Am
The
Role
of Infant
BY GEORGE W. GREENMAN, CECILY LEGG, M.S.W., AND
in Child
Observation M.D.,
RONALD
IVAN
SHERICK,
BENSON,
M.D.,
J Psychiatry
Psychiatry
135:10,
October
1978
Training
LEXINGTON
GRAPENTINE,
M.D.,
PH.D.
in didactic baby and evaluation
The authors discuss the role ofinfant observation in the training ofchild psychiatrists, emphasizing the overriding importance ofthe subtle but crucial interactions in the mother-infant relationship. infant observation is valuable in preparing the student as an observer ofbehavior, and developmental concepts are taught and learned more easily in programs that provide opportunitiesfor observing normal infants. The infant study program in the Department of Psychiatry ofthe University ofMichigan Medical Center is presented as a model.
lectures. The student rarely even more rarely is assigned or treatment.
DEVELOPMENT
OF
AN
INFANT
sees a normal an infant for
OBSERVATION
PROGRAM
BECAUSE OF the numerous reprint requests for articles on infant and early childhood research published in the Journal of the American Academy of Child Psychiatry the editors of that journal published a collection of many of them, entitled (provocatively) infant Psychiatry, A New Synthesis The editors proposed a new subspecialty of infant psychiatry and argued that child psychiatry training is a logical starting place for such a program (1). An upsurge of interest in the first year of life is evident from the large number of recent books and articles dealing with various aspects of infancy (2-6). Selma Fraiberg addressed the problem of who should provide diagnostic assessment and treatment to infants and their families (unpublished manuscript). She advocates a subspecialty in infant mental health for all professionals who serve babies and their parents, including psychiatrists, pediatricians, pediatric and psychiatric nurses, psychologists, and social workers. One of the possible reasons for the call for infant psychiatrists is that most child psychiatry training programs pay scant attention to infancy (7). At best, normal and pathological infant development are presented
Because of the need for more experience with infants and their families, infant observation became part of the two-year program in child and adolescent psychiatry at the University of Michigan in 1974. Couples having their first baby are invited to participate in the program on the basis of their own interest, the probability of a stable family situation, the likelihood of at least a year’s residence in the area, a dclivcry date in September, and the absence of overt psychopathology. Preference is given to first-born infants for several reasons. The student has the opportunity to observe and comprehend, in its incipiency, the cornplex phenomenon of parenting. Inclusion of only single-child families serves as a means of limiting somewhat the number of variables (always large) in the study population. More pragmatically, the singlechild family tends to have greater freedom and flexibility for scheduling appointments to synchronize with the trainee’s limited availability. An additional advantage in the use of single-child families is that, for beginning observers, it is generally easier to carry out an infant observation without the distractions provided by older siblings. Stable couples give the resident a greater opportunity to observe the unfolding of a relatively normal family and, on a more practical level, tend to be home when home visits are scheduled and to keep appointments for office visits. The expectant couples are referred to us by other participants in the program or are recruited by senior staff in contacts with childbirth preparation classes, such as Lamaze.
This
PRENATAL
,
.
is a revised
and combined version of three papers meeting of the American Psychiatric May 10-14, 1976.
the 129th annual Miami,
Fla.,
presented Association,
at
The authors of Michigan
are with the Child Analytic Study Program, University Medical Center, Children’s Psychiatric Hospital, Ann Arbor, Mich. 48109, where Dr. Greenman is Lecturer in Psychiatry; Dr. Benson is Clinical Associate Professor of Psychiatry and Director, Outpatient Program; Dr. Grapentine is Instructor of Psychiatry; Miss Legg is Lecturer in Mental Health; and Dr. Sherick is Clinical Assistant Professor of Psychology in Psychiatry.
1174
0002-953X/78/OOlO-l
174$0.50
© 1978
AND
PERINATAL
PERIOD
Each child psychiatry fellow is assigned a family in July at the beginning of his second year of child psychiatric training. He is asked to interview the couple separately and conjointly in the weeks before the baby is bonn, obtaining a detailed personal history from husband and wife. In addition, an attempt is made during American
Psychiatric
Association
Am
J Psychiatry
135:10,
October
1978
the interviews to gather data concerning the myriad hopes, expectations, and worries surrounding the unborn child. These parental fantasies, both positive and negative, give the resident his first revealing glimpse of the elusive ethos into which the infant will be born. We have found, for example, that important expectations exist regarding the sex, intelligence, motor ability, and physical attractiveness of the child. In the months to come, this fantasy material can be compared with the realities of the young child’s endowment. The attitudinal changes of the parents in the face of this reality can be followed. Often, from the earliest days parents attempt to shape the child to fit their conscious and unconscious expectations. The student is in a good position to learn and to intervene if indicated because he knows the prebirth fantasies. The resident is encouraged to obtain permission to be present at the birth. The delivery experience, which usually includes the fathers, affords the resident a unique opportunity to observe the earliest motherchild-father interactions. At the same time, he can be aware of any complications in the birth process and can assess the newborn along several measures, from the Apgar rating to visual tracking. Also, the resident’s knowledge of obstetrics is occasionally a source of support to the father. Most important, however, is the direct observation of the initial dialogue between mother and child. The mother’s affective state and her comments about the infant can be most revealing, and the newborn’s responses when the mother holds him can be an important index of their future interactions (8). While they are still in the hospital, the mother and infant are visited several times. This gives the resident a chance to explore in depth the mother’s attitudes toward the newborn and to contrast them with her earlien wishes and fantasies. At breast or bottle the child is observed in the mother’s care, and many of her basic nurturing skills come to light. The resident notes the baby’s beginning ability to integrate the complex physiological functions of sucking, swallowing, and breathing that comprise nursing. In the nursery or at the mother’s bedside the baby can be directly examined and held by the trainee for the first time, an intimate contact that may be a new and important experience for the trainee. He acquires a “feel” for his subject, which adds to his ability to assess temperament, alertness, and the infant’s ability to mold. He can observe how primitive and yet how highly organized is the newborn’s behavior. Frustration tolerance, output of activity, contrasts between states of alert inactivity and waking activity (9), and many other characteristics are sometimes precursors of later behavior. In September, usually soon after the baby’s birth, the child psychiatry fellow is joined by a second team member, a nurse enrolled in the master’s degree program in parent and child nursing at the University of Michigan School of Nursing. The nurses are on a semester system and therefore miss the beginning and end of the family’s year-long participation.
