The Case History of a Happy Child Malca K. Aleksandrowicz, Ph.D. Special Services, T o p e k a Public S c h o o l s
Dov R. Aleksandrowicz, M.D.* C. F. M e n n i n g e r M e m o r i a l H o s p i t a l
The authors describe the emotional development of a girl whose behavior was assessed on the Brazelton Scale at various neonatal stages eight times over the 1st month of her life, examined by a psychologist at the age of 12 months, and seen in a family interview at 22 months. The child's Brazelton Scale scores are compared with mean scores obtained in a previous study of 44 subjects. A profile of the girl's inborn characteristics emerges, including average motor ability, high responsiveness to social (human) stimuli and body contact, and high ability to reduce tension caused by unpleasant stimuli. This inborn profile is reflected in the follow-up at the age of 12 and 22 months: the child is average in motor development, but well above average in social skills, including ability to initiate interaction and evoke physical closeness. The parents are seen as tolerant and warm, but undemonstrative, and the parent-child interaction demonstrates how the girl's inborn characteristics play a role in molding the parents' attitudes in a direction more responsive to the child's emotional needs and thus achieving a successful "biological fit." The authors point out that a dynamic diagnostic formulation needs to include the innate characteristics of the subject and that one should recognize the role of the innate characteristics in the transference. ABSTRACT:
M o s t o f us agree t h a t i n b o r n f a c t o r s p l a y a n i m p o r t a n t r o l e i n psychic d e v e l o p m e n t a n d t h a t s u c h v a r i a b l e s as v i g o r o f i n s t i n c t or c h o i c e o f m e c h a n i s m s o f d e f e n s e are a t l e a s t p a r t l y d e t e r m i n e d b y c o n g e n i t a l factors. In actual clinical practice, however, one rarely finds diagnostic s t u d i e s o r t r e a t m e n t s u m m a r i e s w h e r e i n b o r n f a c t o r s are l i s t e d a m o n g the causes of a particular course of d e v e l o p m e n t . With the nota b l e e x c e p t i o n o f E s c a l o n a ' s [ 1 ] classic s t u d i e s , v e r y l i t t l e h a s b e e n w r i t t e n a b o u t the possibility t h a t p a r e n t a l a t t i t u d e s m a y be influe n c e d b y t h e u n i q u e i n d i v i d u a l q u a l i t i e s t h e c h i l d b r i n g s w i t h h i m int o t h e w o r l d . T h i s o m i s s i o n is l a r g e l y d u e t o t h e g r e a t d i f f i c u l t y i n *Reprint queries should be directed to Dr. Dov R. Aleksandrowicz, C. F. Menninger Memorial Hospital, Box 829, Topeka, Kansas 66601. The authors are indebted to numerous colleagues for their help and are especially grateful to Debbie's parents, whose names must remain disguised, for their sincere and selfless participation. 174
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collecting reliable and detailed data about individual characteristics of children from a very early age--before the child's behavior patterns are modified by environmental influences. Even in Escalona's studies, where infants were studied from the age of f our weeks, it is n o t possible to exclude entirely the " c o n t a m i n a t i n g " influence o f the envir o n m e n t on her subjects' behavior patterns. In a previous study one of us administered the Brazelton Neonatal Behavioral Assessment Scale [2] to 44 normal infants in t w o hospitals in Kansas [ 3 ] . The scale was administered daily f r o m birth through 5 days o f age, and again at 7, 10, and 28 days of age. The results were analyzed through factor analysis, and some clear-cut newborn behavioral patterns emerged. Certain behaviors, such as smiling and "cuddliness," tended to cluster around a c o m m o n identifiable factor. Some o f these factors and the behaviors t hat " l o a d e d " into t h e m were remarkably stable across testing days. These factors are: 1. " Or ien tatio n responsiveness" to h u m a n audi t ory and visual stimuli and to the sound and sight of a bell and rattle. This factor also included the Alertness score. 2. " H a b i t u a t i o n , " that is, inhibition of response to repetitive visual and auditory stimuli during sleep; "ignoring" a stimulus t h a t no longer provides the infant with new information. This "shut t i ng o u t " behavior is an i m p o r t a n t adaptive mechanism as the infant c a n n o t physically leave a situation that provides him with distressful stimulation. 3. "Excitability," which is presumably related to a diffuse excitat o r y state o f the central nervous system. Behaviors that load into this factor are: Irritability and Consolability, that is, a m o u n t of intervention needed to console the infant (Consolability loads into the "Excitability" factor in the opposite direction); Rapid changes in skin color, reflecting changes in peripheral blood circulation; Changes in states, that is, sleep to alert or sleep to cry and/ or activity; and Rapidity of buildup, that is, how many unpleasant stimuli p r o d u c e crying. 4. " M o t o r organization," which emerged more clearly f r o m the 10th day of testing on. Behaviors loading into it were: General tonus, Motor maturity, ability to hold head erect when Pulled to sit. At times, other behaviors such as Defensive movement, that is, removal o f a cloth p u t on the infant's face, Cuddliness, and Activity joined this factor. 5. " R e l a x a t i o n , " a cluster of items n o t in all cases consistently correlated during the testing sequence. At times, Smiling, in combination with Self-quieting activity and with Cuddliness, loaded into it. At other times, Hand-to-mogth facility joined it. The lack of a con-
