Vol. 20, No. 1 | January–March 2012 The Signal Newsletter of the World Association for Infant Mental Health

The father-child activation relationship: a new theory to understand the development of infant mental health

By Daniel Paquette, Ph. D. exploration system that fosters the child’s the world (Paquette et al., 2009). According School of psychoeducation, knowledge acquisition and adaptation to Le Camus (2000), paternal roles can be University of Montreal to unfamiliar environments. Children grouped together under the function of regularly seek comfort through contact opening children to the outside world. The activation relationship theory is a with attachment figures when tired, Fathers act as catalysts for risk-taking, complement to the attachment theory. hungry, sick or afraid or when feeling inciting children to use initiative in According to John Bowlby (1969), insecure in the presence of novelty, and unfamiliar situations, to explore, take attachment consists of two opposing, this comfort provides them with the chances, overcome obstacles, be braver complementary behaviour systems: 1) necessary confidence to explore their in the presence of strangers, and stand up the proximity behaviour system that environment further. The Strange Situation for themselves (Paquette, 2004a, 2004b; ensures the child’s protection and 2) the Procedure (SSP) developed by Mary Paquette, Eugène, Dubeau & Gagnon, Ainsworth and colleagues (1978) has made 2009). This function of opening children it possible to assess the quality of the to the world is also mediated by language. Contents attachment relationship in children ages Studies have shown that fathers play the Paquette: The father-child activation 12-18 months by focusing more on the role of a linguistic bridge to the outside relationship: a new theory to understand the secure base than on the ’s response world by using more complex forms of development of infant mental health...... 1 to the baby’s need for stimulation in language (by referring to past events, exploratory contexts. Paquette (2004a; using unfamiliar words and requesting Affiliates Corner...... 5 2004b) has theorized father-child clarification more) than do mothers (Ely et attachment by developing the concept of al., 1995; Ratner, 1988; Tomasello, Conti- Whitney & Holmberg: Connecticut Association the “activation relationship”, the affective Ramsden & Ewert, 1990), which causes for Infant Mental Health...... 6 bond that permits children to open up to children to speak more and to use a more

the outside world, focusing primarily on varied vocabulary with their fathers (Rowe, Guedeney: Michel SOULE ...... 7 parental behaviour in relation to orduring Cocker & Pan, 2004). In addition, mothers’

child exploration of the environment. verbalizations mostly pertain to emotions Tyano & Keren: Reflections on …...... 8 while those of fathers refer primarily to

The activation relationship theory evolved actions (Marcos, 1995). Fathers also make Membership Meeting ...... 12 out of three findings. The first finding more problem-solving related demands

was that father-child attachment has a than mothers, who tend to solve problems Presidents´ Perspective: WAIMH is on the lower explanatory potential than mother- in place of their children (Labrell, 1992). Move!...... 13 child attachment as assessed with the Accordingto Labrell (1996), children must

Strange Situation. The low stability, low learn to respond to unforeseen events and Editors´ Perspective: transmissibility and low predictability it is fathers who facilitate such learning When cry becomes lethal...... 14 of father-child attachment have led by teasing them and destabilizing them

increasing numbers of researchers to with creative, non conventional games. Book Review/ Clinical Skills in Infant Mental question the appropriateness of using Fathers tend to excite children more and Health: The First Three Years...... 15 this procedure with fathers who have little to engage in more physical play with

involvement in daily caregiving (Suess, them than do mothers, especially as far Zero to Three Corner/ Almeida & Merminod: Grossmann & Sroufe, 1992; van IJzendoorn, as boys are concerned (Dixon et al., 1981; Mothers with Severe Psychiatric Illness and 1995; Youngblade, Park & Belsky, 1993). MacDonald & Parke, 1986). Men generally their newborns: a hospital-based model of The second finding concerned emerging take more risks than women (Byrnes, Miller perinatal consultation...... 16 literature with an increasing focus on the & Schaffer, 1999), and father-child physical paternal function of opening the child to From the Kauppi Campus –News from the WAIMH Central Office...... 21