GREENMAN,
HOME
AND
OFFICE
BENSON,
GRAPENTINE,
ET
AL
VISITS
About 2 weeks after delivery, the child psychiatry fellow and nurse make a home visit at a time when the father can be present. This offers both trainees their first opportunity to observe the complete family in its natural surroundings, with the rich variations offered by the ever-changing circumstances of family life, and provides a further chance to sharpen their skills as participant observers. The observers are alerted to note the mother’s affective tone, skill, and comfort as she feeds, bathes, diapers, and interacts with the baby. The baby’s responses are noted in similar detail. With the mother’s consent and approval, each observer holds the baby and makes observations of his social responsiveness, muscle tone, and molding of his body to that of the observer. In addition, they ask the parents about the behavioral patterns of the infant and about their attitudes and behavior toward this new family member. The home visit also allows the team to make direct observations of the nature of the fathering and to take a close look at the quality of interactions between the mother and the father concerning their baby. The program is devised for teaching rather than service. However, parents occasionally seek to use the study situations to further their knowledge of child development or to seek reassurance on their own parenting styles. Appropriate response is made to such requests. Although the observers are not looking for problem situations, when a possible developmental hazard is noted it is shared with the parents. Home visits continue at monthly intervals throughout the year. The visits are required for the nurse and elective for the child psychiatry fellow, depending on the time available in his crowded schedule. Each month, after the initial home visit, the mother, father (if he can come), and baby visit the office. An updated history is taken, focusing on such issues as sleeping and feeding patterns, preferred types of parental interaction with the child, and the infant’s increasing awareness of the world around him. Formal developmental testing is also done (10). The child psychiatry fellow is responsible for the testing procedure. He now becomes familiar with the “tools of the trade” of infant developmental assessmentbell, colored ring, wooden cubes-and learns what tests are appropriate for the child’s age. Among other things, he tests for the presence of neonatal reflexes and learns when a positive response should no longer be expected. In general, he becomes adept at eliciting and understanding the neurophysiologic signs of growth. The test procedure is videotaped and can be followed simultaneously by other trainees from a distant monitor. Thus, other residents gain a first-hand look at more than one infant. In this way, the fellows begin to see the variations among infants in maturation and temperament and come to appreciate the norms and regularities in the unfolding of each infant’s mental and emotional development. In addition, the trainee’s 1175
INFANT
ability to observe accurately and discuss these observations is heightened. As the infant matures the test data include information about such complex phenomena as, for example, his ability to relate to human objects. The attitude of the child toward complete stnangers and toward the tester can be documented, and changes with time in the young child’s response to being out of direct contact with the mother can be assessed. Perceptual ability, gross and fine motor control, and cognitive style can also be assessed early and followed in detail over several months. The nurse is a nonparticipant observer during the office visits. The nurse can note and record complex interactions between the mother, infant, child psychiatry fellow, and video technician during the developmental testing that might otherwise escape notice. For example, the mother’s reactions to the examiner’s “taking over” and managing the baby during the testing are informative. The child psychiatry fellow, as a beginner in infant developmental testing, may be too involved in administering the test to be attuned to these interactions. Before the monthly office visits, the resident-nurse teams meet with one or more senior staff members for a briefing on the administration of the infant tests and a discussion of expectable developmental phenomena for infants of a particular age. The babies are all close to the same age, so normal variation is emphasized. If the child psychiatry fellow has not made the home visit two weeks earlier, he has the opportunity to read the nurse’s written report before the office visit. After the families are seen, the students and teachers reconvene to discuss the results of the morning’s observation and to review the videotape, ifdesirable. Office space suitable for infant observation is limited, so a maximum of three infant-parent pairs is seen on any one morning. Supervision is primarily accomplished in these group briefing and debriefing sessions. Each fellow is assigned an individual supervisor with whom he can meet if a problem arises that cannot be dealt with duning the group supervision.
DATA
Am
OBSERVATION
135:10,
October
1978
tempt to delineate the critical forces that impinge on the first year. Infant observation dovetailed neatly with existing opportunities for observation of normal children in our toddler groups and nursery school. A basic goal of our training program is to enhance a thorough understanding of the variations and common characteristics of normal human development. The influences and attitudes of the people comprising the environment and the elements provided through maturation are closely scrutinized. The infant observation opportunities provide the trainee with a rare opportunity to follow, from the earliest moment, the unfolding of these maturational and environmental dimensions and to observe their manifestations and interactions. For many child fellows, involvement with very young children is not new. Several of the residents are parents; some have come to the child psychiatry program from general practice on a residency in pediatrics, and most have dealt with infants to some degree during their medical school years or internship. What is unique in the infant study experience is the chance it affords to observe objectively essentially healthy infants over a prolonged period and to assess in detail the vicissitudes of early development of a particular child.
