The Signal Vol. 15, No. 3 Newsletter of the World Association for Infant Mental Health October 2007

Twelve Years Later: From “Fraiberg in Paris” to applied to community health care centers for family and toddlers

By 1. Thinking about it is worth the effort, and that the cost Nicole Guédeney, M.D., Ph.D. and the significance to him or her will not be too high. Antoine Guédeney, M.D. of the referred The insecurely attached parent parents’ help- therefore entails two risks while meeting the mental health clinician for seeking behaviors the first time: the difficulty to make a Bowlby (1988) emphasized the We wish to present here the relational “engagement”, and to explore universal meaning of the process of painful affects, with a serious risk main changes attachment help-seeking and the well known research has brought into of rupture or breaking-off (Bowlby, equivalence between proximity-seeking 1977). In these cases, a conflict our clinical practice with and care eliciting. Seeking help shows parents of infants and between the parent’s attachment and the parent’s attachment Internal care-giving systems may arise and will toddlers. Our context of Working Models (IWMs) which govern work is community mental be expressed through ambivalent help his or her expectations in the context. seeking behaviors towards the clinician. health care centers in Paris: In child mental health, parents are the Infancy Units provide entering a care seeking process on Systematic exploration of parents’ free services to families with behalf of their child (Fraiberg, 1980), help-seeking behaviors, and attitudes children under 5, in their although most of them would never towards help is therefore a source allocated local districts. have applied for it or even entertained of valuable information about the Infant psychiatrists are in the idea for themselves. They are conflict between their willingness to charge of the assessment seeking help for their child: whatever help their child and their own fear and the treatment planning, is said or whatever shows up should of receiving help: Have they already as well as the direct be considered also as an indicator for had experience, direct or indirect, of clinical work with parents their care-giving IWMs. Seeking help obtaining help from professionals like and infants. Our general will activate for each parent a complex us? (“The Bureaucratic Transference” approach comes from the picture of procedural, semantic, and as Seligman & Pawl wrote, 1984) field of developmental episodic memories. Who was involved? How did it go? psychopathology. What did they think? Have they had In child mental health as opposed experience with other professionals? to adult mental health, the working We then explore whether in general, Contents alliance has to be achieved with the help-seeking is viewed by them as parents as well as with the child. The a legitimate or illegitimate behavior 8 Smell, Taste and Flavor first session is very often decisive (Bowlby, 1988). What do their family, in terms of the continuation of the social and individual cultures have to 11 By the Red Cedar evaluation (and eventually of the say? How do they construct their own treatment). Parents need to feel from personal general theory? Have there 12 President’s Perspective the very beginning that they will want been changes linked to life events, or to come again or at least that they will encounters, in the private sphere or 12 Editor’s Perspective feel they can do so, without running among professionals? What specific any risk or feeling threatened. We can memories do they have of asking for 15 Literature Monitor help the parent only if he or she has help? Any negative experience reported sufficient trust in the fact that this is by the parents about help seeking possible, that he or she can trust us, that

WAIMH Central Office: Michigan State University, Kellogg Center, Garden Level, MSU, East Lansing, MI 48824-1022 Tel: 517-432-3793 Fax: 517-432-3694 WAIMH Finland Office: University of Tampere, Medical Faculty, Finn-Medi 1, 33014 Univeristy of Tampere, Finland Tel: +358-50-462 7379, Fax: +358-35517710 with professionals as generalized is such as at the beginning of the meeting considered as a “warning” signal: the and at its impending termination. Also, parent is probably not secure.. The are there “unexpected” attitudes, such Editorial Staff explicit utterances of the parent about as the parent giving a boring wealth the process of help seeking by itself of factual details about the child, or are particularly relevant (Braconnier the parents threatening to leave the Editor: et al, 2006): “The parent runs down child alone in the waiting room or in Miri Keren the process”, ”The parent has come the consultation room if he/she does but only because he/she was asked not obey them. Are there clues as Production Editor: to do it”, “He/she expresses fear of to what the parent views as the most dependency if he/she begins to work important thing, such as fulfilling their Minna Sorsa with us”, “For the parent, asking for own expectations as he/she imagines Tina Houghton help means vulnerability or weakness”, them, or rather meeting their child’s “he / she expresses mistrust about the needs? The observed contrast between Editorial Board: professional’s willingness or ability to the parent’s apparent willingness to help and to protect or comfort”. collaborate with and to please the Susan Berger professional while not comforting the Salvador Celia 2. Parents meeting child’s distress is often an indicator Peter de Chateau a professional of a “Parentified” child (Liotti, 2004). Mauricio Cortina Generally speaking, our attention is Graziella Fava-Vizziello in child mental drawn as much by what we see as by health for the what we do not, but should, see; as Emily Fenichel first time much by what we are told as by the Elizabeth Fivaz-Depeursinge way it is told (Crowell, 2003). Peter Fonagy Cynthia Garcia-Coll This context, –meeting a professional Bernard Golse within the context of care eliciting, -is a paradigm of an attachment-activating 3. Assessing the Antoine Guedeney situation: a distressed or vulnerable infant in the light David Lonie subject, who is unable to cope on his of attachment Tuula Tamminen or her own, encounters a professional, and caregiving - Michael Trout i.e. a person “who is stronger, wiser Elizabeth Tuters and willing to help” (Bowlby, 1988). related issues Hisako Watanabe This leads us to the unique meaning of this first meeting for the parents’ own a. When evaluating the infant, one attachment system (Crowell, 2003). has first to explore whether there is President’s Perspective: Once again, we can help the parent only any attachment-related problem. Are Tuula Tamminen if he or she has sufficient trust in the the child’s symptoms directly linked to fact that this is possible, that he or she a threat concerning accessibility to the can trust us, that it is worth the effort, attachment figure (Kobak & Esposito, From the Red Cedar: and that the cost to him or her will not 2004)? Hiram E. Fitzgerald be too high. Research has widened our palette of The reactions of parents to this observation, with a new semiology that The Signal is a quarterly publica- context provide valuable indicators makes it possible to re-visit numerous tion of the World Association for on any insecurity in the parents from symptoms, in particular out-of-control Infant Mental Health. Address cor- the outset, without more detailed anger (tantrums), provocation and respondence to Miri Keren. information being required on their auto-aggressiveness, vicious circles history of attachment. This new type of in behavioral disorders, oppositional semiology includes the following: The disorders, dysregulation of negative All opinions expressed in The concrete manifestations of the parental emotions, difficulty on the part of Signal are those of the authors, not perception of help seeking often start to parents to set limits and cope with necessarily those of WAIMH’s. appear before the first encounter, such assertive behaviors (Lyons-Ruth as during the phone call for scheduling & Spielman, 2004). We also pay a Permission to reprint materi- the appointment, technical difficulties special attention to the history of the als from The Signal is granted, to get to the clinic, criticisms about the infant’s attachment. We look for any provided appropriate citation for quality of reception by staff (Brisch, early separation or loss and conditions source is noted. Suggested format: 2002) and so on. We pay special in which they occur or for repeated attention to the parent’s reactions at affective ruptures with attachment The Signal, 2007 Vol 15, No.3, times of “reunions and separations”, figures (Boris, Fueyo & Zeanah, 1997) WAIMH.

