learned to miscue their parents when they are distressed and act as if they are fine when they are not. This insecure-­avoidant pattern of attachment (Figure 28.2) is called “bottom half” struggle. Caregivers who provide this style of attachment experience distress when they or others need emotional comfort. They often manage feelings of discomfort when their child is upset by discouraging closeness and distracting the child away from attachment-­related feelings by focusing on exploration. Some children seek comfort but resist being comforted. This insecure-­ambivalent pattern of attachment is called “top half” struggle (Figure 28.2). While this struggle can appear to signal the child’s resistance to comfort (bottom half of the circle), it is frequently associated with the caregiver’s discomfort in supporting the child’s autonomy (top half of the circle). This child has learned to keep attachment needs activated and not to be soothed because calming and exploratory behavior will both distress the caregiver. In this instance, it is the caregiver



28. The Circle of Security

who needs to be needed so as not to feel alone, separate, and/or abandoned. Sometimes the child resists comfort and keeps his or her attachment needs activated because the caregiver is only intermittently involved; the child has learned that prolonged demonstration of attachment behaviors tends to force the parent to be involved. This caregiver tends to go away emotionally if there is not a crisis. The “bottom half” need we have labeled as “organize my feelings” is about observing the dyad’s capacity for emotional regulation (Figure 28.1). A number of theorists are currently focusing on the essential role of emotion regulation in the health of individuals and relationships (e.g., Cassidy, 1994; Schore, 2003; Siegel, 1999). The ability to regulate affect competently is not an innate capacity, but rather is learned in and beyond infancy in relationship with attachment figures (Schore, 2003). Intense negative and positive emotional experiences that are beyond the capacity of the child to self-­regulate are managed (coregulated) with the help of the caregiver. Through the process of emotion regulation in relationship, the child’s ability for self-­regulation is developed and enhanced. As the dyad interacts, the child may experience a range of emotions from fear and sadness to joy and excitement. Can the child reach out and express a broad range of emotions to the caregiver? If so, the child demonstrates what Cassidy (1994, p.  232) calls “open, flexible emotional expression,” which is associated with secure attachment. Conversely, is reaching out limited, and if so, in what ways? To which emotions can the caregiver respond in a sensitive manner, and which emotions evoke stress and defensiveness in the caregiver? Some caregivers are very distressed by a particular emotion, such as anger, in the child. Other caregivers are more distressed by the intensity of emotion rather than the specific emotion itself. A significant part of this evaluation is to determine which emotional states in the child can be coregulated in the dyad and which cannot. For many parents the idea that children need help learning to regulate their internal state and experience is new information. “Hands.”  As the parent–child interaction unfolds, it becomes clear which needs on the

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circle are negotiable and which are not, and whether the parent assumes or abdicates the core leadership role we call “hands.” The central question here is, Does the caregiver act “bigger, stronger, wiser, and kind,” versus acting in a way that is frightening, frightened, disengaged, or unreliable as the result of multiple shifting caregiving strategies? The answer to this question reveals whether the dyad is ordered or disordered. The term disordered is used here to denote both disorganized attachments, using the Main and Solomon (1990), system and disorganized, controlling, and other insecure patterns using the Cassidy and Marvin (1992)—Preschool Scoring System. All three of these classifications indicate a relationship that is experienced as frightening by the child and thus is “fear without solution” (Cassidy & Mohr, 2001, p.  285), as there is no one to whom the child can turn when frightened. On the COS graphic in the figures, the icon of the hands represents a caregiver who provides the basic functions of “bigger, stronger, wiser, and kind.” If the caregiver’s hands are not on the circle, so to speak, the child lives with fear because there is no relational safe harbor. This is an important distinction because the developmental outcomes for disorganized attachments are significantly more negative than insecure-­avoidant or ambivalent attachments (van IJzendoorn, Schuengel, & Bakermans-­K ranenburg, 1999). Even though avoidant and ambivalent attachments are insecure and therefore not optimal, they are organized in the sense that they are predictable. There is a relational solution when the child is upset and afraid. The insecure patterns offer at least a roadmap; the disorganized relationship offers the child no predictable solution. Some questions to explore when deciding if the caregiver’s “hands” are on the circle include the following. When the child’s attachment is activated, who organizes the process? When it is time to clean up, who seems to be in charge? Does the parent take responsibility for guiding the interaction, or has the child learned to be responsible for organizing the relationship? When the child organizes the relationship, it can be obvious or subtle. The child’s organization is apparent when a child, upon reunion, anxiously tries to soothe the parent when the child is the one who is upset. More subtly, a child

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might try to keep the parent happy by compulsively amusing him or her with “cute” interaction. Parents can abdicate the roll of providing hands by acting helpless, “spaced out,” disengaged, or neglectful when the child clearly needs their help. Some parents tiptoe around, anxiously trying to avoid intense emotions or conflict with the child. When the child has to direct the relationship during moments when the child has needs, the essential function of “hands” is compromised and the child lives with uncertainty and anxiety. The caregiver’s crucial capacity to take charge and not abdicate his or her role as a parent is necessary if the child is to experience the predictability, structure, and safety necessary to flourish in an organized attachment. When it is time to take charge during the clean-up, does the parent seem confident in negotiating a way for the child to complete the task? Alternatively, does the parent plead and act helpless to get the child to comply? Does the parent use fear as a tool to get the child to obey? If so, what kind of fear is used: punishment, abandonment, aggression? Most parents of disorganized children struggle with effectively taking charge while remaining kind; they either collapse or take charge in a frightening manner. Some dyads demonstrate role distortion in which the child is called upon to provide emotional functions for the adult that are inconsistent with the child’s development. Some parents seem to want a playmate and act as if they were just two children together. Other parents want a companion and treat the child as a confidant and peer. Still others want a completely independent child who does not need them. In all of these examples, the adult looks to the child to help him or her feel emotionally stable. In disorganized/ controlling dyads, the roles of parent and child become reversed. When the child’s attachment needs are activated, the child assumes control of the relationship either by acting aggressively and ordering the parent around or acting as the parent’s caregiver by soothing, amusing, and taking care of the parent. In short, the question of whether or not a parent can provide both the secure base and the safe haven symbolized by the hands is central to the development of an effective treatment plan.

COS State-of-Mind Assessment We have based the COS model on the recognition that all parents use what Bowlby called “working models” (Bowlby, 1973). Each of us uses this internal template to understand current and future relationships, most notably with children in our care. Bowlby’s perception was built upon the idea that attachment relationships in early life become the building blocks for beliefs and expectations about relationships later in life. Using Bowlby’s working models concept in conjunction with the work of James Masterson (1976; Masterson & Klein, 1995), Otto Kernberg (1975) from object relations theory, and the self psychology of Heinz Kohut (1971), the COS approach is centered upon a differential diagnosis of each parent’s specific relational paradigm. This understanding is predicated upon the belief that each parent approaches attachment relationships with a particular blueprint regarding sense of self and sense of other. This blueprint is created within significant past relationships and becomes the basic viewpoint that organizes current interaction on the part of the caregiver with his or her child. Having a series of potential templates or blueprints with which to understand a parent’s worldview concerning relationship is useful for effective intervention, particularly when the therapeutic focus is on problematic representations that the parent currently holds regarding both self and child. Building upon a rich clinical tradition of using differential diagnosis when referring to differing personality struggles, the COS model focuses on distinguishing among defensive strategies rather than using DSM-IV terminology for personality disorders. Thus, we label three distinct but predictable patterns to be “core sensitivities” and describe them in the following way: separation sensitive (which in a rigid and pervasive form can become borderline personality disorder), esteem sensitive (which in a rigid and pervasive form can become narcissistic personality disorder), and safety sensitive (which in a rigid and pervasive form can become schizoid personality disorder) (Hoffman, Cooper, Marvin, & Powell, 1997; Masterson & Klein, 1995). The core sensitivities form a continuum from flexible and adaptive (mild-



28. The Circle of Security

ly defensive) strategies, on one end, to rigid and pervasive disorders of the personality on the other. It cannot be overstated that the COS model uses the term core sensitivity in a nonderogatory and nonblaming per­ spective while simultaneously including the defensive views of self and other that apply to most, if not all, parents seeking treatment. The often unrecognized underbelly of attachment is the fear of abandonment. Just as we all require being in relationship, we all fear being left alone. Disconnectedness leads to painfully dysregulated emotional states that are unmanageable and therefore require defenses to survive. Thus, a central motivation behind insecure/defensive strategies are tactics to avoid what Masterson (1976, p.  39) called “abandonment feelings” and Winnicott, Sheperd, and Madeleine (1989, p. 89) called “primitive agonies.” Each core sensitivity represents a set of nonconscious procedures that a person believes must be adhered to in order to avoid painful memories of previously unregulated affect—for example: “When I show I am smart, she stays nearby, so I’ll keep doing that. When I ask for comfort, she gets chilly or backs away, so I’ll stop asking.” The need for connection and its mirror image the fear of abandonment are recognized to be the central organizing processes in the development of defensive personality structure (Masterson, 1976). Even though these nonconscious rules are amenable to change, without reflection and support they tend to remain constant and often drive problematic parent–child interactions. The COS assessment of core sensitivity is derived from the parent’s responses during the standardized COSI (Cooper, Hoffman, Marvin, & Powell, 1999). The following is a brief description to help clarify the nature of these sensitivities. •• Separation-­sensitive parents have come to believe that to avoid experiences of perceived abandonment, they must comply with what others—­including their children— want, need, and feel, while disavowing their own wants, needs, and feelings. The underlying belief is that if they act on their own behalf, they will be abandoned by those they most need. They tend to feel incapable of liv-

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ing without feeling the continual availability of significant others. They often believe that their job is to focus on another’s needs and appear to be helpless regarding their own. Separation-­sensitive parents struggle to allow their children an experience of autonomy while exploring (the top of the circle) and simultaneously are unable to genuinely support a full experience of comfort (the bottom half of the circle). The children tend to show an ambivalent-­resistant response upon reunion during the SSP. •• Esteem-­sensitive parents have come to believe that who they are, just as they are (imperfect, flawed, average), is not enough to be valued. Therefore, to protect themselves from the fear of criticism and judgment, they continually attempt to prove that they and their children are worthy (unique, special, exceptional, anything but average) through performance and achievement. Perceptions feel all-­important for the esteem-­sensitive parent. Hence, they tend to be vigilant for any implication of having failed or being inadequate as parents or having others see their child as inadequate. These parents often pressure their children for achievement and performance (the top half of the circle) and struggle to provide comfort and organization of feelings (the bottom of the circle). These children can present as avoidant or ambivalent during the SSP. •• Safety-­sensitive parents believe that the cost of being connected and emotionally close to their children is the loss of self­determination, which in turn leads to perceptions of being controlled and/or intruded upon by their children. Therefore, they believe that the only way to have an intact sense of self is to maintain a position of self­sufficiency, and to expect self-­sufficiency from their children. The children of safety­sensitive parents are often frustrated by how their parents continually seeks to control the level of closeness. These children are often forced onto the top of the circle (toward self­sufficiency) when their genuine need is for comfort and connection on the bottom of the circle. The resulting lack of fulfillment in these children often leads to demands that reconfirm the parents’ view of significant others as demanding and controlling. These children can present as avoidant or ambivalent during the SSP.

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Because “one size” of treatment does not fit all caregivers, it is important to note the specific intrapsychic struggle that any given caregiver might be facing. For example, the specific struggles confronting an esteem­sensitive caregiver vary significantly from those of a separation-­sensitive or safety­sensitive caregiver. The esteem-­sensitive parent may well be feeling an internal pressure to have his or her child appear to others as highly skilled and above average (“Timmy knows his colors and numbers and he’s only 2”). The separation-­sensitive parent may become anxious and encourage the child’s return each time the baby starts to walk away to find a new toy (“Look, Jennifer, come back and see what I’ve got here”). The safety-­sensitive parent may find a variety of ways to keep her child focused on exploration as a means of maintaining an acceptable level of distance from the child (“I like that Johnny can play by himself so well”). To compliment the esteem-­sensitive parent on his child’s precocious competence merely exacerbates that dyad’s tendency to remain on the top of the circle. To focus on the separation-­sensitive parent’s warmth and caregiving skills may well give the message that keeping her child dependent is a good thing. To offer the safety-­sensitive parent support for how competently his child plays on his own would only add more fuel to an already well established defensive system being lived out in their relationship. It has been our experience that a better understanding of these differences related to core sensitivities greatly influences the establishment of a therapeutic alliance. More specifically, a working knowledge of differential diagnosis can take some of the guesswork out of how to approach treatment with each particular caregiving strategy. Rather than having to intuit what might be useful with a particular parent, a well-­developed knowledge of differential diagnosis can provide specificity in the choice of interventions. The COS approach uses the COSI as a way to gain initial insight into a caregiver’s core sensitivity. Although a decision tree for building an accurate differential diagnosis is beyond the scope of this chapter, a simpler approach—­asking “How do you think your child responded to the separation?” can often provide the needed insight into the intrapsychic world of the caregiver. A more

esteem-­sensitive parent might answer with a sense of pride that his child played creatively and wasn’t upset. A safety-­sensitive caregiver might comment about how she is relieved to see her child being so self-­contained. A separation-­sensitive caregiver might mention that she’s always worried her child doesn’t really need her. In summary, the COS model uses a systematic differential diagnosis of each caregiver’s nonconscious defensive schema as a means to better understand the core themes for intervention. More specifically, it is understood that each core sensitivity is used by the caregiver to keep a distance from the unregulated affect associated with problematic experiences of self and other. By better understanding precisely which defensive approach is being used by any given caregiver, the clinician is better able to design and aim the intervention at the precise struggle most in need of change. During the COSI caregivers reveal aspects of their capacity for “reflective functioning,” defined as the psychological capacity for understanding one’s own mental states, thoughts, feelings, and intentions as well as those of the other (Fonagy et al., 1997). For instance, when caregivers are asked “Does your child ever soothe you when you are upset or distressed?”, most parents answer, “Yes.” When further asked “How does his/her soothing make you feel?” and “When he/she soothes you, what do you imagine he/she is feeling?”, the caregiver’s reflective capacities are revealed. Most parents say it feels good to have their child soothe them. Highly reflective parents will then add the caveat that they don’t want their child to feel it is there responsibility to do so and worry that it may make them distressed. Minimally reflective parents think that there is really no problem with the child soothing them and may even count on it. In this instance, reflection is about caregivers’ ability to describe their own internal states and the internal states of their child while keeping in mind the context of the relationship in which one is the parent and one is the child. After asking 30 attachment-­related questions, the caregiver’s capacity for reflective functioning becomes clear enough to anticipate how he or she might respond when asked to reflect during treatment. Providing a secure base in which the caregiver can reflect on the relationship



28. The Circle of Security

with his or her child is the key therapeutic road for change, and the ambitiousness of the treatment plan depends on the caregiver’s capacity for this reflective functioning (Fonagy, Steele, & Steele, 1991).

TREATMENT PLAN A treatment plan is formulated after the initial assessments and prior to the first meeting with the parent. The core of the COS treatment plan is selecting the linchpin struggle, defined as the key defensive pattern of attachment–­caregiving interaction and caregiver internal working model that most maintains the pattern of insecurity in the dyad (for additional details, see Cooper et al., 2005; Powell, Cooper, Hoffman, & Marvin, 2007). As a defense, it protects both the child and the parent from engaging in interactions that cause emotional distress (e.g., dismissing-­avoidant dyads defend against emotional closeness, and preoccupied-­ambivalent dyads defend against separation). The child, in response to the parent’s discomfort with addressing particular needs, begins to miscue the parent about those needs. By changing the linchpin, a domino effect ensues, which, with therapeutic guidance, can advance the dyad into a more functional and secure pattern of interaction. For example, the linchpin issue for one caregiver was her fear of taking charge with her child, evidenced by her consistent choice to “collapse” when her 4-year-old acted punitively and controlling on reunion in the Strange Situation (for a detailed review of this case see Powell et al., 2007). The linchpin is a procedural script. It is procedural in that caregivers learned how to interact in this manner from attachment figures during their own development, and the learning is presumed to have few, if any, language-based correlates. Rather, parents develop a state of mind regarding their own attachment needs while growing up and tend to see their own child’s needs in terms of this script. Lyons-Ruth and members of the Change Process Study Group (1998) termed this learning “implicit relational knowing” and described these attachment–­caregiving behaviors as rule-based procedures learned experientially and organized with or without language. Attachment is also a proce-

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dure that is developed prior to language, is based on “procedural memory,” and represents “implicit relational knowing” regarding specific ways to be with a caregiver during times of need. The linchpin script also contains a series of if–then propositions that guide the caregiver and thus come to guide the child regarding the management of attachment-­related affects. For example, a common avoidant script may go like this: “If my child shows a need for comfort, then I feel distress. I can lessen my distress by getting my child to not show need for comfort. I can get my child to stop showing need for comfort by distracting him/her with toys [exploration].” The COS sees these implicit relational scripts as strategies with which caregivers protect themselves from painful affects evoked by their child’s real attachment needs and associated with insecurity in their own attachment histories. The scripts, in turn, evoke certain behaviors in the child. An important part of intervention is to make these implicit relational scripts explicit by helping caregivers to develop a coherent and empathic narrative to describe both their own and their children’s experience. The selection of the linchpin follows a simple decision tree. Does the parent offer the basic function of “hands” by providing leadership, safety, and structure for the child? If the answer is no, then the linchpin must address the missing function. If the answer is yes, then the next question is, Can the parent provide comfort and care when his or her child is upset? If the answer is no, then this is the linchpin. If the answer is yes, then the last question is, Can the child use the parent as a secure base from which to explore? If the parent provides all these functions, the relationship is secure, and the linchpin will then focus on supporting and reinforcing existing strengths. Throughout the COS protocol, the quality of the relationship that the therapist negotiates with the caregiver is crucial. In each phase of the protocol, caregivers are invited to increase their vulnerability by delving into progressively more sensitive material. At first, they are asked to make observations and draw conclusions about their child’s needs and feelings, then they are asked to focus on their own experience, especially times they feel distressed by their child’s at-

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tachment needs. For caregivers to engage in this level of reflection, they must feel safe, supported, and understood by the therapist. The COS protocol organizes treatment using the acronym RAR to characterize the essential aspects for therapeutic change. •• The first R stands for the relationship between the therapist and parent. A safe “holding environment” (Winnicott, 1965) needs to be negotiated for successful treatment. The therapist and the group become a secure base from which parents can explore their relationship with their child. •• A stands for affect regulation (Cassidy, 1994). Each parent brings his or her own unique history of how emotions are managed to the group. During group sessions, some aspects of how caregivers manage chronic painful affects will inevitably be challenged. Feelings that have long interfered with a parent’s ability to respond to his or her child can now be “held” (Winnicott 1965) by the therapist, the group, and the parent him- or herself. This experience of shared understanding and coregulation of difficult emotion lays the foundation of the parent’s emerging ability to provide more secure parenting. •• The last R stands for reflection, the caregiver’s capacity to reflect on both the child’s and his or her own thoughts, feelings, needs, and behavior and ultimately make new choices. Videotaped sequences of parent–child interactions expose procedural scripts that are outside the caregiver’s awareness. Caregivers experience distress and pain when they realize they are not responding to their child as sensitively as they wished. When the participants in the intervention become upset, it is essential that they experience the therapist as a safe haven with whom they can share, process, and understand emerging emotions. If participants can use the therapist as a secure base and a safe haven, the intervention will go well. Participants are encouraged to feel successful if they can reflect on what needs their child may have and how they are behaving, thinking, and feeling about their child’s needs. Even though security or insecurity of attachment is measured by behavior change, the emphasis in treatment is on

the capacity to reflect, to feel, and to share. Behavioral prescriptions for caregivers to try are rarely, if ever, given. The theory of change in COS is that parents have the capacity and desire to respond to their child’s needs, but well-­established defenses against painful affects associated with deprivation in their own developmental histories prevent them from seeing and responding to those basic attachment needs from their child (Fraiberg, Adelson, & Shapiro, 1975). In our view, these key defenses are part of implicit relational knowing and are organized with little awareness or language. A key challenge in developing the COS protocol was how to help caregivers understand and address such a complex construct, representing an entrenched relational pattern, in a relatively brief intervention model without overwhelming them. To help parents understand the construct of a procedurally organized defensive state of mind, we use a two-part audio/video clip, set to music, for this purpose. The first part opens with a beautiful ocean view from atop a bluff. This clip is set to Pachelbel’s Canon in D major. The video clip is taken from the viewpoint of someone strolling down a forested path leading to the ocean. This 50-second clip, which ends on the beach looking out to the water, tends to elicit a calm, pleasant, safe, feeling. The second part of the clip uses the same videotape but is set to a musical composition similar to the theme music from the movie Jaws. This clip tends to evoke quite different feelings. Suddenly, the stroll through the calm forested path is transformed into an eerie trek among looming trees and undergrowth teeming with hidden danger. The final approach to the beach evokes a sense of foreboding and a strong desire to flee from the water. Caregivers quickly grasp that the music dramatically shifts the mood of these two identical visual experiences. We explain that a state of mind is like music we play in our head. Music is an excellent metaphor for state of mind in that it colors or even defines our subjective experience, is emotionally evocative, and is not based on language. The type of music evoked by each of our children’s attachment and exploratory behaviors depends on our history with these behaviors. For example, if in our childhood



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we experienced a sense of safety and support for separation and exploration, then our children’s innate desire to explore will tend to evoke the nonthreatening music. If our history of exploration and individuation is associated with aggression, abandonment, or threats of aggression or abandonment, then our children’s need for autonomy may evoke what participants in the groups have named “shark music.” It is important to clarify that shark music involves a fearful response to something that is actually safe. The same is true with emotional or physical closeness in the sense that early associations with seeking or maintaining proximity can affect the state of mind evoked by our children’s attachment behaviors. In addition, early experience of self-­assertion can establish positive or negative associations with taking charge, setting limits, creating boundaries and other functions of parenting. Sometimes a child expressing a specific need evokes a defensive state of mind in the caregiver because that caregiver, as a child, experienced maltreatment in response to his or her expression of that same need. However, for some caregivers, a defensive response is evoked simply because their own caregiver had a defensive response to that specific need. For example, imagine that a caregiver’s grandfather experienced a traumatic response to his bids for comfort. The grandfather learned to avoid physical and emotional closeness and so chose a spouse who did not seek or demand intimacy. Therefore, the caregiver’s primary attachment figure grew up in a family that was emotionally unavailable and came to associate a need for comfort with withdrawal of both parents. When, as a child, the caregiver made bids for comfort, those bids were met with anxiety and withdrawal. Now imagine our caregiver as a parent trying to understand the origin of the shark music that she or he is passing on to a fourth generation. Whether the shark music is created by a history of trauma and/or by generational transmission, caregivers need to develop an alternative to their insecure implicit relational knowledge. Using plausible leaps of faith about brain–­behavioral relationships, we teach caregivers the difference between “limbic system alerts” and “prefrontal lobe

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assessments” of the current situation. In this presentation to parents, we assert that limbic system alerts are faster than they are accurate, and prefrontally mediated interpretations are slower but more likely to be accurate. By helping parents understand that they can be “hijacked” (Goldman, 1995) by their limbic system into a shark music state of mind, we lay the groundwork to create choice points. Choice points are created when caregivers realize that the amygdala, which is a part of the limbic system, is always scanning for sign of danger. Each of us builds a “library in our amygdala” based on our history of frightening experiences. Some people have an extensive library due to a childhood of trauma, abuse, and/or neglect, whereas others have a very limited amygdala-based library. When people have an extensive amygdala library, there may be many things associated with extreme danger so that even a minor incident can trigger major limbic system responses. We explain to the group that our “feeling brain” (limbic system) does not put a date stamp on these library references or compare the original context with the current situation because it is designed to give an immediate alert that initiates a quick, defensive maneuver. So, for example, if childhood bids for comfort were associated with being little and powerless while facing an angry and rejecting parent, then, in adulthood, a bid for comfort from a small child can be enough of an association to trigger a false-­positive alert in the amygdala and the corresponding defense. By recognizing that an experience that is frightening but not dangerous is a false­positive amygdala alert, a choice point is created. The choice is to continue to defend against nonexistent sharks or to reflect and engage the prefrontal lobe (referred to as the “thinking brain” with parents). By bringing the feeling brain and thinking brain into dialogue, caregivers can develop a response based on a more accurate assessment of the current situation. When working with parents, we use this formula: “When my child does X, I hear shark music, but rather than protect myself by doing Y, I choose to bear the emotional discomfort and reflect on the current situation so that I can respond appropriately to

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my child’s need.” When a parent risks experiencing and reflecting on, rather the defending against, the feelings evoked by shark music, previously unexplored and unregulated negative affects can be brought into reflective dialogue and a therapeutic shift can occur. The first round of videotaped reviews in the COS protocol, referred to as phase one, begins in week 3 of the treatment and continues through week 8. Each week, edited video clips from one parent’s SSP are processed with the parent and the group. Phase One reviews are also used as a base to begin to explore the defensive process that blocks the parent from fully using his or her underdeveloped capacities. During this review, the other parents are given a worksheet to enhance their observational skills and are invited to share insight and support for the parent whose tape is being reviewed. During this beginning phase, parents are introduced to the concepts of secure attachment. They are not formally exposed to the different types of insecure attachments until week 9, after the first phase of taped reviews is completed. During all group meetings, caregivers’ struggles are normalized and the group becomes a safer place in which participants can explore and acknowledge which half of the circle is least comfortable for them. In week 9, just prior to the introduction of shark music, parent struggles are normalized by having all group members read out loud a handout called “Welcome to the Club.” The handout emphasizes the point that all parents struggle. As parents receive permission to experience struggles as common, even inevitable, they begin to relax. To help caregivers explore their relative comfort with the needs noted on the circle in Figure 28.1, we suggest that they reflect on their own parents’ comfort in relation to the various components of the circle. As participants begin to discuss their own experience of growing up, they are able to reflect on what they are, or are not, passing on to their children. We emphasize that we are not interested in blaming. Rather, we find that reflecting on our own history helps to clarify our current strengths and struggles. Beyond normalizing caregiver struggles, the underlying goal of this exercise is to outline specific struggles that caregivers

can expect to encounter. Caregivers are told that struggles may well show up regarding hands issues, top-half issues, bottom-half issues, or a combination of hands, top- and/ or bottom-half issues. At the same time, these struggles are described as understandable, given the pain of the shark music that the parent has been experiencing without awareness. In addition, the “Welcome to the Club” text honors the positive intentionality of all parents. Thus, a context of “no blame” is established, deepening the parents’ sense of trust in the positive intentionality of the group therapist and, by implication, the group process. After “Welcome to the Club” parents are introduced to insecure attachment first by understanding how state of mind affects perception with the use of “shark music” and then with the limited circle graphic (Figure 28.2). This graphic is an oversimplification of avoidant and ambivalent attachments, but it serves the function of illustrating the constructs to parents. We then present the idea that we all tend to be more comfortable on either the top half or the bottom half of the circle. If we don’t attend to the half of the circle with which we are least comfortable, we are in danger of missing our children’s cues and inadvertently teaching them to give miscues about their needs on that half of the circle. During weeks 10–15 parents participate in phase two taped reviews. The focus is on helping parents identify their linchpin struggle and the associated shark music affect. As in prior reviews, one parent a week is presented with video clips that have been reedited from his or her preintervention assessment. The goal in phase two reviews is to help parents recognize that they have the capacity and thus a choice to use more secure strategies when defensively activated by their children’s attachment needs. In week 16, the parents are videotaped in a modified SSP. These tapes are edited for phase three taped reviews, which take place during weeks 17–19 (two taped reviews are completed each week). The focus of phase three is celebrating positive changes and negotiating a direction for future improvement. Week 20 is reserved for the graduation celebration. Each parent receives a “Certificate of Graduation.” Parents are encouraged



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to share their experience of participating in the protocol, and final arrangements are made for the postintervention assessments. After the final assessment, parents are given copies of the video clips used in their taped reviews.

EMPIRICAL EVALUATION A preintervention–­postintervention design using the SSP (Ainsworth or Cassidy & Marvin) with 75 dyads assessed the effectiveness of the COS protocol (Hoffman et al., 2006). Of the 75 caregivers who started the 20-week intervention, 65 (86%) completed the program. We tested the hypotheses that after intervention, there would be (1) a significant decrease in disorganized attachment and (2) a significant increase in secure attachment, with subjects used as their own controls. Disorganized attachments (controlling and insecure/other) decreased from 60% pretreatment to 25% posttreatment, and secure attachments increased from 20% pretreatment to 54% posttreatment. Of the 13 children who were classified as secure on the preintervention SSP, 12 remained secure on the postintervention SSP. The one child who went from secure to insecure had a caregiver who relapsed into drug use during the program. The stability represented by the data that 92% of secure children remained secure over the 6 months is greater than other reported rates of stability in longitudinal nonintervention samples (Moss, Cyr, Bureau, Tarabulsy, & Dubois­Comtois, 2005; Weinfield, Whaley, & Egeland, 2004). The stability of security during the intervention suggests that the intervention not only does no harm but also provides needed support in high-risk populations for secure dyads to remain secure. Further research using a random trial design is needed to verify that the results reported here are truly due to the intervention. Results from this study provide encouraging preliminary data that the COS protocol is effective in reducing disorganization and increasing security for children in the age range between toddler and the early school years. Randomized controlled trials and replication by other investigators are now needed to demonstrate the efficacy of this approach.

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SUMMARY The COS approach has met a need in the field of early intervention for a clinical model that is theoretically sound, research based, and user-­friendly for both parents and the psychotherapists who serve them. Typically, those involved in the COS intervention (i.e., parents and professionals) use the COS paradigm as an opportunity to reflect upon their own attachment history. The increased empathy on the part of professionals for their own attachment struggles translates directly into helping parents build empathy for the struggles they experience within intimate relationships. Thus, this model has a way of eliminating the distinct demarcation between those providing and those receiving treatment. The human condition, which encompasses a struggle with painful and often unresolved memories regarding dyregulated affect within close relationships, unites us with similar challenges. From this perspective, it is not necessary to pathologize parents who are seeking help for relationships with their young children. Indeed, as we evolve as a species, pathology fades in significance. In its place is an increased clarity and empathy about specific attachment needs and how to better respond to them. Acknowledgments We wish to thank Janet and Paul Mann from the Children’s Ark for their help in editing this chapter. They gave us a secure base from which we could write.

References Aber, J. L., Slade, A., Berger, B., Bresgi, I., & Kaplan, M. (1985). The Parent Development Interview. Unpublished manuscript, City University of New York. Ainsworth, M. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the Strange Situation. Hillsdale, NJ: Erlbaum. Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation. New York: Basic Books. (Original work published 1969) Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss. New York: Basic Books. Bowlby, J. (1982). Attachment and loss: Vol. 1. Attachment. New York: Basic Books. Britner, P. A., Marvin, R. S., & Pianta, R. C. (2005).

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Development and preliminary validation of the caregiving behavior system: Association with child attachment classification in the preschool Strange Situation. Attachment and Human Development, 7, 83–102. Carlson, E. A., & Sroufe, L. A. (1995). Contribution of attachment theory to developmental psychopathology. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Vol. 1. Theory and methods (pp. 581–617). New York: Wiley. Cassidy, J. (1994). Emotion regulation: Influences of attachment relationships. In N. Fox (Ed.), The development of emotion regulation (pp.  73– 134). Monographs of the Society for Research in Child Development, Vol. 59. Chicago: Society for Research in Child Development. Cassidy, J., & Marvin, R. S. (1992). Attachment organization in preschool children: Procedures and coding manual. Unpublished manual, University of Virginia, Charlottesville, VA. Cassidy, J., & Mohr, J. (2001). Unsolvable fear, trauma, and psychopathology: Theory, research, and clinical considerations related to dis­organized attachment across the life span. Clinical Psychology: Science and Practice, 8, 275–298. Cooper, G., Hoffman, K., Marvin, R., & Powell, B. (1999). The Circle of Security Interview. Unpublished manuscript, Marycliff Institute, Spokane, WA. Cooper, G., Hoffman, K., Powell, B., & Marvin, R. (2005). The Circle of Security intervention: Differential diagnosis and differential treatment. In L. J. Berlin, Y. Ziv, L. M. Amaya-­Jackson, & M. T. Greenberg (Eds.), Enhancing early attachments: Theory, research, intervention, and policy (pp. 127–151). New York: Guilford Press. Fonagy, P., Steele, H., & Steele, M. (1991). Maternal representations of attachment during pregnancy predict the organization of infant–­mother attachment at one year of age. Child Development, 62, 891–905. Fonagy, P., Steele, M., Steele, H., & Target, M. (1997). Reflective-­functioning manual, Version 4.1, for application to Adult Attachment Interviews. Unpublished coding manual, University of London. Fraiberg, S. H., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problem of impaired mother–­infant relationships. Journal of the American Academy of Child Psychiatry, 14, 387–422. George, C., Kaplan, N., & Main, M. (1996). The Adult Attachment Interview, Third Edition. Unpublished manuscript, University of California, Berkeley. Goldman, D. (1995). Emotional intelligence: Why it can matter more than IQ. New York: Bantam Books. Hoffman, K., Cooper, G., Marvin, R., & Powell , B. (1997). Seeing with Joey. Unpublished manuscript, Marycliff Institute, Spokane, WA.

Hoffman, K., Marvin, R., Cooper, G., & Powell, B. (2006). Changing toddlers’ and preschoolers’ attachment classifications: The Circle of Security intervention. Journal of Consulting and Clinical Psychology, 74(6), 1017–1026. Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York: Aronson. Kobak, R., Cassidy, J., Lyons-Ruth, K., & Ziv, Y. (2006). Attachment and developmental psychopathology. In D. Cicchetti (Ed.), Developmental psychopathology (2nd ed., pp.  333–369). New York: Wiley. Kohut, H. (1971). The analysis of the self. New York: International Universities Press. Lyons-Ruth, K., Bronfman, E., & Gwendolyn, A. (1999). A relational diathesis model of hostile–­ helpless states of mind. In M. Solomon & C. George (Eds.), Attachment disorganization (pp. 33–71). New York: Guilford Press. Lyons-Ruth, K., & members of the Change Process Study Group. (1998). Implicit relational knowing: its role in development and psychoanalytic treatment. Infant Mental Health Journal, 19, 282–289. Main, M. (1981). Avoidance in the service of attachment: A working paper. In K. Immelmann, G. Barlow, M. Main, & L. Petrinovitch (Eds.), Behavioral development: The Bielefeld interdisciplinary project (pp.  651–693). New York: Cambridge University Press. Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M. T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp.  121–160). Chicago: University of Chicago Press. Marvin, R. S., & Britner, P. A. (1995). A classification system for parental caregiving behavior patterns in the preschool Strange Situation. Unpublished classification manual, University of Virginia, Charlottesville, VA. Marvin, R. S., Cooper, G., Hoffman, K., & Powell, B. (2002). The Circle of Security project: Attachment-based intervention with caregiver–­ preschool child dyads. Attachment and Human Development, 4, 107–124. Masterson, J. (1976). The psychotherapy of the borderline adult. New York: Brunner/Mazel. Masterson, J., & Klein, R. (Eds.). (1995). The disorders of the self: New therapeutic horizons— The Masterson approach. New York: Brunner/ Mazel. Moss, E., Cyr, C., Bureau, J.-F., Tarabulsy, G. M., & Dubois-­Comtois, K. (2005). Stability of attachment during the preschool period. Developmental Psychology, 41, 773–783. Powell, B., Cooper, G., Hoffman, K., & Marvin, R. (2007). The Circle of Security project: A case study. In D. Oppenheim & D. Goldsmith (Eds.),  Clinical application of attachment theory: Bridging the gap between theory, research, and practice. New York: Guilford Press.



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Schore, A. (2003). Affect regulation and repair of the self. New York: Norton. Schore, A. (2003). Affect dysregulation and disorders of the self. New York: Norton. Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York: Guilford Press. Sroufe, L. A., Egeland, B., Carlson, E. A., & Collins, W. A. (2005). The development of the person: The Minnesota Study of Risk and Adaptation from birth to adulthood. New York: Guilford Press. van IJzendoorn, M. H., Schuengel, C., & Bakermans­K ranenburg, M. J. (1999). Disorganized attach-

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ment in early childhood: Meta-­analysis of precursors, concomitants, and sequelae. Development and Psychopathology, 11, 225–249. Weinfield, N. S., Whaley, G. J. L., & Egeland, B. (2004). Continuity, discontinuity, and coherence in attachment from infancy to late adolescence: Sequelae of organization and disorganization. Attachment and Human Development, 6, 73–97. Winnicott, C., Sheperd, R., & Madeleine, D. (1989). D.W. Winnicott: Psycho-­analytic explorations. Cambridge, MA: Harvard University Press. Winnicott, D. W. (1965). The maturational processes and the facilitating environment. London: Hogarth Press.

Chapter 29

Principles of Family Therapy in Infancy Nicolas Favez France Frascarolo Miri Keren Elisabeth Fivaz-­Depeursinge

T

he nuclear family, comprising the father, mother, and child, constitutes the basic social environment in which the child develops and learns his or her social skills (Parke & Buriel, 1998). Despite this established fact, models of early intervention have often favored interventions centered on the mother–­infant dyad, partly because the relationship to the mother has been theoretically conceptualized as the most important, and partly due to the difficulty of involving fathers in therapeutic processes. Nevertheless, there is increasing clinical and research evidence emphasizing the family triad as a unit in its own right, playing a specific role in the child’s development and constituting a promising and effective therapeutic level of intervention. In this chapter we present a structured method of assessing family functioning that is intended to guide the intervention. We begin by reviewing research on family relations as the child’s context of development as well as by briefly mentioning evidence-based practice in the field of family therapy.

THE CASE FOR FAMILY-LEVEL MECHANISMS IN INFANCY As soon as she is born, the baby is involved in a complex network of relations: first of

all with the mother, who is the person with whom the baby will interact the most, according to the most common model of role distribution in occidental societies (see Cowan & Cowan, 1992), then with the father, with possible brothers and sisters—not to mention all the relationships outside the family unit, such as those with the grandparents and the whole of the extended family. This network is both the environment that will influence the child’s socioemotional development and the one into which the child must be integrated. Therefore, a reciprocal adaptation takes place that will condition most of the child’s, and her family’s, emotional well-being, as well as development. In a structuralist perspective, the network of family relations can be analyzed in terms of systems and subsystems that are hierarchically organized and interrelated (Minuchin, 1985). The child is member of both the dyadic (mother–child, father–child) and the triadic (father–­mother–child) systems. Before becoming parents, the spouses constitute a marital couple that forms a system in itself. When the first child is born, the complexity of this system increases greatly: The mother–­ father–baby triad constitutes a familial system, which subdivides into two parent–child subsystems, a marital subsystem, and one system specific to the relation between the parents centered on the child (i.e., the co468



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parental system; Minuchin, 1974). These subsystems are both linked together and autonomous; they are interdependent but, from the child’s point of view, each forms a specific relational universe, and each has received attention from developmentalists.

Parent–Child Relationships As noted, the traditional emphasis has been on the mother–child relationship. A great number of research and clinical studies have shown how much the mental state of the mother, her parenting “aptitudes,” and the child’s development are intricately connected. Two levels have been investigated. First, interactions observed during naturalistic observations, which initially allowed descriptions of the “anatomy” of ordinary interactions (see Brazelton, Koslowski, & Main’s classic works on the subject, 1974), and deviations in these interactions depending on a whole set of variables derived from mother or child. A second level studied is that of the mother’s representations (before or after birth), which have been correlated with her sensitivity and responsiveness in the interaction (see, e.g., Benoit, Zeanah, Parker, Nicholson, & Coolbear, 1997). Clinicians’ interest rapidly turned toward the systemic properties of this mother–­infant relationship; that is, they no longer looked for pathology in the individual, per se, but diagnosed the relationship itself as an emerging property (Anders, 1989; Stern, 1977). The relationship’s disturbances were then identified as the main mediating variable by which emotional difficulties or a psychopathology affecting the mother would have an impact on the child (e.g., effect sizes between 0.53 and 0.60 in cases of mother’s depression; see Goodman & Gotlib, 1999; Tatano Beck, 1999). As a prelude to interest shown for the early triad, a number of works have emphasized the specificity of the relationship with the father for the child’s development, whether it be normal (see Lamb, 1996; Phares, Duhig, & Watkins, 2002) or affected by paternal pathology. Roughly five times as many studies have been devoted to maternal pathology, but a meta-­analysis highlighted a significant effect size (between 0.28 and 0.32) of fathers’ degree of health on the child’s development. Interestingly, the type of predicted child psychopathology is

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different according to the parent: Difficulties with the father are linked more closely to externalizing symptoms, whereas troubles with the mother are linked more to internalizing symptoms (Connell & Goodman, 2002). Finally, indications of triangular processes are to be found in the recognized role played (or not) by the father as a support when the mother is in difficulty; thus, report by the mother of paternal support, for example, in the case of postpartum depression, is one of the best predictors of the link between the mother’s trouble and the child’s development; the support provided by the father plays the role of moderating factor (Bost, Cox, Burchinal, & Payne, 2002). To establish how both parents have an impact on the child’s development, their actions need to be considered jointly, not separately. The parent–child dyads are not isolated (even in the case of a divorce) and influence one another mutually, just as the relationship between the parents influences the relations with the child (Emery, Fincham, & Cummings, 1992).

The Marital Relationship Many of the first studies taking into account the relationship between the parents and its influence on the child focused on the impact of the transition to parenthood on the marital relationship. Special attention has been devoted to an aspect of this relation: conflict management in the marital couple and the impact of marital conflict on the child’s development—the perinatal period being one of high risk for tension in the parental couple. Indeed, during the perinatal period, exchanges between parents become more instrumental, with fewer emotional exchanges directed to one another; they are centered on the child, on the care she has to receive, and the organization of everyday life (Cowan & Cowan, 1992; McHale, 2007). This shift toward predominantly instrumental communication often reduces marital satisfaction, which can last a year or two and then fade, but which also can develop into a sustained conflict—­especially if the parents already had a tense or conflicted relationship before the child’s conception (Fearnley Shapiro, Gottman, & Carrère, 2000; Frosch, Mangelsdorf, & McHale, 1998; Heinicke &

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Guthrie, 1996; Katz & Gottman, 1991). The quality of the marital relationship is the best predictor of whether this decreased communication becomes a sustained conflict. Lewis (1988a), for example, described “marital competence” as partners’ ability to communicate emotions openly, to express warmth to each other, and to resolve disagreements in an open manner, with satisfactory outcomes for both. This competence seems clearly related to the capacity to adjust to parenthood (Lewis, 1988b). Moreover, the expectancies each parent develops toward the other “partner-as-­parent” also play an important role. The violation of those expectancies once the child is born results in a deterioration of the marital relationship, as in the case where the mother expects more involvement in child care from the father (McHale, Lauretti, Talbot, & Pouquette, 2002; Van Egeren, 2003). The deterioration of the relationship between the spouses increases the probability of (1) disrupting the child’s capacity to adapt socially and (2) of the appearance of symptoms. Two processes of influence of the parental conflicts on the child’s psychological development have been described. According to Bandura’s social learning theory (1973), there is first a direct effect of the marital conflict on the child, who learns disruptive behaviors via vicarious learning—that is, by seeing his parents engage in hostile and aggressive behaviors and imitating them. Moreover, parents in conflict do not provide to the child the “emotional security” necessary for her to regulate her emotions; consequently, the child may intervene directly in the conflict to tone it down (acting as a go-­between), or respond by withdrawal—by not engaging in social relationships so as not to be confronted with potentially negative emotions (Davies, Cummings, & Winter, 2004; Davies & Forman, 2002; Davies, Harold, Goeke-Morey, & Cummings, 2002; Gottman & Katz, 2002). Even in infants, exposure to an unresolved conflict between the parents is registered via physiological dysregulations (e.g., atypical vagal regulation) and a tendency to withdraw in situations in which the child is confronted with something new (Crockenberg, Leerkes, & Lekka, 2007). The second effect is indirect; parenting is affected by the disruptions in the parent–­

parent relationship, a phenomenon called the “spillover effect” (Erel & Burman, 1995). The parenting of conflicting partners is typically irascible, unresponsive, markedly low in warmth and emotional availability, rejecting and controlling, with little setting of boundaries—all of which leads the child to adopt quick-­tempered and noncompliant behavior, with his parents as with his peers (Davies et al., 2002; Webster-­Stratton & Hammond, 1999). The conflict not only modifies the parents’ behavior but also their representations of the child via a “negative halo” effect. That is, the child is seen by the parents as more difficult than she is, according to external informant reports, which in turn leads the parents to respond to her as a difficult child (Katz & Gottman, 1991, 1996). The spillover effect has been clearly demonstrated (effect size = 0.46 according to Erel & Burman’s meta-­analysis, 1995) during infancy as well (Crockenberg & Leerkes, 2003a). However, the impact of the marital conflict on the child seems to concern mostly adaptation problems rather than the development of psychopathology (average effect size = 0.16; see Reid & Crisafulli, 1990).

Coparenting The coparenting alliance (Abidin, 1992) points to the specific function of the parents’ relationship in relation to the child and her needs. First suggested by Minuchin (1974), using the term “parental subsystem,” the coparenting alliance forms by differentiating from the marital system, while to carry out the tasks of the child’s socialization. Coparenting is intimately linked to the marital relationship (Frosch et al., 1998; Margolin, Gordis, & John, 2001), even though the two subsystems are conceptually and functionally distinct—the coparental relationship outlives the marital relationship at the time of a divorce, for example (Cowan & McHale, 1996; Schoppe-­Sullivan, Mangelsdorf, Frosch, & McHale, 2004). The relation between the two is circular: Marital satisfaction prior to the birth predicts a cooperative coparenting alliance after the birth (Van Egeren, 2003), but coparenting has, in turn, an impact on the marital relationship, since it becomes one of the best predictors of recovery from the phase of marital dissatisfaction following the birth (Belsky & Hsieh,



29. Principles of Family Therapy in Infancy

1998; Schoppe-­Sullivan et al., 2004). Cooperation and solidarity between the adults while parenting constitute the driving force behind coparenting, which is then marked by emotionally positive and supportive exchanges between the spouses, be it when the whole family is present or, when the child reaches the verbal age, by the parent’s promotion of the absent parent to the child and of family integrity (McHale, 1997). When conflict has invaded the coparental relationship as well, several outcomes are possible. First, hostile coparenting may occur in which each parent openly contradicts the decisions made by the other parent (overt conflict) or speaks ill of the other parent, undermining the absent parent’s image in the child’s mind (covert conflict). Second, discrepancies in coparental involvement may manifest themselves by one of the parent’s withdrawal from family life (often the father). A hostile coparenting during the early years gives inconsistent signals to the child, who in turn experiences uncertainty and unsteadiness. The child has to cope with contradictory or even paradoxical messages about relationships (Gable, Crnic, & Belsky, 1994), which creates a cognitive and emotional incongruence that is predictive of the appearance of externalizing symptoms (aggressive behaviors) at 4 years old, as reported by teachers (McHale & Fivaz­Depeursinge, 1999; McHale & Rasmussen, 1998; Schoppe, Mangelsdorf, & Frosch, 2001). In the case of a parent’s withdrawal, the child experiences an emotional “emptiness” predictive of internalizing symptoms such as anxiety and insecurity—­withdrawal being perceived as a way of facing conflict. These changes in coparenting undermine the child’s sense of family integrity and the confidence he or she can put in the family as a secure place (McHale, Kuersten, & Lauretti, 1996). A third type of coparenting modification is called “child-at-­center” (McHale et al., 2002), which occurs when exchanges between parents have dwindled and now have a pleasant surface but with forced tone to the emotions expressed. The dyadic parent– child interactions can still be warm, but there are few genuine interactions between the parents. Assessment of separate dyads may not allow detection of anything preoccupying in terms of social relationships,

471

whereas the family, seen as a whole, shows a lack of positive emotions and pleasure at being together—which can be a cause of concern. By jointly assessing the marital relationship (as self-­reported satisfaction or in conflict discussion tasks) and coparenting (the image each parent has of the other as a parent or the support they provide for each other in the interaction with the child), studies have shown that the link between the different forms of coparental conflict and the presence of symptoms in the child holds even after variables related to the marital relationship are controlled (Frosch, Mangelsdorf, & McHale, 2000; McHale, 1995). Finally, coparenting is even predictable during pregnancy, because it is linked to the parents’ capacity to imagine the family triad, or their capacity to symbolically enact in play a threesome interaction before the birth of the baby (Bürgin & von Klitzing, 1995; Carneiro, Corboz-­Warnery, & Fivaz-­Depeursinge, 2006; Van Egeren, 2003, 2004). The child’s contribution to the coparental relationship then remains an open question; the most widespread measures of coparenting or of the parental alliance pertain to the parents’ relationship to the baby or to the parents’ interactions in the baby’s presence, but do not usually include the baby herself (Schoppe-­Sullivan et al., 2004). It is of interest to highlight that McHale noted that clinicians-­observers tend to rate more severely the same coparenting violation if it affects the child than if it doesn’t. This observation implies that it is essential to take the child into account while assessing family interactions, since the meaning attributed to a coparental behavior will vary according to its effect on the child (McHale & Alberts, 2003; Van Egeren & Hawkins, 2004).

The Child’s Contributions The child’s contribution can be assessed in two ways: by focusing either on her capacities or on the individual differences in terms of gender or temperament (McHale, Kazali, et al., 2004; McHale, Kuersten-Hogan, & Rao, 2004). Increasing evidence speaks in favor of a child’s capacity to manage multiperson interactions as early as the first months of life. Recent findings from researchers in differ-

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V. INTERVENTION

ent countries converge to show that, under certain conditions, infants as young as 3 months have attentional, communicative, and emotional competencies that allow them to exhibit some joint-­attention behaviors, including gaze following, triangular sharing of affects, and precursors of social referencing (Fivaz-­Depeursinge & Favez, 2006; Fivaz-­Depeursinge, Favez, & Frascarolo, 2004; Fivaz-­Depeursinge, Favez, Lavanchy, de Noni, & Frascarolo, 2005; Tremblay & Rovira, 2007). Moreover, studies taking the child’s temperament into account have shown that the disposition to regulate emotions may have an effect on parenting. Parents of a “difficult child,” as assessed by observational measures, may develop a style of parenting that is all the more responsive during the first months, but in the end, their unsuccessful efforts to calm the child may lead them to show a style of parenting that is colder and more distant (Crockenberg & Smith, 1982; van den Boom, 1994). This impact of temperament, however, seems to be moderated by several risk factors in the personalities of the parents, their socioeconomic status, and/ or the quality of their marital relationship before the birth of the baby (Crockenberg & Leerkes, 2003b; Schoppe-­Sullivan, Mangelsdorf, Brown, & Szewczyk Sokolowski, 2007). Parents whose marital relationship was satisfactory before the birth shows supportive coparenting at 3 months of a baby with a fussy and difficult temperament. On the other hand, if the marital relationship was difficult prior to the birth, the encounter with a difficult child can undermine coparenting. In our own study on the transition to parenthood in 51 normative families, we have reported that the child’s temperament reported by the mother at 3 months and the coparental family interactions during the pregnancy are the two best predictors of the quality of the triadic interactions at 18 months (Favez, Frascarolo, & Lavanchy, 2007). Results in this domain are somewhat inconclusive because of the methodological differences assessing temperament (i.e., “objective” assessment vs. parent-­reported questionnaire). The child’s gender also has an impact on family dynamics, although meta-­analyses do not reveal any marked differences (McHale, Crouter, & Whiteman, 2003). However,

when observing within-­family interactions, one can see individual differences appear according to the parents’ and children’s gender (Maccoby, 2003; McHale & Crouter, 2003). When the family structure lends itself well to the gender factor (i.e., two heterosexual parents and two children of different sex), each parent tends to spend more time with the same-sex child and carries out sex-typed activities with him or her (McHale & Crouter, 2003). Outlining the predominant relational factors of influence in the child’s social development is not easy; in fact, it seems unlikely that any one particular relationship could, by itself, modify the child’s development independent of the wider context. There is an abiding feature in the data we have reviewed: Each time we focus on one of the dyads that make up the family unit, we have found that the third partner influences or contributes to that dyad’s functioning. Together, all of these complex triangular interrelations between the subsystems are indications in favor of a direct family perspective, supplementing what has already been presented up to this point. However, all of the presented studies have had a tendency to highlight a cumulative effect of the various subsystems investigated, rather than a differential or specific effect. The coparental subsystem thus explains “more of the same variance” of the child’s development than what the marital subsystem can explain of it; it is still unclear if family-level phenomena have a specific effect or simply explain more of the same variance.

Family-Level Interventions Working with the triad, or the primary family unit, falls within the scope of a family approach. Family interventions are generally based on the assumption that a behavioral difficulty is linked to the patterns of relational behaviors of the social system in which it exists, and in the most noteworthy way within the family (Sexton & Alexander, 2002). Furthermore, an intervention directed at one family member will always have an impact on the other members—to the extent that a “positive” change in a child can be followed by a “negative” change in one of the parents, according to a homeostatic dynamic described by the classical systems



29. Principles of Family Therapy in Infancy

approaches (Jackson, 1965). The family intervention’s specificity, then, is to intervene not with individuals but in systems of relationships. Many studies have shown the effectiveness of family interventions (70% of treated cases do better than the control population) and report effect sizes between 0.47 and 0.53 (Carr, 2000; Sexton, Alexander, & Leigh Mease, 2004; Shadish et al., 1993). Most studies have assessed, as outcome, the symptomatic reduction of the child’s disorder(s) (either measured as a change in diagnosis or by symptom reduction on a dimensional checklist). Significant positive effects of family therapy were observed for, among others, conduct disorders, autism, aggression and noncompliance in attention-­deficit/hyperactivity disorder (ADHD), substance misuse, and eating disorders in children and adolescents (Cottrell & Boston, 2002; Kazdin, 2000; Pinsof, Wynne, & Hambright, 1996). Historically, though, family therapy has shown little interest in infancy. In their review of literature on empirically validated treatments, Sexton et al. (2004) counted only two studies out of sixty concerning children under 3 years old. Clearly more data are needed in this field.

THE LAUSANNE TRILOGUE PLAY PARADIGM Observation and assessment of family interactions are very informative about family interaction patterns, and time-­limited but intensive evaluation of the family as an interacting group reveals core principles of a family’s functioning (McHale & Alberts, 2003; Minuchin, 1985). Before discussing the basic tenets of our method, we describe the observation paradigm of the Lausanne Trilogue Play (LTP), which is the core of family assessment and serves as a basic framework for all of the observational situations that we have developed. LTP allows the systematic observation of family interactions in a three-way relationship between the father, the mother, and the infant. The goal of LTP is that the three members of the family share moments of pleasure. The framework of LTP includes several possible interactional configurations that reproduce everyday configurations of threesome interactions (Corboz-­Warnery, Fivaz-

473

­ epeursinge, Gertsch Bettens, & Favez, D 1993): 1. One parent plays with the infant, while the other parent is the third party (2 + 1). 2. The parents reverse roles (2 + 1). 3. The three partners play together (3 together). 4. The parents interact with each other, while the infant is the third party (2 + 1). The parents sit on chairs arranged in a triangle, at a distance encouraging dialogue. These chairs cannot be moved. The infant is in a baby-­reclining chair that can be oriented toward one parent, toward the other, and between the two. The following instructions are given: “We ask you to play together as a family. You will settle the child in the seat and follow the directions for the four separate parts of the exercise. In the first part, one of you plays with the child, the other one being simply there. In the second part, roles are reversed. In the third part, you both play with the child together. In the last part you will talk a while together; it will be the child’s turn to be simply present.” The parents decide how long each part of the scenario is to last (the average duration during the first year is around 12 minutes for the entire game; Favez, Frascarolo, & Fivaz­Depeursinge, 2006). The design is adapted to the age; thus, after 12 months, the parents and child sit around a small round table with various toys are at hand (e.g., wooden blocks, animals, a dinner set, a small hairbrush, a car). The entire play is videotaped to be used later by the therapist. Variations of the situation have been developed for specific assessments. The prenatal LTP allows clinicians to assess how expecting parents can anticipate and enact in play the encounter with their baby, simulated by a doll; the instructions are the same as for the standard LTP (Carneiro et al., 2006). The still-face LTP allows the assessment of the child’s resources; specifically, the extent to which she can turn to engage the second parent when the other parent poses a still face (Fivaz-­Depeursinge et al., 2005). Finally, a revised version of LTP has been designed to systematically assess dyadic interactions versus triadic interactions. It is structured in

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V. INTERVENTION

five parts: (1) Parent 1 (P1) and infant play, and parent 2 (P2) is outside the room; (2) P2 comes in the room, sits on the second chair, and is “simply present” while P1 and infant continue to play; (3) the three play together; (4) P1 is “simply present” while P2 and infant play together; and (5) P1 leaves the room while P2 and infant continue to play. The setting of this LTP is otherwise the same as the classical LTP. The LTP situation restrains the interactions, and family members have to adapt their communication, verbal and mostly nonverbal, to the situation’s needs. It is, first and foremost, through bodily configurations that each family is able to implement an interaction context that both respects the instructions and allows an emotionally satisfying exchange between the partners. Take the first part of the LTP, for example. The parent who has to stay in the background faces a delicate situation: By the positioning of the chairs, he or she finds him- or herself sitting next to the other parent, who is as close to the baby as he or she, but at the same time signal that he or she is not available—which this parent often does by leaning against the back of the chair. The active parent generally leans forward to interact with the baby. The assessment is based mainly on these bodily configurations that the family adopts to carry out the different parts of the game and on the emotions expressed and shared between the partners. The change from one configuration to another inside a same-play session allows assessment of the way the family negotiates transitions and reorganizes itself after a change of configuration. This observation and assessment situation is also used for interventions in several ways. Based on the family’s interactive behaviors, direct intervention during the situation itself can be used to suggest alternative, nonproblematic patterns, or the information stemming from the situation can be used to prescribe rituals to be carried out at home between two sessions. In addition, video feedback can be used as a powerful way to enhance family experience of their threeway relationships by supporting awareness of positive and negative interactive patterns (Fivaz-­Depeursinge, Corboz-­Warnery, & Keren, 2004; McDonough, 1993). These interventions, while aimed at observable be-

haviors and interactive patterns, also may impact the partners’ representations and their intersubjective experience of threesome interactions (Stern, 1995).

A Specific Family-Level Relational Pattern To intervene with a family, a model of family functioning that leads to specification of the intervention’s goals is necessary. The systems approach is meant to be holistic. In a review of the contribution of dynamic systems theory to family therapy, Cox and Paley (1997) summarize the family’s systemic properties as follows: (1) wholeness—a whole is more than the sum of its parts and has properties that cannot be understood from the combination of the characteristic of each part; (2) hierarchical structure—each system is composed of subsystems that are systems of their own; (3) adaptive self-­stabilization—­homeostatic features of the system that compensate for changing conditions in the environment by making coordinated changes in the internal working of the system; and (4) adaptive self­organization—­capacity of systems to reorganize in response to changes from external forces acting on internal constraints. According to the systems approach, the clinician focuses on the family’s structure (the interrelation of its members) and on its adaptability, namely, its capacity to change in response to internal and external demands. The balance between stability and change determines the functional aspect of the family system, that is, the system’s capacity to promote a stable structure that includes all its members, who experience at least a minimal degree of cognitive congruence among them; in turn, this stability provides members an emotional security (Favez, Frascarolo, & Lavanchy, 2005; Wertheim, 1975) and a capacity to change in a flexible and adaptive way. We have conceptualized the family structure in terms of alliances; that is, the degree of coordination that the family can achieve while carrying out a task (Fivaz-­Depeursinge & Corboz-­Warnery, 1999). The alliance depends on four interactive functions: participation, organization, focalization, and affect sharing. These functions are hierarchically embedded; each is a necessary condition for the achievement of the next. All family members have to participate in the activ-



29. Principles of Family Therapy in Infancy

ity so that the roles can be distributed (e.g., who will be the game’s “animator”) and the interaction can be organized toward the task. Once the roles are distributed among all the participants, everyone’s attention has to be focused on the same theme in order to co-­construct the activity. The joint focus promotes the sharing of emotions between family members (Frascarolo, Favez, Carneiro, & Fivaz-­Depeursinge, 2004). The degree to which these functions are, or are not, achieved indicates several types of alliances: disorganized, conflicted, and cooperative. The assessment of the alliance is an integral part of the family intervention because it allows evaluation of the triadic relationships and determines the intervention’s targets (Fivaz-­Depeursinge et al., 2004; Keren, Feldman, & Tyano, 2001; Ron-Miara, Keren, & Sharf, 2006).

Assessing Participation The prerequisite of the first function, the most basic one, is that all family members have to take part in the action. Operationally, the clinician assesses to what extent the flaws in the participation take the form of exclusion patterns. In the LTP’s setting, participation implies that the baby be prepared to interact (e.g., by a correct positioning, by choosing to play when the baby is in an appropriate state of wakefulness) and that the parents give signals of their availability to interact and be responsive to those given by the baby. The inability to carry out a threeway interaction or the systematic exclusion of one family member leads to a “disorganized” type of alliance. A parent may exclude him- or herself from the interaction either by turning away from it or by being emotionally absent; stonewalling is one example. Or, a dyad may leave no room for the third partner. For example, a mother’s extreme gatekeeping with the child may systematically leave the father aside by not allowing the 2 + 1 between the father and the baby to unfold. Finally, both parents may exclude the baby by not placing her in optimal conditions to interact with them (e.g., by seeking the baby’s attention at inadequate moments, by not settling her in an appropriate position, or by overstimulating her, which will cause the baby to withdraw).

475

The parents may even seem coordinated and “work” in the same direction, but the baby’s exclusion prevents the achievement of a truly triadic interaction. Agreement between parents is not sufficient for the assessment; we have to see how the child is included in the interaction. Exclusively dyadic centerings—­interactions occur but never on a triadic level—­constitute a form of disorganization through exclusion. In this case, the intervention may be aimed directly at the exclusion, at a psychoeducational level, for example. In extreme cases, the family is incapable of organizing itself on whatever level; the simple fact of all three ending up together induces a degree of stress that overwhelms the partners’ resources, and no pattern of interaction, even dyadic, is detectable. In these situations, the alliance is said to be “chaotic disorganized.” The partners interact in a confused context that leaves the roles undefined and does not allow the implementation of shared activities. Moreover, the stimulations offered to the child are not adjusted to his or her developmental skills. Despite their efforts, parents are unable to create a comfortable context for the child and are unable to respond adequately to his behaviors and affect signals. This kind of alliance is observed in families with serious parental psychopathology. The child can be triangulated, caught in a role reversal, or withdraw into him- or herself. The development of his or her capacities to interact in a threesome is hindered, put in the service of the family’s homeostasis. For instance, the child may multiply “triangular bids” (rapid shifts of the child’s attention between the parents) as a strategy to reconcile the parents (Fivaz-­Depeursinge, Frascarolo, Lopes, Dimitrova, & Favez, 2007).

Assessing Organization When all members of the triad participate in the interaction, the family has to organize itself following certain rules (Jackson, 1965) that prescribe everyone’s behaviors and ensure differentiated roles. In some families, even though all members are included in the interaction, interferences or competition appears. Parents then may have difficulty in coordinating themselves, negotiating activities together, and cooperating. For example,

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each parent intervenes in the other parent’s activities, not contingent on the given instructions; in the 2 + 1, the third-party parent makes gestures and facial expressions to attract the baby’s attention, even though it is not his or her turn to play. With this kind of intervention, the parent breaks the contact in the relationship between his or her spouse and the child. These competing and uncoordinated activities give the impression that each parent tries to attract the child’s attention and enter into a special relationship with her, to the detriment of the exchange between the other parent and the child. Interactions marked by a difficulty in dividing the roles between spouses reveal a conflicted alliance. Conflict may appear first in a “covert conflict” configuration. Parents show apparent ease, but often they do pseudo-­positive comments to each other. These can take the form of advice giving, whereby one parent regularly intervenes to tell the other what she or he is supposed to do with the child. Such recurring remarks disrupt the relational exchange between the parent involved and the child, and although positive in appearance only, the remarks disqualify the parent to whom they are directed. These remarks may be accompanied by inauthentic laughs. Both parents may also address critical remarks at the child, which typically emerges after a disagreement between the parents that has not been resolved. The observer then understands that criticizing the child has the function of bringing the partners closer, allowing them to find themselves and to feel like a team. This attitude reveals a hidden conflict in the couple. Conflict also may be “overt.” Here, the verbal comments are openly negative and critical remarks are exchanged between the parents; they may have an argument in front of the child and even interrupt the game to continue their dispute. The conflict manifests itself at a nonverbal level as well; this may lead to competition for the child’s attention, each parent trying to outdo the other parent’s stimulations to the child. In this context, the infant’s triangular bids to the parents are ignored or misinterpreted; each parent may, for example, consider an infant glance at him or her as a sign of preference or exclusive complicity.

Assessing Focalization Once all three partners are included and their roles distributed and respected, their ability to co-construct an activity is assessed. Sometimes accomplishing joint activities is a struggle. The co-construction may involve some false starts, and the emotions may be a bit forced. The lack of creativity produces games that are quite flat emotionally, even though empathy is present among the family members. Small mistakes, inevitable in any communication, are repaired more slowly and provoke a tense atmosphere, the task developing in a fitful way. The transitions between different relational configurations may confuse members and break the flow. Thus the task unfolds with ups and downs. Interactions globally characterized by a systemic cohesion but lacking fluidity in the construction of the games and in the pleasure expressed at being together indicate a “cooperative stressed” alliance. Here, intervention is easier compared to the two preceding cases; the therapist or consultant can encourage the parent(s), either by direct intervention or by using the video feedback, to follow the child’s initiatives, persist in the initiated games, and let him- or herself be more animated.

Assessing Affect Sharing The fourth function assesses to what extent the partners are emotionally attuned. This does not apply to positive emotions only, even if, during a standard play sequence, positive emotions are expected to predominate. What is assessed here is the extent to which the affects circulate in the family, and if expressed negative emotions are acknowledged and regulated during the family interaction. Ideally, the alliance is classified as “harmonious cooperative.” The determination of the alliances according to the functions is summarized in Table 29.1.

Integrating the Family-Level Relational Assessment The evaluation of the four functions involves conceptualizing an interaction with the following characteristics in LTP: each partner’s participation in the game’s elaboration; respecting the successive roles required



29. Principles of Family Therapy in Infancy

477

TABLE 29.1. Family Alliances According to Interactive Functions Disorganized

Conflicted

Cooperative +

Participation

(Chaotic)–/–(Exclusive)

+

Organization

–

(Overt)–/+ (Covert)

+

Focalization

–

–

(Stressed)–/+

Affect sharing

–

–

+(Harmonious)

Problematic

by the instructions, with a fluid transition between the different configurations; family members stay involved in the activities and enrich them as they go along; and the activity carried out is sustained, coherent, and consistent, with a narrative outline. The global emotional atmosphere is warm and empathic. The partners are emotionally in touch with one another, as evidenced by their facial and vocal expressions. If the child isn’t collaborating much or expresses negative emotions, the parents support him or her in an adequate way that allows the baby to self-­regulate. Generally, positive affects are shared, observable in mutual smiles and light marks of humor. The assessment of the alliance is carried out by trained clinicians, with the help of validated measuring tools, such as the Family Alliance Assessment Scales (Favez, Lavanchy, & Cuennet, 2004). Assessment can thus be used to both clinical and research ends. This appreciation has allowed us to highlight, in the context of our longitudinal research with ordinary families, that the family alliance is very stable in time, from the fifth month of pregnancy (alliance measured by the prenatal LTP) to the end of the second year and until the firstborn child has reached the age of 5 years old. This data confirm that the alliance constitutes a stable relational context in which the child learns social skills more or less favorable to his or her emotional development (Carneiro et al., 2006; Favez, Frascarolo, & Fivaz-­Depeursinge, 2006; Favez, Frascarolo, et al., 2006). Problematic alliances are predominant in families referred for parental psychopathology (e.g., postpartum depression), and the alliance assessment distinguishes referred and nonreferred families (Fivaz-­Depeursinge, Frascarolo, & Lob-­I zraelski, 2000; McHale & Fivaz-­Depeursinge, 1999).

Good enough

Case Examples Next we review two examples of the use of the LTP paradigm and family assessment. The first case is a longitudinal preventive follow-up by the Centre of Family Studies (Department of Psychiatry, University of Lausanne), in Switzerland, the other case is an intervention for an oppositional disorder in a 2-year-old child in an infant health community center in Israel.

Preventive Intervention in a Research Protocol An important aspect of the LTP paradigm is that its clinical and research uses are intertwined. The objective assessment of the family alliance during LTP goes hand in hand with the intersubjective experience the family creates out of how they work together and how they share their mind states. This experience is enhanced through videofeedback. Thus, depending on the situation, assessment is intervention, be it developmental, preventive, or therapeutic. We illustrate this process with the example of a family at psychiatric risk, which we followed in the context of our longitudinal research protocol at the Centre of Family Studies. Both parents were treated in the community for serious psychopathology. Pregnant with their first child, they were referred to our study as a preventive measure. They signed a research contract, whereby they provided us with data for our studies, and we provided them with expert feedback. They were interviewed about their families of origin and their representations of their family-to-be during the sixth month of pregnancy. Their coparenting alliance in formation was assessed in the prenatal LTP.

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V. INTERVENTION

The birth of their baby girl went without complication. Their interactions as a triad and as separate dyads were observed at the center when their daughter was 11 weeks, 9 months, and 18 months old. A video feedback session took place between sessions. Below, we compare similar sequences of LTP across observation sessions and summarize the main points brought to the parents’ attention during the video feedbacks.