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sistent p a t t e r n m a y be due to the fact t h a t (a) in the first m o n t h these m e c h a n i s m s are n o t y e t established and (b) obstetrical drugs interfere with the f u n c t i o n i n g o f these m e c h a n i s m s . The first five t o seven testing sessions using the B r a z e l t o n Scale were c o n d u c t e d in the hospital n u r s e r y and, with the e x c e p t i o n o f brief visits to their m o t h e r s , the babies were e x p o s e d t o practically the same e n v i r o n m e n t . Differences in behavior, especially in p a t t e r n s o f behavior clustered a r o u n d a specific f u n c t i o n (i.e., the factors), m a y t h e r e f o r e be a t t r i b u t e d to e q u i p m e n t , be it due t o genetic, intrauterine, or perinatal influences. Personality profiles o b t a i n e d later reflect a c o m b i n a t i o n o f innate characteristics (which c o n t i n u e t o unfold with the d e v e l o p m e n t a l sequence) and o f e n v i r o n m e n t a l influences, with the latter b e c o m i n g progressively m o r e p r o m i n e n t . We f o u n d t h a t the B r a z e l t o n N e o n a t a l Assessment Scale lends itself to a p p l i c a t i o n f r o m t h e first d a y of life and offers a q u a n t i t a t i v e assessment o f a wide range of behaviors and t h a t the " i n b o r n characteristic"* profile derived f r o m the scale can t h e n be i n c l u d e d in the analysis o f the parent-child relationship. The case we p r e s e n t here illustrates the favorable d e v e l o p m e n t of a child in terms o f the i n t e r a c t i o n b e t w e e n the i n b o r n qualities and the attitudes and personalities o f the parents. Debbie is a h a p p y little creature; for this reason we feel t h a t her case lends itself well t o p o i n t o u t h o w the individual characteristics of the child and the parents can m o l d the f a m i l y relationships in a w a y t h a t will p r o d u c e a successful biological " f i t . " Case R e p o r t
Family Background Debbie is the youngest of three siblings; at the time she was born her mother was 33 and her father 41. Mrs. A., Debbie's mother, was a science teacher but has not worked since the birth of her first child. Mrs. A. was the only child of working parents and was often left alone to take care of herself. She worked her way through teachers' college and was satisfied with her job, yet does not regret leaving it to keep house and take care of her family. Mr. and Mrs. A. dated for four years before getting married. Mr. A. was also an only child from a working family. As his parents had separated when he was young, he was brought up by his grandmother. Mr. A. was never very close to either of his parents. He described his father as a self-centered, materialistic man with little interest in the *"Inborn" as used here does not differentiate between characteristics of behavior determined genetically and those due to environmental factors during gestation and delivery.
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family, including the three grandchildren. Mr. A. has an administrative position in the air force; his job kept him away from the family, but in recent years he was given a position that allows him to spend most of his free time at home. Both Mr. and Mrs. A. have few hobbies and seem satisfied spending their leisure time together with the children.
Medical Data Mrs. A. has had three normal pregnancies and has no history of gynecological abnormalities. During her pregnancy with Debbie, the mother did not experience any health problems, and both labor and delivery were normal. About an hour before delivery, Mrs. A. received a 50-milligram dose of Mepergan (meperidine and promethazine), and during the delivery general anesthesia with nitrous oxide combined with Penthrane was administered, accompanied by pudendal block. It should be mentioned that our own [4] and other investigators' studies [5, 6, 7] have demonstrated that a combination of narcotics with a potentiating drug (such as a meperidine-promethazine combination), as well as general anesthesia, given to the mother, may exert significant depressive effects on the behavior of the neonate.
Debbie's Brazelton Scale Scores State (ranging from deep sleep through alertness to crying). During the first three days Debbie's predominant state was sleep or drowsing. From the fourth day on, she was either alert or could be brought to alertness easily. Neurological ratings. The initial pattern was scattered from hypo- to hyperreactivity, but by the fifth day only rooting and sucking reflexes were hyperactive. At one month the Babinsky reflex, Crawling, Incurvation reflex, Glabella reflex, and Tonic neck reflex were still hypoactive. Behavioral items ratings. On the first day, Debbie was drowsy, hypoactive, and hyporeactive, but irritable--all probably due to obstetrical drugs. Gradually, her motor organization improved (though Hand-to-mouth facility remained generally low) as did her responsiveness. Her scores on the items comprising "Orientation" and "Habituation" were usually well above average. The most remarkable finding was that Debbie's scores were consistently high on at least one of the items composing the "Relaxation" factor, that is, Cuddliness, Consolability, or Self-quieting ability, with correspondingly low scores on Irritability and Lability of skin color. Also, her responses to animate stimuli were consistently more pronounced than to inanimate stimuli. Summing up, we can say that Debbie was an infant with fair motor development, high ability to achieve relaxation (by herself or with help), and was highly responsive to physical contact and to the human voice and face. Interview at the Age o f One Year When Debbie was one year old, she was seen by a child psychologist who had no knowledge of the child's Brazelton Scale scores. The psychologist described Debbie as a responsive child who did not exhibit stranger anxiety (except for a
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slight diffidence at the beginning of the interview), invited and initiated social interaction, and was quite relaxed and happy. Debbie was also described as a persistent goal-oriented toddler. Debbie's vocabulary included five words, and she understood and responded to verbal orders such as "Bring me the dolly." At the time of the interview, Debbie could walk by herself but often resorted to crawling.