 The Signal October 2007 b. The assessment of the infant’s contradictory demands). The caregiving past (Slade, 1999). Current parental attachment quality is one of function is also assessed according to attitudes towards attachment-relevant the cornerstones of our clinical the presence or absence of the other issues are systematically noticed: evaluation (Boris et al., 1997, parent, when the child is present or not, “How important is attachment for Lieberman & Zeanah, 1999, Brisch, according to the emotional register of the parents?, How important are 2002, Crowell, 2003). the child (negative or positive emotion) relationships? How important are (Kobak & Mandelbaum, 2003). This negative emotions (anger, sadness, The parameters of the security base systematic assessment of attachment fear)? phenomenon and its developmental and caregiving-related issues at the history are systematically explored: individual, dyad, family and contextual We also pay attention to behavioral or before 6 months, the patterns and levels makes it possible to identify emotional indices (we call them “infra behaviors of the pre-attachment period; possible focuses for an attachment- verbal indices”) each time there is an around 8 to 10 months, the balance informed intervention (Belsky, 1999). attachment relevant situation: parent’s attachment/exploration with attachment behavior toward the child, the clinician, figures; after the age of 2 years, We emphasize that what we observe the spouse; emotion expressiveness, autonomy and capacity for seeking help is informative only in relation to the tone of the voice (Slade, 2004). The during exploration; from the age of 3 to context in which the observation is reactions of the parents when the 4 years, ability to negotiate, collaborate obtained. For instance, one has to process of the consultation itself and to accept set limits. Finally signs define the level of contextual stress activates the system of attachment, (for of attachment disorganization, and in which the observations are made, instance the beginning and the end of for toddlers, controlling-punitive or such as facing the unfamiliar first the encounter, clinician’s errors, delays, controlling-caregiving behaviors are encounter, any separation or threat and interruptions in the session) also systematically looked for (Main & of separation, or the end of the reveal their usual protective strategies Solomon, 1990, Solomon & George, consultation with the cleaning up (Holmes, 2001). The parents’ history 1999) phase. The expression and regulation of attachment is cautiously and mechanisms of positive emotions at gently explored when possible. Is Our attachment-informed assessment low levels of stress can be observed, there any history of early separation pays particular attention during the and likewise for negative emotions at or loss, repeated affective ruptures, session (or in the waiting room and higher levels of stress, as can needs maltreatment, sexual abuse, negligence on the way to the consultation room) for attachment or for exploration and (Slade, 1999)? to the handling of distances and self-assertion, according to the level of interpersonal orientation, to the child’s stress (Kobak & Esposito, 2004). Also, The quality of their present network of reaction to reunion with caregivers the observed behaviors are interpreted interpersonal support is systematically after a mini-separation, to the child’s according to the interpersonal context, explored (Collins & Feeney, 2002). reaction to stress when the caregiver are they directed toward the attachment is present, and to attention-seeking figure(s)?, or towards the clinician who d. The assessment of parents’ behaviors towards the caregiver. We is still a stranger for the infant? Who caregiving systems: another also assess the resources that parents has brought the child? When there is cornerstone of our evaluation. have available to respond to the only one parent, it is usually, the main What does attachment-informed attachment needs of their child, and attachment figure (Kobak & Esposito, how they can be used. The assessment assessment show about the parents’ 2004). As wrote Crowell (2003): “What interactions with their child? is focused on the care-giving alliance are the child’s behaviors? With whom? with the partner, the existence of What behaviors are absent, and with The reasons for the parents’ complaint interpersonal demands that monopolise whom? (Crowell, 2003) or their visit, for instance doubts the attention of the parent, the presence about their parental abilities or the of contextual stress which undermines c. Assessing the parent’s presentation of the child’s problem, can the caregiver’s security, and finally the representations of attachment provide valuable information (Crowell, appearance of “ghosts in the nursery” leads on to the semiology of trans- 2003). Parents of young children coming between parent and child. Does generational issues. seeking help concerning their the child elicit in the parents’ what difficulties may say some typical Marvin called “their shark music” Parental discourse when talking about any situation linked with the system sentences which are really “warning” (2002), that means their own specific clues of transgenerational issues about emotional interpretation of child’s of attachment during their childhood, is analysed with the semiology derived attachment and caregiving (Guedéney signals. The care-giving function is N. cited in Braconnier et al., 2006). systematically assessed according to from the Adult Attachment Interview (AAI) (for instance coherence, quality Here are several examples: Parents the level of stress (George & Solomon, who do not feel the need to respond 1999). The stress can be elicited of access to memories, discords observed between experiences linked to vital needs of protection, closeness by the clinical setting: for instance; and security: “Why is my baby crying? evolution from the first encounter to episodic memory and those linked to semantic memory, emotional Why does my baby cling to me?”; through the following ones, stress of Parent who interprets the signals of the consultation by itself (limited time, expression, realistic evaluation of the