11-Week LTP The sequence begins at the end of the mother’s play, with father as third party. The first priority was to assess whether the three partners were included in the interaction or whether one or the other was excluded, and whether they respected their roles: mother and baby actively engaged and father as participant observer. Then, were they all affectively in touch with each other? In particular, was the baby sharing her experience with both parents by means of triangular bids and were the parents validating these bids ? We observed the following pattern. The engagement between mother and baby was intense. In fact, the baby was fascinated by the mother, who made an expert show, so expert that the baby hardly had space for responding and even less for taking turns. She remained focused on her mother, in spite of her father’s intrusion in the mother–baby dyadic space: Father leaned forward, commenting and resonating to the interaction to an extreme degree. He interrupted the mother in the middle of a game to proceed to the 3-together part. For a while they played in a coordinated and very animated way, with the baby sharing her delight with both of them, until she became overwhelmed with the rapid tempo and lack of pauses and began rubbing her face. The parents perceived the signal, and the father slowed down the tempo for an instant. But instead of letting the baby fully recover, the parents joined together to animate her again, quickly rising to an even higher level of stimulation. Surprisingly, the baby adjusted, and they went on and on in that manner. Comment.  Although the three partners were included in the interaction—a resource—the distribution of roles was prob-

lematic: In the 2 + 1, the father repeatedly intruded in the mother–baby space, including at the time of the transition to the 3-together, which he imposed without negotiation. It appeared that the more the father intruded, the more mother and baby intensified their interaction, as if to strengthen the boundary against the father to be able to be together as a twosome. The baby never turned to the father to share her experience with him, as one would expect her to do once or twice at that age. But there was no overt conflict about that between the parents. In the 3-together, the parents succeeded in playing a coordinated, joint game with the baby, and the baby shared her pleasure with both of them through triangular bids. However, the parents stretched their interactional demands beyond the capacities of a young infant, persisting in spite of noticing her (admittedly) weak signals to downregulate. The observer wondered at the baby’s amazing capacities, verging on hypervigilance, to adjust to this speedy level of stimulation. Video Feedback.  Upon careful reviewing of the LTP and assessment by an independent expert, the clinical researchers reviewed the tape with the parents, prepared to show them first their strengths, particularly their intuitive parenting behaviors and the capacities of their child (her alertness and ability to communicate with both of them). The parents were delighted, open, and also motivated to learn about their weaknesses, so that the problem of intrusion and overstimulation also could be approached. Briefly, the take-home message was that they had everything they needed to be good-­enough parents, and baby had everything she needed to be a good-­enough baby. But the parents’ very wish to be good prevented them from noticing when their baby was tired and needed to be on her own, even though she tended to accommodate to her parents’ styles and stretch her resources to meet their expectations. The parents felt relieved. The father explained that whenever the baby gave a negative signal, he felt he was not good enough and tried to do more. Mother went along, though she remained more reserved. We strongly recommended that they give themselves a break and try to follow the signals of their baby.



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9-Month LTP During the 2 + 1 between mother and baby, we observed clear differences compared to the 11 weeks LTP. Firstly, instead of leaning forward, the father sat up, allowing interactive space for the mother–baby dyad. Secondly, true to his style, the father interfered with the mother at some point, but the mother playfully pointed it out to him—a repair action. Thirdly, it was the mother who took the initiative of transitioning to the 3-together. Fourthly, the mother also gave more space and time to the baby to take some initiatives. For instance, the baby initiated a game of gestures or showed her interest in her seat and the mother followed her for brief moments. So was it also in the father–baby play part, so much so that he tended to overdo it. But as the parents proceeded to the 3-together, some disorganization appeared. The baby showed that she was tired, and the mother changed the inclination of the seat, but both father and baby protested. Finally, the father took over to soothe baby as the mother sat back. During the 3-together, the parents mostly took turns but, despite their efforts, did not succeed in coordinating to create real 3-together games. Comment.  In sum, the boundaries between the parents and with baby were clearer in the 2 + 1 than at 3 months. However, competition between the parents had become overt in the 3-together, and the baby was also allowed to protest. It appeared that these processes could be related and part of a positive, though incomplete, change. Video Feedback.  The parents reported that their family life was easier, that they allowed themselves to let baby be on her own and that she enjoyed it at times. The explicit take home message was to go on. As we reviewed the tape together, the parents showed their awareness of their competition and conflict, but the message about it remained implicit on our part. Between the 9 and 18 months session, the strengthening of the boundaries between parent–child + third party further exacerbated the marital conflict and the parents spontaneously asked for marital therapy. In sum, this family was able to use the resources offered by the clinical research

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context to progress towards better parental functioning. Their experience of having been effectively helped for their serious problems (both having been drug addicts and mother suffering bipolar disorder, among other difficulties) was essential in providing them with the trust necessary to build a family alliance as a threesome in the context of a positive working alliance with the clinical researchers.

Understanding a Child’s Symptom Here, we briefly outline the therapeutic assessment of a disorganized family alliance. It illustrates the model’s emphasis on implicit communication within the family and with the therapist, highlights the pattern of exclusion, and exemplifies the use of nonverbal probes for therapeutic assessment. The therapeutic assessment took place in three sessions: an unstructured session with the family, a session with the two parents, and a family session to plan the therapy. It is of note that the formal LTP procedure was not used in this case during the assessment; the basic elements for determining the family alliance were visible in the free triadic play session. Y, a 3-year-old girl, the only child of a young couple, was referred to a communitybased infant mental health unit near Tel-Aviv by a kibbutz developmental psychologist. The symptom of referral was an unusually strong refusal to interact with the father and to stay alone with him. Any kind of abuse had been ruled out. The parents had been married for 3 years and were well educated.

First Session (Parents and Child) The therapist invited the family to sit as they wished. The parents chose to sit on the carpet; the mother held Y inside her crossed legs and arms, while father sat on the far right side. Their affect was strikingly sad. The therapist then sat on the carpet, too, at an equal distance from the three of them. She began by inviting Y to play. Y made eye contact with her but declined to play, and at that point the father moved a bit closer to the mother and Y’s embraced dyad. None of them initiated a game, but they all focused on the therapist—­implicitly manifest-

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ing their need for help. Next, the therapist, still silent, took a soft ball, half making the gesture to send it to Y; Y stayed stuck to her mother. The mother did not encourage Y to “open up” to the therapist, the therapist sent the ball to the father. The father rolled it to Y. In response, Y smiled at him, took the ball, and gave it immediately to the mother. But the mother failed to follow suit, stopping the four-way interaction. She held Y tightly, looking even sadder. Comment.  The body formation the family initially adopted was at once revealing, as were their first moves. Y excluded her father; she was trapped in an enmeshed relation with her mother, in a disengaged one with her father, and she did not to engage with the therapist. Yet there were some clues of readiness for change: Not only was the family asking for help, but the father, on receiving the ball from the therapist, had readily rolled it back to Y, who in turn had given it to the mother. By stopping the game, the mother manifested resistance. Interestingly, by a simple move, the therapist was able to probe the resources and vulnerabilities in the family network; she would continue to do so in parallel with the dialogue she led with the parents. The therapist started the dialogue by asking the parents about the mother’s pregnancy with Y and the delivery. Of note, as the mother began telling about the traumatic delivery, she inadvertently opened her arms, thus letting go of Y. While listening to the mother, the therapist again tried to interest Y with a toy. This time, Y got up but stood close to her mother. She looked at the toy as if in conflict between keeping an eye on her mother and exploring the room. Neither Y nor her mother had looked at the father. The mother described at length her depressive reaction to the consequences of Y’s traumatic delivery: Y’s slow development and neurological deficits, including hypotonicity— later diagnosed as mild cerebral palsy (CP). When the mother’s eyes filled with tears, Y immediately came back to sit between her mother’s legs. The father, looking helpless, did not move nor speak. We noted other resources and vulnerabilities: As the mother found the therapist ready to listen to her, she let go of Y. Y stood up, but felt conflicted about letting go of her

mother and exploring, versus keeping watch over her mother—a role reversal function that she served, as confirmed when she returned to her crying mother. In contrast, the father acted helpless in the face of mother’s distress.

Second Session (Parents Only) In this session the therapist and the couple were able to explicitly discuss the implicit scenario that had played out during the first session, with references to the scenarios of the families of origin. The mother told about her wish to “be there all the time” for her daughter, unlike her experience of her mother at the kibbutz. She confided her basic lack of trust in others’ capacity to protect Y, including her husband’s. The father acknowledged feeling hurt by this lack of trust and had withdrawn even more from the caretaking of his daughter as a consequence.

Third Session (Family) On the basis of the previous discussion session, the therapist proposed triadic therapy. Interestingly, on hearing the therapist’s proposition, Y turned to her father, saying, “Daddy?” Then Y turned to her mother with an interrogative look, as if asking, “Are you okay with that plan too?” The therapist said to Y, “Dad and Mom will learn to play together with you, because they both love you very much and you need both of them.” In sum, the child’s exclusion of her father appeared different in the context of the family triangle. From Y’s perspective, it seemed to reflect a way of dealing with the unbearable anxiety of provoking conflict between her parents. But being treated by her mother as a vulnerable child also covered up the role reversal between them: substituting for her father in caring for her mother’s depression. From the parents’ perspective, their complaints about their child being the one who excluded one of them helped them cover up their conflict by projecting on her their own mutual exclusion. They excluded one another because of their lack of trust in each other. In the family structural model, this dynamic corresponds to a binding coalition, with one of the parents tied with the child against the other parent. This situation is not uncommon in referred cases, be it the



29. Principles of Family Therapy in Infancy

mother or the father who is excluded by the child. In this consultation, the family interaction during the free triadic play in the first session revealed the disorganized alliance: Not only was exclusion the symptom of referral, but it was vividly played out in the body formation the family members spontaneously adopted. Thus, as noted above, no formal LTP procedure was required to assess the family alliance. However, the formal procedure was used later, during the triadic therapy, as a therapeutic tool allowing the family to experience their three-way communication, to review it and elaborate on it via video feedback. This process often strengthens the therapeutic alliance because it is perceived by the parents as a “3-together” communicative experience with the therapist that conveys to them a feeling of mastery. It may be one of the factors fostering relatively rapid change. Indeed, based on our clinical experience, the combination of LTP with dyadic parent–child and parental therapeutic assessment sessions (Fivaz-­Depeursinge et al., 2004) seems to shorten the duration of the treatment (5 sessions vs. 12 usual dyadic and/or triadic unstructured, psychodynamic sessions). One may wish to use the formal LTP particularly in the assessment process of those families whose problem is not obvious after the first free play triadic session and when there is a gap between the severity of the reason for referral and the clinical understanding we get from the observation of nonstructured parent–­infant interactions. Such is the case with the often intriguing symptom of trichotillomania in very young infants, wherein the family assessment uncovers a latent disturbed family emotional communication (Keren, Ron-Miara, Feldman, & Tyano, 2006).

CONCLUSIONS Developmental research findings have shown the importance of considering the triadic family level to comprehensively understand the child’s development. Research in psychotherapy shows that intervention at a family level is beneficial; however, data about the early mother–­father–infant family triad are missing, as well as studies on the processes responsible for therapeutic change.

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The model we have presented is a first step in that direction. Based upon observable interactions, determining the quality of family relationships in terms of alliances according to four interactive functions is an effective and valid way of making a “diagnosis” of family functioning, which in turn allows the clinician to calibrate the intervention according to the type of coordination difficulty the triad presents. References Abidin, R. (1992). The determinants of parenting behavior. Journal of Clinical Child Psychology, 21, 407–412. Anders, T. (1989). Clinical syndromes, relationship disturbances and their assessment. In A. Sameroff & R. Emde (Eds.), Relationship disturbances in early childhood (pp.  125–162). New York: Basic Books. Bandura, A. (1973). Aggression: A social learning analysis. Englewood: Prentice-Hall. Belsky, J., & Hsieh, K. (1998). Patterns of marital change during the early childhood years: Parent personality, coparenting, and division-of-labor correlates. Journal of Family Psychology, 12, 511–528. Benoit, D., Zeanah, C. H., Jr., Parker, K., Nicholson, E., & Coolbear, J. (1997). “Working Model of the Child Interview”: Infant clinical status related to maternal perceptions. Infant Mental Health Journal, 18(1), 107–121. Bost, K., Cox, M., Burchinal, M., & Payne, C. (2002). Structural and supportive changes in couples’ family and friendship networks across the transition to parenthood. Journal of Marriage and Family, 64, 517–531. Brazelton, T., Koslowski, B., & Main, M. (1974). The origins of reciprocity: The early mother–­ infant interaction. In M. Lewis & L. Rosenblum (Eds.), The origins of behavior: The effect of the infant on its caregiver (pp.  49–76). New York: Wiley. Bürgin, D., & von Klitzing, K. (1995). Prenatal representations and postnatal interactions of a threesome (mother, father, baby). In J. Bitzer & M. Stauber (Eds.), Psychosomatic obstetrics and gynaecology (pp. 185–191). Bologna: Monduzzi Editore. Carneiro, C., Corboz-­Warnery, A., & Fivaz­Depeursinge, E. (2006). The prenatal Lausanne Trilogue Play: A new observational assessment tool of the prenatal coparenting alliance. Infant Mental Health Journal, 27(2), 207–228. Carr, A. (2000). What works for children and adolescents. London: Routledge. Connell, A., & Goodman, S. (2002). The association between psychopathology in fathers versus mothers and children’s internalizing and exter-

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C h a p t e r 30

The Mothers and Toddlers Program An Attachment-Based Intervention for Mothers in Substance Abuse Treatment Nancy Suchman Cindy DeCoste Linda Mayes

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lthough not all mothers who seek treatment for their substance abuse have difficulties parenting their children, as a group, substance-­abusing women are twice as likely as non-­substance-­abusing women to lose custody of their children because of recurrences of substance abuse and child neglect (Eiden, Foote, & Schuetze, 2007; Pelton, 2008; Schilling, Mares, & El-­Bassel, 2008; Wobie, Eyler, Garvan, Hou, & Behnke, 2008). Over the last 20 years research has shown that, although some mothers who use illicit substances are able to provide home environments and parenting that support their children’s development, mothers with substance use disorders are at greater risk for maladaptive parenting practices than mothers who do not have substance use problems (Mayes & Truman, 2002). Problems in maternal interactions with children have been observed during children’s first 3 years of life, including patterns of poor attachment, attunement, involvement, responsiveness, adaptability, and structure, juxtaposed with heightened maternal physical activity, provocation, and intrusiveness (Burns, Chethik, Burns, & Clark, 1997; Hans, Bernstein, & Henson, 1999; Rodning, Beckwith, & Howard, 1991). Studies reporting substance­abusing mothers’ perspectives about parent

ing have indicated a limited understanding of basic child development issues and ambivalent feelings about having and keeping children (Mayes & Truman, 2002; Murphy & Rosenbaum, 1999). Only a handful of studies to date has reported findings from clinical trials evaluating interventions for substance-­abusing parents of young children (i.e., under 5 years of age; for reviews, see Pajulo, Suchman, Kalland, & Mayes, 2006; Suchman, Pajulo, DeCoste, & Mayes, 2006). Although the findings have generally indicated improvement in parental factors (e.g., in substance use, psychiatric distress, and knowledge of parenting), very few have shown improvement in parent– child dyadic interactions or in child adjustment. Interventions have ranged in focus from behavioral skills training to advocacy for needed services to education about early child development. However, very few have emphasized the emotional quality of the parent–child relationship or the emotional development of the child. Given that women with substance use disorders often have developmental histories characterized by emotional neglect (Luthar & Walsh, 1995), it may be that parenting interventions must first focus on enhancing emotion communication in the parent–child relationship in 485

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order to improve dyadic interactions and foster optimal child development (Suchman, Mayes, Conti, Slade, & Rounsaville, 2004).

ATTACHMENT MECHANISMS OF PARENTING Originating with the ideas of John Bowlby (1982), attachment theory emphasizes parental attunement to infants’ and toddlers’ emotional cues during early caregiving years as a means of promoting optimal social and emotional development (for an overview, see Karen, 1994). Attachment research during the past 30 years has generally shown that children whose caregivers accurately perceived and sensitively responded to their emotional cues during early caregiving years have been more likely to respond to the caregiver’s efforts to soothe and, consequently, develop greater capacities for self-­regulation in response to distress. This self-­regulatory capacity is thought to serve as a protective factor, promoting social competence and reducing risk for behavior problems during school-age and adolescent years (Sroufe, Carlson, Levy, & Egeland, 1999). Bowlby proposed that, over time, young children develop internal “representations” of the caregiving relationship (i.e., enduring perceptions of self and caregiver) based on their experience with early caregivers and that these representations influence children’s expectations and guide their behaviors in subsequent relationships. Children reared by sensitive caregivers are generally thought to develop representations that are balanced in terms of positive and negative affect, whereas children reared by insensitive caregivers are thought more likely to develop mental representations characterized by either denial or distortion of painful negative affect (Slade & Cohen, 1996).

Maternal Representations and Dyadic Interactions In observations of mothers with substance abuse disorders and their young children, mothers have often shown difficulty accurately perceiving and sensitively responding to their children’s emotional cues (Mayes & Truman, 2002). Attachment theorists commonly view these parental misperceptions of children’s emotional distress as a function

of parents’ distorted or denied affect related to their own early experiences (Suchman et al., 2004). Having not experienced an early relationship in which emotional distress was effectively soothed, the mother may use psychological defenses—­denial or distortion— in response to her child’s emotional distress in order to protect herself from reliving painful memories of early childhood. For example, a mother who experienced early trauma in the absence of a caregiver who could potentially recognize the emotional impact of the trauma, may fail to recognize her child’s expressions of fear in order to avoid the reactivation of her own early fears. Likewise, a mother who was once a victim of her partner’s assault might interpret her toddler’s normal aggressive tendencies as being driven by malevolent intentions. One conceivable way for a mother to begin accurately perceiving and interpreting her child’s intentions and emotional cues involves her first developing the capacity to recognize and modulate her own affective distress in order to identify its source (e.g., the child or another significant person) and distinguish it from the child’s distress. For example, a mother might be more likely to recognize, tolerate, and soothe her child’s fear of separation if she could first recognize and tolerate her own anxieties about emotional abandonment. Along similar lines, it is conceivable that a mother might develop the capacity to perceive her child’s personality, intentions, and behaviors accurately by first developing the capacity to recognize and modify her own previously unrecognized expectations and attributions of the child that originated in her own earlier caregiving experiences. For example, a mother might be less punitive in response to her child’s noncompliant behavior if she were able to recognize her own unrealistic expectations for perfection in herself as a mother. Without intervention that targets maternal emotions, expectations, and interpretations, elicited during emotionally charged dyadic interactions with children, a mother is likely to continue making misattributions about her child’s behaviors and responding noncontingently or insensitively. In other words, following one of the core tenets of attachment theory that behavior is fundamentally driven by unconscious internal representations and interpretations, change in behavior is unlikely to improve dyadic interactions or children’s



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development unless it is a direct function of change in maternal representations.

The Mediating Role of Maternal Reflective Functioning Peter Fonagy and colleagues (Fonagy, Gergely, Jurist, & Target, 2002; Fonagy & Target, 1997) have suggested that a caregiver’s capacity for “reflective functioning,” or the ability to recognize the intentionality underlying a child’s behavior, is critical to the caregiver’s capacity to recognize and interpret the child’s emotional cues. The caregiver’s capacity for reflective functioning may, in fact, be the mechanism that explains why a parent’s impoverished or distorted representations of the child interfere with the parent’s ability to perceive accurately and respond sensitively to the child’s emotional cues. Instead, the parent may (1) misattribute the child’s behavior to circumstances that are unrelated to the child or the child’s immediate experience, or (2) attribute the child’s behavior to global personality characteristics or external factors. Without the capacity to recognize possible thoughts, wishes, feelings, and intentional states underlying the child’s behavior, the parent is likely to have difficulty making sense of, and responding to, the child’s underlying emotional needs in a way that restores emotional regulation to the dyad and, most importantly, to the child. In this way, maladaptive representational patterns of distortion and denial are thought to be perpetuated from one generation of caregivers and offspring to the next, again mediated by a capacity (or absence thereof) to think reflectively about behavior. Maternal reflective functioning has been empirically linked with sensitive parenting behavior in at-risk parents (Fonagy et al., 2002; Fonagy & Target, 1997). The absence of, or low, maternal reflective functioning has been linked with maladaptive parenting behavior (e.g., withdrawal, hostility, intrusiveness) and with young children’s limited ability to express emotional distress directly (Grienenberger, Kelly, & Slade, 2005; Slade, Grienenberger, Bernbach, Levy, & Locker, 2005). Low maternal reflective functioning has also been found to mediate associations between maternal cocaine use and diminished psychosocial capacities (e.g., attention, social skills, and withdrawal) of young children (Levy & Truman, 2002).

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SUBSTANCE ABUSE, PARENTING STRESS, AND MATERNAL AFFECT REGULATION Khantzian (1997) has conceived of substance abuse as an attempt to self-­medicate in the presence of painful or difficult affect that has not otherwise been psychologically contained, regulated, or integrated. Drug abuse can therefore be understood as an effort to compensate for deficits in emotional regulation, in general, and parenting distress, in particular. This link between parenting stress and drug abuse is supported by accumulating evidence in addiction research demonstrating that emotional distress is a common element connecting many social and familial factors for addiction (Barrett & Turner, 2006) and suggesting that exposure to relational stressors is one pathway leading to chronic patterns of substance abuse among women (National Center on Addiction and Substance Abuse, 2006; U.S. Department of Health and Human Services, 1999). Attachment theory suggests that avoidant or overly intrusive responses to children’s emotional cues, commonly observed in mothers with substance abuse disorders, may be a function of the mothers’ own high levels of internal distress and negative emotionality related to their own unmet attachment needs that become activated by their children’s typical distress cues (Solomon & George, 1996). Rather than experiencing child emotional cues as a beckoning signal to nurture the child’s distress, a mother who has difficulty in regulating her own affective distress may desire either to avoid or take control of the distressing child behaviors. She may also seek regulation of her own internal distress by using substances that can quickly alter her mood, reduce her psychic pain, and return her to a state that she experiences as emotional equilibrium.

Neural Circuitry of Addiction and Parenting Evidence on the neural circuitry of parenting and addiction is generally consistent with behavioral observations. There is preliminary evidence that infant emotional cues may activate neural circuitry differently in mothers with addictive disorders compared with mothers with no history of substance

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(Fleming, Steiner, & Corter, 1997). Preclinical and human studies have shown that the stress response systems of mothers with no substance abuse histories during the period of heightened maternal sensitivity surrounding the birth of a new infant are typically adaptively activated. In human parents with no history of substance abuse, exposure to visual and auditory infant emotional cues has also been found to activate neural areas related to reward and pleasure while decreasing activity in areas important for negative emotion and avoidance behavior (Bartels & Zeki, 2004; Nitschke et al., 2004; Ranote, Elliot, Abel, et al., 2004). These neural responses are thought to mediate caregiving behaviors that reflect an investment in caring for children, recognition of child cues, and responsiveness to child distress. Many abused substances (e.g., cocaine, heroin) have been shown to affect the dopaminergic pathways in the brain, areas that are associated with initiation of behavior, hedonic reward, and motivation (Koob, 1996; Koob & LeMoal, 1997). These central dopaminergic pathways are also thought to be critically involved in an adult’s capacity to invest in the care of children (Edelman & Tononi, 1995). Preliminary evidence in research on the neural circuitry of addiction and parenting (e.g., Bartels & Zeki, 2004; Volkow, Fowler, & Wang, 2003) suggests that, at least for some mothers with chronic substance use, infant and toddler emotional cues may not activate neural reward circuitry in the same way that reward systems are activated in mothers with no histories of substance abuse. Rather, it appears that illicit drugs alter dopaminergically regulated neural reward systems such that formerly pleasurable experiences (including human attachment experiences) are no longer experienced as rewarding or gratifying. Since the same neural reward systems that are coopted by illicit drugs (e.g., cocaine, heroin) are also involved in mediating the investment in caring for children, the absence of sensitivity and responsiveness to infant cues is likely mediated, in part, by an altered neural response to child cues (e.g., an absence of emotional reward) that is triggered by drug-­induced alterations in neural circuitry (Leckman & Mayes, 1998). Drug abuse can therefore be viewed as a cooptation or hijacking of this endogenous value system. As a consequence,

once this system is coopted by repeated drug use, competing investments in craving the drug versus caring for the child may reduce the caregiver’s capacity to invest in caring for the child. Conversely, as a caregiver’s desire to invest in her child is enhanced, a concomitant decrease in the reward derived from drug use may also occur.

Implications for Parenting Intervention with Substance-­Abusing Mothers The complex behavioral and neurophysiological mechanisms of attachment, parenting, and addiction, outlined above, may help to explain why behavioral training and parent education approaches to intervention with substance-­abusing parents have met with limited success (for a review, see Suchman et al., 2006). Even attachment-based behavioral interventions specifically targeting improvement in maternal recognition of child cues have not led to improvement in maternal responsiveness to children’s emotional distress in at-risk populations of mothers (for reviews, see Egeland, Weinfield, Bosquet, & Cheng, 2000; van IJzendoorn, Juffer, & Duyvesteyn, 1995). Instead, the growing evidence seems to suggest at least five general principles for the development of more promising interventions for parents with substance abuse disorders. First, it may be that addressing parenting deficits and substance abuse concurrently within one program could foster mutually beneficial outcomes for parenting and abstinence. That is, abstinence from drug use may help to reset the neurological reward system such that parenting (especially the formation of attachments) can be experienced as rewarding and pleasurable. Likewise, increased parental sensitivity during dyadic interactions could “prime” the reward system and lead to a reduction in cravings for mood-­altering substances during emotionally charged interactions with children. Second, failures of earlier parenting interventions to bring about change in dyadic interactions and children’s adjustment suggest that maladaptive patterns of parenting are enduring and require intervention at multiple levels (e.g., representational, cognitive, and behavioral). For example, fostering shifts toward the integration of distorted and denied affect in enduring maternal representations



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of the child may provide a necessary foundation of maternal awareness of child distress, allowing a distinction between the mother’s own and her child’s distress that then fosters better recognition of child emotional cues and responsiveness to child distress. Third, evidence from attachment and addiction research suggests the critical role of maternal affect dysregulation in the formation of maladaptive attachment patterns and relapse to substance abuse. It follows that fostering more integrated maternal representations and greater maternal capacities for reflective functioning would necessarily involve a particular focus on the circumstances in which affect dysregulation is most pronounced so that changes at the representational and metacognitive levels can occur in relation to stressors that specifically trigger affective distress. For example, rather than using a set curriculum or intervention protocol targeting generic parenting stressors, addressing affectively charged experiences at moments when they are particularly salient would ensure that idiosyncratic stressors unique to the mother and her child could be resolved and integrated into more balanced and realistic representations of caregiving, which, in turn, would sustain affect regulation when the parenting stressor surfaces again. Fourth, rather than using a single entry point, multiple entry points for intervening (e.g., individual and dyadic therapeutic approaches) may help to promote more enduring change in the attachment system. For example, alternating between a focus on a mother’s representational distortions during individual therapy and a more in vivo focus on supporting the mother’s efforts to make inferences about her child’s underlying mental states during play interactions may provide a level of intervention intensity and comprehensiveness that is capable of bringing sustained change to the attachment system. Finally, there is also a growing consensus among parent skills training and attachmentbased parenting intervention researchers alike that mothers with substance abuse disorders are at risk for multiple psychosocial deficits that require comprehensive services provided in conjunction with parenting interventions. Egeland and colleagues (2000) have noted that attachment-based parenting

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interventions alone may not be sufficiently potent to address the myriad other problems mothers face (e.g., drug addiction, comorbid psychopathology, and problems of daily living). Attachment-based parenting interventions for at-risk mothers are more likely to improve the parent–child relationship when provided in a comprehensive treatment setting wherein treatment for other psychosocial problems and problems of daily living (e.g., housing, food, and child care) are available.

THE MOTHERS AND TODDLERS PROGRAM Overview We are currently developing an adjunct therapy intervention, called the Mothers and Toddlers Program (MTP), for mothers who are enrolled in outpatient treatment for their substance abuse and are caring for at least one child between 12 and 36 months of age. MTP is located on site at the clinic where mothers receive treatment for their substance abuse and have access to psychiatric services, vocational counseling, medical care, and assistance with basic needs and legal aid. Mothers enroll in MTP with their toddlers for 28–40 weeks and are assigned an individual therapist for the duration of their enrollment. Mothers meet weekly with their individual therapists to explore their parenting experiences and observe videotaped interactions with their child. MTP targets improvement in maternal representational balance and capacity for reflective functioning in order to foster change in maternal sensitivity and responsiveness to child cues—which, in turn, would foster optimal emotional regulation in the child. The treatment outcomes being evaluated to assess the program’s efficacy include maternal representational balance, capacity for reflective functioning, sensitivity to child cues during dyadic interactions, psychiatric adjustment, and substance use. Children’s efforts to communicate with and engage the mother are also being assessed. Child temperament and maternal knowledge of child development are also taken into account when evaluating treatment outcomes. The influence of treatment process factors (e.g., therapeutic alli-

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ance, treatment attendance, and treatment integrity) on treatment is also being examined. Below we describe the intervention model and summarize findings obtained to date in the ongoing program evaluation.

Intervention Format Initial Evaluation During the first 4 weeks of the program, mothers complete a psychosocial evaluation (i.e., personal and family history of substance abuse and psychiatric problems, developmental milestones and problems, pregnancy and birth of children, current psychosocial functioning, and socioeconomic stressors). Records of mothers’ urine toxicology screens and attendance are also obtained from the substance abuse treatment program. Mothers are introduced to their therapist, who conducts two attachment interviews with them—the Working Model of the Child Interview (WMCI; Zeanah & Benoit, 1995) and the Parental Development Interview (PDI; Slade, Aber, Berger, Bresgi, & Kaplan, 2002). Mothers and toddlers also participate together in a brief structured videotaped play session—the NCAST Teaching Task (Barnard & Eyres, 1979). Mothers also complete a series of questionnaires about their psychiatric status (e.g., depression, anxiety, and other psychiatric symptoms), parenting stress, perceptions of their child’s temperament, and knowledge of child development (see Suchman, DeCoste, Schmitt, Legow, & Mayes, 2008).

Treatment Phase After completing baseline assessments, mothers meet weekly with their individual therapist for 12 weeks and complete a posttreatment assessment (i.e., attachment interviews, dyadic interaction sessions, psychiatric questionnaires) at the end of the 12 weeks. Mothers then have the option either to continue meeting with their therapist for an additional 12 weeks or to move directly into the followup phase of the study. (Most of the mothers [approximately 70%] who complete the first 12 weeks choose to continue in therapy for an additional 12 weeks.) The therapy follows a developmental progression that begins with a focus on estab-

lishing a strong therapeutic alliance and supporting mothers to recognize and contain strong affect related to parenting and other crises that emerge over the course of the therapy. As the therapeutic relationship becomes a source of reassurance and regulation to the mother, and as the therapist begins to get a sense of the mother’s representational world, the focus shifts more to exploring the mother’s representational world—that is, exploring enduring patterns in how the mother has come to view herself as a mother and her child in the context of her own family. The therapist also begins to encourage the mother to think reflectively, that is, to explore underlying thoughts, feelings, and intentions that might be driving behavior in her relationship with her child and other significant individuals in her life, with a particular emphasis on distressing interactions. During this phase, the mother and toddler also participate in a series of structured and unstructured play sessions that are videotaped. The therapist views these play session videotapes with the mother in order to explore further the underlying thoughts, intentions, and affects of the mother and child that are likely driving their interactive behavior. Finally, MTP consists of a team of researchers, clinicians, and child care specialists, all of whom interact with mothers in the program. The milieu provided by the team is a critical source of support and modeling for mothers enrolled in the program. Each staff member is trained in the therapeutic model and in strategies for interacting with mothers and children that consistently foster a reflective environment in which the mother’s and child’s emotional experiences are recognized and responded to sensitively. Each of these six major components of the therapy—­building a therapeutic alliance, strengthening affect regulation, exploring the representational world, encouraging reflective thinking, and fostering a therapeutic milieu—is described in more detail below.

Building a Therapeutic Alliance During the 4 weeks of baseline assessment, mothers begin meeting weekly with their therapist, and the therapist begins learning about the mother’s perceptions of her parenting problems, her children and family, and other stressors that she sees as contributing



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to the problems. The therapist carefully listens to the mother’s concerns about parenting and works to understand those problems as the mother sees them. The therapist accepts (but does not necessarily condone) the mother’s aberrant views about parenting and attempts to learn how the mother is coping with parenting problems. Strong social mores against substance abuse, particularly regarding women who are caring for children, can make it especially difficult for a mother to trust the therapist’s intentions, increasing the likelihood that the mother will leave treatment prematurely if she perceives that the therapist as judgmental. It is therefore imperative that the therapist be attuned to the relationship and encourage the mother’s efforts to openly discuss her concerns. The goal in the early weeks of therapy is to identify areas of distress for the mother that will continue to be the focus of the therapy. The therapist offers to assist the mother with whatever is stressing her at the moment, including concrete problems (e.g., need for supplies or services) or other relational issues, in order to strengthen the mother’s experience of the therapist as a source of help and support. The program keeps basic supplies on hand (e.g., diapers, healthy snacks) and provides coffee, child care, and transportation when needed. The therapist may help the mother find services, scholarships, or housing, and will receive calls for assistance from the mother during the week. Although the therapist may need to endure feelings of being “had” from time to time, assisting the mother provides an opportunity for the therapist to maintain an alliance and also suggest, in a timely way, the need to work further in therapy. The day-to-day lives of many of the mothers can often be chaotic and abundant with crises that are typically interpersonal or economic in nature. The occurrence of family and personal illness and injury is common. Some mothers have contracted hepatitis, HIV infection, or other socially transmitted diseases. The sudden unavailability of cash, transportation, food, household supplies, and medicine are also commonplace. Living circumstances can change dramatically from one week to the next in terms of housing, presence or absence of family members in the household, partners returning from or

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going to prison, friends and family members becoming ill or dying suddenly of illnesses, car accidents, or drug overdoses. Employment for mothers and their partners is often sporadic, with layoffs and firings occurring more than occasionally. Families often live in areas where threats to personal safety and property are everyday concerns. Often, more than one man has fathered the mother’s children, and contact with fathers varies from one family to the next. In any given week, genuine crises can suddenly develop, affecting the mother’s physical and emotional well-being, economic and material resources, legal and custody status, interpersonal environment, and vocational status, profoundly affecting the stability of the environment in which her children are being reared. Help with managing crises and finding resources is the first order of business because it provides immediate relief and the experience of being helped that will hopefully encourage the mother not to abandon her efforts to seek help from the program. The therapist assists the mother in problem solving and serves as an advocate for the mother’s crisis-­related needs with an eye toward also addressing underlying issues once the crisis has cleared.

Affect Awareness and Containment The therapist almost always focuses the therapy on where the mother’s affect is. Unregulated or unrecognized affect in emotionally charged situations (positively or negatively) can heighten vulnerability to relapse and risk for child maltreatment. Attention to areas of emotional distress is also likely to be experienced by the mother as helpful and reassuring. Containment and resolution of emotional distress also allow mothers to experience being soothed within the context of the therapeutic relationship (i.e., using the therapist as a secure base), which can then promote their functioning in the same soothing way for their child (i.e., serving as a secure base for the child). The therapist therefore watches and listens for precipitating events and behavioral cues (e.g., restlessness, hyperactivity, defensiveness, opposition, or physical complaints) indicative of affective distress and brings these observations to the mother’s attention in an effort to help her recognize, contain, and understand

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them within their given context. Particular care is taken to monitor and probe for affective distress in patients who tend to minimize or deny strong feelings when difficult or stressful circumstances arise.

Exploring the Mother’s Representational World As the therapist works to better understand the mother’s point of view about ongoing problems (parenting and other relational issues) and explores areas of affective distress, the therapist also notes (silently) emerging patterns in the mother’s descriptions of parenting circumstances that give clues to her representational world (e.g., her core perceptions of herself, other adults, her children, and their respective relationships). Many questions can be pondered by the therapist in seeking to identify the contents of the mother’s inner world. For example: Is the mother able to talk about aspects of the child’s personality that she appreciates and enjoys as well as other aspects of the child’s personality that are difficult or challenging to her as a parent? To what degree does the mother view her child as having characteristics or temperamental qualities that are unique and separate from other children and family members? Does the mother dismiss or overlook her child’s vulnerability to emotional distress? Does she find it comical to see her child worried or scared? Does she become overwhelmed by her child’s intense emotions, such as fear or distress? Does the mother view her child as having a set of pat characteristics (e.g., stubborn, strong-­willed, lazy, angelic) that are not likely to ever change? Does she see her child as inanimate or animal-like or cartoon-like—a clown, a pet, a pig, a china doll, a monkey? Does she think that her child will outgrow certain behaviors or tendencies as he or she grows older? How does the mother see herself and her role in relation to the child? Has she experienced a shift in responsibility since the child was born? Has she been able to put her own needs aside

and make room in her mind for the child and his or her well-being? What preoccupies her thinking—­concerns about her child? About herself? About other people, events or matters? Does she view the child as a playmate? A soul mate? A soldier-in-­training? Does the child fill a need of the mother that went unmet by previous caregivers or a current partner—a need for nurture, attention, respect, or love? A need for limits or discipline or structure or distraction? Does she idealize the child’s capacities to know and understand what’s going on around her, perhaps viewing her child as omniscient? On the other hand, does she view her child as her adversary? As a constant menace? As possessed by the devil? As deliberately doing things to bother or upset her? As cunning and manipulative? As capable of deliberate acts of malevolence? Does she provide an elaborate and detailed description of her child that is believable and easy to imagine? Does her description distinguish her child’s personality from other children’s? Does she become focused on, or preoccupied with, one aspect of her child that is annoying or challenging to her but say little about other aspects of the child’s personality? Does the mother seem inordinately worried for her child’s well-being—fear that something may happen out-of-the-blue or that the child is in extreme danger of an unusual event, such as being kidnapped, attacked, or suddenly becoming extremely ill? Does the mother have the confidence that she will be able to rear her child—that, though difficult at moments, parenting her child is generally manageable? Is she confused by her child, carrying many disjointed impressions? For example, does she describe her child as “sometimes being an angel” and other times behaving “just like the devil?” Does she view the different aspects of her child’s personality in a disconnected and confusing way, or does she seem to understand them in a specific context that includes information about the child’s temperament, her own temperament, her child’s developmental capabilities, and the nature of the situation?



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All of these representations of children and parenting are possible; in fact, we based them on our clinical experience in working with this population of mothers. Importantly, the therapist’s job is not to “correct” imbalanced or distorted representations but rather to elucidate, clarify, and help the mother integrate them. Importantly, the therapist adopts a naïve and inquisitive stance, seeking opportunities to probe further about these representations (e.g., “When you call your daughter ‘the devil,’ is this because she does things that seem evil to you or that she does things that scare you?”). The therapist reflects back to the mother her representational world, attempting to place confusing or disparate parts within a logically and emotionally understandable context (e.g., “So most of the time your daughter seems to be doing things to be mean, but every so often she seems to want your affection and comfort”). The ongoing clarification of the mother’s representational world allows the therapist to identify areas of distortion, harshness, incoherence, and insensitivity that she can then explore with the mother in the interest of helping the mother develop a more coherent and integrated understanding of herself and her toddler. The end goal of this exploration is to support shifts in the mother’s representational world toward balance, coherence, and sensitivity to the child’s emotional needs. The therapist is careful to strive for these goals but to expect change to occur slowly and in small increments. Change is expected to occur as a result of the therapist accepting and exploring the mother’s representations and experiences as they are and noting them as they change so that the mother can also recognize how her thinking affects her parenting.

Thinking Reflectively about Relationships When exploring representational models, the therapist specifically encourages the mother to consider the emotional needs, intentions, wishes, and thoughts that might be driving her own behaviors, her child’s, and those of other significant individuals in her life. This process helps to “flesh out” a mental model of behavior that makes it more understandable and predictable. This strategy—­called “mentalizing” (Fonagy, Target, Steele, & Steele, 1998)—is also critical to maintaining emotional regulation. In the context of

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parenting, for example, recognizing that a child’s clinging behavior is often driven by a genuine need for emotional security can help prevent a parent from reacting aggressively or impulsively to the behavior. Again, the therapist is careful not to make assumptions or draw conclusions about representations or mental states but instead adopts a naïve stance and inquires further for the purpose of clarification. To do otherwise would risk intrusively superimposing the therapist’s perceptions while sacrificing the mother’s chance to recognize and modify her own perceptions. As the therapist asks the mother to reflect on underlying mental states during interactions with her child, he or she gets a better idea about the degree to which the mother is able to mentalize about her own and her child’s responses during stressful interactions. For example, the therapist might note to him- or herself whether the mother describes these instances primarily in terms of behavior or whether she thinks about and observes her own and her child’s inner experiences that are driving their behavior? When asked to elaborate about a time she felt out of sync with her daughter, does the mother relate just the daughter’s behavior—that she “refused to eat all her food”—or does she consider the daughter’s underlying state of frustration or tiredness from having been up late the night before, or her own frustration and anxiety about her child not eating? Does the mother recognize that her child’s state of mind might change over time? That she might play a role in calming her child? Does the mother sense that her child’s agitated state is affecting her own? Or that her own frustration about other concerns (e.g., unpaid bills, pending divorce) might be influencing her child’s clinging or whining? Does she feel that if she is experiencing an emotion intensely, she must act on it? Is she able to talk about her own and her child’s emotions without becoming overwhelmed? The therapist uses these observations of the mother’s reflective process to guide the sessions toward expanding on these capacities through mutual exploration and recognition of underlying mental processes. Although the ultimate objective is to engage in a mentalizing process about the mother–child relationship, this may not always be possible because of the mother’s preoccupation with other relationships (e.g.,

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with partners, other family members, the legal system, and substances). Nevertheless, the process of examining any stressful relationship from an inquisitive, mentalizing stance is viewed as productive in that it provides a regulatory function (by addressing affective distress), a chance to identify representations driving these interactions, and can help “free” the mother psychologically to become more emotionally available to her child. When the child or the mother–child relationship is the primary focus of the session, the therapist encourages the mother to explore her own emotional responses to her child, particularly in the context of stressful interactions. She is also encouraged to explore her assumptions about what the child is capable of accomplishing (e.g., cognitively and emotionally as well as behaviorally) and consider any developmental limitations the child might have. The therapist works with the mother to develop a contextual understanding of the child’s behavior and the mother’s response. For example, a mother may mention that her toddler has been “very difficult” that day—­crying, even though she, the mother, has been close by. The therapist urges the mother to seriously consider what might have been stressing the child and then underscores the mother’s accurate attributions or realizations (e.g., the child might be stressed because his father was recently incarcerated). When it is evident that the mother is worried about not seeing, or is expecting to see, unrealistic capacities in her toddler (e.g., long attention span, manners, perspective taking), the therapist provides realistic guidelines about the child’s capacities.

Viewing Videotaped Play Sessions Every 4 weeks mothers participate in a halfhour interactive session with their toddlers that includes a structured teaching session and an unstructured free-play session. For the structured teaching session, the mother is asked to choose from a list of developmentally appropriate tasks one activity that her child does not already know how to do. The mother is then asked to teach the activity to the child. For the free-play session, the mother and child are sequentially introduced to a series of four different activities that involve physical (e.g., tent box

mats, hop scotch, mesh tunnel), mental (e.g., puzzles), and interactive (e.g., farm, kitchen, dollhouse) play. The dyad is given 5 minutes to engage in each activity. All play sessions are videotaped and then watched within the same week by the therapist and mother together. The therapist views the play sessions first on closed-­circuit television in order to observe the relationship. The therapist may note how engaged the mother and child are with each other, whether the child visually references the mother during the play, whether the mother encourages the child to explore or to try a new element of the activity, the affective quality of the interaction (e.g., joyful, subdued, solemn, agitated), whether the mother uses imperatives or give explanations, whether the child is paying attention to the mother or playing autonomously, or how the mother responds to the child’s signals to disengage. Viewing the play sessions together allows the therapist also to understand the mother’s perceptions of the same interaction. The therapist and mother can focus on a specific interaction that they both have witnessed and explore together the thoughts, intentions, and emotions underlying each partner’s behavior. The therapist and mother together explore what the mother and toddler might have been thinking during different interactive moments. Moments of the play session when the mother and child seem particularly in sync and moments when the mother and child seem out of sync are noted. The intent here is to join the mother in thinking about underlying thoughts, intentions, and emotions that are driving her own behavior, her child’s behavior, and their interactions (see Powell et al., Chapter 28, and Favez et al., Chapter 29, this volume for similar approaches).

The Therapeutic Milieu There are many different opportunities at each visit to reinforce the mother’s work in therapy. Often, within the same visit, a mother will spend time with the child care specialist helping her child get settled into day care; meet with a research assistant to complete some questionnaires, interviews, or a play session (with her toddler); and meet with her individual therapist. The ethos and quality of interactions on the team can also strongly impact the mother’s experience in



30. The Mothers and Toddlers Program

the program. Considerable effort, therefore, goes to ensuring that each member of the team is supported, supervised, and guided in terms of the treatment approach and her (all are female in our program) interactions with the mother and toddler. The toddler’s transition to and from the child care worker each week is an opportune time for the clinician and the team to observe how separations are negotiated by the dyad. For example: What does the mother do to help prepare the child for separation? How does she communicate about it with the child? Do the mother and child make eye contact before the mother leaves? How does the child manage emotions around the separation? Does the child interrupt his or her activity to take note of the mother’s departure? How does the child respond once the mother has left the room? How does the mother respond to being separated from the child? How long does each partner tolerate the separation? How do they respond to each other upon reunion? How does the mother respond to the child’s being engaged in an activity when she returns? Does the mother seem to need the child’s immediate attention? Does the child run to greet the mother or observe her from a distance? Each of these interactions can illuminate features of the relationship. The research and clinical staff are guided to “mentalize for three”—for themselves, the mother, and the child. The staff may gently interpret a child’s experience to his or her mother by using the technique of speaking for the child. For example, if a child is crying for his or her mother in the day care room and the mother appears to be puzzled or stressed, the child care worker might say (using a tone that mildly suggests that she is impersonating the child), “Mommy, I really missed you! I’m so relieved that you’re back.” Or, when a mother is venting frustration that her child won’t stay focused for a very long time on an activity, the child care worker might say, “Mommy, I’m done with

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this activity! It doesn’t interest me any more. Is there something else I can do instead?” Likewise, if a child is trying to get his or her mother’s attention by throwing objects at her, a staff member might gently interpret the child’s actions to the mother by addressing the child, “I know you really want your mommy’s attention right now, but throwing things at her might not be the best way to get it.” The staff also support and respect the mother in her role as the child’s parent with the realization that the mother might feel sensitive about her own parenting skills within the context of the clinic. For example, when a parent is using imperatives to get a reluctant child to leave the day care room after a visit, and a staff member sees an alternative way to handle this situation, she might say to the mother, “Look, you know Natasha best—do you think she might want a minute or two to help put things away before she leaves for the day?” Many dyads have difficulty with separations (both the mother and the child) upon first arriving at the program. During the baseline assessments, we arrange for mothers to complete their interviews next door to the child care room so that the child can periodically walk in and see the mother, and the mother can also see the child. Often this coming and going ceases by the end of the mother’s enrollment, as both mother and child become more comfortable and familiar with the clinic staff and surroundings. Finally, the entire team attends a weekly case conference during which each actively enrolled mother is discussed. These meetings serve to support clinicians who have difficult cases, manage burnout and countertransference, brainstorm creative ways to handle clinical dilemmas, and manage outreach to patients who might be at risk for relapse. Team members are also encouraged to take quality time off and personal time when needed, to celebrate events in each others’ lives (e.g., weddings, birthdays, graduations, births), and to raise concerns about working together so that a warm and cohesive interpersonal environment is sustained.

Treatment Setting MTP is located at one of two outpatient substance abuse treatment clinics where mothers receive substance abuse treatment. All mothers who are enrolled in MTP must be

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concurrently enrolled in treatment for their substance abuse. As part of their ongoing substance abuse treatment, mothers have access to individual and group cognitive­behavioral substance abuse treatment; a psychiatrist who can prescribe psychotropic medications; a methadone maintenance program (for women who have histories of chronic and recurring opiate dependence); a physician who can provide general adult medical care; vocational counselors who provide training on job-­search skills, career development, and employment referrals tailored specifically for adults with histories of substance abuse; and child care and ongoing assistance with basic needs (e.g., housing, education, food, child care, legal aid, state and city welfare, and other entitlements). Treatment at the outpatient clinic is paid for by patients’ insurance or by the patients themselves (with payments based on a sliding fee scale). Transportation to the clinic is often provided by insurance carriers or by the clinic (for women who are pregnant). Thus, in addition to the therapy provided in MTP, mothers enrolled in MTP have access to comprehensive services provided on site at the treatment clinic.

REFINING AND EVALUATING THE INTERVENTION In an ongoing project funded by the National Institute on Drug Abuse (NIDA), we are refining and evaluating the MTP intervention. As preliminary steps, we have developed a therapist’s manual, conducted a pilot study testing the preliminary feasibility of the intervention and assessments, conducted a preliminary examination of the proposed mechanisms of change in the treatment model, developed a therapist-­adherence rating scale and coding procedures for measuring treatment integrity, and evaluated the MTP intervention’s preliminary efficacy compared to a parenting education control condition in a small randomized pilot study. In this section we summarize preliminary maternal and child outcomes from the study as well as results of preliminary examinations of proposed mechanisms of change (see Suchman et al., 2008, for a detailed report on maternal measures and preliminary outcomes).

Preliminary Outcomes Previously (Suchman et al., 2008) we reported that, at 12 weeks, mothers’ response to MTP on targeted representational outcomes (e.g., the WMCI and PDI) showed meaningful shifts toward more balanced representations of the child and an increased capacity for reflective functioning. Mothers’ behavior with toddlers during the NCAST Teaching Task showed corresponding improvement in sensitivity to child cues, response to child distress, social–­emotional growth fostering, cognitive growth fostering, and contingency of response. We also examined whether children’s responsiveness to the mother during dyadic interactions showed improvement at 12 weeks (DeCoste, Schmitt, & Suchman, 2007). At the pretreatment assessment, children’s NCAST scores, corresponding to clarity of cues, responsiveness to the mother, and contingency of response to the mother, each fell 1.0–1.3 standard deviations above normative scores, indicating that children were working excessively hard to communicate their emotional needs to their mothers during the teaching task. Mothers’ scores at pretreatment corresponding to sensitivity to child cues fell within normal limits, but scores corresponding to responsiveness to distress, social–­emotional growth fostering, and contingency of response all fell between 0.43 and 1.2 standard deviations below normative scores, indicating that mothers’ sensitivity to children was impaired. At 12 weeks, children’s scores for cue clarity, responsiveness to the mother, and contingency of response had all decreased to within normal limits and these decreases represented large effects (e.g., d > 0.70) for all scores except those representing cue clarity. We have interpreted this finding as indicating that children no longer had to work so hard for their mother’s attention (mother’s increases on all scales ranged from marginally significant to significant) because their mothers had become more sensitive to their cues.

Preliminary Tests of Proposed Treatment Mechanisms We have also completed a series of tests examining proposed treatment mechanisms



30. The Mothers and Toddlers Program

(DeCoste et al., 2007; Schmitt, DeCoste, & Suchman, 2007; Suchman et al., 2008). First, we were interested in determining if improvement in maternal reflective functioning might mediate the impact of improvement in maternal representations of the child on improvement in maternal sensitivity during dyadic interactions. We found a striking mediation effect of 50% for improvement in reflective functioning. In other words, improvement in maternal reflective functioning accounted for 51% of the variance in maternal sensitivity gains that was originally explained by improvement in maternal representations of children (see Suchman et al., 2008). Second, we were interested in determining if improvement in maternal sensitivity at 12 weeks mediated associations between improvement in maternal reflective functioning and reduction in child cues to within normal limits (DeCoste et al., 2007). In other words, was the impact of improvement in maternal reflective functioning on child behavior during interactions with the mother explained by improvement in the mother’s sensitive behavior? Again, we found a striking mediation effect of 70% for gains in maternal sensitivity. That is, improvement in maternal sensitivity accounted for 70% of the variance in the child behavioral gains that was originally explained by improvement in maternal reflective functioning. Third, we were interested in determining if improvement in maternal representational balance and maternal reflective functioning, respectively, corresponded with a reduction in maternal substance abuse at 12 weeks (Suchman, DeCoste, Schmitt, & Mayes, 2007). We found that improvement in maternal representational balance explained 16% and improvement in maternal reflective functioning explained 68% of the variance in reduction of maternal substance abuse. Finally, given the particular risk that maternal exposure to trauma and the subsequent presence of PTSD symptoms pose for maternal representational balance (see Schechter et al., 2005), we were interested in determining if the severity of maternal exposure to trauma and PTSD symptoms were negatively associated with maternal representational balance and overall quality of maternal caregiving, respectively (Schmitt et al., 2007). We were also interested in test-

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ing whether maternal representational balance mediated associations between severity of trauma exposure and PTSD symptoms and subsequent maternal caregiving behavior. Predicted associations were confirmed. Moreover, maternal representational balance explained 97% of the association between severity of trauma exposure and quality of caregiving behavior and 100% of the association between PTSD symptom severity and quality of caregiving behavior. In other words, the impact of maternal exposure to trauma and PTSD symptoms on caregiving behavior was largely mediated by maternal representational balance.

Implications, Caveats, and Future Directions The preliminary findings summarized above suggest that therapy targeting representational balance and reflective functioning in mothers with substance abuse disorders is not only feasible and acceptable to the treatment population, but may be a more potent approach to fostering change in dyadic interactions than more traditional behavioral parent training approaches that have not previously met with success. Targeting change at the representational level may also support improvement in maternal psychosocial adjustment and substance abuse. These conclusions must be considered preliminary until data from the randomized pilot are collected and interpreted. Other treatment and maturation effects may well have contributed to the improvements cited above. Also noteworthy is the preliminary empirical support for many of the attachmentbased mechanisms of action in the proposed treatment model. However, these findings must also be considered preliminary due to limitations in the research design. Most importantly, the temporal order of independent, mediating, and dependent variables cannot be determined due to the cross­sectional nature of data collection at each time point. Future studies are needed to test the predicted temporal order of events, controlling for potentially confounding factors. Limitations notwithstanding, the preliminary feasibility and acceptability of this intervention to a population of women and children who are seldom the focus of systematic parenting intervention development

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research will hopefully stimulate new efforts to bridge the theoretical and logistical gaps between child development specialists and addiction treatment providers. There is nothing to lose and everything to gain in continuing to bring relational approaches to parenting interventions into the substance abuse treatment setting and knowledge of the neurophysiology and psychosocial mechanisms of addiction into the child development research arena. Acknowledgments Preparation of this chapter was funded by grants from the National Institutes of Health (Nos. R01DA017294 and K23DA14606). We wish to thank Bruce Rounsaville, Kathy Carroll, Thomas McMahon, Arietta Slade, Elaine Fagan, Carolyn Parler-McCrae, Jean Larson, Carol Weber, Andy Campbell, Christine Lozano, Julie Scott, Jessie Borelli, Daryn David, and the APT Foundation for their contributions and support on this project.

References Barnard, K. E., & Eyres, S. J. (Eds.). (1979). Child health assessment, Part 2: The first year of life. (Publication No. DHEW No. HRA 79-25). Washington, DC: U.S. Government Printing Office. Barrett, A. E., & Turner, R. J. (2006). Family structure and substance use problems in adolescence and early adulthood: Examining explanations for the relationship. Addiction, 101, 109–120. Bartels, A., & Zeki, S. (2004). The neural correlates of maternal and romantic love. NeuroImage, 21, 1155–1166. Bowlby, J. (1982). Attachment and loss: Vol. 1. Attachment (2nd ed.). New York: Basic Books. Burns, K. A., Chethik, L., Burns, W. J., & Clark, R. (1997). The early relationship of drug abusing mothers and their infants: An assessment at eight to twelve months of age. Journal of Clinical Psychology, 53, 279–287. DeCoste, C., Schmitt, N., & Suchman, N. (2007, June). Preliminary findings on dyadic interactions from the Mothers and Toddlers Program (MTP), an attachment-based parenting intervention for substance abusing mothers. Poster presented at the College on Problems of Drug Dependence annual meeting, Quebec City, Quebec. Edelman, G. M., & Tononi, G. (1995). Neural Darwinism: The brain as a selectional system. In J. Cornwell (Ed.), Nature’s imagination: The frontiers of scientific vision (pp. 78–100). New York: Oxford University Press. Egeland, B., Weinfield, N. S., Bosquet, M., & Cheng, V. K. (2000). Remembering, repeating, and working through: Lessons from attachment-based

interventions. In J. D. Osofsky & H. E. Fitzgerald (Eds.), WAIMH handbook of infant mental health: Vol. 4. Infant mental health in groups at high risk (pp. 38–89). New York: Wiley. Eiden, R. D., Foote, A., & Schuetze, P. (2007). Maternal cocaine use and caregiving status: Group differences in caregiver and infant risk variables. Addictive Behaviors, 32, 465–476. Fleming, A. S., Steiner, M., & Corter, C. (1997). Cortisol, hedonics, and maternal responsiveness in human mothers. Hormones and Behavior, 32, 85–98. Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York: Other Press. Fonagy, P., & Target, M. (1997). Attachment and reflective function: Their role in self-­organization. Development and Psychopathology, 9, 679– 700. Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective-­functioning manual: Version 5. Unpublished manuscript, University College, London. Grienenberger, J., Kelly, K., & Slade, A. (2005). Maternal reflective functioning, mother–­infant affective communication, and infant attachment: Exploring the link between mental states and observed care giving behavior in the intergenerational transmission of attachment. Attachment and Human Development, 7, 299–311. Hans, L. L., Bernstein, V. J., & Henson, L. G. (1999). The role of psychopathology in the parenting of drug-­dependent women. Development and Psychopathology, 11, 957–977. Karen, R. (1994). Becoming attached. New York: Oxford University Press. Khantzian, E. (1997).The self-­medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4, 231–244. Koob, G. F. (1996). Hedonic valence, dopamine, and motivation. Molecular Psychiatry, 1, 186– 189. Koob, G. F., & LeMoal, M. (1997). Drug abuse: Hedonic homeostatic dysregulation. Science, 278, 52–58. Leckman, J. F., & Mayes, L. C. (1998). Understanding developmental psychopathology: How useful are evolutionary accounts? Child and Adolescent Psychiatry, 37, 1011–1021. Levy, D. W., & Truman, S. (2002, June). Reflective functioning as mediator between drug use, parenting stress, and child behavior. Paper presented at the College on Problems of Drug Dependence annual meeting, Quebec City, Quebec. Luthar, S. S., & Walsh, K. G. (2005). Treatment needs of drug-­addicted mothers: Integrated parenting psychotherapy interventions. Journal of Substance Abuse Treatment, 12, 341–348. Mayes, L., & Truman, S. (2002). Substance abuse and parenting. In M. Bornstein (Ed.), Handbook of parenting: Vol. 4. Social conditions and applied parenting (2nd ed., pp. 329–359). Mahwah, NJ: Erlbaum.



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Murphy, S., & Rosenbaum, M. (1999). Pregnant women on drugs: Combating stereotypes and stigma. New Brunswick, NJ: Rutgers University Press. National Center on Addiction and Substance Abuse at Columbia University (NCASA). (2006). Women under the influence. Baltimore: Johns Hopkins University Press. Nitschke, J. B., Nelson, E. E., Rusch, B. D., Fox, A. S., Oakes, T. R., & Davidson, R. J. (2004). Orbitofrontal cortex tracks positive mood in mothers viewing pictures of their newborn infants. NeuroImage, 21, 583–592. Pajulo, M., Suchman, N. E., Kalland, M., & Mayes, L. C. (2006). Enhancing the effectiveness of ­residential treatment for substance abusing pregnant and parenting women: Focus on maternal reflective functioning and mother–child relationship. Infant Mental Health Journal, 27, 448–465. Pelton, L. H. (2008). An examination of the reasons for child removal in Clark County, Nevada. Children and Youth Services Review, 30, 787–799. Ranote, S., Elliott, R., Abel, K. M., et al. (2004). The neural basis of maternal responsiveness to infants: An fMRI study. Neuroreport, 15, 1825– 1829. Rodning, C., Beckwith, L., & Howard, J. (1991). Quality of attachment and home environments in children prenatally exposed to PCP and cocaine. Development and Psychopathology, 3, 351–366. Schechter, D. S., Coots, T., Zeanah, C. H., Jr., Davies, M., Coates, S., Trabka, K. A., et al. (2005). Maternal mental representations of the child in an inner-city clinical sample: Violence-­related posttraumatic stress and reflective functioning. Attachment and Human Development, 7, 313– 331. Schilling, R., Mares, E., & El-­Bassel, N. (2004). Women in detoxification: Loss of guardianship of their children. Children and Youth Services Review, 26, 463–480. Schmitt, N., DeCoste, C., & Suchman, N. (2007, June). Maternal trauma exposure, PTSD, mental representations and caregiving behavior: Implications for the mother–­toddler attachment system. Poster presented at the College on Problems of Drug Dependence annual meeting, Quebec City, Quebec. Slade, A., Aber, J. L., Berger, B., Bresgi, I., & Kaplan, M. (2002). The Parent Development Interview—­Revised. Unpublished manuscript, Yale Child Study Center, New Haven, CT. Slade, A., & Cohen, L. J. (1996). The process of parenting and the remembrance of things past. Infant Mental Health Journal, 17, 217–222. Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal reflective func-

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C h a p t e r 31

Foster Care in Early Childhood Anna T. Smyke Angela S. Breidenstine

O

n September 30, 2006, 169,500 children ages 5 and younger were in foster care in the United States, representing 34% of the 510,000 children in the child welfare system (Administration for Children and Families, 2008). Overall, 40% of foster children were European American, 32% were African American, and 19% were of Hispanic origin. In fiscal year 2006, 131,639 children ages 5 and younger entered the foster care system—44% of the total number of children who entered the child welfare system in that year. Some were reunited with their families or lived with relatives. Others remained in the system. Maltreatment of infants and toddlers poses the highest risk of morbidity and mortality in this age group once they have emerged from the neonatal period (Child Welfare Information Gateway, 2006). For example, among children 0–17 years of age who died from child abuse, 78% were less than 4 years of age (Administration for Children and Families, 2006). A higher percentage of young children are placed in foster care, however, than any other age group (Wulczyn, Hislop, & Harden, 2002). The physical and emotional vulnerability of infants and toddlers and their limited speech and language abili

ties prevent them from telling other adults about their experiences. Children under 12 months of age are especially vulnerable to physical abuse, in particular to shaken baby syndrome (American Academy of Pediatrics, 2001). Infants shaken by their caregivers may experience profound trauma to the brain, retinal hemorrhages, subdural hematomas, and in a third of cases, death (Case, Graham, Handy, Jentzen, & Monteleone, 2001). The incidence of shaken baby syndrome closely tracks the “normal crying curve” and seems to reflect the salience of infant crying as a trigger for adult shaking of the infant (Barr, Trent, & Cross, 2006). The overall goal of this chapter is to communicate the understanding that foster care for young children is an intervention with multiple goals: protecting young children from further abuse, promoting young children’s recovery from maltreatment, and affording maltreating parents the opportunity to have a period of time in which they can learn to parent their young children in a “safe enough” way. Too often foster care is viewed as a “necessary evil”—sometimes worse than the abuse it is supposed to address. In order to describe foster care as an in500



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tervention, we examine briefly the history of out-of-home care for young children. Next, we address the issues that infants and toddlers present as they enter the child welfare system, related to their early experiences of maltreatment and their later experiences in substitute care. Then we describe several evidence-based foster care interventions aimed at addressing the many needs of young children. We discuss the ways in which foster care for young children is inherently different from foster care for school-age and older children. Finally, we examine recommendations for ways in which to enhance the experience of young children in foster care.

OUT-OF-HOME CARE FOR YOUNG CHILDREN In many parts of the world, institutional care is the primary means of caring for young children who cannot be cared for by their own families, whether for “social” or for economic reasons (Zeanah, Smyke, & Settles, 2006), or because they have been maltreated and government policy does not prioritize family care for them (Browne, 2005; Guedeney & Guedeney, 2008). In many Western countries, however, foster care has replaced institutional care as the preferred means of out-of-home care for young children. Although foster care frequently has been considered to be better than institutional care, randomized-­controlled studies to establish this assumption as a fact were not conducted until the 21st century (see Zeanah, Nelson, et al., 2003). Many concerns regarding foster care remain. In the popular press, problems with foster care have left it portrayed as a system in crisis. Recent cases in the United States (e.g., Florida, New Jersey) have pointed to the “disappearance” of children in care or to the system’s inability to monitor adequately the well-being of children brought into state’s custody for abuse and/or neglect. Further, foster parents are often characterized as greedy and are rarely recognized for the important work that they do in caring for children, who often have serious difficulties as a result of the chaotic lifestyles and significant maltreatment they experienced prior to ever entering foster care.

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Models of Foster Care As originally conceptualized, the role of foster parents was quite circumscribed. Children were placed in the foster home and foster parents were instructed to maintain a professional, detached approach with their young charges. The foster parent was expressly discouraged from becoming “too close” to the young child and was not considered as a permanent placement option if the child could not be returned to his or her parents. A permanent placement would be sought for the child that expressly excluded the foster parents in favor of adoptive parents. Thus, the child was certain to have at least two disruptions: the first, when removed from the biological parents and the second, when removed from the foster parents and placed with adoptive parents. In the 1980s, in the United States, this mechanism for deciding permanent placements for foster children began to shift as foster parents were considered in long-term planning for children. This shift resulted in more adoptions by foster parents and, hence, fewer disruptions for children in the child welfare system. Remnants of this older model still persist in the foster care profession. In this model, basically an extended respite model, the caregiver holds the child at arm’s length, remains detached from the child, provides for the child’s instrumental needs (e.g., food, clothing, diapering) but is careful not to become “too attached” to the young child. This approach stymies one of the most salient developmental tasks of infancy and toddlerhood—­forming an attachment to an important caregiver. Some foster parents resist becoming the child’s “go-to person,” either because of instructions given to them by child welfare professionals, because of a predisposition that they have from their own early attachment experiences, or as a result of repeated losses within the child welfare system. In doing so, they deprive the young traumatized child of an opportunity to reestablish a foundation of trust that will serve as the basis for important relationships throughout the child’s lifetime. In a contrasting child-­centered model of foster care, the needs of the young child are recognized and respected by the foster

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caregivers as well as personnel in the child welfare system, ranging from the initial investigator to the foster care worker to the juvenile judge. Rather than maintaining a “safe” distance from the child and providing only instrumental care, foster parents forge a relationship with the young child, even in the face of the child’s seeming resistance. In allowing themselves to love the child as their own, the foster parent faces the uncertainty of knowing that the child may be removed at any moment and yet assumes the emotional risk inherent in the possible loss of the child. The caregiver supports the young foster child and makes it possible for him or her to feel physically and psychologically safe while in out-of-home care. This effort on the part of the foster parent can help to ameliorate many of the issues that infants and toddlers bring with them as they enter foster care (Dozier, 2005).

Relationship Issues for Young Children in Foster Care Attachment Disruptions Foster children often experience disruptions from important caregivers at the time they come into care (Lewis, Dozier, Ackerman, & Sepulveda-­Kozakowski, 2007; Rubin et al., 2004). The young child removed from biological parents is in the difficult position of being connected to, but fearful of, abusive parents. In less dangerous situations, protective services may put in place assistance designed to educate and support the family and reduce the ongoing risk to the child. However, when risk to the child is high, child welfare workers are more likely to remove the child. Some states have an arrangement in which young children enter a residential setting and then, after initial court hearings, proceed to foster care. Other agencies place children directly in diagnostic and evaluation foster homes for several weeks— just enough time for children to begin to form an attachment—and then move them to more permanent placements. The stated priority of the Adoption and Safe Families Act (ASFA; 1997) is placement in the home of a relative at the time of removal. There is sound reasoning to support the placement of children within their families (Hill, 2004; Peters, 2005); however, much evidence sug-

gests that kin placements receive less financial support and fewer services than nonkin foster parents (Hill, 2004; Smith, Rudolph, & Swords, 2002). This discrepancy may occur in part because of the complex family issues that arise in the context of kin placements (Peters, 2005). Further, placement changes that remove the child from a stable placement in order to place the child with a relative often are made precipitously, even when there is clearly no danger in the current foster home. It is particularly important to facilitate transitions for young children (Dozier & Bick, 2007) so that they add attachment figures rather than having the person on whom they have come to rely seem to “fall off the ends of the earth.” Furthermore, decisions regarding changes in children’s foster placements are supposed to be made based on the best interest of the child, rather than other considerations, once the initial placement in care has occurred (Adoption and Safe Families Act, 1997). Attachment to a reliable caregiver is biologically programmed in young children (Bowlby, 1990), and many children enter foster care ready to form such a relationship. If the new caregiver is reasonably available, such children will very quickly refer to the foster mother as “Mommy” and begin to turn to the foster parent for comfort and support. Dozier and colleagues developed a method to track children’s emerging attachment behaviors, using an attachment behavior diary in which foster parents identified secure, avoidant, and resistant behaviors in their day-to-day interactions with their young foster children (Stovall-McClough & Dozier, 2004). To a large extent, foster parents’ willingness to be open to their foster child’s needs for relationship are mediated by foster parents’ own experiences in attachment relationships. Children placed in homes with “autonomous” foster parents are more likely to develop a secure attachment relationship with such caregivers (Bates & Dozier, 2002). In order to forge a new relationship with the young, traumatized foster child, foster parents often must make a concerted effort to demonstrate to the child that they are available to give comfort and protection. Young children growing up in nonmaltreating families typically seek comfort from their parents when they are hurt or upset. The child



31. Foster Care in Early Childhood

approaches the parent, shows or talks about the wound, receives comfort or a Band-Aid, and thus supported, goes back to what he or she was doing. For maltreated young children, this scenario may be quite different. In the past when they were hurt (possibly by the parent), the question of whether it was safe to turn to anyone for comfort was a salient one. Perhaps the parent, who might otherwise be a source of comfort, had been coming down from a drug high and was irritable and dangerous. The child might sit quietly, even in the face of significant pain, or might go elsewhere to cry. It is also possible that the child sits where he or she is and cries, unable to actively seek comfort from the caregiver. When a child who has developed this pattern of behavior to manage his or her needs for comfort arrives in a new foster home, it can be confusing. Foster parents understand that a very young infant who cries needs them to address his or her needs. An older child who is unable to actively seek comfort from the new caregiver may confuse the foster parent as he or she waits for a clearer expression of help seeking. Such children must learn not only that it is safe to seek comfort but that the new caregiver is willing to provide comfort. In many ways, it is important for foster parents to actively offer comfort as they do their best to recognize what the child needs, even if the child cannot directly communicate it. This type of behavior is part of the active effort needed to become the child’s “go-to” person.