Family Interview When Debbie was 22 months old, the family was interviewed by a psychiatrist. During the interview, there was a feeling of quiet closeness between the members of Debbie's family, and the parents' statement that they seldom disagree regarding the children's upbringing came as no surprise to the examiner. There was an atmosphere of tolerance and sensitivity for each other's needs. For instance, Mrs. A. has little concern for regular meal schedules and does not make the meal a family event, but she perceives and respects the father's wish for scheduled family meals. The parents' tolerant attitude does not, however, prevent them from curbing the children and insisting on proper manners. The parents are aware of personality differences in their three children and consider these differences with an amused curiosity, but not in terms of the child's fulfilling or frustrating parental expectations. In general, there seems to be remarkably little pressure on the children to behave according to parental needs and, in terms of Kohut's [8] terminology, we may say that this is a family where the relationship of parents to children is dominated by object libido, and the narcissistic aspect of the relationship is minimal. In Mrs. A.'s words, "My own needs in life are fulfilled, and I do not expect the children to fulfill them." Another family characteristic is emotional restraint, especially on the part of Mrs. A. Though not initiating physical contact, the father took Debbie on his lap when she approached him. Mrs. A., in the same situation, responded with a smile and a pat on the girl's head. She was also much more reserved when describing the relationship between her and the husband. Benjamin, the oldest child, is five years old, a quiet, friendly, and sociable boy. He demonstrated curiosity about the visitors and attempted to get his share of attention, yet readily agreed to leave the room when his parents expressed their wish for more privacy in their discussion with the interviewer. He is described by his parents as being a cuddly and good-natured child. He cried a great deal in his infancy, but the mother attributed this to her own lack of experience. Benjamin shows a great liking for Debbie and, according to the mother, was always affectionate to the middle brother; "For some reason Benjamin always liked babies." Problems of envy were never conspicuous. Carl, the middle child, is three years old and different from Benjamin in behavior. He was much more demanding of attention during the interview and found excuses to return to the room when the parents did not want him around, to the point that both parents became impatient. The parents said that as a baby he did not like to be cuddled; he thrashed around, and was "stubborn." He had resisted bowel training until recently. He was also envious of both Benjamin and Debbie. The parents were able to use his strong competitiveness constructively; that is, they promised him he could take swimming lessons like Benjamin if he keeps himself clean. Carl seems less interested in other children than Benjamin and Debbie, and can spend long hours playing with picture puzzles. The parents
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(especially Mrs. A.) seemed to possess a great deal of flexibility and tolerance in accepting Carl's personality: greater interest in intellectual pursuits, less social warmth, and strong competitive traits. The impression conveyed during the examination, however, was that Carl was not happy and that there was considerable tension between him and the rest of the family. Debbie, who was 22 months old at the time of the interview, cried at the sight of strangers. However, she quickly responded to the mother's soothing words and continued to eat her ice cream with visible pleasure. Mrs. A. told us that Debbie is stranger-shy and cries when left by her parents, y e t she quickly becomes familiar with baby-sitters and/or other children. Indeed, within a few minutes, Debbie approached the interviewer, presented him with a word book, and clearly indicated her wish to play. After engaging each of the adults, and making a brief visit to her father's lap, Debbie proceeded to play with her brothers, engaging our attention only from time to time. She appeared relaxed and happy, able to play with toys by herself, yet she often used a toy as a means for contact with another person. Her vocabulary was age-appropriate; by the Vineland Scale [9] she was judged above average in social development.
Inborn Characteristics and Course o f Development At the age o f 22 months, Debbie's personality profile reveals an active, radiant toddler, persistently seducing the adults into social interaction, including frequent invitations for physical closeness. She is strikingly different from her brothe r s - t h e quiet, relaxed Benjamin and the demanding, unsatisfied Carl. Let us examine the data for a possible explanatory hypothesis. Had Debbie been referred for examination as a neurotic child, we would have been inclined to make pathogenetic formulations: the mother is well meaning but inhibited; she married late and after a long courtship; one may well suspect unresolved conflicts over the role of wife and mother which could be traced hypothetically to her own childhood. A similar analysis could be made of Mr. A.'s traumatic childhood. We would end up with what may be considered a fairly well-substantiated clinical history. Yet Debbie is not a neurotic child, and whatever limitations there may be in the family they do not seem to have affected her development unfavorably. One may hypothesize that the family dynamics are more favorable for the emotional development of a daughter than a son, but that fails to account for Benjamin's successful adaptation. One may also hypothesize that the emotional climate in the family was better when Debbie was born, or that Carl had experienced some emotional trauma at a critical developmental stage. All these explanations are entirely possible, but require postulating additional facts for which there is no evidence. Would it be possible to understand Debbie's development in the context of the available data, namely, her individual innate characteristics? Debbie's endowment profile indicates above average ability to cope with states of displeasure and tension, either on her own (Self-quieting) or in response to contact (Consolability, Cuddliness). She was vigorous in sucking, rooting, crying, and defensive movement, but her general motility was not precocious. She also showed good response to stimuli ("Orientation responsiveness") and an ability to control stimulus input ("Habituation") This vigorous child, with a seemingly strong oral drive, was born to a considerate but reserved mother. Debbie had probably experienced more than a fair share