WAIMH Central Office University of Tampere, Medical Faculty, Laakarinkatu 1, Arvo-building Room C221, 33014 University of Tampere, Finland Tel: + 358 50 4627379, E-mail: [email protected], Web: www.waimh.org play and physical aggression by children various parental responsibilities, generally represent particular forms of risk-taking with boys at the end of childhood, Editorial Staff (Paquette, Bigras & Crepaldi, 2010). depending on the culture (Paquette, 2004a). This parental specialisation may The third finding concerned human- have occurred phylogenetically with Editor specific adaptations and especially human the emergence of the sexual division of fathers’ unique status in the species as labour (hunting for men and gathering for Miri Keren compared to other primate species. women1), fostered, on the one hand, by Humans live longer, and human children the extremely high demands of the human are dependent on their for longer. infant due to its immature status and, on A large brain and a prolonged period of Copy Editor the other, by the growing complexity of development (requiring a high degree the human societies to which the offspring Deborah Weatherston of parental involvement) allow humans must adapt. to learn the great number of things necessary to ensure their adaptation to an The extraordinary increase in the volume environment that has become increasingly of our ancestors’ brains would have Production Editor complex over the course of history caused problems at childbirth, and (MacDonald, 1993). natural selection would have favoured Minna Sorsa, Elina Lehto women who gave birth prematurely. This There is a relation between paternal would explain why the human infant’s involvement, sexual dimorphism, and brain is not completely developed at mating systems in animals. Polygynous Editorial Board birth and continues to develop over primate species are characterized by the course of the first year oflife. Being France Frascarolo pronounced sexual dimorphism, with more vulnerable and dependent than Bernard Golse males being bigger and more aggressive other primate infants, the human baby Antoine Guedeney than females (e.g.: baboons). This Mirjami Mäntymaa would have required more care from its Campbell Paul dimorphism can be explained by the mother, who would thus have had less Kaija Puura strong competition among males for time available to find food, thus resulting Mark Tomlinson exclusive access to females, and also by the in selective pressure for greater paternal Elizabeth Tuters fact that females choose dominant males Martin St. Andre involvement (see Paquette, 2004a, 2004b). Charley Zeanah (Barash, 1982; Fedigan, 1982). Polygynous A series of evolutionary strategies (greater Hisako Watanabe primate males generally provide no genital sensitivity; the establishment Jean Wittenberg paternal care and are either indifferent of continuous sexual activity—due to to youngsters or attack them as the latter females being sexually receptive twelve near puberty, but do protect their group months a year and soon after delivery—; of adult females. In promiscuous primate President’s Perspective concealed ovulation; female selection of species (e.g.: macaques, chimpanzees), male providers, etc.) would have resulted Antoine Guedeney sexual dimorphism is less pronounced in males staying with females for as long than in polygamous species. Malesand as possible (Alexander & Noonan, 1979), females engage in sexual relations with bonding with them, and eventually many partners, but dominant males have becoming involved on both conjugal and Editor’s Perspective priority in terms of access to females. parental levels. In addition to protecting Males show tolerance toward youngsters Miri Keren the mother-child dyad from predators, in the group and may sometimes play with the father would thus have developed them, but provide no paternal care. Finally, an important provider role by supplying there are a few monogamous primate the mother-child dyad with necessary Affiliates Corner species (e.g.: siamangs, titis); these species resources. The literature supports the show little or no sexual dimorphism in notion that this provision of resources Martin St. Andre, Maree Foley terms of size and aggressiveness and helped reduce the risk of males provide intensive parental care. and ensure better physical health for Humans also display sexual dimorphism in children (Geary, 2000). This type of terms of size, strength and aggressiveness, From the Kauppi Campus -News distribution of labour would also have but show that size-related sexual permitted the human species to increase from WAIMH Central Office dimorphism is less pronounced in its population by reducing the interval humans today than it was in our hominoid Pälvi Kaukonen, Kaija Puura, Minna Sorsa between births (1 to 2 years in humans ancestors (McHenry, 1996). Moreover, versus 5 to 6 years in chimpanzees). the human species differs from all other primate species in that while fathers may Fathers would have become involved The Signal is a quarterly publication of the give very little or no direct basic care to directly with boys especially through World Association for Infant Mental Health. children (Hewlett, 2000), they do adopt their previously mentioned function Address correspondence to Miri Keren ([email protected]). parental roles that are distinct from those of opening the child to the world, thus of the mothers (Le Camus, 2000). Human helping boys develop the skills necessary All opinions expressed in The Signal are fathers play, at minimum, the role of to fight, hunt and explore territory in those of the authors, not necessarily those of provider of resources and protection for search of resources; skills they would WAIMH’s. Permission to reprint materials from their spouses and children and assume The Signal is granted, provided appropriate citation for source is noted. Suggested format: 1 — given that our brain today is still the same as that of the hunter-gathers of the Pleistocene Epoch, the The Signal, 2012, Vol 20, No. 1, WAIMH. period spanning from 1.8 million to 10 000 years ago (Tooby & Cosmides, 1990) —