Attachment Disorders Two types of attachment disorders have been identified (Zeanah & Smyke, 2007): disorders of nonattachment and indiscriminate sociability. Both types of disorders are defined as arising from poor rearing environments. Infants and toddlers in foster care are at marked risk for attachment disorders, both because of their earlier maltreatment experience and because they experience attachment disruptions, sometimes frequently (Dozier & Bick, 2007). Such young children must reestablish an attachment relationship with a new set of caregivers. If their earlier relationships were marked by frightening or absent caregiving, such as that found in abusive or neglecting families, young children

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may have difficulty in forging new relationships and miscue their needs for nurturance and care. Although most foster children are able to develop an attachment relationship with their foster parents, there are some children for whom extra effort on the part of the foster parent is absolutely necessary. Becoming the young child’s go-to person should be the primary goal of every foster parent. At times, the foster parent may need support and assistance in accomplishing this goal. Later in the chapter we discuss some evidence-based interventions that target this goal (Dozier, Lindhiem, & Ackerman, 2005; Fisher, Burraston, & Pears, 2005; Zeanah, Nelson, et al., 2003). Children in foster care are also at risk for indiscriminate sociability, particularly if they experience multiple placements prior to, or after, their entry into state custody. Substance-using parents often drop their children off to multiple friends and relatives as they pursue their drug use (Kroll, 2007). In addition, multiple placements following entry into state custody also place the child at risk (Lewis et al., 2007). Approaching strangers and seeking to be picked up, crying when unfamiliar people leave them, being willing to go off with someone they have just met all may be warning signs of indiscriminate behavior. It is very important that those working in the child welfare system recognize that these symptoms may be signs of marked difficulty with significant relationships. Indiscriminate behavior may persist even after the young child has established an attachment relationship with his or her foster parent. Once again, foster parents can actively assist children in the reduction of these symptoms by structuring their interactions with others and discouraging inappropriate interactions. Clinical observation suggests that these behaviors often take quite a bit of time to decrease.

DEVELOPMENTAL ISSUES FOR YOUNG FOSTER CHILDREN Challenging Behavior Foster parents may find it hard to manage challenging behavior (Heller, Smyke, & Boris, 2002) and ask for the child’s removal, particularly when there is little support for the foster parent or understanding

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of how the child’s traumatic experience may have affected him or her (Lieberman & Van Horn, 2005). Foster children with multiple disruptions in placement abound in the child welfare system (Dozier & Bick, 2007), whether due to unforeseen circumstances or to the children’s behavior. Foster care workers should anticipate difficulties with placements and institute appropriate preventive measures so that children who “test” their caregiver’s devotion to them with challenging behavior do not have the power to disrupt the placement. Young children in these circumstances need the adults in their lives to firmly but kindly let them know that the adults are in charge and will love and protect them, regardless of the children’s efforts to see if they are indeed “unlovable.”

Developmental Delays Children entering foster care typically show evidence of developmental delays and deviance in multiple areas (Leslie, Gordon, Lambros, et al., 2005; Leslie, Gordon, Meneken, et al., 2005; Vig, Chinitz, & Shulman, 2005), including growth (Wyatt, Simms, & Horwitz, 1997), speech and language development (Amster, 1999; Fox, Long, & Langlois, 1988; Stock & Fisher, 2006), gross and fine motor development (Greis, 1999; Orlin, 1999), cognitive development (Harwick & Hochstadt, 2001), and socioemotional areas (Lawrence, Carlson, Egeland, 2006; Morrison, Frank, Holland, & Kates, 1999; Pears & Fisher, 2005). Importantly, children who had entered foster care at older ages, were children of color, and had identified developmental issues were shown to remain longer overall in foster care (Horwitz, Simms, & Farrington, 1994).

Speech and Language Delays A majority of young children coming into foster care demonstrate deficits in speech and language skills (Amster, 1999; Stock & Fisher, 2006). Deficits in expressive and receptive language abilities have been linked to psychiatric disorders in young children (Prizant, Wetherby, & Roberts, 2000). Children who are unable to communicate their feelings adequately may display disruptive behavior. Addressing communication issues

through appropriate assessment and speech and language therapy is one means of helping young children regulate their challenging behavior.

Cognitive Delays Klee and colleagues (Klee, Kronstadt, & Zlotnick, 1997) assessed the cognitive skills of a sample of young foster children (all < 3 years of age). Almost half (48%) of the young children had experienced two or more placements. Using the Bayley Scales of Infant Development, 50% of the young children were mildly or significantly delayed on the Mental Development Index (Klee et al., 1997) whereas only 13% of the normative sample fell in that range. Overall, 77% of the infants and toddlers in the sample displayed at least one emotional or developmental problem (Klee et al., 1997). It is essential that maltreated children entering foster care receive comprehensive developmental screening (Horwitz, Owens, & Simms, 2000), including screening for delays in speech and language and cognitive skills—both key developmental skills. The Keeping Children and Families Safe Act (2003) requires that children less than 3 years of age who are victims of validated abuse and neglect be referred to the early intervention program in their state. Early intervention programs are important resources for those attempting to meet the myriad needs of young maltreated children (Dicker & Gordon, 2004).

Socioemotional Dysregulation One of the most challenging issues facing young maltreated children and their foster parents is the behavioral and emotional dysregulation that young children develop in response to the chaotic, inconsistent, and frightening environment presented by abuse and neglect (Heller et al., 2002), including witnessing domestic violence (Kaufman & Henrich, 2000; Lieberman & Van Horn, 2005).

Exposure to Drugs and Alcohol Many children entering foster care have experienced some level of prenatal exposure



31. Foster Care in Early Childhood

to drugs and alcohol (Astley, Stachowiak, Clarren, & Clausen, 2002; Barth, 2001). Prenatal exposure to alcohol and the resultant fetal alcohol syndrome (FAS) and fetal alcohol effect (FAE) represent the single most preventable cause of mental retardation in the United States (Nulman, Gladstone, O’Hayon, & Koren, 1998). Many individuals in the child welfare system have heard of FAS/FAE, but they may fail to recognize the behavioral, sensory, and developmental problems that are associated with the condition as well as the importance of early intervention for children affected by either condition. Programs designed to mitigate the effects of FAS/FAE are most valuable in the context of early intervention, but too frequently they are not provided to the children who so desperately need them (Burd, Cotsonas-­Hassler, Martsolf, & Kerbeshian, 2003; Kodituwakku, 2007; Manning & Hoyme, 2007). Further, parents who engage in alcohol and substance abuse may be so absorbed by their quest for the substance that they do not adequately provide for, or protect, their young children. In turn, family members may have become overwhelmed and angry as the parents fail to “get their act together” and repeatedly drop off their children and retrieve them at their convenience (Kroll, 2007). Smith, Johnson, Pears, Fisher, and DeGarmo (2007) attempted to “unpack” the effects of prenatal and postnatal substance abuse on the occurrence of maltreatment and subsequent placement in foster care (Smith et al., 2007). In a sample of 117 young children in foster care, mothers’ prenatal alcohol use was associated with child maltreatment, and prenatal use of both alcohol and drugs was associated with multiple transitions while children were in foster care (Smith et al., 2007). The harsh, stressful, and chaotic environments in which the young children of substance abusers find themselves (Kroll, 2007) place them at high risk for exposure to domestic violence and other dysregulating experiences, which may, in turn, place them at risk for multiple foster care placements. Below we review three interventions that have been developed to address the socioemotional, behavioral, and developmental needs of young foster children.

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INTERVENTIONS FOR YOUNG CHILDREN IN FOSTER CARE Attachment and Biobehavioral Catch-Up This intervention, designed by Mary Dozier and colleagues, focuses on improving the regulatory capabilities and caregiver–child relationships of infants and toddlers in foster care (Dozier, Dozier, et al., 2002; Dozier, Higley, et al., 2002; Dozier et al., 2005). The rationale for this intervention is rooted in both theory and empirical findings regarding the developmental, relational, and socioemotional needs of infants and young children. Dozier and colleagues have begun reporting preliminary results on the effects of this intervention, and a longitudinal outcome study is ongoing (Dozier et al., 2006; Fisher, Gunnar, Dozier, Bruce, & Pears, 2006). A range of problematic behavioral, emotional, and interpersonal outcomes associated with childhood experiences of maltreatment, neglect, disruptions in caregiving relationships, and disorganized attachment relationships have been identified (Dozier, Albus, Fisher, & Sepulveda, 2002; StovallMcClough & Dozier, 2004). Additionally, some of the developmental tasks associated with infancy and toddlerhood may be particularly affected by early experiences of maltreatment and disrupted relationships. Dozier and colleagues (Dozier, Albus, et al., 2002) noted that the development of organized attachment relationships and of regulatory capabilities are two salient tasks of infancy and early childhood that are vulnerable to the deleterious effects of inadequate care and relationship disruptions. Evidence suggests that young foster children, even up to 20 months of age at time of placement, are able to develop organized attachments to surrogate caregivers when those caregivers are nurturing (Dozier, Albus, et al., 2002). However, foster children whose caregivers are not nurturing are at very high risk for developing disorganized attachment relationships with them (Bates & Dozier, 2002). This finding suggests that “it is critical that foster parents are nurturing, or at least that they learn to respond to their foster children’s . . . distress in nurturing ways” if foster children are to form organized attachment relationships (Dozier, Dozier, et al., 2002, p. 10).

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Young infants rely on caregivers to provide sensitive, contingent responding, which helps them modulate experiences of physiological, emotional, and behavioral arousal. Over time and through repeated interactions, sensitive caregiving enables infants and toddlers to begin building self-­regulation skills (Dozier, Albus, et al., 2002). In contrast, some caregivers are ineffective at helping their infants modulate arousal and remain organized, and some even add to their children’s disorganization. After placement in foster care, even very young children demonstrate physiological dysregulation, as demonstrated by atypical glucocorticoid production (Dozier, Albus, et al., 2002). Evidence suggests that such neuroendocrine dysregulation is caused by separation from primary caregivers, as well as by other stressful and adverse experiences such as disorganized attachment relationships and maltreatment. Of concern are the immediate negative effects of neuroendocrine dysregulation on the developing brain and stress-­response system, and the potential negative long-term effects on the individual’s ability to effectively manage life stressors (Fisher et al., 2006). Young children who enter foster care sometimes appear inconsolable and yet push caregivers away when distressed, thereby not receiving the nurturing caregiving that they need (Stovall & Dozier, 2000). Some surrogate caregivers who would typically respond sensitively to a child’s distress do not understand how to help these children. Additionally, some caregivers have difficulty responding to a child’s distress in general, due to their own interpersonal histories and states of mind with respect to attachment (Dozier, Stovall, Albus, & Bates, 2001). Finally, these children’s histories may predispose them to feeling easily threatened and frightened, which requires particular efforts by caregivers to help them feel safe (Dozier et al., 2005). With a focus on the special needs of infants and young children in foster care and on the qualities of caregiving that can promote optimal development, Dozier and colleagues developed the Attachment and Biobehavioral Catch-Up (ABC) intervention to increase surrogate caregivers’ abilities to meet these children’s unique needs (Dozier et al., 2005). They described four

main intervention goals: (1) to help caregivers provide nurturing care, even when this is not natural for them; (2) to help caregivers recognize children’s needs for nurturance even when children do not communicate this need; (3) to help caregivers provide predictable interpersonal environments to support the development of regulatory capabilities; and (4) to help caregivers create a nonthreatening environment for children (Dozier et al., 2005). The manualized, 10-session ABC intervention was designed to be used with caregivers and their children between 10 and 24 months of age (Dozier, Dozier, et al., 2002). Sessions are conducted in the home and include practice with the child as well as discussions about key concepts and caregivers’ experiences as they apply the concepts from week to week. Early sessions are used to help the caregiver understand the child’s need for nurturing care as well as the fact that these children may not clearly signal their needs and thus may have problems receiving nurturing care. The child’s contribution to the relationship and to the challenges of providing nurturing care is emphasized, as this is often a less threatening topic initially than focusing on the foster parent’s contribution to difficulties. Videotape is used to illustrate how some babies’ behaviors directly cue adults to provide care, whereas others’ behaviors do not. Foster parents are given a homework assignment of recording how their child reacts when distressed and how they respond to the child. Additionally, caregivers learn to reinterpret the child’s behavioral signals and to become more aware of their reactions to the child’s cues as well as the importance of actively providing nurturance even if the child’s behavior does not clearly communicate the need for it. During subsequent sessions, caregivers are encouraged to create predictable interpersonal environments, with the goal of supporting children’s development of regulatory capabilities, by learning to follow their child’s lead in interactions. They are taught the difference between following a child’s lead when the child is not upset and taking the lead with a child is distressed and requires assistance. Caregivers are taught to recognize children’s engagement and disengagement signals, using taped examples of other children who responded in varying



31. Foster Care in Early Childhood

ways to a puppet (e.g., fearfully or with interest and pleasure). They are encouraged to think about what each child is communicating through their behavior and are also supported in examining their child’s cues while watching a videotape. Caregivers are asked to reflect on their own attachment experiences and to consider how those experiences affect their parenting. Dozier and colleagues (2008) reported recent findings regarding the HPA functioning of foster children who had completed their ABC intervention. Cortisol levels were measured when children were seen for the Strange Situation Procedure, a laboratory procedure designed to assess children’s attachment relationships with their caregivers. Immediately before, shortly after (15 minutes), and longer after (30 minutes) the Strange Situation procedure was completed, samples of saliva were obtained in order to assess cortisol levels. Cortisol levels for children in the ABC intervention group and in a nonfostered comparison group were initially lower than those in the Developmental Education for Families (DEF) psychoeducation control group. The results suggested that the ABC intervention, which targets the caregiver–child relationship, had affected the HPA functioning of very young children in foster care in such a way that they resembled children who had never been in foster care (Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008). A preliminary study of whether the ABC intervention affected children’s attachment behaviors was recently completed. Caregivers who completed the ABC intervention reported that the foster children in their care displayed fewer avoidant behaviors when distressed than the young foster children whose caregivers received the DEF intervention (Dozier, Brokawn, Lindheim, Perkins, & Peloso, in press). Children’s attachment behaviors were assessed through caregivers’ observations, recorded in attachment diaries over a 3-day period. Dozier and colleagues hope to extend these findings in the future with larger sample sizes, longer time frames, and additional assessments of children’s attachment behaviors. Clearly, research completed thus far indicates that the ABC intervention represents a promising approach to supporting very young children in foster care and their caregivers.

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Multidimensional Treatment Foster Care Program for Preschoolers Fisher and colleagues adapted an approach aimed at children and adolescents in foster care (Fisher & Chamberlain, 2000) for use with preschoolers in foster care (Fisher, Ellis, & Chamberlain, 1999). They proposed three important areas to address with young foster children to prevent the development of psychopathology in adolescence and adulthood: behavior problems (particularly externalizing issues), emotion regulation, and developmental delay. Team members include an early interventionist, consultants for the foster parents, and a family therapist. Foster parents receive 12 hours of intensive training and direct support and assistance in managing aggressive and destructive behavior during the course of the intervention. The family therapist also provides instruction in these techniques to biological parents to facilitate the young child’s return home. Personnel in the program acknowledge that, given the biological parents’ difficult early experiences, skill building must be approached in a systematic, appropriately paced manner that may differ in pace from that involved in training foster parents (Fisher et al., 1999). Another important component to the program is careful attention to communication among team members. Home visits on the part of the foster care consultant and the early interventionist address both behavioral difficulties and developmental delays. In addition, a therapeutic group aimed at supporting the young foster child’s interactions as well as the child’s school readiness is utilized in this approach. In addition to the intervention itself, the team works with professionals in the child welfare system to plan for long-term placement. As noted, biological parents receive a similar but slower-paced intervention that takes into account the traumatic experiences and paucity of parenting skills that many parents whose children are in state custody possess. The family’s therapist supervises and facilitates parent–child visits, which are expanded as parents master the skills they are being taught and as they begin to better cope with the variety of challenges they face. Some parents, of course, are not amenable to intervention, and in that case the child may be placed with relatives, adopted, or receive

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long-term foster care. Overall, the goal of the program is to decrease disruptions and facilitate children’s long-term emotional and cognitive development. Although Fisher and his colleagues have developed an effective program, they note that, although most children respond to intervention, some do not. In particular, children with prenatal drug exposure (but see Smith et al., 2007) and children who have lost multiple primary caregivers seem to demonstrate consistently greater levels of aggression and have greater difficulties in developing trusting connections with their caregivers (Fisher et al., 1999). Further, foster parents who are reactive in the face of child behavioral difficulties appear to experience more stress in coping with young, challenging foster children. The effectiveness of this approach was evaluated in a randomized, controlled trial of their Multidimensional Treatment Foster Care Program for Preschoolers (MTFC-P; n = 57) model compared to Regular Foster Care (RFC; n = 60) (Fisher, Burraston, & Pears, 2005; Fisher & Kim, 2007; Fisher & Stoolmiller, 2008; Fisher, Stoolmiller, Gunnar, & Burraston, 2007). The intervention approach was as described above. Regular foster care was defined as the usual services provided to a young child in foster care, according to agency policy. This could include health, dental, and mental health assessment and intervention for the child as well as an array of services provided to foster or prospective caregivers (i.e., biological parents, relatives, adoptive parents). Developmental screening sometimes occurred but primarily if delay was suspected and not on a consistent basis (Fisher et al., 2007). Fisher and his colleagues examined a variety of outcome variables as they assessed the MTFC-P model, including the success or failure of the child’s permanent placement; the number of placement disruptions and the total length of time that the child remained in foster care; the emergence of secure and insecure attachment behaviors; cortisol activity and its relationship with improved caregiving; and foster parent stress reduction and its relationship with child behavior problems. The Child Behavior Checklist (CBCL) was used to assess behavior problems. The type(s) of abuse that the child had

experienced as well as the number of different types of abuse also were coded. Three relative and six biological parent placements (total = 36%) failed in the group experiencing RFC, and three (36%) of the placements in the MTFC-P group, all biological parent reunifications, failed. Although placements generally did not fail through the first half year or so of placement, it was noted that breakdowns in placements, in both groups, usually occurred between 8 and 14 months (Fisher et al., 2005). The likelihood of further failure was almost 14 times higher than that for children who had only one placement, an important but not surprising finding. Children’s attachment-­related behaviors were examined over five 3-month intervals using a version of the diary developed by Stovall-McClough and Dozier (2004) and adapted for preschoolers (Fisher & Kim, 2007). Foster children who were randomized to the MTFC-P intervention demonstrated more secure behaviors and fewer avoidant behaviors when compared to children randomized to the RFC group. Both groups demonstrated reduced resistant behaviors over the course of the study. An important age-­related effect was noted. Overall, young foster children placed earlier in foster care showed greater increases in secure behavior than did children placed later. However, an interaction between age at placement and MTFC-P versus RFC condition was evident. Children in the MTFCP condition who were older when they first came into foster care had greater increases in their display of secure behavior than did children in the program who were placed at younger ages. In contrast, children in the RFC condition who were placed earlier showed greater increases in their display of secure behaviors than did children placed later (Fisher & Kim, 2007). Fisher and Stoolmiller (2008) examined the relationship of foster children’s cortisol activity with caregiver stress regarding children’s behavior problems. Foster parents whose young foster children participated in the MTFC-P intervention reported a rapid, marked decrease in stress, and their stress remained at lower levels throughout the year-long study. Foster parents whose foster children were randomized to RFC reported



31. Foster Care in Early Childhood

greater levels of stress sensitivity to children’s behavior problems across the duration of the study. Children in the RFC condition whose caregivers reported greater levels of stress had lower levels of morning cortisol. The MTFC-P intervention had served not only to lower caregiver stress but also to protect children from the effects of caregiver stress on the young child’s HPA axis functioning (Fisher & Stoolmiller, 2008). Children with a history of placement breakdown before the study began fared better in the MTFC-P group than did children who received RFC. This finding is especially important because multiple placements put children at risk. Children with multiple behavioral difficulties who have had poor prior relationships will experience particular challenges as they attempt to forge yet another attachment relationship. Importantly, Fisher and colleagues stressed the importance of intervening earlier rather than waiting for children to fail multiple placements and then try to intervene when they are school age or adolescents (Fisher et al., 2005).

The Bucharest Early Intervention Project The Bucharest Early Intervention Project (Zeanah, Nelson, et al., 2003) was implemented in 2001 to assess the impact of foster care as an intervention to address the effects of institutionalization on young children. The project consisted of a multifaceted baseline assessment for all children between the ages of 6 and 30 months living in institutions in Bucharest, Romania, in 2001. After medical screening to rule out frank genetic syndromes or conditions such as fetal alcohol syndrome, 136 institutionalized children were randomized into either foster care or continued institutional care. A group of 72 children from the same maternity hospitals and clinics where the institutionalized children were born was recruited to serve as a community comparison group. Extensive baseline assessments were conducted to assess language, cognitive skills, temperament, attention, brain activity, attachment, and caregiving environment (Smyke et al., 2007; Zeanah, Nelson, et al., 2003). After randomization, children were reevaluated fully at regular intervals (30, 42, and 54 months).

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The foster care intervention was based on the U.S. work of Zeanah and Larrieu (1998) and was conceived as following the child-­centered model. Foster care was new to Romania at the start of the project, having been in place earlier only for purposes of transitioning children out of institutions and, 6 months later, into international adoptive placements. The social workers with the project had case loads of 15–20 children and were in frequent contact with the project foster parents. They supported foster parents as the formerly institutionalized children transitioned to their homes and helped them address behavioral and other issues. Children residing in institutions have both very regimented and very unstructured daily lives. Meals, toileting, and bedtimes occur at predetermined times that do not take the individual child’s needs into account. For example, a child does not eat when hungry, only when food is served. Children sit for long periods of time on small potty chairs, whether or not they need to use the toilet. In contrast, “play” time is largely unstructured, and there may be relatively few toys. Thus, interaction with caregivers occurs almost exclusively during the provision of instrumental care such as bathing, feeding, and diapering, but is rare during “free” time. Children squabble aggressively over few toys, engage in stereotypies, sometimes with two or three children lined up next to each other performing the same rocking movements, or walking or running around aimlessly. Toys that could be used for pretend play, such as play food, dolls, bottles, and trucks, are largely absent. The children randomized into foster care thus made the transition from this unstimulating, at times highly structured, at other times very unstructured, environment to life with their foster families. The transition often was challenging for both child and foster parent. In addition to the foster parent training provided by a Romanian agency, foster parents visited with their young charges in the institutional setting so that they could begin to appreciate the caregiving environment from which the children would be transitioning. Children responded in a variety of ways to family life, and project social workers supported the foster child and foster parent as

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they created new families. Some had marked difficulties. For most of the children, language was an area of particular deficit, and the children’s difficulties in communicating their wants and needs, feelings and fears were challenging for the foster parents. Some children became very dysregulated and began to scream when they were upset about something. Many foster parents resided in large apartment complexes and were concerned about what the neighbors, who had little sympathy for formerly institutionalized children, would think they were doing. It was often the case that the first month was the most challenging for the new dyad, and sensitive support during this initial period facilitated the adaptation of the young foster children to their new families. Project personnel in the United States conducted weekly phone/videophone consultation with the project personnel in Romania (Wajda-­Johnston, Smyke, Nagle, & Larrieu, 2005), encouraging them to bring forward for discussion problems with which they were contending as they introduced a new model of foster care. Sessions were used to provide not only practical suggestions about how to manage difficult child behavior but also ways in which to understand such behavior from an attachment perspective and to monitor and intervene in caregiver–child relationships. Additionally, the goal was to provide support to the social workers, who would in turn provide support to foster parents as they strove to nurture their foster children. We sought to encourage social workers to recognize developmental, behavioral, and emotional issues and to interpret these for the foster parents. In turn, when project personnel implemented an intervention, they were sometimes confused as to why the foster parents did not always follow through. Having faced similar responses in our own work in the United States (Heller et al., 2002), the consultants worked with Romanian personnel to help them to gather sufficient information from foster parents to understand whether psychological issues, rather than lack of information as to how to manage child behavior, were a primary concern. Social workers were reluctant initially to ask personal questions of the foster parents, such as the nature of their early caregiving experiences. Clinical consultants

were familiar with the impact that early experiences have on subsequent development and felt that this factor was important in understanding how foster mothers responded to, for example, the implementation of a behavioral program to decrease inappropriate behavior. In this context, we identified “the child has suffered enough” syndrome, which occurs when foster parents feel sorry for a child, given their previous experiences, and feel that setting limits is unkind. Additionally, sometimes foster parents wanted the child to “like them” and felt that setting limits would work against this goal. Social workers made efforts to communicate the importance of structure, in the context of loving caregiving, for the healthy development of young children. In one case they found that a foster parent and her sister had been placed in an institution when they were 7–8 years of age because their mother could not afford to care for them. Several of the foster parents who were recruited into the project after they had previously fostered children who were adopted internationally spoke eloquently about how difficult it had been to nurture a child for 6 months, work with the child to decrease difficult behaviors, only to have the child removed, never to know where he or she had gone or how he or she was doing. Awareness of the importance of loss for Romanian foster parents informed our work in the United States. Random assignment of children to either foster care or to continued institutional care has allowed exploration of intervention effects (Nelson et al., 2007; Windsor, Glaze, Koga, & Bucharest Early Intervention Project Core Group, 2007). For example, children placed in foster care made greater cognitive gains than those who remained in the institutional setting, although foster children did not recover completely to the levels of never-­institutionalized children (Nelson et al., 2007). Further, those placed in foster care before age 2 fared better than those placed later (Nelson et al., 2007). In a smaller study examining language output, children who had remained in the institution and children exposed briefly to foster care had substantial language delays (e.g., several produced no recognizable words) (Windsor et al., 2007). In contrast, children who had been living in their foster



31. Foster Care in Early Childhood

placement for at least a year had expressive output and language comprehension similar to that of family-­reared children, although their use of more complex Romanian grammar was impaired when contrasted with family-­reared children. For the children who remained in the institution, having a preferred caregiver and being taller were related to increased language production (Windsor et al., 2007). Caregiver report of attachment disorder symptoms, particularly with regard to RAD withdrawn/inhibited, suggests that placement in foster care quickly decreases signs of this disorder (Zeanah, Smyke, Koga, & Carlson, 2003). Children who were placed into foster care at younger ages were more likely to exhibit substantial reductions in signs of RAD indiscriminate/disinhibited (Zeanah, Smyke, et al., 2003).

Addressing the Needs of Foster Parents Foster parents are essential partners in the intervention of foster care, but their needs for education and psychological support often go unmet, particularly for kin placements (Ehrle & Geen, 2002). Foster parents may struggle with the impact on their own biological children when the family is stressed by the presence of young, disruptive foster children in their home (Heller et al., 2002). Our experience in Romania showed us that support through the difficult initial period in the home when the infant or toddler is testing whether he or she can actually trust this new caregiver is essential. Further, in areas where the pool of foster parents is shrinking and the number of children in foster care is increasing, it can seem like a luxury to conduct careful selections of foster parents, but doing so is essential. Placements in which a “professional” foster parent has had many, many children but has not adopted any (Gillis-­A rnold, Crase, Chase-­Stockdale, & Shelley, 1998) may be inappropriate for infants and toddlers who need an adult willing to meet their needs for a warm, available attachment figure, not just for instrumental care. Additionally, it is essential to recognize and support the “family-­building” foster parents through their ambivalence and grief when the young foster child’s parents “get their act together” and the child is returned

511

to them. Most foster parents understand their role, but, if they are good caregivers for infants and toddlers, they will become attached to them. They take the emotional risk of loving and supporting the young foster child even in the face of the possible loss. They deserve emotional support in this situation and may be able to continue to lovingly foster children if they are given adequate opportunity to voice their concerns and their loss (Edelstein, Burge, & Waterman, 2001; Urquhart, 1989). Professionals working with such parents may feel uncomfortable knowing that the “best interest of the child” has been interpreted as a return to “good enough” parents rather than a future in the consistent, reliable and loving foster/adoptive placement in which the child has lived for at least a year. Foster parents report that they can cope more readily if they are convinced that the child will be safe in their return to their parents. Although young children are not knowingly returned to unsafe families, it is often the case that the child’s future is by no means guaranteed and that this is a challenge with which both foster parents and child welfare professionals must cope.

DIFFERENCES IN FOSTER CARE FOR YOUNGER AND OLDER CHILDREN Foster care for young children is inherently different from foster care for older, schoolage children. School-age foster children have established a solid connection with their family of origin and can interact with their parents over the telephone and during visits. These older foster children can voice their wishes to maintain a relationship with their maltreating parents and can “keep their parents in mind” even when residing with the foster family. They may feel that they are being disloyal in establishing a close relationship with their foster family and experience marked ambivalence regarding this struggle. In contrast, it is developmentally appropriate and emotionally essential for the infant and toddler in foster care to establish a relationship with the new caregiver. “Placeholding” is out of the question for the infant or toddler, who may remain with the foster

512

V. INTERVENTION

parent for the amount of time allowed by ASFA for parents to regain custody (12–15 months). In effect, one-third to one-half of a young child’s life may be spent in the home of this additional attachment figure. The infant, toddler, or preschooler in foster care may not have developed as thorough a connection with members of his or her extended family, in contrast to the school-age foster child. Further, young children in the child welfare system may not yearn as much for their biological family as they spend the vast majority of their time with their foster family. Visitation schedules that allow for 1–2 hours a week do not make it easy for young children to maintain the level of relationship with their biological parents that may be possible for a school-age foster child. There is an important, essential need for stability in the life of the young child in foster care. Although this stability is important for school-age foster children as well, they may have the cognitive capacity to maintain the relationship with their biological parents even in the face of missed visits or their parents’ disappearance. Biological parents who do not maintain regular, predictable visitation with their young children or who have left them with a variety of substitute, often uncommitted, caregivers may not understand the drive that infants and toddlers have for a go-to person and may strenuously object to the young child calling the foster parent “Mama.” Although this is a very painful experience for biological parents, who can keep in mind their relationship with their young child, infants and toddlers can not be “made” to stop calling a foster parent “Mama.” This is a word that infants and toddlers use for someone who does “Mommy things” and is based on their history with the foster parent. As Dozier’s work shows, infants and toddlers in the child welfare system thrive in the care of committed caregivers (Dozier, Stovall, Albus, & Bates, 2001). In some ways, child welfare workers understand that commitment to the care of a young child is a good thing, but they may find it “inconvenient” that a foster parent is truly devoted to a young, maltreated child (Urquhart, 1989), particularly if the workers are used to precipitous transitions during foster care. Foster care workers who are truly aware of attachment and its implications for young

children in foster care do not move children precipitously because they understand the nature of attachment disruptions for young children. The transition to the child-­centered rather than extended respite model of foster care requires that everyone in the child welfare system, from judges to transportation workers, understands the needs of young foster children and makes decisions based first and foremost on what is in the “best interest of the child”—a principle that is inevitably rooted in a careful consideration of attachment issues.

THE FUTURE OF FOSTER CARE FOR YOUNG CHILDREN Best practice for infants and toddlers in out-of-home placement should always be informed by the developmental and socioemotional needs of young children because these issues are the most salient in the lives of foster children in early childhood. Fisher and colleagues make the important point that meeting the needs of young children in the child welfare system is not only appropriately humane but cost-­efficient (Fisher et al., 1999). The cost, in human lives and in government resources, involved in managing the dysregulated, out-of-­control behavior of a maltreated adolescent whose needs have never been properly addressed is much greater than that of intervening in the life of the infant or toddler in foster care. Future directions in developing best practice for young children in foster care should draw lessons from the interventions reviewed above. For example, direct and careful training of specialized child welfare workers who appreciate and can address the needs of young foster children, including developmental and attachment issues, should be tested for its impact on the wellbeing of young foster children and their parents, both biological and foster. Ensuring that participants in the entire system—from judges through child protection and parent attorneys to foster parents—are aware of and committed to the needs of young children would go far in fulfilling the potential of foster care to serve as an effective, healing intervention for both young children and their maltreating parents.



31. Foster Care in Early Childhood

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Early intervention foster care: A model of preventing risk in young children who have been maltreated. Children Services: Social Policy, Research, and Practice, 2, 159–182. Fisher, P. A., Gunnar, M. R., Dozier, M., Bruce, J., & Pears, K. C. (2006). Effects of therapeutic interventions for foster children on behavioral problems, caregiver attachment, and stress regulatory neural systems. Annals of the New York Academy of Sciences, 1094, 215–225. Fisher, P. A., & Kim, H. Y. (2007). Intervention effects on foster preschoolers’ attachment-­related behaviors from a randomized trial. Prevention Science, 8, 161–170. Fisher, P. A., & Stoolmiller, M. (2008). Intervention effects on foster parent stress: Associations with child cortisol levels. Development and Psychopathology, 20, 1003–1021. Fisher, P. A., Stoolmiller, M., Gunnar, M. R., & Burraston, B. O. (2007). Effects of therapeutic intervention for preschoolers on diurnal cortisol activity. Psychoneuroendocrinology, 32, 892– 905. Fox, L., Long, S. H., & Langlois, A. (1988). Patterns of language comprehension deficit in abused and neglected children. Journal of Speech and Hearing Disorders, 53, 239–244. Gillis-­A rnold, R., Crase, S. J., Chase-Stockdale, D. F., & Shelley, M. C. (1998). Parenting attitudes, foster parenting attitudes, and motivations of adoptive and nonadoptive foster parent trainees. Children and Youth Services Review, 20, 715–732. Greis, S. M. (1999). Feeding disorders in infants and young children. In J. A. Silver, B. J. Amster, & T. Haecker (Eds.), Young children and foster care (pp. 65–91). Baltimore: Brookes. Guedeney, A., & Guedeney, N. (2008). The infant protection system in France: How does it work? Infant Mental Health Journal, 29, 5–20. Harwick, N. J., & Hochstadt, N. J. (2001). Intellectual functioning in abused-­neglected children. Education, 107, 76–82. Heller, S. S., Smyke, A. T., & Boris, N. W. (2002). Very young foster children and foster families: Clinical challenges and interventions. Infant Mental Health Journal, 23, 555–575. Hill, R. B. (2004). Institutional racism in child welfare. Race and Society, 7, 17–33. Horwitz, S. M., Owens, P., & Simms, M. D. (2000). Specialized assessments for children in foster care. Pediatrics, 106, 59–66. Horwitz, S. M., Simms, M. D., & Farrington, R. (1994). Impact of developmental problems on young children’s exits from foster care. Devel­ opmental and Behavioral Pediatrics, 15, 105– 110. Kaufman, J., & Henrich, C. (2000). Exposure to violence and early childhood trauma. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 195–207). New York: Guilford Press. Keeping Children and Families Safe Act of 2003, 42 U.S.C. § 5101, P.L. 108-36.

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C h a p t e r 32

Psychopharmacology in Early Childhood Does It Have a Role? Mary Margaret Gleason

F

or an increasing number of young children with psychiatric disorders, mental health treatment includes psychopharmacological agents (Zito et al., 2000). Although the group receiving medications represents a small proportion of those with psychiatric disorders (DeBar, Lynch, Powell, & Gale, 2003), the discussion of psychopharmacological treatment for young children elicits strong responses. The traditional infant mental health perspective has focused on infant–­parent relationship assessment and treatments, which have been increasingly applied to older children and their families. Infant mental health uses a developmentally focused, relationship-­centered approach to treating young children. Psychopharmacological treatment has been used by non­infant-mental-­health physicians and generally represents a downward extension of treatments used in older children. Preschool (over 36 months) psychopharmacological treatment is an area where these two approaches intersect. Attempting to integrate the infant mental health perspective with the traditional medical model, it seems that psychopharmacological approaches have only a circumscribed role in treating children between 3 and 5 years old and do not contribute to the treatment of infants and toddlers

(< 36 months). Psychopharmacological treatment for young children must be informed by evidence and provided only in the context of a developmentally sensitive, relationship­focused intervention. Considering psychopharmacological treat­ ment for early childhood psychiatric disorders is based on four premises: (1) these disorders exist and cause current and future suffering, (2) intervention for these disorders is warranted to reduce current distress and future morbidity, (3) these disorders have biological correlates that psychopharmacological treatment may target, and (4) in the current scientific, regulatory, and societal context, it is appropriate to consider using medications. The first three premises have strong support in the infant mental health literature and are generally not debated within in our field, although as a society, there is still reluctance to acknowledge the reality of early childhood mental health problems. Most infant and early childhood mental health professionals agree that clinical and empirical research clearly document that young children can and do experience clinically relevant psychiatric disorders (as reviewed in Egger & Angold, 2006) and that early childhood mental health problems are pre516



32. Psychopharmacology in Early Childhood

dictive of future problems (e.g., Lavigne et al., 1998). As a field, infant mental health is founded upon the second premise: Intervention is warranted for these early disturbances. A substantial body of literature describes the theoretical and empirical bases of this intervention (e.g., Fraiberg, Adelson, & Shapiro, 1975; Lieberman, Ippen, & Van Horn, 2006; Zeanah et al., 2001). Increasing evidence supports the premise that mental health problems, early experiences, and relationship patterns in young children are associated with biological markers, and some evidence suggests that biological abnormalities can change with treatment (e.g., Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008; Scheeringa et al., 2004). The fourth premise of preschool psychopharmacological treatment requires consideration of the multifaceted scientific, clinical, and systemic factors that impact early childhood mental health treatment. The first section of this chapter describes the complex environment of preschool psychopharmacology, with attention to the current prescribing practices, child developmental and assessment factors, treatment alternatives, and systemic considerations. The second section of this chapter reviews the evidence supporting use of psychopharmacological agents in preschoolers and describes one system of psychopharmacological intervention within an infant mental health setting.

CURRENT PRESCRIBING PRACTICES Discussion of preschool psychopharmacological treatment begins with a description of the extent of the practice. In 2000, Zito and colleagues reported significant increases in prescriptions for children 2–4 years old, with a 1.2- to 3.1-fold increase in stimulant prescriptions and a dramatic 6- to 28-fold increase in clonidine prescription rates in the early 1990s (Zito et al., 2000). By 1996, 10–18 children per 1,000 children less than 5 years old were receiving psychotropic prescriptions (Zito et al., 2003). Zito’s reports brought attention to important trends in prescribing practices. More recent data have suggested that preschool prescription rates, at least for stimulants, have since plateaued (Zuvekas, Vitiello, & Norquist,

517

2006), though rates of atypical antipsychotic prescriptions have increased (Patel et al., 2005). A number of possible explanations have been proposed to explain the increase in psychotropic prescriptions for this population in the 1990s. A benign interpretation suggests that the trend reflects increased attention to existing and impairing early childhood psychopathology, which historically has been underrecognized and undertreated (Jellinek, 2003). The trend might also reflect physicians’ increased comfort using newer medications such as selective serotonin reuptake inhibitors (SSRIs) or atypical antipsychotic agents thought to be more benign than their predecessors (Kalb, 2000). However, others raised concerns that the prescription rates represent a societal quest for the quick fix or that medications were being prescribed indiscriminately (Pear, 2000; Shute et al., 2000). Further data are needed to understand prescribing patterns, which likely represent complex interactions of multiple medical and societal factors. Although epidemiological trends in rates of prescription are valuable, it is critical to understand more about the contexts in which prescriptions are being written, including rates of prescribing, disorders treated, prescriber training, and concurrent mental health evaluation or treatment. National data focused on decision-­making processes in preschool psychotropic prescribing are not yet available. Thus, our understanding of the prescribing context is based on the two primary studies that have examined these patterns in two different populations (see Table 32.1). These studies provide a preliminary glimpse at some prescribing patterns for early childhood psychiatric disorders and highlight areas for further intervention, including the need to train primary care providers in the early childhood mental health principles and triage skills.

DEVELOPMENTAL ISSUES Biology Early childhood is a period of extraordinary brain development. The target of psychopharmacological agents, the brain grows rapidly during the first 3 years of life, reaching 80% of adult size in these first years (Needl-

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V. INTERVENTION

TABLE 32.1.  Summary of Reported Prescribing Patterns in Two Published Studies Population

HMO (DeBar et al., 2003)

Michigan Medicaid (Rappley et al., 1999, 2002)

Method

Electronic medical record review

Medicaid claims database review

Age

0–5 years old

0–3 years old

Disorder studied

Any mental health or behavioral problem

ADHD only

Number in population with a diagnosis

743

223

% with diagnosis who received prescription (N)

16 (120)

57 (127)

% of those on medications who accessed at least one mental health appointment (N)

82 (722)

26.5 (59)

% of prescribers who were primary care physicians (N)

74 (89)

Not reported

Medication–diagnosis pattern

•• Stimulants: ADHD •• Alpha agonists: sleep, aggression •• Antidepressants: no detectable pattern

•• 22 medications used •• Methylphenidate most commonly used (n = 73); clonidine second most commonly used (n = 48) •• 35% (n = 44) received more than one prescription at a time

man, 2004). In fact, children develop adultlike myelinization patterns by age 2 years and synapse formation rates peak in the first years of life (Gilmore, Weili, & Gerig, 2006; Shonkoff & Phillips, 2000). Increasing evidence demonstrates that early brain development is sensitive to environmental factors, including experiences and neurochemical factors (see Sheridan & Nelson, Chapter 3, this volume). To date, no published data have examined the impact of early psychotropic exposure on the preschool brain. Animal models (as reviewed in Vitiello, 1998) and studies of lead exposure (e.g., (Kosnett, 2001) suggest differential vulnerability depending on age of exposure to an agent, with younger brains being more vulnerable than more mature brains. The likely vulnerability of developing neural circuits is a primary reason for recommending that not take psychotropic medication not be prescribed for children less than 3 years old. Prenatal exposure to antidepressants provides the only existing data about psychopharmacological exposures early in develop-

ment, and these data are limited. Prenatal antidepressant exposure is associated with detectable but subtle differences in pain responsivity and early motor development, but not preschool intellectual development (Casper et al., 2003; Oberlander et al., 2005; Oberlander, Warburton, Misri, Aghajanian, & Hertzman, 2006). The functional significance of these differences is unclear at this time. However, these data suggest that ongoing research regarding central nervous system effects of medication exposure in preschoolers is important. Young children absorb and eliminate medications differently than older children and adults. In toddlers and preschoolers, gastric acidity, gastrointestinal track motility, proportion of total body water, and renal and hepatic metabolic rates generally result in lower plasma levels for the same medication exposure than occurs in older children (Coté, 2005). In practice, this trend must be balanced with our knowledge that young children also experience side effects more often than older children and adults



32. Psychopharmacology in Early Childhood

(e.g., Greenhill et al., 2006). Taken together, developmental pharmacokinetic issues and sensitivity to adverse effects makes titrating medications in young children a delicate balancing act.

Whom to Treat Often, parents of preschoolers with psychiatric disorders also have symptoms or disorders. For example, in one urban infant and early childhood mental health treatment program for low-­income families, 60% of mothers had clinical-level scores on the Beck Depression Inventory–II (personal communication, Letia Bailey, September 15, 2007). Recent data suggest that maternal symptoms influence child treatment outcome, and that successful maternal treatment may reduce child symptoms in older children (Weissman et al., 2006). Given the complexities of preschool prescribing, clinicians may consider treating a parent before considering prescribing for a preschooler.

Assessment and Psychiatric Diagnosis Careful assessment and diagnosis are necessary for making treatment decisions about the psychopharmacological treatment of very young children. Preschool assessment includes attention to the unique aspects of the rapid early development, sensitivity to contextual factors, and an awareness of the importance of the parent to child relationship as the central organizing context for early affective experiences. A comprehensive psychiatric assessment involves multiple visits, multiple reporters, and multiple assessment modalities. During an early childhood mental health assessment, a clinician attends not only to the data a caregiver reports, but also to the manner in which it is reported and the meaning of the symptoms to the caregiver. An adequate assessment provides sufficient data to develop a biopsychosocial formulation focused on the child, the parent, and the parent–child relationship. Without viewing a child and family’s clinical presentation through the lens of infant mental health, it can be easy to overlook important factors that could influence treatment—both protective factors that can be enhanced in treatment and factors that contribute to the development or maintenance of impairment.

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For example, a distorted working model of a child will affect how a parent experiences and therefore interprets and describes a child’s patterns of behaviors. Recognizing distorted attributions must influence decisions about further assessment, diagnosis, and treatment. Additionally, an assessment that involves psychopharmacological considerations should explore the meaning of medication treatment in the family, as parental expectations undoubtedly influence parents’ experience of medication effects and side effects. In clinical practice, it is clear that for some parents, discussion of medications means that “it’s not my fault and there is an easy fix” for some parents, whereas others interpret discussion of disorders and medication treatment as confirmation of their fears that their child is on a developmental path toward failure. Within the context of a developmentally focused formulation, systematic diagnosis guides treatment. Application of developmentally sensitive diagnostic nosology, such as the Research Diagnostic Criteria: Preschool Age (American Academy of Child and Adolescent Psychiatry Task Force on Research Diagnostic Criteria, 2003) allows a clinician to make treatment decisions based on empirical treatment evidence in older children with the same disorder. Not every child with an impairing constellation of symptoms will meet criteria for a specific disorder. However, a concerted effort to apply standard diagnostic criteria may increase rational use of medications and reduce the risk of using medications to treat challenging but developmentally appropriate patterns. Additionally, use of standard diagnostic criteria can facilitate communication across providers. It should be noted that the preschool diagnosis data are nearly all derived from studies of children over 36 months, and that the validity of most DSM-IV diagnoses in younger children has not yet be established.

PSYCHOTHERAPEUTIC INTERVENTIONS As alternatives to psychopharmacological interventions in young children, psychotherapies have a number of advantages, including fewer side effects, dosing that does not depend upon early biological development

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(e.g., absorption, distribution, excretion), and the potential for longer-­lasting effects, as seen in older children (POTS Study Team, 2004). Additionally, research has demonstrated that preschool psychotherapy can act as a powerful, bioactive treatment that impacts biological processes (e.g., Dozier et al., 2008). A limited number of randomized controlled studies has evaluated treatment of psychiatric disorders in preschoolers. Strong evidence supports manualized parent­focused treatments for children with disruptive behavior disorders, such as oppositional defiant disorder or conduct disorder (Hood & Eyberg, 2003; Webster-­Stratton, Reid, & Hammond, 2004). Cognitive-­behavioral therapy has been shown to be effective for sexually abused preschoolers, and new research shows promising results for treatment of posttraumatic stress disorder (PTSD) (Cohen & Mannarino, 1997; Scheeringa et al., 2007). Evidence-based therapies reduce symptoms in high-risk children, such as those exposed to partner violence and foster children (Dozier et al., 2008; Fisher, Gunnan, Chamberlain, & Reid, 2000; Lieberman et al., 2006). Unfortunately, empirically supported psychotherapies and early childhood mental health treatment, in general, are primarily available in academic centers. Thus, clinicians in low-­resource areas may have limited options to treat children with severe, impairing disorders and may feel compelled to use psychopharmacological agents without trials of evidence-based psychotherapies. Dissemination of evidence-based treatments and studies of real-world effectiveness is a priority for clinicians, researchers, and policymakers interested in the psychopharmacological treatment in young children.

SYSTEMS ISSUES Regulatory Issues In the United States, a small proportion of medications is approved for use in pediatrics, and many medications are used offlabel (American Academy of Pediatrics, Committee on Drugs, 2002). Only three medications—­haloperidol, dextroamphetamines, and chlorpromazine—are approved for the psychiatric treatment of children

under 5. Although a Food and Drug Administration (FDA) indication reflects empirical support, the lack of an indication does not necessarily reflect practice patterns, a lack of published evidence, or inappropriate use. For example, the methylphenidate label, the most commonly used preschool medication and one with empirical support for its efficacy, explicitly warns against use in the preschool period.

Access to Mental Health Care Access to preschool mental health care is limited on a number of levels. First, shortages in child mental health professionals are worsening in this country (Thomas & Holzer, 2006), and early childhood mental health specialists are even rarer. These shortages mean that most preschoolers are unlikely to be evaluated by early childhood specialists who could offer a full spectrum of treatment modalities. Second, professionals with limited experience in early childhood mental health are likely to be less aware of, or unable to provide, evidence-based psychotherapeutic treatments, or may be uncomfortable treating young children, such that these patients are effectively excluded from evaluation or treatment. For example, in Louisiana, until 5 years ago, community mental health centers refused to evaluate and treat children less than 6 years old. Collaborative and colocated models of health and mental health providers, consultations, postgraduate specialty training, and telemedicine may all be useful approaches to optimize the mental heath care of young children in this context (Connor, McLaughlin, et al., 2006; Savin, Garry, Zuccaro, & Novins, 2006). Third, mental health service utilization and access are increasingly impacted by directto-­consumer advertising, which may increase the potential for enhanced awareness of disorders as well as unrealistic patient expectations (Hollon, 2004). These advertisements generally do not mention the value of nonpharmacological interventions (Lacasse, 2004) and may influence how parents advocate for their children, although no directto-­consumer marketing has yet targeted preschoolers specifically. Access to mental health care is also limited in child care and preschool settings, where many young children spend their weekdays.



32. Psychopharmacology in Early Childhood

Although Head Start and some other child care providers include mental health consultation services, most child care settings do not have access to mental health care. Child care settings without mental health consultation often cannot accommodate young children with severe mental health problems, and the children may fail in those settings (Gilliam, 2005). In Rhode Island, for example, 44% of child care settings has expelled a child for behavioral problems (Rhode Island Department of Health, 2001). Parents of these children often face multiple pressures of child care and employment, and may feel compelled to seek a medication as a “quick fix” to prevent expulsion.

ETHICAL QUESTIONS Use of psychopharmacological interventions in preschoolers raises ethical questions focused on treatment in the context of less than optimal data. Ethical practice requires that physicians consider the context of the child’s presentation and the risks of psychopharmacological treatment versus risks of continuing inadequate treatment in order to make the best decision for the individual child and family. Though a full discussion is beyond the scope of this chapter, some questions warrant reflection. These questions are without definitive answers. Does the evidence support the use of preschool psychopharmacology as therapy or research? This question highlights the value of treating every psychopharmacological intervention as an “N of 1” study, with clear target symptoms, measurement approaches, and criteria for discontinuation or continuation of treatment. How much information is enough for informed consent? Most providers feel that informed consent should include attention to the FDA status of the medication, level of evidence supporting its use as well as known and possible risks, benefits, and alternatives to the medication. Can parents of extremely disordered young children have a sufficient sense of choice to make their consent truly voluntary? While no answer exists, the provider is obligated to (1) create a holding space for the parents that provides real alternatives to psychopharmacological intervention, and (2) attempt to reduce some of the external pressures on parents to use medication (or

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to avoid medication). Does an oppositional 5-year-old need to provide assent? Although parents provide official consent to treatment, engaging the child in the treatment planning process and anticipating challenges in administering treatments may facilitate the process. Can private child care settings require treatment for a child’s inclusion in program? Prescribers and nonprescribing clinicians can consider these questions when discussing treatment options with families.

MEDICATION: ONE COMPONENT OF THE TREATMENT PLAN In Louisiana’s Early Childhood Supports and Services (ECSS) program, psychopharmacological treatment is embedded within an infant mental health context for children ages 0–6 years old. All children undergo an initial screening evaluation by a physician or doctoral-level psychologist. Based on that evaluation, further referrals, information from child care providers and other caregivers, and structured evaluations focused on including structured parent–child interactions and parent perception interviews may be recommended. Children with extreme symptoms, impairment, or diagnostic uncertainty are scheduled for a follow-up with the physician and primary clinician to review the comprehensive assessment, reassess symptoms, and discuss treatment options. For each child for whom medications are considered, the risks of using a medication must be weighed against the risks of continuing inadequate treatment. If a preschooler’s symptoms continue to be impairing and the child has a diagnosis for which medications are indicated after a psychotherapy trial, the physician, primary clinician, and parent discuss the treatment alternatives. In this model comprehensive assessments and trials of psychotherapy by infant mental health clinicians provide multiple levels of information on which to make decisions about psychopharmacological treatment. Medications are generally considered only when a preschooler is over 36 months, has at least moderate-to-­severe impairment associated with symptoms of a psychiatric diagnosis, continues to have significant impairment after an adequate trial of psychotherapy and other treatment modalities (e.g., educational

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interventions, speech and language therapy, parent psychiatric treatment as needed). Also, medications are offered only when the prescriber and family can develop a shared understanding about the goals of the treatment plan, expectations about ongoing therapy participation, and indications to discontinue the therapy. Physicians in any system must always evaluate a family’s ability to maintain and administer the medication safely before prescribing. In the ECSS model children and parents continue to receive regular psychotherapy during the psychopharmacological treatment. This component of the program serves two purposes: (1) It ensures that the child and family continue to receive comprehensive, relationship-­centered treatment, and (2) it allows clinicians to observe the child on medications on a regular basis, monitoring for beneficial and adverse effects. Early childhood psychiatry is a collaborative process, and nonprescribing clinicians are important partners in the process when the prescriber is not also the therapist. In most settings nonprescribing clinicians may have opportunities for more frequent follow-up, as well as home and school observations. In some communities nonprescribing clinicians may also have more experience in early childhood mental health than prescribers. Thus, collaboration between prescriber and therapist can enhance treatment planning and monitoring. Regardless of the treatment setting, these partners can share information about past psychotherapy interventions, their diagnostic assessments and formulation, and history of symptoms before prescribing. Ideally, a physician and therapist will identify a system and schedule for information sharing, comonitoring of symptoms and side effects, and timing of the use of structured symptom monitoring tools before the psychopharmacological treatment begins. In clinical practice, when faced with a child who shows unsafe behavioral patterns or severe impairment as a result of psychiatric symptoms, clinicians must weigh the risks and make medication decisions based upon the existing database as well as other clinical factors. Because of rapid developmental processes, which may make the symptoms a moving target, and the potential for substantial responses to context changes and

therapy, medication trials can be time limited, with a plan for discontinuation and reassessment of the child’s psychiatric status when off medications. Additionally, use of “N of 1” trials, with a structured monitoring of symptoms and response and a plan for sharing the results, may improve individual care and advance the field’s understanding of medication effects in young children. Using the evidence in Table 32.1, psychopharmacological treatment of children with comorbid disorders may be guided by the level of evidence for the treatment of each disorder. For example, for a child with impairing symptoms associated with ADHD and major depressive disorder (MDD) who has not responded to treatment, ADHD treatment should precede consideration of antidepressant use.

MEDICATION EVIDENCE AND USES Table 32.2 summarizes existing evidence supporting the use of medications commonly used in preschool psychopharmacology. This table does not include all medications for which reports have been published, but only reports of commonly used medications for which individual medication effects can be interpreted.

Attention-­Deficit/Hyperactivity Disorder Stimulants are the most commonly prescribed class of medications for preschoolers. Methylphenidate is the only medication whose preschool use is supported by a large, multisite, randomized controlled trial in children 3.5–5 years old (Greenhill et al., 2006). The study found that preschoolers’ optimal daily doses varied widely, with a range of 7.5–30 mg per day, not associated with weight or age. Although the study found that methylphenidate was superior to placebo in treating ADHD, the magnitude of the effect was less than that seen in older children. As the authors noted, it is possible that higher doses would have increased the effect size, but results may suggest that stimulants are not as effective for younger children as they are for older children. This study also identified a side effect of more emotionality among preschoolers on meth-



32. Psychopharmacology in Early Childhood

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TABLE 32.2. Evidence and Regulatory Status of Commonly Used Medications in Preschoolers Randomized controlled trials in older children?

Medication

FDA indication

Preschool level of evidence

Methylphenidate

ADHD > 6 years old

ADHD: large, multisite randomized controlled trial (Greenhill et al., 2006); 10 smaller studies

ADHD (as reviewed in Pliszka et al., 2006)

Mixed amphetamine salts

ADHD > 4 years old (d-amphetamine)

None

ADHD: at least equivalent to methylphenidate (Faraone et al., 2002); first-line medication (Pliszka et al., 2006)

Clonidine

Hypertension

ADHD + sleep disturbance: retrospective chart review (Prince, Wilens, Biederman, Spencer, & Wozniak, 1996) PTSD + aggression: open trial (N = 7) (Harmon & Riggs, 1997)

ADHD: smaller effect size than stimulants (Connor, Boone, & Steingard, 2003)

Guanfacine

Hypertension

ADHD: open trial

ADHD (Connor et al., 2003)

Atomoxetine

ADHD > 6 years old

ADHD: open trial (Kratochovil et al., 2007)

ADHD (Kelsey et al., 2004; Michelson et al., 2002)

Risperidone

Autism (irritability) > 5 years old; mania and schizophrenia > 18 years old

Autism: randomized controlled trial (N = 24; minimal difference vs. placebo) (Luby, Mrakotsky, et al., 2006) Autism: randomized controlled trial (2–9 years old) (Nagaraj et al., 2006) PDD/aggression: case series (N = 53) (Masi, Cosenza, Mucci, & Brovedani, 2003) Aggression: case series (N = 8) (Cesena et al., 2000) Aggression: retrospective chart review (N = 10 on risperidone) (Staller, 2007) Bipolar disorder: open trial (N = 16) (Biederman et al., 2005)

Aggression, aggression in PDD (reviewed in American Academy of Child and Adolescent Psychiatry, in press)

Fluoxetine

MDD > 8 years old; OCD > 7 years old

Anxiety: three case reports (Avci et al., 1988; Celik et al., 2007; Wright et al., 1995)

MDD (reviewed in Bridge et al., 2007; Whittington et al., 2004) OCD (reviewed in Geller et al., 2003) Anxiety disorders (Birmaher et al., 2003)

Sertraline

OCD > 6 years old

OCD: case report of three children (Oner & Oner, 2008)

Valproate

Seizure disorder > 2 years old

Mania: retrospective chart review (N = 9) (Mota-Castillo et al., 2001)

None (highest level of evidence: open trials)

Note. ADHD, attention-deficit/hyperactivity disorder; PTSD, posttraumatic stress disorder; PDD, pervasive developmental disorder; MDD, major depressive disorder; OCD, obsessive–compulsive disorder.

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ylphenidate (compared with school-age children), although the majority of preschoolers tolerated the medication. Based on the study findings, the authors suggest that preschoolers with ADHD be started on 2.5 mg methylphenidate twice a day, with an increase to 7.5 mg three times a day over the course of the first week of treatment. In clinical practice, extended-­release methylphenidate formulations, for which no preschool data exist, are also used because these medications reduce the number of doses of medication needed per day, sometimes eliminating the need of doses during the school or child care day. A risk of these longer-­acting medications in small children is the potential for worsened side effects because the higher available doses, and some recommend that children under 16 kg not start with a long-­acting medication (Pliszka et al., 2006). Other medications for ADHD have significantly less preschool empirical support, although they may be reasonable second-line medications. For example, mixed amphetamine salts (Adderall products) have no empirical support in preschoolers, but are equally efficacious in older children and are recommended as first-line medications in treatment algorithms (Faraone, Biederman, & Roe, 2002). Alpha-­agonists, such as clonidine and guanfacine, are the second most commonly prescribed medication for preschoolers (Zito et al., 2003). In older children these medications are less effective than stimulants in treating ADHD, although superior to placebo (as reviewed in Connor et al., 2003). Although the utility of alpha-­agonists’ in treating preschoolers with PTSD and aggression has been reported, the potential for cardiovascular side effects (and even death in overdose) may limit their use in families for whom regular dosing or maintaining medications out of the reach of children is challenging (Harmon & Riggs, 1997; Klein-­Schwartz, 2002). Atomoxetine has been studied in an open trial with 22 preschoolers and shown to be well tolerated and associated with clinically significant improvement in ADHD symptoms (Kratochvil et al., 2007). This small, uncontrolled trial suggests that atomoxetine has promise as an agent for ADHD treatment in preschoolers, although this limited information would not support first-line treatment.

Disruptive Behavior Disorders Aggressive behaviors or behavior problems are the most common reason for referral for early childhood mental health treatment. While the differential diagnosis of these disorders is broad, these behaviors may reflect disruptive behavior disorders (DBDs). As described above, parent management and behaviorally focused parent–child interaction therapy have strong empirical support and should always be considered first-line treatments (Hood & Eyberg, 2003; Webster­Stratton et al., 2004). However, clinicians sometimes face situations in which the level of aggression a child is presenting is so unsafe that psychopharmacological treatments may be considered in addition to psychotherapy. It should be noted that these treatments should not be considered chemical restraints but rather short-term adjuncts to behaviorally focused treatments to maintain safety. There are no controlled studies of medications for DBDs in preschoolers. Meta­analyses in older children and adolescents describe moderate-to-large effect sizes of a range of medications, including stimulants, atypical antipsychotic agents, and mood stabilizers in treating aggression (Connor, Carlson, et al., 2006). Two retrospective chart reviews have also examined 28 preschoolers with aggression associated with a range of psychiatric diagnoses (Cesena, Gonzalez-­Heydrich, Szigethy, Kohlenberg, & DeMaso, 2002). Both described clinically significant improvement in aggression, although the heterogeneity of disorders and concomitant medications limit the generalizability of the studies. Of the atypical antipsychotic agents, only risperidone has been evaluated in controlled studies in preschoolers, primarily those with autism (Luby, Mrakotsky, et al., 2006; Nagaraj, Singhi, & Malhi, 2006). Though generally reported to be tolerated, weight gain can be substantial with these medications and must be monitored carefully. Additionally, atypical antipsychotic medications are associated with diabetes and elevated prolactin levels that require monitoring with blood tests (American Academy of Child and Adolescent Psychiatry, in press). Other medication used in older children with aggression, such



32. Psychopharmacology in Early Childhood

as lithium and valproic acid, require regular blood draws, which may limit their use in preschoolers.

Depression and Anxiety Disorders MDD is a reasonably well-­validated diagnosis in the preschool years (see Luby, Chapter 25, this volume; Luby et al., 2006). To date, however, no data exist to guide treatment decisions for preschoolers with this disorder. In the absence of either compelling psychotherapeutic treatments or supported psychopharmacological treatment, caution suggests trials of psychotherapeutic treatment as the primary mode of intervention. Little research has focused on diagnosis or treatment of anxiety disorders, with the exception of PTSD, for which empirically supported psychotherapies exist (Lieberman et al., 2006; Scheeringa et al., 2007). Published reports of pharmacotherapy for preschool anxiety are limited to five case reports describing the use of SSRIs with and without concominant medications to treat a range of anxiety symptoms (Avici, Diler, & Tamam, 1988; Celik, Diler, Thiroglu, & Avici, 2007; Hanna, Feibusch, & Albright, 2005; Oner & Oner, 2008; Wright, Cuccaro, Leonhardt, Kendall, & Anderson, 1995). Despite positive case reports, a case series of 39 children under 7 years old highlights the rate of moderate adverse effects (28%), including a substantial proportion with behavioral activation (Zuckerman et al., 2007). In older children, randomized controlled trials support the use of SSRIs, particularly fluoxetine, in major depression and anxiety disorders (Bridge et al., 2007; Whittington et al., 2004). Like the other SSRIs, fluoxetine has a “black box” warning on its label, describing the possibility of increased risk of suicidality in children and adolescents on this medication (Food and Drug Administration, 2004). Thus all children on SSRIs must be monitored closely (American Academy of Child and Adolescent Psychiatry, 2004). In this context, psychotherapy seems to present a conservative and theoretically reasonable intervention for preschoolers with MDD and anxiety disorders. Clinical experience suggests that, at most, a very small proportion of preschoolers with MDD may require

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pharmacotherapy (J. L. Luby, personal communication).

Affective Dysregulation Bipolar disorder presents the opposite picture: The application of the diagnosis itself continues to be controversial, but multiple reports describe psychopharmacological treatment of preschoolers with mania (American Academy of Child and Adolescent Psychiatry, 2007; Danielyan, Pathak, Kowatch, Arszman, & Johns, 2007; Pavuluri, Janicak, & Carbray, 2002; Scheffer & Niskala Apps, 2004; Tumuluru, Weller, Fristad, & Weller, 2003; Tuzun, Zoroglu, & Savas, 2002). Only one study has systematically assessed mania symptoms in preschoolers (Luby & Belden, 2006). The other publications, describing retrospective chart reviews, case reports, and open trials, are limited by their lack of systematic approaches to assessing the diagnosis, with one explicitly reporting that the diagnosis was applied in cases in which the cardinal symptoms of mania were not present (Biederman et al., 2005; Danielyan et al., 2007; Pavuluri et al., 2005). The increasing reports of psychopharmacological treatment of severe mood dysregulation raise a number of concerns. First, the preschoolers described in these papers clearly exhibit severe and impairing psychopathology in need of treatment. Although there are serious doubts about whether bipolar disorder exists in preschool children, there is little doubt that severe mood dysregulation in preschoolers occurs. It is vital to learn more about the family and community contexts of these problems in order to guide rational treatment decisions. Secondly, these reports describe use of atypical antipsychotic medications and mood stabilizers, often in combination, a practice with even less empirical support than monotherapy. Atypical antipsychotic medications are associated with significant weight gain, endocrine, and metabolic disorders in older children, and the long-term outcomes of early and chronic exposure have not been studied (American Academy of Child and Adolescent Psychiatry, in press). Widespread use of these medications in the child psychiatry population has potential public health implications that cannot be ignored. Finally, when treating

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preschoolers with severe emotional dysregulation, it seems necessary to consider parent–child focused psychotherapeutic interventions as adjunctive or primary treatments (Luby & Belden, 2006). Family therapy is gaining empirical support as a part of treatment for bipolar disorder in older children (Milkowitz, Biukians, & Richards, 2006). Further, aggression, which is often the major sign/symptom being targeted, is known to be reduced by specific forms of psychotherapy such as Parent–Child Interaction Therapy (Hood & Eyberg, 2003) and the Incredible Years Series (Webster-­Stratton et al., 2004)

Pervasive Developmental Disorders Children with autism and other pervasive developmental disorders (PDDs) often have comorbid psychiatric disorders (as reviewed in Tidmarsh & Volkmar, 2003). For the most part, psychopharmacological treatment decisions are similar to those in typically developing children. However, aggression and irritability, regardless of specific comorbidity, have been studied more extensively in children with PDD and/or developmental delays, often including preschoolers (McCracken et al., 2002; Nagaraj et al., 2006; Posey, Puntney, Sasher, Kem, & McDougle, 2004; Potenza, Holmes, Kanes, & McDougle, 1999; Shea et al., 2004). Recently, the FDA approved an indication for risperidone for irritability and aggression in children with autism older than 5 (Jannsen, 2006). Although risperidone is associated with significant adverse effects, including weight gain and hyperprolactinemia in this population as well as in typically developing children, the stronger empirical support for this medication in the PDD population may offset some of the risks in certain highrisk clinical settings (American Academy of Child and Adolescent Psychiatry, in press; Luby, Mrakotsky, et al., 2006a).

PRESCHOOL PSYCHOPHARMACOLOGICAL PRINCIPLES •• Any treatment, especially psychopharmacological intervention, should be guided by careful assessment and diagnosis. •• In infants and toddlers under 36 months,

psychotherapy is the treatment of choice. In preschoolers 36 months and above, psychotherapy is the first-line treatment and should precede consideration of medication and should continue if medications are used. •• Parent referral or treatment for psychopathology may optimize ability to participate in treatment as well as family mental health. •• A system to track symptoms and impairment before initiating treatment should be developed. •• Use of medications primarily to address side effects of other medications is not recommended. •• Collaboration and clear communication between nonprescribing clinicians and prescribers are important components to infant mental health treatment (Gleason et al., 2007).

CONCLUSIONS This chapter started with a question of whether psychopharmacological treatment has a role in preschool mental health treatment. For nearly all disorders, psychosocial interventions have a stronger evidence base than pharmacological treatment and may offer promise of sustained effects that are not seen with pharmacological management. However, when psychosocial treatments fail to provide sufficient relief for children with severe, dangerous mental health problems, psychopharmacological treatment may play a role in a multimodal treatment plan. This chapter has described the complex factors involved when treating preschoolers with severe psychopathology, including their rapid biological and affective development, specific assessment and diagnostic challenges, limitations of the mental health care system, and the limited evidence base supporting the use of medications in this population. The Hippocratic Oath entreats physicians to “First, do no harm.” Caution in using powerful medications is warranted. However, as physicians, we often feel obligated to intervene to prevent harm—to the patient, to the family, or to peers. Thus, we must acknowledge that the complexity of preschool psychiatric treatment means that there is no single answer that will match the needs and strengths of every family.



32. Psychopharmacology in Early Childhood

Collaborative, multidisciplinary models of care and frequent peer and specialty consultation may optimize the care a physician gives. Advocating for support for research in early childhood mental health interventions, increased training in early childhood psychopathology for physicians and other mental health providers, mental health parity (for parents and children), and child care quality all are important steps toward providing optimal psychiatric care for young children. References American Academy of Child and Adolescent Psychiatry. (2004). Physicians medguide. Retrieved April 24, 2007, from www.aacap.org. American Academy of Child and Adolescent Psychiatry. (2007). Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(1), 107–125. American Academy of Child and Adolescent Psychiatry. (in press). Practice parameters for use of atypical antipsychotic agents. Journal of the American Academy of Child and Adolescent Psychiatry. American Academy of Child and Adolescent Psychiatry. Task Force on Research Diagnostic Criteria. (2003). Research diagnostic criteria for infants and preschool children: The process and empirical support. Journal of the American Academy of Child and Adolescent Psychiatry, 42(12), 1504–1512. American Academy of Pediatrics Committee on Drugs. (2002). Uses of drugs not described in the package insert (off-label uses). Pediatrics, 110(1), 181–182. Avci, A., Diler, R. S., & Tamam, L. (1988). Fluoxetine treatment in a 2.5-year-old girl. Journal of the American Academy of Child and Adolescent Psychiatry, 37(9), 901–902. Biederman, J., Mick, E., Hammerness, P., Harpold, T., Aleardi, M., Dougherty, M., et al. (2005). Open-label, 8-week trial of olanzapine and risperidone for the treatment of bipolar disorder in preschool-age children. Biological Psychiatry, 58(7), 589. Birmaher, B. M., Axelson, D. A., Monk, K. R., Kalas, C. R., Clark, D. B., Ehmann, M. B., et al. (2003). Fluoxetine for the treatment of childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 42(4), 415–423. Bridge, J. A., Iyengar, S., Salary, C. B., Barbe, R. P., Birmaher, B., Pincus, H. A., et al. (2007). Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antide-

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32. Psychopharmacology in Early Childhood

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Pa r t V I

APPLICATIONS OF INFANT MENTAL HEALTH

A n exciting new development is the extension of infant mental health beyond the clinical treatment of infants and parents to other relationships and settings. Infant mental health has a much more visible profile than when previous versions of this Handbook were published. Indeed, the field has been embraced by many policymakers based on increasing evidence of the potentially powerful effects of prevention and early intervention. That makes this an exciting but also a challenging time. Determining which aspects of infant mental health can be applied in nontraditional settings and what skills are necessary to teach which professionals to enhance infant mental health in those settings is a vital issue for the field. In Chapter 33 Hinshaw-­Fuselier, Zeanah, and Larrieu highlight a number of issues of training that follow from efforts to apply infant mental health in settings that extend well beyond the consulting room. They delineate goals of training in infant mental health and describe a framework from which to consider the similarities and differences among the various disciplines involved in infant mental health practice. They emphasize the importance of maintaining fidelity to training models and ensuring accountability, and they call for the development of an empirical base for training in infant mental health. Next, Zeanah and Gleason (Chapter 34) consider the application of infant mental health in pediatric health care settings. They convincingly argue that these settings provide a number of avenues from which to enter and enhance adaptive qualities of developing infant–­caregiver relationships. Importantly, Zeanah and Gleason also consider challenges to integrating an infant mental health perspective into primary care settings. First, they note that the relational framework of infant mental health represents a paradigm shift for primary care providers, who typically focus on the direct needs of the child. Second, they consider the inherent difficulties in developing a system of referrals to mental health services. Third, they also underscore the reality that developing mechanisms for reimbursement remains a challenge. They conclude by arguing that the application of infant mental health

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in primary health care settings should lead to increased and appropriate early care for infants and parents and also provide opportunities for developing innovative interventions, strengthen interdisciplinary collaboration, and extend knowledge about infant mental health to more infants and families. In Chapter 35 Johnston and Brinamen describe the application of infant mental health to child care settings. They note that huge numbers of young children in the United States spend many hours a week in child care, and as a result, mental health consultation in those settings is burgeoning. The approach they outline, derived from an extension of infant–­parent psychotherapy, maintains a focus on the infant–­parent relationship through attending to the network of relationships surrounding the young child in child care. Chapter 36 concludes the section as Nagle provides an overview of the economics of infant mental health. From its origins, the field of infant mental health was derived from the premise that intervening early in the life of a child was more cost effective than waiting until later, but evidence in support of this premise was lacking. Nagle argues that we have sufficient evidence at present to support the premise that prevention is more cost effective and more effective than remediation and that prevention efforts ought to begin as early as possible. He concludes with an example that illustrates making the economic case in a real-world effort to enhance the quality of care provided to young children in child care settings.