 World Association for Infant Mental Health October 2007 the baby in a surprising manner: “He helpless, and angry (Lyons-Ruth & dual/trial perspective, all the while only does it to annoy me! It’s all an Spielman, 2004). remaining emotionally involved. act! It’s capricious! “; Parent who He/She has seen a behavior, has gives the response that seems the most 4. Our therapeutic application of imagined the complexity of the motives appropriate, based on his or her own attachment therapeutic programs underlying it, has contextualized theory on what helps babies to grow up: (Holmes, 2001, Marvin et al., 2002, the behavior, accepts what is shown “You shouldn’t be weak! You shouldn’t Kobak & Esposito, 2004, Lyons-Ruth without any negative judgment because get attached to people! You should be & Spielman, 2004, Dozier, Lindhiem he or she can imagine what each able to manage on your own! I never & Ackerman, 2005, Slade et al., 2005, partner is feeling and has the conviction had anything and that didn’t stop me Juffer, Bakermans-Kranenburg & Van they are moving towards a solution. from getting on! “; Parent who lacks an IJzendoom, 2007). “instruction manual” about parenthood The clinician gently and firmly “Caring for the caregiver” (Kobak & or does not know how to prevent assumes that it is he or she who is Mandelbaum, 2003). We must allow destiny when exposed to vulnerability: in a position to “lead the dance” of caregivers to retrieve their abilities to “I would like you to have more than open communication in an emergent support and protect their child, or to use I had! Why aren’t you well-behaved, partnership, and in doing so, imagines such abilities, where they do exist, in docile or grateful like I was, even what each partner is feeling and creates an efficient and “consistent” manner, though I had nothing? Who’s looking the conditions for a goal-corrected while at the same time meeting their after me, a nostalgic and wounded partnership (Marvin & Britner, 1999). own unsatisfied needs for comfort child? I explode. I can’t cope! How and support. This can only occur on Emphasis put on the importance of does a child think or feel?” the basis of a therapeutic relationship open communication on the parent’s The evaluation of the parental care- which in itself is a vehicle for change. negative emotions, whatever their giving system also provides a new object (healthcare setting, previous The integration of an experience semiology for systemized observation experience of assistance, professional’s that is unlike the pattern that the (Fonagy et al., 2002, Cassidy et al., actions, or the child itself and parent has learned to expect from 2005, Slade, Sadler & Mayes, 2005, parenthood) validates Fraiberg’s the world and from him/herself in a Koren-Karie, Oppenheim & Goldsmith, intuition on the priority of working situation of stress gives that parent 2007): on what she termed the negative a chance to reassess all his or her transference. Seeing the importance 1. Consistent and contingent response previously working models through and the value that the clinician attaches to the infant’s attachment and assimilation/accommodation processes to open communication about negative exploration needs. (Mallinckrodt, 2000). Thus, focusing emotions is generally a very new first on the caregivers’ distress experience for parents (Cooper et al., 2. Identification of her/his distorted gives the therapist an opportunity 2005). perception the child entertains of him/ to provide a corrective relational her as being non responsive. experience (Marvin et al., 2002) This This empathy towards the parent new experience can give them the suffering as a parent is close to 3. Mirroring, reflective functioning willingness for the process and to mirroring, because the clinician and insightfulness capacities. In the engage themselves because “they are communicates at the same time the case of parents of toddlers, we assess worth it” fact that he or she is confident that the quality of their goal-corrected the parent will in the end be able partnership, their level of flexibility and All the studies on the qualities of to understand the child’s behavior quality of communication (Marvin & caregiving (Speltz, 1990, Fonagy et sufficiently for a positive relationship Britner, 1999). al., 2002, Kobak & Esposito, 2003, to develop, and that the clinician is Lyons-Ruth & Spielman, 2004, there for that purpose. The recognition 4. Detection of parents’ disorganizing Slade et al., 2005, Koren-Karie et al., by the professional of any “technical” behaviors, by using the paradigm of 2007, in particular) give us a better error from the reaction of the parent frightening/frightened behaviors from understanding of how we can provide initiates the experience of a process (Main & Hesse 1990, Lyons-Ruth & this secure base which also helps of mismatch repair, unfamiliar to the Spielman, 2004) and the abdicating parents to explore the unknown. insecure parent, but which contributes behaviors from George & Solomon’s to developing trust and the feeling of work (1999). The observation of The clinician has to use his or her worth for the Other. trans-generational transmission of mentalization abilities: the clinician disorganized attachment is striking can indeed simultaneously integrate Attachment informed intervention while a coercive vicious circle starts up the perspective of each member of the has the general goals of interrupting between the parent and the child, when dyad/family, address both members the symptomatic cycle in family the infant becomes more and more of the dyad/family with the same relationships and of increasing the demanding, anger increasingly becomes attention, and communicate very parent’s acceptance of the child and mixed up with demands for comfort quickly with each protagonist, in the child’s confidence in parent’s and the mother feels increasingly presence of both, on how they see this availability. Restoring the parent’s

 The Signal October 2007 sense of efficiency as a caregiver what solely this other person could the impact of the parent’s sensitive becomes essential. give, generally has a powerful impact behavior on the child can reinforce the on parents (Bowlby, 1988, Marvin et parent in responding appropriately and Research on attachment has enriched al., 2002). Anger and distress may be quickly to the child’s signals (Marvin et our palette of interventions designed expressed or even exaggerated to signal al., 2002). to improve parenting skills. Various to the parent that his/her attention applications can be used: and care are needed. Parental care is 3. Developing parents’ reflective divided up into different dimensions: skills. Work on representations is a 1. Sharing present-day knowledge parents may love their child but be way to come to understand what gets on attachment and caregiving with the unable or lack the skill to respond in the way of a parent’s ability to parents has become an essential step. to the child’s needs for protection, form a secure base or a partnership Secure parents already have basic comfort and security. Explaining with their child: this is not solving skills, but they may be inadequate for the role of interpersonal regulation, the parent’s relevant attachment children with special needs; however showing the caregivers that their child, issues but making them improve their for insecure parents these skills have like all children, needs the caregiver caregiving by giving meaning to been lost and for disorganized parents, to regulate and organise his or her what has seemed, up to then, to carry these skills are not functional. negative experiences, is often very new nothing but failure, incomprehension, anger and helplessness (Lyons-Ruth Five pieces of information have a information, especially if the child has & Spielman, 2004). Three levels can particularly strong impact on parents. special needs (Marvin et al., 2002). be elicited. Firstly we can explore The human species is the only species What can be traumatic for a child is parent’s own theory about caregiving: that usually respond to a behavior not the negative emotion, it is to be how does each parent think that one according to the interpretation given suffering alone. Parents, accompanied should respond to the child’s needs for to it and not only according to an by the professional, can more easily protection and exploration? (George automatic way. This notion introduces gain access to and reassess their IWMs & Solomon, 1999). Secondly we can the idea that parents need to interpret of self and others, in attachment and explore the conscious representations the meaning of their infant’s behaviors, in caregiving, in the light of this new of past memories, which can influence and hence the idea of representations information (Kobak & Mandelbaum, present behavior as a parent: what are underlying behaviors. Reassuring 2003). the memories of situations involving parents that the need for attachment, The first issue is to draw the attention aloneness, vulnerability, sadness, i.e. seeking for proximity and comfort, of the parent to the behaviors of anger, authority or comfort, with their is not only necessary, but the only the child and to the impact of the own parents? (Lieberman & Zeanah, possible means to provide the child parent’s own behaviors on the child, 1999). Thirdly, we can go after the with freedom to explore while still in a positive way. For the parent “ghosts” with new implements. For being connected with his/her caregiver. in interaction with his/her child, instance the reframing technique can These same needs can underpin an attention to current infant’s capture unconscious representations openly rejecting, provocative, or behaviors is now well known as that surge automatically in a parent distancing behavior on the part of buffering factor against an unwanted and adversely affect their caregiving the child and is often a very moving surge of unresolved parental affects (Mallinckrodt, 2000, Marvin et al., discovery for parents with a traumatic (Schuengel et al., 1999). This is a 2002, Kobak & Esposito, 2004). history of attachment or for parents particular sort of attention, which the Exploration of these representations can with children with special needs. parent has rarely experienced in this contribute to breaking the automatic Helping the parents to conceptualize form, since it is underpinned by the pattern of procedures, and facilitate the attachment domain separately from idea that a behavior always means the parental reflective function (by the domain of limits setting, that has something, but not necessarily what intervening on exchanges that are “mis- more to do with respecting the rights one thinks in the first instance. cued”, or that lead to a more defensive of others can contribute to separating attitude). The clinician can use all the “strands of the knot” (Lyons-Ruth 2. Improving observation skills. these steps to improve the parent’s & Spielman, 2004) and to understand Video techniques an essential ability to use his or her reflexive the “terrible twos”. Explaining that part, since they provide images that function to monitor, reassess and repair negative emotions are a source of are different from those in the parent’s problematic communication with the information and communication with mind (George Downing, personal child (Cooper et al., 2005). others, and particularly sadness, fear communication); they operate at bodily and anger, is a very new information and sensory levels, which probably 4. Use of problem-solving for non secure parents. Explaining have more impact on automatic techniques. Whatever the level of in particular that anger is the parental functioning, thus facilitating reflective processing, we wish to help strongest signal to remind the other re-evaluation of the IWMs. Discussion parents to emerge from dilemmas by of one’s own importance, and what is with the parent on his or her actions finding a “third way” (Lyons-Ruth & expected of him or her, or to express and the immediate impact on the child Spielman, 2004). The use of clinical disappointment at not having received gives the opportunity for exchanges, vignettes from the day routine or use of and possible changes: showing that video clips, heightens a parent’s ability