2 THE SIGNAL JANUARY–MARCH 2012 need once they were adults in order to The activation relationship theory also of risk-taking significantly explains the ensure the survival of their own children predicts that fathers will activate children activation score after controlling for child (see Paquette, 2004a). Due to the great more than mothers will, and that boys will characteristics (sex and temperament). plasticity of human behaviour, we are be activated more than girls. In addition, Finally, Paquette and Bigras’ (2010) currently witnessing increased paternal the activation relationship theory should article showed that fathers of activated involvement in Western industrialized predict competition and risk-taking in children tend to have a greater tendency societies, especially in middle socio- children. The theory considers aggression to supervise from slightly more than economic families: fathers are more to be a form of risk-taking, and therefore arm’s length than do other fathers. This involved in caregiving than before, predicts that the father-child relationship father-child distance, in which the father with younger and younger children, will be a greater determinant of the is neither too close to nor too far from and progressively more with girls, even development of aggression problems in the child, allows the father to protect the in rough-and-tumble play (Dumont & boys than the mother-child relationship. child in case of danger while providing the Paquette, 2008; Paquette, 2005; Paquette, Indeed, to date, problems of aggression child with the necessary room to practice Carbonneau, Dubeau, Bigras, & Tremblay, have been linked more to disorganization abilities independently. 2003). While fathers involved in caregiving (Lyons-Ruth & Jacobvitz, 2008) than to the become increasingly important sources A-B-C types of attachment (Berlin, Cassidy Flanders et al. (2009, 2010) have shown of comfort for their children, studies show & Appleyard, 2008; Deklyen & Greenberg, that the association between the that such fathers continue to engage in 2008). The prediction can be made frequency of father-child rough-and- vigorous, physical play with their children that over-activated children will have a tumble play (RTP) in the preschool period (Dumont & Paquette, 2008). Further, greater tendency to develop externalising and the frequency of physical aggression humans engage in the most parent-child problems while under-activated children (which are both evaluated with a self- play of all primates that live in their natural will have a greater tendency to develop report questionnaire) is moderated by the environment (Biden & Suomi, 1993). internalising problems. father’s dominance during RTP (evaluated through observation). When fathers are The secondary role attributed to fathers Paquette and Bigras (2010) have validated not dominant over their children, the in attachment theory is not surprising a procedure called the Risky Situation greater the frequency of RTP, the more given that Bowlby’s inspiration came from (RS) which allows for assessment of the physically aggressive the children are and research on sexually promiscuous primate parent-child activation relationship in the less they regulate their emotions five species (rhesus monkeys, baboons, children 12-18 months. Gaumon and years later. etc.) in which the young are raised by Paquette (submitted) have adapted this their mothers. However, the activation procedure for preschool-age children. The Paquette and Dumont (submitted) have relationship theory predicts that, under RS is a twenty-minute-long observational found a positive association between the difficult environmental conditions, procedure that takes place in an unfamiliar activation relationship in toddlerhood and children will benefit more from the room with toys and in the presence of RTP frequency at the age of three years direct involvement of both their parents a male stranger. It is divided into six only in boys, despite the fathers in their when the latter play complementary structured episodes during which the sample engaging in as much RTP with parental roles. It also predicts that, in child is presented first with a social risk (an girls as with boys. When fathers encourage general, fathers will serve as children’s increasingly intrusive male stranger), then their boys to take risks in their physical primary activation figures and secondary with a physical risk (a set of stairs), and and social environments, protecting their attachment figures, while the opposite then forbidden by the parent to climb the sons through the use of a combination will be true of mothers. The activation stairs. In the RS, under-activated children of supervision and discipline, the boys relationship theory predicts that the tend to engage in little exploration, to engage in more risky physical play such as activation relationship will be the result be passive and anxious and to remain RTP with their fathers. The study’s results of the interaction of child temperament close to the parent. Activated children are also support the idea that the Strange with parental encouragement to explore confident and prudent in their exploration Situation evaluates something different (especially to take calculated risks) and and obey when the parent sets a limit. when used with father-child dyads (see parental control (aimed at protecting the Over-activated children are reckless and also Dumont & Paquette, submitted). child). To a certain extent, temperament do not obey when the parent sets limits. Using the preschool risky situation, is a reflection of the inherited variability The under-activated relationship is linked Gaumon and Paquette (submitted) have of a group of adaptive dimensions tied to to parental overprotection, while the confirmed the hypothesis of an association our ancestral environment. The activation over-activated relationship is linked to between the activation relationship and relationship fosters children’s confidence in parental difficulty in obtaining obedience internalising disorders (ID) in children their own abilities to cope with threats and from the child. The coding sheet also (as evaluated with the Child Behaviour strangeness in their physical and social provides an activation score between 0 Checklist: Achenbach & Rescorla, 2000). environments as their parents stimulate and 5 indicating the extent to which the The more positively activated children them to push their exploration further child is optimally activated (with a score are in their relationship with their father, while at the same time providing them of 5 corresponding to the most positive the fewer internalising disorders they with the confidence of knowing they are activation relationship). Results have display. The association was found to protected from possible danger —hence shown that boys are more activated by be significant after controlling for child the importance of discipline. In other mothers and fathers than girls are, and temperament, parental behaviour and words, children have an innate motivation that, depending of the sample, child’s the number of hours worked per week to explore their environment and develop temperament (shyness, impulsivity, by fathers. Moreover, underactivated their autonomy, and the role of parents is sociability) may be linked to the activation children have significantly more ID than to channel this energy according to their score. Moreover, and most importantly, the activated children. The exploration of child’s biological predisposition as well as activation relationship reflects the history links between the activation relationship environmental conditions or dangers. of parent-child interactions and not only and ID subscales revealed a unique child characteristics: parental stimulation connection to anxiety. Underactivated