Chapter 33

Training in Infant Mental Health Sarah Hinshaw-­Fuselier Paula Doyle Zeanah Julie Larrieu

R

ecent years have witnessed an increasing awareness of the social, emotional, and behavioral health needs of young children. Researchers and clinicians have made efforts to apply results of developmental research to prevention and intervention with families with young children. Despite the proliferation of materials on the clinical application of research findings, the field remains uncertain regarding how to prepare professionals from various fields to provide services to families with young children. In part, the lack of consensus on how to train professionals may be related to defining the scope of infant mental health. In this chapter we use Johnston and Brinamen’s (2005) conceptualization, who described infant mental health as “a set of principles, a field of practice, and a state of being” (p. 269). We understand “state of being” to encompass the complete mental health of the infant, including the individual, social, and emotional development of the child and the caregiver, and the state of their relationship, including their subjective experiences and their objective (i.e., observable) interactions. Practitioners and proponents of infant mental health come from many disciplines, with varying types of skill and training in their “discipline of origin.” Many practitio

ners who potentially could provide infant mental health services come from disciplines that are not mental health professions, per se, and thus role definition becomes problematic. Who practices infant mental health? What does the practice of infant mental health encompass? The education and training of many mental health clinicians do not include any focus on the development and treatment of infants and toddlers. As a result, even clinicians trained to work with children tend to work exclusively with those in middle childhood and beyond, unless they have been specifically trained in infant mental health. On the other hand, non-­mentalhealth practitioners who routinely work with young children (e.g., early interventionists, nurses, speech therapists, primary care physicians, child care providers) are not trained in mental health, yet they are in prime positions to guide and support parent–child dyads and to make referrals to mental health specialists when significant problems are apparent. Growing numbers of such professionals are being expected to work within the relationship context to promote “infant mental health,” regardless of their preparation to do so. In the midst of this broad field, then, can be found room for confusion regarding the practice of infant mental health 533

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and the boundaries that define the roles of the professionals who practice it. Expertise among professionals working with young children and their families ranges from a detailed understanding of development, including an appreciation for the interplay between the infant and his or her caregiving environment, to ameliorating risks and building upon protective factors, to identifying and treating psychopathology in infants and caregiving relationships. Although some of these efforts cross disciplines, each discipline has a unique purpose into which infant mental health practice can be incorporated to varying degrees. Clearly, the way in which the practice of infant mental health is defined has implications for training efforts in the field. A perusal of various training programs around the country illustrates the different interpretations of infant mental health practice and the perceived training needs associated with each (cf. Center for Early Education and Development, 2007). Intensity and breadth of training vary widely, from brief introductory presentations on infant mental health, to mini-­courses or training “institutes,” to months-long intensive training for mental health professionals. Though actual data about learner needs are lacking, training often seems to depend on the merging of interests or perceived needs of learners, and the skills, experience, and availability of trainers, as well as the availability of funding. In some cases, state-level legislation exists that helps shape training efforts through such avenues as the ongoing educational requirements various professionals must meet (e.g., Michigan, Florida). As training programs develop to meet the demands of the rapid expansion of the field of infant mental health, concern regarding accountability in training and practice has grown. As a result, infant mental health credentialing and endorsement systems are becoming available in some states (e.g., Michigan, New Mexico, Texas). These systems offer extensive guidelines regarding competent practice at varying levels; they cover knowledge base, skill level, and experience across a range of areas of practice, from direct practice to administration, research, and policy. Credentialing systems are intended to be cross-­disciplinary; that is, they

are applicable for service providers ranging from child care workers to early intervention specialists, health and allied health professionals, as well as mental health clinicians from various disciplines. The interpretation and implementation of these systems differ among the states that are promoting them, and there is no widely held agreement regarding the training needs of each group, nor about the best way to deliver training and information. Nonetheless, the endorsement efforts have spurred dialogues about these issues and potentially provide an avenue through which to address competency in the field. In this chapter we propose broad goals for professional training in infant mental health. We present a consolidated model, the Levels of Family Involvement for Infant Mental Health, to guide the direct practice of infant mental health, such that role definition and the concordant training needs are clarified. We also review some of the needs and challenges of training the work force in infant mental health and discuss the gaps in understanding and agreement regarding these approaches. We consider accountability among professionals trained in infant mental health, including a discussion regarding endorsement and certification efforts, as well as research needs and ethical issues.

GOALS FOR TRAINING Based on Johnston and Brinamen’s (2005) conceptualization of infant mental health, we propose three overarching goals for meeting the training needs in this field of practice: First, define and promote a core set of principles pertaining to the understanding of infant development in context that is relevant to the training of all practitioners who work with young children. Second, develop and refine training experiences that differentially develop the knowledge and skills appropriate to the degree to which professionals should be involved with an infant’s state of being, based on their discipline of origin. And, third, provide supervision/consultation that promotes professional development in the context of a supportive relationship.



33. Training

Goal 1: Promote Principles The first goal implies that trainers should promote a core set of principles that are central to working with young children in their biological, relational, and cultural contexts, across disciplines. Guiding principles of infant mental health provide a backdrop against which content of training can be more clearly defined to ensure some uniformity of understanding across the field of infant mental health. Core principles of infant mental health focus distinctly on the relationship context and have been outlined previously (see Table 33.1). Extrapolating the principles into specific training content poses challenges, such as how to establish agreement about core content across disciplines, and how to handle material that may be controversial. In a field in which there is an explosion of awareness and material written for practitioners from many disciplines, research on best approaches has not kept pace. In other words, how does one determine that a topic has enough theoretical and/or empirical support to be widely taught? Other challenges include determining what “evidence” is needed to constitute “evidence-based training.” How broadly should theory, practice, and educational approaches be tested before they are incorporated into training programs (e.g., are approaches appropriate for families from different cultural or ethnic origins, geographic locations, socioeconomic status groups)? Who—or what entity (if any)—should make such decisions? There is no current consensus about such issues nor a clear process in place for evaluating how such consensus should be determined. Practitioners outside the field of mental health are often in the best position to intervene or refer children in need of services because young children are most commonly seen by pediatricians, health care providers, and/or child care providers. Children at risk may be seen by early interventionists, which may include occupational therapists, physical therapists, speech therapists, as well as medical and nursing specialists; others may be involved in foster care or the legal system. Some families with young children traverse all of these systems. In each of these examples, the professionals have specific goals and activities that they are trying to accomplish, and attention to the parent–­

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TABLE 33.1.  Principles of Infant Mental Health 1. Infant mental health is considered synonymous with healthy social and emotional development. 2. Warm, nurturing, protective, stable, and consistent relationships provide the fundamental building blocks of infant mental health. 3. Behavioral “markers” of infant mental health include emotion regulation, the ability to communicate feelings to caregivers, and active exploration of the environment. These behaviors lay the groundwork for later social and emotional competence, readiness to enter school, and better academic and social performance. 4. Risk and protective factors have been clearly identified that relate to current and later function; infants can experience psychological disorders in the first 3 years of life. 5. Any factors that impact the relationship between the infant and caregiver have the potential to impact the infant’s mental health. 6. A continuum of services is needed to address preventive and treatment aspects of infant mental health; integration into existing networks and cross-­system collaboration are essential. 7. Programs that address infant mental health must focus on relationships, be based in current developmental knowledge, and be supportive of the family. 8. Families need to be involved in the planning and delivery of infant mental health services. 9. Values, including personal, familial, ethnic, cultural, professional, and organizational, impact every aspect of infant mental health. Professionals working with infants and families need training and supervision in order to meet the social and emotional needs of children and families appropriate to the range and scope of services provided.

infant relationship is usually not the primary focus of their work. Nevertheless, because of the emphasis on prevention in infant mental health, there is growing interest in the need for these groups to have a working knowledge of infant mental health, including the ability to provide screening, education, and other forms of prevention and early intervention. Any efforts to routinely incorporate such practice into these disciplines, even rudimentarily, will require training for professionals in these areas.

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For infants and parents receiving mental health services, it is unlikely that their mental health provider has knowledge or skill in infant mental health. Education about infant mental health principles and practice is rarely included as part of the education and training in psychiatry, psychology, or social work. As a result, most mental health practitioners do not treat young children, consider their needs when treating other family members, or know when to refer a family to an infant mental health clinician. For example, few adult mental health providers systematically consider the adult client’s symptoms in the parenting context. Although adult psychiatric symptoms may be treated, the concomitant effects on parenting ability are likely not addressed, despite the well-­documented risk parental mental illness poses to young children (see Goodman & Brand, Chapter 9, this volume). When one considers the number of young children who may be affected by their parents’ mental health issues, the need for all mental health professionals to be trained in infant mental health concepts becomes clear. Similarly, assessment, diagnosis, and treatment of infants and young children are complicated matters. Symptoms must be understood within a developmental context, including careful consideration of a range of issues, from distinguishing normative developmental perturbations from clinical disturbances, to the influence of development on the symptom picture, to the vulnerability of young children to environmental risk (Zeanah, Boris, & Scheeringa, 1997). For example, a young child referred for “hyperactive” behavior may be quickly prescribed stimulant medication unless trauma, parent–child relationship problems, abuse, parental depression or domestic violence, or other possible contributing factors are carefully assessed and ruled out. Because many child mental health providers are not trained to consider or assess such problems in young children, it is possible that children are actually misdiagnosed, even if specific symptoms receive treatment. We believe mental health clinicians should have, at a minimum, sufficient knowledge to identify risk and contextual factors that may impact young children directly (as in the case of trauma and “hyperactive” behavior) or indirectly (as in the case of the effects of

parental mental illness on children’s wellbeing). In addition, the field should support training programs and supervision/consultation that allow mental health professionals to subspecialize in infant mental health in order to provide direct treatment to young children and their caregivers.

Goal 2: Differential Training A second goal for training is to go beyond a basic understanding of key concepts in development so that practitioners learn to attend to the state of being of the infant and parent. Thus, training experiences need to be tailored differentially to enhance the knowledge and skills of practitioners who will intervene with the infant caregiver relationship. The degree to which professionals are explicitly involved with, or focused on, the infant–­parent relationship can be expected to vary based on their discipline of origin, including their prior education, training, and experiences. Training should support the depth of intervention required by the goals of the profession. Just as it is desirable to individualize treatment protocols in order to make intervention most beneficial to each client, so also can training effectiveness be maximized by tailoring it to the unique needs of each group. When training extends beyond basic concepts, individualized efforts can address the different needs, perspectives, and goals of professionals from multiple fields. For example, as awareness of the importance of the caregiving relationship on infant development across domains has grown, there has been movement in fields such as speech therapy, physical therapy, and occupational therapy to work with parents and other caregivers when delivering services to young children, rather than working with the children in isolation (Dunn, 2003). As these practitioners become more intimately involved with families, it is essential that they have an understanding of the infant–­ caregiver relationship, including the way in which it impacts the success of the intervention they are implementing. These practitioners also need to know how to work within the relationship to achieve their goals of promoting motor or language development, including maintaining appropriate boundaries and referring for mental health services



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when psychological or relationship barriers to successful intervention arise. The latter may require additional training to develop knowledge and skills that are not routinely included in their educational experience. Conversely, a group of mental health practitioners may already possess a good understanding of boundaries when working intimately with families, yet not understand early development in the same detail as professionals in the health and allied health fields. Training for such practitioners may weighted more heavily on development and psychopathology, so that they can focus on treatment goals of improving the quality of the parent–child relationship and also recognize when to refer a child and parent to another specialist to assist the family with other developmental goals. Thus, the way in which a trainer teaches a group about more advanced concepts in infant mental health will vary depending on the information particular group members need and the goals of their practice. At the same time that individualized training is desirable when practitioners are specializing in the application of infant mental health to their chosen field, the multidisciplinary influence of the broad field of infant mental health need not be lost. Maintaining a balance between the two is challenging, however. Consider, for instance, the way in which symptoms are discussed and treatment plans are developed in light of the discrepancy about diagnostic constructs when defining behavioral symptoms in infancy. A recent study found that when evaluating symptoms as sensory overresponsivity versus anxiety, psychologists and occupational therapists tended to classify the symptoms based on professional perspectives rather than shared understanding of the behavior (i.e., occupational therapists were more likely to call the symptoms a sensory processing disorder; psychologists were more likely to call the symptoms an anxiety disorder), and the recommendations for treatment also followed professional perspective (Ben-­Sasson, Cermak, Orsmond, Carter, & Fogg, 2007). When professionals interpret similar symptoms through different lenses, their language, emphasis and level of concern, and contextual perspectives affect assessment and intervention, as well as how explanations are provided to the parent. Whereas

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single-group training allows for discussion of clinical issues as they are understood within the professionals’ discipline of origin, multidisciplinary group training stimulates professionals to consider different explanations for commonly seen behavior. A significant challenge for trainers in the field, then, is to be sensitive to these different “languages” and professional cultures as they attempt to integrate them into a coherent approach to the promotion and practice of infant mental health across disciplines.

Goal 3: Provide Supervision/Consultation The third goal we propose for training in the field of infant mental health is the inclusion of ongoing supervision/consultation to facilitate effective assimilation and implementation of training material. Though there exist no data about how much supervision is “enough” for whom, it has been recognized that professionals, even those with much experience, need supervision as they attempt to incorporate into their practice new material learned in training (Fenichel, 1992). Moreover, work with young children and their families often engenders strong positive and negative feelings about the child and/or caregiver. The need for mental health consultation/supervision for professionals working with young children and their families has been widely recognized (e.g., Boris et al., 2006; Gilkerson & Als, 1995; Johnston & Brinamen, 2005; Weider, Drachman, & DeLeo, 1989). Just as the training content varies among professionals, so, too, do the specific needs for supervision vary. For example, for many non-­mental-health professionals, attention to the emotional experience of the client or the self has not traditionally been part of their work; thus the focus of supervision may be to manage both new content and new interpersonal processes in their work. For mental health professionals, subspecialization in infant mental health requires new ways of thinking—and practicing—­clinically. In addition to requiring clinicians to develop new skills, this new clinical paradigm may tap previously unexamined emotional responses in themselves. Although supervision is common to most professions during training as well as in the workplace, it takes many forms, depend-

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ing on the goals. For example, the goals of “administrative” supervision are often focused on quantity/adequacy of work output, quality assurance, adherence to policies and procedures, and evaluation of the supervisee (Michigan Association of Infant Mental Health, 2002). The frequency, duration, and style of the supervision can vary greatly. For example, health and education professionals often work toward the goal of acquiring specific knowledge and skills by observing the supervisor perform a procedure or technique, then practicing it, followed by feedback from the supervisor, eventually demonstrating their own proficiency with the procedure. Supervision typically decreases as the learner increases in proficiency and knowledge and develops the capacity to perform reliably and consistently, according to the identified practice standard. In both of these examples, the supervisor is in a role of power over the supervisee (e.g., can give the supervisee a grade or make recommendations for hiring, promotion, and firing decisions) and the focus is on the accomplishment of the task, and less on the learning experience of the supervisee. In mental health professions, similar administrative and learning processes occur, but the learner’s experience, thoughts, and feelings are also emphasized; the supervisor helps the supervisee understand transference and countertransference issues related to his or her practice, based on the idea that the practitioner’s personal and professional experiences will affect his or her ability to understand the client and to make clinical decisions in the best interest of the client. This is a more intimate experience wherein the growth of the supervisee, professionally and personally, is considered as important as the honing of clinical skills and knowledge. Supervision or “consultation” may continue for mental health clinicians after formal training is completed and often takes place outside of the workplace. The clinical supervisor/consultant may or may not have direct clinical responsibility for the actions of the supervisee and often is sought by the supervisee because of the supervisor’s special knowledge or expertise. Thus, there is more equality between the supervisor and supervisee, and more of a collaborative approach; the quality of the supervision depends upon the development of trust and open commu-

nication within the supervisory relationship (Michigan Association of Infant Mental Health, 2002). While mental health consultation may not be practical or feasible in all situations in which professionals are working with young children, aspects of clinical supervision are increasingly being recognized as a critical piece of helping all practitioners who work with young children manage their experience and deal with the myriad of concerns that are raised in this work. “Reflective supervision” has gained popularity in the broad field of infant mental health. Jeree Pawl defined reflective supervision as “a respectful, understanding and thoughtful atmosphere where exchanges of information, thoughts, and feelings about the things that arise around one’s work can occur. The focus is on the families involved and on the experience of the supervisee” (Shahmoon Shanok, Gilkerson, Eggbeer, & Fenichel, 1995, pp.  43–44). The goal of reflective supervision is to appreciate the “complex nest” of relationships that are involved in providing services to families with young children, and the parallel processes, or experiences, that occur between the child and parent, parent and professional, and professional and supervisor. Pawl summarizes the “essential aspect” of the supervisory relationship to be “Do unto others as you would have others do unto others,” and posited that the relationship between supervisor and supervisee sets the tone for how the professional works with the child and family (Parlakian, 2001). Increasingly, there is recognition not only of the need to provide supervision to practitioners as part of ongoing training, but also to train supervisors in reflective practice (e.g., Dawley, Loch, & Bindrich, 2007; Johnston & Brinamen, 2005), as it represents a shift in the requisite skills and roles of supervisors in the workplace (see Michigan Association of Infant Mental Health, 2002, for a discussion of the differences between reflective and administrative supervision). From our experience, it can be challenging for a supervisor who has previously provided administrative supervision to move into the role of reflective supervision. Often, it is easier to “fall back” into getting a report of how many cases are being seen, reviewing paperwork, and discussing administrative issues rather than feeling comfortable with reflection on



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difficult problems that may not have clear or simple answers. Helping the supervisee with his/her own strong feelings and providing guidance about how to manage such feelings, both in the moment and in the context of the client–­professional relationship, is difficult. Issues such as maintaining confidentiality, getting help for the supervisee when personal traumas or issues are beyond the skill/expertise of the supervisor, balancing the needs of the supervisee with the family, balancing administrative issues with clinical issues, and dealing with the supervisor’s own need for support and guidance are frequently encountered. In summary, the goals we have proposed support a coordinated training effort in the field of infant mental health, such that professionals engaged in training others develop formalized methods for agreeing on appropriate training content and processes that can be tailored to the unique needs of particular professional groups. Consideration needs to be given to the roles and boundaries of the various professionals who are providing direct services to families, as well as those who are providing training and supervision to such professionals. Finally, we believe that attention to the process of service delivery is an inherent part of successful prevention and intervention efforts, and that appropriate consultative support for practitioners and their supervisors should be considered part of ongoing training efforts.

TRAINING FRAMEWORK In an effort to follow the goals outlined above and address some of the questions pertaining to training in the field, we adapted a model that is in use in other professions that struggle with similar issues of training and role definition. The Levels of Family Involvement for Infant Mental Health Model (LFI-IMH; see Table 33.2) was adapted from the model originally developed for family-­centered medical practice (Doherty & Baird, 1986) and later adapted for school psychologists (Doherty & Peskay, 1992) and parent educators to help delineate the boundaries between parent education and family therapy (Doherty, 1995). In a small study (Marvel, Doherty, & Weiner, 1998), family practice physicians who completed a fellow-

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ship in marital and family therapy demonstrated higher levels of patient involvement in medical interviews, emotional support to patients, and family involvement in the medical process, than did physicians in the control group, who did not have specialized training. Interestingly, the length of office visits did not vary between the two groups. These findings are relevant to the field of infant mental health because they suggest that practitioners from a non-­mental-health discipline can provide emotionally supportive, relationship-­oriented services to clients without increasing the amount of time spent with them. Given the importance of the relationship context for the development of the infant, we assert that the provision of broadbased training in infant mental health to all practitioners serving infants and their families is a pathway to delivering the preventive intervention services that have long been a part of the field of infant mental health. The LFI-IMH outlines goals, requisite knowledge base, skills, and supervision needs, as well as qualities of personal development that are desirable for various levels of work with young children and their families. Previous efforts to outline training content have emphasized the areas shared by various disciplines, while recognizing that practitioners from different fields require varied depths of knowledge across these shared content areas (Zeanah, Larrieu, & Zeanah, 2000). The LFI-IMH furthers the previous efforts by delineating more specific levels of knowledge and the associated skills and supervision required for professionals from different fields to intervene with respect to the infant’s state of being at varying levels of intensity. This approach supports multidisciplinary collaboration in an effort to provide the best services to infants and toddlers and their families. At the same time, the model supports professionals practicing within boundaries appropriate to their respective disciplines, experience, and available training and supervision. The model can be used as a guideline for professionals to develop content and process-­oriented training to promote sensitive practice with young children and their families. Similar to some early intervention models of service delivery (see IDEA Infant and Toddler Coordinators Association, 2008), the LFI-IMH is a three-level model that ad-

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TABLE 33.2. Levels of Family Involvement for Infant Mental Health Level 1: Promotion, awareness, and collaboration •• Early intervention (case managers, speech therapists, occupational therapists, physical therapists, early intervention specialists) •• Health care (nutritionists, pediatric nurses, pediatricians, obstetricians, family practice physicians) •• Child welfare systems (child protection workers, attorneys, family court judges) •• Education (teachers, child care providers, administrators) Goals   1. Improvement in the identified area of concern (e.g., increased motor skills in a nonwalking toddler referred to physical therapy).   2. Understand the development of the child and of the caregiver, and understand the importance of the relationship between the two; advocate for the relationship. Knowledge base   1. Content information in the professional’s specialty.   2. Basic knowledge of social and emotional development for children ages 0–3 years.   3. Basic understanding of the importance of the parent–child relationship in the development of young children, particularly as it relates to the professional’s area of specialization (e.g., how speech delays may be influenced by the parent–child relationship).   4. Basic knowledge of impact of stress (e.g., environmental stress, developmental disability) on parent– child relationship and child outcomes. Personal development: Openness to engage families in collaborative ways. Skills   1. Communicating information clearly.   2. Eliciting questions and areas of concern in the professional’s area of specialization.   3. Conducting informative family conferences regarding professional’s area of specialization.   4. Making pertinent and practical recommendations in the professional’s area of specialization.   5. Generating mutually agreed-upon action plans for addressing concerns in the professional’s area of specialization.   6. Respecting cultural concerns that families raise and being sensitive to cultural differences in delivering care.   7. Providing information on community resources in the professional’s area of specialization. Supervision •• Prior to licensing, supervision provided by licensed professional in the area of specialization; following licensing, supervision as needed/dictated by field of specialization. •• Peer supervision, as needed, for support and supervision from a mentor who provides feedback and ongoing learning in professional’s area of specialization. •• Periodic training, consultation, or other professional development activities to support ongoing understanding of basic social–­emotional contexts for young children. •• Regularly scheduled reflective supervision may be useful. Level 2: Preventive intervention •• Licensed mental health clinicians •• With supervision from licensed mental health professionals: •• Early intervention (speech therapists, occupational therapists, physical therapists, early intervention specialists, case managers) •• Health care (nutritionists, pediatric nurses, pediatricians, obstetricians, family practice physicians) •• Child welfare systems (child protection workers) •• Education (teachers, child care providers, administrators) Goals   1. Support of healthy parent–­infant relationship behavior.   2. Identification of psychological, environmental, or caregiver–child relationship barriers to improvement in the identified area of concern and/or healthy relationship behavior.   3. Provision of basic interventions regarding psychological, environmental, or parent–­infant relationship issues that are interfering with progress in the area of concern.

(contiinued)



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TABLE 33.2.  (continued) Knowledge base   1. Risk factors related to parent–­infant relationships.   2. Signs of disturbed parent–­infant relationships.   3. Basic knowledge of impact of stress (e.g., environmental stress, developmental disability) on parent– child relationship and child outcomes.   4. Knowledge of basic supportive intervention modalities in infant mental health (e.g., Reflective Developmental Guidance, Speaking for the Baby).   5. Basic understanding of developmentally appropriate diagnostic considerations in infant mental health (i.e., recognition of need for evaluation of problems such as attachment disorders, PTSD, and other relationship disturbances).   6. Ability to recognize individual psychopathology (e.g., maternal depression) and its impact on the relationship with the young child.   7. Legal and ethical issues. Personal development •• Awareness of one’s own feelings in relation to family members, and ability to tolerate family members’ feelings without fleeing or trying to fix them. •• Awareness of one’s own participation in systems, including one’s own family, client family systems, and larger community systems. •• Awareness of how one’s own experiences influence one’s perception of parent–child relationships. Skills   1. Eliciting expressions of feelings and concerns.   2. Engage in empathic listening.   3. Recognizing feelings and reactions.   4. Creating an open and supportive climate.   5. Recognizing gross impairments in the social and emotional development of young children and engaging the family in making appropriate arrangements for a more comprehensive developmental evaluation when appropriate.   6. Recognizing risk factors and obtaining appropriate supervision to elicit more information or making appropriate referral.   7. Recognizing signs of disturbed parent–­infant relationships and making appropriate referral.   8. In group settings protecting a family member from too much self-­disclosure.   9. Asking questions and making observations about interactions to acquire a detailed picture of the parent–child relationship. 10. Developing a hypothesis about the behaviors and individual perceptions involved in the problem. 11. Working with the family for a short period of time to facilitate change in the parent–child relationship (e.g., helping parents and children understand each other’s needs and communications; facilitating the development of sensitive, age-­appropriate caregiving behavior in the parent). 12. Being aware of professional competence and boundaries, and referring when issues are beyond the scope of one’s skills and ethical practice. 13. Recognizing individual pathology in caregivers and making appropriate referrals to address it. 14. Orchestrating a referral by educating the family and the therapist about what to expect. 15. Engaging families in collaborative problem solving. 16. Tailoring recommendations to the unique needs and concerns of the family. 17. Working closely with therapists and community systems. 18. Maintaining appropriate professional boundaries with families. 19. Recognizing impact of cultural issues and helping the family use its cultural resources to address a problem. Supervision •• For all, prior to licensing, supervision provided by licensed professional in the area of specialization; following licensing, supervision as needed/dictated by field of specialization. •• For non-­mental-health clinicians, close and regular supervision and mentoring provided by an infant mental health professional to support appropriate intervention and maintenance of appropriate professional boundaries. •• For mental health professional, recommended regular consultation with other infant mental health professionals; regularly scheduled peer supervision for support and feedback. •• For all, peer supervision, as needed, for support and for feedback in professional’s area of specialization. (continued)

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TABLE 33.2.  (continued) Level 3: Clinical intervention Optional: Training and supervision •• Mental health clinicians Goals   1. Provision of comprehensive, relationship-based assessments to identify all areas of concern regarding the child, caregiver, and the relationship context.   2. Provision of intensive relationship-based treatment to change the developmental trajectory and facilitate sustained improvements in dyadic interactions; provision of adjunctive individual therapies when indicated.   3. For clinicians with clearly developed expertise in infant mental health, facilitation of relationshipbased practice through training and consultation to, or supervision of, both mental health and non­mental-health practitioners may be a goal. Knowledge base   1. Caregiver–child relationship assessment.   2. Common intervention techniques in infant mental health (e.g., interaction guidance, infant–­parent psychotherapy).   3. Internal working models (i.e., parents’ perceptions of their children; adult attachments).   4. Understanding of individual psychiatric diagnosis (i.e., ability to use DSM and ICD classification systems) and ability to diagnose problems in parent–­infant relationships, including familiarity with DC:0–3R.   5. Family systems and patterns whereby distressed families interact with professionals and other community systems.   6. For clinician trainers, teaching methods and up-to-date critical analysis of relevant literature in the field. Personal development: Ability to handle intense emotions in families, children, and self and to maintain one’s balance in the face of strong pressure from family members or other professionals. Skills   1. Interviewing families or family members who are quite difficult to engage.   2. Working intensively with families during crises.   3. Interpretation of relationship assessment tools.   4. Defining goals for intervention and engaging in intervention strategies to achieve those goals.   5. Interpreting children’s behavior in a way that allows parents to see their children differently.   6. Creating a safe “holding space” in which parents can explore how their early experiences may be affecting their relationship with their child.   7. Facilitating therapeutic play.   8. Working on culturally related stress and conflicts that are impairing the family.   9. Negotiating collaborative relationships with other professionals and systems, even when these groups are at odds with one another. 10. Using consultation with colleagues (e.g., reflective supervision) to understand one’s own reactions to families, which may be impacting delivery of clinical services. 11. For clinician trainers, ability to guide other practitioners in their provision of developmentally sensitive services to young children and their families, including assessment and intervention efforts, as well as helping them understand their own reactions to families. Supervision •• Recommended regular consultation with other infant mental health professionals; regularly scheduled peer supervision for support and feedback.

dresses promotion, preventive intervention, and clinical intervention. The interventions in LFI-IMH Level 1, Promotion, Awareness, and Collaboration, are considered “universal” because they reflect developmentally sensitive practice that should be

standard within a profession among the multiple disciplines who routinely interact with infants and their families. LFI-IMH Level 2, Preventive Intervention, describes an intermediate level of practice regarding the state of being of the infant, in which the



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development of the professional subsumes and extends beyond Level 1 development. This level also encompasses interventions for “high-risk” families, such as nurse–home visiting and Head Start, which focus on identification of risk and provision of preventive interventions to improve outcomes. In such situations, training and supervision become critical for ethical practice. LFI-IMH Level 3, Clinical Intervention, represents service delivery when a problem has been identified and includes provision of mental health interventions. Thus, this level of training is appropriate for mental health clinicians who have subspecialized in infant mental health.

ACCOUNTABILITY As the number of professionals practicing and obtaining training in infant mental health increases, discussions arise as to how to maintain integrity within the field and across disciplines.

Research While there seems to be some consensus across disciplines that training in infant mental health is timely, to our knowledge little data exist to support the effectiveness of training or to identify the influence of training on service delivery. At a basic level, there is a lack of data regarding the actual infant mental health training needs for the various professional disciplines, leaving the field essentially without structured guidelines within which to develop and evaluate training efforts. Although some training programs may conduct evaluations of the training itself, such evaluations are unlikely to capture a comprehensive picture of preand posttraining expertise and effect on service delivery. Systematic evaluations of how training impacts individuals and systems appear to be underdeveloped. Ongoing research is needed to address a range of outcome constructs, such as (1) change in the level of knowledge of training participants (i.e., What was learned as a result of the training?); (2) change in the quality and quantity of service delivery (e.g., What types of interventions are provided? Who is being referred for services?); (3) treatment outcomes for infants and caregiv-

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ers served by the participants; (4) indirect effects of a training program or posttraining service program on other institutions (e.g., maltreatment team effects on family courts and child protective services); and (5) whether the training impacts the culture of the institution (e.g., inclusion of reflective supervision; types of referrals made for infant mental health-­related concerns). Practical issues such as the centrality of the training to the overall clinical service or program may impact the time and money being devoted to the evaluation of training. Simple measurement complications, such as the way in which similar services are defined differently across programs (e.g., parent–child therapy may be called “behavioral services,” “counseling,” or something else for which a program can receive financial reimbursement) may interfere with the accumulation of a comprehensive body of research regarding training efforts. Finally, the varied nature of the field poses challenges, in that the range of training goals and outcomes are numerous as we attempt to educate practitioners from a vast array of professional fields to intervene with young children and their families in various capacities with varying goals. Supervision as training also should be considered from a research perspective. As reflective supervision becomes more prevalent across disciplines in the field of infant mental health, the need, characteristics, scope, and effectiveness of reflective supervision should be evaluated. Questions such as how much, for whom, what types of training and support are needed for the supervisor, and consideration of ethical issues in supervision all need further elaboration. Despite these difficulties, anecdotal evidence is accumulating about the importance of ongoing training in infant mental health. In our experience, at a programmatic level, supervisors and directors report differences in the quality and quantity of service delivery following training. For example, mental health clinicians who are trained in relationship assessment and intervention indicate that they have changed the way they practice, from providing supportive counseling to parents and/or focusing on child behaviors, to intervening in relationship issues that are interfering with healthy development. Moreover, in multidisciplinary settings such as early childhood intervention, trained men-

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tal health clinicians can, in turn, train and consult with other early intervention staff, thereby increasing staff knowledge of infant mental health issues across disciplines, which may result in increased mental health referrals. In one such case, an early intervention program doubled the number of referrals to the mental health team over a 2-year period following a 60-hour training of their mental health clinicians in relationship assessment and intervention, as well as expansion of the reasons for referral (e.g., concerns about the parent–child relationship (M. Glovier, personal communication, October 24, 2007). This example illustrates the effect of training on practitioner knowledge, as well as a change in both the quality and quantity of services delivered. Multiple individual anecdotes also exist to support the importance of training individuals in infant mental health principles and practice. These vignettes illustrate the ways in which training can meet the goals, outlined above, regarding knowledge base, role definition, and supervision. •• Training provided to non-­mental-health clinicians increased knowledge of clinical concerns that merit referral. For example, as part of a 36-hour training course in infant mental health for non-­mental-health professionals, a nurse–home visitor recognized that a developing fetus may be at risk once the infant was born because the pregnant mother commented negatively about the baby’s movement. She remarked to the nurse that she already had the form of the infant’s punishment chosen, as he clearly was trying to make her life difficult by his movement in the womb when she attempted to rest. •• Training provided to mental health clinicians offered a paradigm shift in the way they conceptualize work with young children (i.e., understanding and attending to development in the context of relationships). For example, a social worker who was not experienced with very young children began to appreciate that a 3-year-old’s desire to be held by unknown workers in the health clinic raised a red flag about the child’s relationship with the primary caregiver, possibly indicating indiscriminant behavior and a relationship problem rather than friendly, competent sociability.

•• Training provided to non-­mental-health clinicians helped clarify roles and expectations regarding the incorporation of infant mental health principles into their “discipline of origin.” For example, when learning about ways in which they could support parents and children together, physical therapists expressed relief that they would not be expected to provide mental health services. This allowed them to be more open to providing physical therapy services in the context of the parent–child relationship. •• Supervision allowed practitioners to understand the way in which their experience affects their implementation of knowledge gained in training. For example, a beginning infant mental health trainee advocated that a parent not be involved with her 40-monthold son in treatment, believing that he could make more progress with his behavior problems without her present. As this belief was explored, it became clear that the trainee was experiencing anger at the caregiver and was not aware of it; this countertransference was sabotaging the treatment plan. As these feelings were discussed in supervision, the trainee was able to deal with the anger, and she began to include the mother in dyadic work with her son.

Degrees, Endorsements, and Certifications Infant mental health certificate programs and endorsement systems have begun to emerge, presumably out of concern that professionals have the opportunity to obtain adequate training for work with young children and their families and that the field have some way of denoting expertise among professionals. However, without general agreement as to what constitutes necessary and sufficient training to practice at various levels, there is no standard way to determine the meaning of certification, endorsement, or continuing education programs on clinical practice. Additionally, we need to consider how professionals’ practices are overseen once the certification is acquired. At this time, there is no universally acknowledged infant mental health licensing board to assure maintenance of competence and ethical practice in infant mental health. Some universities offer certificate programs or degrees at the associate or master’s level (e.g.,



33. Training

Center on Infant Mental Health and Development, University of Washington; Erikson Institute in Chicago), but such programs are not widely available. Other programs, such as the University of Minnesota’s Infant and Early Childhood Mental Health Certificate Program, require completion of 16–20 credit hours over a 2-year period to obtain the certificate of completion of the program, but the program does not actually offer certification or licensure. Since most current participants are licensed in their discipline of origin (e.g., education, psychology, nursing, social work), the infant mental health training certificate documents an additional area of knowledge obtained. A number of state-level infant mental health associations have begun to offer an infant mental health endorsement. These systems allow practitioners to become endorsed at various levels, typically from “infant–­family specialists” to “mentors.” Endorsed individuals are generally required to have acquired a certain number of training hours, direct experience, reflective supervision, and, at some levels, to have passed a test (Michigan Association of Infant Mental Health; 2002). An endorsement that identifies levels of clinical expertise has potential for many meaningful practical applications, such as identifying practitioners who are developmentally sensitive and who have skills in working with young children and their families. It also provides a structure for the development and implementation of training programs for practitioners from various disciplines. Of course, to be effective, such training programs must be predicated on an acceptance of a core set of skills, knowledge, and professional qualities expected of individuals who successfully complete these programs. Endorsement competencies also hold the potential for influencing policy regarding young children and their families (e.g., impacting licensing requirements for individuals who work with young children). Although the potential benefits of an infant mental health endorsement can be identified, there is controversy about the integrity and merit of endorsement systems. First, there is lack of consistency in the application of the endorsement systems among the organizations that offer an infant mental health

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endorsement. Though there are similarities between them—most clearly in defining the competencies for four levels of practice— there is lack of consistency in the education, experience, and professional background of individuals endorsed at the same level. The determination of who qualifies at what level may be influenced by the culture of the endorsing entity, the local history of the infant mental health field, and the availability of practitioners and trainers who can help shape the infant mental health landscape locally. As the consistency within levels varies by the endorsing entity, the focus of training and supervision may also vary, potentially affecting the focus of practitioners’ assessments and intervention. Along these lines, there may be resistance to engaging in cross-­disciplinary supervision. For example, mental health clinicians might object to being supervised by a non-­mental-health clinician because they feel that reflection is necessary but not sufficient for supervision to be effective in supporting their work (i.e., clinical supervision that includes reflection is preferred). Similarly, consultation from an infant mental health clinician (e.g., a psychologist, clinical social worker, or psychiatrist who has subspecialized in infant mental health) may be beneficial to a speech therapist, for example, as he or she works through the parent–child interaction to improve a child’s communication skills, but the consulting mental health clinician would be unable to provide guidance as to specific speech therapy techniques to employ. In other words, to practice to the full limit of one’s license, whatever the field, supervision from a similarly licensed practitioner with more experience is valuable; we must take care not to wholly replace such supervision with “reflective supervision” if it results in professionals not receiving the breadth and depth of supervision necessary to practice competently within their discipline. Another concern about the presently available endorsements is directly related to training, in that there does not appear to be consensus between, and sometimes within, administering entities as to what training is acceptable to meet the requirements of the endorsement. What is the exact content of the training? Who is qualified to provide the

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training? How are disagreements about controversial topics resolved? How is controversial material taught? How much evidence is required for material to be “endorsed” as worthy of being taught? Who decides which trainings count toward the required hours for the endorsement? Although these questions are relevant to any training, they take on particular importance when the training is part of a new standard being set in the field. Lastly, there may be difficulty in endorsements gaining wide acceptance because of the time and cost involved in developing such systems. While endorsement systems presumably lead to improved skills and knowledge, better clinical practice, more appropriate referrals, and possibly improved employment conditions (i.e., responsibility, status, compensation), there is currently no evidence to suggest that these presumptions are true. Data are needed so that potential changes in policy, training, service delivery, and professional benefits as a result of endorsement can be documented and used as support for the system. Despite the problems, the growing interest in endorsement systems reflects the increasing awareness of the need for training across disciplines to deliver services in a way that promotes the healthy social–­emotional development of young children. In addition, administrators and policymakers seem to be developing a greater awareness that practitioners within and across disciplines possess varied degrees of knowledge and skills with respect to working with young children and their families and that the way in which services are delivered can have an enormous impact on children’s outcomes.

Ethical Considerations While a host of ethical issues may arise as training in infant mental health proliferates, we would like to draw attention to a few concerns that have already become apparent. First, preserving the multidisciplinary nature of the field of infant mental health, although valuable, creates an atmosphere in which there is “political” debate over who is qualified to do what with respect to practice, supervision, and training. To whom does the field belong, if anyone? Adding to the controversy is the relative newness of the field,

which has resulted in professionals practicing, supervising, and training other professionals, both within and across their disciplines of origin, but lacking the experience of being carefully supervised by a truly qualified “mentor” in any infant-­mental-health­related discipline. Such mentoring helps assure appropriate professional practice, but there is a lack of sufficiently prepared and experienced professionals to meet this need. The current focus on reflective supervision as a mechanism for developing a better practicing infant mental health work force is beneficial in that it promotes attention to the process of providing infant mental health services. However, individuals providing reflective supervision vary widely in their education and experience. As they “mentor” others, there is little or no mechanism to oversee this practice, so the potential exists for individuals to be endorsed and practice beyond their area of expertise, especially when the reflective supervision is provided by a “mentor” from a different discipline of origin than that of the supervisee. Without an overseeing entity, when is it determined that an individual is practicing out of the bounds of his or her expertise, and what are the consequences for doing so? Related to the questions surrounding the training of individuals is the inherent conflict in training individuals from any discipline to provide services differently when the larger systems in which they operate do not support the so-­called “best practice” for the care of young children. For example, judges may override the recommendations that an infant mental health clinician makes regarding the best interest of a child in state custody because of the way the law is written or the judge’s lack of understanding about infant development in context. What level of support do newly trained professionals need to operate within a system that maintains a different standard of understanding regarding infant development and needs? With respect to system change, we must also consider the pool of resources available to young children and their families. Recent epidemiological studies have found that the proportion of children under 5 years of age with significant externalizing and internalizing problems is similar to that of older children (Egger et al., 2006). In addition, the plethora of data showing high rates of



33. Training

maternal depression, maltreatment, domestic violence, and other problems that directly impact the parent–­infant relationship and early child behavior and development have contributed to increased awareness of the need to provide mental health services to young children and their families. However, for problems requiring more specialized infant mental health assessment or treatment, referral sources often are not available. In a climate of limited funding, a number of questions are raised. Should training efforts be directed at preprofessional students, practicing professionals, or policymakers who influence the systems that support young children and their families? Should fewer professionals be trained more thoroughly, or should wider audiences be given some information, even when training and supervisory systems are not in place to help them learn to apply their knowledge appropriately? Perhaps such efforts are not mutually exclusive. Nonetheless, as training efforts in infant mental health grow, consideration should be given to the impact of the training on individuals as they practice and on larger systems as they attempt to support the needs of young children and their families.

SUMMARY AND CONCLUSIONS In this chapter we briefly addressed the definition of infant mental health and discussed the associated implications for training. We proposed goals of training and a framework to further delineate the similarities and distinctions among the various disciplines. We emphasized the importance of maintaining fidelity to training models and ensuring accountability for responsible practice once an individual completes a training program. The training programs that currently exist are quite diverse in their breadth and depth. Given the significant gaps in our understanding about effective and appropriate training models and their impact on clinical practice, there is an urgent need for the development of an empirical basis for training in infant mental health. We have touched only briefly on issues related to preprofessional training in infant mental health, and we have not tackled the dissemination of knowledge regarding infant mental health to the general public. Thus,

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the issues raised in this chapter highlight only a portion of the dilemmas and the opportunities facing this rapidly evolving field. Exploration of the myriad of challenges of training in infant mental health as well as a systematic examination of current solutions will further clarify the scope and limits of the field. It is also an opportunity to engage multiple disciplines in fruitful discussions of the major principles and practices of infant mental health. The explosion of interest in infant mental health is encouraging, and we believe that the dialogue among practitioners, policymakers, and researchers will help ensure that more vulnerable youngsters and their caregivers are better served. References Ben-­Sasson, A., Cermak, C. A., Orsmond, G. I., Carter, A. S., & Fogg, L. (2007). Can we differentiate sensory over-­responsivity from anxiety symptoms in toddlers? Perspectives of occupational therapists and psychologists. Infant Mental Health Journal, 28, 536–558. Boris, N., Larrieu, J., Zeanah, P. D., Nagle, G., Steier, A., & McNeill, P. (2006). The process and promise of mental health augmentation of nurse– home visiting programs: Data from the Louisiana Nurse–­Family Partnership program. Infant Mental Health Journal, 27, 26–40. Retrieved November 8, 2007, from cehd.umn.edu/CEED/ IECMHCP/iecmhFAQ.htm. Center for Early Education and Development. (2007). Infant and Early Childhood Mental Health Certified Program. Retrieved November 8, 2007, from cehd.umn.edu/CEED/IECMHCP/iecmhFAQ.htm. Dawley, K., Loch, J., & Bindrich, I. (2007). The Nurse–­Family Partnership. American Journal of Nursing, 107, 60–67. Doherty, W. J. (1995). Boundaries between parent and family education and family therapy. Family Relations, 44, 353–358. Doherty, W. J., & Baird, M. A. (1986). Developmental levels of family-­centered medical care. Family Medicine, 18, 153–156. Doherty, W. J., & Peskay, V. E. (1992). Family systems and the school. In S. L. Christenson & J. C. Conoley (Eds.), Home–­school collaboration (pp. 1–18). Silver Spring, MD: National Association of School Psychologists. Dunn, W. (2003). A sensory-­processing approach to supporting infant–­caregiver relationships. In A. Sameroff, S. McDonough, & K. Rosenblum (Eds.), Treating parent–­infant relationship problems: Strategies for intervention (pp.  152–187). New York: Guilford Press. Egger, H. L., Erkanli, A., Keeler, G., Potts, E.,

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Walter, B. K., & Angold, A. (2006). Test–­retest reliability of the Preschool Age Psychiatric Assessment (PAPA). Journal of the American Academy of Child and Adolescent Psychiatry, 45, 538–549. Emde, R. N., Bingham, R. D., & Harmon, R. J. (1993). Classification and the diagnostic process in infancy. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp.  225–235). New York: Guilford Press. Fenichel, E. (Ed.). (1992). Learning through supervision and mentorship to support the development of infants, toddlers, and their families: A sourcebook. Washington, DC: Zero to Three. Florida State University Center for Prevention and Early Intervention Policy. (2003). Program evaluation: Florida infant and young child mental health pilot project (year 3). Tallahassee, FL: Author. Gilkerson, L., & Als, H. (1995). Role of reflective process in the implementation of developmentally supportive care in the newborn intensive care unit. Infants and Young Children, 7, 20–28. Gilkerson, L., & Stott, F. (2000). Parent–child relationships in early intervention with infants and toddlers with disabilities and their families. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 457–471). New York: Guilford Press. IDEA Infant and Toddler Coordinators Association. (2008). Infant mental health approaches and IDEA: Part C. Retrieved January 17, 2008, from www.ideainfanttoddler.org/ITCA_infant_ Mental_Health_7_05.pdf. Johnston, K., & Brinamen, C. (2005). Integrating and adapting infant mental health principles in the training of consultants to childcare. Infants and Young Children, 18(4), 269–281. Marvel, M. K., Doherty, W. J., & Weiner, E. (1998). Medical interviewing by exemplary family physicians. Journal of Family Practice, 47, 343–348. McAllister, C. L., & Thomas, T. (2007). Infant mental health and family support: Contributions of Early Head Start to an integrated model for community-based early childhood programs. Infant Mental Health Journal, 28(2), 192–215. Michigan Association of Infant Mental Health. (2002). Michigan Association of Infant Mental Health endorsement for culturally-­sensitive, relationship-based practice in infant mental health: Guidelines for reflective supervision and

consultation. Retrieved January 17, 2008, from mi-­ainfant mental health.msu.edu/ aboutus/29 RecommendedReferencesforPreparingforEndo rsement/09-GuidelinesforReflectiveSupervisionandConsultation.pdf. Michigan Association of Infant Mental Health. (2008). Michigan Association of Infant Mental Health endorsement for culturally-­sensitive, relationship-based practice in infant mental health: Endorsement brochure. Retrieved January 17, 2008, from mi-­ainfant mental health.msu.edu/ aboutus/Endorsement%20Brochure11-1- 07. pdf. Michigan Department of Community Health. (2008). Infant mental health. Retrieved March 30, 2008, from www.michigan.gov/mdch/0,1607,7132-2941_4868_7145-14659—,00.html. Parlakiah, R. (2001). Look, listen, and learn: Reflective supervision and relationship-based work. Washington, DC: ZERO TO THREE. Shahmoon Shanok, R., Gilkerson, L., Eggbeer, L., & Fenichel, E. (1995). Reflective supervision: A relationship for learning. Washington, DC: ZERO TO THREE. Slade, A. (2002). Keeping the baby in mind: A critical factor in infant mental health. Washington, DC: ZERO TO THREE. Stott, F., & Gilkerson, L. (1998). Taking the long view: Supporting higher education on behalf of young children. Zero to Three, 19, 27–33. Weider, S., Drachman, D., & DeLeo, T. (1989). Inservice training model for public health nurses serving multirisk infants and families. Washington, DC: Zero to Three. Zeanah, C. H., Jr., Boris, N., & Scheeringa, M. (1997). Psychopathology in infancy. Journal of Child Psychiatry, Psychology, and Allied Disciplines, 38, 81–99. Zeanah, P. D., Larrieu, J. L., & Zeanah, C. H., Jr. (2000). Training aspects of infant mental health. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 548–558). New York: Guilford Press. Zeanah, P. D., Stafford, B., Nagle, G. N., & Rice, T. (2005). Addressing social–­emotional development and infant mental health in the State Early Childhood Comprehensive Systems Initiative, Building State Early Childhood Comprehensive System Series, No. 12. National Center for Infant and Early Childhood Health Policy, University of California, Los Angeles.

Chapter 34

Infant Mental Health in Primary Health Care Paula Doyle Zeanah Mary Margaret Gleason

I

n this chapter we discuss the integration of infant mental health (IMH) approaches into primary pediatric health care. There are several reasons why this integration is important. First, in the developed world, virtually all young children are seen regularly throughout the early years in primary health care settings. Therefore, universal approaches to screening and intervention can be applied to large populations of infants and toddlers. Second, common problems in young children, such as sleep or feeding disturbances, language abnormalities, or aggressive behavior problems often present first to health care professionals. Third, a number of preventive interventions have been developed using health care practitioners as providers. For all of these reasons, interest in how to apply principles of IMH to practice in primary care has grown. We begin by describing opportunities and challenges of providing IMH services in primary care settings. Then we consider models of IMH service delivery in primary care. Finally, we present selective interventions designed for pediatric primary health care professionals to improve parent–­infant relationships and/or the developmental or behavioral outcomes of young children.



ROLE OF PEDIATRIC HEALTH CARE PROVIDERS Child Health Visits Current pediatric practice in the United States emphasizes the need for behavioral and developmental surveillance as part of preventive health care, which typically takes place within the context of “well-child” health visits (health supervision). Child health visits ideally begin during the prenatal period, when the pediatric primary care provider (PCP) begins to develop a positive relationship with parents and to identify factors that can impact infant health and development. Pregnancy characteristics (e.g., planned/wanted, pregnancy health, prenatal exposures), financial resources, level of social support, child and parent health status, risk of violence in the family’s home or community, and other family stressors and strengths can be assessed (Green & Palfrey, 2000; Hagan, Shaw, & Duncan, 2008). PCPs see young children and their family more frequently than any other health professionals. During the first 5 years of life, it is recommended that children have a minimum of 10 scheduled visits with their PCP for well-child health care (American Acad549

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emy of Pediatrics, 2008). The structure of the well-child visits allows PCPs to monitor children’s physical, social, and emotional development over time, recognize changes in emotions and behaviors between visits, and discuss their observations with parents. Through well-child and sick visits, PCPs develop important relationships with families, and parents usually view their children’s PCPs as important resources about their children’s emotional development (Burkow, Vaugh, Valerius, & Schultz, 2001; Young, Davis, Schoen, & Parker, 1998). The well-child assessment includes a brief history, informal observations, physical assessment, and use of brief screening measures, mostly focused on the development of the child. Assessment of infant mental health specifically focuses on the infant’s social–­ emotional development, including factors that impact the development and quality of the parent–­infant relationship. Though nearly all infant mental health problems affect the parent–child relationship, some problems reside more within the parent (e.g., parental depression) or the environment (e.g., violence exposure), some derive from factors intrinsic to the child (e.g., prematurity or health problems, autism, or attention-­deficit/

hyperactivity disorder [ADHD]), and others seem to develop within the parent–child relationship itself (e.g., relation-­specific power struggles between one parent and one child). Thus, the provider must assess environmental, parent-­focused, child-­focused, and relationship-­focused variables. Examples of risk factors within each of these domains that can be assessed during child health visits are shown on Table 34.1. A systematic approach to assessment may enhance the PCP’s confidence in addressing social–­emotional and mental health issues with parents, increase parents’ comfort discussing such issues, and increase identification of issues related to infant mental health. Attention to each of these identified infant mental health domains can be integrated into each well-child assessment activity.

Obtaining History Information regarding past medical history and environmental and psychosocial factors can be obtained through routine clinical history taking and parent-­completed intake or history forms (e.g., Jellinek, Patel, & ­Froehle, 2002). In opening the child heath visit, the PCP can use active listening and

TABLE 34.1. Domains of IMH Assessment in Primary Care Settings Domain

Selected risk factors

Environmental factors

Poverty Teenage parent Less than 12 years education Social isolation/unstable living situation

Infant factors

Prematurity or low birthweight Chronic or significant health problems Difficult temperament Difficult to regulate (sleep, feeding, emotions) Developmental delay

Parent/caregiver factors

Unwanted pregnancy History of losses, particularly during pregnancy or other children Past or current mental disorder Past or current domestic violence Substance abuse

Relationship factors

Lack of warmth or nurturance Harsh or rough handling/tone of voice Lack of comforting/comfort seeking Consistent negative or critical remarks about baby Inappropriate or unrealistic expectations

Note. Jellinek, Patel, and Froehle (Eds.). (2002) and Zeanah (2000).



34. Infant Mental Health in Primary Health Care

open-ended “trigger” questions to elicit parental concerns about the child, followed by more specific questions to obtain relevant data for further assessment. In addition to problems or concerns, strengths and factors in the child, family, and community that may positively impact child health and development should also be identified (Green & Palfrey, 2000; Hagan et al., 2008).

Office Observations Observations of parent–­infant interactions during pediatric health care visits are a rich source of information regarding the relationship between the parent and infant and also provide opportunities for intervention (Brazelton, 1995; Green & Palfrey, 2000; Hagan et al., 2008). While systematic observation measures for use in primary care settings are limited, informal observations, performed consistently and over time, can yield valuable information. For example, PCPs can assess the degree to which the parent is aware of, and attends to, the infant’s needs, whether the parent appears comfortable holding the infant, the infant’s ability to self­regulate and be soothed, and on occasion, feeding interactions. Across infancy and early childhood, the PCP may look for positive reciprocal interactions (e.g., eye contact, joint attention, verbal interchanges, sharing joy or excitement); the parent’s awareness of, and responsiveness to, the child’s needs; tone of interaction (e.g., warm, harsh, indifferent); and style of limit setting. The primary care visit also provides opportunities to observe attachment behaviors, such as the child’s response to a stranger (i.e., medical staff) and how the child uses a parent for comfort during stressful experiences, including physical examination and immunizations. For example, does a child turn or move closer to the parent during stressful parts of the examination? Does the child receive comfort and appear to be comforted? Bright Futures Guidelines for Health Supervision suggests specific clinical observations at each child health visit (Green & Palfrey, 2000; Hagan et al., 2008; Jellinek et al., 2002). Although such observations are not scored or rated, they provide observations that are particularly salient to the quality of the relationship, particularly when noted over time.

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One formal observation, the Pediatric Infant Parent Exam, provides a structured approach to observing and classifying interactions during health care visits. Parents are asked to play a game of peek-a-boo, during which their interactions are coded for level of engagement and reciprocity. Further validity and feasibility data are needed for this procedure, however (Fiese, Poehlmann, Irwin, Gordon, & Curry-­Bleggi, 2001). For toddlers and preschoolers, the PCP may observe the child’s emotional or behavioral regulation during the primary care visit. Like older children and adults, some preschoolers may experience severe, impairing anxiety, mood disturbances, or aggressive and oppositional behaviors. Although the snapshot of behavior during the visit may not be representative of the child’s usual behavior, repeated observations over time, or extreme inhibition or dysregulation, warrants additional history taking to explore symptoms of early psychiatric disorders.

Physical Examination The physical examination, a hallmark of the pediatric health visit, also plays an important—­albeit often untapped—role in IMH assessment. For example, abnormal growth parameters may reflect feeding disorders, genetic disorders, limited access to food, or neglect. Abnormal head circumference may indicate a central nervous system disorder (e.g., intracranial bleed, space-­occupying lesion, autism), metabolic problem, or poor nutritional status. Children with suspected social, emotional, or behavioral problems may have concurrent dysmorphic features related to a genetic syndrome, prenatal infection, or exposure to a teratogen such as alcohol. Abnormal neurological examination, including asymmetrical reflexes, abnormal tone, or abnormal gait, may reflect a central nervous system disorder requiring further evaluation. In older toddlers and preschoolers presenting with symptoms such as pica, hyperactivity, and/ or developmental delays, lead toxicity can be considered (Gilbert & Weiss, 2006; Mendelsohn et al., 1998). A history of snoring and/ or apnea in preschoolers may suggest that sleep-­disordered breathing is contributing to presenting behavioral concerns (Gottlieb et al., 2003). PCPs are also in a unique position

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to consider the possible effects of a child’s health problems and medications, including nontraditional remedies, on behavioral and emotional symptoms. Identifying children in need of further evaluation may increase access to appropriate treatment and improve the prognostic accuracy. In addition to determining if there are physical problems, physical assessment provides the opportunity to teach the parent about the infant’s growth and development. Parents expect the pediatric provider to share this information (Heneghan, Mercer, & DeLeone, 2004), and the parent’s and provider’s shared interest in the child’s health is a useful avenue into discussing related psychosocial issues.

Structured Child Behavioral Screening Assessment in IMH includes attention to all developmental domains. The American Academy of Pediatrics (AAP) has issued new recommendations encouraging regular developmental surveillance in young children and is in the process of developing recommendations for mental health screening (American Academy of Pediatrics, 2006). Although traditional approaches to identifying mental health problems in young children, such as informal observations and “trigger questions,” can provide useful information, they do not identify developmental or mental health perturbations or problems sensitively. Structured screening is a more sensitive and efficient way of identifying young children with these issues (Earls & Hay, 2006). A variety of screening measures is available for use in primary care settings. The choice of specific measures depends upon the goals of screening, the measure’s psychometric properties, and the feasibility of conducting the screen within the practice. Interpretation of the screen is based on knowledge about the tool, the reporter, and the clinical context. Clinicians should select tools that have sufficient psychometric properties to provide useful clinical information. A sensitivity and specificity of at least 70% are recommended for clinical practice (Cicchetti, 1994). Structured, systematic screening can increase rate of identification of older children’s mental health problems from 1 to 12%, which represents the expected prevalence of pediatric mental health problems

(Jellinek & Murphy, 1990); indeed, a recent study found that structured screening significantly increased the number of infants and young children identified and referred for developmental services (Kaye & Rosenthal, 2008). Critics of screening suggest that early childhood mental health screens may not be identifying children at risk of psychopathology. However, in a recently published study, results of the Brief Infant–­Toddler Social and Emotional Screening Assessment (BITSEA) in toddlers significantly predicted psychiatric status, teacher report, and parent report of mental health problems in 5- and 6-yearolds (Briggs-Gowan & Carter, 2008). Table 34.2 presents selected tools that may be useful for primary care screening of early childhood mental health problems. Although a positive or negative screen provides information about the probability that a mental health problem exists, further assessment of symptoms and the clinical context may be warranted. Additional focused history, observations, and consultation may guide intervention or treatment decisions. By using one or two of these instruments regularly, clinicians can become comfortable with the data provided by them. A few caveats warrant some attention. First, there is tremendous variability in caregivers’ knowledge, experiences, and perspectives about the child’s behaviors. Parent-­report measures reflect the parent’s experience and knowledge of the child’s behaviors, emotions, and responses. Thus, there may be notable differences between reported and observed behaviors by reporter, each reflecting the relationship of the responder/caregiver with the child. Since most screening tools focus on child behaviors, relationship aspects are not directly addressed. Thus, overreliance on parent report screening tools may miss important relationship effects on development. Clinicians also need to recognize that simply an increased number of risk factors is associated with increased risk of poor outcomes, even if there are no specific developmental delays or deviances currently present (Sameroff & Fiese, 2000). Second, although adult caregivers are reliable reporters of some aspects of child development (Glascoe, 2000), there is ample evidence that there is a low degree of agreement among parents, teachers, and health/mental health providers’ ratings about the serious-



34. Infant Mental Health in Primary Health Care

ness of behavior problems in young children (Zeanah, Boris, & Scheeringa, 1997). Thus, it is important to obtain and integrate information from multiple informants whenever possible to obtain the broadest view of the child’s developmental status. A third concern is that, despite the availability of reliable and valid screening for general developmental problems, primary care providers do not routinely use screening tools (Glascoe, 2000). Practical issues such as cost, length of the tool, or difficulties in scoring may inhibit use, and inconsistent use or inappropriate administration of measures may lead to inaccurate data. In addition, some pediatricians have raised concerns about identifying mental health problems in a context of limited or no referral options (e.g., Kaye, 2006; Kaye & Rosenthal, 2008; Perrin & Stancin, 2002). This issue warrants consideration by the PCP prior to screening, but it should be noted that, unlike screening for clinically undetectable medical disorders, screening for mental health problems allows the PCP to recognize symptoms that a parent may have already noted and usually with which the parent and/or child is struggling. Implementing a screening process requires planning regarding the logistics of administration and scoring, as well as developing plans for positive or negative screens. Finally, while further exploration may clarify whether the parental concern reflects a diagnosable disorder, parental concern itself is generally worthy of attention. As noted, a selection of early childhood screening tools that can be used in primary health care settings is listed in Table 34.2.

Assessing Parental Mental Health Parental mental health exerts a powerful influence on infant and early childhood development (e.g., Carter, Garrity-­Rokous, Chazan-Cohen, Little, & Briggs-Gowan, 2001; Dawson et al., 2003; Seifer, Dickstein, Sameroff, Magee, & Hayden, 2001) as well as on safety practices and use of medical resources (McLearn, Minkovitz, Strobino, Marks, & Hou, 2006; Minkovitz et al., 2005). Postpartum depression has received significant attention; however, rates of maternal depression may increase during the toddler and preschool years, and other psychiatric illness can also adversely influence

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early childhood development (McLennan, Kotelchuck, & Hyunsan, 2001). Reliable and valid tools are available for clinical problems such as maternal depression and substance abuse (see Green & Palfrey, 2000; Jellinek & Froehle, 1998; Jellinek, Patel, & Froehle, 2002). The U.S. Preventive Health Task Force Two-­Question Depression screener is both feasible and effective as a screen for maternal depression in pediatric settings (Olson, Dietrich, Prazar, & Hurley, 2006; Olson et al., 2005). This screen asks a parent about depression and anhedonia in the last 2 weeks, and a “yes” to either question indicates a positive screen (Pignone, Gaynes, Lohr, Rushton, & Mulrow, 2002). The Edinburgh Postnatal Depression Scale also reliably identifies maternal depression in pediatric settings, up to a year after birth (Cox, Holden, & Sagovsky, 1987). Recently published studies recommend caution regarding screening for family and partner violence (Nygren et al., 2004; U.S. Preventive Service Task Force, 2004), despite the prevalence of these problems and their profound impact on child development. This stance in part reflects the fact that many clinicians do not feel comfortable asking about or addressing these issues if a problem were identified (American Academy of Pediatrics, 2000). If such tools are used, clinicians need training in the rationale, administration, and clinical use of them, and they also need to be informed about the availability of resources for referral when problems are detected. Finally, health care professionals are in an excellent position to obtain this information; however, the quality of information obtained depends partly on the quality of the relationship between the professional and the caregiver (Green & Palfrey, 2000; Heneghan et al., 2004). Studies show that parents often feel unsatisfied and pediatricians often feel uncomfortable discussing behavioral/psychosocial issues (Glascoe, 2000; Halfon, Regalado, McLearn, Kuo, & Wright, 2003). Many parents recognize that their emotional health affects their children’s well-being, but they are reluctant to discuss their own depression or stress for fear of being negatively judged, or they lack trust in the provider (Heneghan et al., 2004). Provider discomfort in discussing mental health issues is not uncommon and may interfere with his or her ability to address



554

18–60 months

Early Childhood Screening Assessment (Gleason & Zeanah, 2005)

24–60 months

Devereaux Early Childhood Assessment (Lebbuffe & Nagliere, 2002)

12–36 months

6–60 months

Ages and Stages Questionnaire—­ Social–­ Emotional (Squires, Bricker, & Twombley, 2002)

Brief Infant–­ Toddler Social and Emotional Assessment (Briggs-Gowan & Carter, 2002)

Age

Measure

Need for mental health assessment for child, parental depression, and distress

Emotional and behavioral problems and strengths

Problems: Attention, aggression, withdrawal, emotional control Protective factors: Initiative, self­control, attachment

Self-­regulation, compliance, communication, adaptive behaviors, autonomy, affect, and interaction with people

What is measured

5–10 minutes

7–10 minutes

5–10 minutes

10–15 minutes

Time to complete

TABLE 34.2.  Screening Measures in Primary Care

3-point rating for each item; parents also indicate concern and desire for assistance with each item

3-point rating scale for each item; strength items must be reverse-­scored

37 items focused on protective factors; 10 items focused on behavioral problems; items scored on 5-point rating scale.

Different form for ages (total eight forms), each item scored on 3-point scale that asks if parent is concerned about item

Format/item scoring

1–2 minutes

Not reported

Not reported

1–3 minutes

Time to score

Free

$1.40 per screen; starter kit: $99 (manual + 25 parent forms and 25 child care forms); refills (25 checklists): $35

$125 for kit, including manual, 30 forms, and norms reference form

Full set, including forms and User Guide: $149 (on paper or on CD-ROM); can reproduce forms

Costs

.66–.78 (parents); .8–.9 (teachers)

.88

•• Sensitivity predicting diagnosis: 86% •• Specificity: 83% •• Scores converge with Child Behavior Checklist (.81)

Not reported

•• Children with known clinical disorders have higher problem scores than those without •• Scores converge (r = .48–.60) with Child Behavior Checklist

•• Children with known disorders had statistically significantly higher scores than those without •• 74% accuracy in assigning clinical classification •• Identifies 67% of children with psychiatric disorders 4 years

.91

•• Sensitivity: 71–85% (overall 78%) predicting clinical Child Behavior Checklist, Social Emotional Early Childhood Scales, or known diagnosis •• Specificity: 90–98%

Psychometrics

Test–­retest reliability (1–3 weeks)



34. Infant Mental Health in Primary Health Care

such issues directly (Glascoe, 2000). For example, resident physicians can discourage discussion regarding “uncomfortable” psychosocial issues by ignoring the parent’s concerns, minimizing or undermining the importance of the issue from the parent’s perspective, providing an overly simplistic explanation, or giving “helpless” responses that inadequately address the concerns (Wissow et al., 2005). Furthermore, though pediatricians generally feel positively toward their patients, some parents elicit strong, negative responses in PCPs or the staff. For example, some parental behaviors may reflect the presence of psychopathology or substance use, or other stressors, and may serve to make the clinician uncomfortable during interactions. Negative reactions also may signal issues such as values differences between parent and clinician, transference reactions on the part of the parent toward the clinician, or countertransference reactions on the part of the clinician toward the parent. Experience suggests that pediatricians are not trained to use their own reactions to parents or patients as a signal for further exploration. In sum, during even brief well-child visits, pediatric health care providers are positioned to conduct an assessment comprehensive enough to identify strengths and risk factors and specific problems in social–­ emotional development and mental heath. By organizing observations and physical assessment findings and using structured screening approaches, PCPs improve their ability to help young children and families gain access to appropriate services, and they also may increase parents’ sense that their concerns are taken seriously. Discussions about psychosocial issues and parental mental health are most effective in the context of an ongoing, trusting relationship with the PCP who is prepared to address issues in a helpful manner (Heneghan et al., 2004; Wissow et al., 2005). It is when the clinician routinely makes the effort to develop the “conversation” regarding the infant’s—and parent’s—­behaviors that the parent is more likely to discuss psychosocial issues (Halfon, Olson, Inkelas, et al., 2002). Identification of very young children or dyads in need of further assessment or intervention is an important first step toward supporting young families. In some cases,

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further assessment by a mental health professional will be necessary before developing a specific treatment plan. However, whenever an infant mental health problem is identified in the primary care setting, a PCP can enhance the infant and parents’ emotional well-being by continuing to implement universal supports for infant mental health.

Interventions Education and Counseling PCPs provide parents with information and counseling about normal development and typical as well as problematic behaviors. A large literature describes the opportunities, needs, and challenges of providing parenting education in primary care and other early childhood settings (see Zepeda, Varela, & Morales, 2004, for a review). An important role of pediatric health care providers is that of anticipatory guidance: the provision of information to the parent about the child’s current and expected health and development. Highlighting those issues most salient to social–­emotional and behavioral development and the parent–­infant relationship is a natural extension of routine anticipatory guidance. Another powerful approach is the use of observations to demonstrate development and relationship issues. For example, a provider might point out to a parent how the child turns to him or her when distressed, or note the child’s interest in the parent’s voice or facial responses to highlight how the infant shows his or her need for the parent. These situations create “teachable moments” (Brazelton, 1995) and enable the provider to reinforce positive interactions, highlight common and age-­appropriate behaviors, and gently correct misinterpretations of behavior. However, many parents want more information on parenting and child development than typically is provided to them, and they often are dissatisfied because they feel their concerns are not adequately addressed (Taaffe Young, Davis, & Schoen, 1996). Conversely, pediatricians voice numerous impediments to providing such information (American Academy of Pediatrics, 2000). Increasingly, there are resource materials being developed specifically for use in

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VI. APPLICATIONS OF INFANT MENTAL HEALTH

pediatric settings. For example, the Bright Futures in Practice: Mental Health (Jellinek et al., 2002) anticipatory guidance tools emphasize the relationship between the infant and caregiver when addressing common concerns during infancy and early childhood, such as temperament, feeding, sleep, and infant distress. In addition, the guidelines provide information about parental functioning and family relationships, the importance of attachment (including recognizing infant cues and responding in a sensitive manner), providing a stimulating environment at home and obtaining appropriate child care, socialization and peer relationships, and common behavioral problems. The Bright Futures guidelines provide information in a straightforward, developmentally sound, and relationship-­sensitive manner, and emphasize the importance of the provider–­parent relationship in facilitating a discussion about the infant’s behaviors and abilities. A number of other approaches have been developed to address the need for parents to get information about parenting and child health and development (Fenichel, 1997; Zepeda et al., 2004). From an infant mental health perspective, the focus for anticipatory guidance and parenting education is the importance of a nurturing, consistent, predictable, and positive relationship between the caregiver and infant. This emphasis is important whether or not the child demonstrates overt problems or needs additional services.