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of frustration. Two innate features that we find in Debbie's profile, namely, very high ability to cope with tension ("Relaxation" and "Habituation") and alertness to sensory stimuli ("Orientation responsiveness"), may well have contributed, perhaps crucially, to the fact that in spite of frustrations, Debbie successfully accomplished the early tasks of ego integration and object integration. The ability to reduce tension helped to prevent the flooding of the ego by anxiety, and perceptual alertness may have facilitated the integration of part-objects. The mother-child relationship, however, is not just a simple quantitative formula in the sense that a child needs some innate strength to cope with shortcomings of mothering. The relationship is a mutual one, and the child's behavior contributes a great deal to shaping the pattern of mothering. Even when frustrated, Debbie did not become a whining, cranky baby, which few mothers can wholeheartedly fondle. By responding quickly and affectionately to being held (Cuddliness and Consolability), she actually "reinforced" the mother to use physical contact. Mrs. A., in fact, commented that she often picked the baby up "because Debbie would quiet down so easily." Later on Debbie developed her own style to cope with mother's reserve--a style based on initiative, active approach, and seduction. "Debbie will not be satisfied with a kiss unless it is on the mouth," Mrs. A. commented. The parents' tolerance and flexibility, in turn, contributed to the success of Debbie's active approach. Conclusions T h e r e l a t i o n s h i p b e t w e e n i n b o r n e n d o w m e n t and e n v i r o n m e n t a l influences ( o f which p a r e n t a l a t t i t u d e s are the m o s t i m p o r t a n t ) can be d e s c r i b e d in t e r m s o f a " c o m p l i m e n t a r y scale"; t h a t is, a h e a l t h y e n d o w m e n t m a y c o m p e n s a t e f o r u n f a v o r a b l e e n v i r o n m e n t a n d vice versa. We suggest a m o r e c o m p l e x m o d e l of " b i o l o g i c a l f i t " t o e m p h a size t h a t n e i t h e r p a r e n t a l a t t i t u d e s n o r i n b o r n qualities are i m m u t a ble, b u t t h a t t h e y i n f l u e n c e each o t h e r in a process o f r e c i p r o c a l stimulation, f r u s t r a t i o n , a n d gratification. In this sense the child creates, in p a r t , his o w n e n v i r o n m e n t . A h e a l t h y d e v e l o p m e n t , t h a t is, a successful " b i o l o g i c a l fit," occurs w h e n t h e s t r e n g t h s and w e a k n e s s e s o f b o t h child and p a r e n t s can be c o m p e n s a t e d f o r in a m u t u a l l y enjoyable w a y . This view o f d e v e l o p m e n t implies t h a t in f o r m u l a t i n g a d y n a m i c diagnosis one s h o u l d at least a t t e m p t to p r o c u r e d a t a a b o u t a p e r s o n ' s i n b o r n characteristics. A l t h o u g h p a r e n t a l d e s c r i p t i o n s o f early develo p m e n t are s u b j e c t t o d i s t o r t i o n s , reflecting conflicts and p r o j e c t i o n s , t h e y o u g h t to be c a r e f u l l y e x a m i n e d f o r i n f o r m a t i o n t h a t m a y shed light on i n b o r n characteristics. T h e u n d e r s t a n d i n g o f t r a n s f e r e n c e s h o u l d also be b a s e d o n this d e v e l o p m e n t a l v i e w p o i n t , and o n e m a y a s s u m e t h a t w h a t is b e i n g p l a y e d o u t in the t h e r a p e u t i c regression reflects t h r e e factors: (a) actual early life events and p a r e n t a l a t t i t u d e s ; (b) f a n t a s i e d p a r e n t a l images, including p r o j e c t i o n o f p a r t - o b j e c t s ; a n d (c) infantile e x p r e s s i o n s o f i n n a t e qualities and dispositions.
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The development of reliable methods for quantitative study of neonatal behavior and the rapid growth of knowledge about neonates a n d i n f a n t s o f f e r a n o p p o r t u n i t y t o m o v e t h e issue o f i n b o r n p e r s o n ality factors from the realm of theoretical postulates to the realm of research and clinical practice. References 1. Escalona SK: The Roots o f Individuality. Chicago, Aldine Publishing Co, 1968. 2. Brazelton TB: Neonatal Behavioral Assessment Scale. Philadelphia, Lippincott, 1973. 3. Aleksandrowicz MK: Neonatal behavioral patterns and their relation to obstetrical medication. Doctoral dissertation, University of Kansas, 1973. 4. Aleksandrowicz MK, Aleksandrowicz DR: Obstetrical pain-relieving drugs as predictors of infant behavior variability. Child Dev 45, 1974 (in press). 5. Conway EF, Brackbill Y: In WA Bowes et al: The effect of obstetrical medication on fetus and infant. Monogr Soc Res Child Dev 35: 24-34, 1970. 6. Brackbill Y, Kane J, Manniello RL, et al: Obstetric meperidine usage and assessment of neonatal status. Anesthesiol 40:116-20, 1974. 7. Brackbill Y, Kane J, Manniello RL, et al: A m e r J Obstet Gynecol 118:37784, 1974. 8. Kohut H: Thoughts on narcissism and narcissistic rage. Psychoanal Study o f the Child 27:360-400, 1973. 9. Doll EA: Vineland Social Maturity Scale: The Measurement o f Social Competence. Minneapolis, Educational Test Bureau, Educational Publishers, 1953.