 World Association for Infant Mental Health October 2007 to monitor his/her communication to collaborate to change only if they Nicole Guédeney��������������������, Unité de la petite with his/her child, to consider other are sure that to make their child able Enfance, Institut Mutualiste Montsou- alternatives, and to find opportunities to accept boundaries will not mean for ris, Paris 75014, for problem solving. This can improve their child blackmail or submission. Université Paris V René Descartes. the parents’ sense of their own competence and trust in the child and in To co construct the tasks to reach our Antoine Guédeney, Service de Psy- themselves. Negotiation, collaboration common objectives takes account of can contribute to developing new three essential dimensions: 1. The chiatrie de l’Enfant et de l’Adolescent, models for balancing the parent’s own parents’ state of mind with respect Hôpital Xavier Bichat, AP HP Paris needs and those of the child and to to attachment gives us information 75018, Université Paris VII Denis Di- reducing the antagonism between the about the risks of disclosure to each derot. parent’s own attachment and caregiving parent (Steele & Steele, 2003). 2. The systems (Lyons-Ruth & Spielman, parents’ feed-back to our interventions 2004). about representations (Slade, 2004) allows us “to approach parents the References Clinical practice routine is different way they would want the parents to from protocol-based intervention approach their children” (Lyons-Ruth Belsky, J. (1999). Interactional studies. In clinical practice what & Spielman, 2004). 3. Duration of and contextual determinants of matters is not “the group effect”, but treatment: in our system of care, there attachment security. In J. 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An attachment based parental behavior the linking Cooper, G., Hoffmann, K., Powell, B, intervention. London: Laurence mechanism? In M.T. Greenberg & Marvin, R. (2005). The circle of Erlbaum Associates. & D. Cicchetti (Eds). Attachment security intervention: differential Kobak, R. & Esposito, A. (2004). in the preschool years: theory, diagnosis and differential Levels of processing in parent- research and intervention. (pp. treatment. In L.J. Berlin, Y. child relationships: implication for 161-182). Chicago: University of Ziv , L. Amaya-Jackson & M.T. clinical assessment and treatment. Chicago Press. Greenberg (Eds), Enhancing early In L. Atkinson & S. Goldberg Main, M. & Solomon, J. (1990). attachment: Theory, research (Eds) Attachment issues in Procedures for identifying infants intervention and policy (pp. 127- psychopathology and intervention as disorganized/disoriented 151). New York: Guilford. (pp. 139-166). London: Laurence during the Ainsworth Strange Crowell, J.A. (2003). 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Keeping Research, 10, 239-266 Enhancing early attachment: the inner world of the child in Marvin, R., Cooper, G., Hoffman, K., Theory, research intervention and mind. Using the insightfulness & Powell, B. (2002). The circle of policy (pp. 178-194). New York: assessment with mothers in a security project: attachment-based Guilford. therapeutic preschool. In D. intervention with caregiver-pre- Fonagy, P., Gergely, G., Jurst, M., Oppenheim & D.F. Goldsmith school child dyads. Attachment & & Target, M. (2002). Affect (Eds) Attachment theory in clinical Human Development, 4, 107-124. regulation, mentalization and the work with children. Bridging the Marvin, R.S.., Britner, P.A. (1999). development of the self. New gap between research and practice Normative development. The York: Other Press. (pp. 31-57). New York: Guilford. ontogeny of attachment. In J. Fraiberg, S. (1980). Clinical studies Lieberman, A.F., Zeanah, C.H. (1999). Cassidy & P.R. Shavers (Eds), of infant mental health. The first Contributions of attachment theory Handbook of attachment: Theory, year of life. London: Tavistock to infant- parent psychotherapy and research, and clinical implications Publications. other interventions with infants (pp. 44-67 ). New York: Guilford. George, C. & Solomon, J. (1999). and young children. In J. Cassidy O’Connor, T.G. & Zeanah, C.H. The caregiving behavioral system. & P. Shaver (Eds.), Handbook of (2003). Attachment disorders:

 World Association for Infant Mental Health October 2007 Assessment strategies and Slade, A. (1999). Attachment theory attachment concepts. In M.T. treatment approaches. Attachment and research. Implications for the Greenberg & D. Cicchetti (Eds). & Human Development, 5, 223- theory and practice of individual Attachment in the preschool years: 244. psychotherapy with adults. In J. theory, research and intervention. Schuengel, C., Bakermans- Cassidy & Schaver P.R., (Eds), (pp. 399-426). Chicago: University Kranenburg, M.J., Van IJzendoorn, Handbook of attachment: Theory, of Chicago Press. M.H. (1999). Frightening maternal research, and clinical implications Steele, H. & Steele, M. (2003). behavior linking unresolved (pp. 575-594 ). New York: Clinical uses of the Adult loss and disorganized infant Guilford. Attachment interview. In M. attachment. Journal of Consulting Slade, A., Sadler, L.S., Mayes, Cortina & M. Marrone (Eds) and Clinical Psychology, 67, 54-63 L.C. (2005). Minding the baby. Attachment theory and the Seligman, S.P., Pawl, J.H., (1984). Enhancing parental reflective psychoanalytic process (pp. 107- Impediments to the formation of functioning in a nursing mental 126). London: Whurr Edition. the working alliance in infant- health home visiting program. In parents psychotherapy. In E. L.J. Berlin, Y. Ziv , L. Amaya- Galenson & R. Tyson (Eds), Jackson & M.T. Greenberg (Eds), Frontiers of Infant Psychiatry Enhancing early attachment: (pp. 232- 238). New York: Basic Theory, research intervention and Books. policy (pp. 152-175). New York: Guilford. Slade, A. (2004). Two therapies: attachment organization and the Solomon, J. & George, C. (1999). clinical process. In L. Atkinson & Attachment disorganisation. New S. Goldberg (Eds). Attachment in York: Guilford. psychopathology and intervention Speltz, M. (1990). The treatment of (pp. 181-206). London: Laurence preschool conduct problems. An Erlbaum Associates. integration of behavioural and