VIDEOTAPE
USE
All office visits and many home visits are recorded on videotape. A first imperative for the use of videotape is a camera operator who is more than a technician. The camera operator must have an interest in and some basic knowledge of the psychological development of the infant. In the hands of a skillful trained video technician who is fully conversant with the aims and goals of the particular study, the video camera is an invaluable instrument for recording and collecting data that would otherwise be omitted from the record or documented only inferentially.
RECORDING CASE
Another facet of the infant study experience is documentation of data. Following each contact, the trainee writes a report outlining the important observations. At the end of the year, each resident gathers together his knowledge of the child he has been following into an infant developmental profile, a modification of Ernest Freud’s baby profile (11). The profile requires a detailed awareness of parental history, the pregnancy and peninatal period, the range of parent-child interaction, latent parental attitudes, and neurophysiologic milestones. Preparing the profile allows the resident to formulate his understanding of the infant’s maturational unfolding, constitutional strengths and weaknesses, and significant environmental influences. The profile imposes on the trainee a sense of discipline in his at1176
J Psychiatry
ILLUSTRATIONS
The practical value of the infant observations child psychiatric training can be underscored by brief case vignettes. Case fants, cated
1. We when parents
John we could accepted consistently
grew
began
following
he was 6 weeks had heard about
and developed
John old. His the infant
A, one
of our
intelligent, study from
exceedingly
in two
first
in-
well-edua friend.
well in all areas
that
measure. He was breast-fed and ate well; later he solids readily. He was sleeping through the night by 18 weeks. Motor and language development
proceeded
at or above
the expected all who
rate.
His most
charac-
had contact with him, was his winning and frequent smile. He was a person-oriented baby, and he smiled broadly at anyone who approached, teristic
trait,
which
charmed
Am
J Psychiatry
until
135:10,
“stranger
anxiety,”
October
1978
which
started
GREENMAN,
when
he was
about
6
months old, made him a bit more wary. A crisis requiring intervention by the child psychiatry fellow occurred when John was about 7 months old. Mrs. A had taken John to visit her mother in a distant state. The grandmother was described as a compulsively neat woman who ingly
would mobile
not adjust grandson.
or rearrange She refused
her home for to participate
her
increasin John’s
care because he was crawling and required control. Mrs. A cut her visit short and returned home feeling dominated by John. The demands of his care seemed endless, and she felt that she had no time for herself. A few days later, her former employer called to see if she could return to work. She felt tempted but was ambivalent about leaving John in the care of a stranger.
During
the
office
visit
in which
the
child
psychia-
try fellow obtained this information Mrs. A had to leave the room for about 5 minutes. The change in John was dramatic. He had mother,
been the
eraman looking
to that around
his
smiling joyously child psychiatry
mother
at every fellow,
eye and
contact with his the video cam-
point but quickly became somber as if trying to locate his mother.
returned
he
was
fussing
and,
and started By the time
although
he
was
comforted when she held him, he would not cooperate in the developmental testing. The child psychiatry fellow used the above observation to underscore the intervention he now made. He told Mrs. A that he agreed with John but empathized ess of child rearing
preted
her
crawl,
as
desire being
her about with her, can seem
to return somehow
her continuing importance noting how endless the from time to time. He
to work, an
echo
now of her
that
John
mother’s
to procinter-
could attitude
during the recent her mother about the office thinking
visit. Mrs. A recalled intense conflict with messiness, seemed to settle down, and left in terms of a part-time job that would give her some time for herself. A month later, she had dropped the idea of returning to work and contented herself with taking some informal classes. We believe that John’s despair at discovering absence in the presence of strangers in a strange
his mother’s place shows
that at 7 months his cognitive development had proceeded to the point at which he could clearly differentiate the strange from the familiar. He responded with anxiety when his mother
left
object, priate
i.e. care.
,
the the
He
room person
had
because of fear of the who reduces tensions
loss of the prethrough appro-
recognized
as a source
his
mother
of
need satisfaction, and her absence evoked anxiety. Indeed, other observations indicated that John desired his mother for more than a source of tension relief, and thus his object relationships had started along the developmental line from need satisfaction to object constancy. To have been separated
from her at this point in his development could have been particularly traumatic for him and might have resulted in developmental interference or more serious problems. The intervention helped to allow John’s development to unfold without
hindrance.
Case 2. Margaret B was conceived 6 months after the death, at age 3 weeks, of an infant born with multiple congenital
anomalies.