Dov R. Aleksandrowicz, M.D.* C. F. M e n n i n g e r M e m o r i a l H o s p i t a l
The authors describe the emotional development of a girl whose behavior was assessed on the Brazelton Scale at various neonatal stages eight times over the 1st month of her life, examined by a psychologist at the age of 12 months, and seen in a family interview at 22 months. The child's Brazelton Scale scores are compared with mean scores obtained in a previous study of 44 subjects. A profile of the girl's inborn characteristics emerges, including average motor ability, high responsiveness to social (human) stimuli and body contact, and high ability to reduce tension caused by unpleasant stimuli. This inborn profile is reflected in the follow-up at the age of 12 and 22 months: the child is average in motor development, but well above average in social skills, including ability to initiate interaction and evoke physical closeness. The parents are seen as tolerant and warm, but undemonstrative, and the parent-child interaction demonstrates how the girl's inborn characteristics play a role in molding the parents' attitudes in a direction more responsive to the child's emotional needs and thus achieving a successful "biological fit." The authors point out that a dynamic diagnostic formulation needs to include the innate characteristics of the subject and that one should recognize the role of the innate characteristics in the transference. ABSTRACT:
M o s t o f us agree t h a t i n b o r n f a c t o r s p l a y a n i m p o r t a n t r o l e i n psychic d e v e l o p m e n t a n d t h a t s u c h v a r i a b l e s as v i g o r o f i n s t i n c t or c h o i c e o f m e c h a n i s m s o f d e f e n s e are a t l e a s t p a r t l y d e t e r m i n e d b y c o n g e n i t a l factors. In actual clinical practice, however, one rarely finds diagnostic s t u d i e s o r t r e a t m e n t s u m m a r i e s w h e r e i n b o r n f a c t o r s are l i s t e d a m o n g the causes of a particular course of d e v e l o p m e n t . With the nota b l e e x c e p t i o n o f E s c a l o n a ' s [ 1 ] classic s t u d i e s , v e r y l i t t l e h a s b e e n w r i t t e n a b o u t the possibility t h a t p a r e n t a l a t t i t u d e s m a y be influe n c e d b y t h e u n i q u e i n d i v i d u a l q u a l i t i e s t h e c h i l d b r i n g s w i t h h i m int o t h e w o r l d . T h i s o m i s s i o n is l a r g e l y d u e t o t h e g r e a t d i f f i c u l t y i n *Reprint queries should be directed to Dr. Dov R. Aleksandrowicz, C. F. Menninger Memorial Hospital, Box 829, Topeka, Kansas 66601. The authors are indebted to numerous colleagues for their help and are especially grateful to Debbie's parents, whose names must remain disguised, for their sincere and selfless participation. 174
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collecting reliable and detailed data about individual characteristics of children from a very early age--before the child's behavior patterns are modified by environmental influences. Even in Escalona's studies, where infants were studied from the age of f our weeks, it is n o t possible to exclude entirely the " c o n t a m i n a t i n g " influence o f the envir o n m e n t on her subjects' behavior patterns. In a previous study one of us administered the Brazelton Neonatal Behavioral Assessment Scale [2] to 44 normal infants in t w o hospitals in Kansas [ 3 ] . The scale was administered daily f r o m birth through 5 days o f age, and again at 7, 10, and 28 days of age. The results were analyzed through factor analysis, and some clear-cut newborn behavioral patterns emerged. Certain behaviors, such as smiling and "cuddliness," tended to cluster around a c o m m o n identifiable factor. Some o f these factors and the behaviors t hat " l o a d e d " into t h e m were remarkably stable across testing days. These factors are: 1. " Or ien tatio n responsiveness" to h u m a n audi t ory and visual stimuli and to the sound and sight of a bell and rattle. This factor also included the Alertness score. 2. " H a b i t u a t i o n , " that is, inhibition of response to repetitive visual and auditory stimuli during sleep; "ignoring" a stimulus t h a t no longer provides the infant with new information. This "shut t i ng o u t " behavior is an i m p o r t a n t adaptive mechanism as the infant c a n n o t physically leave a situation that provides him with distressful stimulation. 3. "Excitability," which is presumably related to a diffuse excitat o r y state o f the central nervous system. Behaviors that load into this factor are: Irritability and Consolability, that is, a m o u n t of intervention needed to console the infant (Consolability loads into the "Excitability" factor in the opposite direction); Rapid changes in skin color, reflecting changes in peripheral blood circulation; Changes in states, that is, sleep to alert or sleep to cry and/ or activity; and Rapidity of buildup, that is, how many unpleasant stimuli p r o d u c e crying. 4. " M o t o r organization," which emerged more clearly f r o m the 10th day of testing on. Behaviors loading into it were: General tonus, Motor maturity, ability to hold head erect when Pulled to sit. At times, other behaviors such as Defensive movement, that is, removal o f a cloth p u t on the infant's face, Cuddliness, and Activity joined this factor. 5. " R e l a x a t i o n , " a cluster of items n o t in all cases consistently correlated during the testing sequence. At times, Smiling, in combination with Self-quieting activity and with Cuddliness, loaded into it. At other times, Hand-to-mogth facility joined it. The lack of a con-