Care Management Care management includes referrals for further evaluation or intervention, as well as follow-up. Making referrals for potential or active IMH problems can be fraught with difficulties, ranging from lack of available, convenient, or culturally sensitive services; to provider discomfort in presenting concerns to the parent; to conflicting personal values about parenting and mental health. Often pediatricians are not involved in the network of available community services (Inkelas, Regalado, & Halfon, 2005; Kaye & Rosenthal, 2008). In addition to access problems, parents (and providers) often are biased against using mental health services, and parents may feel blamed or criticized if

a referral is made. In general, only a small percentage of families are believed to follow through on mental health referrals from primary care (Rushton, Bruckman, & Kelleher, 2002). As systems develop, practitioners need to learn more effective referrals skills and how to collaborate across service systems (Inkelas et al., 2005). Follow-up of referral status and follow­through of recommendations are warranted. When a referral is successful, the pediatric provider and referral agent should discuss and coordinate the plan of care as needed. Coordination of services provides both the pediatric provider and referral agent access to a wealth of additional information that might not be otherwise available to either, and of course, can provide reassurance to the caregiver that there is a “team” investment in the child’s health and well-being. Of course, PCPs may want to schedule close follow-up appointments to ensure that the child is seen by a clinician, even if they do not make the specialty appointment. Increased monitoring not only serves to keep track of the problem, but also can be one way to provide substantial support for parents, even if the visits are brief. In sum, pediatric health care providers have numerous opportunities to intervene with parents and young children regarding social–­emotional development and infant mental health issues. Nevertheless, children’s mental health needs are generally underidentified and undertreated in primary care settings (Costello et al., 1988; Horwitz, Gary, Briggs-Gowan, & Carter, 2003). And, though parents do turn to their health care provider for information regarding parenting and child development (Inkelas, Halfon, Olson, Newachek, & Schuster, 2002a; Inkelas, Glascoe, Regalado, & Peck, 2002b), they are often left with their guidance needs unmet (Olson et al., 2004). Time constraints, limited mental health training, and limited referral options can all limit PCPs’ ability to identify and address mental health issues in primary care settings (Horwitz et al., 2002, 2007; Wissow, Roter, & Wilson, 1994). Given these challenges, several models are being developed to increase opportunities for developmental and infant mental health assessments and interventions in health care settings.



34. Infant Mental Health in Primary Health Care

IMH DELIVERY MODELS IN PRIMARY CARE Several strategies have been developed to meet the challenges of providing social–­ emotional services via primary health care settings.

Medical Home The concept of “medical home” was first developed by the American Academy of Pediatrics (1992) in response to the need of children with special health needs to have a PCP who could provide consistent, comprehensive care and/or coordinate care with other professionals. More recently, an expanded view of the medical home construct emphasizes the pediatric primary heath care provider as the “primary source of comprehensive, continuous care,” and as accessible, family­centered, and culturally effective (Inkelas et al., 2005). Given these characteristics, the medical home can be identified as a place in which infant mental health concerns, including parental mental health needs, can be identified, initial or brief interventions can take place, and coordinated, collaborative care can occur. In their comprehensive overview of the use of medical home to improve developmental services, Inkelas et al. (2005) describe examples of approaches developed by health departments in several states.

Touchpoints Program Another effort to assist pediatric primary health care professionals to address social–­ emotional development has been led through the Touchpoints program, developed by Brazelton (www.touchpoints.org). Touchpoints uses a strengths-based, relationship-­building approach to identify key points of child development. The child’s behavior is used as the “language” to help the parent understand the child’s needs. Methods of facilitating a working alliance between parent and professional are emphasized (Stadtler, O’Brien, & Hornstein, 1995).

Developmental Specialists The use of a multidisciplinary approach to address infant mental health issues has been

557

advocated for a number of years (see Fenichel, 1997). Healthy Steps was designed to respond to pediatric providers’ contention that they lack the time and are underprepared to assess and intervene regarding many social–­emotional issues (American Academy of Pediatrics, 2000). Healthy Steps places a specially trained child developmental specialist, nurse, or social worker in a pediatric setting. The specialist addresses social, emotional, physical, and cognitive growth and development during the first 3 years of life by forging a strong, positive relationship with the parent and using a holistic, family-­centered approach. Services include individual guidance, a telephone information line and informational materials, home visits, parent groups, child health and family health checkups, and links to community services. Initial outcome studies found that Healthy Steps parents were more likely to discuss developmental concerns, be satisfied with the care, and engage in more preventive health care practices compared to non-­Healthy Steps families (Minkovitz et al., 2003). In addition, Healthy Steps families were more likely to engage in positive parenting practices, such as reading to their children, establishing regular routines, and using discipline strategies such as negotiation and time outs, and were less likely to use discipline strategies such as spanking, yelling, and slapping. Also, mothers in the Healthy Steps program were more likely to discuss feelings of sadness with someone in the pediatric practice compared to mothers in control groups. In summary, a number of patient-care­related and systems approaches have been designed to address infant mental health concerns in primary care health settings. These universal approaches are useful for all parents with young children, whether or not any specific problems have been identified.

PRIMARY CARE PREVENTIVE INTERVENTIONS Targeted or indicated interventions provide services to groups presumed to be at higher risk for poorer health or developmental outcomes. Though mostly preventive in nature, these interventions provide specific ap-

558

VI. APPLICATIONS OF INFANT MENTAL HEALTH

proaches and services for issues more salient to these groups. Frequently such programs target specific risk groups, such as low­income parents, teenage mothers, families of premature babies or children with special health needs, or children in foster care. Goals of targeted programs may include maternal or child health, child developmental, and parenting outcomes. In this section, we describe several examples of targeted interventions that have emerged from the health care setting and are relevant to infant mental health.

Assuring Better Child Health and Development The Assuring Better Child Health and Development (ABCD) Initiative was funded through the Commonwealth Fund to develop strategies and policy to improve the delivery and financing of health care to young children in low-­income families, focusing on improving developmental outcomes. Four states (North Carolina, Utah, Vermont, and Washington) participated in the 3-year program, funded from 2000 to 2003. Service models focused on improving screening, surveillance and assessment, provision of developmentally based health promotion (e.g., anticipatory guidance), educational materials for parents and professionals, and referral and service coordination. Initial outcomes found that there was improvement in assessment and screening in general, development of new educational materials, increased training of the work force, innovative strategies for care coordination and collaboration across systems that provide services to young children and their families, and strategies for reimbursement of developmental services, but several challenges across sites also were identified, including the need for improvements in addressing mental health needs (Pelletier & Abrams, 2003). A second initiative, ABCD-II, was funded in five states (Utah, California, Illinois, Iowa, and Minnesota) to focus on improving mental development in children from low-­income families through well-child visits. Emphases included improved screening of social–­ emotional development; improved referrals; increased links to, and collaboration with, community partners; and provider training. Recommendations for screening tools and

methods to increase physician comfort in use of screening tools and educational materials resulted in the development of training modules and learning collaboratives and the use of physician mentors. Recent findings indicated that pediatricians were willing to use validated, standardized screening tools, but their use diminished when appropriate referral sources were not available. Strategies for developing and improving referral networks, including databases, referral pathways, and other tools, were developed. In addition, each state identified policy barriers to providing social–­emotional health care, and all developed strategies, such as developing work groups or establishing partnerships, to improve policy and practice (Kaye, 2006; Kaye & Rosenthal, 2008). The findings are relevant to all primary health care practices that provide services to low-­income families.

Healthy Start Healthy Start is an initiative developed by the Maternal Child Health Bureau (MCHB), Health Resources and Services Agency (HRSA), U.S. Department of Health and Human Services, in response to high infant mortality rates associated with significant racial and ethnic disparities. Healthy Start works with women during pregnancy and through the child’s second year, with the overarching health goals of reducing infant mortality and perinatal and child health disparities. System goals include decreasing racial and ethnic disparities to access to health care, improving use of health system resources, improving local health care systems, and increasing the consumer/community voice and participation in health care decisions. Core services include outreach, case management, health education, perinatal depression screening and referral, and interconceptional care. Healthy Start programs utilize lay workers as well as trained paraprofessionals and professional service providers (usually nurses and social workers), and all Healthy Start programs have an active communitybased consortium. There is variability in the range of services provided to families, depending on community needs and program resources, though most provide at least some home visiting and group-based educational



34. Infant Mental Health in Primary Health Care

services. Based on the 2006 evaluation, 97 programs had been funded throughout the United States. Clinical outcome data are not yet available; however, the intermediate evaluation indicates that programs are actively providing outreach, educational screening and referral services, as well as systems development activities that are expected to impact clinical outcomes (U.S. Department of Health and Human Services, 2006).

Nurse–­Family Partnership The Nurse–­Family Partnership (NFP) is an intervention designed for first-time low­income mothers and involves specially trained registered nurses who work with the mothers from the first two trimesters of pregnancy through the child’s second birthday. The nurses provide in-home support, education, and guidance to mothers in order to improve pregnancy outcomes, to assure healthy infant and toddler growth and development, and to increase self-­sufficiency in families. To reach those broad goals, nurses focus on six different domains in each visit: personal health of the mother, maternal role development, life course development of the mother, the infant’s health and development, increasing use of family and human services for support, and increasing awareness of environmental health and safety. Each visit lasts approximately 1 hour and occurs weekly or every 2 weeks throughout most of the program. The program has been shown to be effective in three randomized controlled trials, conducted in demographically diverse sites (Kitzman et al., 1997; Olds et al., 2002; Olds, Henderson, Tatelbaum, & Chamberlin, 1986). Positive program effects include: •• 56% reduction of emergency visits for accidents and poisonings and a 32% reduction in emergency visits in the second year of life (Olds et al., 1986) •• 23% fewer subsequent pregnancies and 31% fewer closely spaced subsequent pregnancies (Kitzman et al., 1997) •• 50% reduction in language delays of child age 21 months (Olds et al., 2002) •• 67% reduction in behavioral/intellectual problems at child age 6 years (Olds et al., 2004) •• 83% increase in mother’s labor force par-

559

ticipation by child’s fourth birthday (Olds et al., 1988) •• 48% reduction of child abuse and neglect at age 15 years (Reanalysis of Olds 1997) •• 59% reduction in arrests of child at age 15 years (NFP, 2006; Olds et al., 1998) •• 61% fewer arrests and 72% fewer convictions of mothers at child age 15 years (NFP, 2006; Olds et al., 1991). Although the program is relatively expensive and intensive up front, studies have found that, because of the positive short- and longterm health and social outcomes, the NFP provides a cost savings of $2–$3 for each dollar spent (Aos, Lieb, Mayfield, Miller, & Pennucci, 2004; Karoly, Kilburn, & Cannon, 2005). In summary, focused/targeted programs aim to facilitate the relationship between provider and parent, improve provision of health education and anticipatory guidance, and screen for early child social–­emotional development and/or parental psychosocial issues. They include strategies such as frequent phone calls, outreach, and home visits to involve families more actively. Increasingly, there is recognition of need for mental health services and/or consultation.

CHALLENGES AND FUTURE DIRECTIONS Pediatric health care settings provide a number of avenues by which to enter and positively affect the developing infant–­caregiver relationship, but challenges are significant. Perhaps the most important to the aims of infant mental health is recognition of the importance of attending to the parent–child relationship. This focus represents a paradigm shift for most pediatric health care professionals, who typically focus on the direct needs of the child. A new approach to training and support is needed to develop a pediatric work force able to understand early social–­emotional development, assess infant mental health and problems, and intervene appropriately (American Academy of Pediatrics, 2000). Similarly, while pediatric health professionals typically enjoy positive relationships with their families, quality infant mental health care in primary care depends upon an improved understanding of the im-

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VI. APPLICATIONS OF INFANT MENTAL HEALTH

portance of the provider–­family relationship in assessment and interventions. Developing a system of referrals (including how to approach parents about referrals to social and mental health services, as well as cultivating adequate referral sources) and methods to enhance follow-up and communication between health care provider and referral agency is also needed (Kaye & Rosenthal, 2008; U.S. Department of Health and Human Services, 2006; Zeanah, Stafford, Nagle, & Rice, 2005). Of course, developing mechanisms for reimbursement is an urgent issue as well. As interest grows in providing mental health screening and preventive services in primary health care settings, there is a growing literature about the challenges and successes some states have experienced in financing early childhood mental health services in primary care and other settings (see Johnson, Knitzer & Kaufmann, 2002; Kautz, Mausch & Smith, 2008). Finally, provision of infant mental health services in primary care settings provides opportunities (1) to increase the likelihood that young children and their caregivers receive early and appropriate care, (2) to develop innovative approaches, (3) to strengthen interdisciplinary collaboration, and (4) to extend knowledge of early childhood developments and relationships. References American Academy of Pediatrics. (2000). Fellows survey. Elk Grove Village, IL: Author. American Academy of Pediatrics. (2002). Medical home initiatives for children with special needs project advisory committee: The medical home. Pediatrics, 110, 184–186. American Academy of Pediatrics. (2006). Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening. Pediatrics, 118, 405–420. American Academy of Pediatrics. (2008). Recommendations for preventive pediatric health care. Retrieved May 19, 2008, from www1.amerigroupcorp.com/providers/AAP Recommendations Preventive Pediatric Health Care_ 2008. pdf. Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of prevention and early intervention programs for youth. Olympia, WA: Washington State Institute for Public Policy. Brazelton, T. B. (1995). Working with families: Op-

portunities for early intervention. Pediatric Clinics of North America, 42, 1–9. Briggs-Gowan, M. J., & Carter, A. S. (2002). Brief Infant–­Toddler Social and Emotional Assessment (BITSEA) manual version 2.0. New Haven, CT: Yale University. Briggs-Gowan, M. J., & Carter, A. S. (2008). Social–­emotional screening status in early childhood predicts elementary school outcomes. Pediatrics, 121, 957–962. Burkow, K., Vaughn, L., Valerius, K., & Schultz, J. (2001). Parental expectations regarding discussions on psychosocial topics during pediatric office visits. Clinical Pediatrics, 40, 555–562. Carter, A. S., Garrity-­Rokous, F. E., ChazanCohen, R., Little, C., & Briggs-Gowan, M. J. (2001). Maternal depression and comorbidity: Predicting early parenting, attachment security, and toddler social–­emotional problems and competencies. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 18–26. Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6, 284–290. Costello, E. J., Burns, B. J., Costello, A. J., Edelbrock, C., Dulcan, M., & Brent, D. A. (1988). Service utilization and psychiatric diagnosis in pediatric primary care: The role of the gatekeeper. Pediatrics, 82, 435–441. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782– 786. Dawson, G., Ashman, S. B., Panagiotides, H., Hessl, D., Self, J., Yamada, E., et al. (2003). Preschool outcomes of children of depressed mothers: Role of maternal behavior, contextual risk, and children’s brain activity. Child Development, 74, 1158–1175. Earls, M. F., & Hay, S. S. (2006). Setting the stage for success: Implementation of developmental and behavioral screening and surveillance in primary care practice—the North Carolina Assuring Better child Health and Development (ABCD) project. Pediatrics, 118, e183–e188. Fenichel, E. (Ed.). (1997). Pediatric primary care. Zero to three, 17[whole issue]. Fiese, B. H., Poehlmann, J., Irwin, M., Gordon, M., & Curry-­Bleggi, E. (2001). A pediatric screening instrument to detect problematic infant–­parent interactions: Initial reliability and validity in a sample of high- and low-risk infants. Infant Mental Health Journal, 22, 463–478. Gilbert, S. G., & Weiss, B. (2006). A rationale for lowering the blood lead action level from 10 to 2 [mu]g/dl. NeuroToxicology, 27, 693. Glascoe, F. P. (2000). Early detection of developmental and behavioral problems. Pediatrics in Review, 21, 272–280. Gleason, M. M., & Zeanah, C. H., Jr. (2005). Screening for emotional and behavioral problems in young children: Preliminary validity of



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the early childhood screening assessment (poster e48). Poster presented at the 52nd annual meeting of the American Academy of Child and Adolescent Psychiatry, Toronto, Canada. Gottlieb, D. J., Vezina, R. M., Chase, C., Lesko, S. M., Heeren, T. C., Weese-Mayer, D. E., et al. (2003). Symptoms of sleep-­disordered breathing in 5-year-old children are associated with sleepiness and problem behaviors. Pediatrics, 112, 870–877. Green, M., & Palfrey, M. S. (2000). Bright futures: Guidelines for health supervision of infants, children, and adolescents. Washington, DC: Georgetown University. Hagan, J. F., Shaw, J. S., & Duncan, P. (2008). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics. Halfon, N., Olson, L. M., Inkelas, M., Hochstein, M., Kogan, M., Bethell, C., et al. (2002, May 4). National survey of early childhood health: Parents concerns, content and quality of care. Paper presented at the Pediatric Academic Society annual meeting, Baltimore, MD. Halfon, N., Regalado, M., McLearn, K. T., Kuo, A., & Wright, K. (2003). Building a bridge from birth to school: Improving developmental and behavioral health service for young children [Briefing note]. New York: Commonwealth Fund. Heneghan, A. M., Mercer, M., & DeLeone, N. L. (2004). Will mothers discuss parenting stress and depressive symptoms with their child’s pediatrician? Pediatrics, 113, 460–467. Horwitz, S. M., Gary, L. C., Briggs-Gowan, M. J., & Carter, A. S. (2003). Do needs drive services use in young children? Pediatrics, 112, 1373– 1378. Horwitz, S. M., Kelleher, K., Boyce, T., Jensen, P., Murphy, M., Perrin, E., et al. (2002). Barriers to health care research for children and youth with psychosocial problems. Journal of the American Medical Association, 288, 1508–1512. Horwitz, S. M., Kelleher, K. J., Stein, R. E. K., Storfer-Isser, A., Youngstrom, E. A., Park, E. R., et al. (2007). Barriers to the identification and management of psychosocial issues in children and maternal depression. Pediatrics, 119, e08–e218. Inkelas, M., Glascoe, F. P., Regalado, M., & Peck, C. H. (2002b). National patterns and disparities in parent concerns about child development. Paper presented at the Pediatric Academic Societies’ annual meeting, Baltimore, MD. Inkelas, M., Halfon, N., Olson, L. M., Newachek, P., & Schuster, M. (2002a, May). Having a particular clinician for well child care and quality of early childhood health care. Paper presented at the Pediatric Academic Societies annual meeting, Baltimore, MD. Inkelas, M., Regalado, M., & Halfon, N. (2005). Building community systems to promote medical home and integrated primary care developmental

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services: Policy and community-based practice strategies. In N. Halfon, T. Rice, & M. Inkelas (Eds.), Building state early childhood comprehensive systems series, No. 10. National Center for Infant and Early Childhood Health Policy, Los Angeles. Jellinek, M. S., & Froehle, M. C. (Eds.). (1998). Bright futures in practice: Mental health. Arlington, VA: National Center for Education in Maternal and Child Health. Jellinek, M. S., & Murphy, J. M. (1990). The recognition of psychosocial disorders in pediatric office practice: Current status of the Pediatric Symptom Checklist. Journal of Developmental and Behavioral Pediatrics, 11, 273–278. Jellinek, M. S., Patel, B. P., & Froehle, M. C. (Eds.). (2002). Bright futures in practice: Mental health—Vol. 1. Practice guide: Vol. 2. Tool kit. Arlington, VA: National Center for Education in Maternal and Child Health. Johnson, K., Knitzer, J., & Kaufmann, R. (2002). Making dollars follow sense: Financing early childhood mental health services to promote healthy social and emotional development in young children. New York: National Center for Children in Poverty. Karoly, L. A., Kilburn, M. R., & Cannon, J. S. (2005). Early childhood interventions: Proven results, future promise. Santa Monica, CA: RAND. Kautz, D., Mausch, D., & Smith, S. A. (2008). Reimbursement of mental health services in primary care settings (HHS Publication No. SMA-084324). Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Kaye, N. P. (2006). Improving the delivery of health care that supports young children’s healthy mental development: Early accomplishments and lessons learned from a five-state consortium. New York: National Academy for State Health Policy and The Commonwealth Fund. Kaye, N. P., & Rosenthal, J. (2008). Improving the delivery of health care that supports young children’s healthy mental development: Update on accomplishments and lessons from a five-state consortium. New York: National Academy for State Healthy Policy and The Commonwealth Fund. Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., et al. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: A randomized controlled trial. Journal of the American Medical Association, 278, 644–652. Lebbuffe, P. A., & Nagliere, J. (2003). The Devereux Early Childhood Assessment (DECA): A measure of within-child protective factors in preschool children. Retrieved January 24, 2004, from www.devereuxictr.org. McLearn, K. T., Minkovitz, C. S., Strobino, D. M., Marks, E., & Hou, W. (2006). The timing of maternal depressive symptoms and mothers’

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parenting practices with young children: Implications for pediatric practice. Pediatrics, 118, e1 74–e182. McLennan, J. D., Kotelchuck, M., & Hyunsan, C. (2001). Prevalence, persistence, and correlates of depressive symptoms in a national sample of mothers of toddlers. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1316–1323. Mendelsohn, A. L., Dreyer, B. P., Fierman, A. H., Rosen, C. M., Legano, L. A., Kruger, H. A., et al. (1998). Low-level lead exposure and behavior in early childhood. Pediatrics, 101, E10. Minkovitz, C. S., Hughart, N., Strobino, D. M., Scharfstein, D., Grason, H., Hou, W., et al. (2003). Practice-based intervention to enhance quality of care in the first three years of life: Healthy Steps for young children program. Journal of the American Medical Association, 290, 3081–3091. Minkovitz, C. S., Strobino, D., Scharfstein, D., Hou, W., Miller, T., Mistry, K. B., et al. (2005). Maternal depressive symptoms and children’s receipt of health care in the first 3 years of life. Pediatrics, 115, 306–314. NUBE–Family Partnership. (2006). Interview with Dr. David Olds. Accessed September 5, 2007, at www.nubefamilypartnership.org/resources/ files/PDF/DavidOldsinterview1-24-06.pdf. Nygren, P., Nelson, H., & Klein, J. (2004). Screening children for family violence: A review of the evidence for the U.S. Preventive Services Task Force. Annals of Family Medicine, 2, 161–169. Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., et al. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year  follow-up of a randomized trial. Journal of the American Medical Association, 278, 637–643. Olds, D. L., Henderson, C. R., Kitzman, H., Eckenrode, J., Cole, R., & Tatelbaum, R. (1998). The promise of home visitation: Results of two randomized trials. Journal of Community Psychology, 26, 5–21. Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 78, 65–78. Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1988). Improving the life course development of socially disadvantaged mothers: A randomized trial of nurse home visitation. American Journal of Public Health, 78, 1436– 1445. Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D., et al. (2004). Effects of nurse home visiting on maternal life-­course and child development: Age-six follow-up of a randomized trial. Pediatrics, 114, 1550–1559. Olds, D. L., Robinson, J., O’Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., et al. (2002). Home visiting by nurses and by parapro-

fessionals: A randomized controlled trial. Pediatrics, 110, 486–496. Olson, A. L., Dietrich, A. J., Prazar, G., & Hurley, J. (2006). Brief maternal depression screening at well-child visits. Pediatrics, 118, 207–216. Olson, A. L., Dietrich, A. J., Prazar, G. M., Hurley, J. M., Tuddenham, A. M., Hedberg, V. M., et al. (2005). Two approaches to maternal depression screening during well child visits. Journal of Developmental and Behavioral Pediatrics, 26, 169–176. Olson, L. M., Inkelas, M., Halfon, N., Schuster, M. A., O’Connor, K. G., & Mistry, R. (2004). Overview of the content of health supervision for young children: Reports from parents and pediatricians. Pediatrics in Review, 113, 1907–1916. Pelletier, H., & Abrams, M. (2003). ABCD: Lessons from a 4 state consortium. New York: National Academy for State Health. Perrin, E. C., & Stancin, T. (2002). A continuing dilemma: Whether and how to screen for concerns about children’s behavior. Pediatrics in Review, 23, 264–282. Pignone, M., Gaynes, B., Lohr, K., Rushton, J., & Mulrow, C. (2002). Screening for depression: Recommendations from the U.S. Preventive Services Task Force. Annals of Internal Medicine, 136, 765–765. Reanalysis Olds et al. (1997). Journal of the American Medical Association, 278, 637–643. Reanalysis Olds et al. (1998). Journal of the American Medical Association, 280, 1238–1244. Rushton, J., Bruckman, D., & Kelleher, K. (2002). Primary care referral of children with psychosocial problems. Archives of Pediatric and Adolescent Medicine, 156, 592–598. Sameroff, A. J., & Fiese, B. H. (2000). Models of development and developmental risk. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 3–19). New York: Guilford Press. Seifer, R., Dickstein, S., Sameroff, A., Magee, K., & Hayden, L. (2001). Infant mental health and variability of parental depressive symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1375–1382. Shonkoff, J. P., & Phillips, D. A. (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press. Squires, J., & Bricker, D. (1999). Ages and Stages Questionnaires (2nd ed.). Baltimore, MD: Brookes. Squires, J., Bricker, D., & Twombly, M. S. (2002). Ages and Stages Questionnaires: Social–­ Emotional. Baltimore, MD: Brookes. Stadtler, A. C., O’Brien, M. A., & Hornstein, J. (1995). The Touchpoints model: Building supportive alliances between parents and professionals. Zero to Three, 16, 24–28. Taaffe Young, K., Davis, K., & Schoen, C. (1996). The Commonwealth Fund survey of parents with young children. New York: The Commonwealth Fund.



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U.S. Department of Health and Human Services. (2006). A profile of Healthy Start: Findings from Phase I of the evaluation. Washington, DC: Author. U.S. Preventive Services Task Force. (2004). Screening for family and intimate partner violence: Recommendation statement. Annals of Internal Medicine, 140, 383–386. Wissow, L. S., Larson, S., Anderson, J. H., & Hadjiisky, E. (2005). Pediatric residents’ responses that discourage discussion of psychosocial problems in primary care. Pediatrics, 115, 1569–1578. Wissow, L. S., Roter, D. L., & Wilson, M. E. (1994). Pediatric interview style and mothers disclosure of psychosocial issues. Pediatrics, 93, 289–295. Young, K. T., Davis, K., Schoen, C., & Parker, S. (1998). Listening to parents: A national survey of parents with young children. Archives of Pediatrics and Adolescent Medicine, 152, 255–263.

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C h a p t e r 35

Mental Health Consultation A Transactional Approach in Child Care Kadija Johnston Charles Brinamen

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onsultation addressing the intricacies of early development is not a new endeavor. In the mid 1970s Greenspan, Nover, and Brunt (1975) asserted that mental health consultation had the potential to enhance the quality of child care while simultaneously serving as an inoculation for emotional and behavioral disturbances by intervening early with infants and toddlers. It is also not new to consider and describe infant–­parent interaction as a transactional system: Each partner is understood in relation to his or her effect on the other (Sameroff & Emde, 1989; Stern, 1995). Dyadic treatment aimed at freeing an infant from parental distortions to promote positive development is increasingly accepted. However, mental health consultation premised on a transactional view of early development and carried out by adapting the core concepts of infant–­parent psychotherapy is a relatively recent development (Johnston & Brinamen, 2005, 2006). By expanding the dyadic intervention, our consultation approach attends to the extensive network of human relationships that make up and affect children’s development in child care.

CHILD CARE CHARACTERISTICS Consultation anchored in an infant mental health perspective is burgeoning (Brennan, Bradley, Allen, Perry, & Tsega, 2005), in part because swiftly increasing numbers of young children in the United States spend large portions of their days, weeks, and lives in care outside the home. The largest increases are in infant care (National Institute of Child Health and Human Development [NICHHD] Early Child Care Research Network, 1997; National Research Council [NRC] & Institute for Medicine [IM], 2000). As our youngest children typically spend over 30 hours a week in child care, their relationships with child care providers have correspondingly increased significance on their development.

Quality Is Most Important Although quantity of time spent in nonmaternal care, especially center-based child care, is associated with kindergartners’ problem behaviors and conflict with adults (National Institute of Child Health and 564



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Human Development, 2003), quality of care is a more prominent predictor of children’s social and emotional adjustment, as well as other developmental outcomes (Love et al., 2003; National Institute of Child Health and Human Development, 2001). Regrettably, several studies report that quality in 80% of child care programs is mediocre to poor (Cost Quality and Child Outcomes Study Team [CQO], 1995; National Institute of Child Health and Human Development, 2000, 2005). Poor programs were those in which no learning was encouraged and, most important, no warmth or support from adults was observed. More disturbingly, low-­quality care appears to more negatively impact children who are already at risk and who need the most intervention (National Institute of Child Health and Human Development, 1997). Quality care is most related to program and staff characteristics, primarily wages, followed by adult–child ratio, group size, caregiver continuity, and caregiver training (Cost Quality Outcome, 1995). In combination, these factors have a significant impact on relationship formation between caregivers and children, compounded by a consistently high turnover rate (Cost Quality Outcome, 1995). Relationships between caregivers and children benefit from smaller groups, lower ratios, stability of relationships, and training for caregivers, but most child care programs do not possess these correlates of quality.

Developmental and Behavioral Concerns As the overall population participating in child care has grown, so too has the number of children presenting in these settings with puzzling developmental and behavioral profiles. Although estimates of the number of preschool-age children with significant emotional and/or behavioral concerns ranges from 4 to 16% (Child and Adolescent Health Measurement Initiative, 2003; Egger et al., 2006; McDonnell & Glod, 2003), child care providers report that as many as 30% of their charges warrant special attention because of behavioral difficulties or developmental deviations (Raver & Knitzer, 2002). The discrepancy may be due to the developing role of child care as an intervention for children

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with challenges, which would increase the number of children with special needs in typical child care. For instance, child protective service plans for children who have suffered abuse or neglect often include child care as a protective measure, to offer respite for a stressed family system and a safe haven for the child. The unexpressed expectation is that the experience will be reparative for the child, offering a template for interaction currently unavailable with parents, but this expectation contributes to the unacknowledged burden on child care providers. Research has reported the lack of deleterious affects of child care on young children, but little attention has been paid to the possible benefits of child care for children experiencing poor maternal care (Booth & Kelley, 2002). Some children arrive at child care programs with unidentified but no less extreme needs. Staggering numbers of young children experience, and are affected by, their family’s struggles with substance abuse and mental illness, domestic and community violence, poverty, and homelessness. Others bear the burden of disrupted relationships due to immigration, mobility, or divorce. Contributing to the complex conundrums in which families find themselves are attributes of the children. Infants who arrive in the world with constitutional compromises, disabilities, or sensory sensitivities contribute these qualities to their relationships. Children bring all of who they are and expressions of how they have been treated to their child care settings. Although being in child care can be ameliorative, at times it may amplify a child’s distress. Whether the result of inborn qualities, distressed relationships, poor program quality, or a combination, emotional and developmental difficulties among children in child care seem to increase annually (Arnold, McWilliams, & Arnold, 1998; Raver & Knitzer 2002; Yoshikawa & Knitzer, 1997). Children with idiosyncratic and often immense needs place high demands on caregivers’ investment, emotional availability, and skills. Many providers feel ill equipped or lack the training necessary to respond to the children in their care (Knitzer, 1996), specifically when those children present with disabilities or other special needs (Dinne-

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beil, McInerney, Fox, & Juchartz-­Pendry, 1998; Knoche, Peterson, Edwards, & Jeon, 2006; Rafferty & Griffin, 2005; Wolery et al., 1994). Grounding in typical development among child care providers is not commonplace, which makes the identification of developmental deviations difficult. Even when providers are educationally equipped to understand and respond to children with differences, the distress that a child’s behavior demonstrates can be emotionally overwhelming. These combined circumstances have culminated in a preschool expulsion rate that is three times greater than the rate for schoolage children (Gilliam, 2005; Gilliam & Shahar, 2006). Others report that 1 in 3 children enters kindergarten unprepared or unable to learn (Carnegie Task Force on Meeting the Needs of Young Children, 1994; Shonkoff & Phillips, 2000). Research has begun to demonstrate that mental health consultation has been effective in reducing expulsion rates in preschool (Green, Everheart, Gordon, & Gettman, 2006; Perry, Dunne, McFadden, & Campbell, 2008). The mechanism for this reduction may be found in the positive effects of mental health consultation on the quality of child care, particularly in regard to teachers’ sensitivity to children’s needs and classroom management (Raver et  al., 2008).

MENTAL HEALTH CONSIDERATIONS IN CHILD CARE The relationships offered in child care play an increasingly crucial role in determining each child’s sense of self and the trajectory of his or her development. Upon entering child care, every child exhibits, through behavior, a set of expectations based on experiences and interactions with the important people in his or her life. The child care provider confirms, refutes, or adds to these relationship expectations—a powerful role. The child’s course of development and sense of self adapt to the quality of the interaction offered by the substitute caregiver. Mental health services are rarely aimed at preserving positive states. The work of mental health practitioners is usually limited to intervening when harmful relational effects

are already evident in a young child’s development. Similarly, mental health consultation is rarely sought until caregiving staff feels itself to be, or is perceived by others as being, depleted of options for dealing constructively with a troubled child. This need not be the exclusive point of entry, however. After all, the nutritional needs of children in child care are not attended to only at the point at which we identify signs of malnutrition in one child. Mental health is an issue for all children in child care. Because children’s experiences of themselves and the world are inextricable from the network of relationships that defines their developmental trajectory, the mental health of providers and parents should be considered as a matter of course. This conviction is integral to our philosophy of mental health consultation. Specific aspects of this approach are articulated below, but first we provide a brief historical overview of mental health consultation from which the general principles guiding our work have been derived.

HISTORY OF MENTAL HEALTH CONSULTATION From its inception, the term mental health consultation has referred to the work of assisting others in dealing with a work dilemma (Caplan, 1964). Voluntary participation and the consultant’s expertise were assumed. Early conceptualizations of consultation adhered to a “deficit perspective,” identifying what was lacking within an individual client or consultee. Caplan (1970) suggested that the focus of consultation shifts to the consultee when the work difficulty is identified as an inadequacy in the consultee’s skills, knowledge, self-­confidence, or professional objectivity. By the mid-1970s, a more expansive view of mental health consultation was developing. Greenspan, Nover, and Brunt (1976) concentrated on the growth-­promoting potential of early childhood care settings and on the caregiver’s internal experiences. Another of this group’s endeavors highlighted the multiple layers of influence exerted on program functioning and staff relationships from administrative to interstaff. Consequently, consultation was aimed at address-



35. Mental Health Consultation

ing adversity within adult interactions, appreciating that quality care can occur only in the context of collaborative, productive relationships among the providers of care. Solym’s (1981) prevention approach emphasized the continuity of the mental health consultant’s relationship with staff as a parallel and support to the staff’s relationship with their infant charges. These endeavors, albeit diverse, coalesced around the notions of applying mental health expertise toward understanding individual and systemic influences on the quality of child care. The conceptualization of consultation put forward by these early practitioners acknowledges the matrix of human relationships and transactions to which consultation must attend. Even when not overtly articulated, parallel process remains a crucial component of the potential efficacy of consultation.

GENERAL PRINCIPLES OF CONSULTATION We conceptualize dilemmas as transactional rather than as static states within the consultee. Even when the difficulty emanates from a particular child or individual provider, it is invariably expressed in the interactions between them. Solutions emerge as transactional tangles are understood and unwound. Through observation and inquiry the consultant seeks to identify obstacles to change wherever they reside. Even when consultation is “client” focused, on a particular child, the consultee’s subjective experience and contribution to the child’s situation are considered. Institutional impediments are also taken into account as possible contributors to the transaction. Solutions to an identified difficulty are also seen as interactional. Ameliorating a child’s distress is predicated on a change in the provider’s characteristic way of interpreting and responding to the behavior. Together consultant and consultee decipher the meaning of behavior and revise responses based on their mutually developed deeper awareness.

The Collaborative Nature of Consultation Collaboration has always been a hallmark of consultation. Each participant is acknowl-

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edged to possess expertise. Consultation should aspire to an alchemy that exceeds the exchange of expertise. The transformative power resides in the relationship (Green et al., 2006). The consultant’s respect for the provider’s perspective engenders a reciprocal sense. His or her ability to listen determines the consultee’s willingness to hear and integrate the information offered. From a dynamically driven relational approach, the consultee is regarded simultaneously as a collaborator and a client. Client here refers to the consultee as the recipient of a service. However, the clinical connotation of the term applies to the extent that the consultant’s clinical training in understanding human behavior is extended to adults as well as to children. The consultant attempts to understand the motivations, projections, defenses, and expectations evidenced in the provider’s behavior, always acknowledging the multiple and complex determinants of any action. This double consciousness requires that the consultant maintain a delicate balance between collegial engagement and clinical distance. The consultant must authentically engage consultees, while maintaining an acute awareness of contributors to a consultee’s perceptions, and respond sensitively.

CENTRAL TENETS OF A TRANSACTIONAL APPROACH Consultation, like parent–child therapy, takes many forms. Program consultation serves to support a state of social–­emotional health throughout the child care system, thereby promoting the mental health of all affected children. Case consultation focuses on an individual child whose development or behavior is of concern. Whether a promotion, prevention, or intervention activity, consultation is guided by the same clinical concepts as treatment. An essential component of each is the clinician’s ongoing attempts to understand the influences on the adult–child relationship. Acknowledging the contribution of both partners, the intervention examines the interaction rather than exclusively focusing on the individual and addresses the transactions created between them (Fraiberg, 1980; Lieberman & Pawl, 1993; Lieberman, Silverman, & Pawl, 2000;

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Pawl & Lieberman, 1997). In treatment, the therapist tries to trace parental perceptions, attributions, and actions toward the child to origins in the parent’s past or present circumstances. The baby’s contributions, such as constitutional and physical characteristics, are examined with equal intensity for the meaning they hold for parents. Consultation proceeds from these same premises. The hub of consideration is the provider– child relationship. Adhering to a proactive and transactional view of mental health, the aim of consultation is to improve the quality of relationships, especially the provider–child relationship. This improvement occurs as the providers’ ideas about children in their care and the practices that emanate from these beliefs are aligned with children’s developmental capacities and individual needs. In group care the provider–child relationship cannot be meaningfully considered or addressed separately from the myriad other affiliations in which it exists and unfolds. To this end, the concentric relational rings surrounding the provider–child relationship are considered and addressed. In child care, these include numerous adult relationships between providers and parents, among the child care staff, and between the consultant and consultee.

Consultant–­Consultee Relationship: A Mutative Factor The consultant–­consultee relationship is considered first because it transforms the other relationships in child care. Ascribing centrality to the consultant’s connections with consultees resonates with current conceptualizations of the mutative function of the therapeutic relationship in parent–child treatment (Lieberman et al., 2000). Through the active use of understanding, empathy, and reflection of the consultee’s subjective experience, consultation strives to shore up or enhance the provider’s sense of his or her professional self. More basic, the motivation to engage a child differently or expand a repertoire of responses hinges wholly on the provider’s sense that his or her actions toward a child are meaningful. A reciprocally reinforcing beneficial relationship, whether with a child or the consultant, relies on the

caregiver’s ability to accurately discern the other’s positive intention. In its initial iteration, infant–­parent psychotherapy was premised on a view of the infant as a powerful transferential trigger for parental projections. The parent places repudiated aspects of his or her past or of him- or herself in the baby’s inherent receptivity. While never losing sight of the actual infant, treatment aims, through interpretation, to make conscious the connections between the past and the present (Fraiberg, 1980). Similarly, consultants hold the idea that the child functions in a transferential capacity. Transference also may influence the way in which the consultant is viewed and, consequently, treated.

Subjective Experience Particularly in the early stages of consultation, the consultant must attune to and hold the consultees’ attributions and projections that are the result of their prior experiences. Bearing the brunt of perceived inadequacies, intrusions, or missteps can be perplexing or even injurious. When the consultant interprets the behavior as an indicator of expectations based on the past, he or she begins to understand the consultee’s subjective experience. The consultant attempts to decipher the meaning of providers’ perceptions and attitudes by actively seeking a sense of each provider’s role expectations, emotional capacities, and beliefs about development because these are inevitably expressed in providers’ attitudes toward, and relationship with, children. When engaging parents, we appreciate that, and therefore, inquire about the ways in which their experiences, cultural values, and history impact perceptions of parenting and childrearing practices. However, at times we mistakenly assume that professional training takes precedence over beliefs based on personal experience. Attributions ascribed to a child or coworker and the feelings that arise often stem from personal experiences that can trump, or at least temporarily obscure, the knowledge a provider possesses. The consultant seeks access to the consultee’s subjective experience by listening and asking permission to explore the past and by noticing the messages in a child’s behavior. A



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provider’s history of abuse leads him or her to interpret a toddler’s swipe as a predictor of violent tendencies. The consultant appreciates this explanation and empathizes with the experience but does not argue, educate, or validate. Instead, through exploration the consultant assists in uncovering these connections and freeing the provider, and eventually the child, from misperceptions shaped by his or her past experience. This circumscribed exploration often allows the consultee to uncover his or her previously obscured knowledge of children’s development.

Levels of Influence In addition to the intrapsychic sway, there are numerous influences on consultees’ views of children and capacity for care. At the interpersonal level, each provider’s relationship with coworkers, director, parents, and children affects the possibilities of interacting positively with a particular child. Provider–child relationships are configured by program philosophy and policy, bureaucratic pressures, licensing requirements, and budgetary constraints. Culture colors the provider’s ways of interacting, values, and understanding about child development. The consultant’s task is to inquire about and acknowledge multiple possible contributors to behavior. With the consultee, the consultant strives to understand the effect of these often interlocking forces as they exert themselves in a current work dilemma or a provider’s chronic distress. When related to a child-­specific consultation, the consultant assists the caregiver in identifying internal and external factors shaping both the provider’s perceptions and the child’s presentation with the eventual intent of enhancing the provider’s understanding and interaction with the child. Behavior, even a newborn’s, has meaning. Meaning is forged and understood interactionally. Whether articulated or not, many providers’ practices are based upon this theoretical platform. If not, the consultant seeks to instill these ideas. With these assumptions as guideposts, a child care provider can follow his or her internal responses in developing hypotheses about the child. From here the provider is optimally positioned to use him- or herself and the interactions with

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the child to facilitate developmental progress and revise distorted images of self and other.

Contributing Expertise in Infant Mental Health In the context of internal and external contributors to a consultee’s actions, the consultant tries to contribute his or her expertise. The consultant must incorporate what has been learned about a provider’s or a child care community’s capabilities as well as their constraints and limitations. Consultation, by definition, is a collaborative endeavor in which each participant’s expertise is honored, as noted previously. A consultant must genuinely respect and trust the consultee’s know-how as distinct from, but equal to, his or her own. At times, the consultant must increase and legitimize a provider’s or parent’s knowledge. Intellectual or experiential contradictions are not discounted but rather explored for the richness that difference invariably holds. Conflicting descriptions of a child’s behavior at home and in child care are embraced as potentially meaningful. This is not to suggest that the consultant does not have crucial and complimentary expertise. However, he or she must avoid the pull to proffer advice that may preclude others from offering information, because solutions not developed by all will lack the support necessary for success.

Inquiring as Intervention The consultant’s stance of inquiry also demonstrates to the consultee that understanding is a process, not a moment. What follows then is the importance of wondering aloud with caregivers. Asking elicits the providers’ or parents’ currently held interpretations about a child and the meaning of his or her behavior. Often, the way that behaviors are labeled immediately implies we know the cause. For example, a child who cries incessantly and can’t nap without constant comforting is labeled “spoiled,” locating the etiology of the concern primarily with the parents. This assumption stops a search for other explanations. The consultant’s curiosity helps identify obstacles to change and suggests that multiple or alter-

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nate views can be entertained. Inquiry can also start to shift a provider’s view about a child or family.

Addressing the Network of Relationships in Child Care Thus far we have described interactional influence as a back-and-forth process between provider and child or consultant and consultee. In reality, most child care settings have multiple caregivers and an exponentially greater number of children and parents who all interact on a daily basis. Consultation focuses on the dyadic relationships while simultaneously attending to the web of interaction that surround’s the central child–­ provider relationship. While each caregiver’s perspective must be heard and valued by the consultant, it must also be appreciated by those with whom he or she works. The consultant is particularly attuned to listen for, and give voice to, those who literally have little language—the children—­positioning him- or herself in such a way as to create and hold spaces for communication. Whenever necessary, the consultant represents the perspective of one consultee to another, with the eventual aim of increasing the adults’ capacity to, and belief in the usefulness of, communicating directly to one another.

Attending to Parallel Process Thus far we have emphasized how consultation attends to adults’ experiences, feelings, and the relationships created among them. This focus may seem antithetical to the stated aim of enhancing the quality of care for children. However, our approach assumes that the ways in which people are treated affects how they feel about themselves and how they treat other people. Parallel process extends in all directions and beyond the consultant–­consultee relationship. Therefore, the consultant not only behaves as he or she envisions other might, she encourages such characteristic ways of behaving among all—­directors, providers, and parents. Specifically, we postulate that the providers’ sense of efficacy, satisfaction with their work, and the tenor of their relationships are transmitted to, and, to a large degree, decide the quality of interactions offered to, chil-

dren. In our formal process evaluation (Pawl & Johnston, 1991), those programs reporting the greatest degree of organizational difficulty prior to consultation were also rated as having the lowest overall quality of care. Only as providers feel respected, clear about what is expected of them, and able to anticipate changes will they treat the children they care for similarly.

CONSULTATIVE PRACTICE Because an understanding of mutually influencing interaction is acquired over time, we offer open-ended, long-term consultation relationships. By meeting regularly—­ usually weekly and over an extended period of time—the consultant becomes part of the matrix of relationships that makes up the culture of a program. Establishing forums in which to talk and helping staff to see the usefulness of doing so are often initial goals in the consultative process. The majority of programs with which we consult do not initially hold staff meetings. Having little opportunity to think together about children or program issues is, in and of itself, a contributing factor to interstaff and programmatic difficulties. Through regular meetings with the staff, the consultant assists in untangling the knots of misperception by addressing adult interactions, organizational functioning, individual agonies, or the more practical program practices. Meeting individually and then securing therapy for a teacher whose experience with a child in his or her care has resurrected memories of his or her own early trauma or helping to amend a naptime routine in which no one rests are within the realm of issues addressed. Through regular contact and by employing the principles described previously, consultation can serve to support a state of psychological and organizational well-being throughout the child care system thereby promoting the mental health of all involved participants. Understanding the intricacies of a program is equally important to successfully consulting in regard to an individual child. Considering the meaning of the child’s behavior and engaging all the adults in the child’s life in understanding and respond-



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ing to the messages these behaviors express, consequently ameliorating difficulties, is the aim of case consultation. The child’s parents are involved from the beginning. The consultant may initially think, with the child care providers, about the least threatening and most useful way to introduce the consultation services to the family. However, specific information about the child is shared with the consultant only with the parents’ knowledge and consent. The reasons for soliciting parental permission and involvement may seem obvious, but at times, the consultant’s efforts to honor those reasons are perceived by providers as impediments to immediately receiving the assistance they desire—“fixing the child,” lending legitimacy to the provider’s assessment of the child, or relieving them of the responsibility of communicating with parents. Speaking with parents about the wish for the consultant’s help can be awkward if it is not embedded in an already established relationship. Even when communication has occurred, identification of developmental difficulties or a child’s distress in the program can cause a fissure in the relationship. At times these factors contribute to a provider’s reticence to talk with the parents about the consultant’s involvement. In these situations, the consultant and providers together develop ways to overcome the mutual mistrust that would not only prohibit the consultant’s inclusion but would also likely impede the adults’ efforts to construct the bridge of communication necessary to address the concerns of the child.

Child Observation With parental permission, the consultant observes the child in the child care setting. The frequency and timing of the observations are based on several factors. Consideration of the caregiver’s wishes and perspectives are paramount in establishing the validity of the consultant’s observations. Therefore, scheduling is determined primarily by the providers’ view of when the consultant is most likely to witness the behaviors that concern them and at their convenience. The consultant’s presence at these times underlines his or her respect for the provider’s knowledge of the child. Witnessing the child’s distress

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and the caregiver’s struggles to understand and respond to this distress contributes to the feeling that the consultant possesses a true picture from which useful ideas will be generated. These observations enable the consultant to evaluate the child’s abilities, limitations, vulnerabilities, and strengths, as well as to view a variety of interactions that shed light on the goodness of fit between the child’s needs and the program. The luxury of being uninvolved in these interactions allows the consultant to identify antecedents to behavior that would likely go unnoticed by caregivers as they are engaged in responding to the multiple demands of the group, which necessarily precludes the sustained focus on an individual child.

Parent Participation The development of a complete picture depends on the consultant’s ability to elicit and integrate the perspectives of the providers and parents. We convey to parents that their participation is vital. One way that we demonstrate this message is in our intentional flexibility. Although we might meet them at the child care center or at their office, often it is most convenient to meet with them in their homes. Home visits also provide an opportunity to observe the child in another environment. Inherent in all exchanges is the sense that the parent possesses knowledge that is essential to our understanding of the child—the child’s behavior in child care can be meaningfully considered only in connection to all other aspects of the child’s experience. To this end, the consultant asks about the child’s development, relational history, possible constitutional particularities, and current functioning outside the child care setting. The consultant makes explicit the intent of the inquiry, linking what he or she is learning to the goal of improving the child’s experience in child care. While acknowledging the usefulness of hearing about the child from the parents’ perspective, the consultant is always asserting the prominence of the parent–­provider relationship as the place in which mutual understanding will best benefit the child. When this exploration reveals a need for additional or longer-term help, the consultant suggests possible referrals for

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services and follows the family through the process to ensure their engagement.

Provider Participation The process with parents parallels the one with the child care providers. The consultant starts by eliciting and listening carefully to providers’ description of a child, alert to hearing the attributions providers attach to behaviors as well as their reasoning. Simultaneously, the consultant is prepared to offer additional or alternate conceptions. The consultant’s observations in tandem with the information he or she acquires from all of the child’s caregivers is added to his or her own impressions and assessment. Combining these sources of knowledge the consultant generates, and assists providers and the parents in developing, hypotheses about the meaning of, and contributing influences on, the child’s behavior. The consultant helps translate the now mutually held understanding of the child’s needs into responsive action. How ideas are offered is crucial. The consultant inquires about the feasibility of his or her suggestions, aware of the constraints of group care and with the understanding that suggesting special treatment may evoke feelings about fairness. Providers often express worry that changes on behalf of one child will create a cascade of need in the others—no one, they protest, will want to sleep if one child is allowed an alternative. The consultant invites, and is eager to be reminded of, what providers feel will or will not work. An intervention strategy that organically evolves and is mutually endorsed affords the greatest likelihood of being implemented successfully. When providers believe in the importance of their relationship to a child, they typically generalize their newly developed understanding about particular interactions to other exchanges with that child and even to their ways of being with other children.

MENTAL HEALTH CONSULTATION IN PRACTICE To illustrate a transactionally informed approach to consultation, we focus on a child whose behavior has challenged his child care providers, stopping along the way to exam-

ine underlying tenets and the consultant’s stance (Johnston & Brinamen, 2006). The following example is a case consultation, but the effort incorporates an understanding of the programmatic elements influencing the response to a child. For the last couple of months, Gina had been consulting to ABC Childcare, a program in an economically deprived neighborhood. ABC had recently gone through a number of programmatic changes and was struggling to provide care for a large group of infants and toddlers while understaffed. A new consultant with a number of cases, Gina had limited time. Although the program had difficulty using the hours she did provide and could not regularly convene classroom staff meetings, the director focused on the lack of Gina’s availability, insisting she needed more. Gina wanted to be responsive and was willing to extend her work week to accommodate the request. Her supervisor helped her to maintain the previously established boundary and focus on the motivations for the request. Although it would be a long process, Gina held firm while empathizing with and naming the experience of scarcity and intense unmet needs in the program. For a long time, this approach disturbed the director, who believed that other programs must be receiving more of Gina’s energy. At times, Gina became impatient with her supervisor for not allowing her to offer additional hours. Together they explored the anxiety raised when she did not please others. The reality that the program could not use more time was often obscured by the profound need and vulnerability of the program and the director’s resulting anger.

Parallel Process as an Organizing Principle Throughout this vignette, we refer to Gina’s supervisor. The inclusion of the supervisor is deliberate. Mental health consultation is based on considering and reflecting on one’s own and others’ experiences. As a contributing participant in that work, the consultant also needs support to reflect on his or her own, and others’, experiences and to understand his or her own, and others’, motivations. Even the most seasoned consultant benefits from access to regular reflection. When adults have the experience of being cared for, responded to, and empathized



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with, they can then extend these qualities to the children in their care. Child care’s success is in its relationships. Consultation uses the same guiding principle. Here, the supervisor is able to tolerate the anxiety so that the consultant can offer this containment to her consultees. Ultimately, the child care providers can pass these experiences on to the children in their care. Meanwhile the staff was struggling with Kyle, a 25-month old biracial African American and European American boy who resisted naps, cried easily and loudly, refused to be held or comforted, and often hit his peers and adults. The director and Kyle’s primary provider had been concerned since he arrived but had withheld their worry from Gina. Herself African American, the director felt protective of this boy and did not want him labeled. She feared that the European American consultant’s involvement would destine him for special education—a fate she felt befell too many African American boys. Eventually, unable to contain her distress, Kyle’s teacher asked Gina to observe him. Gina agreed readily because she saw an opportunity to be responsive. In supervision, Gina realized that she should have slowed down the process. Kyle’s guardian, his Great-Aunt Rose, had not yet given permission. To exclude her would give the staff and the aunt the idea that her involvement wasn’t important. It was also unclear what the purpose of the observation might be. In their wish for relief, child care providers often hope that observation will be the remedy rather than part of the process in understanding and developing a response. Gina needed more information. She called the director to find out more, but the director was impatient and felt that Gina always resisted helping them. She just wanted Gina to give them some answers. In her frustration, she blurted out, “I am close to kicking Kyle and his Aunt Rose out if you don’t do something soon.” Gina said, “I hadn’t realized how dire the situation had gotten and how burdened you and the staff must feel. I really want to respond, but I’m worried that my observing in isolation of what you and his aunt already know wouldn’t offer us much more.” This calmed the director enough to acknowledge that she feared losing staff members because Kyle’s presence was so stressful to them and to the other children.

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Understanding the Perspective of All Participants The child’s functioning and the adults’ understanding of the child are intricately linked to the adults’ experiences. In addition, the subjective experience of each of the individuals is as important as the “facts” in understanding the interpretations and responses to a child as well as in developing interventions. In this case, the theme of scarcity threads throughout the program. The consultant’s identification of these themes in the adults’ experience and sensitivity to their fears will help her to make room for the child’s experience. The director reported that all of the children’s naps were interrupted because Kyle was so fierce in his resistance to being held and comforted. She wanted Gina to offer an alternative. Gina wondered if they had asked Aunt Rose how she handles him. She suggested that talking to his guardian would also provide an occasion to ask permission for a consultant’s involvement. “I’m not so sure you should talk to her. She’s berated the staff and me, and I don’t want to open myself to any more of that,” said the director exasperatedly. “And besides,” she added, “her idea about how to handle that baby is downright cruel.” In response to their concerns, Aunt Rose had told them, “Put him in the rocking chair and leave him alone when he gets wound up.” Although she had provided the rocking chair, this seemed particularly cold, especially for a child who seemed to struggle with relating to others. Despite her wish to understand, even the consultant came to believe that his aunt had contributed to Kyle’s current difficulties. Sensing Gina’s solidarity, the director revealed that she believed that the European American Aunt Rose was racist. She didn’t care about Kyle because he was African American. Although the director questioned whether Gina could handle Aunt Rose, they all agreed that the teacher would introduce the idea of Gina’s involvement to her as a way to help the child care providers better serve Kyle. This was delicate business. In their last meeting, Aunt Rose had yelled at the director, “Stay out of my business!” Gina was able to reassure the director by stressing that she was gathering rather than

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giving information. She continued, “When I do share things, it’s to help understand a child’s experience. I’ll get your permission when that information seems confidential. For instance, I would never say anything about your fears of Aunt Rose’s racism. However, when I think something is important to share toward helping Kyle, I’ll think with you about the best way to do that. Right now, though, I’m only going to voice the concerns about Kyle’s behavior and our wish to find a way to soothe him.”

Appreciating Each Others’ Subjective Experience The goal in consultation is always to help individuals better understand one another. Ideally, people will talk directly to one another, but in the early stages of consultation or when relationships have become contentious, the consultant can act as a conduit. In addition, sometimes consultees share information about their experience that is not meant for the group. For instance, the director’s own experiences with racism, which she previously shared with the consultant, affect her interpretation of Aunt Rose’s behavior. Although this knowledge shapes the way that the consultant presents and understands information, she does not need to make Aunt Rose aware of this information, per se. She can, however, underscore the director’s similar wish to protect Kyle. Gina parked her car on Kyle’s block. She looked around and became somewhat nervous. Several men in their late teens and early 20s were hanging out on the stoop next door, and it was the middle of the day. In addition, several cars on the street had been vandalized. Gina walked quickly to Aunt Rose’s home. The doorbell was broken and the shades were drawn, but finally someone responded to her knocks. Aunt Rose could barely move. She leaned up against the wall as she walked. She was extremely obese. When they finally sat down, Aunt Rose said, “So what’s wrong with Kyle now.” Sensing the annoyance, Gina said, “They’ve spoken to you before? It sounds like you’re expecting complaints.” Aunt Rose exploded, “That woman [referring to the director] came into this house and had the nerve to tell me that I didn’t care about my nephew.” Gina responded, “I’m sorry to hear that. It sounds like your efforts with

him were challenged.” Aunt Rose, surprised to hear empathy in Gina’s voice, suddenly calmed. Gina reminded her that she was there to help the teachers understand Kyle better and that she wanted to hear Aunt Rose’s experience. Warily, Aunt Rose said, “I chose this school because I thought that it was a good one. It’s across town, but I knew he needed help. It’s not easy to get to, you know.” Gina reflected, “It is across town, and it seems like it can be hard for you to get around. You must really want him to be there.” Aunt Rose agreed, “I did. I told them right from the beginning he would be a handful, and I told them exactly what had worked at home. They just don’t believe me.” “Why don’t you tell me what you know about him so that I can understand,” offered Gina. Aunt Rose filled Gina in on Kyle’s history. He had been a difficult child to soothe. When he came to her at 6 months, he was “stiff as a board.” His mother, her niece, had used crystal meth during the pregnancy. Aunt Rose added, “I loved my sister, but she was never a good mother. I just didn’t want these kids to be lost in the foster system. I made that mistake with my niece.” Gentle inquiry revealed that Aunt Rose had taken in three other children from Kyle’s generation. They had challenges much more pronounced than his. Although Kyle had more potential for an average developmental trajectory than his cousins and sibling, he came to her sensitive to light and to sound, and he hated to be touched. She continued, welling up with tears, “It broke my heart not to hold him, but he just couldn’t calm down if I touched him too much. It took a while to figure it out, but the best thing for him is to rock himself to sleep. I told them this already and even brought him a rocking chair, but they refuse to use it. I’m at my wits’ end. I know my rights. I’ve been fighting for all of my nieces and nephews. Each one has needed special education and all kinds of therapies. Every service has been a battle. Now, I know what to do. If they want a fight, I’ll give them a fight. That’s what I told that lady.” Suddenly, Gina understood. Now, how to repair this fractured relationship? She offered, “How frustrating. You’ve had a sense all along of what’s best for him, and it feels like no one has been listening.” Aunt Rose nodded. Gina continued, “I think they have been worried about his ability to make relationships and how he doesn’t seem to want or need adults. Their worries



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made it hard to hear how you struggled with the same thing.” Aunt Rose added, “He’s my last hope. He can make it with just a little help. He doesn’t belong in special education.” Gina asked if perhaps she could share some of this information with the staff. It would help them understand. She also wondered if maybe they had some of the same goals. “It seems like everyone is worried and affected by the fact that Kyle doesn’t allow comfort from adults. It sounds like that has been really hard on you. Maybe we could start with what you know— he does well in the rocking chair—and expand his repertoire.” Aunt Rose seemed satisfied. Gina returned to the school with a new found appreciation for Aunt Rose. She asked the child care providers, “What have you noticed about Kyle? What works best with him?” His primary caregiver painted a picture of Kyle that was similar to Aunt Rose’s. Gina added, “I know that everyone feels the rocking chair is more of a punishment, but given what everyone has said, I think Kyle actually benefits from it. What’s your concern about relying on the rocking chair?” They worried that other children would want to use it, that Kyle would become too dependent on it, and that it didn’t meet his attachment needs. Since it seemed like the only thing that worked now, perhaps they could use it with some modifications until they helped him to develop some other skills. As for the other children overwhelming the resources of staff time and hogging the rocking chair, so far, they realized, the other children only occasionally wanted to sit in the rocking chair. Together, they developed a plan to expand Kyle’s tolerance for sensory input and comfort. The child care provider offered, “Maybe I could sit with him and talk to him when he rocks himself. I won’t touch him yet.” This newly developed option immediately shifted Kyle’s experience.

Wondering, Not Knowing At the very beginning of this case consultation, there was a wish to observe and to find a solution to Kyle’s challenges quickly. The consultant worked hard to slow down the process. As is often the case in consultation, people want expert advice and answers from the consultant. The providers were frustrated with the perceived delay. Consultation, however, relies on thoughtful consideration. Sometimes people fear this approach be-

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cause if they know more, they will have to do more. As was the case here, they sometimes need to do less. Kyle needed them to step back. The stance of “wondering, not knowing” is central to our consultation approach. The education level of child care providers is varied, but they often have the training needed to address the problems raised by a child’s behaviors. What usually impedes quality responsive care are the other issues in child care—staff relationships, parent–­provider relationships, a child’s individual needs, and the individual daily and historical experiences of providers, among others. Here, the feelings about Aunt Rose stopped them from listening to her seasoned advice. Rather than build on it, they dismissed it. The consultant wonders about the circumstances surrounding children’s behaviors and the adults’ decisions and interventions. Finally, “wondering, not knowing” allows the consultees the opportunity to find successful answers. Child care providers are much more likely to support the plan for a child when they have participated in its development. Gina, the consultant, might have offered “expert” advice based on initial observations, but she would have been mistaken. Before getting to know Aunt Rose, Gina also misinterpreted her motivations and couldn’t believe that the response to Kyle that worked was the most appropriate. It was only with knowledge from all the participants—­caregiver, childcare provider, and director—that the consultant helped them to discover a solution. The child care providers worried that the attention being paid to Kyle wasn’t fair to the other children in the classroom. Gina asked them to consider how much time they were already spending and wondered with them about the children’s needs in general. After some discussion she suggested, “Maybe fairness is giving each child what he or she needs. It may not necessarily be equal.” Gina shared her experiences of Aunt Rose with the staff. They too lightened in their assessment of her. Just as headway was being made, Kyle’s attendance dropped off. Antagonism between the director and Aunt Rose erupted again. Aunt Rose felt that this was the best she could do, and the director worried about funding based on attendance. The

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director’s threats to drop him enraged Aunt Rose. The director retaliated by returning to a rigid stance, withholding use of the rocking chair. Momentarily forgetting its usefulness because she again saw Aunt Rose as uncaring, the director argued, “If rocking chairs were the answer, they would be in all classrooms.” Gina thought that that didn’t sound like a bad idea, but she said, “You’re right, it probably wouldn’t help all children, but Kyle seems to benefit. The rocking is one of the few things that seems to organize him. His experience of the world feels so chaotic that he needs the physical input to settle his racing mind.” With considerable effort, Gina also assisted each to understand the other and to see the other’s protective motivation. The director wanted to shield this African American child, and Aunt Rose wanted what worked best for Kyle and made him least different. She couldn’t afford to see him as a child with special needs—­because he was her “good child.”

“Hearing and Representing All Voices”1 Gina worked hard to speak for Kyle. Sometimes the adults’ needs drowned out his voice, but she repeatedly gave voice to his experience. She also made sure that every person involved felt heard and that each one’s concerns were raised. She paid particular attention to the needs of the child. Although Gina had some success in navigating this rocky terrain, ultimately, the attendance issue was insurmountable, not to mention the animosity between these well-­intentioned women. The director feared that if Gina continued contact with this family, she would undermine their decision to expel Kyle. Gina reassured her that her role was to maintain some level of neutrality and that she wanted to help Kyle, who had such difficulty in relating, make the transition to a new and appropriate program. With reluctance, the director trusted Gina to respond to his needs without jeopardizing the program’s integrity. She did not block contact between Gina and Aunt Rose.

Considering All Levels of Influence Throughout this vignette, the consultant has stopped to notice the pressures on the pro1 Pawl

(2000, p. 5).

gram, the child care providers, and the family. In this instance, the program’s history of understaffing and its surrounding community, in part, explained the feeling of scarcity and the resistance to providing something special for a particular child. Later, the demands of funding influenced their insistence on attendance at a level with which Aunt Rose was unable to comply, resulting in Kyle’s transfer. The teacher’s understanding of attachment and the director’s experience as an African American justifiably led to the subsequent misinterpretation of Aunt Rose’s motivations and Kyle’s needs. The condition of Aunt Rose’s neighborhood, her experiences advocating for her other nieces and nephews with special needs, and her family’s history help to explain her vociferousness in protecting her nephew. Initially, Aunt Rose resisted more meetings, but Gina reminded her that as a consultant she was a resource for the school but remained outside its hierarchy and authority. Perhaps she could help her find another setting for Kyle. Among issues they considered together were the types of programs that might cater to his sensory sensitivities, preparation of the staff before Kyle’s arrival, and the vicinity of the program. Aunt Rose eventually welcomed Gina’s involvement and enlisted her in pondering child care possibilities. Aunt Rose picked a program for Kyle that had a home visit as part of admission. She invited Gina to support her during this interview. Although Aunt Rose had worried about stigmatizing Kyle with his history, Gina helped her to share information that would be useful. Kyle’s transition to his new school wasn’t easy, but the staff was prepared to respond to his needs. Aunt Rose called Gina again and asked her to observe him in the new program “just to make sure everything was okay.” After checking with the new program’s staff and understanding Aunt Rose’s concerns, Gina did observe Kyle. Aunt Rose thanked her for helping her and added, “You know, they thought that I was lazy and ignorant because I am so overweight and poor. I knew a lot more than they thought I did. You know I have a master’s degree in child development, but I never told them. I figured, ‘let them think what they want.’ ” “I’m sorry you didn’t feel like you could share your knowledge with them. Kyle is lucky to have an advocate like you,” observed Gina. As they ended, Aunt Rose added, “You



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know what I like about you? I don’t have to be mean to you to get what I need.” Later that week, Gina arrived at her usual time at ABC Childcare. The director was in the hall and greeted her, “So you’ve finally increased your hours.” Gina reminded her that she was there at her usual time, but the director was puzzled. She was sure that she was getting more time. The experience of Gina supporting and acting as a buffer made the director more aware of the benefits of Gina’s services and less aware of what the school wasn’t getting. This experience would come to serve as a model for handling and understanding other situations. It also began to break down the general views of parents as the sole cause of difficulties and the belief that outcomes could only be completely successful or entirely failures. With Gina’s ability to understand all sides, including the child’s experience, the staff was able to explore multiple reasons for behavior and interactions.

relationships surrounding the central child–­ provider relationship. Changes are predicated on the consultant’s ability to attend to the multileveled elements influencing interaction while providing an inquisitive and nonjudgmental presence. This approach supposes that the mutual trust and respect generated by the consultant’s supportive stance allows the consultee to consider, and if necessary amend, perceptions that are interfering with his or her ability to acknowledge and adequately respond to children’s expressions of need. The consultant simultaneously finds places in which his or her ideas can be usefully integrated with the providers’. Through this process a child care program can make enduring changes in the way that adults consider and respond to the individual children in their care.

Our goal of improving provider–child relationships is a long-term one. Sometimes the consultation cannot influence the current cohort of children but benefits the children to come. The consultant helped to balance what seemed like opposing sides by offering empathy to the adults so that they could focus on the child. Aunt Rose’s belief that all care has to be hard fought has begun to melt, and the director’s experience of scarcity is shifting. The child care providers have experienced a new way of wondering about motivations, constructing hypotheses about children, including parents in their work, resolving conflicts, and expressing themselves. The process is slow, but the ways in which providers engage others begins to shift, and, in turn, their relationships with children improve.

Arnold, D. H., McWilliams, L., & Arnold, E. H. (1998). Teacher discipline and child misbehavior in day care: Untangling causality with correlational data. Developmental Psychology, 34 (2), 276–287. Booth, C. L., & Kelly, J. F. (2002). Child care effects on the development of toddlers with special needs. Early Childhood Research Quarterly, 17, 171–196. Brennan, E., Bradley, J., Allen, M. D., Perry, D., & Tsega, A. (2006, July). The evidence base on mental health consultation in early childhood settings: Research synthesis and review. Paper presented at Research and Training Center on Family Support and Children’s Mental Health of the Regional Research Institute for Human Services, Portland State University and the National Technical Assistance Center for Children’s Mental Health, Georgetown University (see attached). Caplan, G. (1964). A method of mental health consultation. In G. Caplan (Ed.), Principles of preventative psychiatry (pp.  232–265). New York: Basic Books. Caplan, G. (1970). The theory and practice of ­mental health consultation. New York: Basic Books. Carnegie Task Force on Meeting the Needs of Young Children. (1994). Starting Points: Meeting the needs of our youngest children. New York: Carnegie Corporation of America. Child and Adolescent Health Measurement Initiative. (2003). National Survey of Children’s Health. Portland, OR: Oregon Health & Science University. Cost, Quality, and Child Outcomes Study Team. (1995). Cost, quality and child outcomes in

CONCLUSIONS Mental health consultation based on the conceptually compatible framework of infant–­parent psychotherapy is ultimately aimed at enhancing the provider–child relationships in child care. Whether directed at a specific relationship with a child whose behavior is challenging or at the exchanges that define a program’s tone for all children, consultation seeks to strengthen the adult

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Raver, C. C., & Knitzer, J. (2002). What research tells policymakers about strategies to promote social and emotional school readiness among three and four-year-old children. New York: National Center for Children in Poverty. Sameroff, A. J., & Emde, R. N. (1989). Relationship disturbances in early childhood: A developmental approach. New York: Basic Books. Shonkoff, J., & Phillips, D. (Eds.). (2000). From neurons to neighborhoods: The science of child development. Washington, DC: National Academy of Science Press. Solym, A. (1981). Mental health consultation in infant daycare: A new frontier of prevention. Infant Mental Health Journal, 2(3), 181–197. Stern, D. N. (1995). The motherhood constellation: A unified view of parent–­infant psychotherapy. New York: Basic Books. Wolery, M., Huffman, A., Holcombe, A., Martin, C. G., Brookfield, J., Schroeder, C., et al. (1994). Preschool mainstreaming: Perceptions of barriers and benefits by faculty in general early childhood education. Teacher Education and Special Education, 17, 1–9. Yoshikawa, H., & Knitzer, J. (1997). Lessons from the field: Head Start mental health strategies to meet changing need. New York: National Center for Children in Poverty.