Throughout
the
prenatal
interviews
both
parents made repeated references to the first baby and expressed concern about the health of the unborn infant. At delivery, Margaret was found to be fully intact, but the parents, understandably, continued to harbor latent concerns. By age 6 months, there were slight differences between Margaret’s development of similar age. Mrs.
and that B became
of the other infants overtly anxious.
in the At this
study point
the child
psychiatry
a video
her
fellow
cameraman.
the death awareness to
BENSON,
made
Parental
an extra
lack
of
athletic
were
reviewed. delayed
abilities
parents ‘
have
In this
normalcy. important considerably.
periodically
‘consultation’
which
baby’s achieved waned
‘
case,
when
the
threatened
used
and
primary to
interfere
cause
for the
with
implied
optimum
without and
that
she
than she had his earlier state-
psychiatry
or concerns
AL
B tied her milestones
Shortly after milestones Since that
the child
questions
visit explored
Mrs. motor
wanted her daughter to be better endowed been. The child psychiatry fellow reaffirmed ments about the visit, Margaret mother’s anxiety
ET
home
concerns
of the first baby was of Margaret’s slightly
own
GRAPENTINE,
have
the home and the time, the
fellow
in
arisen.
parental
anxiety,
parenting
for
Margaret, was the earlier birth and death of the multiply deformed child. The mother’s reference to her own “unathletic” nature and some of her other comments suggest a selfconcept of damage or deformity that would have been (understandably) exacerbated by the birth of a deformed baby. The supportive and expressive intervention gave the parents a chance to once again review their feelings about the first baby, to express their concerns about Margaret, and to re-
view
the
objective
evidence
indicating
Margaret’s
in-
tactness.
DISCUSSION
A comprehensive discussion of the advantages to child psychiatrist, and the adult psychiatrist for matter, of a thorough understanding of maturation development (see reference 12) during the first year of life by direct observation could be the subject of another paper, and a few of the most important aspects will be mentioned here (see reference 13). Near the top of any list of advantages must be the opportunity to observe that the human infant develops in a matrix of object relations and that during the first year the relationship to his mother is of overriding prominence. The importance of the infant-mother relationship is usually taught so didactically that the phrase may become meaningless. Its meaning is given immediate substance when one observes the interaction between the pair, beginning when the baby is given to the mother in the delivery room. The informed observer can see that the mother’s role as the infant’s first teacher begins then. The teaching may have varying qualities within the same mother-infant pair, as seen recently when a delighted young mother, who was very adept at holding, comforting, and nursing her 2day-old baby, stopped the baby from touching his mouth, saying that it could develop into a bad habit. The relationship is not only in terms of how the mother affects the infant. The infant’s characteristics, such as sex, health, appearance, activity, and ease with which it can be comforted, can have a profound influence on the mother. The trainee is in a unique position to observe this phenomenon because of his previous knowledge of the mother’s hopes, fantasies, and expectations concerning the baby. Knowledge of the mutual influences of the mother and child from birth is useful to the future child psychiatrist in assessing both the that and
1177
INFANT
Am
OBSERVATION
infants and judgmental
children. The skill of unintrusive, nonobservation that the trainee learns in observing infants will enhance his work as a psychotherapist of children and adults. Nearly everything that is learned in lectures, seminars, and from reading takes on new meaning when directly observed. Developmental milestones are a good example. Observing the 4-week-old infant smile in response to its mother, watching the 16- to 20-weekold’s efforts to reach and grasp, noting the transfer patterns of the sitting 28-week-old, the wariness toward strangers of the 40-week-old, and the delight in locomotion of the 52-week-old, provides more powerful inducements to remembering milestones. Perhaps even more important is the opportunity to watch the precursors of mental functioning taking shape. Primitive reactions to displeasure may foretell what kinds of ego defenses the infant will use in the future (11). Earliest memory for inanimate objects can be seen when, as part of the infant test, a toy is hidden. Very early, one can see which infants are people-oriented, which are thing-oriented, and which show an even balance between the two. One can discern styles of cognitive development and the different ways by which early concept formation is achieved. The teaching and learning of all developmental concepts is enhanced by direct infant observation. We are often asked why families volunteer to be in our program and what we give them in return. We do not offer service or advice. The answer, in general, is on multiple levels. On the surface are such motivations as the wish to cooperate in a program that helps to train doctors, the opportunity to have their baby seen (and admired) by experts, and reassurance that the baby’s development will be monitored. Slightly below the surface is the desire for emotional support during the transition from being a separate entity into that ever demanding Parents often
1178
and potentially rewarding wish, unconsciously,
that
role as parent. participation
J Psychiatry
135:10,
October
1978
in the
program will that have happened This was illustrated A training program
protect their infant from disasters to family members in the past. in case 2. like ours is not designed to graduate infant mental health specialists; rather, it is designed to acquaint the trainee with the developmental vicissitudes of infancy. With that background, the graduate can make some interventions and knows when
to
refer
more
complicated
cases.
REFERENCES I. Shapiro New New
T: A psychiatrist
2.
Spitz R: The First Year versities Press, 1965
3.
Mahler
MS.
Human
Infant.
4.
5.
for
Emde
RN,
Pine
of Life.
F, Bergman
New
Basic
TJ,
Psychological
ternational
Universities
Press,
York,
Mohaesy
I, Porter
observation. 8. Klaus MH, CV Mosby,
RT,
Ri:
Emotional
Monograph
of the
Expression
37. New
York,
In-
implications for Child Psychoanalysis.
Handbook 1972
of
A: Teaching
Arch Gen Psychiatry Kennell JH: Maternal 1976
Psychoanalysis.
infant
18:28-35, Infant
per-
of psychological
Child
development 1968
Bonding,
and Organizational Issues, Monograph Press, 1966
International Universities A, Amatruda C: Developmental Diagnosis Harper Press, 1967 WE: The baby profile, part 11. Psychoanal
26:172-195,
by
St Louis, Behaviors 17. New
(3rd ed).