Smell, Taste and Flavor

By search for comfort and food. passing from the oral cavity through Peter J. Scheer, M.D. and Julie A. For infant mental health the nasal pharynx (retronasal route) Mennella, Ph.D. clinicians, the knowledge of when foods or liquids are in the mouth. the capabilities of infants This latter route, often referred to as and the frontiers of research retronasal olfaction, contributes more on their development is significantly than does taste to the important. As we learn about complexity of flavor (Rozin, 1982). The chemical senses of taste the sensory world of human To demonstrate this, if you pinch and smell are crucial for infants, it will enhance our your nostrils closed while eating you survival since all animals understanding and in turn, will interrupt retronasal olfaction and depend on the consumption we will be able to advise thereby eliminate many of the subtleties of nutrients. These senses parents correctly. of food, leaving the taste components evolved to reject that which remaining. This is clearly noted by is harmful and to seek out Although there are only a small number head cold sufferers who lose the ability that which is beneficial and of primary taste qualities (e.g., sweet, to discriminate common foods when pleasurable. They are among salty, bitter, sour and savory tastes) their olfactory receptors are blocked the oldest, the most primitive which can be perceived in all areas by a head cold. Similarly, foods often and the least analytic of the of the tongue, olfactory sensations ‘taste’ better after a person quits senses. But perhaps their result from the activation of a thousand smoking perhaps because their sense of most significant contribution or more distinct types of chemical smell has improved, allowing them to comes when the combine to receptor proteins located on millions of detect more subtleties of flavor. form the flavor of the foods receptor cells lining the upper recesses and beverages we ingest. As of the nose (Buck and Axel, 1991). The senses of taste and smell are will be discussed, infants The receptors for the olfactory system quite developed before birth (see are born with the ability are stimulated when we inhale through Ganchrow and Mennella, 2003 for to taste and to smell and our nose (orthonasal route) as well as review). That is, by the last trimester they rely on these senses to when molecules reach the receptors by of pregnancy, the taste and olfactory

 The Signal October 2007 receptors, the machinery which detects One of the earliest sources of flavor intra-cultural study of women living in tastes, smells and flavors, is capable of experiences is amniotic fluid and several regions of Mexico (Mennella et conveying information to the central mothers’ milk since these first foods al., 2005a). Despite the differences in nervous system, and this information is directly reflect the flavors of the foods cuisine, there were striking similarities available to systems organizing changes and beverages ingested or substances in the types of foods fed to weaning in sucking, facial expressions, and other inhaled (e.g., tobacco) by the mother. and eaten more of by mothers during affective behaviors. At birth, infants pregnancy. In a sense, the foods eaten are sensitive to a wide range of odors, During the past few decades, scientific by the mother (e.g., fruits) formed especially those emanating from their research revealed that not only learning the basis of their children’s weaning mothers (see Schaal, 1988; Ganchrow about flavors is occurring during patterns. and Mennella, 2003 for review). Within pre-natal life and but these early hours after birth, mothers and infants experiences contribute to long-term Perhaps the most striking taste can recognize each other through the food preferences. In other words, difference between children and adults sense of smell alone. Newborns will sensory experiences provide continuity is the strong liking for sweet-tasting prefer their mothers’ breast unwashed between the fetal and postnatal foods and beverages, and the dislike as compared to when it had been environments. The European rabbit of bitter-tasting vegetables during thoroughly washed and thereby less provides an elegant example of such childhood. Is the strong preference odorous. Like that observed in other learning. Researchers found that when that children have for sweets solely mammalian young, this recognition they fed the mother rabbit juniper a product of modern marketing, of and preference for maternal odors berries during either pregnancy or technology (e.g., sugar refining) may play a role in guiding the infant lactation, young rabbit pups ate more of and availability or does it reflect to the nipple area and facilitating early this food at weaning. This learning was some aspect of their basic biology? nipple attachment and breastfeeding. quite robust and the preference lasted Research suggests that these likes Whereas odors emanating from mothers for several months (Bilko et al., 1994). and dislikes reflect the latter. From cue feeding and digestive functioning an evolutionary perspective, these A similar phenomenon was reported and calm infants, those emanating from responses serve important biological in human infants. Psychophysical infants affect maternal responses such functions. Preference for sweet tasting research studies conducted at the as regulation of empathy and influence foods may have evolved to solve a Monell Chemical Senses Center in on the lactational process. basic nutritional problem of attracting Philadelphia, USA, revealed that like children to sources of high energy other animals, a variety of flavors such during periods of maximal growth since Similarly, infants are sensitive to the as garlic and carrot are transmitted foods (e.g., mother’s milk, fruits) that odor and taste component of flavors to and flavor human amniotic fluid are rich in energy often taste sweet. and can detect sweet, sour, and bitter and mothers’ milk. Human infants The rejection of bitter tastes may have tasting foods as well as a wide variety can not only detect the flavors evolved to protect from poisoning of flavors. However, sensitivity to salt but experiences lead to increased since many toxic substances are, by and other flavors don’t emerge until enjoyment and preference for the their nature, bitter and often distasteful infants are approximately four months flavor later in life (Mennella et al., (Mennella et al., 2005b). of age. In other words, infants are not 2001). That amniotic fluid and breast merely miniature adults since their milk share a commonality in flavor Because the senses of taste and smell sense of taste continues to develop profiles with the foods eaten by the are the major determinants of whether during infancy and childhood. The mother suggests that breast milk young children will accept a food large olfactory component of flavor may ‘bridge’ the experiences with (e.g., they eat only what they like), may shed light as to why flavors flavors in utero to those in solid foods. they take on greater significance in experienced early in life remain Moreover, the sweetness and textural understanding the biological basis preferred, and to some extent, provide properties of human milk vary from for children’s food choices. Although “comfort”. That is, memories mother to mother, thus suggesting we are beginning to learn how the evoked by odors and flavors are more that breast feeding, unlike formula chemical senses develop during infancy emotionally charged than those evoked feeding, provides the infant with the and its impact on food choice and by other sensory stimuli because of potential for a rich source of varying other behaviors, there are many gaps the olfactory system=s intense and chemosensory experiences. In this in our knowledge. In particular, we immediate access to the neurological way, culture-specific flavor preferences know little about the contingencies for substrates underlying emotion. The are likely initiated early in life and early learning and how the absence of emotional potency of odor- and flavor- early experiences in a sense, educate chemosensory experience, disruptions evoked memories, and the reward the young child to appreciate the in mother-infant attachment, or the systems that encourage us to seek out flavors typical of the culture into which negative associations with early pleasurable sensations together play a she or he was born. Significant traces feeding interferes with the acquisition role in the strong emotional component of this may remain as children become of feeding skills. The increasing of food habits – an integral part of adults and pass on their food habits importance of infant dysphagia makes all cultures that has its beginnings to the next generation. Of interest are it imperative to determine the extent to during pregnancy and breastfeeding. recent findings infants during from an which restoration of normal oral motor