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The Economics of Infant Mental Health Geoffrey A. Nagle

I

nfant mental health has grown dramatically in the past 20 years. A major impetus for this growth has been the intuitive appeal of its emphasis on prevention. Efforts to enhance competence and reduce subsequent maladaptation in children are fundamental pillars of infant mental health (see Zeanah & Zeanah, Chapter 1, this volume). Implicit in this reasoning is the idea that investing in infant mental health makes sense, not just from the humane standpoint of reducing suffering but also from the more pragmatic economic considerations of health policy. Certainly, from a political perspective, if it could be shown that early intervention reduced morbidity and was economically advantageous, then the case could be made that these efforts should be adopted far more broadly than they have been to date. Beyond targeted interventions designed for various “high-risk” groups, provision of child care, guided by principles of infant mental health, offers a “universal” opportunity to intervene with young children. There is abundant evidence regarding quality of care as a contributor to positive outcomes in young children (National Institute of Child Health and Human Development Early Child Care Research Network, 2006). There is even evidence that for children from



low-­income families, quality child care may serve as a buffer from the adverse effects of stressful environments (Duncan & Magnuson, 2006; Schweinhart, Barnes, & Weikart, 1993). Nevertheless, questions remain about whether or not targeted or universal prevention efforts in early childhood can be justified economically. Many infant mental health clinicians as well as researchers in developmental psychopathology may be unaware, or unconvinced, that the case for the economic viability of early intervention through preventive interventions or through high-­quality child care can be made today. They may believe that “someday” we may have the data, but not that this evidence exists now. When considering the economic development of communities, many people tend to think of factories and manufacturing plants, stadiums and sports franchises, or tax incentives to draw businesses and stimulate job creation. Nevertheless, results of research about the benefits of these initiatives are equivocal and subject to vastly different assumptions and interpretations. A report by the Federal Reserve Bank of Minneapolis, for example, renewed questions about the positive economic impact of local and state 580



36. The Economics of Infant Mental Health

initiatives designed to stimulate business and jobs. In fact, results suggest that in many cases, the subsequent private businesses would be created even without the support of government, and new jobs are created at the expense of older existing jobs (Rolnick & Grunewald, 2003). Therefore, these kinds of economic development initiatives may not result in improved quality of life or in reductions in poverty and crime that are often cited as the goals. In this chapter we begin by reviewing evidence demonstrating efficacy of selected early intervention programs in the United States. We also cite data from economic analyses suggesting that there are already sufficient data to make the case that early intervention is justifiable economically. Then we review substantial evidence that high-­quality child care programs, directed at families with young children, will recoup their expenses and produce substantial cost savings over time. We suggest that careful investment in early childhood through quality child care programs is one of the most advantageous and justifiable investments that communities can make, and we urge making these data available to decision makers and policy planners. Finally, to illustrate how this perspective can be translated into policy, I describe the case example of the development of a program designed to enhance the quality of child care in Louisiana.

SUCCESSFUL PREVENTIVE INTERVENTIONS Although not all early intervention programs have been effective (see Aos, Lieb, Mayfield, Miller, & Pennucci, 2004; Beckwith, 2000; The David and Lucile Packard Foundation, 1999, for reviews), considerable research over the past 25 years has demonstrated convincingly that some programs designed to improve the lives of young children are quite effective. The following are three examples with longitudinal evidence of important program achievements.

Perry Preschool Project The Perry Preschool Project enrolled 123 children from low-­income families in Ypsilanti, Michigan, ages 3–4 years old, from

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1962 to 1967. These children were randomly assigned to receive the intensive preschool intervention program or to a control group. The intervention was 2½-hour daily preschool classes and one 90-minute teacher home visit per week, occurring for 1–2 years. Data have been collected measuring the program effects through the children’s 40th birthday. Key findings were that after 27 years, program children showed significant reductions in welfare utilization as well as significant reductions in the incidence and severity of criminal activity. In fact, control group children had a fivefold increase in crime. Employment rates and earnings for the program group also increased. Similarly, there were significant improvements in high school graduation (or achieving a general equivalency degree [GED]) in the program group (Duncan & Magnuson, 2006; Karoly et al., 1998; Schweinhart et al., 1993).

Nurse–­Family Partnership The Nurse–­Family Partnership (NFP) is a prenatal and early childhood intervention designed to improve the health, social functioning, and economic self-­sufficiency of low-­income first-time mothers and their babies. Weekly to biweekly home visits by public health nurses begin during pregnancy and continue through the child’s second birthday. There are three primary goals of the program: (1) to improve a women’s health behavior (focusing on improved nutrition and the prevention of substance use); (2) to improve family caregiving of children (improving parents’ understanding of their children and development and reducing injuries and abuse and neglect); and (3) to improve maternal life course development (­focusing on subsequent pregnancy planning, educational achievement, and employment). The original program in Elmira, New York, included 400 first-time pregnant women who were randomly assigned to receive the home visiting intervention or to be part of a control group. Over the 15-year follow-up period, program children born to these women experienced a 79% reduction in verified reports of child abuse and neglect, and 56% fewer hospital emergency room visits where injuries were detected. In addi-

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VI. APPLICATIONS OF INFANT MENTAL HEALTH

tion, the program mothers had 31% fewer subsequent births and more than a 2-year longer interval between the births of the first and second child, a 69% reduction in the number of maternal arrests, a 30-month reduction in the receipt of Aid to Families with Dependent Children (AFDC), and an 83% increase in work-force participation by the time the child reached 4 years old (Olds et al., 1997; Olds et al., 1998). Because this New York sample was comprised primarily of white women, subsequent studies of the replication of the model focused on the effects in other populations. Similar results were achieved in a more urban setting with a primarily African American population in Memphis, Tennessee (Kitzman et al., 1997; Kitzman et al., 2000), and with a Hispanic population in Denver, Colorado (Olds et al., 2002).

Child–­Parent Center Program The Child–­Parent Center (CPC) program provides comprehensive educational and family support services from preschool to early elementary school. The program targets children ages 3–9 years old from low­income families in Chicago’s inner city. The goal of the program is to improve the children’s academic success while improving parental involvement in the education process. The program works in four specific domains: providing early intervention, involving the parent, providing a structured language-based curriculum, and building continuity between preschool and early elementary school. Longitudinal research has tracked 989 program children and 550 comparison group children from preschool through early adulthood. Program children had a 20% higher rate of high school completion, a 42% lower rate in juvenile arrests for violent offenses, a 41% decreased placement in special education services, a 52% reduction in child abuse and neglect, an increase of 86% in the number of children by age 5 that scored at or above national norms in cognitive–­literacy skills, and a 59% improvement in school achievement by age 14 (Duncan & Magnuson, 2006; Reynolds & Robertson, 2003; Reynolds, Temple, Robertson, & Mann, 2001).

Economic Benefits of Early Intervention Programs These three programs demonstrated important gains that were sustained over time. Of equal importance is the financial return that is gained from these social investments. A 1998 study published by the Rand Corporation showed that investment in early childhood programs are beneficial compared to cost. This report documented that conservative estimates of total net savings from the Perry Preschool project are $13,289 per family (Karoly et al., 1998). The Federal Reserve Bank of Minneapolis determined that the inflation-­adjusted rate of return was 16%, with 80% of the benefit being realized by the general population due to the reduction in crime and the improved behavior in school of the intervention children (Rolnick & Grunewald, 2003). Similarly, the Rand study showed that the NFP produced a net savings of $18,611 per family. Ultimately, however, this was a conservative estimate of savings, as it did not project future earnings for the children or the mother, the increase in tax revenues from this work, or the decreased likelihood that the child would receive public assistance. Similarly, a report by the Washington State Institute for Public Policy showed that NFP had a benefit of $17,180 per family. This was the largest benefit of all 41 programs studied in the various domains: prekindergarten education programs, child welfare/home visitation programs, youth development programs, monitoring programs, youth substance abuse prevention programs, and teen pregnancy prevention programs (Aos et al., 2004). Entergy Corporation, an energy company that provides electricity to four Southern states, commissioned a report by Oppenheim and MacGregor (2002), “The Economics of Education: Public Benefits of High-­Quality Preschool Education for Low-­I ncome Children,” that examined the benefits of early childhood education programs. This evaluation reported that programs such as Perry Preschool and Head Start have produced reductions in crime, improved high school graduation rates, decreased health care and welfare utilization, and improved employment that has resulted in savings well in excess of $100,000 (net present dollar value) per program participant. Specifically, they



36. The Economics of Infant Mental Health

found that completing high school increased lifetime earnings by $89,000 (net present value). The importance of education becomes even more compelling when examining yearly earnings. The 1999 median annual income for a male worker with a bachelor’s degree was $20,000 more than a worker with a high school degree, and $28,000 more if only a 9- to 12-grade education. For women, these differences are $15,000 and $21,000, respectively (U.S. Department of Education, 2002b). Oppenheim and MacGregor document that lifetime earnings increased by at least $15,120 (net present value) due to preschool education programs. The importance of education transcends earning potential as seen through self­reported health. According to the National Center for Health Statistics, for those over age 25, better educated people report “excellent” or “very good” health twice as often as those without a high school diploma (80% compared to 39%). Of course, there is a connection between earning money and good health. People with earnings in excess of $75,000 compared to those with less than $20,000, reported excellent or very good health almost two times more often (80% compared to 41%, respectively). Even when taking family income into account, education is associated with an increase in positive health reporting when comparing those with a bachelor’s degree, to those with a high school diploma only, or to those who have no high school degree (U.S. Department of Education, 2002a). While all areas of early childhood program success result in cost savings, perhaps there is no greater long-term financial and social benefits than when crimes are prevented. Estimates of the benefits of reduced crime range considerably. Donohue and Siegelman (1998) documented that the savings in reduced incarceration costs generated by early childhood enrichment programs targeted at high-risk disadvantaged youths would pay for the programs even if the benefits were only half of those recognized in pilot studies, such as those cited above. Cohen (2000) estimated the savings from preventing one youth becoming involved in a life of crime to be between $1.3 and $1.5 million in 1997 dollars.

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The Policy–­Evidence Base Dilemma Despite the successes of these three interventions, other interventions have not been as successful or cost effective. The problem for policymakers is how to determine when sufficient evidence exists to justify investment. Implementing policies almost always means extrapolating beyond the evidence base that exists. For example, the NFP, as mentioned earlier, originally shown to be effective with a largely rural white sample (Olds et al., 1997, 1998), has been subsequently replicated with an urban African American sample (Kitzman et al., 1997, 2000) and a third trial with almost half of the sample comprised of Hispanics (Olds et al., 2002). Nevertheless, it has not yet been shown to be effective in other subcultural groups in other geographical locations. Researchers may legitimately remain skeptical about the universal application of this method of intervention until more data are in. On the other hand, waiting leaves children behind and misses the opportunity to intervene early and in a more preventive mode. There are several different ways to examine data that may inform a policymaker’s decision making. For example, is the critical component of decision making to be based on efficacy, cost–­benefit analysis, return on investment, need, or even quality versus quantity tradeoffs (Kilburn & Karoly, 2008)? Even if there were the fortunate circumstance in which all of these data were available to inform decision makers, which is rarely the case, how the information is presented, by whom, and under what circumstances is often the result of advocates who have been pushing an agenda for some time. Data may help their cause, and certainly data that explain the benefits in economic terms may be the most potent of all.

ECONOMIC BENEFITS OF CHILD CARE Providing quality child care is essential to achieving two of the most pressing goals for young children and families: helping families work and ensuring that every child enters school ready to learn. In addition, quality child care is associated with reducing the demands on special education, lowering

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VI. APPLICATIONS OF INFANT MENTAL HEALTH

dropout rates, decreasing criminal activity, and reducing poverty by increasing earning power (Cubed, 2002). Complementing these societal benefits is the tremendous economic impact, demonstrated by a growing body of evidence, that results from the provision of quality child care. These studies determine the economic development impact by measuring (1) the direct effects (revenues taken in by child care providers/centers), (2) indirect effects (child care providers spend money on needed goods and services through local businesses), (3) the induced effects (income that is spent by child care employees in local communities), and (4) the parent effects (parents of children in child care are enabled to work as productive employees) of child care (Stoney, Warner, Woolley, & Thorman, 2003). Of critical political importance is the fact that there is an immediate economic impact of child care investment on state budgets that can be explored, quantified, and documented. Much, if not all, of the state and federal monies that flow through these programs result in spending in local communities. This spending provides jobs that result in state income and sales tax revenues and creates services (e.g., child care) that allow parents to continue to be engaged in the work force, thereby avoiding dependence on welfare and other social services. Therefore, jobs are created, directly and indirectly, and the pressure on the social service safety net is relieved to serve the neediest families. Many states, and a number of cities and counties, have already documented the substantial benefits derived by investing in child care. Findings to date include: •• In Rhode Island, approximately $228 million is spent on licensed child care. This investment returns approximately $400 million into the economy while creating 9,626 jobs across multiple sectors. Bottom line: $1.75 is returned into the Rhode Island economy from each dollar that is invested (Quigley & Notarantonio, 2003). •• In Vermont, approximately $208 million is spent on licensed child care. This investment returns approximately $426 million into the economy while creating 7,231 jobs across multiple sectors. Bottom line: $2.05 is returned into the Vermont economy from each dollar that is invested. In addition,

licensed child care enabled 37,489 parents to work, resulting in earnings of $1 billion, or 13% of the total earnings in the state. These earnings are spent in the local community and provide increased state and federal income tax revenues (Windham Child Care Association and the Peace & Justice Center, 2002). •• In Louisiana, conservative estimates of the size of the child care sector show that there are 12,701 businesses, employing 22,644 workers, serving over 149,000 children and 136,000 working parents, and generating approximately $658 million in gross receipts. Bottom line: $1.72 is returned into the economy for every dollar that is spent in the child care sector (Nagle & Terrell, 2005). •• In terms of job creation, for every child care job, 1.27–1.8 jobs are created in the economy, including 1.27 in Louisiana and Tompkins County, New York; 1.46 in Vermont, 1.54 in San Antonio, Texas; and 1.68 in California (Nagle & Terrell, 2005; Stoney et al., 2003). The significance of the child care sector as an engine of economic development is perhaps best understood by looking at child care as an essential component of infrastructure that is needed to allow the economy to flourish. Just as roads, electricity, and mass transit are needed to make a work force and industry efficient and productive, so too is quality child care needed. Despite its value to the economy, families pay roughly 60% of the cost of child care, with public funds providing the difference. This ratio is in stark contrast to the 23% families pay for a public college education (Cubed, 2002). Fortunately, there are many options available to communities and states to improve their support of child care. These include providing state or municipal tax breaks for the child care sector, waiving fees, or working with businesses to offer flexible spending accounts that allow for child care expenses. Some communities have already initiated efforts to help stimulate the development of additional child care: •• New York: A Chamber of Commerce brought together bank vice presidents, human resource executives from large corporations, local government, and the



36. The Economics of Infant Mental Health

United Way to help create child care scholarships and subsidies in their community. •• California: A foundation donation helped establish a revolving loan fund through a community credit union. This created the availability of low-­interest loans to child care centers that were usually unable to afford improvements, or expand their facilities, due to limited cash flow. •• Oklahoma: The Success By Six in Lawton County helped raise $125,000 from the local and national United Way, which in turn helped bring in $1.2 million in new funds. This money was used to create new Early Head Start programs as well as for grant applications to build additional Head Start centers.

AN ECONOMIC POINT OF VIEW It is difficult to apply the majority of these theories to early childhood investment. Perhaps only economic base theory, which measures economic development in terms of income or employment, is directly applicable. Other theories may focus more on the composition of development (producing goods and services), the control of development (community), or the products or innovation that are developed. The multitude of theories and definitions that fail to address the benefits of early childhood investment is part of the reason that economic development has been left out of the argument and advocacy for increased funding of these programs. Fortunately, there are studies that have demonstrated the value of investments in early childhood programs. Nobel laureate James Heckman, an economist at the University of Chicago, has written extensively about the benefits of investing in people, or human capital. He described a process called “dynamic complementarity” wherein capable people acquire more skills, and people with more skills become more capable. In Heckman’s view, expenditures on education and job training programs for adult workers are based on “fundamental misconceptions” about the importance of cognitive skills and the failure to recognize how socially useful skills are created. He has emphasized that the focus on school expenditures or the results of academic achievement tests fails to recognize the critical importance of fami-

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lies in developing and fostering the skills in young people that are needed for later success in life. He further cautioned against early intervention programs falling into the same trap of measuring success by IQ scores as opposed to the enhanced social and emotional competence of the program participants (Heckman, 2000, 2007). As Heckman (2000) detailed, much of the benefit of investing in young children is due to dynamic complementarity as well as the fact that there is greater time to recoup the benefits of the intervention when they are delivered to young people. Heckman asserts that it makes the most economic sense to redirect funds toward improving basic social, emotional, and cognitive skills of children. He uses economic models of analysis to demonstrate convincingly that the longer we wait to intervene with children, the more expensive it becomes to fix the problems and the less return on the investment is recognized over time. Heckman reasons that as states are under constant pressure to improve the efficient use of ever dwindling financial resources, any investment away from young people can be viewed as a diversion of resources from the most efficient use of those funds to the people who would likely produce more favorable returns over the long term. A recent review has made a compelling case that, in fact, there is a striking convergence of research findings from neuroscience, economics, and child development about the value of investing in early childhood (Knudsen, Heckman, Cameron, & Shonkoff, 2006). This review details evidence that clearly indicates that the best strategy to use to develop the future work force is to focus on the social and cognitive development of children from disadvantaged environments. The definitive conclusion is that the benefits of prevention are less costly and more effective than remediation and that these prevention efforts need to begin when the children are as young as possible.

A CASE EXAMPLE In February 2005 the Tulane University Institute of Infant and Early Childhood Mental Health and the Louisiana State University Division for Economic Development and

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Forecasting produced a report documenting the economic impact of the child care sector in Louisiana (Nagle & Terrell, 2005). Using the methodology developed at Cornell University (Ribeiro & Warner, 2004), the Louisiana report demonstrated conservative estimates of the size of the child care sector, showing that there are 12,701 businesses, employing 22,644 workers, serving over 149,000 children and 136,000 working parents, and generating approximately $658 million in gross receipts. In addition, for every dollar that is spent in the child care sector, $1.72 is returned into the Louisiana economy. Furthermore, for each new child care job that is created, 1.27 jobs are created in the state economy. At the time, the state contributed $40 million dollars into child care, which helped leverage $251.7 million federal dollars into the child care system. In turn, this $251.7 million has a total impact of $433 million in the Louisiana economy. During the time the economic impact study was being finalized, the state Advisory Council on the Child Care and Development Block Grant was preparing their recommendations to the state Department of Social Services. They used the findings of the economic impact study to call for additional supports for the child care sector. In addition, the Advisory Council’s number one recommendation was for the development of a quality rating system for child care (Report of the Advisory Council on Child Care and Development Block Grant, 2005). Over the next several months, advocates worked to build support for the development of the quality rating system. Data from the economic impact study were used in an effort to enhance the call for improved quality child care by framing the message in terms of economic impact. The strategy was to talk about child care as an important component of economic development in Louisiana and not just in terms of the long-term benefits of quality child care. These efforts were ongoing in August 2005 when Hurricane Katrina struck Louisiana. That storm, compounded less than a month later by Hurricane Rita, suspended all ongoing advocacy and reform efforts. Nevertheless, by January 2006, with a long rebuilding effort just beginning to take form, the conversation about developing a quality rating system was revisited. Perhaps

surprisingly, the talk was no longer focused on building support for such an undertaking but rather how quickly could it be achieved. Somehow, the experience of Hurricane Katrina seemed to remove resistance to such change, and there was a new willingness to embrace this systemic overhaul of the child care sector. The Louisiana Department of Social Services soon convened a large steering committee comprising public and private stakeholders, including child care providers, and national consultants were used to help guide the process of developing the quality rating system. In little over a year, the model was developed, public comment was solicited and received, and a final model was adopted. In the 2½ years since it was formally decided to explore the creation of a quality rating system, almost 25% of licensed child care centers have participated in the rating system. This level of participation in such a short period is considered a huge success by child care advocates in the state. During the development phase of the new system, the most often cited concern, especially from child care providers, was the limited financial resources to support higher-­quality child care. The options for deriving additional dollars were limited. The usual suggestions included an annual appropriation in the state budget to be used to pay increased reimbursement rates for state subsidized child care, or some sort of bonus payments tied the level of quality as determined by the rating system. Unfortunately, this scenario seemed unlikely, as Louisiana had traditionally appropriated less than the minimum state dollars needed to draw down all of the available federal child care dollars. State support was so lacking, in fact, that recent reports indicated that Louisiana placed some of the highest copayment burdens in the country on low-­income families involved in the child care subsidy program. Furthermore, even if there were success in getting increased appropriations for child care, these dollars would be secure for only 1 year at a time, and efforts to secure the same dollars, and additional dollars, would have to be pursued through the legislative process each and every year. So the prospects of additional funds, and the security of those funds if obtained, were both very low.



36. The Economics of Infant Mental Health

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TABLE 36.1.  School Readiness Tax Credit for Parents Star rating of center Five stars Four stars Three stars Two stars One star Center not participating in the quality rating system

Increase to existing state tax credit

Maximum credit for one child

Maximum credit for two or more children

200% 150% 100% 50% No change No change

$1,575 $1,313 $1,050 $788 $525 $525

$3,150 $2,625 $2,100 $1,576 $1,050 $1,050

Fortunately, with the data available from the economic impact study, child care advocates had new “tools” at their disposal that could be used to justify increased funding. Moreover, by framing child care as an economic development issue, new funding avenues could be pursued. Looking at more traditional means of funding economic development initiatives, it was decided that tax credits to support the child care industry should be the goal. When looking at existing state tax credits, it was clear that many were implemented in the name of economic development. A partial list includes Motion Picture Employment Credit, New Jobs Credit, Quality Jobs Program, Capital Companies Credit, Credit for Investment in a Louisiana Film, and Inventory Tax Credit. The simple question became, “Why not a tax credit to support child care?” With that in mind, a package of tax credits to support quality child care was developed. This package became known as the School Readiness Tax Credits (SRTCs). The SRTCs were designed to offer tax incentives to four key groups for their support of quality child care. These four groups are parents, child care providers/owners, child care teachers, and businesses or employers. A brief overview of each of the tax credits is provided here.

SRTC for Parents Families with a child under 6 years of age enrolled in child care are eligible for a refundable tax credit based upon the quality rating of the center. This credit helps defray the increased costs associated with higher­quality child care. This credit to parents represents an increase to the current state child

care tax credit based on the parents’ choice of a higher-­quality child care center. Tax credit increases are detailed in Table 36.1.

SRTC for Providers This tax credit is designed to assist child care providers as they incur increased costs that are associated with providing higher-­quality care (e.g., improving facilities, enhancing learning supplies, paying higher wages for more educated staff). This refundable tax credit is tied to the center’s level of quality, as measured by the rating system, and is based on the number of children served in the Child Care Assistance Program or in foster care. These credits have two intended benefits: (1) to offset a portion of the increased cost of providing higher quality care; and (2) to improve access to quality care for children in the Child Care Assistance Program or foster care. The credits are applied as shown in Table 36.2.

SRTC for Directors/Teachers This refundable credit is provided directly to child care professionals based on increased levels of educational attainment. These credits effectively provide bonus funds for salaries in the child care system without driving up the price of care and thereby the costs passed on to families. A tax credit to a child care director or teacher is a refundable credit and varies depending on the level of credentialing and/or educational attainment. A credit of $3,000 is granted for those with the highest educational attainment, with lesser credits of $2,500, $2,000, and $1,500 available for others based on the staff qualifications criteria of the rating system.

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VI. APPLICATIONS OF INFANT MENTAL HEALTH TABLE 36.2.  School Readiness Tax Credit for Providers Star rating of center Five stars Four stars Three stars Two stars One star Center not participating in the quality rating system

The purpose of the tax credit for directors/teachers is to address recruitment and retention of child care professionals, especially highly qualified teachers. A great challenge to the success of the quality rating system is the ability of child care centers to hire and retain such workers. Professionals in the child care sector earn little over the minimum wage. As they work to improve their skills, they often leave child care to teach in the school system or leave the field completely to obtain higher pay. Several states have successfully addressed this challenge through a wage supplement program. In effect, the Louisiana wage supplement program is now being handled through the tax system. The wage supplement is based on the teacher’s educational attainment and not the star rating of the center, so as not create a situation in which there was an incentive for teachers to work at only the most highly rated centers. The center does need to be participating in the rating system, but the teacher needs only one start to receive his or her full wage supplement.

Tax credit (per child on child care assistance or in foster care) $1,500 $1,250 $1,000 $750 No credit No credit

SRTC for Businesses/Employers This refundable tax credit is provided to businesses/employers who donate money to a child care center, maintain and operate a center, or subsidize child care for their employees. The amount of the tax credit is tied to the quality rating of the facility (see Table 36.3). These credits incentivize the infusion of additional capital into the child care sector by increasing the connection between the business community and efforts to support early childhood development. Examples of child care expenses that are eligible for the tax credit are: 1. Employers who construct, renovate, or expand a child care center; purchase equipment for a center; or maintain and operate a center can claim up to $50,000 in expenses. 2. Employers can claim up to $5,000 in expenses for each child for whom the employer pays for child care services to support employees. 3. Employers who purchase child care slots

TABLE 36.3.  School Readiness Tax Credit for Businesses/Employers Star rating of center

Tax credit

Five stars Four stars Three stars Two stars One star Center not participating in the quality rating system

20% of eligible expenses 15% 10% 5% No tax benefit No tax benefit



36. The Economics of Infant Mental Health

provided or reserved for children of employees can claim up to $50,000 in expenses. One other tax credit available to businesses is for donations made directly to child care resource and referral entities, up to $5,000. This refundable credit is designed to provide support to the child care resource and referral centers because they are a valuable resource to parents and providers in supporting quality child care. This new tax credit gives the child care resource and referral centers an opportunity to receive greater financial support from businesses in their community. A key component of these tax credits is that they are refundable credits. (Note: The credit for parents, which builds on the existing state child care tax credit, is refundable only for the group with adjusted gross income less than $25,000. For all other income groups the tax credit is nonrefundable but can be carried forward for 5 years.) In addition, even nonprofit child care providers are able to access the full value of the credits. Likewise, nonprofit businesses that make donations, as described above, to for­profit centers can access the full value of the tax credits.

CONCLUSIONS Longitudinal studies have contributed greatly to what is now a growing body of evidence that investment in quality early childhood programs improves the lives of the program participants, benefits the society as a whole, and is cost-­effective. Nevertheless, these findings, while impressive, have produced only limited support in state capitals or among state officials because the savings may take 15–25 years to be redeemed. When explaining the long-term value of such investments to state budget leaders, one may encounter resistance because of the short-term budgetary costs and because the leaders want immediate demonstrable gain. Fortunately, recent evidence demonstrates that an investment in child care programs does produce profound and immediate economic development benefits, including jobs, in the current fiscal year. Furthermore, noted economists now emphasize the need to invest in young

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children and to target basic skills and socialization as opposed to cognition. An investment in early childhood programs should become more compelling to policymakers because it is now clear that this investment will pay off in tangible ways today and for generations to come. Such investment is the most efficient means of helping children become productive adults members of their communities. Early childhood interventions have lasting effects on learning and motivation that make it more likely that individuals will complete high school and less likely that they will require welfare benefits, become teen parents, or participate in criminal activities. References Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of prevention and early intervention programs for youth. Washington State Institute for Public Policy. Retrieved June 1, 2008, from www.wsipp.wa.gov/ rptfiles/04-07-3901.pdf. Beckwith, L. (2000). Prevention science and prevention programs. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 439–456). New York: Guilford Press. Cohen, M. A. (2000). Measuring the costs and benefits of crime and justice. In Measurement and Analysis of Crime and Justice: Criminal Justice 2000 (Vol. 4, pp.  263–316). National Institute of Justice. Washington, DC: U.S. Department of Justice. Cubed, M. (2002). The national economic impacts of the child care sector. : National Child Care Association. Donohue, J. J., & Siegelman, P. (1998). Allocating resources among prisons and social programs in the battle against crime. Journal of Legal Studies, 27, 1–44. Duncan, G. J., & Magnuson, K. (2006). Costs and benefits from early investments to promote human capital and positive behavior. In N. F. Watt, C. Ayoub, R. H. Bradley, J. E. Puma, & W. A. LeBoeuf (Eds.), The crisis in youth mental health: Early interventions programs and policies (Vol. 4, pp. 27–52). Westport, CT: Praeger. Heckman, J. J. (2000). Policies to foster human capital. Research in Economics, 54, 3–56. Heckman, J. J. (2007). Investing in disadvantaged young children is good economics and good public policy. Testimony before the Joint Economic Committee, Washington, DC. Karoly, L. A., Greenwood, P., Everingham, S., Hoube, J., Kilburn, R., Rydell, C., et al. (1998). Investing in our children: What we know and don’t know about the costs and benefits of early

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VI. APPLICATIONS OF INFANT MENTAL HEALTH

childhood intervention. Santa Monica, CA: Rand. Kilburn, M. R., & Karoly, L. A. (2008). The economics of early childhood policy: What the dismal science has to say about investing in children. Santa Monica, CA: Rand. Retrieved June 5, 2008, from www.rand.org/pubs/occasional_ papers/OP227/. Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., et al. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: A randomized controlled trial. Journal of the American Medical Association, 278, 644–652. Kitzman, H., Olds, D. L., Sidora, K., Henderson, C. R., Hanks, C., Cole, R., et al. (2000). Enduring effects of nurse home visitation on maternal life courses: A 3 year follow-up of a randomized trial. Journal of the American Medical Association, 283, 1983–1989. Knudsen, E. I., Heckman, J. J., Cameron, J. L., & Shonkoff, J. P. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce. Proceedings of the National Academy of Sciences, 103(27), 10155– 10162. Nagle, G., & Terrell, D. (2005). Investing in the child care industry: An economic development strategy for Louisiana. Louisiana Department of Social Services. Retrieved June 15, 2008, from www.dss.state.la.us/assets/docs/searchable/ OFS/Investing_In_The_Chil.pdf. National Institute of Child Health and Human Development Early Child Care Research Network. (2006). Child-care effect sizes for the NICHD study of early child care and youth development. American Psychologist, 61, 99–116. Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., et al. (1997). Longterm effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association, 278, 637–643. Olds, D. L., Henderson, C. R., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., et al. (1998). Longterm effects of nurse home visitation on children’s criminal and antisocial behavior: 15 year followup of a randomized trial. Journal of the American Medical Association, 280, 1238–1244. Olds, D. L., Robinson, J., O’Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., et al. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110, 486–496. Oppenheim, J., & MacGregor, T. (2002). The economics of education: Public benefits of high-

­ uality preschool education for low-­income q children. Report prepared for the Entergy Corporation. Packard Foundation, The David and Lucile. (1999). Home visiting: Recent program evaluations. The Future of Children, 9(1). Quigley, C. J., & Notarantonio, E. M. (2003). The economic impact of Rhode Island’s child care industry. Report sponsored by the Greater Providence Chamber of Commerce, Providence, RI. Report of the Advisory Council on Child Care and Development Block Grant. (2005). Retrieved June 15, 2008, from dss.state.la.us/Documents/ OFS/CCDBG_ Advisory_Repor.pdf. Reynolds, A. J., & Robertson, D. L. (2003). Schoolbased early intervention and later child maltreatment in the Chicago longitudinal study. Child Development, 74, 3–26. Reynolds, A. J., Temple, J. A., Robertson, D. L., & Mann, E. A. (2001). Long-term effects of an early childhood intervention on educational achievement and juvenile arrest: A 15-year follow-up of low-­income children in public schools. Journal of the American Medical Association, 285, 2339–2246. Ribeiro, R., & Warner, M. (2004). Measuring the regional economic importance of early care and education: The Cornell methodology guide. Retrieved May 15, 2008, from government.cce. cornell.edu/doc/pdf/MethodologyGuide.pdf. Rolnick, A., & Grunewald, R. (2003). Early childhood development: Economic development with a high public return. Federal Reserve Bank of Minneapolis. Retrieved May 20, 2008, from www.minneapolisfed.org/pubs/fedgaz/03- 03/ earlychild.cfm. Schweinhart, L. J., Barnes, H. V., & Weikart, D. P. (1993). Significant benefits: The High/Scope Perry preschool study through age 27. Ypsilanti, MI: High/Scope Press. Stoney, L., Warner, M., Woolley, A. E., & Thorman, A. (2003). Investing in the child care industry: An economic development strategy for Kansas. El Dorado, KS: Mid America Regional Council. U.S. Department of Education. (2002a). The condition of education 2002: Social and cultural outcomes. Retrieved May 1, 2008, from nces. ed.gov/pubs2002/2002025.pdf. U.S. Department of Education. (2002b). Digest of education statistics 2000 Outcomes of education. Available at nces.ed.gov/pubs2002/2002130e. pdf. Windham Child Care Association and the Peace and Justice Center. (2002). The economic impact of Vermont’s child care industry. Brattleboro, VT: Author.

Author Index

Abbeduto, L., 305, 336 Abel, K. M., 488 Aber, J. L., 95, 106, 138, 141, 453, 490 Aber, L., 141 Abidin, R., 470 Abma, J. C., 33 Abrams, M., 148, 558 Abrams, S. M., 156 Abramson, R., 217 Achenbach, T. M., 236, 245, 247, 289, 290 Achermann, P., 363 Acheson, S., 334 Ackerman, A., 107 Ackerman, J. P., 502, 503 Ackley, R. S., 336 Acra, F., 303 Acredolo, L. P., 320 Adams, C., 309 Adamson, L., 254 Adamson, L. B., 160 Adamson, T. M., 364 Adashi, E. Y., 181 Adelman, B., 5, 435 Adelson, E., 111, 205, 266, 442, 462, 517 Adrien, J. L., 302 Afrank, J., 233 Agatsuma, S., 174 Aggen, S. H., 159 Aghajanian, J., 518 Ahadi, S., 290 Ahnert, L., 65, 66, 72 Ainsworth, M. D. S., 92, 94, 266, 272, 422, 442 Ainsworth, M. S., 254, 256, 257, 260, 450, 452, 453, 465 Aksan, N., 399



Akshoomoff, N., 302 Albers, A. B., 142 Albersheim, L., 121 Alberti, P. M., 141 Alberts, A., 471, 473 Albright, K. J., 525 Albus, K., 505, 506 Albus, K. E., 95, 506, 512 Aldred, C., 309 Alexander, D. B., 366 Alexander, D. G., 321 Alexander, J., 472, 473 Algarín, C., 363–364 Allen, J., 246 Allen, J. P., 423 Allen, L., 398 Allen, M. C., 182, 183 Allen, M. D., 564 Allwood, M., 199 Alpern, L., 50 Als, H., 184, 188, 191, 254, 537 Als, H. A., 184 Altomare, M., 172 Alwin, J., 66 Ames, E. W, 428 Amini-Virmani, E., 275 Amster, B. J., 504 Anand, K. J. S., 183, 184 Ananth, C. V., 181, 182 Ancel, P.-Y., 182 Anda, R. F., 7 Anders, T., 366, 469 Anders, T. F., 82, 95, 233, 241, 363, 364, 365, 366 Andersen, S. L., 203, 204 Anderson, D. K., 306, 310 Anderson, E., 221 Anderson, J. H., 525

591

Anderson, J. W., 218 Anderson, P., 183 Anderson, S. A., 33 Andreassen, C., 257 Andrews, B., 381, 383 Angold, A., 10, 11, 199, 203, 234, 246, 247, 281, 282, 285, 287, 289, 290, 292, 294, 297, 392, 393, 395, 396, 400, 516 Anokhin, A. P., 159 Ansermet, F., 134, 180, 185, 186, 187, 191 Antonioli, M. E., 95 Antonucci, T. C., 218 Aoki, Y., 427 Aos, S., 16, 559, 581, 582 Apfel, N. H., 218, 220 Appel, A. E., 198 Applegate, B., 357 Arend, R. A., 260 Ariagno, R. L., 362 Armatruda, C. S., 81 Armstrong, E. M., 218 Armstrong, J. M., 416 Arnold, D. H., 565 Arnold, E. H., 175, 565 Arredondo, P., 108 Arseneault, L., 395 Arsenio, W. F., 82 Arszman, S. P., 525 Arts-Rodas, D., 379 Ascher, 393 Asefa, M., 381 Aserinsky, E., 364 Asgharian, A., 310 Ashman, S. B., 72, 415 Astley, S. J., 505 Atella, L. D., 25

592 Atkins, M., 109 Atkinson, D. R., 238 Atkinson, L., 95, 96, 155 Atwood, G., 273 Auerbach, J., 86 Augustyn, M., 174 Aureli, T., 320 Austin, M.-P., 156, 162 Avci, A., 525 Avery, A., 380 Aviezera, O., 94 Baca, P., 206 Bacon, P. L., 221 Bahrick, L., 347 Bailey, A., 292, 307 Bailey, B. N., 200 Bailey, K., 309 Bailey, L., 519 Baillargeon, R., 395, 396, 397 Bain, B. A., 325 Baird, G., 301, 311 Baird, J., 386, 387 Baird, M. A., 539 Baker, A., 182 Baker, W., 349 Baker, W. L., 185 Bakermans-Kranenburg, M., 306 Bakermans-Kranenburg, M. J., 16, 65, 68, 86, 97, 457 Baker-Ward, L., 346 Bakshi, S., 8 Baldwin, A., 10, 235 Baldwin, C., 10 Balk, S. J., 220 Balla, D., 91, 307, 416 Balla, D. A., 238 Bamford, F. N., 364 Bandura, A., 470 Baranek, G., 302 Baranek, G. T., 324 Barbaresi, W., 392 Barbera, M., 309 Barbour, N., 219 Bar-Haim, Y., 348 Barinaga, M., 44 Barker, D. J., 124 Barker, E. D., 202 Barlow, D. H., 71 Barlow, J., 216 Barlow, S. E., 386, 388 Barnard, K., 188 Barnard, K. E., 254, 256, 257, 258, 490 Barnes, H. V., 580 Barnett, B., 155 Barocas, R., 176 Baron-Cohen, S., 246, 303 Barr, C. S., 207 Barr, R. G., 500 Barraza, V., 67 Barrera, I., 109 Barrett, A. E., 487 Barrett, H. C., 203 Barrett, K. C., 83, 84, 335 Barry, K. L., 154 Bartels, A., 488 Bartels, M., 159 Barth, R. P., 222, 505 Barthel, M., 65 Barthm, R., 198

Author Index Bartko, W. T., 10, 235 Bartlett, T. R., 186 Barton, L. R., 108 Barton, M., 267, 311 Barton, M. L., 246, 267 Basham, R. B., 163 Bastuji, H., 363 Bates, B., 506, 512 Bates, B. C., 502, 505 Bates, E., 321 Bates, J., 290, 394, 399 Bates, J. E., 85, 86, 142, 366, 368 Bauchner, H., 156 Bauer, A. M., 59 Bauer, P. J., 204 Baum, C. L., 137 Bax, M., 366, 398 Bayer, J. K., 365, 367 Bayles, K., 290, 394 Bayley, N., 307 Beach, S. R., 430 Beaton, J. M., 28 Becerra, A. M., 337 Beck, A. T., 71, 154 Becker, G. S., 138 Beckett, C., 125 Beckmann, K., 146 Beckwith, L., 175, 188, 189, 485, 581 Bédard, A., 43 Bee, H., 188 Beeghly, M., 174, 202, 322 Behne, T., 203 Behnke, M., 485 Behrman, R. E., 181, 182, 183 Beitchman, J. H., 321 Belanger, K., 30 Belden, A., 418, 525 Belden, A. C., 11 Bell, M., 348 Bell, M. A., 52, 83, 88, 158 Bell, R. Q., 5, 392, 396 Bellagamba, F., 320 Bellavance, F., 380 Bell-Dolan, D., 199 Bellefeuille-Reid, D., 184 Bellow, S. M., 261 Bellugi, U., 337 Belsher, G., 154 Belsky, J., 73, 86, 95, 97, 121, 269, 274, 470, 471 Belyea, M., 187 Benasich, A., 322 Bendell, D., 412 Benedek, T., 25 Bengtson, V. L., 217 Benjamin, J., 86 Bennett, D., 394 Bennett, H. A., 155 Bennett, S., 26, 31 Benoit, D., 17, 27, 95, 189, 241, 267, 283, 352, 377, 378, 379, 380, 469, 490 Benoit, O., 364 Ben-Sasson, A., 537 Bensley, L., 215 Bentley, M., 220 Berardi, N., 123 Berckelaer-Onnes, I., 306 Berger, B., 95, 453, 490 Bergman, A., 83 Bergman, K., 8

Bergmann, R., 387 Beriama, A., 109 Berkowitz, R. I., 386 Berlin, L., 272 Berlin, L. J., 96, 214, 215 Bermejo, E., 172 Bernbach, E., 96, 487 Bernier, K. Y., 341 Bernier, P. J., 43, 44 Bernstein, V. J., 216, 217, 485 Berrebi, A. S., 204 Bertrand, J., 173 Berument, S., 307 Betz, S., 321 Beyers, J., 366 Beyers, J. M., 142 Beylin, A., 43 Bhattachan, K. B., 110 Bhutta, A., 183 Bianchi, S., 92 Bibring, G., 24, 25 Bick, J., 502, 503, 504 Biederman, J., 372, 392, 523, 524 Biesanz, J. C., 141 Bilbe, G., 123 Bindrich, I., 538 Bingham, R. D., 231, 285 Bingham, R. P., 106, 109, 115 Birch, H. G., 290, 292 Biringen, Z., 94, 335 Birks, E., 380, 381, 382, 383 Birmaher, B. M., 523 Bishop, D. M. V., 322 Bishop, D. V. M., 322, 323, 337 Bishop, S., 216, 305 Bishop, S. L., 304 Biukians, A., 526 Blacher, J., 338 Black, J. E., 46, 123 Black, M. M., 215, 218, 220, 222, 224, 377, 380, 381 Blacker, D., 358 Blair, P., 380 Blair, P. S., 377, 381, 384 Blakley, T., 349 Blakley, T. L., 185 Blankenship, S., 417 Blazer, D., 350 Blehar, M., 442 Blehar, M. C., 92, 254, 272, 422, 450 Blickman, A. L., 186 Block, D., 207 Block, R. W., 380, 381 Blondel, B., 181 Bloom, F. E., 40, 47 Blow, F. C., 154 Boardman, J. P., 183 Bocian, K. M., 334 Boddy, J., 381, 383 Bodfish, J., 304 Bogat, G., 349, 352, 353 Bogat, G. A., 27, 65, 95, 200, 207 Bohlin, G., 188 Bolton, P., 303 Bomben, M. M., 369, 372 Bond, A., 29 Bonsall, R., 127 Boomsma, D., 394 Boomsma, D. I., 159, 290 Boone, R. T., 523

Booth, C. L., 565 Booth-Laforce, C., 94 Borbély, A. A., 363 Borelli, J., 498 Borelli, J. L., 2, 7, 59 Borghini, A., 186, 189, 191 Boris, N., 8, 348, 536, 537 Boris, N. W., 8, 10, 134, 171, 293, 425, 427, 430, 431, 503, 553 Borkowski, J. G., 216 Borman-Spurrell, E., 378, 423 Borowitz, E. B., 112 Boruch, R., 109 Bosquet Enlow, M., 2, 7, 55, 59, 488 Bosson-Heenan, J., 238 Bost, K., 469 Boston, P., 473 Botting, N., 183, 322 Botto, L. D., 128 Bouard, G., 364 Boukydis, C. F. Z., 171 Boukydis, Z., 186 Boutry, M., 380 Bowlby, J., 26, 63, 65, 66, 81, 82, 92, 94, 124, 125, 205, 421, 422, 431, 442, 456, 458, 486, 502 Bowman, P. J., 221 Boyce, W. T., 59, 61, 68, 70 Boyd, K., 341 Boyd, R. C., 156 Boyle, J., 322, 324, 325 Bradley, J., 564 Bradley, R., 358 Bradshaw, G. A., 111 Brady-Smith, C., 214 Brake, W. G., 72 Brand, S. R., 29, 50, 134, 141, 153, 536 Braungart-Rieker, J. M., 94 Brave Heart, M. Y., 107, 111 Brazelton, T., 184, 469 Brazelton, T. B., 156, 184, 254, 551, 555, 557 Breart, G., 181 Breaux, A., 400 Bredenkamp, D., 428 Breedlove, G., 217 Breedlove, S. M., 59 Breidenstine, A. S., 436, 500 Bremner, J., 348 Bremner, J. D., 49, 202 Brender, W., 162 Brendgen, M., 399 Brennan, E., 564 Brennan, P. A., 156 Brenner, C., 440 Brent, H. P., 46 Bresgi, I., 95, 453, 490 Bretherton, I., 205, 206, 411 Brian, J., 301 Bricker, D., 235, 237, 311, 554 Bridge, J. A., 525 Briggs-Gowan, M. J., 231, 233, 235, 236, 237, 238, 240, 241, 242, 243, 246, 247, 254, 285, 289, 324, 392, 393, 394, 396, 397, 399, 400, 401, 402, 404, 414, 552, 553, 554, 556 Brinamen, C., 531, 533, 534, 537, 538, 564, 572 Briscoe-Smith, A., 349

Author Index Britner, P. A., 426, 453 Brivanfou, A. H., 41 Brocklehurst, P., 172 Brodersen, L., 49, 60, 66, 71, 157 Brogan, D., 162 Brohawn, D., 507 Broman, J. E., 368 Bromet, E., 350 Bronfenbrenner, U., 81, 113, 114, 122 Bronfman, E., 161, 273, 453 Bronner-Fraser, M., 42 Brooks-Gunn, J., 33, 67, 136, 138, 139, 142, 214, 216, 217, 219 Brophy-Herb, H. E., 216 Brosnan-Maddox, S., 311 Brotman, L. M., 127 Brovedani, P., 523 Brown, A. S., 122 Brown, G., 472 Brown, G. K., 154 Brown, G. W., 163 Brown, J., 187, 206 Brown, J. L., 111 Brown, K., 415 Brown, M., 42, 394 Browne, K., 501 Brubaker, S. J., 215, 217 Brubakk, A. M., 183 Bruce, J., 206, 505 Bruce, M. L., 163 Bruckman, D., 556 Bruder, M. B., 341 Bruer, J. T., 128 Bruinsma, Y., 320 Brumley, E. H., 257 Brunelli, S. A., 206 Brunson, L., 219 Brunssen, S., 186 Brunt, C. H., 564, 566 Bryant, B., 347 Bryant, R., 347 Bryk, A., 322 Bryson, S., 301, 303, 307 Brzustowicz, L. M., 202 Bubenzer, D., 219 Buchsbaum, H., 411 Buckhalt, J. A., 364 Bugental, D. B., 67, 157, 241 Buist, A., 29 Buitelaar, J. K., 156 Bull, R., 396 Bullinger, A., 184, 185 Burchinal, M., 128, 141, 469 Burchinal, P., 186 Burd, L., 505 Bureau, J.-F., 465 Burge, D., 511 Burgess, A. W., 204 Bürgin, D., 471 Buriel, R., 468 Burke, M. G., 285 Burkow, K., 550 Burlingham, D. T., 205 Burman, B., 470 Burman, I., 372 Burnham, M. M., 82, 283, 362, 363, 364 Burns, K. A., 175, 485 Burns, W. J., 175, 485 Burraston, B., 503, 508

593 Burraston, B. O., 508 Burt, K. B., 235 Burton, L., 221, 223, 224, 225 Burton, L. M., 217 Burton, R., 286 Buschsbaum, H. K., 82 Bush, M. A., 200 Buss, A. H., 85, 290 Buss, K., 50, 71 Buss, K. A., 66, 67, 158, 159 Butcher, P. R., 188 Butland, B., 386 Buysse, V., 341 Cabral, H., 156 Cabrera, N., 163 Cacioppo, J. T., 122 Caetano, R., 109, 198 Cahill, D., 216, 217 Cairns, B. D., 221 Cairns, P., 176 Cairns, R. B., 221 Caldeira da Silva, P., 293 Caldji, C., 72 Caldwell, C. H., 218 Calhoun, F., 173 Calkins, S. D., 13, 52, 53, 82, 85, 87, 88, 236 Callaghan, W. M., 182 Callum, J., 380, 382, 386 Camaioni, L., 320 Cameron, A., 159 Cameron, J. L., 14, 125, 129, 585 Cameron, N. M., 63, 66, 67 Campbell, A., 498 Campbell, C., 319 Campbell, D., 566 Campbell, E. A., 29 Campbell, E. K., 66 Campbell, F. A., 128 Campbell, S., 392, 394, 395, 399, 400 Campbell, S. B., 156, 160, 241, 245 Campos, J. J., 83 Campos, R. G., 83 Candelaria, M., 86 Canfield, R. L., 121 Canger, C. I., 191 Cannard, C., 363 Cannella, B. L., 26 Cannon, J. S., 16, 559 Cantwell, D. P., 414 Caplan, G., 566 Carbone, V., 309 Carbray, J. A., 525 Card, J., 319 Carey, W. B., 366 Carlin, J. B., 183 Carlson, B. E., 198, 205 Carlson, E. A., 60, 88, 93, 122, 156, 215, 423, 424, 453, 486, 504, 511 Carlson, G. A., 413, 414, 524 Carmichael-Olson, H., 188 Carneiro, C., 471, 473, 475, 477 Carpenter, R., 320 Carper, R., 302 Carr, A., 473 Carr, T., 11, 282, 301 Carrère, S., 469 Carrington, H. A., 84 Carrion, V. G., 202, 203

594 Carrol, B., 142 Carroll, K., 498 Carroll, S. R., 84 Carskadon, M. A., 368 Carson, D. K., 325 Carta, J. J., 10 Carter, A., 392, 396, 397, 398, 400, 404 Carter, A. S., 89, 231, 233, 234, 235, 236, 237, 238, 240, 241, 242, 243, 245, 246, 247, 255, 257, 285, 289, 296, 324, 333, 414, 537, 552, 553, 554, 556 Carter, C. S., 126 Carter, M. C., 428 Carty, E. M., 367 Carver, L., 49, 303 Carver, L. J., 204 Case, M. E., 500 Casey, P., 183 Casper, R. C., 518 Caspi, A., 49, 68, 86, 120, 121, 139, 143, 159, 201, 202, 290, 291, 418 Cassidy, B., 216 Cassidy, J., 95, 267, 272, 453, 457, 462, 465 Castle, J., 396 Catalano, S., 198 Cathcart, K., 308 Caughy, M. O., 115, 142 Cauthen, N., 136, 144 Cauthen, N. K., 135 Cavaleri, M. A., 30 Cavanaugh, D., 149 Ceballos, R. M., 156 Celik, G., 523, 525 Cen, G., 107 Cermak, C. A., 537 Cervera, N., 224 Cesena, M., 523, 524 Chacko, A., 404 Chaffin, M., 422, 426 Challamel, M. J., 363 Chalmers, J. C., 29 Chamberlain, P., 507 Chamberlain, P. P., 520 Chamberlin, R., 559 Champagne, F., 72 Chan, W., 126 Chandler, G., 176 Chapieski, M. L., 183 Chapman, G., 155 Chapman, M., 257 Chapman, R., 321 Chapman, R. S., 336 Charak, D. A., 202 Charman, T., 301, 303, 305, 306 Charney, D., 348, 349 Charney, D. S., 197 Chase-Lansdale, P. L., 214, 216, 217, 219, 221 Chase-Stockdale, D. F., 511 Chatoor, I., 204, 285, 351, 378, 380 Chattarji, S., 73 Chau, M., 136, 137 Chaudhuri, J. H., 215 Chawarska, K., 301, 303, 304, 305, 307, 310 Chazan-Cohen, R., 241, 553 Chen, E., 346 Chen, F.-M., 216

Author Index Chen, M., 175 Chen, W., 305 Chen, W. J., 172 Chen, X., 107 Cheng, V. K., 488 Cheong, J. L., 183 Cheour, M., 368 Cherny, S. S., 159 Chess, S., 85, 290, 292 Chethik, L., 175, 485 Chevalier, A., 366 Chicz-Demet, A., 122 Childress, D., 303 Chinitz, S., 504 Chisholm, K., 122, 425, 426, 428, 430 Cho, E., 51 Chobanian, A. V., 288 Choi, I., 117 Choi, L., 68 Choudhury, N., 322 Christakis, D. A., 127 Christensen, M., 239, 255 Chrousos, G. P., 61 Chugani, H. T., 53, 126 Cicchetti, D., 17, 91, 107, 110, 127, 128, 155, 156, 159, 163, 164, 199, 200, 202, 204, 206, 208, 235, 238, 307, 349, 399, 416, 427, 440, 442, 448, 552 Cigales, M., 412 Citro, C. F., 136 Clark, L., 174 Clark, M. K., 199 Clark, R., 163, 175, 236, 256, 257, 259, 293, 485 Clarke, A. D. B., 128 Clarke, A. M., 128 Clarke, C., 85 Clarren, S. K., 505 Clasky, S., 412 Clausen, C., 505 Clauson, M., 367 Claycomb, M., 222 Clemmens, D. A., 217, 218, 221 Cleves, M., 183 Clubb, P., 346 Coates, S., 351 Coates, S. W., 206 Coatesworth, D. J., 12 Coatsworth, J. D., 235 Cobo-Lewis, A. B., 319 Coccaro, E. F., 159 Cocci, V., 95 Cocco, N., 358 Coffey, C., 183 Coggins, D., 320 Cohen, D., 235 Cohen, D. J., 208 Cohen, E., 148 Cohen, H., 349 Cohen, J., 106, 357 Cohen, J. A., 208, 442, 520 Cohen, L. J., 1, 22, 27, 31, 486 Cohen, M., 308 Cohen, M. A., 583 Cohn, J. F., 67, 87, 156, 160, 161, 411, 412 Cole, J. O., 223 Cole, P., 84, 88, 399 Cole, P. M., 84, 110

Coley, R. L., 221 Colin, V., 378 Colletta, N. D., 225 Collie, R., 345 Collins, W. A., 60, 88, 156, 453 Colombi, C., 309 Comfort, K., 126 Condon, J. T., 26, 28, 29 Conger, R. D., 139 Conlin, S., 259 Connell, A., 469 Connell, A. M., 162 Connell, D., 161 Connell, D. B., 161 Connelly, C. D., 198 Conners, N. A., 174 Connor, D. F., 520, 523, 524 Connors, J., 60 Constantino, J., 307 Conti, J., 486 Conti-Ramsden, G., 322 Contreras, J. M., 219 Cook, C. A., 349 Cook, D. G., 388 Cook, E., 303 Cook, E. H. J., 202 Cooke, R. W., 183 Coolbear, J., 95, 378, 380, 469 Coombs, R., 215 Coonrod, E., 306, 307 Coons, S., 363 Cooper, G., 97, 177, 275, 436, 450, 451, 453, 454, 455, 458, 459, 461 Cooper, K., 382 Cooper, P., 161 Cooper, P. J., 29, 378, 411 Copeland, W. E., 203 Coplan, J., 320 Coplan, J. D., 122, 125 Corbett, S. S., 377, 382, 385, 386 Corboz-Warnery, A., 471, 473, 474 Cordeiro, M., 293 Cordero, J. F., 173 Cordy, N. I., 155 Coren, E., 216 Corklindale, C., 26, 28, 29 Corley, R. P., 159 Corona, R., 303 Corriveau, E. A., 122 Corso, R. M., 109 Corter, C., 488 Corwin, E. J., 156 Cosenza, A., 523 Costello, C. G., 154 Costello, D. W., 182 Costello, E. J., 11, 199, 203, 287, 289, 556 Costello, J., 200 Costigan, K. A., 25 Coté, C. J., 518 Cote, S., 397, 398 Cote, S. M., 202 Cotsonas-Hassler, T. M., 505 Cottrell, D., 382, 473 Counsell, S. J., 183 Couperus, J. W., 59 Coupland, V. A., 24 Courage, M., 346 Courchesne, E., 302 Covington, C., 200 Covington, C. Y., 176

Cowan, C., 468, 469 Cowan, C. P., 214 Cowan, P., 468, 469, 470 Cowan, P. A., 214 Cowlin, A., 33 Cox, J. L., 154, 155, 380, 553 Cox, M. J., 141, 469, 474 Coy, K., 393 Coyle, J. C., 411, 412 Cradock, M., 183 Craig, K. D., 184 Crais, E. R., 318, 324 Cramer, A., 233 Crase, S. J., 511 Craske, M., 346 Crawford, D., 377 Crisafulli, A., 470 Crittenden, P. M., 95 Crnic, K. A., 86, 163, 188, 338, 471 Crockenberg, S. B., 8, 9, 86, 87, 88, 89, 92, 163, 220, 222, 224, 393, 399, 470, 472 Croft, D., 380 Cross, J., 500 Crouter, A., 472 Crowell, J., 121, 366 Crowell, J. A., 252, 253, 254, 255, 256, 257, 260 Cruz, A., 160 Csizmadia, A., 23 Cubed, M., 584 Cuccaro, M. L., 525 Cuennet, M., 477 Culp, A. M., 215, 218, 219 Culp, R. E., 215, 218 Culver, C., 87 Cummings, E. M., 9, 156, 157, 257, 399, 469, 470 Cunningham, M., 162 Cunningham, N., 206 Curfs, L. M., 369 Curry, C. J., 335 Curry-Bleggi, E., 551 Cutrona, C. E., 67, 163, 221, 222 Cyr, C., 465 Dabhholkar, A. S., 44, 45 DaCosta, D., 162 Dagher, A., 72 Dahl, L. B., 183, 190 Dahl, R. E., 368 Dahlgren, S. O., 301, 302 Dailey, J., 27, 32 Dalakar, J., 106, 136 Dale, P. S., 322, 323 Dalgleish, T., 13 Dallas, C., 223 Daniels, J., 312 Danielyan, A., 525 Danis, B., 283, 392 Danziger, S. K., 217, 221 Dapretto, M., 207 Darwin, C., 409, 410 Dauber, S., 162 Davalos, M., 73 Davanzo, P., 332 Davey-Smith, G., 388 David, D., 498 Davidson, J., 350, 357 Davidson, R. J., 51, 52, 53, 66, 158, 159, 393, 398, 399, 412

Author Index Davidson, W. S., 65, 95, 200, 349, 353 Davies, D., 82 Davies, L., 222, 396 Davies, M., 337 Davies, P., 470 Davies, P. T., 9, 157 Davis, K., 550, 555 Davis, N., 414 Davis, N. O., 235, 285 Davis, N. S., 365 Davis, S. M., 334 Dawley, K., 538 Dawson, G., 50, 52, 53, 54, 72, 73, 156, 157, 160, 302, 303, 304, 305, 410, 413, 415, 553 Day, A., 29 Day, N., 173 Day, W., 393 Dayan, J., 181 Dayton, C. J., 2, 80, 89, 95 De Bellis, M. D., 73, 126 De Bruyn, E. J., 415 de Geus, E. J., 159 de Haan, M., 46, 47, 66 de Kloet, E. R., 63 De Los Reyes, A., 240, 241, 242 de Moor, J. M., 369 de Noni, S., 472 de Weerth, C., 157 de Wit, C. A. M., 415 De Wolff, M. S., 94, 96 Dearing, E., 141, 142, 143, 368 Deayton, J. M., 364 DeBar, L. L., 516, 518 DeBellis, M. D., 202, 204, 348 Deblinger, E., 357, 442 DeCoste, C., 436, 485, 490, 496, 497 DeFries, J. C., 159 DeGarmo, D. S., 505 Degnan, K. A., 8, 13 DeJonghe, E., 65, 349, 353 DeKlyen, M., 394, 423 Delaney-Black, V., 176, 200 DelCarmen-Wiggins, R., 296, 392 DeLeo, T., 537 DeLeone, N. L., 552 Delliquadri, E., 290 DeLoache, J., 203 DeMaso, D. R., 524 Dement, W. C., 363 DeMier, R., 186, 187 Demissie, K., 181 Demos, V., 410 den Ouden, A. L., 184 Denham, S. A., 157, 235, 399, 409 Dennis, T. A., 88, 399 Dermer, M., 31 Derryberry, D., 85 DeSouza, N., 377 DeStefano, F., 305 Dettling, A. C., 66, 68, 126 Devescovi, A., 320 DeVries, M. W., 110 Di Giacomo, A., 301 Diamond, M. C., 61 Dicker, S., 146, 148, 504 Dickerson, S. S., 64, 66 Dickson, N., 290 Dickstein, S., 9, 553

595 Didden, R., 369 Diego, M. A., 30, 67, 161, 411, 412 Diener, M. L., 94, 219 Diener-West, M., 372 Dietrich, A. J., 553 Dietz, W. H., 377, 386, 388 DiLalla, L. F., 158 DiLavore, P., 305 Diler, R. S., 525 Dimas, J. M., 238 Dimitrova, N., 475 Dinan, K. A., 136, 138 Dinesen, S. J., 183 Dinges, D. F., 364 Dinnebeil, L. A., 565–566 Diorio, J., 55, 72, 122 DiPietro, J. A., 25, 30 Disbrow, M. A., 363 Dishion, T. J., 13, 403 Dissanayake, C., 303 Dittrichová, J., 363, 364 DiVitto, B., 188, 189 Dix, T., 87, 393 Dixon, J. A., 320 Doan, H., 26 Dobkin, P., 291 Dodge, K. A., 86, 88, 142, 399 Doherty, W. J., 28, 539 Dole, N., 181 Dolev, S., 96, 273, 274, 275 Dollaghan, C. A., 323 Dombrowski, S., 358 Dong, M., 7 Donnell, F., 94 Donohue, J. J., 583 Donzella, B., 60, 66, 68, 69, 143 Doormaal, E. F., 188 Dougherty, L., 409 Douglas, D., 318 Douglas-Hall, A., 136, 137, 138 Doussard-Roosevelt, J. A., 158 Dowdney, L., 382 Downey, G., 411, 412 Downey, J. I., 24 Doyle, L. W., 183 Dozier, D., 505, 506 Dozier, M., 71, 72, 95, 127, 128, 206, 208, 278, 430, 502, 503, 504, 505, 506, 507, 508, 512, 517, 520 Drabick, D. A., 399 Drachman, D., 537 Drasgow, E., 323 Drell, M. J., 204, 293, 349, 351 Drewett, F., 377, 378, 380, 381, 382, 385 Drewett, R. F., 377, 380, 381, 384, 385, 386 Driessens, C., 122 Dritsa, M., 162 Drotar, D., 380 Drum, C. E., 202 Dube, S. R., 7 Dubois-Comtois, K., 465 Dubowitz, H., 386 Ducournau, P., 411 Dudek-Schriber, L., 186, 191 Duhig, A., 469 Dumitrescu, A., 424, 425 Duncan, G. J., 67, 136, 138, 580, 581, 582

596 Duncan, P., 549 Dunitz-Scheer, M., 378 Dunkel-Schletter, C., 122 Dunn, W., 536 Dunne, M. C., 566 Dunst, C. J., 336, 341 Duran, L., 320 Durbin, E. E., 162 Dutra, L., 358 Duyvesteyn, M. G. C., 488 Dwyer, T. F., 24 Dyet, L. E., 183 Dykens, E. M., 282, 332, 335, 337, 339 Earls, F. J., 398 Earls, M. F., 552 East, P. L., 214, 215, 216, 217, 218 Easterbrooks, M. A., 215, 216, 219 Eaves, L. J., 162, 202, 386 Ebstein, R., 86 Eckerberg, B., 367 Edelbrock, C. S., 290 Edelman, G. M., 488 Edelstein, S. B., 511 Edleson, J. L., 198 Edwards, C. P., 566 Edwards, E. P., 177 Edwards, G. H., 175 Egeland, B., 60, 88, 93, 156, 161, 206, 423, 453, 486, 488, 489, 504 Eggbeer, L., 538 Egger, H. L., 10, 11, 234, 246, 247, 281, 282, 285, 287, 289, 290, 292, 294, 297, 392, 393, 394, 395, 400, 404, 425, 427, 516, 546, 565 Ehlers, A., 347 Ehlert, U., 69 Ehrensaft, M. K., 200 Ehrle, J., 511 Eiden, R. D., 162, 177, 485 Eigsti, I. M., 202 Eikeseth, S., 309, 326 Eilers, R. E., 319 Einarson, A., 155 Einarson, T. R., 155 Einfeld, S. L., 337 Einon, D., 393, 398 Eisemann, M., 27 Eisenberg, N., 88 Ekman, P., 52, 159 El-Bassel, N., 485 Elder, G. H., 139, 356 Eldevik, S., 309, 326 Eley, T. C., 290, 368 Elgen, I., 183 Eliez, S., 335 Ellingson, K. D., 237, 242 Elliott, A. J., 370 Elliott, R., 488 Ellis, A. R. M., 312 Ellis, B. H., 507 Ellis, B. J., 61, 68, 70 Ellis, M., 176 Elmore, M., 160 Elo, I. T., 221 Else-Quest, N. M., 325 El-Sheikh, M., 364 Elson, L. M., 61 Elster, A. B., 221 Eluvathingal, T. J., 126, 127

Author Index Emde, R. N., 9, 82, 215, 231, 239, 255, 266, 285, 292, 364, 402, 411, 447, 564 Emery, R., 469 Emmett, P., 380 Emond, A., 380 Emory, E., 160 Endicott, J., 292 Englemann, T. G., 363 Epel, E. S., 67 Eppe, S., 199 Epstein, M., 380 Epstein, R., 368 Erel, O., 470 Erickson, M. F., 68 Erikson, E., 441 Erkanli, A., 11, 199, 287, 400 Escalona, S., 7 Escobar, G. J., 182 Espinosa, M., 303 Espy, K., 396, 404 Essex, E. L., 340 Essex, M. J., 51 Estroff, D. B., 158 Eth, S., 203 Etzion-Carasso, A., 273 Evankovich, K. D., 183 Evans, C. D., 31 Evans, D. W., 336 Evans, G. W., 142 Evans, J. L., 155, 325 Everhart, K. D., 447 Everheart, M., 566 Evinder, A., 142 Ewing, L., 400 Eyberg, S. M., 410, 417, 520, 524, 526 Eyler, F. D., 485 Eyres, S. J., 490 Fagan, E., 498 Fagen, J. W., 157 Fagioli, I., 363 Fairbank, J. A., 199 Faja, S., 410 Fanklin, C. L., 142 Fantuzzo, J., 109, 198 Faraone, S. V., 159, 523, 524 Farber, B., 338, 339 Farber, E., 93 Farber, N. B., 172 Farel, A. M., 257, 258 Faroy, M., 86 Farrington, R., 504 Farver, J. A., 199, 200 Fass, S., 135 Fauth, R. C., 138 Favez, N., 9, 255, 260, 436, 468, 472, 473, 474, 475, 477, 494 Fazzi, E., 364 Fearnley Shapiro, A., 469 Fearon, R. M. P., 73, 97, 121 Federenko, L. S., 159 Feeley, N., 188 Fehlings, D., 366 Feibusch, E. L., 525 Fein, D., 246, 311 Feinberg, M. E., 223 Feinman, D., 31 Feinman, S., 83, 84 Feintuch, M. G., 25, 29, 30, 34

Feldman, R., 25, 146, 293, 475, 481 Feldman, S. S., 254, 256, 257, 260 Feldon, J., 126 Felice, M. E., 214, 215, 216, 217, 218 Felitti, V. J., 7, 109 Fenichel, E., 275, 537, 538, 556, 557 Fenson, J., 323 Fenson, L., 235, 307, 320, 325 Ferber, S. G., 372 Fermanian, J., 296 Fernald, A., 113 Fernandez, A., 199 Fernyhough, C., 87, 94, 255, 273 Fey, M. E., 327 Ficca, G., 363 Fidler, D. J., 335, 336, 337, 339, 340 Field, T. M., 30, 50, 66, 67, 73, 87, 156, 157, 158, 159, 160, 161, 163, 188, 372, 411, 412 Fielding, B., 162 Fiese, B. H., 8, 10, 106, 155, 551, 552 Figueiredo, H., 63 Finch, C. E., 205 Fincham, F., 469 Fine, M. A., 219 Finucane, B., 335 Fiori-Cowley, A., 161 First, E., 206 Fischer, K. W., 202 Fish, M., 67 Fisher, C., 363 Fisher, P. A., 127, 204, 206, 208, 290, 503, 504, 505, 506, 507, 508, 509, 512, 520 Fisk, N. M., 159, 160, 185 Fitzgerald, H. E., 108 Fitzgerald, M., 324 Fitzhardinge, P., 187 Fivaz-Depeursinge, E., 9, 436, 468, 471, 472, 473, 474, 475, 477, 481 Fivush, R., 204, 346, 347 Flaherty, M. J., 220 Flanders, J., 393 Flannagan, P. F., 33 Fleischmann, M. A., 252, 253, 255 Fleming, A. S., 122, 215, 488 Fleming, C., 239, 255 Florian, V., 27 Florio, T., 337 Florsheim, P., 222, 223 Floyd, R. L., 173 Flynn, H. A., 154 Fogel, A., 83, 320 Fogg, L., 537 Folkman, S., 60, 63 Fombonne, E., 301, 305 Fonagy, P., 8, 27, 32, 71, 96, 206, 241, 255, 443, 451, 460, 461, 487, 493 Foote, A., 485 Forcada Guex, M., 186, 189, 190, 191, 192 Forehand, R., 162 Forman, E., 470 Foster, S., 400 Foulder-Hughes, L. A., 183 Fowler, J. S., 488 Fox, C., 566 Fox, G., 181 Fox, L., 504 Fox, N., 157, 319, 348, 412