New
Study
Child
1971
12. Hartman H: Comments on the psychoanalytic Psychoanal Study Child 5:74-96, 1950 13. Freud WE: Infant observation: its relevance training.
Birth
1976
Wolff PH: The Causes, Controls, in the Neonate. Psychological
York, 10. Gesell York, 11. Freud
Uni-
1975
and the treatment
Blan
a T.
International
Psychological
Nagera H: Social deprivation in infancy: sonality development, in Handbook of New York, Van Reinholt, 1972
S: Psychoanalysis
Psychiatry,
Sander LW, Shapiro Press, 1976
Books,
Harmon
Issues,
disorders in infancy, in New York, Van Reinholt,
9.
in Infant
New
A: The
York,
Gaensbauer
in Infancy.
6. Provence
7.
infants?
Synthesis. Edited by Rexford EN, Haven and London, Yale University
Psychoanal
Study
Child
30:75-94,
theory
of the ego.
to psychoanalytic 1975
The
Role
of Infant
BY GEORGE W. GREENMAN, CECILY LEGG, M.S.W., AND
in Child
Observation M.D.,
RONALD
IVAN
SHERICK,
BENSON,
M.D.,
J Psychiatry
Psychiatry
135:10,
October
1978
Training
LEXINGTON
GRAPENTINE,
M.D.,
PH.D.
in didactic baby and evaluation
The authors discuss the role ofinfant observation in the training ofchild psychiatrists, emphasizing the overriding importance ofthe subtle but crucial interactions in the mother-infant relationship. infant observation is valuable in preparing the student as an observer ofbehavior, and developmental concepts are taught and learned more easily in programs that provide opportunitiesfor observing normal infants. The infant study program in the Department of Psychiatry ofthe University ofMichigan Medical Center is presented as a model.
lectures. The student rarely even more rarely is assigned or treatment.
DEVELOPMENT
OF
AN
INFANT
sees a normal an infant for
OBSERVATION
PROGRAM
BECAUSE OF the numerous reprint requests for articles on infant and early childhood research published in the Journal of the American Academy of Child Psychiatry the editors of that journal published a collection of many of them, entitled (provocatively) infant Psychiatry, A New Synthesis The editors proposed a new subspecialty of infant psychiatry and argued that child psychiatry training is a logical starting place for such a program (1). An upsurge of interest in the first year of life is evident from the large number of recent books and articles dealing with various aspects of infancy (2-6). Selma Fraiberg addressed the problem of who should provide diagnostic assessment and treatment to infants and their families (unpublished manuscript). She advocates a subspecialty in infant mental health for all professionals who serve babies and their parents, including psychiatrists, pediatricians, pediatric and psychiatric nurses, psychologists, and social workers. One of the possible reasons for the call for infant psychiatrists is that most child psychiatry training programs pay scant attention to infancy (7). At best, normal and pathological infant development are presented
Because of the need for more experience with infants and their families, infant observation became part of the two-year program in child and adolescent psychiatry at the University of Michigan in 1974. Couples having their first baby are invited to participate in the program on the basis of their own interest, the probability of a stable family situation, the likelihood of at least a year’s residence in the area, a dclivcry date in September, and the absence of overt psychopathology. Preference is given to first-born infants for several reasons. The student has the opportunity to observe and comprehend, in its incipiency, the cornplex phenomenon of parenting. Inclusion of only single-child families serves as a means of limiting somewhat the number of variables (always large) in the study population. More pragmatically, the singlechild family tends to have greater freedom and flexibility for scheduling appointments to synchronize with the trainee’s limited availability. An additional advantage in the use of single-child families is that, for beginning observers, it is generally easier to carry out an infant observation without the distractions provided by older siblings. Stable couples give the resident a greater opportunity to observe the unfolding of a relatively normal family and, on a more practical level, tend to be home when home visits are scheduled and to keep appointments for office visits. The expectant couples are referred to us by other participants in the program or are recruited by senior staff in contacts with childbirth preparation classes, such as Lamaze.
This
PRENATAL
,
.
is a revised
and combined version of three papers meeting of the American Psychiatric May 10-14, 1976.
the 129th annual Miami,
Fla.,
presented Association,
at
The authors of Michigan
are with the Child Analytic Study Program, University Medical Center, Children’s Psychiatric Hospital, Ann Arbor, Mich. 48109, where Dr. Greenman is Lecturer in Psychiatry; Dr. Benson is Clinical Associate Professor of Psychiatry and Director, Outpatient Program; Dr. Grapentine is Instructor of Psychiatry; Miss Legg is Lecturer in Mental Health; and Dr. Sherick is Clinical Assistant Professor of Psychology in Psychiatry.