3 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH JANUARY–MARCH 2012 children are more anxious when they DeKlyen, M. & Greenberg, M.T. (2008). Labrell, F. (1992). Contributions paternelles receive less encouragement to take risks Attachment and psychopathology in au développement cognitif de l’enfant and explore their environment and when childhood. In J. Cassidy & P.R. Shaver dans la deuxième année de vie. Thèse they are overprotected through the use (Eds.), Handbook of attachment: de doctorat Nouveau Régime, Paris-V. of more control than necessary in light Theory, research, and clinical Labrell, F. (1996). Paternal play with of any potential danger. Dumont and applications (pp. 637-665), Second toddlers: Recreation and creation. Paquette (submitted) also have found the Edition. New York and London: The European Journal of Psychology of same results in a longitudinal study with Guilford Press. Education, 11(1), 43-54. another sample, assessing the activation Dixon, S., Yogman, M., Tronick, E., relationship in toddlerhood with the LaFreniere, P. J.,& Dumas, J. E. (1995). Social Adamson, L., Als, H., & Brazelton, T.B. Risky Situation and assessing internalising Competence and Behavior Evaluation: (1981). Early infant social interaction problems at three years with the Social Preschool edition. Los Angeles, CA: with parents and strangers. Journal Competence and Behaviour Evaluation Western Psychological Services. of the American Academy of Child Scale (SCBE: LaFreniere & Dumas, 1995). Psychiatry, 20, 32-52. Le Camus, J. (2000). Le vrai rôle du père. Paris : Éditions Odile Jacob. In conclusion, the activation relationship Dumont, C. & Paquette, D. (2008). theory has the potential to provide L’attachement père-enfant et Lyons-Ruth, K. & Jacobvitz, D. (2008). us with a better understanding of the l’engagement paternel : deux concepts Attachment disorganization: Genetic development of infant mental health centraux pour mieux prédire le factors, parenting contexts, and by taking into account the specific roles développement de l’enfant. Revue de developmental transformation from played by fathers as a complement to psychoéducation, 37 (1), 27-46. infancy to adulthood. In J. Cassidy those exercised by mothers in the family & P.R. Shaver (Eds.), Handbook of Dumont, C., & Paquette, D. (submitted). system. attachment: Theory, research, and What about the child’s tie to the clinical applications (pp. 666-697), father? A new insight into fathering, Second Edition. New York and London: father-child attachment, children’s References The Guilford Press. socio-emotional development and the Achenbach, T.M., & Rescorla, L. A. (2000). activation relationship theory. Early MacDonald, K. (1993). Parent-child play: Manual for the ASEBA Preschool Forms Child Development and Care. An evolutionary Perspective. In K. & Profiles. Burlington, VT: University of MacDonald (Ed.), Parent-child play: Ely, R., Gleason, J.B., Narasimhan, B. & Vermont, Research Center for Children, Descriptions & implications (pp. 113- McCabe, A. (1995). Family talk about Youth, & Families. 