Fox, N. A., 8, 48, 52, 53, 73, 81, 82, 85, 86, 156, 157, 158, 199, 425 Fracasso, M. P., 158 Fradley, E., 94, 255 Fraiberg, S. H., 5, 17, 34, 111, 188, 205, 266, 267, 435, 440, 442, 443, 462, 517, 567, 568 Francis, D. D., 55, 72, 122 Francomb, H., 155 Frank, D. A., 174 Frank, M. A., 27 Frank, M. G., 368 Frank, S. J., 504 Frankenburg, W., 311 Franklyn-Banton, L., 310, 312 Frascarolo, F., 9, 436, 468, 472, 473, 474, 475, 477 Freato, F., 187 Fredman, L., 163 Freeman, R. D., 369, 372 Freeman, S. F. N., 309, 336 Freeman, V. A., 258 French, M. T., 171 Frenkel, O. J., 269 Freud, A., 205 Freud, S., 188, 440 Freund, M., 188 Frey, K., 50, 53 Frías, J. L., 172 Frick, J. E., 160 Frick, P. J., 13 Fridman, A., 273 Friedrich, L. K., 199 Friedrich, W. L., 338 Friesen, W. V., 52, 159 Fristad, M. A., 525 Frith, U., 303 Froehle, M. C., 550, 553 Frosch, C., 469, 470, 471 Frosch, D. L., 200 Frye, C., 60 Fulker, D. W., 159 Fuller, B., 142 Furstenberg, F. F., Jr., 221 Fusco, R., 198 Futris, T. G., 223 Gable, S., 471 Gabreels, F., 334 Gadow, K., 289 Gaensbauer, T., 204, 350, 351, 353, 358 Gaffan, E., 155 Gage, F. H., 43 Gage, J. D., 28 Gahagan, S., 380 Gahart, M., 363 Gale, J., 516 Gallagher, K. C., 236 Gallant, M., 187 Galynker, I., 34 Gamble, V. N., 114 Ganiban, J., 378, 380 Garcia Coll, C. T., 33, 85, 105, 107, 109, 114, 255 Gardner, C. O., 162 Gardner, F., 8 Garmezy, N., 10 Garner, P. W., 86, 87 Garrett, Z., 325 Garrett-Mayer, E., 301, 302

Author Index Garrison, M. M., 127 Garrity-Rokous, F. E., 241, 553 Garrod, E., 27 Garry, M. T., 520 Garvan, G. W., 485 Garwood, M. M., 94 Gary, L. C., 556 Gass, J. T., 174 Gavin, L. E., 220, 224 Gavin, N. I., 155 Gaylor, E. E., 363, 365 Gaylord, N. K., 200 Gaynes, B., 553 Gazdag, G. E., 327 Gee, C. B., 221, 224, 225 Geen, R., 511 Gelfand, D. M., 159, 163 Geller, B., 414 Geller, D. A., 523 Geller, V., 86 Gelles, R. J., 198 Gendreau, P., 399 George, C., 26, 31, 85, 95, 423, 454, 487 George, L., 350 Gergely, G., 27, 71, 86, 87, 206, 241, 443, 487 Gerig, G., 518 German, M. L., 334 Gerner, L., 28 Gershoff, E., 141, 393 Gershon, A., 356 Gertsch Bettens, C., 473 Gesell, A., 81 Gestsdottir, S., 215 Getahun, D., 181 Gettman, M. G., 566 Ghera, M. M., 86, 89 Ghosh Ippen, C., 2, 104, 110, 208, 349, 350, 357, 448 Gianino, A. F., Jr., 156, 160 Gibbons, J., 53 Gibson, P., 176 Giedd, J. N., 45 Gilbert, S. G., 551 Gilbertson, M. W., 49, 202 Gilchrist, L. D., 219 Giles, W. H., 7 Gilkerson, L., 108, 217, 275, 537, 538 Gill, K. L., 88 Gill, M. M., 442 Gillberg, C., 246, 301, 302 Gillespie, J. F., 200 Gilliam, W. S., 13, 521, 566 Gilliom, M., 392, 396, 397 Gillis-Arnold, R., 511 Gilmore, J., 518 Ginsberg, N., 254 Ginsburg, N., 366 Giovannelli, J., 290, 397 Gisel, E. G., 380 Gissler, M., 181 Gitau, R., 159, 160 Gjelsvik, A., 198 Gladstone, J., 505 Glascoe, F. P., 237, 242, 311, 552, 553, 555, 556 Glaze, L. E., 510 Gleason, J. R., 320 Gleason, M. M., 6, 288, 436, 437, 516, 526, 531, 549, 554

597 Glenn, S., 186 Glidden, L. M., 339, 340 Glink, P., 217 Glod, C., 565 Glover, V., 8, 124, 159, 160, 162, 181, 185 Glovier, M., 544 Gluckman, P., 124 Glucksman, E., 13 Glynn, L. M., 122 Godoy, L., 231, 233 Goebert, L., 30 Goeke-Morey, M., 470 Goffinet, F., 182 Goffman, L., 325 Goldberg, A., 347 Goldberg, S., 96, 188, 189, 260, 269 Goldfarb, W., 423 Golding, J., 124, 155 Goldman, D., 463 Goldschmidt, T., 293 Goldsmith, D. F., 270, 276, 277 Goldsmith, H. H., 66, 159, 290, 399 Goldstein, L. H., 94, 416 Goldstein, S., 50, 67, 159, 412 Goldwyn, R., 94, 95, 423 Golse, B., 191 Gonzalez, A., 412 Gonzalez, J., 156, 157 Gonzalez-Heydrich, J., 524 Goode, S., 309 Goodenough, F., 398 Goodlin-Jones, B. L., 82, 363, 365 Goodman, R., 398 Goodman, S. H., 29, 50, 68, 134, 141, 153, 157, 158, 159, 162, 257, 411, 469, 536 Goodwyn, S. W., 320 Gordis, E. B., 200, 470 Gordon, B., 346 Gordon, E., 504 Gordon, J. N., 504 Gordon, L., 566 Gordon, M., 551 Gordon, R. A., 217 Gotham, K., 307 Gotlib, I. H., 155, 158, 159, 162, 412, 469 Gottesman, I. I., 159 Gottlieb, D. J., 551 Gottlieb, L., 188 Gottman, J. M., 469, 470 Goubet, N., 184 Gould, E., 43, 44 Gozdziak, E. M., 136 Grace, D., 67 Grace, S. L., 142 Graf Estes, K., 325 Graham, M. A., 500 Graham, M. V., 386 Graham, Y. P., 157 Graham-Bermann, S. A.,199, 352 Granic, I., 398 Gratton, A., 72 Gray, F. L., 336 Gray, R., 172 Green, B. L., 566, 567 Green, C. E., 109, 198 Green, J. M., 24, 94, 246, 309, 311, 423 Green, M., 549, 551, 553

598 Greenberg, M. T., 163, 188, 338 Greene, J., 358 Greenfield, L., 171, 177 Greenhill, L., 519, 522, 523 Greenough, W. T., 46, 123 Greenspan, S. I., 176, 301, 308, 564, 566 Greenwald, R., 358 Greer, 142 Gregory, A. M., 368 Greis, S. M., 504 Greisen, G., 183 Grella, C. E., 177 Gresham, F. M., 334 Grienenberger, J., 96, 487 Griffin, K. W., 566 Griffith, E., 303 Griffiths, C., 182 Griffiths, P. D., 183 Grizzle, N., 163 Groen, A. D., 308, 326 Grofer Klinger, L., 52, 53 Gross, C. G., 44 Gross, J., 411 Grossmann, K. E., 49, 65, 68, 71, 92, 93, 94 Gruber, C., 307 Gruber, R., 368 Grunau, R. E., 184, 185 Grunau, R. V., 184 Grunebaum, H. U., 161 Grunewald, R., 581, 582 Guedeney, A., 296, 501 Guedeney, N., 293, 501 Guerra, N., 402 Guerrini, I., 173 Guilleminault, C., 363 Gunderson, B., 173 Gunnan, M. R., 520 Gunnar, M. R., 47, 48, 49, 50, 60, 65, 66, 67, 68, 69, 71, 72, 122, 125, 127, 143, 157, 158, 206, 349, 505, 508 Gunthorpe, D., 67 Gupta, M. D., 273 Gurling, H. D., 173 Guthertz, M., 50, 159 Guthrie, D., 470 Guthrie, W., 307 Gutierrez, J., 108 Guyer, A. E., 238, 295 Guze, S. B., 287, 414 Gwendolyn, A., 453 Habib, C., 28 Hack, M., 182, 183 Haden, G., 307 Hadjiyannakis, K., 156 Hadzi-Pavlovic, D., 156 Haft, W. L., 95 Hagan, J. F., 549, 551 Hagekull, B., 188 Hagerman, R., 305 Haggerty, R. J., 14, 15, 18 Hägglöf, B., 26, 27 Haight, W., 322 Hailey, A., 29 Halbower, A. C., 372 Haley, D. W., 67, 160 Halfon, N., 553, 555, 556 Hall, F. S., 204

Author Index Hall, R. E., 262 Hall, R. W., 183 Hall, T., 308 Hall, W. A., 367 Hallahan, D. P., 340 Halle, J. W., 323 Halpern, L. F., 364 Hambright, A., 473 Hamburger, E., 378 Hamby, D. W., 341 Hammal, D., 307 Hammen, C., 162 Hammond, M., 188, 470, 520 Hampton, A., 365 Handleman, J., 308 Handy, T. C., 500 Hane, A. A., 73, 86 Hann, D. M., 215 Hanna, C., 49, 73 Hanna, G. L., 525 Hanna, M., 380 Hannigan, J. H., 200 Hans, L. L., 485 Hans, S. L., 134, 176, 214, 215, 216, 217, 221 Hanson, M., 124 Hanson, S. L., 220 Happé, F., 303 Happé , F., 303 Harden, B. J., 500 Harder, T., 387, 388 Hardy, J., 214 Harkness, A., 322, 324, 325 Harkness, S., 114 Harlow, H., 125 Harmon, R. J., 231, 285, 378, 523, 524 Harold, G., 470 Harper, R. M., 364 Harris, F., 322, 324, 325 Harris, K. M., 221 Harris, M. L., 66 Harris, S., 308 Harris, T. O., 163 Harris, W., 442, 444 Harris, W. W., 111 Harrison, M. J., 189 Harrison, P. L., 238 Harrist, A. W., 94 Hart, A. R., 183 Hart, B., 137, 322, 327 Hart, H., 366, 398 Hart, J., 66 Hart, S. L., 84 Hartman, C. R., 204 Hartshorn, K., 204 Harwick, N. J., 504 Harwood, R. L., 113 Hassibi, M., 85 Hastings, R. P., 339 Hatten, M. B., 42 Hauri, P. J., 364 Hauser, S. T., 423 Hauser-Cram, P., 340 Hawkins, D., 471 Hay, D. F., 73, 158, 393, 396, 397, 399, 400 Hay, S. S., 552 Hayden, L., 553 Hayes, A., 305 Hayne, H., 345

Hays, P. A., 239 Hazen, A. L., 198 He, Y., 107 Healy, B. T., 50, 67, 159, 412 Heath, A. C., 159, 162 Heckman, J. J., 14, 129, 585 Hedrick, D., 307 Heffelfinger, A., 415 Heikura, U., 335 Heim, C., 65, 69, 126, 127, 157, 185 Heinicke, C. M., 469 Heller, S. S., 253, 293, 400, 430, 503, 504, 510, 511 Hellhammer, D. H., 69, 159 Helmreich, D. L., 122 Hembree, E., 410 Hembree, E. A., 83 Henderson, B. F., 221 Henderson, C. R., 559 Henderson, H. A., 8, 85 Henderson, J., 172 Heneghan, A. M., 552, 553, 555 Henly, J. R., 225 Henrich, C., 504 Henriques, J. B., 53 Henry, B., 290 Henry, D., 403 Henry, J., 347 Hensch, T. K., 123 Henshaw, E. K., 33 Henson, L. G., 225, 485 Hepburn, K., 147 Hepburn, S. L., 305, 335, 336 Herbison, J., 308 Herman, J. P., 60, 61, 63 Hernandez, B., 386 Hernandez, D. J., 136 Hernandez-Reif, M., 30, 67, 161, 372, 412 Heron, J., 124, 155, 162 Hersey, K., 290 Hertsgaard, L., 66, 68, 71 Hertzmann, C., 142, 518 Hertzog, C., 85 Hesketh, L. J., 321, 336 Hess, C. R., 215, 216, 219 Hesse, E., 65, 71, 110, 423 Hessl, D., 50 Hessling, R. M., 221 Hetta, J., 368 Heycock, E. G., 380 Heyerdahl, S., 183 Higgitt, A., 96, 206 Higley, E., 505 Hill, A., 82, 87, 88, 236 Hill, C., 254, 400, 401, 402, 404 Hill, D., 52, 53, 413 Hill, R. B., 502 Hill-Soderlund, A. L., 13 Hinde, R. A., 125 Hinkley, C., 24 Hinshaw-Fuselier, S., 17, 531, 533 Hiroi, N., 174 Hirsch, R., 378 Hirshberg, L., 267 Hirshberg, L. M., 233 Hirshfeld-Becker, D. R., 290, 291 Hiscock, H., 365, 367 Hislop, K. B., 500 Hobson, J. A., 368 Hochstadt, N. J., 504

Hock, E., 162 Hodapp, R. M., 282, 332, 335, 338, 339, 340 Hodges, J., 11, 426 Hodges, K., 416 Hodson, B. W., 320 Hoek, H. W., 122 Hofer, M. A., 60, 122, 207 Hofferth, S. L., 92 Hoffman, E., 112 Hoffman, K., 177, 275, 436, 450, 451, 453, 454, 455, 458, 459, 461, 465 Hoffman, K. T., 97 Hogan, A., 325 Holahan, C. J., 201 Holcomb, W. R., 413 Holden, G. W., 198, 201 Holden, J., 154 Holden, J. M., 553 Holditch-Davis, D., 186, 187, 190 Holland, C. C., 504 Hollon, M. F., 520 Holman, K., 301 Holmes, J. P., 526 Holmes, O. W., 450 Holsti, L., 184 Holt, A. R., 200 Holt, R. W., 235 Holzer, C. E., 520 Honig, A. S., 216 Honzik, M., 398 Hood, K. K., 520, 524, 526 Hook, E. B., 335 Hooker, K. A., 85 Hooper, R., 161 Hopper, E., 31, 32 Horner-Johnson, W., 202 Hornstein, J., 557 Horowitz, S. M., 235 Horvath, D. D., 93 Horvath, T. B., 159 Horwitz, S. M., 237, 238, 504, 556 Hossain, Z., 412 Hou, W., 485, 553 Houck, G. M., 235 Howard, J., 175, 485 Howe, M., 346 Howe, M. L., 204 Howell, C. T., 236 Howell, H. B., 30 Howlin, P., 309, 310, 337 Hoyme, H. E., 505 Hser, Y. I., 177 Hsieh, K., 470 Hsieh, K. H., 83, 84, 86 Hua, A., 364 Huang, L., 337 Huang, Z. J., 123 Hubbard, R. L., 171 Huber, C. J., 258 Huebner, R., 410 Huebner, R. R., 83, 409 Huganir, L. S., 24 Hughes, G., 350 Hughes, M. A., 186, 336, 350 Hughes, P., 31, 32 Hughes, S., 216 Huizinga, D., 202 Huizink, A. C., 156 Hunsberger, B., 187

Author Index Hunt, J. P., 201 Huntington, D. C., 24 Huot, R. L., 156 Huppi, P. S., 183 Hurley, J., 553 Hus, V., 303 Hussain, S., 199 Huston, A. C., 140 Huston, L., 423 Hutcheson, J. J., 386 Huth-Bocks, A. C., 23, 27, 95, 207, 349, 352 Hutman, T. M., 275 Huttenlocher, J., 322 Huttenlocher, P. R., 44, 45, 53 Hyde, J. S., 163 Hyman, S. L., 308 Hyunsan, C., 553 Iacoboni, M., 207 Iannotti, R. J., 157, 399 Iglowstein, I., 364 Iiersich, A. L., 185 Ikhlas, M., 219 Ikonomidou, C., 172 Inder, T. E., 183 Indredavik, M. S., 183 Ingersoll, B., 309 Ingoldsby, E. M., 392 Ingram, M., 289 Inkelas, M., 555, 556, 557 Insel, T. R., 126 Invernizzi, R., 95 Ippen, C. G., 13, 17, 164, 517 Irwin, J. R., 324 Irwin, M., 551 Isaacs, B., 217 Isensee, J., 60 Ispa, J. M., 23, 219, 222 Issa, N. P., 368 Iverson, J., 320 Izard, C. E., 83, 409, 410 Jabbi, M., 68 Jacklin, C. N., 363 Jackson, D., 473, 475 Jackson, J. J., 61, 68 Jackson, J. S., 218 Jackson, K., 186, 190 Jacobi, D., 303 Jacobson, J., 426 Jacobson, S., 426 Jacobvitz, D., 93, 206 Jaffee, S. R., 414 Jahr, E., 309, 326 Jakubek, S., 184 James, S., 109 James, W., 80 Janicak, P. G., 525 Jankowski, K. R. B., 162 Janssen, P. A., 367 Jarvis, S., 380, 382 Jaycox, L. H., 199 Jebb, S. A., 386 Jeffries, R., 323 Jellinek, M. S., 517, 550, 551, 552, 553, 556 Jenkins, S., 366, 398 Jenni, C. B., 28 Jenni, O. G., 363, 364 Jentzen, J. M., 500

599 Jeon, H., 566 Jernigan, T. L., 44, 337 Jessell, T. M., 42, 43 Jevtovic-Todorovic, V., 172 Joels, M., 63 Johanson, R., 155 John, R., 470 Johns, E. S., 525 Johnson, A. B., 505 Johnson, A. L., 175 Johnson, C., 369 Johnson, F., 94 Johnson, I., 155 Johnson, K., 148, 531, 560 Johnson, M. C., 88 Johnson, M. H., 88 Johnson, R. W., 55 Johnson, S. M., 128 Johnson, W. E., Jr., 221, 222, 223, 224, 225 Johnston, C., 175, 184, 233 Johnston, J., 326 Johnston, K., 533, 534, 537, 538, 564, 572 Jones, H. A., 327 Jones, J. D., 191 Jones, K., 394 Jones, N. A., 52, 67, 73, 157, 158, 161 Jones, P. W., 380 Jones, S. M., 106, 138, 235, 289, 396, 397 Jones, W., 426 Joseph, K. S., 181 Joshi, V., 177 Jotzo, M., 186 Jouriles, E. N., 109, 198 Juchartz-Pendry, K., 566 Juffer, F., 16, 97, 125, 126, 488 Jurist, E. L., 27, 71, 443, 487 Kaaresen, P. I., 190 Kaba, M., 381 Kagan, J., 52, 53, 68, 85, 121, 254 Kagan, S. L., 142 Kahana, M., 86 Kahn, R. S., 142, 176 Kahn, V., 52, 121 Kaiser, A. P., 339 Kalb, C., 517 Kalil, A., 217, 219, 221, 222, 224 Kalin, N. H., 51, 66 Kalland, M., 485 Kallischnigg, G., 387 Kalverboer, A. F., 188 Kan, P. F., 320 Kandel, E. R., 42, 43 Kanes, S. J., 526 Kangas, M., 347 Kanner, L., 304 Kaplan, M., 95, 453, 490 Kaplan, N., 31, 95, 267, 454 Kaplow, J. B., 201, 204 Karen, R., 486 Karim, K., 200 Karoly, L. A., 16, 18, 559, 581, 582, 583 Kasari, C., 309, 336 Kashani, J. H., 413 Kataoka, S., 199 Kates, W. R., 504

600 Katz, E., 346 Katz, J., 185 Katz, L., 470 Kaufman, J., 86, 174, 197, 340, 348, 349, 504 Kaufmann, R. K., 149, 560 Kautz, D., 560 Kavanagh, K., 403 Kaye, N. P., 15, 148, 552, 553, 556, 558, 560 Kazali, C., 471 Kazdin, A. E., 240, 241, 242, 473 Keane, S. P., 13 Keeler, G., 11, 203 Keenan, K., 67, 234, 235, 290, 392, 394, 404 Keenan, N. L., 258 Keener, M. A., 95, 233, 241, 363, 366 Kees, M. R., 399 Keilty, B., 188 Kelleher, K., 198, 556 Keller, M. B., 154 Keller, P. S., 157, 364 Kelly, J. F., 565 Kelly, K., 289, 487 Kelly, S. J., 173 Kelsey, D. K., 523 Kem, D. L., 526 Kemeny, M. E., 64, 66 Kendall, D. F., 525 Kendall, P. C., 156, 402 Kendell, R. E., 29, 30 Kendler, K. S., 159, 162, 174 Kennard, B., 410 Kennedy, C. R., 321 Kennell, J., 24 Kennerly, H., 29 Kenny, E. D., 200 Kerbeshian, J., 505 Keren, M., 9, 293, 436, 468, 474, 475, 481 Kernberg, O. F., 458 Kerr, D. C., 242 Kerr, M., 380, 381 Kersting, A., 186, 187 Kerwin, M. E., 377, 378, 379 Kessler, R. C., 154, 162, 350, 357 Kestenbaum, R., 93 Keynes, R., 42 Khantzian, E., 487 Kieffer, J. E., 202 Kilburn, M. R., 16, 559, 583 Kilmer, T., 372 Kim, G. S., 238 Kim, H. Y., 508 Kim, J. E., 200 Kim, K., 327 Kim-Cohen, J., 143, 144, 394, 395, 396 King, B. H., 332 King, R. B., 221 King, S., 158 Kinnunen, A. K., 123 Kintner, C., 42 Kirk, R., 28 Kiselica, M. S., 221, 222, 223 Kisilevsky, B. S., 257 Kitayama, S., 84 Kitzinger, J. V., 24

Author Index Kitzman, H., 16, 35, 208, 559, 582, 583 Kitzmann, K. M., 200 Klar, H. M., 159 Klaus, M., 24 Klebanov, P. K., 67 Klee, L., 504 Klee, T., 325 Klein, D. N., 162 Klein, H., 28 Klein, L. C., 156 Klein, M. H., 51 Klein, R., 458 Klein Velderman, M., 97 Kleinke, J., 305 Kleinman, J. M., 303, 305, 311 Klein-Schwartz, W., 372, 524 Kleitman, N., 363, 364 Klin, A., 292, 301, 303, 304, 305, 310 Klinger, L. G., 413 Kluger, A. N., 86 Knight, B., 387 Knight, W. G., 174 Knitzer, J., 8, 10, 14, 106, 133, 135, 136, 138, 144, 145, 146, 147, 148, 149, 560, 565 Knoche, L., 566 Knudsen, E. I., 7, 14, 46, 123, 129, 585 Kobak, R., 453 Koball, H., 136, 137 Kochanska, G., 88, 393, 396, 399, 411 Kodituwakku, P. W., 173, 505 Koegel, L. K., 309, 320 Koegel, R. L., 309, 320 Koenig, A. L., 399 Koenig, J. I., 123 Koga, S. F., 122, 424, 510, 511 Kogan, N., 89, 257 Kohen, D. E., 142 Kohlberg, 112 Kohlenberg, T. M., 524 Kohnert, K., 320, 325 Kohut, H., 458 Kok, J. S., 364 Koniak-Griffin, D., 33, 216 Koob, G. F., 488 Koolhaas, J. M., 68 Kopelman, P., 386 Koper, J. W., 159 Kopp, C. B., 88 Koren, G., 155, 185, 505 Korenberg, J. R., 336 Koren-Karie, N., 94, 96, 176, 232, 266, 269, 270, 273, 274, 277 Korfmacher, J., 220 Korja, R., 189 Kornack, D. R., 43 Korte, S. M., 68, 69, 70, 73 Kose, S., 175, 207 Koslowski, B., 469 Kosnett, M. J., 518 Kosofsky, B. E., 172 Koss, M. P., 109 Kotelchuck, M., 553 Koverola, C., 49, 73 Kowalenko, N. M., 155 Kowatch, R. A., 525

Kracke, K., 208 Kraemer, G. W., 122 Kraemer, H. C., 242 Kratochvil, C. J., 523, 524 Krauss, M. W., 339, 340 Kreader, L., 145 Krebs, N. F., 380 Kripke, D. F., 364 Krishnakumar, A., 222, 224, 380 Krist, A., 372 Kroll, B., 503, 505 Kronstadt, D., 504 Kroonenberg, P. M., 255, 257, 260, 269 Krpan, K. M., 215 Krueger, K., 49, 60, 157 Krugman, S. D., 386 Kuang, L., 141 Kubicek, L., 335 Kuczynski, L., 257, 399 Kuersten, R., 471 Kuersten-Hogan, R., 471 Kuhl, P. K., 46 Kuhn, B. R., 366, 370 Kuhn, J. C., 274, 275 Kuint, J., 372 Kumar, R., 158 Kuo, A., 553 Kurstjens, S., 73 Kvaal, J. T., 320 Lacasse, J. R., 520 Lackritz, E. M., 182 Ladd, C. O., 72, 122 Lahey, B. B., 291, 292 Laing, E., 338 Lakatos, K., 68 Lam, P., 367 Lamb, M. E., 65, 158, 252, 469 Lambros, K., 504 Lancaster, S., 28 Landa, R., 301, 302, 305 Landau, S., 305 Landry, R., 303 Landsverk, J., 198 Lane, S., 66 Lang, A. J., 30 Langlois, A., 504 Laor, N., 208, 356 Laplante, D. P., 158 Lara, M. A., 144 Largo, R. H., 364 Larouche, J., 162 Larrieu, J. A., 17, 253, 261, 267, 293, 349, 400, 430, 509, 510, 531, 533, 539 Larson, J., 498 Larson, M. C., 66 Larson, N. C., 219 Larus, D., 346 Lashley, C. O., 215 Latchman, A., 334 Laudon, M., 372 Launer, P. B., 320 Laurenceau, J. P., 208, 507, 517 Laurent, A. C., 326 Lauretti, A., 470, 471 Lavanchy, C., 472, 474, 477 Lavie, P., 364, 366 Lavigne, J. V., 394, 395, 517

Lavori, P. W., 154 Law, J., 322, 324, 325, 326 Lawrence, A. J., 174 Lawrence, C. R., 504 Layton, T. L., 327 Lazarus, R. S., 60, 63 Le, H. N., 144, 164 Leadbeater, B., 216 Leader, L., 156 Leaf, P. J., 163 Leahy, K. L., 200 Leavitt, L. A., 199 Lebbuffe, P. A., 554 Lebeck, M. M., 30 LeBlanc, J., 397 Lebovici, S., 191 Leckman, J. F., 24, 25, 488 LeCours, A.-R., 44 LeCouteur, A., 307 Lederman, C., 148 LeDoux, J., 185 Lee, B. S., 26 Lee, F. C. H., 217 Lee, K., 356 Lee, L. C., 309 Lee, S. S., 380 Leerkes, E., 8, 87, 88, 89, 92, 470, 472 Lefkowitz, J., 14, 138, 147, 148 Legow, N., 490 Lehn, L., 94 Leifer, M., 23, 24, 25, 26, 28, 29 Leiferman, J. A., 162 Leigh Mease, A., 473 Lekka, S., 470 Lemerise, E. A., 82, 88 Lemery, K. S., 159, 290 LeMoal, M., 488 Lemonde, S., 68 Lennon, M. C., 141 Lenon, M., 141 Lenroot, R. K., 45 Leon, I. G., 31, 32 Leonard, J., 325 Leonard, K. E., 162, 177 Leonard, L. B., 322, 324 Leonhardt, T. V., 525 Lequien, P., 185 Lerman, R. I., 221 Lerner, J. V., 85 Leslie, L. K., 504 Lesser, I. M., 414 Lesser, J., 33 Lester, B. M., 171, 174, 184, 186 Lester, E., 24, 25 Levendosky, A. A., 27, 65, 95, 200, 207, 349, 352, 353 Leventhal, B. L., 202, 393, 394, 395, 396, 4 Leventhal, T., 142 Lévesque, M., 43 Levin, A. V., 46 Levine, A., 25 Levine, J., 86 Levine, R. A., 107 Levine, S., 72, 208, 507, 517 Levinson, A., 148 Levy, A. K., 486 Levy, D. W., 96, 487 Levy, S. E., 308, 312

Author Index Levy-Shiff, R., 187 Lewin, D. S., 366 Lewinsohn, P. M., 154, 158 Lewis, D. A., 155 Lewis, E. E., 208, 502, 503, 507, 517 Lewis, J., 470 Lewis, M. L., 9, 60, 62, 64, 83, 84, 87, 88, 105, 110, 175, 231, 252, 254, 255, 256, 257, 261, 348 Lewis, T. L., 46 LewisBarbera, M., 304 Leyendecker, B., 252 Li, D., 107 Lichtenberger, E. O., 334 Lieb, R., 16, 559, 581 Lieberman, A. F., 8, 13, 17, 82, 83, 105, 107, 108, 109, 110, 111, 200, 201, 204, 205, 206, 208, 267, 275, 349, 357, 430, 435, 439, 440, 442, 445, 447, 448, 504, 517, 520, 525, 567, 568, 570 Light, J. C., 327 Lin, M., 411 Linares, L. O., 199 Lindh, V., 184 Lindhiem, O., 503, 507 Linscheid, T. R., 379 Linver, M. R., 138, 139 Lipmann, J., 357 Lipper, E. G., 380 Lippitt, J., 149 Listerud, J., 312 Litman, C., 393, 399 Little, C., 241, 553 Little, T., 397 Little, T. D., 235, 289 Litz, B. T., 26 Liu, D., 72, 122 Liu, H. M., 46 Liu, J. Y., 176 Llewellyn, A. M., 29 Lobato, D., 338 Lob-Izraelski, R., 477 Loch, J., 538 Locker, A., 96, 487 Loeb, S., 142 Loeber, R., 240 Loehlin, J. C., 159 Logan, S., 381, 386 Lohr, K., 553 Lombroso, P. J., 42 Long, S. H., 504 Look, A. T., 336 Loomis, A., 222 Lopes, F., 475 López, I., 262 Lopez, J. F., 72 Lorberbaum, J. P., 175, 207 Lord, C., 11, 252, 282, 292, 301, 302, 303, 304, 305, 306, 307, 309, 310, 312, 324, 398, 400, 404 Louis, J., 363 Lovaas, O. L., 326 Lovallo, W. R., 61 Love, J. M., 137, 565 Lovett, J., 358 Lozano, C., 498 Lozoff, B., 365 Luborsky, L., 444

601 Luby, J. L., 11, 64, 283, 409, 411, 414, 415, 416, 417, 418, 523, 524, 525, 526 Luecken, L. J., 72 Lui, S., 171 Lukowski, A. F., 203 Lumley, J., 181 Lumsden, A., 42 Lundy, B. L., 156, 157, 161 Lunkenheimer, E. S., 242 Lunshof, S., 363 Lupien, S. J., 63, 65 Luster, T., 216 Luthar, S. S., 143, 144, 172, 485 Lutz, M. M., 222 Luyster, R., 302, 305, 307 Ly, T. M., 337, 339, 340 Lykken, D. T., 159 Lynch, F., 516 Lynch, M. E., 162, 199 Lyons, S. L., 225 Lyons, T., 322 Lyons-Ruth, K., 9, 50, 93, 161, 206, 207, 273, 423, 453, 461 Lyubchik, A., 161 Maas, Y. G., 362 Maccoby, E. E., 363, 472 MacDorman, M. F., 181, 182 Macfarlane, A., 181 MacFarlane, J., 398 MacGregor, T., 582, 583 Mackenzie, M. J., 176 Mackenzie, W. L., 124 Mackner, L. M., 377, 380, 381 MacMillan, D. L., 334 Madeleine, D., 459 Madigan, S., 67, 71 Maes, H. H. M., 386 Maestripieri, D., 207 Maffei, L., 123 Magai, C., 89, 93 Magee, K., 553 Magill-Evans, J., 189 Magistretti, P., 185, 191 Magnuson, K., 580, 581, 582 Maguen, S., 26 Mahler, M. S., 83 Mahowald, M. C., 282, 318 Maier, S. E., 172 Main, M., 31, 65, 71, 85, 93, 95, 110, 261, 267, 272, 423, 453, 454, 457, 469 Maislin, G., 386 Maisto, A. A., 334 Maiti, A. K., 158 Malanga, C. J., 172 Malatesta, C. Z., 83, 87 Malcuit, G., 215 Malesa, E., 86 Malhi, P., 524 Malphurs, J. E., 161 Mammen, O., 430 Mandell, D. S., 238, 312 Mangelsdorf, S. C., 50, 68, 94, 219, 469, 470, 471, 472 Manikam, R., 377, 378, 379 Manly, J. T., 17, 128, 200, 440, 448 Mann, E. A., 582 Mann, J., 465

602 Mann, P., 465 Mannarino, A., 357 Mannarino, A. P., 208, 442, 520 Manni, M., 72 Manning, M. A., 505 Marakovitz, S. E., 231, 233, 241, 333 Marans, S., 440 Marchand, J. F., 162 Marchant, P., 382 Marchman, V. A., 320 Marcovitch, S., 431 Marcus, H., 84 Marcus, S. M., 154 Mares, E., 485 Margolin, A., 163 Margolin, G., 200, 470 Markestad, T., 183 Marks, E., 553 Marlow, N., 183 Marret, S., 183 Marsee, M. A., 13 Marshall, N. L., 368 Marshall, P. J., 72, 348 Marshall, T. R., 52 Marsiglio, W., 221 Martin, D. J., 414 Martin, J. A., 33, 214, 221 Martin, M. M., 388 Martin, S. E., 88, 399 Martinez, E., 192 Martínez-Frías, M. L., 172 Martins, C., 155 Marton, P., 188 Martorell, G. A., 67 Martsolf, J. T., 505 Marvel, M. K., 539 Marvin, B., 177, 436, 450 Marvin, R. S., 97, 276, 426, 450, 451, 453, 454, 455, 457, 458, 459, 461, 465 Mash, E., 400 Masi, G., 523 Maslin-Cole, C., 305 Maslow, A. H., 112 Mason, J. W., 63 Masten, A., 200 Masten, A. S., 10, 12, 235 Mastergeorge, A., 320 Masterson, J., 458, 459 Matas, L., 260 Mathews, T. J., 181, 182 Matias, R., 161 Matsumoto, D., 108 Matsumoto, H., 84 Matthews, C. A., 162 Maughan, A., 17, 110, 440 Maurer, D., 46 Mausch, D., 560 May, J., 148 Mayer-Davis, E. J., 387 Mayes, L. C., 35, 175, 356, 436, 485, 486, 488, 490, 497 Mayfield, J., 16, 559, 581 Mayou, R., 347 Mayseless, O., 95 Mazza, C., 222 Mazzoni, D. S., 336 McBride, B. A., 222, 223 McCabe, P. M., 66 McCall, 428 McCarthy, A. M., 199

Author Index McCarthy, K., 397 McCartney, K., 141, 368 McCarton, C. M., 8 McCaul, M. E., 68, 176 McCaw, J., 208 McClarty, B., 49 McClellan, J., 285, 392 McCollum, J., 186 McComas, J., 323 McConachie, H., 307, 308 McConaughy, S. H., 236 McConnell, S. K., 42 McCracken, J. T., 526 McCubbin, H., 338 McCusker, J., 380 McDavis, R. J., 108 McDermott, C., 301 McDermott-Sales, J., 347 McDonald, C., 289 McDonald, K. B., 218 McDonald, R., 109, 198 McDonnell, M. A., 565 McDonough, S. C., 17, 84, 87, 89, 96, 194, 276, 435, 474 McDougle, C. J., 526 McElroy, S. W., 221 McElwain, N. L., 94 McEwen, B. S., 65, 68, 73, 201, 203 McFadden, L., 566 McFarlane, A., 356, 357 McGarvey, S. T., 387 McGaulley, G. A., 32 McGee, G., 309 McGinness, G., 409 McGrath, M. M., 33, 417 McGrath, S., 24 McHale, J., 94, 225, 469, 470, 471, 473, 477 McHale, S., 472 McInerney, W., 566 McKee, M. D., 156, 162 McKinney, M. K., 24, 32 McKinnon, M., 222 McLaughlin, T. J., 520 McLearn, K. T., 553 McLellan, J., 394 McLennan, J. D., 553 McLoyd, V. C., 138 McLurin, C., 312 McMahon, C. A., 155 McMahon, M., 215 McMahon, T., 498 McManis, M., 85 McMillen, I. C., 356, 364 McNeil, C., 358 McSweeny, J. L., 322 McWilliam, R. A., 341 McWilliams, L., 565 Meadows-Oliver, M., 33 Meaney, M. J., 55, 63, 67, 72, 122, 185 Mebert, C. J., 241 Meijer, A. M., 367 Meinlschmidt, G., 126, 127 Meins, E., 87, 94, 96, 255, 273 Meiser-Stedman, R., 13 Mellier, D., 185 Meltzer, L. J., 366, 367 Meltzoff, A. N., 84, 127 Menacker, F., 182 Mendelsohn, A. L., 551

Mendelson, G., 114 Meneken, L., 504 Mercer, M., 552 Merenstein, D., 372 Merrick, S., 121 Merritt, K., 346 Mervis, C. B., 322, 337 Mesibov, G., 308 Meyer, E. C., 33, 105, 109, 186, 255 Mezulis, A. H., 163 Miceli, P. J., 190, 216 Michael, R. T., 136 Michels, K. B., 388 Michelson, D., 523 Middlebrooks, J. S., 7 Mikulincer, M., 27 Miles, M. S., 186, 187 Milgram, 112 Milkowitz, D. J., 526 Millar, D. C., 327 Miller, A., 84 Miller, A. H., 127, 157 Miller, C. L., 216 Miller, D. B., 221, 224 Miller, J. F., 302, 320, 325, 336 Miller, L. J., 126, 294 Miller, M., 1, 16, 22, 559, 581 Miller, S. A., 233 Miller, W. R., 175 Milligan, K., 95 Milne, K., 155 Mincy, R. B., 222 Minde, K., 187, 188 Mindell, J. A., 365, 366, 367, 370, 372 Minderaa, R. B., 188 Minkovitz, C. S., 553, 557 Minnes, P., 338 Minshew, N., 303 Minuchin, P., 9, 468 Minuchin, S., 469, 470, 473 Mirmiran, M., 362, 363 Miron, D., 175, 231, 252 Misri, S., 518 Mistry, R. S., 141 Moessinger, A., 189 Moffitt, T. E., 143, 290 Mogilner, M. B., 187 Mohr, J., 457 Mol Lous, A., 415 Moldin, S. O., 159 Molfese, V. J., 334 Molinari, L., 364 Monk, C., 30 Monroe, S. M., 156, 159, 162 Monteiro, P. O. A., 387 Monteleone, J. A., 500 Moore, D. R., 222, 223 Moore, G. A., 86, 88, 160, 236 Moore, K. A., 221 Moore, M. R., 33 Morales, A., 555 Moran, G. S., 96, 206 Moran, T. E., 142 Morikawa, H., 113 Morison, S. J., 122, 428 Morland, L., 30, 31 Morley, R., 183 Morrell, J., 366, 378 Morris, C. A., 337 Morris, K., 382

Morrison, J. A., 504 Morrissey, J. P., 312 Morton, G., 238 Moses, E. L., 30 Moses-Kolko, E. L., 25, 29, 30, 34 Mosher, N. D., 33 Mosley, M., 356 Moss, C. J., 111 Moss, E., 465 Moss, H. A., 121 Mota-Castillo, M., 523 Moulton, D., 294 Mount, J. H., 155 Moye, E. P., 236 Mrakotsky, C., 411, 415, 523, 524, 526 Mrazek, P. B., 14, 15, 18 Mucci, M., 523 Muehlbach, M. J., 368 Mueller, N. K., 63 Mulder, E. J. H., 156 Mullen, E., 307 Müllen, R., 321 Muller Nix, C., 134, 180, 186, 188, 189 Mulrow, C., 553 Munck, A., 63 Mundy, P., 303, 319, 325, 336 Munford, T. L., 223 Munholland, K. A., 206 Munoz, R. F., 164 Munson, J. A., 304, 305 Murdock, K. K., 234 Murloz-Sanjuan, I., 41 Murphy, J. M., 552 Murphy, S., 485 Murray, C., 175 Murray, D., 155 Murray, K., 393 Murray, L., 29, 158, 161, 162, 378, 411, 412 Musick, J. S., 222 Mustillo, S., 11 Muzik, M., 2, 80, 84, 87, 94 Myers, E., 159 Myers, J., 174 Myers, L., 13, 109, 200, 349 Mzarek, D. A., 378 Naber, F., 306 Nachmias, M., 50, 68, 71 Naegele, J. R., 42 Nagaraj, R., 523, 524, 526 Nagin, D. S., 202, 392, 398 Nagin, R., 397 Nagle, G. A., 6, 14, 129, 510, 531, 560, 580, 584, 586 Nagliere, J., 554 Nagy, Z., 183 Najman, J. M., 240 Narang, D., 219 Narrow, W. E., 285 Nash, D. J., 336 Natera, L. X., 200 Nauta, W. J. H., 51 Navelet, Y., 364 Nawrocki, T., 156, 157 Neal, R. A., 319 Neal-Barnett, A., 262 Neale, M., 202 Neale, M. C., 162, 386

Author Index Needleman, R., 400 Needlman, R. D., 517–518 Nelson, C. A., 2, 7, 40, 46, 47, 48, 49, 55, 59, 66, 122, 125, 126, 204, 345, 350, 425, 501, 503, 509, 510, 518 Nelson, E. E., 25 Nelson, H. D., 324 Nelson Goff, B. S., 30 Nemeroff, C. B., 29, 72, 127, 157, 185, 197, 414 Nett, K., 320 Neuman, R. J., 414 Neunaber, D. J., 29 Nevitt, S. G., 320 Newachek, P., 556 Newman, D. L., 290 Newman, M. C., 296 Newport, D. J., 65, 127 Newschaffer, C., 309 Newton, L., 311 Niccols, A., 173, 334 Nichols, K., 411 Nichols, R. C., 159 Nicholson, E., 380, 469 Nicholson, M. J., 225 Nickerson, K., 115 Nicole, A., 186 Nicolson, N. A., 67 Nilsson, K. W., 202 Nisbett, R. E., 117 Niskala Apps, J. A., 525 Nitschke, J. B., 488 Nolan, E., 289 Noland, D., 218 Nordstrom, B., 176 Norenzayan, A., 117 Normand, C., 395, 396 Norquist, G. S., 517 Norris, F., 356 North, C., 356 Notarantonio, E. M., 584 Notman, M. T., 24, 25 Novak, M., 238 Novak, M. F. S. X., 25 Nover, R. A., 564, 566 Novins, D., 520 Nowak, R., 364 Nugent, J., 184 Nulman, I., 505 Nye, C., 322, 324, 325 Nygren, P., 324, 553 Nylen, K. J., 142 Oakland, T., 238 Oberlander, S. E., 218, 219 Oberlander, T. F., 184, 518 O’Brian, M., 161 O’Brien, L. M., 380 O’Brien, M. A., 557 O’Campo, P. J., 115, 142 O’Connor, M. J., 173 O’Connor, T. G., 2, 8, 120, 122, 124, 125, 126, 127, 128, 162, 163, 181, 368, 424, 425, 426, 427, 428, 429, 430, 431 O’Day, D. H., 122 Ogbu, J. U., 114 Ohan, J. L., 233 O’Hara, M. W., 29, 30, 142, 154, 155, 163

603 O’Hayon, B., 505 Ohmi, H., 349, 350 Oitzl, M. S., 63 Oke, S., 155 Olds, D. L., 16, 18, 35, 128, 147, 208, 559, 582, 583 O’Leary, S., 175 Oligny, P., 399 Olive, M. F., 174 Oliver, B., 323 Oller, D. K., 319 Olney, J. W., 172 Olrick, J. T., 426 Olsen, E. M., 380 Olson, A. L., 553 Olson, L. M., 555, 556 Olson, S. L., 242 Olsson, C. A., 183 Olswang, L. B., 325 Ondersma, S. J., 176 Oner, O., 523, 525 Oner, P., 523, 525 Onoye, J., 30 Oosterman, M., 424, 425 Opitz, J. M., 335 Oppenheim, D., 96, 176, 232, 266, 269, 270, 273, 274, 275, 276, 277, 411 Oppenheim, J., 582, 583 O’Riordan, M. A., 337 Ornstein, P., 346, 347 Orsmond, G. I., 537 Orvaschel, H., 413 Orzol, S. M., 142, 176 Osaki, D., 308 Osborne, L. N., 225 Osiovich, H., 184 Osofsky, H. J., 215 Osofsky, J. D., 148, 198, 208, 215, 216 Oster, H., 84 Osterling, J., 50, 302, 304, 305 Ostrander, M. M., 63 Ostrosky, M. M., 323 O’Sullivan, C., 162 Oswald, L. M., 68 Ousley, O. Y., 307 Owen, C. G., 366, 388, 398 Owens, D., 262 Owens, J., 283, 362, 372 Owens, M. J., 72, 414 Owens, P., 504 Owens-Stively, J., 368 Oyelese, Y., 181 Ozer, E. J., 200 Ozonoff, S., 302, 305, 308 Padden, T., 186 Paden, E. P., 320 Padrón, E., 111, 442 Paikoff, R., 216 Pajulo, M., 485 Paley, B., 474 Palfrey, M. S., 549, 551, 553 Palmer, P., 303 Panagiotides, H., 50, 52, 53, 72, 413, 415 Pancer, S. M., 187 Panksepp, J., 25 Panoscha, R., 324 Paparella, T., 309

604 Papas, M. A., 215 Papiernik, E., 182 Paquette, D., 92 Parent, A., 43 Parfitt, D. B., 2, 120, 122 Parikh, S. S., 222 Parke, R., 468 Parker, D., 304 Parker, G., 156 Parker, J., 347 Parker, K. C. H., 27, 95, 241, 267, 380, 469 Parker, S., 142, 156, 550 Parker, S. W., 66 Parkinson, K. N., 377, 384, 385 Parlakiah, R., 538 Parler-McCrae, C., 498 Parmar, P., 114 Parmelee, A. H., 363 Parnell, S. E., 172 Parra-Cardona, J. R., 223, 224 Parritz, R. H., 50, 68 Pascalis, O., 46 Paschal, A. M., 221, 223, 224, 225 Patel, B. P., 550, 553 Patel, N. C., 517 Patel, V., 368, 377, 380 Pathak, S., 525 Patterson, G. R., 233, 398, 442 Patterson, J., 338 Patterson, M., 31 Patterson, P., 403 Patton, G. C., 183 Paul, R., 304, 307, 323, 324 Paulson, A., 259 Paulson, J. F., 162 Pautsch, J., 417 Pavuluri, M. N., 525 Pawl, J. H., 17, 117, 205, 430, 440, 448, 538, 567, 568, 570, 576 Payne, C., 469 Pear, R., 517 Pearce, K., 325 Pearce, V., 311 Pearlman, D. N., 198 Pears, K. C., 204, 206, 503, 504, 505, 508 Peck, C. H., 556 Peebles, C. D., 215, 349, 353 Peifer, K., 296 Peirano, P., 363 Pelaez-Nogueras, M., 412 Pell, T., 174 Pelletier, H., 558 Peloso, E., 71, 208, 507, 517 Pelton, L. H., 485 Peng, K., 117 Pennington, P., 303 Pennucci, A., 16, 559, 581 Pepe, M. S., 377 Percansky, C., 216 Perez, L. M., 296 Perez-Edgar, K., 295 Perkins, E., 507 Perman, J. A., 377, 378, 379 Perrin, E. C., 245, 553 Perrotta, M., 188 Perry, B. D., 185, 349, 356 Perry, D. F., 106, 133, 135, 144, 147, 148, 149, 564, 566 Perry, S., 67, 412

Author Index Persinger, M., 378 Persson, K., 188 Peskay, V. E., 539 Peters, J., 502 Peterson, A., 28 Peterson, C. A., 346, 347, 566 Peterson, J., 393 Petit, G., 399 Petryshen, P., 184 Petterson, S. M., 142 Pettit, G. S., 86, 142 Pfefferbaum, B. J., 200 Phares, V., 469 Phelps, J. L., 95 Phelps, M. E., 53 Philips, L. H., 29 Phillips, D. A., 104, 110, 323, 409, 518, 566 Philofsky, A., 305, 335, 336 Piacentini, J. C., 110, 442 Pianta, R. C., 161, 453 Pickens, J., 156, 157, 412 Pickett, K., 396 Pickles, A., 287, 303, 307, 322, 324, 382, 393, 396 Pierce, E., 400 Pierce, P. L., 318 Pierrat, V., 185 Pierrehumbert, B., 186, 189 Pignone, M., 553 Pihet, S., 185 Pihl, R., 291 Pinderhughes, E., 238 Pine, D., 396, 404 Pine, D. S., 12, 200, 285 Pine, F., 83 Pines, D., 24, 25, 26 Pinsof, W., 473 Pinto-Martin, J., 312 Pitcairn, T. K., 336 Piven, J., 303 Pizzorusso, T., 123 Plagemann, A., 387 Platt, R., 380 Platz, C., 29 Pleck, J., 92 Plessinger, M. A., 172 Plewis, I., 364 Pliszka, S. R., 523, 524 Plomin, R., 85, 159, 290, 303, 322, 323, 368 Plotsky, P. M., 55, 72, 122, 156, 197, 414 Plummer, N., 378 Poehlmann, J., 155, 551 Poets, C., 186 Poland, R. E., 414 Pollak, S. D., 206 Pollard, R. A., 185, 349 Pomerleau, A., 215 Poole, J. H., 111 Porché-Burke, L., 106, 109 Porges, S. W., 60, 61, 158, 159 Porter, F. L., 157 Porter, N., 23 Poschman, K., 30 Posey, D. J., 526 Posner, M. I., 88 Potegal, M., 393, 398 Potenza, M. N., 526 Potter, H. W., 332

Potter, L., 311 Poulton, L., 95 Pouncy, H. W., 222 Pouquette, C., 470 Powell, B., 177, 255, 275, 276, 423, 427, 436, 450, 451, 453, 454, 455, 458, 459, 461, 494 Powell, J., 516 Powell, R. P., 322 Powers, B. P., 94 Powls, A., 183 Pozdol, S., 306 Prather, E., 307 Pratt, M., 187 Prazar, G., 553 Preisser, D. A., 320 Prescott, C. A., 159, 162, 174 Price, T. S., 322, 323 Prigot, J. A., 157 Prince, J. B., 372, 523 Prizant, B. M., 307, 311, 319, 321, 325, 326, 504 Proctor, B., 106 Prodrmidis, M., 156 Propper, C., 85 Pruessner, J. C., 72 Pryce, C. R., 72, 126 Pungello, E. P., 128 Puntney, J. I., 526 Putnam, F. W., 13, 109, 200, 201, 204, 349 Pynoos, R. S., 110, 200, 201, 203, 204, 440, 442 Qin, C., 182 Quas, J. A., 59 Quevedo, K., 125, 127 Quigley, C. J., 584 Quigley, M. A., 388 Quinton, R. L., 29 Rachal, J. V., 171 Radin, N., 221 Radke-Yarrow, M., 257 Rafferty, Y., 566 Ragozin, A. S., 163 Rains, P., 222 Rakic, P., 43, 44 Ramey, C. T., 128, 137 Ramey, S. L., 137 Ramisetty-Mikler, S., 109, 198 Ramsay, D. S., 60, 62, 64, 87, 88 Ramsay, M., 380 Randazzo, A. C., 368 Randolph, S. M., 115, 142 Rane, T. R., 222, 223 Ranganath, C., 158 Ranote, S., 488 Rao, N., 471 Rapaport, D., 442 Rapee, R., 289 Rappley, M. D., 518 Rasmussen, J., 471 Rasmussen, S. A., 182 Rasmussen, T., 309 Rattaz, C., 185 Raval, V., 96 Raver, C. C., 138, 141, 216, 565, 566 Raviv, A., 368 Ray, A., 221 Ray, J. S., 413

Raynor, P., 380, 382 Rea, K. J., 369, 372 Reams, R., 293 Reaven, J., 308 Rebert, C. S., 205 Redshaw, M., 183 Rees, J., 423, 424, 426 Reeves, A., 43 Regalado, M., 553, 556 Regan, C., 267 Reichle, J., 282, 318, 323 Reid, J. B., 520 Reid, M. J., 394, 520 Reid, W., 470 Reifsnider, E., 386 Reilly, J. J., 323, 368 Reiss, A. L., 202 Ren, J. Q., 172 Repaccholi, B. M., 84 Rescorla, L. A., 247, 289, 290, 323 Reul, J. M., 63 Reus, V. I., 162 Reusing, S. P., 25 Reuter, M. A., 28 Reynell, J., 307 Reynolds, A. J., 128, 582 Reznick, J. S., 53, 68, 85, 324 Rhodes, H. J., 199 Rhodes, J. E., 219, 221, 224, 225 Ribeiro, R., 586 Ricci, L. A., 339, 340 Rice, J. P., 414 Rice, M., 321 Rice, M. L., 321, 322, 324 Rice, T., 6, 560 Richards, J. A., 526 Richardson, R., 219, 225 Rich-Edwards, J. W., 154 Richler, J., 304, 305 Richman, N., 245, 365 Richters, J. E., 240, 399 Ridge, B., 394, 399 Rie, H. E., 289, 409 Rieger, M., 67 Rifkin-Graboi, A., 2, 7, 59, 143, 201 Rigatuso, J., 49, 60, 71, 157 Riggs, P. D., 523, 524 Riksen-Walraven, J. M., 68, 415 Ringwalt, C. L., 172 Risdal, D., 339 Risi, S., 303, 307, 310, 324 Risk, N., 160 Risley, T., 137, 327 Risley, T. R., 322 Risser, D., 409 Rivara, F. P., 221 Robbins, I., 202 Roberts, D., 83, 84 Roberts, J. E., 504 Robertson, C. M., 182 Robertson, D. L., 128, 582 Robertson, S., 24 Robin, N. H., 337 Robins, D. L., 246, 305, 311 Robins, E., 287, 292, 414 Robinson, J. R., 294, 380 Robinson, M., 6 Robinson, N. M., 163 Robles de Medina, P. G., 156 Rocco, P. L., 24 Rodgers, C. S., 30

Author Index Rodning, C., 188, 189, 485 Rodrigues, M., 377 Rodríguez-Pinilla, E., 172 Roe, C., 524 Roeleveld, N., 334 Roffwarg, H. P., 363, 364 Rogal, S., 30, 31 Rogers, S. J., 303, 305, 308, 309, 336 Rogosch, F. A., 17, 127, 128, 155, 164, 200, 206, 349, 416, 427, 440, 448 Roid, G., 307 Roizen, N. J., 335 Rollnick, S., 175 Rolnick, A., 581, 582 Rombough, V., 301 Romero, M., 63 Romundstad, P., 183 Ronald, A., 303 Ronis, D. L., 199 Ron-Miara, A., 475, 481 Ronning, J. A., 190 Rose, S. A., 158 Rosen, C., 372 Rosenbaum, M., 485 Rosenberg, A. A., 158 Rosenberg, S., 148 Rosenblatt, M. J., 27, 32 Rosenblum, K. L., 2, 80, 84, 87, 89, 94, 95, 96, 97, 141 Rosenfeld, J. P., 158 Rosenthal, J., 15, 552, 553, 556, 558, 560 Rosenzweig, M. R., 59 Rosman, E., 147 Rosmond, R., 69 Rosner, B. A., 337 Rossiter, L., 339 Roter, D. L., 556 Roth, C., 404 Rothbart, M. K., 85, 88, 290, 291 Rounsaville, B., 486, 498 Rovee-Collier, C., 204 Rovira, K., 472 Roy, K., 221, 223, 224, 225 Roye, C. F., 220 Rubin, D. M., 502 Rubin, E., 326 Rubin, H. R., 372 Rubin, K. H., 8, 85 Rubin, R. T., 414 Rudolf, M. C. J., 380, 381, 382, 386, 502 Ruffman, T., 87 Rushton, J., 553, 556 Russ, E., 358 Russell, D. W., 221 Russell, K. Y., 262 Russell, S. T., 217 Rutgers, A., 305 Rutter, M., 8, 10, 12, 124, 125, 141, 159, 162, 202, 290, 292, 307, 393, 395, 425, 426, 428, 429, 430 Ryan, R. M., 138, 141, 142, 229 Ryan-Krause, P., 33 Rydell, P. J., 326 Ryff, C. D., 339 Saarni, C., 82, 84, 97, 409 Sabatelli, R. M., 33 Sabatini, M. J., 125

605 Sable, M. R., 23 Sadato, N., 46 Sadeh, A., 364, 366, 368 Sadler, L. S., 1, 16, 22, 31, 33, 34, 35, 208, 217, 218, 221, 337 Sagi, A., 94, 110, 273 Sagi-Schwartz, A., 94 Sagovsky, R., 154, 553 Saigal, S., 183 Saint, K., 156 Sakamoto, H., 204 Saller, N., 27, 32 Salovey, P., 67 Salt, A., 183 Saltzman, K. M., 201 Salzarulo, P., 363, 366 Sameroff, A. J., 8, 10, 81, 84, 94, 96, 106, 108, 159, 176, 235, 266, 402, 447, 552, 553, 564 Samms-Vaughn, M., 310, 312 Sanchez, M. M., 67, 72, 122 Sander, L. W., 91 Sandman, C. A., 122 Santiago, N. J., 162 Sapolsky, R. M., 63, 64, 73, 202, 205 Sarkar, P., 8 Saron, C. D., 52, 159 Sasher, T. M., 526 Sattler, J. M., 240 Saunders, R. A., 367 Savas, H. A., 525 Savin, D., 520 Sawyer, D., 83, 84 Saxe, G. N., 201, 204 Sayal, K., 8 Sayer, L., 92 Scafidi, F., 156 Scalzo, F. M., 184 Scarr, S., 15 Schaal, B., 185 Schaefer-Graf, U. M., 386–387, 387 Schaer, M., 335 Schaffer, C. E., 158 Schaffer, H. R., 124 Schechter, D. S., 51, 96, 134, 197, 199, 206, 207, 208, 351, 357, 497 Scheer, P., 378, 379 Scheeringa, M. S., 8, 13, 65, 109, 200, 201, 203, 205, 206, 208, 282, 293, 345, 348, 349, 350, 351, 353, 354, 355, 356, 357, 430, 517, 520, 536, 553 Scheffer, R. E., 525 Scheibel, A. B., 61 Schein, A., 378 Scher, A., 366, 368 Scher, M., 186 Scherer, K., 84 Schermann-Eizirik, L., 188 Schieche, M., 68, 71 Schilling, R., 485 Schirmer, B., 368 Schlechte, J. A., 155 Schlosser, R. W., 327 Schmidt, L. A., 85 Schmitt, N., 490, 496, 497 Schneiderman, N., 66 Schnell, C. R., 126 Schoeller, D., 386 Schoelmerich, A., 113 Schoen, C., 550, 555

606 Schollin, J., 186 Scholmerich, A., 252 Scholtens, S., 387 Schoolcraft, S. A., 340 Schopler, E., 306, 308 Schoppe, S., 471 Schoppe-Sullivan, S. J., 223, 470, 471, 472 Schore, A. N., 111, 349, 356, 457 Schorr, C., 357 Schreiber, M. D., 200 Schreibman, L., 309 Schuder, M., 122 Schuengel, C., 65, 424, 425, 457 Schuerman, J. R., 225 Schuetze, P., 485 Schultz, J., 550 Schultz, R. T., 292 Schulz, H. R., 363 Schulze, P. A., 113 Schuster, M., 556 Schwab-Stone, M., 240 Schwartz, J. H., 42, 43 Schwartz, C. E., 85 Schwartz, D., 199 Schwartz, E., 112 Schwartz, T. A., 186 Schweinhart, L. J., 580, 581 Schweitzer, P. K., 368 Schwerdtfeger, K., 30 Scott, J., 498 Scott, M., 55 Scott, R., 55 Scott-Heller, S., 267 Scuccimarri, C., 215 Searcy, Y. M., 337 Sebanc, A., 66 Sebanc, A. M., 69 Seccombe, K., 33 Seckl, J., 185 Sedin, G., 188 Seeley, J. R., 154 Segal, L. B., 257 Seibert, J., 325 Seibert, L., 323 Seidel, K. D., 377 Seifer, R., 10, 86, 175, 176, 236, 553 Seitz, V., 218, 220 Seltzer, M. M., 322, 339, 340 Selvam, N., 181 Selye, H., 63 Semel, M. A., 349, 352 Seng, J. S., 24, 199 Senulis, J. A., 52 Senulis, R., 159 Sepulveda, S., 278, 505 Sepulveda-Kozakowski, S., 502 Settles, L. D., 501 Sexton, T., 472, 473 Shadish, W., 473 Shah, B., 332 Shahar, G., 566 Shahinfar, A., 199 Shahmoon Shanok, R., 538 Sham, P., 305 Shankaran, S., 172, 173, 176 Shankman, S. A., 162 Shannon, B., 29 Shannon, C., 207 Shannon, J. D., 163 Shapiro, D. L., 349, 352

Author Index Shapiro, R. W., 154 Shapiro, V., 5, 111, 205, 266, 435, 442, 462, 517 Sharf, R., 475 Sharir, H., 187 Sharma, S., 72 Sharon, C., 158 Sharp, E. A., 223 Sharpe, D., 339 Sharpe, L., 358 Shaw, D. S., 235, 290, 392, 394, 396, 397, 398, 399 Shaw, J., 357 Shaw, J. S., 549 Shea, S., 526 Shea, V., 308 Shelley, M. C., 511 Shepard, B., 87 Sheperd, R., 459 Sher, E., 273 Sherer, M., 309 Sheridan, M. A., 2, 7, 40, 55, 518 Shin, L., 349 Shipstead-Cox, N., 320 Shonkoff, J. P., 14, 104, 110, 129, 149, 323, 409, 518, 566, 585 Shors, T. J., 43 Shrestha, S., 84, 110 Shriberg, L. D., 322 Shulman, C., 305 Shulman, S., 504 Shute, N., 517 Siddiqui, A., 26, 27 Siegel, D., 204, 303, 351 Siegel, D. J., 457 Siegelman, P., 583 Siegfried, Z., 86 Siever, L. J., 159 Sigman, M., 303, 305, 309, 336, 426 Silberg, J., 141, 159, 202 Siller, M., 309 Silva, P., 290 Silva, P. A., 290, 291 Silverman, J. M., 159 Silverman, R. C., 17, 267, 440, 567 Simcock, G., 203 Simkin, P., 24 Simkin, Z., 322 Simms, M. D., 504 Simons, A. D., 159, 162 Simpson, J. A., 92 Sinclair, D., 411 Singer, G. H. S., 339, 340 Singer, L. T., 182, 186, 188, 189, 386 Singhi, P., 524 Siperstein, R., 305 Skuban, E. M., 235 Skuse, D., 381, 382, 383 Slade, A., 1, 22, 27, 31, 35, 95, 96, 267, 272, 441, 453, 486, 487, 490, 498 Slegers, D. W., 321 Sloan, D., 308 Slone, L., 356 Sluyter, F., 159 Smedje, H., 368 Smith, C. J., 502 Smith, C. L., 88 Smith, D. K., 505, 508 Smith, E., 148, 356 Smith, M. F., 183

Smith, M. V., 30, 31 Smith, P., 13, 472 Smith, R. S., 12 Smith, S. A., 560 Smith, T., 308, 326 SmithBattle, L., 218, 219 Smits, M. G., 372 Smoller, J. W., 68 Smyke, A. T., 122, 283, 421, 424, 425, 427, 428, 429, 431, 436, 500, 501, 503, 509, 510, 511 Snidman, N., 52, 53, 68, 85, 121 Snow, M. E., 363 Snowdon, C. T., 29 Snowling, M. J., 322 Snyder, J., 233, 241 So, S. A., 336 Sokol, R. J., 173, 176, 200 Solnit, A., 338 Soloman, A., 154 Solomon, J., 26, 93, 95, 261, 272, 423, 453, 457, 487 Solter, A., 350, 358 Solym, A., 567 Sommerfelt, K., 183 Sonnega, A., 350 Sonuga-Barke, E., 8 Soumi, S. J., 48, 51 South, M., 302 Southam-Gerow, M. A., 156 Sowan, N. A., 386, 387 Sowell, E. R., 60 Spagnola, M., 17, 440 Spangler, G., 49, 65, 68, 71 Sparrow, S. S., 91, 238, 241, 243, 307, 333, 334, 416 Speltz, M., 285, 392, 394, 395 Spence, S. H., 289 Spencer, K., 336 Spencer, M. S., 219 Spencer, T., 392 Spencer, T. J., 372, 523 Spencer-Booth, Y., 125 Spengler, M., 126 Spicer, P., 107, 111 Spicker, B., 346 Spieker, S. J., 53, 215, 219, 413 Spinrad, T. L., 85 Spitz, R. A., 125, 409, 411, 423 Spitzer, R. L., 292 Spitznagel, E., 415, 418 Sprafkin, J., 289 Squires, J., 235, 237, 246, 311, 554 Sroufe, L. A., 8, 9, 10, 60, 88, 91, 92, 93, 97, 156, 160, 254, 260, 395, 423, 442, 453, 486 St. James-Roberts, I., 364 St. John, M., 117 Stachowiak, J., 505 Stadtler, A. C., 557 Stafford, B., 6, 14, 293, 348, 560 Stahmer, A., 309 Stalets, M., 417 Staller, J., 523 Stallings, V. A., 386 Stancin, T., 245, 553 Stansbury, K., 47, 66, 67, 160 Stanton, W., 290 Stark, M., 338 Starr, R. H., 377, 380 Starr, R. H., Jr., 218

State, M. W., 332 Stebbins, H., 136, 144, 145, 146 Steele, H., 8, 96, 206, 366, 451, 461, 493 Steele, M., 8, 96, 206, 451, 461, 493 Steer, R., 357 Steer, R. A., 154 Stein, A. H., 199 Stein, B. D., 199 Stein, M. B., 49, 73 Steinberg, A. M., 110, 200, 442 Steinberg, G. K., 73 Steiner, M., 215, 488 Steingard, R. J., 523 Steinmetz, S. K., 198 Stember, M. L., 386, 387 Stephens, D., 366 Sterba, S., 292 Stern, D., 430, 469, 474 Stern, D. N., 17, 87, 88, 89, 445, 564 Stevens, B., 184 Stevenson, J., 398, 400 Stevenson-Hinde, J., 72 Steward, D., 142, 380 Stewart, A., 393 Stewart, L., 95, 241 Stewart-Brown, S., 216 Stickgold, R., 368 Stickle, T., 401 Stieben, J., 402 Stifter, C. A., 85, 88 Stith Butler, A., 181, 182, 183 Stjernqvist, K., 183 Stock, C. D., 504 Stockman, I. J., 325 Stockton, L., 366 Stoddard, F., 349, 353, 355 Stoddard, J. L., 164 Stoel-Gammon, C., 320 Stoleru, S., 191 Stoller, S., 160 Stone, W., 306, 307 Stone, W. L., 303, 310, 327 Stoney, L., 584 Stoolmiller, M., 508, 509 Storey, A. E., 29 Stouthamer-Loeber, M., 240 Stovall-McClough, K. C., 95, 430, 502, 505, 506, 508, 512 Stowe, Z. N., 29, 156 Strassberg, Z., 216, 399 Strathearn, L., 175, 207 Straus, M. A., 198 Street, K., 176 Streissguth, A. P., 173 Strobino, D. M., 553 Stroud, L. R., 67 Stryker, M. P., 368 Stueve, J. L., 92 Stunkard, A. J., 386, 387 Suchman, N. E., 172, 255, 436, 485, 486, 488, 490, 496, 497 Sue, D. W., 106, 108, 109, 234, 238 Sue, S., 109 Suess, G. J., 93 Sullivan, J., 415 Sundberg, M., 309 Suomi, S., 122, 125 Suomi, S. J., 65, 68, 70 Super, C. M., 114

Author Index Susser, E. S., 122 Sussman, A., 146 Sussman, F., 309 Suyemoto, K. L., 238 Svenningsen, N. W., 183 Swain, A. M., 154, 163 Swain, J. E., 175, 207 Swanson, D., 83, 84 Swanson, K., 175 Swartz, M. K., 33 Sweeney, P. J., 221 Swinkels, S., 311 Swords, P., 502 Symons, F., 304 Szewczyk Sokolowski, M., 472 Szigethy, E., 524 Szumowski, E., 400 Taaffe Young, K., 555 Tabit, E., 172 Taddio, A., 155, 184, 185 Tager-Flusberg, H., 306, 307, 323 Tagore, R., 117 Talbot, J., 470 Tallal, P., 44 Tamam, L., 525 Tamang, B. L., 84, 110 Tamang, R., 110 Tamis-LeMonda, C. S., 163 Tanapat, P., 43 Tarabulsy, G. M., 465 Target, M., 27, 71, 96, 206, 241, 255, 443, 451, 487, 493 Tarjan, G., 332 Tatano Beck, C., 469 Tatelbaum, R., 559 Taumoepeau, M., 87 Taunt, H. M., 339 Taylor, A., 143, 185 Taylor, B. A., 141 Taylor, C. L., 141, 321, 322 Team, T. A. S., 162 Teicher, M. H., 203, 204 Teichman, J., 219 Teixeira, J. M., 160 Tellegen, A., 10, 159 Temple, J. A., 582 Tennant, C. C., 155 Ternestedt, B. M., 186 Terplan, M., 171 Terr, L., 345, 346, 351 Terrell, D., 584, 586 Tesman, J. R., 87 Tessema, F., 381 Teti, D. M., 86, 159, 163 Teti, L. O., 88 Teti, L. T., 220 Thabet, A. A. M., 200 Thal, D. J., 320, 323 Thanh Tu, M., 49 Theran, S. A., 27, 95, 207, 352 Thiedke, C. C., 365 Thiroglu, A. Y., 525 Thomas, A., 85, 290, 292 Thomas, A. M., 162 Thomas, B., 393 Thomas, C. R., 520 Thomas, J. M., 293 Thomas, K. C., 312 Thomas, K. M., 47 Thomas, T. L., 61