1174
0002-953X/78/OOlO-l
174$0.50
© 1978
AND
PERINATAL
PERIOD
Each child psychiatry fellow is assigned a family in July at the beginning of his second year of child psychiatric training. He is asked to interview the couple separately and conjointly in the weeks before the baby is bonn, obtaining a detailed personal history from husband and wife. In addition, an attempt is made during American
Psychiatric
Association
Am
J Psychiatry
135:10,
October
1978
the interviews to gather data concerning the myriad hopes, expectations, and worries surrounding the unborn child. These parental fantasies, both positive and negative, give the resident his first revealing glimpse of the elusive ethos into which the infant will be born. We have found, for example, that important expectations exist regarding the sex, intelligence, motor ability, and physical attractiveness of the child. In the months to come, this fantasy material can be compared with the realities of the young child’s endowment. The attitudinal changes of the parents in the face of this reality can be followed. Often, from the earliest days parents attempt to shape the child to fit their conscious and unconscious expectations. The student is in a good position to learn and to intervene if indicated because he knows the prebirth fantasies. The resident is encouraged to obtain permission to be present at the birth. The delivery experience, which usually includes the fathers, affords the resident a unique opportunity to observe the earliest motherchild-father interactions. At the same time, he can be aware of any complications in the birth process and can assess the newborn along several measures, from the Apgar rating to visual tracking. Also, the resident’s knowledge of obstetrics is occasionally a source of support to the father. Most important, however, is the direct observation of the initial dialogue between mother and child. The mother’s affective state and her comments about the infant can be most revealing, and the newborn’s responses when the mother holds him can be an important index of their future interactions (8). While they are still in the hospital, the mother and infant are visited several times. This gives the resident a chance to explore in depth the mother’s attitudes toward the newborn and to contrast them with her earlien wishes and fantasies. At breast or bottle the child is observed in the mother’s care, and many of her basic nurturing skills come to light. The resident notes the baby’s beginning ability to integrate the complex physiological functions of sucking, swallowing, and breathing that comprise nursing. In the nursery or at the mother’s bedside the baby can be directly examined and held by the trainee for the first time, an intimate contact that may be a new and important experience for the trainee. He acquires a “feel” for his subject, which adds to his ability to assess temperament, alertness, and the infant’s ability to mold. He can observe how primitive and yet how highly organized is the newborn’s behavior. Frustration tolerance, output of activity, contrasts between states of alert inactivity and waking activity (9), and many other characteristics are sometimes precursors of later behavior. In September, usually soon after the baby’s birth, the child psychiatry fellow is joined by a second team member, a nurse enrolled in the master’s degree program in parent and child nursing at the University of Michigan School of Nursing. The nurses are on a semester system and therefore miss the beginning and end of the family’s year-long participation.
GREENMAN,
HOME
AND
OFFICE
BENSON,
GRAPENTINE,
ET
AL
VISITS
About 2 weeks after delivery, the child psychiatry fellow and nurse make a home visit at a time when the father can be present. This offers both trainees their first opportunity to observe the complete family in its natural surroundings, with the rich variations offered by the ever-changing circumstances of family life, and provides a further chance to sharpen their skills as participant observers. The observers are alerted to note the mother’s affective tone, skill, and comfort as she feeds, bathes, diapers, and interacts with the baby. The baby’s responses are noted in similar detail. With the mother’s consent and approval, each observer holds the baby and makes observations of his social responsiveness, muscle tone, and molding of his body to that of the observer. In addition, they ask the parents about the behavioral patterns of the infant and about their attitudes and behavior toward this new family member. The home visit also allows the team to make direct observations of the nature of the fathering and to take a close look at the quality of interactions between the mother and the father concerning their baby. The program is devised for teaching rather than service. However, parents occasionally seek to use the study situations to further their knowledge of child development or to seek reassurance on their own parenting styles. Appropriate response is made to such requests. Although the observers are not looking for problem situations, when a possible developmental hazard is noted it is shared with the parents. Home visits continue at monthly intervals throughout the year. The visits are required for the nurse and elective for the child psychiatry fellow, depending on the time available in his crowded schedule. Each month, after the initial home visit, the mother, father (if he can come), and baby visit the office. An updated history is taken, focusing on such issues as sleeping and feeding patterns, preferred types of parental interaction with the child, and the infant’s increasing awareness of the world around him. Formal developmental testing is also done (10). The child psychiatry fellow is responsible for the testing procedure. He now becomes familiar with the “tools of the trade” of infant developmental assessmentbell, colored ring, wooden cubes-and learns what tests are appropriate for the child’s age. Among other things, he tests for the presence of neonatal reflexes and learns when a positive response should no longer be expected. In general, he becomes adept at eliciting and understanding the neurophysiologic signs of growth. The test procedure is videotaped and can be followed simultaneously by other trainees from a distant monitor. Thus, other residents gain a first-hand look at more than one infant. In this way, the fellows begin to see the variations among infants in maturation and temperament and come to appreciate the norms and regularities in the unfolding of each infant’s mental and emotional development. In addition, the trainee’s 1175
INFANT
ability to observe accurately and discuss these observations is heightened. As the infant matures the test data include information about such complex phenomena as, for example, his ability to relate to human objects. The attitude of the child toward complete stnangers and toward the tester can be documented, and changes with time in the young child’s response to being out of direct contact with the mother can be assessed. Perceptual ability, gross and fine motor control, and cognitive style can also be assessed early and followed in detail over several months. The nurse is a nonparticipant observer during the office visits. The nurse can note and record complex interactions between the mother, infant, child psychiatry fellow, and video technician during the developmental testing that might otherwise escape notice. For example, the mother’s reactions to the examiner’s “taking over” and managing the baby during the testing are informative. The child psychiatry fellow, as a beginner in infant developmental testing, may be too involved in administering the test to be attuned to these interactions. Before the monthly office visits, the resident-nurse teams meet with one or more senior staff members for a briefing on the administration of the infant tests and a discussion of expectable developmental phenomena for infants of a particular age. The babies are all close to the same age, so normal variation is emphasized. If the child psychiatry fellow has not made the home visit two weeks earlier, he has the opportunity to read the nurse’s written report before the office visit. After the families are seen, the students and teachers reconvene to discuss the results of the morning’s observation and to review the videotape, ifdesirable. Office space suitable for infant observation is limited, so a maximum of three infant-parent pairs is seen on any one morning. Supervision is primarily accomplished in these group briefing and debriefing sessions. Each fellow is assigned an individual supervisor with whom he can meet if a problem arises that cannot be dealt with duning the group supervision.