 World Association for Infant Mental Health October 2007 and sensory experience impact upon of detergents, antibacterial fluids and Selected References the feeding skills and nutrition. We other cleaning items. The long-term present here some examples of gaps in consequences remain unknown. Bilkó, A., Altbacker, V. & Hudson, knowledge: R. (1994) Transmission of food Clearly, more research is needed to preference in the rabbit: The necessity of tube-feeding presents develop evidence-based practices the means of information transfer. a paradox in the care of infants because aimed at infant feeding difficulty Physiology & Behavior 56, 907- it precludes sensori-motor experience (dysphagia) which constitutes a 12. that could be expected to promote medically and economically important feeding skills. Tube-fed infants have complication for some neonatal Buck L, Axel R. (1991) A novel a relatively constrained olfactory and diseases. Applying the knowledge multigene family may encode for flavor experience in the context of gleaned from such research and clinical odorant receptors: a molecular feeding that is not fully understood. practice which takes into account the basis for odor recognition. Cell developing sensory world of the child 65,175-87. A common feature of dysphagia is could have long-term consequently in Ganchrow, J.R., Mennella, J.A. discomfort and interruption of the preventing eating disorders in early (2003) The ontogeny of human continuity of feeding behavior. Over infancy. Moreover, understanding the flavor perception. In R.L. Doty time, negative feeding experiences development and functioning of these (ed). Handbook of olfaction and lead to aversive feeding behaviors senses may assist in the development gustation, 2nd edition. (pp.823- that create a self-perpetuating cycle. of evidence-base strategies to improve 946) New York: Marcel Dekker Such negative feeding experiences their diets since many of the illnesses Inc. and aversive feeding behavior are that plague modern society (e.g., Mennella, J.A., Griffin, C., evident in a wide variety of medical obesity, diabetes and hypertension) are Beauchamp, G.K. (2004) Flavor contexts of infant dysphagia such the consequence of poor food choices. programming during infancy. as infants with gastroesophageal Pediatrics 113, 840. reflux, chronic respiratory disease, neuromuscular disease, and cerebral Peter J. Scheer, Psychosomatics Mennella, J.A., Jagnow, C.J., Beauchamp G.K. (2001) Pre- palsy. That learning plays a role in the und Psychotherapy, Division for pathogenesis of feeding difficulty is and post-natal flavor learning by therefore fundamental to the clinical General Pediatrics, University De- human infants. Pediatrics 107, practice of infant dysphagia specialists. partment for Pediatrics, A-8036 e88. Graz, Austria. Mennella, J.A., Turnbull B., Ziegler In the NICU or even normal infants P.J., Martinez H. Infant feeding wards in hospitals, infants often do not Julie A. Mennella, Monell Chemi- practices and early flavor experience the smell of ‘adult food’ experiences in Mexican infants: or have others eat in their presence. cal Senses Center, Philadelphia, PA 19104-3308 USA. An intra-cultural study. Journal of Instead, infants are exposed to specific the American Dietetic Association smells of NICUs which can be 105: 908-915, 2005a. described as “hospital smell” consisting Mennella J.A., Pepino M.Y., Reed D.R. (2005) Genetic and environmental determinants of bitter perception and sweet preferences in children and adults. Pediatrics 115, e216-22. Rozin, P. (1982) “Taste-smell confusions“ and the duality of the olfactory sense. Perception & psychophysics 31, 397-401. Schaal, B. (1988) Olfaction in infants and children: development and functional perspectives. Chemical Senses 13, 145-190.

10 The Signal October 2007 By the Red Cedar

Transition, Growth, and Democratic Process

By Infant Mental Health and forged an vote! Soon every WAIMH member Hiram E. Fitzgerald, Ph.D. association with a world-wide mission will be receiving a document that will Executive Director, WAIMH but a locally focused organizational illustrate all of the proposed changes in structure. The has given birth the by-laws along with justifications for to Affiliates on five continents spanning each change. You will also receive a slightly more than 50 countries. ballot. It is critical that all members of Clearly there is a need for broader WAIMH vote and return their vote by involvement in the management regular mail, by fax, or by email within of WAIMH’s organization. More the specific time (all is explained in voices must be contributing to policy the documents you will receive). If Hopefully all WAIMH members recommendations, expanded training the bylaws are approved, we will begin are fully aware that WAIMH is in programs need to be developed, to implement them immediately. In transition as it moves its central offices greater sensitivity to cultural anticipation, as chair of the Yokohama from the United States of America diversity is required, and diversity world congress, I have given time at the to Finland. Many meetings and a of early prevention programs must congress for the initial meeting of the steady stream of emails is facilitating be examined. To meet these needs, Affiliate Council. the process of transition and we the WAIMH restructured its board anticipate a smooth and error free by reducing the number of members, move immediately after the Yokohama while simultaneously allocating two We are extremely excited about the World Congress in 2008. A second board positions for individuals from proposed changes in WAIMH’s planned transition was put into place Affiliates. To accomplish this it will organizational structure. Since there this past summer when the WAIMH be necessary to create an Affiliate are currently 46 Affiliates and all will board met in Ahvenanmaa and adopted Council, consisting of all of the be members of the Council, we will a series of bylaw changes designed Affiliate presidents. The Council have an extraordinarily diverse set of to both streamline the association chairperson will serve on the WAIMH opinions contributing to the formulation and to increase the role of Affiliate board of directors along with one other and implementation of WAIMH Associations in WAIMH’s governance. individual elected by the members business and association practices. Our This transition and democratization of affiliate associations. The newly transition was fueled by growth, our of WAIMH is directly related to the organized seven member board will growth has led to democratization in extraordinary growth in the association, meet annually to review progress governance, and we expect our new growth that has doubled the number made on WAIMH’s action agenda. structure will fuel even greater growth of Affiliates over the past decade. On biennial years, the seven will be and world-wide impact for infant We have received an application for joined by WAIMH’s past president, mental health. Affiliate status from the Gauteng the editors of the Infant Mental Health Association for Infant Mental Health Journal and The Signal, the current and in South Africa and in November, past chairpersons of the world congress colleagues in Ireland will hold their program committee in order to act on organizing meeting and soon thereafter any policy or program issues developed we expect to receive yet another by the Affiliate Council or by the application for Affiliate status. WAIMH board itself. We anticipate that the Affiliate Council will emerge as a major influence on WAIMH Our original organizational structure policy. served us well. We blended the best organizational components of the World Association for Infant BUT, WAIMH members hold the key Psychiatry and Allied Disciplines to all of these changes. The key is a and the International Association for

11 World Association for Infant Mental Health October 2007 PRESIDENT’S PERSPECTIVE

DEVELOPING WAIMH

has a joint vision in which affiliates The spectrum of memberships is even will have more power and a clearer richer and broader in affiliates than status or position in the organization. in WAIMH. However, the number of This vision will be reached step by step members in WAIMH has been quite if WAIMH members agree with the steady over the last years although Board of Directors recommendations. the number of affiliates and affiliate Of course, if the number of affiliate members has increased dramatically. In members who become members of order to have a more diverse affiliate By WAIMH increases, the transition voice in WAIMH discussions we Tuula Tamminen, M.D. towards the proposed reorganization need more active people who want will proceed much more quickly. to work at both national affiliate and President, WAIMH international WAIMH levels. Still we One of WAIMH’s most important all need to remember that only those strengths is the fact that we are a who are WAIMH members have and WAIMH members and representatives multi-professional, multidisciplinary will have real power in WAIMH. This and especially members of affiliates and multicultural association. Among is how democratic associations are have been motivated for some time to the WAIMH members there are build up and how they operate. develop WAIMH as an organization. high-quality researchers and senior The joint wish has been to make clinicians as well as trainers and And so, I urge you to use your power WAIMH an ever more democratic, trainees, there are professionals from and in order to proceed to support transparent and efficient world different kinds of organizations and the proposed changes in the bylaws. organization with active members sectors and different professions from Each current WAIMH member will around the world. As stated in our different cultures. We all are needed in be receiving a copy of the proposed bylaws, the aims of WAIMH are promoting infant mental health across restructured bylaws in November. strong and clearly articulated and the world. Please vote. because they are based on science and humanistic values; there is no need to change them. But the organizational Editor’s perspective structure of WAIMH is unique and challenging; WAIMH is not an hierarchical association, it is more like a modern network of people who want About the to have international collaborations and impacts. International Attachment Conference