143). Albany: State University of New talk: Mothers lead the way. Discourse York Press. Ainsworth, M.D.S., Blehar, M.C., Waters, E. & Processes, 19, 201-218. Wall, S. (1978). Patterns of attachment: MacDonald, K., & Parke, R.D. (1986). Parent- Fedigan, L.M. (1982). Primate paradigms. A psychological study of the strange child physical play: The effects of sex Sex roles and social bonds. Montreal: situation. Hillsdale, NJ: Lawrence and age of children and parents. Sex Eden Press Inc. Erlbaum. Roles, 15, 367-378. Flanders, J.L., Simard, M., Paquette, D., Alexander, R.D., & Noonan, K.M. (1979). Marcos, H. (1995). 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4 THE SIGNAL JANUARY–MARCH 2012 the father-child activation relationship. le développement des enfants? In D. of genetics and adaptation, Journal of Early Child Development and Care, Dubeau, A. Devault & G. Forget (Eds.), Personnality, 58, 17-67. 180(1-2), 33-50. La paternité au 21e siècle (pp. 99-122). Tomasello, M., Conti-Ramsden, G. & Québec : PUL. Paquette, D., Bigras, M., & Crepaldi, M.A. Ewert, B. (1990). Young children’s (2010). La violence : un jugement de Ratner, N.B. (1988). Patterns of parental conversations with their mothers and valeur sur les rapports de pouvoir. vocabulary selection in speech to fathers: Differences in breakdown Revue de Psychoéducation, 39(2), very young children. Journal of Child and repair. Journal of Child Language, 245-274. Language, 15(3), 481-492. 17(1), 115-130. Paquette, D., Carbonneau, R., Dubeau, Rowe, M.L., Coker, D. & Pan, B.A. (2004). A van IJzendoorn, M.H. (1995). Adult D., Bigras, M. & Tremblay, R.E. (2003). Comparison of Fathers’ and Mothers’ attachment representations, parental Prevalence of father-child rough-and- Talk to Toddlers in Low-income responsiveness, and infant attachment: tumble play and physical aggression in Families. Social Development, 13(2), A meta-analysis on the predictive preschool children, European Journal 278-291. validity of the Adult Attachment of Psychology of Education, 18(2), Interview. Psychological Bulletin, 117, Suess, G.J., Grossmann, K.E., & Sroufe, L.A. 171-189. 387-403. (1992). Effects of infant attachment Paquette, D., & Dumont, C. (submitted). to mother and father on quality of Youngblade, L.M., Park, K.A., & Belsky, Is father-child rough-and-tumble adaptation in preschool: From dyadic J. (1993). Measurement of young play associated with attachment or to individual organization of self. children’s close friendship: A activation Relationships? Early Child International Journal of Behavioral comparison of 2 independent Development and Care. Development, 15, 43–65. assessment systems and their associations with attachment security. Paquette, D., Eugène, M.M., Dubeau, D. Tooby, J. & Cosmides, L. (1990). On the International Journal of Behavioral & Gagnon, M.-N. (2009). Les pères universality of human nature and the Development, 16, 563–587. ont-ils une influence spécifique sur uniqueness of the individual: The role