DATA
Am
OBSERVATION
135:10,
October
1978
tempt to delineate the critical forces that impinge on the first year. Infant observation dovetailed neatly with existing opportunities for observation of normal children in our toddler groups and nursery school. A basic goal of our training program is to enhance a thorough understanding of the variations and common characteristics of normal human development. The influences and attitudes of the people comprising the environment and the elements provided through maturation are closely scrutinized. The infant observation opportunities provide the trainee with a rare opportunity to follow, from the earliest moment, the unfolding of these maturational and environmental dimensions and to observe their manifestations and interactions. For many child fellows, involvement with very young children is not new. Several of the residents are parents; some have come to the child psychiatry program from general practice on a residency in pediatrics, and most have dealt with infants to some degree during their medical school years or internship. What is unique in the infant study experience is the chance it affords to observe objectively essentially healthy infants over a prolonged period and to assess in detail the vicissitudes of early development of a particular child.
VIDEOTAPE
USE
All office visits and many home visits are recorded on videotape. A first imperative for the use of videotape is a camera operator who is more than a technician. The camera operator must have an interest in and some basic knowledge of the psychological development of the infant. In the hands of a skillful trained video technician who is fully conversant with the aims and goals of the particular study, the video camera is an invaluable instrument for recording and collecting data that would otherwise be omitted from the record or documented only inferentially.
RECORDING CASE
Another facet of the infant study experience is documentation of data. Following each contact, the trainee writes a report outlining the important observations. At the end of the year, each resident gathers together his knowledge of the child he has been following into an infant developmental profile, a modification of Ernest Freud’s baby profile (11). The profile requires a detailed awareness of parental history, the pregnancy and peninatal period, the range of parent-child interaction, latent parental attitudes, and neurophysiologic milestones. Preparing the profile allows the resident to formulate his understanding of the infant’s maturational unfolding, constitutional strengths and weaknesses, and significant environmental influences. The profile imposes on the trainee a sense of discipline in his at1176
J Psychiatry
ILLUSTRATIONS
The practical value of the infant observations child psychiatric training can be underscored by brief case vignettes. Case fants, cated
1. We when parents
John we could accepted consistently
grew
began
following
he was 6 weeks had heard about
and developed
John old. His the infant
A, one
of our
intelligent, study from
exceedingly
in two
first
in-
well-edua friend.
well in all areas
that
measure. He was breast-fed and ate well; later he solids readily. He was sleeping through the night by 18 weeks. Motor and language development
proceeded
at or above
the expected all who
rate.
His most
charac-
had contact with him, was his winning and frequent smile. He was a person-oriented baby, and he smiled broadly at anyone who approached, teristic
trait,
which
charmed
Am
J Psychiatry
until
135:10,
“stranger
anxiety,”
October
1978
which
started
GREENMAN,
when
he was
about
6
months old, made him a bit more wary. A crisis requiring intervention by the child psychiatry fellow occurred when John was about 7 months old. Mrs. A had taken John to visit her mother in a distant state. The grandmother was described as a compulsively neat woman who ingly
would mobile
not adjust grandson.
or rearrange She refused
her home for to participate
her
increasin John’s
care because he was crawling and required control. Mrs. A cut her visit short and returned home feeling dominated by John. The demands of his care seemed endless, and she felt that she had no time for herself. A few days later, her former employer called to see if she could return to work. She felt tempted but was ambivalent about leaving John in the care of a stranger.
During
the
office
visit
in which
the
child
psychia-
try fellow obtained this information Mrs. A had to leave the room for about 5 minutes. The change in John was dramatic. He had mother,
been the
eraman looking
to that around
his
smiling joyously child psychiatry
mother
at every fellow,
eye and
contact with his the video cam-
point but quickly became somber as if trying to locate his mother.
returned
he
was
fussing
and,
and started By the time
although
he
was
comforted when she held him, he would not cooperate in the developmental testing. The child psychiatry fellow used the above observation to underscore the intervention he now made. He told Mrs. A that he agreed with John but empathized ess of child rearing
preted
her
crawl,
as
desire being
her about with her, can seem
to return somehow
her continuing importance noting how endless the from time to time. He
to work, an
echo
now of her
that
John
mother’s
to procinter-
could attitude
during the recent her mother about the office thinking
visit. Mrs. A recalled intense conflict with messiness, seemed to settle down, and left in terms of a part-time job that would give her some time for herself. A month later, she had dropped the idea of returning to work and contented herself with taking some informal classes. We believe that John’s despair at discovering absence in the presence of strangers in a strange
his mother’s place shows
that at 7 months his cognitive development had proceeded to the point at which he could clearly differentiate the strange from the familiar. He responded with anxiety when his mother
left
object, priate
i.e. care.