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sistent p a t t e r n m a y be due to the fact t h a t (a) in the first m o n t h these m e c h a n i s m s are n o t y e t established and (b) obstetrical drugs interfere with the f u n c t i o n i n g o f these m e c h a n i s m s . The first five t o seven testing sessions using the B r a z e l t o n Scale were c o n d u c t e d in the hospital n u r s e r y and, with the e x c e p t i o n o f brief visits to their m o t h e r s , the babies were e x p o s e d t o practically the same e n v i r o n m e n t . Differences in behavior, especially in p a t t e r n s o f behavior clustered a r o u n d a specific f u n c t i o n (i.e., the factors), m a y t h e r e f o r e be a t t r i b u t e d to e q u i p m e n t , be it due t o genetic, intrauterine, or perinatal influences. Personality profiles o b t a i n e d later reflect a c o m b i n a t i o n o f innate characteristics (which c o n t i n u e t o unfold with the d e v e l o p m e n t a l sequence) and o f e n v i r o n m e n t a l influences, with the latter b e c o m i n g progressively m o r e p r o m i n e n t . We f o u n d t h a t the B r a z e l t o n N e o n a t a l Assessment Scale lends itself to a p p l i c a t i o n f r o m t h e first d a y of life and offers a q u a n t i t a t i v e assessment o f a wide range of behaviors and t h a t the " i n b o r n characteristic"* profile derived f r o m the scale can t h e n be i n c l u d e d in the analysis o f the parent-child relationship. The case we p r e s e n t here illustrates the favorable d e v e l o p m e n t of a child in terms o f the i n t e r a c t i o n b e t w e e n the i n b o r n qualities and the attitudes and personalities o f the parents. Debbie is a h a p p y little creature; for this reason we feel t h a t her case lends itself well t o p o i n t o u t h o w the individual characteristics of the child and the parents can m o l d the f a m i l y relationships in a w a y t h a t will p r o d u c e a successful biological " f i t . " Case R e p o r t
Family Background Debbie is the youngest of three siblings; at the time she was born her mother was 33 and her father 41. Mrs. A., Debbie's mother, was a science teacher but has not worked since the birth of her first child. Mrs. A. was the only child of working parents and was often left alone to take care of herself. She worked her way through teachers' college and was satisfied with her job, yet does not regret leaving it to keep house and take care of her family. Mr. and Mrs. A. dated for four years before getting married. Mr. A. was also an only child from a working family. As his parents had separated when he was young, he was brought up by his grandmother. Mr. A. was never very close to either of his parents. He described his father as a self-centered, materialistic man with little interest in the *"Inborn" as used here does not differentiate between characteristics of behavior determined genetically and those due to environmental factors during gestation and delivery.
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family, including the three grandchildren. Mr. A. has an administrative position in the air force; his job kept him away from the family, but in recent years he was given a position that allows him to spend most of his free time at home. Both Mr. and Mrs. A. have few hobbies and seem satisfied spending their leisure time together with the children.
Medical Data Mrs. A. has had three normal pregnancies and has no history of gynecological abnormalities. During her pregnancy with Debbie, the mother did not experience any health problems, and both labor and delivery were normal. About an hour before delivery, Mrs. A. received a 50-milligram dose of Mepergan (meperidine and promethazine), and during the delivery general anesthesia with nitrous oxide combined with Penthrane was administered, accompanied by pudendal block. It should be mentioned that our own [4] and other investigators' studies [5, 6, 7] have demonstrated that a combination of narcotics with a potentiating drug (such as a meperidine-promethazine combination), as well as general anesthesia, given to the mother, may exert significant depressive effects on the behavior of the neonate.
Debbie's Brazelton Scale Scores State (ranging from deep sleep through alertness to crying). During the first three days Debbie's predominant state was sleep or drowsing. From the fourth day on, she was either alert or could be brought to alertness easily. Neurological ratings. The initial pattern was scattered from hypo- to hyperreactivity, but by the fifth day only rooting and sucking reflexes were hyperactive. At one month the Babinsky reflex, Crawling, Incurvation reflex, Glabella reflex, and Tonic neck reflex were still hypoactive. Behavioral items ratings. On the first day, Debbie was drowsy, hypoactive, and hyporeactive, but irritable--all probably due to obstetrical drugs. Gradually, her motor organization improved (though Hand-to-mouth facility remained generally low) as did her responsiveness. Her scores on the items comprising "Orientation" and "Habituation" were usually well above average. The most remarkable finding was that Debbie's scores were consistently high on at least one of the items composing the "Relaxation" factor, that is, Cuddliness, Consolability, or Self-quieting ability, with correspondingly low scores on Irritability and Lability of skin color. Also, her responses to animate stimuli were consistently more pronounced than to inanimate stimuli. Summing up, we can say that Debbie was an infant with fair motor development, high ability to achieve relaxation (by herself or with help), and was highly responsive to physical contact and to the human voice and face. Interview at the Age o f One Year When Debbie was one year old, she was seen by a child psychologist who had no knowledge of the child's Brazelton Scale scores. The psychologist described Debbie as a responsive child who did not exhibit stranger anxiety (except for a
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slight diffidence at the beginning of the interview), invited and initiated social interaction, and was quite relaxed and happy. Debbie was also described as a persistent goal-oriented toddler. Debbie's vocabulary included five words, and she understood and responded to verbal orders such as "Bring me the dolly." At the time of the interview, Debbie could walk by herself but often resorted to crawling.