WAIMH, as all democratic in Braga, Portugal (11.-13.07.07) associations, is owned by its members and the members have the strongest By University of Minho (Portugal) and her power in the association’s decision Miri Keren, M.D. team, and Klaus and Karin Grossman making. Voting in elections for from the University of Regensburg WAIMH officers and representatives Editor, The Signal (Germany), was special in its diversity is naturally the way by which all of points of view about the concept and members can use their power. But If one ever wished to see and hear diagnosis of attachment disorders. WAIMH also has affiliate associations, the main attachment researchers and which in turn are owned by their clinicians under the same roof…he/she Isabelle Soares’s lecture about members. Collectively, there are more should have come to Braga and the “Changing troubled attachment members of Affiliate associations than Minho University this last summer. relationships: From theory, research, there are members of WAIMH. This For those who couldn’t, here are some and clinic”, started with reminding reality often creates confusion and highlights that struck me the most listeners of Bowlby’s view of the five misunderstanding. (obviously this is not a comprehensive main therapeutic tasks: establishing a summary of the conference). secure base, exploring past attachments, WAIMH’s Board of Directors has exploring the therapeutic relationship, worked quite intensively to develop a Indeed, this conference, jointly linking past experiences to present plan for structural changes. The Board organized by Isabelle Soares from the ones, and revising internal working

12 The Signal October 2007 models. Observation of attachment did matter when it was associated with . Her main findings stress behaviors include not only the SSP, a certain genetic pattern. It seems that again the importance of the adoptive but also Alan Sroufe’s AMBIANCE neuroendocrine factors are also at play. parent’s own security of attachment, tool for assessing problem-solving O’Connor concluded with the need and the father’s role in buffering the toddlerhood. She emphasized the to formulate a “more nuanced model mother’s insecurity: regardless of the main attachment-based interventions, of the impact on early deprivation in parents’ attachment classification, including the Circle of Security, STEP, humans”, to refine our assessment all the children showed an increasing Attachment-based intervention for process of attachment disorders, so that amount of secure elements, but themes foster and adoptive parents, and the we can make a better differentiation of aggression, disorganization, and Early Bucarest intervention. between relationships disorders and defensive avoidance of maltreated attachment disorders, and consequently, children did not change when the Jay Belsky (Birbeck Univ. of London, to better define the treatment goals adoptive parents were insecure. It UK) then presented surprising data when we face very deprived infants seems that, as Bowlby had already from his Early Study: he before and after adoption. predicted, that insecure parents find found that family factors and processes the child’s negative emotions too hard were more consistent in predicting The second day of the conference to deal with, and therefore cannot socio-emotional development than addressed intervention issues. make reparation of “interactive errors” child day care factors…for the good (Edward Tronick’s term). By the way, Mary Dozier’s colleague (Univ. of and for the bad. The effects – positive contrary to our intuitive thinking, the Delaware, USA) presented recent as negative – of the day care on number of previous caregivers before research and intervention findings infants, were modest, if not small. Low adoption did not correlate with the related to foster parents and attachment. sensitive maternal care was the variable children’s prognosis. that made the difference between the Again the notion of critical age of children who had more than 10 weeks adoption/placement, was raised: Robert Marvin, (Univ. of Virginia, of daycare per week versus those who infants placed before the age of one USA) with his usual enthusiasm, had nore than 30 hours of daycare per year (not six months, as reported by presented a further elaboration of week. Belsky concluded with two very O’Connor) showed secure behaviors the “Circle of Security” intervention, important messages: (1) Small effects within two weeks if placed with a named “Circle of Repair”, that that impact many individuals may be secure caregiver, as opposed to those specifically defines what the difficult more dangerous for society than large who were placed after one year of age young child needs from the parent effects that impact few individuals. and showed insecure patterns across in times of frustration and temper (2) The common clinical practice to the first two months after placement. tantrums (Take charge of me, Be send infants from multirisk families to Their additional finding that foster- kind with me, Soothe me, Stay with daycare in order to decrease the infants’ care infants often become disorganized me, Help me to return to what I was exposure to inadequate maternal when the foster parent is insecure doing, with a new option…); He also behaviors, is probably less efficacious and not necessarily disorganized developed the “Circle of Limited than we would like to think. (as opposed to the usual pattern of Security” for the miscuing child, , transmission U to D in biological which is actually tailored for high risk Thomas O’Connor’s (Univ. of dyads, stresses the importance of foster/adopted children: “I need you to Rochester, USA) lecture was extremely having secure foster parents, or at least welcome my coming to your home, but interesting and provocative: “The early providing them attachment-focused that makes us uncomfortable because care experience case in humans is not interventions. An additional very I come from a “rejecting dance circle” yet proven”’ he claimed, meaning interesting finding, this time related and you may have a difficult history of that we need a more evidence-based to biology and behavior, was about your own. Therefore I send you a false assessment of what we call attachment the abnormal cortisol levels in half of signal, being an “as if” exploratory disorders. For instance, do post- their foster children, and its potential behavior or an “as if” distant behavior”. institutionalized adopted children significance in terms of vulnerability Cues and miscues are the main target who still show a disinhibited pattern ( for later psychopathology. Their of intervention for these dyads (as meaning a tendency to go to strangers) most recent study is the comparison Mary Dozier has concretized in her at age 11 still meet the diagnosis of between their 10-sessions attachment manualized attachment intervention). attachment disorder, in spite of their intervention and cognitive intervention being clearly differentially attached to with foster parents, while one of their Martha Erickson (Univ of Minnesota, their adoptive parents? (By the way, outcome measures that is the foster USA) presented her well-known this pattern was seen in 255 of the infant’s cortisol level. STEEP model of intervention. This children who had been adopted after the model, is, I think, an example of the age of 6 months, as compared to 10% in Miriam Steele (New School, NY, creativity and flexibility that make the those adopted before 6 months of age). USA) presented her astonishing infant mental health work a special art, How to explain the finding that some of data about changes in attachment as a parallel process to what makes the institutionalized children do show a representations in adoptive children a good-enough parenting. Prenatal secure attachment pattern? In animals, (4-8 year olds) who were previously home visits, video use, parent-infant it was shown that maternal insensitivity maltreated, comparing early and late groups, family nights with fathers’