,
the the
He
room person
had
because of fear of the who reduces tensions
loss of the prethrough appro-
recognized
as a source
his
mother
of
need satisfaction, and her absence evoked anxiety. Indeed, other observations indicated that John desired his mother for more than a source of tension relief, and thus his object relationships had started along the developmental line from need satisfaction to object constancy. To have been separated
from her at this point in his development could have been particularly traumatic for him and might have resulted in developmental interference or more serious problems. The intervention helped to allow John’s development to unfold without
hindrance.
Case 2. Margaret B was conceived 6 months after the death, at age 3 weeks, of an infant born with multiple congenital
anomalies.
Throughout
the
prenatal
interviews
both
parents made repeated references to the first baby and expressed concern about the health of the unborn infant. At delivery, Margaret was found to be fully intact, but the parents, understandably, continued to harbor latent concerns. By age 6 months, there were slight differences between Margaret’s development of similar age. Mrs.
and that B became
of the other infants overtly anxious.
in the At this
study point
the child
psychiatry
a video
her
fellow
cameraman.
the death awareness to
BENSON,
made
Parental
an extra
lack
of
athletic
were
reviewed. delayed
abilities
parents ‘
have
In this
normalcy. important considerably.
periodically
‘consultation’
which
baby’s achieved waned
‘
case,
when
the
threatened
used
and
primary to
interfere
cause
for the
with
implied
optimum
without and
that
she
than she had his earlier state-
psychiatry
or concerns
AL
B tied her milestones
Shortly after milestones Since that
the child
questions
visit explored
Mrs. motor
wanted her daughter to be better endowed been. The child psychiatry fellow reaffirmed ments about the visit, Margaret mother’s anxiety
ET
home
concerns
of the first baby was of Margaret’s slightly
own
GRAPENTINE,
have
the home and the time, the
fellow
in
arisen.
parental
anxiety,
parenting
for
Margaret, was the earlier birth and death of the multiply deformed child. The mother’s reference to her own “unathletic” nature and some of her other comments suggest a selfconcept of damage or deformity that would have been (understandably) exacerbated by the birth of a deformed baby. The supportive and expressive intervention gave the parents a chance to once again review their feelings about the first baby, to express their concerns about Margaret, and to re-
view
the
objective
evidence
indicating
Margaret’s
in-
tactness.
DISCUSSION
A comprehensive discussion of the advantages to child psychiatrist, and the adult psychiatrist for matter, of a thorough understanding of maturation development (see reference 12) during the first year of life by direct observation could be the subject of another paper, and a few of the most important aspects will be mentioned here (see reference 13). Near the top of any list of advantages must be the opportunity to observe that the human infant develops in a matrix of object relations and that during the first year the relationship to his mother is of overriding prominence. The importance of the infant-mother relationship is usually taught so didactically that the phrase may become meaningless. Its meaning is given immediate substance when one observes the interaction between the pair, beginning when the baby is given to the mother in the delivery room. The informed observer can see that the mother’s role as the infant’s first teacher begins then. The teaching may have varying qualities within the same mother-infant pair, as seen recently when a delighted young mother, who was very adept at holding, comforting, and nursing her 2day-old baby, stopped the baby from touching his mouth, saying that it could develop into a bad habit. The relationship is not only in terms of how the mother affects the infant. The infant’s characteristics, such as sex, health, appearance, activity, and ease with which it can be comforted, can have a profound influence on the mother. The trainee is in a unique position to observe this phenomenon because of his previous knowledge of the mother’s hopes, fantasies, and expectations concerning the baby. Knowledge of the mutual influences of the mother and child from birth is useful to the future child psychiatrist in assessing both the that and
1177
INFANT
Am
OBSERVATION
infants and judgmental
children. The skill of unintrusive, nonobservation that the trainee learns in observing infants will enhance his work as a psychotherapist of children and adults. Nearly everything that is learned in lectures, seminars, and from reading takes on new meaning when directly observed. Developmental milestones are a good example. Observing the 4-week-old infant smile in response to its mother, watching the 16- to 20-weekold’s efforts to reach and grasp, noting the transfer patterns of the sitting 28-week-old, the wariness toward strangers of the 40-week-old, and the delight in locomotion of the 52-week-old, provides more powerful inducements to remembering milestones. Perhaps even more important is the opportunity to watch the precursors of mental functioning taking shape. Primitive reactions to displeasure may foretell what kinds of ego defenses the infant will use in the future (11). Earliest memory for inanimate objects can be seen when, as part of the infant test, a toy is hidden. Very early, one can see which infants are people-oriented, which are thing-oriented, and which show an even balance between the two. One can discern styles of cognitive development and the different ways by which early concept formation is achieved. The teaching and learning of all developmental concepts is enhanced by direct infant observation. We are often asked why families volunteer to be in our program and what we give them in return. We do not offer service or advice. The answer, in general, is on multiple levels. On the surface are such motivations as the wish to cooperate in a program that helps to train doctors, the opportunity to have their baby seen (and admired) by experts, and reassurance that the baby’s development will be monitored. Slightly below the surface is the desire for emotional support during the transition from being a separate entity into that ever demanding Parents often
1178
and potentially rewarding wish, unconsciously,
that
role as parent. participation
J Psychiatry
135:10,
October
1978
in the
program will that have happened This was illustrated A training program
protect their infant from disasters to family members in the past. in case 2. like ours is not designed to graduate infant mental health specialists; rather, it is designed to acquaint the trainee with the developmental vicissitudes of infancy. With that background, the graduate can make some interventions and knows when
to
refer
more
complicated
cases.
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