Family Interview When Debbie was 22 months old, the family was interviewed by a psychiatrist. During the interview, there was a feeling of quiet closeness between the members of Debbie's family, and the parents' statement that they seldom disagree regarding the children's upbringing came as no surprise to the examiner. There was an atmosphere of tolerance and sensitivity for each other's needs. For instance, Mrs. A. has little concern for regular meal schedules and does not make the meal a family event, but she perceives and respects the father's wish for scheduled family meals. The parents' tolerant attitude does not, however, prevent them from curbing the children and insisting on proper manners. The parents are aware of personality differences in their three children and consider these differences with an amused curiosity, but not in terms of the child's fulfilling or frustrating parental expectations. In general, there seems to be remarkably little pressure on the children to behave according to parental needs and, in terms of Kohut's [8] terminology, we may say that this is a family where the relationship of parents to children is dominated by object libido, and the narcissistic aspect of the relationship is minimal. In Mrs. A.'s words, "My own needs in life are fulfilled, and I do not expect the children to fulfill them." Another family characteristic is emotional restraint, especially on the part of Mrs. A. Though not initiating physical contact, the father took Debbie on his lap when she approached him. Mrs. A., in the same situation, responded with a smile and a pat on the girl's head. She was also much more reserved when describing the relationship between her and the husband. Benjamin, the oldest child, is five years old, a quiet, friendly, and sociable boy. He demonstrated curiosity about the visitors and attempted to get his share of attention, yet readily agreed to leave the room when his parents expressed their wish for more privacy in their discussion with the interviewer. He is described by his parents as being a cuddly and good-natured child. He cried a great deal in his infancy, but the mother attributed this to her own lack of experience. Benjamin shows a great liking for Debbie and, according to the mother, was always affectionate to the middle brother; "For some reason Benjamin always liked babies." Problems of envy were never conspicuous. Carl, the middle child, is three years old and different from Benjamin in behavior. He was much more demanding of attention during the interview and found excuses to return to the room when the parents did not want him around, to the point that both parents became impatient. The parents said that as a baby he did not like to be cuddled; he thrashed around, and was "stubborn." He had resisted bowel training until recently. He was also envious of both Benjamin and Debbie. The parents were able to use his strong competitiveness constructively; that is, they promised him he could take swimming lessons like Benjamin if he keeps himself clean. Carl seems less interested in other children than Benjamin and Debbie, and can spend long hours playing with picture puzzles. The parents
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(especially Mrs. A.) seemed to possess a great deal of flexibility and tolerance in accepting Carl's personality: greater interest in intellectual pursuits, less social warmth, and strong competitive traits. The impression conveyed during the examination, however, was that Carl was not happy and that there was considerable tension between him and the rest of the family. Debbie, who was 22 months old at the time of the interview, cried at the sight of strangers. However, she quickly responded to the mother's soothing words and continued to eat her ice cream with visible pleasure. Mrs. A. told us that Debbie is stranger-shy and cries when left by her parents, y e t she quickly becomes familiar with baby-sitters and/or other children. Indeed, within a few minutes, Debbie approached the interviewer, presented him with a word book, and clearly indicated her wish to play. After engaging each of the adults, and making a brief visit to her father's lap, Debbie proceeded to play with her brothers, engaging our attention only from time to time. She appeared relaxed and happy, able to play with toys by herself, yet she often used a toy as a means for contact with another person. Her vocabulary was age-appropriate; by the Vineland Scale [9] she was judged above average in social development.
Inborn Characteristics and Course o f Development At the age o f 22 months, Debbie's personality profile reveals an active, radiant toddler, persistently seducing the adults into social interaction, including frequent invitations for physical closeness. She is strikingly different from her brothe r s - t h e quiet, relaxed Benjamin and the demanding, unsatisfied Carl. Let us examine the data for a possible explanatory hypothesis. Had Debbie been referred for examination as a neurotic child, we would have been inclined to make pathogenetic formulations: the mother is well meaning but inhibited; she married late and after a long courtship; one may well suspect unresolved conflicts over the role of wife and mother which could be traced hypothetically to her own childhood. A similar analysis could be made of Mr. A.'s traumatic childhood. We would end up with what may be considered a fairly well-substantiated clinical history. Yet Debbie is not a neurotic child, and whatever limitations there may be in the family they do not seem to have affected her development unfavorably. One may hypothesize that the family dynamics are more favorable for the emotional development of a daughter than a son, but that fails to account for Benjamin's successful adaptation. One may also hypothesize that the emotional climate in the family was better when Debbie was born, or that Carl had experienced some emotional trauma at a critical developmental stage. All these explanations are entirely possible, but require postulating additional facts for which there is no evidence. Would it be possible to understand Debbie's development in the context of the available data, namely, her individual innate characteristics? Debbie's endowment profile indicates above average ability to cope with states of displeasure and tension, either on her own (Self-quieting) or in response to contact (Consolability, Cuddliness). She was vigorous in sucking, rooting, crying, and defensive movement, but her general motility was not precocious. She also showed good response to stimuli ("Orientation responsiveness") and an ability to control stimulus input ("Habituation") This vigorous child, with a seemingly strong oral drive, was born to a considerate but reserved mother. Debbie had probably experienced more than a fair share