13 World Association for Infant Mental Health October 2007 involvement, they are all there, and looked at intergenerational patterns system, can be used in individual and their positive impact on outcomes of of attachment from pregnancy in one couple therapies, but also with parents 154 high risk parents and infants, has generation in the next. Here are some of teens for understanding better their been proven. Martha emphasized the of their interesting findings: the 11 “tough teen”. ongoing need to “train the trainer”, year old child’s ability to coherently while “the biggest challenge lies in the acknowledge distress and elaborate Karen Lyons-Ruth (Harvard Medical space between what we know and what a resolution, was correlated with School, USA) continued the topic of we do”. secure mother’s attachment (The borderline adult personality disorder, as Friends and Family Interview, Steele she found it linked with disorganized Robert Pianta (Univ. of Virginia, and Steele, 2004 in Attachment in and controlling forms of attachment USA) presented approaches aimed at Middle Childhood). They found a in late adolescence. Severity of improving the quality of relationships relatively low stability from infancy abuse, genetic vulnerability to stress between teachers and children, and to adolescence, high understanding (presence of the short form of serotonin stressed the important role that of mixed emotions at the Affect Task transporter promoter polymorphism schools may/should have in enhancing at six years of age, predicted whom 5-HTTLPR), and early (meaning during children’s social outcomes. children would be secure at adolescence infancy) referral to mental health and showed good mental health. Mental services were the three predictors Roger Kobak (Univ. of Delaware, health at 16 years was correlated with of borderline personality disorders USA) addressed the topic of mother’s secure AAI during pregnancy. among the children she followed from adolescent attachment, while asking I thought it interesting to note that infancy to young adulthood. Borderline the very pertinent question of the fathers’ view of the marriage when the personality disorder was especially link between the adolescent’s state child was six years old, was correlated linked with maternal withdrawal of mind as reflected in the AAI, and with the adolescent’s AAI. relational pattern (this finding may the adolescent’s attachment status, remind some of us about the classical as reflected in conflict discussion and Carole George (Mills College, USA) psychoanalytical concept of the Dead negociation tasks. He reported his study described her Adult Attachment mother, introduced by Andre Green in of 225 caregivers and adolescents, Projective (AAP) tool for assessing France many years ago…). and shared with us the following traumatic attachment dysregulation findings that support his concept in adults. In her experience, this tool I must confess I did not attend the last of the “Dual model”: Caregiver’s is much easier to administer and to two lectures, presented by Jude Cassidy insecurity plus unresolved loss is code than the AAI. The stimuli used and Nicole Guedeney respectively, the combination that impact on the to trigger attachment representations because my exploratory system pulled adolescent. Caregiver’s insecurity plus are picture drawings of attachment me out of Minho University to Porto, unresolved abuse have a much stronger events put on a range of intensity (ball, before going back to Israel! impact on the adolescent’s chance child at window, departure of adult To conclude, this conference, in to have dissociative and depressive from adult, bench, bed, ambulance, my eyes, was special in the way symptoms. Security of attachment cemetery, child in corner…). The it integrated very updated data of at age 13 predicted increased level adult is asked to tell a story about the various top researchers in the field of empathy and decreased level of pictures, through which agency of self, of attachment, each one of them externalizing problems; Role reversed relationships with others, and defensive bringing up different aspects of attachment predicted increased processes are assessed. The themes attachment, ranging from biological behavior problems at age 15 in boys that appear in traumatic dysregulation, to psychological, from infancy to only, and disorganized attachment at include violence in relationships, in the adulthood, in community as well as in 13 predicted increased internalizing environment, abandonment, murder, clinic, and at home as well as at school. behavioral problems at 15 years. Roger suicide, wish to become invisible/to addressed also the issue of the teacher’s disappear, and characters in fetal role for the adolescent, and suggested position. An astonishing link has to enhance the teachers’ reflective been shown between these themes, functioning with videotape-based especially the item of being alone as training. being the most terrifying situation, and activation of the hippocampus, Elisabeth Carlson (Univ of Minnesota, the amygdala and the prefrontal cortex USA) presented her research on in functional MRI. Carol mentioned attachment disorganization and the work of Hobson et al. (2005) that disorder, that supports her notion provide insight into the dynamics of that the difference between the two is Borderline personality disordered mainly a matter of degree. mothers’ interactive and emotional Howard Steele (New School breakdown with their infants, and have University, NY, USA) presented the significant clinical applications. The London Parent-Child project that AAP analysis is similar to AAI coding

14 The Signal October 2007 Literature Monitor we encounter in our daily practice. evolving form of social communication Concepts of neural plasticity, mirror biological basis. neurons and the biology of attachment, Relationships become biological are very clearly explicated, with in- structures. The amygdala is the hub of Book Review depth description of the links between emotional processing. Empathy requires cognitive and emotional development many levels of neural processing The neuroscience of human with specific brain areas. The mediating and integration beyond resonance relationships, Attachment and effect of good-enough parenting on behaviors. Social memory: the system the developing social brain. the infant’s brain becoming a social of memory is especially important for organ is clearly defined. Here is just Louis Cozolino, 2006, W.W. the formation of emotional regulation one example the author’s virtuosity and cultural identity. The author Norton and Company. at integrating knowledge from views the superego as the result of the Reviewed by Sam Tyano, Professor different domains, while explaining parents’ implicit memories of their Emeritus at Tel-Aviv University the biochemical cascade activated own experiences and unknowingly Sackler Medical School. by infant-mother interaction: “What transferred by them to their child. impact does the sight of a mother’s Colonizo clusters under the category face have on the baby’s social brain? of “Disorders of the social brain”, Reading this book has been a special For one, it triggers high levels of the clinical entities of social phobia, experience for me, as a child and endogenous opiates, which are borderline personality disorder, adolescent as well as an adult psychiatrist, responsible for the pleasurable aspects psychopathy, and autism, and brilliantly because the author brilliantly puts of social interactions and act directly shows the impact of prolonged stress “under one roof” the knowledge that on the subcortical reward centers. and neglect stress on the has accumulated from the 1990s from Positive and exciting stimulation by developing brain. basic neurology sciences as well as the mother also triggers the production He ends with a chapter untitled “Social from developmental psychopathology of CRF in the infant’s hypothalamus, neural plasticity”, and through vignettes research. This very concise, clear, and thereby activating the sympathetic of his own clinical cases, he shows the scientific integrative book enables each nervous system. CRF, which controls benefit for the therapist to think the of us, regardless of our professional endorphins and ACTH production in cases in terms of Loving brain, Fearful background, to understand how the the anterior pituitary, also stimulates brain. In short, I strongly recommend brain is a social organ built through production of dopamine”. this captivating and well written book. interpersonal experience, and to make Louis Cozolino also relates to what he It is not an everyday experience to find new formulations of the clinical cases calls “social smells”, being the earliest an easy-to-read real scientific book!

WORLD ASSOCIATION FOR NON-PROFIT ORG. INFANT MENTAL HEALTH U.S. POSTAGE PAID University Outreach & Engagement EAST LANSING, MI Kellogg Center, Garden Level PERMIT NO. 21 Michigan State University East Lansing, MI 48824-1022

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15 World Association for Infant Mental Health October 2007