607 Thomes, N., 138 Thompson, 49 Thompson, M. S., 225 Thompson, P. M., 60 Thompson, R., 82, 88 Thomson, A. D., 173 Thomson, N. R., 11 Thorman, A., 584 Thornburg, K. R., 219 Thornton-Wells, T. A., 282, 332 Thullen, M. J., 134, 214 Thurm, A., 309, 310 Tidmarsh, L., 526 Timmer, S., 358 Tinker, R., 358 Tirella, L., 126 Tizard, B., 11, 423, 424, 426 Tluczek, A., 236 Tobin, A., 307 Todd, R. D., 414 Toga, A., 60 Tolan, P., 394, 402, 404 Tomarken, A. J., 53 Tomas, A., 85 Tomasello, M., 319 Tomblin, J. B., 322 Tomlinson-Clarke, S., 238 Tomoda, A., 204 Tonge, B. J., 337 Tononi, G., 488 Torchia, M. G., 49, 73 Torrey, W., 356 Torrey-Schell, S. A., 206 Toth, S. L., 17, 110, 128, 155, 159, 164, 200, 204, 206, 416, 427, 440, 448 Tout, K., 66, 68, 69 Towsley, S., 52, 121 Trad, P. V., 25, 26, 29 Treboux, D., 121, 216 Trehub, S. E., 95 Tremblay, H., 472 Tremblay, R. E., 202, 291, 392, 393, 397, 398, 399 Trent, R. B., 500 Trevathan, W. R., 49 Tristam, S., 309 Trivette, C. M., 341 Tronick, E. Z., 67, 84, 87, 89, 156, 160, 161, 174, 175, 184, 236, 254, 256, 257, 258, 411, 412 Troutman, B. R., 163 Truman, S. D., 175, 485, 486, 487 Tsao, F. M., 46 Tsega, A., 564 Tsigos, C., 61 Tsuang, M. T., 159 Tu, M. T., 183, 189 Tuber, S. B., 24, 27 Tucker, A. M., 364 Tuckey, M., 255, 273 Tufnell, G., 358 Tumuluru, R. V., 525 Turk, J., 202 Turley, R. N., 214 Turner, L. M., 303, 306, 310 Turner, P., 411 Turner, R. J., 487 Turton, P., 31, 32 Tuzun, U., 525 Twombly, E., 237

608 Twombly, M. S., 554 Twomey, J. E., 171 Tyano, S., 293, 475, 481 Uauy, R., 364 Udwin, O., 337 Uhart, M., 68 Ulvund, S. E., 190 Unger, D. G., 222 Ungerer, J., 305 Uno, H., 159, 205 Uphold, C. R., 386 Urbano, R. C., 336, 340 Urquhart, L. R., 511, 512 Urquiza, A., 358 Vail, N., 44 Vaillancourt, T., 202, 397 Vaillant, G., 356 Valenstein, A. F., 24 Valerius, K., 550 Valliere, J., 253, 267, 400 van Bakel, H. J. A., 68 Van den Berg, M., 159 van den Boom, D. C., 16, 472 van den Bree, M. B., 174 van den Oord, E. J. C. G., 290, 394 van den Wittenboer, G. L., 367 van der Kolk, B., 442 van Driel, S., 369 van Dulmen, M. M. H., 69, 125 Van Egeren, L., 470, 471 van Geert, P., 157 Van Hoers, H., 72 Van Horn, P. J., 13, 17, 105, 111, 200, 208, 275, 357, 435, 439, 440, 442, 445, 447, 448, 504, 517 van IJzendoorn, M. H., 16, 65, 67, 68, 71, 86, 94, 96, 97, 110, 125, 126, 255, 257, 260, 269, 273, 274, 306, 457, 488 Van Lier, P., 403 van Os, J., 122 van Rossum, E. F. C., 159 Van Tassel, E. B., 366 Varela, F., 555 Vasquez, M. J. T., 106, 109 Vaughn, L., 550 Vazquez, D. M., 66, 67, 69, 72, 158, 349 Venter, A., 306 Ventola, P., 303, 305, 312 Ventura, S. J., 33 Vera, Y., 412 Verdejo-García, A., 174 Verhoek-Oftedahl, W., 198 Verhulst, F. C., 290, 394 Verloove-Vanhorick, S. P., 184 Vermeer, H. J., 68 Vermetten, E., 348 Verzemnieks, I., 216 Vestal, K. D., 199 Vicari, S., 321 Victora, C. G., 387 Vig, S., 504 Vigilante, D., 185, 349 Vik, T., 183 Viken, R. J., 366 Vinet, J., 43 Vintzileos, A. M., 181 Vismara, L., 309

Author Index Visser, G. H. A., 156 Vitaro, F., 291, 399 Vitiello, B., 517, 518 Vizziello, G. F., 95 Vohr, B. R., 387 Voight, J. D., 217, 219, 222, 225 Volkmar, F. R., 292, 301, 303, 304, 305, 526 Volkow, N. D., 488 Volpe, J. J., 42, 183 Volpe, R., 289 Von Dongen, H. P., 364 von Eye, A., 27, 65, 200, 349, 353 von Klitzing, K., 471 Vondra, J. L., 290, 394 Vostanis, P., 200 Vouloumanos, A., 46 Wadhwa, P. D., 67, 122, 157 Wagers, M., 44 Wagmiller, R. L., 141 Wailoo, M. P., 67 Wainwright, R., 87, 273 Wainwright, S., 29 Wajda-Johnston, V. A., 510 Wake, M., 365, 367, 368 Wakschlag, L. S., 215, 218, 219, 225, 241, 254, 283, 392, 393, 394, 395, 396, 397, 398, 399, 400, 401, 402, 403 Walbot, H., 84 Walf, A., 60 Walker, E. F., 156, 160 Walker, M., 324 Walker, S., 364 Wall, S., 92, 254, 272, 422, 442, 450 Wallace, C. S., 123 Wallace, G., 67 Wallace, I. F., 158 Wallerstein, R., 444 Walsh, C. J., 29 Walsh, J. K., 368 Walsh, K. G., 485 Walther, F. J., 184 Walton, J. R., 122 Wampler, R. S., 223 Wand, G. S., 68 Wandersman, L. P., 222 Wang, E. L., 17, 378 Wang, G., 488 Wang, H., 183 Wang, P., 337 Wang, X., 94 Wang, Y., 200 Warburton, W., 518 Ward, M. J., 215, 380 Warfield, S. K., 183 Warner, M., 584, 586 Warner, R. M., 368 Warren, K., 173 Warren, S. F., 309, 320, 321, 327, 423 Wasdell, M. B., 369, 372 Watamura, S. E., 66, 68 Waterman, J., 511 Waters, E., 92, 121, 254, 272, 422, 442, 450 Watkins, M., 469 Watson, J. S., 86, 87, 206 Watson, L. R., 324 Watson, S. J., 72

Watston, N. V., 59 Watt, M. J., 182 Waugh, R. M., 94 Weatherby, A. M., 326 Weaver, I. C., 122 Weber, C., 498 Webster-Stratton, C., 394, 400, 470, 520, 524, 526 Wechsler, J., 336 Wechsler, N., 216, 217 Weems, C. F., 202, 401 Wehner, E., 303 Weider, S., 537 Weikart, D. P., 580 Weili, L., 518 Weinberg, M. K., 84, 87, 154, 161, 175, 258 Weinberger, A. D., 71 Weiner, E., 539 Weinfield, N. S., 93, 206, 423, 488 Weinraub, M., 93 Weiss, B., 551 Weiss, M. D., 369, 372 Weiss, S., 366 Weissman, M. M., 162, 163, 164, 519 Weller, A., 25, 372 Weller, E. B., 525 Weller, R. A., 525 Werker, J. F., 46 Werner, E. E., 12, 304, 305 Wertheim, E., 474 Wesner, K. A., 67 West, J., 257 West, J. R., 172 Westen, D., 358 Westney, O. E., 223 Weston, D. R., 17, 252, 448 Wetherby, A. M., 304, 305, 307, 309, 311, 318, 319, 321, 325, 504 Whalen, N., 347 Whaley, G. J., 206 Whaley, S. E., 173 Wheeler, R. E., 53 Whelan, E., 378 Wheller, L., 182 Whidbee, D., 368 Whiffen, V. E., 155, 158 Whifield, M. F., 184 Whincup, P. H., 388 Whitaker, R., 142 Whitaker, R. C., 176, 377 Whitby, E. W., 183 Whitelaw, A., 187 Whiteman, S., 472 Whitfield, M. F., 184 Whitlingum, G., 176 Whitman, T. L., 216 Whittington, C., 523, 525 Widom, C. S., 202 Wieck, A., 30 Wieder, S., 301, 308 Wiggs, L., 369 Wijnroks, L., 189 Wilens, T. E., 372, 392, 523 Wilensky, D., 381 Wiley, J., 45 Wilhelm, K., 154 Wilken, M., 378 Wilkinson, C. W., 72, 415 Willheim, E., 134, 197

Williams, C. E., 172 Williams, E. G., 34 Willms, J., 397 Wilson, M., 262 Wilson, M. E., 556 Wilson, S., 358 Wilson, S. M., 186 Wilson-Costello, D., 182 Windsor, J., 282, 318, 325, 510, 511 Wingfield, J. C., 68 Winnicott, C., 459 Winnicott, D. W., 24, 26, 35, 188, 452, 456, 462 Winslow, J. T., 126 Winter, M., 470 Winters, N. C., 378 Wise, B. K., 447 Wise, S., 254 Wishart, J. G., 336 Wissow, L. S., 555, 556 Wobie, K., 485 Wolde, Y., 188 Wolery, M., 566 Wolf, A. W., 365 Wolf, C. M., 157 Wolf, M. J., 183 Wolfe, C. D., 83, 88 Wolfe, N., 154 Wolfe, R., 161 Wolfson, A. R., 368 Wolke, D., 73, 296, 381 Wolkind, S. N., 50, 125, 423 Wolmer, L., 208, 356 Woodhead, M., 202 Woods, J. R., Jr., 172, 309 Woodward, S., 85 Woolgar, M., 378 Woolley, A. E., 584 Wozniak, D. F., 172 Wozniak, J. R., 372, 523 Wright, C. M., 215, 217, 377, 380, 381, 382, 383, 384, 385, 386 Wright, E. J., 29, 155 Wright, H. H., 523, 525 Wright, J. A., 377 Wright, K., 553

Author Index

609

Wright, M. J., 201 Wu, L. T., 172 Wulczyn, F., 500 Wust, S., 159 Wyatt, D. T., 504 Wynn, J. W., 308, 326 Wynne, L., 473 Wynne-Edwards, K. E., 29

352, 353, 354, 356, 366, 380, 392, 396, 400, 421, 424, 425, 426, 427, 429, 430, 431, 469, 490, 501, 503, 509, 511, 517, 536, 539, 550, 553, 554, 580 Zeanah, P. D., 1, 5, 6, 9, 14, 17, 40, 258, 531, 533, 539, 549, 560, 580 Zebell, N., 358 Zeigler, T. E., 29 Zeiss, A., 154 Zeitlin, J., 181 Zeki, S., 488 Zekoski, E. M., 29 Zelkowitz, P., 163, 188 Zeltzer, L., 346 Zepeda, M., 555, 556 Zhang, T. Y., 72 Zhang, X., 322 Zielhuis, G. A., 334 Zigler, E., 146, 333 Zimmerman, A., 26 Zimmerman, F. J., 127 Zimmermann, P., 95 Zinga, D., 215 Ziol-Guest, K. M., 221, 222, 224 Zisapel, N., 372 Zito, 288 Zito, J., 392 Zito, J. M., 516, 517, 524 Ziv, Y., 453 Zlotki, S. H., 17 Zlotkin, S. H., 378 Zlotnick, C., 504 Zoccolillo, M., 216, 395 Zoll, D., 161 Zoroglu, S. S., 525 Zubrick, S. R., 321, 322 Zuccaro, P., 520 Zuckerman, 142 Zuckerman, B., 156, 174, 400 Zuckerman, M., 417 Zuckerman, M. L., 525 Zukerman, S., 368 Zuvekas, S. H., 517 Zwaigenbaum, L., 301, 302, 303, 304

Xie, H., 221 Xu, Y., 199 Yakovlev, P. I., 44 Yamada, E., 72, 415 Yasui, Y., 182 Yeargin-Allsop, M., 312 Yehuda, R., 67, 185, 207 Yeung, W. J., 138, 139 Yim, D., 320 Yirmiya, N., 274, 336 Yoder, P. J., 309, 320, 327 Yonkers, K., 30 Yoshikawa, H., 565 Young, E. A., 159 Young, J. B., 72 Young, J. E., 71 Young, K. T., 550 Youngstrom, E., 240 Yule, W., 13 Zacchello, F., 187 Zagoory-Sharon, O., 25 Zahn-Waxler, C., 84, 88, 157, 399, 400 Zajicek-Coleman, E., 50 Zamsky, E. S., 217 Zanardo, V., 187 Zax, M., 176 Zayas, L., 162 Zayas, L. H., 156 Zeanah, C. H., Jr., 1, 5, 6, 8, 9, 10, 13, 27, 29, 32, 35, 40, 48, 65, 87, 95, 109, 122, 1287, 128, 138, 175, 186, 189, 190, 191, 200, 201, 203, 204, 205, 206, 208, 231, 233, 241, 252, 253, 254, 257, 258, 260, 261, 267, 273, 283, 293, 348, 349, 351,

Subject Index

Abuse, 33, 65, 380–381 Academic functioning, preterm birth and, 183 Acceptance, 268 Adaptation, 29–33, 46 Adaptive Behavior Assessment System–II (ABAS-II), 238 Adaptive programming model, 123–124 ADHD. see Attention-deficit/ hyperactivity disorder (ADHD) Adolescent motherhood, 214–225. see also Teen pregnancy fathers and, 221–224 mother–grandmother relationships, 217–221 mother–infant relationships and, 215–217 relational context, 224–225 Adolescents, preterm birth and, 183. see also Teen pregnancy Adoption and Safe Families Act (ASFA), 502 Adoption studies, 428–429 Adrenals, stress in infancy and, 61–62, 62f Adrenocorticotropic hormone (ACTH), 61–62, 62f Adult attachment, 95 Adult Attachment Interview (AAI), 31–32, 95 “Adversarial care”, 219 Adverse childhood experiences (ACE) study, 7 Adversity, 161–162 Affect, 25, 51–54, 491–492 Affect regulation, 462, 487–489, 525–526



Ages and Stages Questionnaires (ASQ), 235, 311, 554t Aggression adolescent motherhood and, 216 cortisol and, 68–69 developmental context of, 393–394 disruptive behavior disorders and, 398–400, 404t overview, 12–13 parental substance abuse and, 176 pharmacological interventions and, 523t, 524–525 sleep and, 368 violence exposure and, 200–201 Alcohol abuse/use, 173. see also Substance abuse/use, parental Alliances within a family, 474–477, 477t Alpha-agonists, 524. see also Pharmacological interventions Ambivalence, pregnancy and, 27 Ambivalent attachment, 93, 423, 457–458 Amygdala Circle of Security and, 463 stress in infancy and, 61, 62f violence exposure and, 201, 203–204 Angelman syndrome, 369 Anger, 401–402, 401t Anhedonia, 413–414 Animal studies, 122, 207 Anorexia, infantile, 378 Antidepressants, 34, 518. see also Pharmacological interventions Antisocial behavior, 394 Anxiety, 30, 31, 186, 200

611

Anxiety disorder attachment disorders and, 426 diagnosis and, 292 pharmacological interventions and, 523t, 525 during pregnancy, 29 Anxious-ambivalent attachment pattern, 93 Anxious-avoidant attachment pattern, 92–93 Applied Behavior Analysis (ABA), 308 Apprenticeship model, 218–219 Approach–withdraw dichotomy, 51–54 Asperger syndrome, 309–310, 369. see also Autism spectrum disorders ASQ-SE, 246–247 Assertion, Circle of Security and, 462–463 Assessment attachment disorders and, 426–427 autism spectrum disorders and, 306–308 categorical diagnostic approaches and, 288–295 challenges in, 235–238 Circle of Security and, 453–461, 455f depression and, 154 domains of, 234–235 of the effects of early experience, 121–122 emotion regulation, 88 failure to thrive and, 380 feeding disorders and, 379

612 Assessment (cont.) infant–caregiver relationship and, 6–7, 266–278 intellectual disabilities and, 333–335 language disorders and, 324–325 Lausanne Trilogue Play (LTP), 473–477 observational measures, 252–263 of an organizations cultural and linguistic competence, 106 overview, 231–232 parent report measures, 233–248 pharmacological interventions and, 519, 526 posttraumatic stress disorder (PTSD) and, 353–356 preterm birth and, 184 in primary health care settings, 549–556, 550t, 554t recommendations regarding, 246–247 selecting an instrument for, 242–246 temperament and, 85–86 training and, 536 types of, 246–247 Assuring Better Child Health and Development (ABCD) Initiative, 558 Atomexetine, 523t, 524. see also Pharmacological interventions Attachment, 421–431. see also Attachment disorders; Attachment relationships classifications of, 422–423 clinical perspectives of, 423–425 developmental context of, 422 fathers and, 28 hormonal functioning and, 24–25 overview, 421 pregnancy and, 25–27 social development and, 90t Attachment, culture, and trauma (ACT) model, 109–112, 110f, 117 Attachment and Biobehavioral Catch-Up (ABC) intervention, 505–507 Attachment disorders, 421–431. see also Attachment; Attachment relationships assessment and, 426–427 clinical perspectives of, 423–425, 427t course and prognosis associated with, 426 diagnosis and, 425–426, 427 foster care and, 503 intervention and, 427–430 overview, 283 relational context, 430–431 Attachment relationships. see also Attachment; Attachment disorders; Caregiving relationship; Infant–caregiver relationship attachment, culture, and trauma (ACT) model and, 109–112, 110f brain development and, 48–50

Subject Index Circle of Security and, 450–465 early experiences and, 121, 125–126 foster care and, 502–503, 505–507 indicated preventions and, 16 maternal depression and, 155–156, 164–165 overview, 8, 486–487 parenting and, 486–487 preterm birth and, 189 social development and, 92–94 Strange Situation Procedure (SSP), 260 unavailability, rejection and neglect by parents, 66–67 violence exposure and, 205–206 Attachment theory, 81, 92, 128, 442 Attentional functioning, 91t, 176. see also Attention-deficit/ hyperactivity disorder (ADHD) Attention-deficit/hyperactivity disorder (ADHD) attachment disorders and, 426 autism spectrum disorders and, 303–304 defining disorder and, 287–288 depression and, 411 diagnosis and, 291–292, 297 infant–caregiver relationship and, 48–50 parental substance abuse and, 173, 175 pharmacological interventions and, 522, 523t, 524 posttraumatic stress disorder (PTSD) and, 356 preterm birth and, 182–183 sleep problems and, 369, 372 Attributions, parental, 241, 267, 487 Atypical antipsychotics, 34, 517, 524–525. see also Pharmacological interventions Autism Diagnostic Interview— Revised (ADI-R), 307 Autism Diagnostic Observation Schedule (ADOS), 307, 398–399 Autism Observational Scale for Infants (AOSI), 307 Autism spectrum disorders, 11, 301–313 communicative disorders and, 326 course and prognosis associated with, 309–310 diagnosis and assessment and, 306–308 in infancy, 304–306 insightfulness and, 274–275 language disorders and, 324 overview, 282 pharmacological interventions and, 523t policy and, 310–312 research issues in, 302–303 screening and, 310–312 sleep and, 369 treatment and intervention and, 308–309, 308t Autistic Diagnostic Observation Schedule (ADOS), 252 Autonomic nervous system, 59–63, 62f

Avoidant attachment, 92–93, 422–423, 457–458 Asynchronous interactions, 87 Baby blues. see Postpartum blues Background information, 239 Bayley Development Quotient (DQ), 334–335 Bayley Scales of Infant Development, 161 Bayley Scales of Infant Development—Third Edition (BSID-III), 334 Beck Depression Inventory-II (BDIII), 154 Bedtime problems, 366–367, 371. see also Sleep disorders Behavior adolescent motherhood and, 214 assessment and, 235, 236 child care and, 565–566 disruptive behavior disorders and, 398–400 foster care and, 503–504 maternal depression and, 156–157 preterm birth and, 182–184 sleep and, 368 violence exposure and, 200–201 Behavioral disinhibition exuberance (BD), 290–291 Behavioral inhibition, 85–86, 159, 290–291. see also Inhibition Behavioral regulation, 319t, 401–402, 401t Behavioral treatment, 369, 379 Belongingness, need for, 112–113 Benzodiazepines, pregnancy and, 34 Berkeley Puppet Interview, 394 Between groups validity, 244 Bias, caregiver report measures and, 240–241 Bidirectional models, 351–352 Biological risk factors. see also Risk factors depression and, 414–415 infant depression and, 412–413 infant–caregiver relationship and, 8 maternal depression and, 157–158 stress reactivity and, 72 violence exposure and, 201–202 Bipolar disorder, 29 Blaming, Circle of Security and, 464 BMI, 386. see also Obesity Brain development. see also Neurobiology of fetal and infant development infant depression and, 412–413 neural plasticity and, 45–51 overview, 40–45, 41f, 42f, 43f, 45f temperament and, 51–54 Brazelton Neonatal Assessment Scale, 156 Breastfeeding, obesity and, 387–388 Brief Infant–Toddler Social and Emotional Screening Assessment (BITSEA), 246–247, 552, 554t Bright Futures Guidelines for Health Supervision, 551 Bucharest Early Intervention Project (BEIP), 48, 426, 429, 509–511

Care management, 556 Caregiver Behavior Classification System, 453–454 Caregiver report measures, 233–248 considerations regarding, 238– 242 limitations in, 236–237 overview, 231 recommendations regarding, 246–247 selecting an instrument for, 242–246 Caregivers, primary health care settings and, 550–551, 550t Caregiving relationship. see also Attachment relationships; Infant–caregiver relationship assessment of, 252–263 attachment disorders and, 429 early experiences and, 8–9 infant depression and, 411–412 insightfulness and, 275 violence exposure and, 205–206 Caregiving system, 26, 450–465 Case conceptualization, 241–242 Case management, 445 Catecholamines, stress responsivity and, 67–68 Categorical diagnostic approaches, 11, 288–295, 295–297 Centers for Epidemiological Studies—Depression Scale (CES-D), 154 Central nervous system, 42–43, 42f, 43f, 59–63, 62f Cerebellar vermis, 203–204 Cerebral cortex, 203–204 Checklist for Autism in Toddlers (CHAT), 246, 311 Child Behavior Checklist (CBCL), 290, 352, 508 Child Behavior Checklist/1½–5 (CBCL/1½–5), 237, 247, 289 Child care access to mental health in, 520–521 caregiver report measures and, 241–242 case example of, 572–577 consultation and, 564–566, 569–572 economics benefits of, 583–585 mental health considerations in, 566 Mothers and Toddlers Program (MTP) and, 494–495 poverty and, 145 prevention interventions and, 15 separation and, 66 Child Care and Development Block Grant, 145 Child factors, family functioning and, 471–472 Child psychotherapy, feeding disorders and, 379 Childbirth, 24 Child-centered model, foster care and, 501–502 Childhood adjustment, 200 Child–Parent Center Program (CPC), 582

Subject Index Child–parent psychotherapy, 439–448 developmental context of, 439–442 empirical support for, 448 intervention modalities of, 442–445 overview, 17, 435–436 “ports of entry” concept and, 445–448 theoretical models for, 442 Cingulate gyrus, 44 Circle of Security, 450–465, 451f assessment and, 453–461, 455f empirical support for, 465 overview, 97, 423, 435, 436 protocol of, 452–453 treatment planning and, 461–465 Circle of Security Interview (COSI), 450–451, 453–461, 455f Circle of Security State-of-Mind Assessment, 458–461 Classification of psychopathology in early childhood, 285–297 Clinical problem-solving procedure, 254 Clonidine, 523t. see also Pharmacological interventions Coercive parenting, maternal depression and, 161 Cognitive delays, foster care and, 504 Cognitive functioning assessment of, 235 Down syndrome and, 336–337 failure to thrive and, 382t–385t maternal depression and, 158 preterm birth and, 183 sleep and, 368 Cognitive-behavioral therapy (CBT), 357, 379, 442 Collaboration, 542–543, 567 Comfort, 456–457 Commonwealth Fund, 148 Communication, 304–305, 440–441 Communication and Symbolic Behavior Scales— Developmental Profile (CSBS– DP), 307, 311–312 Communication disorders, 318–328 assessment of, 324–325 intervention and, 325–327, 326t primary and secondary, 321–324 Community violence, effects of, 200 Community-based interventions, 128, 149 Conception, 23 Conceptual model, 138–140, 139f, 144 Conduct disorder (CD), 394, 395, 411 Conduct problems, 216. see also Behavior Conflict management, 469–470 Construct validity, 244 Consultation, 564–577 case example of, 572–577 child care and, 564–566 consultative practice, 570–572 history of, 566–567 overview, 537–539 principles of, 567

613 as training, 543–544 transactional approach to, 567–570 Containment, 491–492 Content validity, 243–244 Context of development. see also Developmental processes assessment and, 236 caregiving relationship and, 8 overview, 1 pregnancy and, 22–23 training and, 536 Continuity, social development and, 91t Continuum of services model, 14f Convergent validity, 244 Coparenting, 470–471 Coping skills, maternal depression and, 156–157 Core sensitivities, 458–461 Corpus callosum, 203–204 Corticosteroids, 61–62, 62f Corticotropin-releasing factor (CRF), 68–69 Cortisol Attachment and Biobehavioral Catch-Up (ABC) intervention and, 507 depression and, 414–415 early experiences and, 127 maternal depression and, 157–158, 159–160 separation and, 66 stress responsivity and, 68–69 violence exposure and, 207 Countertransference, 17 Couvade, 28–29 Credentialing systems, 534, 544–546. see also Training, professional Crisis intervention, 445 Crowell Procedure, 256t, 257t, 260–261 Cultural competence, 106, 108–109 Cultural factors. see also Multicultural perspective; Sociocultural context caregiver report measures and, 238–240 childbirth and, 24 early experiences and, 9 intervention and, 107–109 observational measures and, 254–255 social development and, 92 theoretical models for, 109–117, 110f, 115f Cultural–ecological model, 114–115 Day care. see Child care Deficit Reduction Act, 148 Defining infant mental health, 5 Degrees, professional, 544–546 Denver Early Start Model, 309 Denver–II, 311 Depression, 409–418. see also Depression in parents; Maternal depression case example of, 417–418 diagnosis and, 153–154, 292 early indicators of, 11

614 Depression (cont.) emotional development and, 410–411 identifying in the very young, 289 in infancy, 411–413 pharmacological interventions and, 525 in preschool children, 413–417 prevalence of, 154–156 resilience and, 143 temper tantrums and, 11 treatment and intervention and, 416–417 Depression in parents. see also Depression; Maternal depression adolescent motherhood and, 216 aggression and, 13 brain development and, 48, 50 caregiver report measures and, 240–241 child–parent psychotherapy and, 17 fathers and, 162–163 following perinatal loss, 31 infant depression and, 411–413 parent–infant interactions and, 188 policy and, 147 postpartum depression, 29–30 during pregnancy, 29, 30 preterm birth and, 186, 188 stress in infancy and, 67 teen pregnancy and, 33 Depression-distortion hypothesis, 240–241 Deprivation, early, 124–127 Developmental delays, 369, 504– 505 Developmental Education for Families (DEF), 507 Developmental processes. see also Context of development; Emotional development; Social development adolescent motherhood and, 214 attachment and, 422 brain development, 40–45, 41f, 42f, 43f, 45f child care and, 565–566 child–parent psychotherapy and, 439–442 disruptive behavior and, 393–400, 397t failure to thrive and, 382t–385t foster care and, 503–505 language development, 318–321, 319t neural plasticity and, 45–51 pharmacological interventions and, 517–519, 518t sleep and, 362–364, 368 socioeconomic status and, 106 trajectories of development, 9–10 violence exposure and, 202, 202–205 Developmental programming model, 123–124 Developmental specialists, 557 Devereaux Early Childhood Assessment, 554t

Subject Index Diagnosis assessment and, 247 attachment disorders and, 425–426, 427 autism spectrum disorders and, 306–308 categorical diagnostic approaches and, 11, 288–295, 295–297 defining disorder, 287–288 depression and, 153–154, 413, 415 disruptive behavior disorders and, 394–400, 397t, 400–403, 401t during infancy, 11–12 infant depression and, 413 intellectual disabilities and, 332, 334–335 language disorders and, 321 overview, 291–295 pharmacological interventions and, 519, 526 posttraumatic stress disorder (PTSD) and, 201, 349–351 training and, 536 which classification system to use, 295–297 Diagnostic and Statistical Manual of Mental Disorders (DSM) attachment and, 423–424 autism spectrum disorders and, 303–304 categorical diagnostic approaches and, 290 Circle of Security and, 458–459 defining disorder, 287–288 depression and, 153–154, 413, 415 diagnosis and, 11–12, 291–295 disruptive behavior disorders and, 393–400, 397t feeding disorders and, 377–378 homosexuality and, 114 intellectual disabilities, 332, 332–341 postpartum period and, 349–350 posttraumatic stress disorder (PTSD) and, 255, 351 violence exposure and, 203 which classification system to use and, 295–297 Diagnostic Classification:0–3 (DC:0–3). see also Zero to Three feeding disorders and, 378 infant depression and, 413 overview, 247, 292–295 which classification system to use, 296 Dialogue, 105 Diathesis–stress model, 124 Differential diagnosis, 425–426, 453–461, 455f, 458. see also Diagnosis Differential training, 536–537. see also Training, professional Dimensional approaches to diagnosis, 289–291 Discrete trial, 326–327, 326t Discriminant validity, 244 Disengaged parents, 272–273, 278 Disorder, defining, 287–288. see also Psychopathology Disorganized attachment, 16, 93, 423

Disruptive Behavior Diagnostic Observation Schedule (DB– DOS), 400–403, 401t Disruptive behavior disorders, 392–404 developmental context of, 393–400, 397t diagnosis and, 11, 292 overview, 283 pharmacological interventions and, 524–525 Distress reactions, 83–84 Divergent validity, 244 Diversity, 106. see also Multicultural perspective Diversity awareness model, 115–117, 115f Domestic violence, 176, 200, 352 Dopamine, 30, 86, 488 Dose–response effect, 200 Double ABCX model, 338 Double jeopardy phenomenon, 142–143 Down syndrome, 332–333, 334–335, 335–337 Down Syndrome Critical Region Gene 1 (DSCR 1), 336 DRD4, 86 Drug abuse/use. see Substance abuse/ use, parental Dyadic relationships, 9, 564, 570 Dysthymia, diagnosis of, 153–154 Early Childhood Inventory–4 (ECI–4), 289 Early Childhood Longitudinal Studies (ECLS), 140 Early Childhood Screening Assessment, 554t Early experiences, 120–129 brain development and, 48–50 caregiving relationship and, 8–9 deprivation, 124–127 development and, 7–8 neural plasticity and, 47–51 prevention and intervention and, 127–128 theoretical models for, 120–124 Early Head Start adolescent motherhood and, 215 attachment disorders and, 425 overview, 147, 148, 149 Early intervention, 13–14. see also Intervention Early Intervention Program, 148–149 Early Relational Assessment (ERA), 256t, 257t, 259–260 Early Screening of Autistic Traits (ESAT), 311 Early Social Communication and Symbolic Behavior Scales, 325 Early Social Interaction Model, 309 Earned Income Tax Credit (EITC), 144–145 Ecological models, 113–115, 400–401 Economic base theory, 585 Economics of infant mental health, 580–589 case example of, 585–589, 587t, 588t

child care and, 583–585 successful prevention and intervention programs, 581–583 Ecosystem model, 81 Edinburgh Postnatal Depression Scale (EPDS), 154 Effortful attention, brain development and, 48 “Elephant Breakdown” story, 111 Emotion, 51–54, 83–84 Emotion regulation Circle of Security and, 457, 462 maternal depression and, 156–157 models of, 81 overview, 87–89 parenting and, 472 Emotional development, 80–97. see also Developmental processes assessment of, 235 Circle of Security and, 457 depression and, 410–411 maternal depression and, 156–157 overview, 83–89 poverty and, 138–144, 139f preterm birth and, 182–184 sleep and, 368 theoretical models for, 81–82 transitions in, 82–83 Emotional support, 444–445 Emotional withdrawn/inhibited RAD, 424, 426, 427t Emotions, parental responses to, 86–87 Empathic responding, 84–85, 404t Employment of parents, 136–138, 137f Endorsements, professional, 544– 546 Environment, 65–66, 253, 253t. see also Environmental risk factors Environmental risk factors. see also Risk factors compared to prenatal substance exposure, 10 failure to thrive and, 380–381 infant–caregiver relationship and, 8 language disorders and, 322 neuroscience and, 55 obesity and, 386 parental substance abuse and, 176–177 parenting and, 67 postpartum period and, 30 poverty and, 142 primary health care settings and, 550–551, 550t teen pregnancy and, 33 violence exposure and, 201–202 Epinephrine (EPI), 60–61 Esteem sensitivity, 458–461 Estrogen levels, 30 Ethnic minority groups, 106, 136, 181–182, 238–240 Etiology-based approach, 332–333 Evolutionary perspective, 64 Executive functioning, 303 Expectability in context, 399 Expectations of parents, 241 Experience-dependent development, 47

Subject Index Experience-expectant development, 46–47 Expertise, consultation and, 569 Exposure treatments, 358 Extended respite model, foster care, 501 External reorganization, pregnancy and, 27–28 Extinction procedures, 370–371 Eye gaze, 304, 319 Eye movement desensitization and reprocessing (EMDR), 358 Face validity, 243–244 Face-to-Face Paradigm, 254 Face-to-Face Still Face (FFSF), 256t, 257–258, 257t Facial expressions, 410 Failure to thrive, 377–388 feeding disorders and, 378–379 overview, 380–386, 382t–385t Family Administered Neonatal Activities (FANA), 217 Family factors adolescent motherhood and, 224–225 aggression and, 13 failure to thrive and, 380 intellectual disabilities and, 338–340 overview, 9, 468–473 pregnancy and, 22–23, 27–28 sleep problems and, 367–368 Family leave for new parents, 146 Family Life Impairment Scale (FLIS), 238 Family process model, 138–139, 139f “Family stress” model, 139, 139f Family structure, 473–477, 477t Family therapy, 468–481 case example of, 477–481 family factors and, 468–473 Lausanne Trilogue Play (LTP), 473–477, 477t overview, 191, 379 Fathers absence of, 29 adolescent motherhood and, 221–224 childbirth and, 24 cultural factors and, 92 maternal depression and, 162–163 parent–child relational issues and, 469 pregnancy and, 28–29 Feeding disorders, 377–388 assessment of, 379 intervention and, 379 overview, 283, 377–379 Felt security, violence exposure and, 205 Fetal alcohol effect (FAE), 505 Fetal alcohol syndrome (FAS), 173, 334–335, 505 Fetal development. see also Pregnancy brain development, 40–45, 41f, 42f, 43f, 45f maternal depression and, 157 maternal stress and, 30 neural plasticity and, 45–51

615 neurobiology of, 40–55 overview, 23–24 parental substance abuse and, 171–177 Fight or flight responses, 69–71, 201 5-HTT gene, 53, 143, 202 5-HTTLPR, 86, 159, 174–175 Flooding treatment, 350 Fluoxetine, 523t. see also Pharmacological interventions Food refusal, 378 Foster care, 500–512 brain development and, 48–50 developmental context of, 503–505 differences in, 511–513 future of, 512 insightfulness and, 274 intervention and, 436, 505–511 policy and, 148 Fragile Families and Child WellBeing study, 140 Fragile X syndrome, 334–335 Frontal lobe, 157, 412–413, 463 Functionalist approaches, 83 Functioning, maternal depression and, 156–157 Gamma-aminobutyric acid (GABA), 68 Gender, family functioning and, 472 Gene–environment interaction model, 81, 85–86, 201–202 Genetic factors emotional development and, 85–86 fetal and infant development and, 40–55 intellectual disabilities and, 335–338 language disorders and, 322 maternal depression and, 158–159 obesity and, 386 parental substance abuse and, 174–175 resilience and, 143 stress in infancy and, 67–73 temperament and, 52–53, 85–86 violence exposure and, 201–202 Gestational diabetes, 387 Global Assessment of Functioning (GAF), 294–295 Glucocorticoid receptors brain development and, 48 fight or flight responses and, 69–70 stress in infancy and, 62–63, 73 violence exposure and, 207 Glucose metabolism, 123–124 Goal-corrected partnership, 91t “Goodness-of-fit” model, 86 Grief, perinatal loss and, 30–34 Growth deficiency, 378, 382t–385t. see also Failure to thrive Guanfacine, 523t. see also Pharmacological interventions Guilt abortion and, 33 depression and, 411 parental substance abuse and, 175–176 preterm birth and, 187

616 Hair-combing task (HCT), 256t, 257t, 261–262 Harsh parenting, 161 “Hawk” children, 70 Health. see also Health care failure to thrive and, 382t–385t feeding disorders and, 378 genetic disorders and, 339 preterm birth and, 187 sleep problems and, 369–370 Health and Behavior Questionnaire (HBQ), 416 Health care, 549–560. see also Health challenges and future directions for, 559–560 policy and, 145 prevention and, 557–559 treatment and intervention and, 557 Healthy Start initiative, 558–559 Healthy Steps, 557 Heritability, maternal depression and, 158–159 Heterotypic continuity, 11 Hierarchical models, 112–113 Hierarchy of needs, 112 Hippocampus fetal development and, 43–44 fight or flight responses and, 70 neural plasticity and, 48 stress in infancy and, 61, 62f, 73 violence exposure and, 202, 203–204 “Holding” therapies, 127 Holistic view, 108 Home-visiting programs, 148, 191, 571–572 Homosexuality, diagnosis of in the DSM, 114 Hormonal functioning, 24–25, 30 Hospitalization, preterm birth and, 190–191 HPA (hypothalamic–pituitary– adrenal) axis Attachment and Biobehavioral Catch-Up (ABC) intervention and, 507 depression and, 414–415 early experiences and, 127 genetic variation and, 69–71 maternal depression and, 159 neural plasticity and, 47–51, 55 separation and, 66 stress in infancy and, 60, 61–63, 62f, 69–71, 73 Hyperactivity, 176, 303–304, 368. see also Attention-deficit/ hyperactivity disorder (ADHD) Hypertension, 523t Hypocortisolism, 69 Hypothalamic influences, 61–62, 62f, 70, 207 Hypothetical Anxiety Measure for Preschoolers (HAMP), 243–244 ICD, 291–295, 296, 424 Identity, pregnancy and, 25–27 Immigrants, 136, 138 Impairment, assessment and, 237–238 Impulsivity, 175, 368, 426

Subject Index Indian boarding school, 114 Indicated preventions, 15, 16 Indiscriminate/disinhibited pattern of RAD, 424–425, 426, 427t Individual differences attachment relationships and, 92–93 categorical diagnostic approaches and, 288 family functioning and, 472 foster care and, 511–513 maternal depression and, 159 sleep problems and, 367–368 stress in infancy and, 67–73 Individualized Education Plan (IEP), 341 Individualized Family Service Plan (IFSP), 341 Individuals with Disabilities Education Act, 147–148, 321, 340–341 Infant, defining, 6 Infant Alarm Distress Scale, 296 Infant and Young Child Diagnostic Work Group, 285 Infant development, neurobiology of, 40–55 Infant massage, sleep problems and, 372 Infant mental health in general, 5–18, 108, 531–532 economics of, 580–589 emotional development and, 89 empirical foundations of, 7–14 mental health consultation and, 564–577 primary health care and, 533–547 social development and, 96–97 training in, 533–547 Infant–caregiver relationship. see also Attachment relationships; Caregiving relationship adolescent motherhood and, 215–217 assessment of, 6–7, 236 brain development and, 48–50 child care and, 15 early interventions and, 14 emotional development and, 86–87 feeding disorders and, 378 overview, 469 posttraumatic stress disorder (PTSD) and, 351–353 preterm birth and, 187, 191 training and, 536 violence exposure and, 205–206 Infantile anorexia, 378 Infant–parent attachment relationship, 92–94 Infant–parent psychotherapy, 440. see also Child–parent psychotherapy Infant–parent relationship assessment, 266–278 Infant–Toddler Checklist (ITC), 311–312, 312 Infant–Toddler Social and Emotional Assessment (ITSEA) cultural factors and, 240 disruptive behavior disorders and, 397, 397t

overview, 236, 237, 247, 289–290 reliability of, 243 response format of, 245–246 Influence, levels of, 569, 576–577 Inhibition, 48, 53, 85–86, 159, 290–291. see also Behavioral inhibition Initiative, infant, 90t Insecure attachment brain development and, 49–50 child–parent psychotherapy and, 17 Circle of Security and, 457–458 indicated preventions and, 16 maternal depression and, 164–165 stress in infancy and, 67 Insightfulness, 96, 268–269, 269–272, 271t Insightfulness Assessment (IA), 266–278 classifications from, 270–272, 271t clinical implications of, 276–278 empirical support for, 272–275 overview, 96 Insightfulness Procedure, 232 Insight-oriented interpretation, 444 Institutional child rearing attachment disorders and, 428, 431 brain development and, 48–50 Bucharest Early Intervention Project (BEIP) and, 48, 426, 429, 509–511 overview, 125 Institutional racism, 114 Intellectual disabilities, 332–341. see also IQ assessment of, 333–335 classifications from, 333 defining, 333 etiology of, 335 failure to thrive and, 382t–385t family adaptation and, 338–340 genetic disorders, 335–338 overview, 282 Intellectual functioning, 158. see also Intellectual disabilities Interactional therapy, feeding disorders and, 379 Interest reactions, 83–84 Internal consistency, 243 Internal reorganization, pregnancy and, 25–27 Internal working model, 9, 94–96, 458. see also Representations Internalizing symptoms, 68–69 International Classification of Sleep Disorders—2 (ICSD–2), 265 Internet, as a source of violence exposure, 199 Interrater reliability, 243 Intervention. see also Child–parent psychotherapy; Circle of Security; Early intervention; Family therapy; Foster care; Pharmacological interventions adolescent motherhood and, 216–217, 220–221, 222–224 autism spectrum disorders and, 308–309, 308t child–parent psychotherapy and, 442–445

consultation and, 569–570 early experiences and, 127–128 failure to thrive and, 386 at the family level, 472–473 fathers and, 222–224 feeding disorders and, 379 foster care as, 500–512 grandmothers and, 220–221 infant–caregiver relationship and, 6–7 insightfulness and, 275–276 Insightfulness Assessment (IA) and, 276–278 intellectual disabilities and, 340–341 language disorders and, 325–327, 326t Levels of Family Involvement for Infant Mental Health Model (LFI–IMH) and, 540t–542t maternal depression and, 163– 164 Mothers and Toddlers Program (MTP), 489–496 need for comprehensive interventions, 14–18, 14f neuroscience and, 54–55 overview, 435–437 parental substance abuse and, 174–175, 177 posttraumatic stress disorder (PTSD) and, 357–358 poverty and, 148–149 pregnancy and, 33–35 preterm birth and, 181, 190–191 primary health care settings and, 555–556 sleep problems and, 370–372 social development and, 97 sociocultural context and, 107–109 strengths and, 296–297 substance abusing parents and, 485–498 successful programs for, 581–583 violence exposure and, 208 Intrusive parenting, maternal depression and, 161 Investment perspective, 138–139, 139f IQ assessment of, 333–335 autism spectrum disorders and, 306 defining, 333 diagnosis and, 334 early experiences and, 7 failure to thrive and, 382t–385t parental substance abuse and, 173 Irritability, 368, 523t Joint attention, 91t, 304, 319t Kiddie Disruptive Behavior Disorders Schedule (K-DBDS), 394 Labels, categorical diagnostic approaches and, 297 Language delays, 235, 504 Language development, 318–321, 319t Language Development Survey, 325

Subject Index Language disorders, 318–328 assessment of, 324–325 intervention and, 325–327, 326t preterm birth and, 182–183, 324 primary and secondary, 321–324 Language in treatment, 443 Laughter, development of, 83–84 Lausanne Trilogue Play (LTP), 473–477, 477–481, 477t Learning disabilities, preterm birth and, 182–183 Levels of Family Involvement for Infant Mental Health Model (LFI-IMH), 534, 539–543, 540t–542t Life-course patterns, 124 Limbic system, Circle of Security and, 463 Limit-setting, bedtime problems and, 366–367 Linchpin script, 461–465 “Linchpin struggle” concept, 461 Linguistic competence, 106 Lithium, pregnancy and, 34 Locus coeruleus–amygdala loop, 61, 62f Loss, perinatal, 30–34 MacArthur–Bates Communicative Development Inventories (CDIs), 235, 307–308, 325 Major depressive disorder, 356, 413, 523t, 525. see also Depression Maladjustment, 368 Maltreatment, 197–208 attachment disorders and, 431 child care and, 565 developmental context of, 202–205 epidemiology of, 198–199 foster care, 500–512 nature of, 199–201 parental substance abuse and, 174–175 Mania, pharmacological interventions and, 523t Marital competence, 470 Marital relationship of parents coparenting alliance and, 471 fathers and, 28 overview, 9, 136–138, 137f, 469–470 pregnancy and, 27–28 Marital violence, 17 Maslow’s hierarchy of needs, 112 Massage, sleep problems and, 372 Maternal behavior, brain development and, 48–51 Maternal depression, 153–164. see also Depression in parents adolescent motherhood and, 216 clinical practice and, 163–164 defining, 153–155 family leave for new parents and, 146 fathers and, 162–163 infant depression and, 411–413 overview, 134 sleep problems and, 367 substance abuse and, 176 vulnerabilities in infants of, 155–162

617 Maternal diabetes, obesity and, 387 Maternal negative attributions, 267 Maternal trait anxiety, 156 Maternal–fetal attachment, 26, 27 Maturational model, 81 Media viewing, 127, 199 Medicaid, 145, 148, 149 “Medical home” concept, 557 Medication. see Pharmacological interventions Melancholic subtype of depression, 415 Memory brain development and, 48 child–parent psychotherapy and, 444 posttraumatic stress disorder (PTSD) and, 345–347 violence exposure and, 204–205 Mental illness. see Psychopathology Mental representations. see Representations Mentalizing, 27, 493–494 Metacognitive capacity, 235–236 Methylphenidate, 522, 523t, 524. see also Pharmacological interventions Milieu language intervention, 326–327 Minding the Baby (MTB) program, 35 Minimum wage, 144 Miscarriage, 23, 31–33 Mixed amphetamine salts, 523t. see also Pharmacological interventions Modeling appropriate protective behavior, 444 Modified Checklist for Autism in Toddlers (M-CHAT), 246, 311–312 Modulation, disruptive behavior disorders and, 399 Monoamine oxidase-A (MAO-A), 143, 202 Mood, sleep and, 368 Mood disorders, during pregnancy, 29 Mood stabilizers, 34, 524–525. see also Pharmacological interventions More Than Words program, 309 Mother–infant interaction, 188–189, 216–217 Mothers and Toddlers Program (MTP), 489–496, 496–498 Motor dysfunction, 182–183 Mourning, following perinatal loss, 30–34 Multicultural perspective. see also Cultural factors; Sociocultural context intervention and, 107–109 overview, 106–107 theoretical models for, 109–117, 110f, 115f Multidimensional framework, 403–404, 404t, 507–509 Multidimensional Treatment Foster Care Program for Preschoolers (MTFC-P), 507–509

618

Subject Index

Multigenerational families, adolescent motherhood and, 217–221 Myelination, fetal development and, 44–45

Nursing Child Assessment Satellite Training (NCAST), 254, 256t, 257t, 258–259 Nursing Child Assessment Teaching Scales (NCATS), 256t

National Center for Cultural Competence, 106 National Longitudinal Survey of Children and Youth (NLSCY), 396–398, 397t Natural disasters, stress in infancy and, 64–65 NCAST Teaching Task, 490 Needs, 453–458, 455f, 511 Neglect, 66–67, 160–161, 380–381 Neonatal Individualized Developmental Assessment Care Program (NIDCAP), 191 Nervous system, 41–43, 42f, 43f Neural circuitry acute stress and, 59–63, 62f early experiences and, 123 substance abusing parents and, 487–488 violence exposure and, 207 Neural plasticity, 45–51 Neurobiology of fetal and infant development, 40–55 brain development, 40–45, 41f, 42f, 43f, 45f early experiences and, 126 neural plasticity and, 45–51 posttraumatic stress disorder (PTSD) and, 348–349 preterm birth and, 182–183 relational context, 206–208 stress in infancy, 59–74 temperament and, 51–54 violence exposure and, 203–204, 206–208 Neurobiology of pregnancy, 24–25 Neuroblasts, 44 Neurodevelopmental disorders, 168–169 Neuroendocrine functioning, 157–158 Neurogenesis, 41–44, 42f, 43f Neuroticism, 159 Neurulation, 42–43, 43f NICHD Early Child Care Research Network, 396–398, 397t Night waking, 265–266. see also Sleep disorders Noncompliance, 393, 393–394, 404t Nondevelopmental model, 124 Norepinephrine (NE), 60–61, 157 Normalizing in treatment, 464 Norms in assessment instruments, 245 Nosology of psychopathology in early childhood, 285–297 reasons for, 285–288 which classification system to use, 295–297 Nurse–Family Partnership (NFP) economics of, 581–582, 583 overview, 16, 35, 147, 559, 581–582 violence exposure and, 208 Nursing Child Assessment Feeding Scales (NCAFS), 256t, 258–259

Obesity, 377–388 Object relations, 25–27, 458 Observational methods, 252–263 attachment disorders and, 427 consultation and, 571 depression in preschoolers and, 415 ethical and professional considerations, 262–263 guidelines for, 253–255, 253t infant depression and, 412 Lausanne Trilogue Play (LTP), 473–477 overview, 231 in primary health care settings, 551, 555–556 Obsessive–compulsive disorder, 29, 523t Openness, insightfulness and, 268 Oppositional defiant disorder (ODD), 48–50, 356, 394, 411 Ounce of Prevention Fund Developmental Program, 216–217 Oxytocin, 24–25, 126 Oyate Ptayela parenting curriculum, 111–112 Pain, preterm birth and, 184 Panel Study of Income Dynamics (PSID), 141 Panic disorder, 31 Parallel process, 570 Paraventricular nucleus (PVN), 61, 62f Parent Development Interview, 267, 453–454 Parent education programs, 371–372, 452–453, 555–556 Parent report measures, 233–248 considerations regarding, 238–242 limitations in, 236–237 overview, 231 posttraumatic stress disorder (PTSD) and, 354 recommendations regarding, 246–247 selecting an instrument for, 242–246 Parental Development Interview (PDI), 490 Parental education, 136–138, 137f Parental mental health, 553, 555 Parent–Child Early Relational Assessment, 256t, 257t, 259–260 Parent–child interaction therapy (PCIT), 358, 416–417, 526 Parent–infant interactions child–parent psychotherapy and, 446–447 Lausanne Trilogue Play (LTP) and, 473–477, 477t preterm birth and, 188–189 Parent–infant relationship. see Infant–caregiver relationship

Parent–Infant Relationship Global Assessment of Functioning (PIR-GAS), 294 Parenting. see also Parents adolescent motherhood and, 215–216, 223–224 aggression and, 13 attachment, culture, and trauma (ACT) model and, 111–112 attachment mechanisms and, 486–487 bedtime problems and, 366–367 coparenting alliance and, 470–471 early experiences and, 8, 9 early interventions and, 14 fathers and, 223–224 maternal depression and, 160–161 policy and, 149 posttraumatic stress disorder (PTSD) and, 352–353 poverty and, 141–142 representations and, 95–96 responses to infant emotions, 86–87 as a risk factor, 160–161 sleep problems and, 370–372 social development and, 94–96 stress in infancy and, 71–72 substance abusing parents and, 488–489 unavailability, rejection and neglect by parents, 66–67 Parenting models, 351 Parenting Stress Index (PSI), 238 Parent Interview for Autism— Clinical Version (PIA-CV), 306–307 Parents. see also Parenting assessment and, 233–248 consultation and, 571–572 experience of preterm birth, 186–188 primary health care settings and, 550–551, 550t representations and, 95–96 sleep problems and, 367 Parent–staff relationship, 190 Past experiences, stress in infancy and, 71–72 Pediatric health care providers challenges and future directions for, 559–560 prevention and, 557–559 role of, 549–556, 550t, 554t treatment and intervention and, 557 Peer relationships, 91t, 183 Perceptual functioning, 47 Perinatal depression, 154 Peripheral nervous system, 59–63, 62f Perry Preschool Project, 581 Personality disorders, 458–459 Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS). see also Autism spectrum disorders attachment disorders and, 425–426 course and prognosis associated with, 309–310 overview, 302–303

pharmacological interventions and, 523t, 526 treatment and intervention and, 308 Pharmacological interventions, 516–527 current practices in, 517 developmental issues in, 518t ethical considerations, 521 evidence and uses of medication, 522–526, 523t as one component of treatment, 521–522 overview, 436–437 pregnancy and, 33–34 psychotherapeutic interventions and, 519–520 sleep problems and, 369–370, 372 systems issues and, 520–521 Phonological development, 320–321 Physical health. see Health Physical contact in treatment, 443 Physical examinations, 551–552 Pituitary gland, 62f Plasticity, neural, 45–51 Play child care and, 566 child–parent psychotherapy and, 441, 443 Circle of Security and, 456 Mothers and Toddlers Program (MTP) and, 494 play therapy, 358 Policy, 144–148, 148–149, 310–312, 583 “Ports of entry” concept in CPP, 445–448 Positive/joy reactions, 83–84 Postpartum blues, 30, 155, 411–412. see also Postpartum depression Postpartum depression fathers and, 162–163 infant depression and, 411–412 overview, 29–30 preterm birth and, 189 prevalence of, 155 stress hormones in infants of, 157 vulnerabilities in infants of mothers with, 155–162 Postpartum period, 29–30. see also Postpartum depression Posttraumatic reactions, parental, 186, 189 Posttraumatic stress disorder (PTSD), 345–359 assessment and, 353–356 child–parent psychotherapy and, 17 comorbidity and associated symptomatology, 356 course of, 356–357 developmental context of, 345–349 diagnosis and, 201, 292, 349–351 early experiences and, 49 following perinatal loss, 31, 32 Mothers and Toddlers Program (MTP) and, 497 overview, 13, 200–201, 282 parent–child relational issues and, 351–353 pharmacological interventions and, 520, 525

Subject Index pregnancy and, 30–34 teen pregnancy and, 33 treatment and intervention and, 357–358 violence exposure and, 199, 202 Posttraumatic Stress Disorder Semi-Structured Interview and Observational Record for Infants and Young Children (PTSD-SSI), 355 Poverty, 135–149. see also Socioeconomic status adolescent motherhood and, 218 defining, 135–138, 137f, 140–141 failure to thrive and, 380 overview, 106 policy and, 144–149 recommendations regarding, 148–149 social–emotional development and, 138–144, 139f Predictive validity, 244 Prefrontal cortex emotion and, 51–54 fight or flight responses and, 70 stress in infancy and, 61, 62f violence exposure and, 204 Pregnancy, 22–36. see also Maternal depression; Prenatal experiences adaptation to, 29–33 depression during, 155, 159–160 developmental overview of, 23–25 family leave for new parents and, 146 fathers and, 28–29 intervention and, 33–35 parental substance abuse and, 171–177 psychological processes in, 25–28 risk factors and, 29–33 Prenatal experiences. see also Pregnancy attachment and, 26 brain development and, 41–45, 41f, 42f, 43f, 45f defining infant mental health and, 6 exposure to drugs and alcohol, 504–505 parental substance abuse and, 171–177 pharmacological interventions and, 518 selective prevention and, 16 sleep and, 362–363 stress responsivity and, 67 substance exposure, 10 Preschool Age Psychiatric Assessment (PAPA) disruptive behavior disorders and, 394, 395 overview, 234, 247, 394 posttraumatic stress disorder (PTSD) and, 255 Preschool and Early Childhood Functioning Assessment Scales (PECFAS), 416 Preschool Anxiety Scale (PAS), 289–290 Preterm delivery, 180–191 causes of, 181 defining, 181

619 incidence rates, 181–182 language disorders and, 324 mortality and survival rates of, 182 outcomes of, 182–184 overview, 134 parental discourse and, 186–188 parent–infant interactions and, 188–189 parent–staff relationships and, 190 posttraumatic stress disorder (PTSD) and, 31 representations of infant following hospital discharge, 190 Prevention adolescent motherhood and, 216–217 challenges in, 17–18 continuum of services model, 14–15, 14f early experiences and, 127–128 infant–caregiver relationship and, 6–7 Levels of Family Involvement for Infant Mental Health Model (LFI-IMH) and, 540t–541t obesity and, 388 pregnancy and, 34–35 preterm birth, 181 primary health care settings and, 557–559 sleep problems and, 373 successful programs for, 581–583 types of, 15–17 violence exposure and, 208 Primary care providers challenges and future directions for, 559–560 prevention and, 557–559 role of, 549–556, 550t, 554t treatment and intervention and, 557 Primary health care. see Health care “Primary maternal preoccupation” period, 24, 26 Proactive aggression, 399–400 Programmatic interventions, 436 Prolonged exposure therapy, 358 Propopiomelanocortin (POMC), 61–62, 62f Protective factors overview, 10 poverty and, 142–143 pregnancy and, 22–23 resilience and, 12 sleep problems and, 373 social competence and, 12 violence exposure and, 200 Psychoanalytic theory, 442 Psychodynamic model, 188 Psychological risk factors, 30 Psychopathology categorical diagnostic approaches and, 288–295 classification of, 285–297 early indicators of, 10–12 infant–caregiver relationship and, 8–9 overview, 281–283 in parents, 202–203, 240–241 during pregnancy, 29 sleep and, 368–370

620 Psychopathology (cont.) violence exposure and, 200–201 which classification system to use, 295–297 Psychosocial characteristics, 382t–385t Psychosocial evaluation, 490 Psychotherapy depression in preschoolers and, 416–417 overview, 435 pharmacological interventions and, 519–520 pregnancy and, 33–34 Psychotic disorders, 29 Psychotropic medication, 517. see also Pharmacological interventions Racial factors, 181–182, 238–240 Racism, 114 RAR acronym, 462 Reactive aggression, 399–400 Reactive attachment disorder (RAD) assessment and, 426–427 clinical perspectives of, 423–425, 427t course and prognosis associated with, 426 diagnosis and, 425–426, 427 intervention and, 427–430 overview, 421–422 relational context, 430–431 Reactivity, 85, 185 Reciprocal exchange, 90t Recognition, 91t Reflection, 96, 462, 545 Reflective functioning maternal, 487, 497 Mothers and Toddlers Program (MTP) and, 493–494, 497 pregnancy and, 27, 35 Reflective supervision, 538, 545–546 Regression, autism spectrum disorders and, 305 Rejection, 64, 66–67, 71–72 Relational context, 236 Relational disorders of attachment, 430–431 Relational ecologies, adolescent motherhood and, 224–225 Relational PTSD model, 200, 351–353 Relationship assessment, 232 Relationships adolescent motherhood and, 224–225 between consultant and consultee, 568 consultation and, 570 foster care and, 502–503 parent–staff following a preterm birth, 190 pregnancy and, 27–28 primary health care settings and, 550–551, 550t representations and, 95 violence exposure and, 205–208 Reliability of an assessment instrument, 243 Reorganization, external, 27–28

Subject Index Reorganization, internal, 25–27 Repetitive movements, 305 Representations. see also Internal working model child–parent psychotherapy and, 447–448 maternal, 486–487, 492–493, 497 Mothers and Toddlers Program (MTP) and, 492–493, 497 pregnancy and, 25–27 preterm birth and, 190 social development and, 94–96 violence exposure and, 206 Research Diagnostic Criteria— Preschool Age (RDC-PA), 292 Research needs, 18 Resilience, 12, 124, 143 Resistant, 93 Resistant attachment, 423 Resperidone, 523t. see also Pharmacological interventions Response cost, 371 Response formats of an assessment instrument, 245–246 Responsiveness, substance abusing parents and, 488 Rett syndrome, 369 Reward systems, 488 Reynell Developmental Language Scales, 307 Risk factors disruptive behavior disorders and, 402–403 failure to thrive and, 380–381 fight or flight responses and, 70–71 language disorders and, 322 maltreatment and, 202 maternal depression as, 155–162 obesity and, 386 overview, 7–8, 10, 133–134 parental substance abuse and, 176–177 poverty and, 142–143 pregnancy and, 22–23, 29–33 primary health care settings and, 550–551, 550t psychopathology and, 10–12 resilience and, 12 selective prevention and, 15–16 sleep problems and, 373 temperament and, 290–291 training and, 536 Risk model, 133 Routines, sleep problems and, 371 Safe haven, Circle of Security and, 453–461, 455f Safety, attachment relationships and, 205–206 Safety sensitivity, 458–461 Scheduled awakenings technique, 371 Schizophrenia, pharmacological interventions and, 523t School Readiness Tax Credits (SRTCs), 586–589, 587t, 588t Screening autism spectrum disorders and, 310–312 intellectual disabilities and, 334 in primary health care settings, 549–556, 550t, 554t

Screening Test for Autism in TwoYear-Olds (STAT), 307 Screening tools, 246–247 Secure attachment brain development and, 49–50 child–parent psychotherapy and, 17 Circle of Security and, 464 indicated preventions and, 16 overview, 422–423 social development and, 92 Secure base, 452 Selective preventions, 15, 15–16 Selective serotonin reuptake inhibitors (SSRIs), 517, 525. see also Pharmacological interventions Self psychology, 458 Self-assertion, 91t, 462–463 Self-awareness, 84 Self-concept, 91t Self-control, 68–69 Self-esteem, 159, 183 Self-harm, 11 Self-regulation brain development and, 48 caregiving relationship and, 8 maternal depression and, 156–157 social development and, 90t Sensitive periods, 46 Sensitivity of an assessment instrument, 244–245 caregiving and, 13, 94, 95–96, 488 in infants, 84–85 Sensorimotor problems, 182–183, 184–185 Sensory functioning, 47, 304–305, 378 Separation. see also Strange Situation Procedure (SSP) Circle of Security and, 456 Crowell Procedure and, 261 Mothers and Toddlers Program (MTP) and, 495 observational measures and, 254 preterm birth and, 187 social and emotional development and, 82 stress in infancy and, 66 Separation anxiety, 11, 93, 356 Separation sensitivity, 458–461 Sequenced Inventory of Communicative Development— Revised (SICD-R), 307 Sequenced treatment alternatives to relieve depression (STAR*D), 164–165 Serotonin emotional development and, 86 estrogen levels and, 30 fight or flight responses and, 70 parental substance abuse and, 174–175 resilience and, 143 stress in infancy and, 61 stress responsivity and, 68 Sertraline, 523t. see also Pharmacological interventions Sexual abuse, 202, 204, 354–355 Shame, parental substance abuse and, 175–176

Shared genetic vulnerability models, 351–352 Shyness, 68–69, 107 Sibling influences, 9, 225 Single parenthood, 29, 33 Sleep disorders, 200, 362–373 developmental context of, 362–364 feeding disorders and, 378 other disorders and, 368–370 overview, 283, 364–368 treatment and intervention and, 370–372 Sleep hygiene, 369 Sleep problems, 200 Sleep training, 370–371 Smiles, development of, 83–84 Smith–Magenis syndrome, 369 Sociability, 90t, 159 Social Communication Questionnaire (SCQ), 307 Social competence, 12 Social development, 80–97. see also Developmental processes assessment of, 235 failure to thrive and, 382t–385t overview, 89–97, 90t–91t poverty and, 138–144, 139f preterm birth and, 183 theoretical models for, 81–82 transitions in, 82–83 Social engagement, 84 Social fearfulness, 68–69 Social functioning, 304–306, 319t, 336 Social orientation, autism spectrum disorders and, 304 Social reciprocity, 378 Social referencing, 82–83, 84 Social Responsiveness Scale (SRS), 307 Social Security, 144–145 Social support, 30, 225, 444–445 Socialization, 110, 113 Social–pragmatic approaches, 326–327, 326t Sociocultural context. see also Cultural factors; Multicultural perspective intervention and, 107–109 overview, 104–117 theoretical models for, 109–117, 110f, 115f Socioeconomic status. see also Poverty adolescent motherhood and, 218 aggression and, 13 autism spectrum disorders and, 312 cultural factors and, 106 failure to thrive and, 380 observational measures and, 257t pregnancy and, 22 preterm birth and, 181–182 selective prevention and, 15–16 Socioemotional dysregulation, 504 Solution to Poverty campaign (SToP), 145 Special education services, 340–341 Specificity of an assessment instrument, 244–245 Speech delays, 504

Subject Index Stanford–Binet test, 333, 334 State Child Health Insurance Program (SCHIP), 145 Stereotyping, poverty and, 149 Steroid hormones, 61–62, 62f Stillbirth, 32 Still-Face Procedure emotion regulation and, 88–89 emotional development and, 87 infant depression and, 412 maternal depression and, 160–161 overview, 84 Stimulants, 524–525. see also Pharmacological interventions Strange Situation Procedure (SSP) Attachment and Biobehavioral Catch-Up (ABC) intervention and, 507 Circle of Security and, 453–454, 456, 465 overview, 254, 256t, 257t, 260, 422–423 social development and, 92 Stranger approach, 66 Strengths-based focus, 10, 296–297 Stress adolescent motherhood and, 218 child–parent psychotherapy and, 17 development and, 7 early experiences and, 121–122 during infancy, 59–74, 63–67, 64f, 67–73, 73–74 maternal depression and, 156–157 memory development and, 346–347 neural plasticity and, 47–51 parent–infant interactions and, 188 postpartum period and, 30 poverty and, 143 during pregnancy, 30 preterm birth and, 184, 189–190 violence exposure and, 201–202 Stress-and-coping models, 339 Stress–diathesis models, 159 Structuralist approaches, 83 Subjective experience, 568–569 Subjective well-being, 159 Substance abuse/use, parental, 171–177 effects of, 172–174 foster care and, 503, 504–505 intervention and, 436, 485–498 maternal affect regulation and, 487–489 Mothers and Toddlers Program (MTP) and, 489–496 overview, 134 predictors of, 174–176 refining and evaluating MTP, 496–498 risk factors and, 176–177 violence exposure and, 202–203 Suicidality, 31 Supervision, professional case example of, 572–573 Levels of Family Involvement for Infant Mental Health Model (LFI-IMH) and, 540t–542t overview, 17, 537–539, 545 as training, 543–544 Sympathetic nervous system, 201

621 Sympathetic–adrenomedullary system (SAM), 60–61 Symptomatology, 11, 12–14, 356, 398–400 Synaptogenesis, 44–45 Systems issues, 520–521, 546–547 Tantrums. see Temper tantrums Tax credits, 586–589, 587t, 588t TEACCH program, 308 Teen pregnancy, 29, 33, 34. see also Adolescent motherhood Temper tantrums, 11, 394, 400, 404t Temperament bedtime problems and, 366–367 caregiver report measures and, 240–241 emotional development and, 85–86 family functioning and, 471–472 insecure attachment and, 50 maternal depression and, 159 Mothers and Toddlers Program (MTP) and, 489–490 neurobiology of, 51–54 primary health care settings and, 550–551, 550t psychopathology and, 290–291, 295–296 risk factors and, 290–291 sleep problems and, 367–368 Temperament models, 81 Temporary Assistance to Needy Families (TANF), 148 Terrorism, effects of, 200 Test–retest reliability, 243 Theory of Mind, 303, 336 Therapeutic relationship, 461–462, 490–491 Threats, 64–67, 71–72 Title V, 149 Toddler–parent psychotherapy, 440. see also Child–parent psychotherapy Touchpoints intervention, 147, 557 Toxic stress, 7, 143 Training, professional, 533–547 accountability and, 543–547 ethical considerations, 546–547 goals for, 534–539, 535t Levels of Family Involvement for Infant Mental Health Model (LFI-IMH), 539–543, 540t–542t overview, 17 Trajectory model, 124 Transactional models, 81, 567–570 Transgenerational transmission, 207 Transitions, 82–83, 502 “Transmission gap”, 96 Trauma attachment, culture, and trauma (ACT) model and, 109–112, 110f child–parent psychotherapy and, 444 parental, 185–188 postpartum period and, 30 posttraumatic stress disorder (PTSD), 13 pregnancy and, 24, 30–34

622 Treatment. see also Child–parent psychotherapy; Circle of Security; Family therapy; Foster care; Intervention; Pharmacological interventions autism spectrum disorders and, 308–309, 308t depression in preschoolers and, 416–417 failure to thrive and, 386 Insightfulness Assessment (IA) and, 276–278 intellectual disabilities and, 340–341 maternal depression and, 163–164 Mothers and Toddlers Program (MTP), 489–496 obesity and, 388 overview, 16–17 parental substance abuse and, 177 posttraumatic stress disorder (PTSD) and, 357–358 preterm birth and, 181, 190–191 in primary health care settings, 557 sleep problems and, 370–372 strengths and, 296–297 training and, 536 violence exposure and, 208 Treatment planning caregiver report measures and, 239, 241–242 child–parent psychotherapy and, 445–448 Circle of Security and, 461–465 pharmacological interventions and, 521–522 Triadic family therapy, 468–481 case example of, 477–481 family factors and, 468–473

Subject Index Lausanne Trilogue Play (LTP), 477t overview, 435, 436 Tuskegee syphilis study, 114 Unavailability of parents, 66–67 United Nations Children’s Fund (UNICEF), 199 Universal preventions, 15 Unpredictable parenting, 161 Unresponsive parenting, 160–161, 215–216 Unstructured reflective developmental guidance, 443–444 Vaccinations, autism spectrum disorders and, 305 Validity of an assessment instrument, 243–244, 254 Valproate, 523t. see also Pharmacological interventions Valproate acid, 34 Values, cultural factors and, 107–108 Values of practitioners, 17, 108–109 Verbal abilities, 235–236 Video-based Intervention to Promote Positive Parenting, 16 Vineland Adaptive Behavior Scales, 307–308, 333 Vineland Adaptive Behavior Scales-II (Vineland-II), 238 Vineland Scales of Adaptive Functioning, 416 Violence exposure, 197–208 constitutional differences in infants and, 201–202 developmental context of, 202–205

epidemiology of, 198–199 nature of, 199–201 neurobiology and, 203–204, 206–208 overview, 134 parental substance abuse and, 176 prevention and intervention and, 208 relational context, 205–208 Vocabulary development, 323 Walden Program, 309 War, effects of, 200 Wechsler-based tests, 333 Well-child visits, 549–556, 550t, 554t Williams syndrome diagnosis and, 334–335 overview, 332–333, 336, 337– 338 sleep and, 369 Women, Infants, and Children Supplemental Nutrition Program (WIC), 145 “Wondering, not knowing” stance, 575–576 Working alliance, 17 Working Model of the Child Interview (WMCI), 189, 267, 352, 490 Zero to Three. see also Diagnostic Classification:0-3 (DC:0-3) cultural factors and, 108 defining infant mental health and, 6 diagnosis and, 12 early experiences and, 128 feeding disorders and, 378