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of frustration. Two innate features that we find in Debbie's profile, namely, very high ability to cope with tension ("Relaxation" and "Habituation") and alertness to sensory stimuli ("Orientation responsiveness"), may well have contributed, perhaps crucially, to the fact that in spite of frustrations, Debbie successfully accomplished the early tasks of ego integration and object integration. The ability to reduce tension helped to prevent the flooding of the ego by anxiety, and perceptual alertness may have facilitated the integration of part-objects. The mother-child relationship, however, is not just a simple quantitative formula in the sense that a child needs some innate strength to cope with shortcomings of mothering. The relationship is a mutual one, and the child's behavior contributes a great deal to shaping the pattern of mothering. Even when frustrated, Debbie did not become a whining, cranky baby, which few mothers can wholeheartedly fondle. By responding quickly and affectionately to being held (Cuddliness and Consolability), she actually "reinforced" the mother to use physical contact. Mrs. A., in fact, commented that she often picked the baby up "because Debbie would quiet down so easily." Later on Debbie developed her own style to cope with mother's reserve--a style based on initiative, active approach, and seduction. "Debbie will not be satisfied with a kiss unless it is on the mouth," Mrs. A. commented. The parents' tolerance and flexibility, in turn, contributed to the success of Debbie's active approach. Conclusions T h e r e l a t i o n s h i p b e t w e e n i n b o r n e n d o w m e n t and e n v i r o n m e n t a l influences ( o f which p a r e n t a l a t t i t u d e s are the m o s t i m p o r t a n t ) can be d e s c r i b e d in t e r m s o f a " c o m p l i m e n t a r y scale"; t h a t is, a h e a l t h y e n d o w m e n t m a y c o m p e n s a t e f o r u n f a v o r a b l e e n v i r o n m e n t a n d vice versa. We suggest a m o r e c o m p l e x m o d e l of " b i o l o g i c a l f i t " t o e m p h a size t h a t n e i t h e r p a r e n t a l a t t i t u d e s n o r i n b o r n qualities are i m m u t a ble, b u t t h a t t h e y i n f l u e n c e each o t h e r in a process o f r e c i p r o c a l stimulation, f r u s t r a t i o n , a n d gratification. In this sense the child creates, in p a r t , his o w n e n v i r o n m e n t . A h e a l t h y d e v e l o p m e n t , t h a t is, a successful " b i o l o g i c a l fit," occurs w h e n t h e s t r e n g t h s and w e a k n e s s e s o f b o t h child and p a r e n t s can be c o m p e n s a t e d f o r in a m u t u a l l y enjoyable w a y . This view o f d e v e l o p m e n t implies t h a t in f o r m u l a t i n g a d y n a m i c diagnosis one s h o u l d at least a t t e m p t to p r o c u r e d a t a a b o u t a p e r s o n ' s i n b o r n characteristics. A l t h o u g h p a r e n t a l d e s c r i p t i o n s o f early develo p m e n t are s u b j e c t t o d i s t o r t i o n s , reflecting conflicts and p r o j e c t i o n s , t h e y o u g h t to be c a r e f u l l y e x a m i n e d f o r i n f o r m a t i o n t h a t m a y shed light on i n b o r n characteristics. T h e u n d e r s t a n d i n g o f t r a n s f e r e n c e s h o u l d also be b a s e d o n this d e v e l o p m e n t a l v i e w p o i n t , and o n e m a y a s s u m e t h a t w h a t is b e i n g p l a y e d o u t in the t h e r a p e u t i c regression reflects t h r e e factors: (a) actual early life events and p a r e n t a l a t t i t u d e s ; (b) f a n t a s i e d p a r e n t a l images, including p r o j e c t i o n o f p a r t - o b j e c t s ; a n d (c) infantile e x p r e s s i o n s o f i n n a t e qualities and dispositions.
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The development of reliable methods for quantitative study of neonatal behavior and the rapid growth of knowledge about neonates a n d i n f a n t s o f f e r a n o p p o r t u n i t y t o m o v e t h e issue o f i n b o r n p e r s o n ality factors from the realm of theoretical postulates to the realm of research and clinical practice. References 1. Escalona SK: The Roots o f Individuality. Chicago, Aldine Publishing Co, 1968. 2. Brazelton TB: Neonatal Behavioral Assessment Scale. Philadelphia, Lippincott, 1973. 3. Aleksandrowicz MK: Neonatal behavioral patterns and their relation to obstetrical medication. Doctoral dissertation, University of Kansas, 1973. 4. Aleksandrowicz MK, Aleksandrowicz DR: Obstetrical pain-relieving drugs as predictors of infant behavior variability. Child Dev 45, 1974 (in press). 5. Conway EF, Brackbill Y: In WA Bowes et al: The effect of obstetrical medication on fetus and infant. Monogr Soc Res Child Dev 35: 24-34, 1970. 6. Brackbill Y, Kane J, Manniello RL, et al: Obstetric meperidine usage and assessment of neonatal status. Anesthesiol 40:116-20, 1974. 7. Brackbill Y, Kane J, Manniello RL, et al: A m e r J Obstet Gynecol 118:37784, 1974. 8. Kohut H: Thoughts on narcissism and narcissistic rage. Psychoanal Study o f the Child 27:360-400, 1973. 9. Doll EA: Vineland Social Maturity Scale: The Measurement o f Social Competence. Minneapolis, Educational Test Bureau, Educational Publishers, 1953.