News from the WAIMH Affiliates Corner Affiliates Council March 2012

Welcome to 2012 – the year of the WAIMH congress in Cape Town. This congress will include a time to reflect on how we are going in regard to our growing relationships with each other and with WAIMH. This brief letter invites you to join with us in reflecting on a few issues for us all as affiliates.

First, affiliates have the opportunity to create and sustain an interdisciplinary collaboration based on a shared view of infant mental health. While interdisciplinary theory and practice is often espoused, the actual practice of this is more difficult with both academics and practitioners increasingly identifying themselves within specific streams of theory and practice. While the benefit of this trend is potential depth of knowledge, a coexisting risk is creating a world within a stream; a bit like seeing a baby on its own. Yet, as Winnicott would remind us; there is never a baby there is always a baby and someone. We encourage you all to embrace the tensions and struggles that come with growing a shared view within your affiliates – perhaps as our affiliates grow they will do so amidst the ebb and flow of “rupture and repair” – a process Ed Tronick so eloquently has described.

Second, as WAIMH reaches out to its members via the affiliate council it has become increasingly clear that someAI W MH members are not actively engaged with their local affiliates and vice-versa. We are keen to understand this situation more and invite your ideas and experiences of this issue. Your contribution will help to build a broader picture, from which we can meaningfully respond. It is clear however, we have some more bridges to build in this regard with each other. So if you are reading this and you are a member of WAIMH but not linked in with an affiliate, but you would like to be, let us know and we will put you in touch with the nearest affiliate to you – which may be a different country. This capacity withinAI W MH is a great strength that we can tap into. Also if you are a member of an affiliate but not ofAI W MH and would like to share with us your experience of this, please send us an email. We would be delighted to hear from you.

Third, at the WAIMH congress, we will meet as a council. We are in the process of formulating the agenda. So, whether you plan to be at the congress or not we would very much appreciate any ideas you might wish to have discussed. If you do, you can send these to [email protected] or to either of us.

Finally, we wish you all the very best for 2012. We especially look forward welcoming new affiliates from across the globe; and in turn introducing them to you during the year.

Martin St-André Maree Foley Affiliate Council Chair Affiliate Representative

5 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH JANUARY–MARCH 2012

Connecticut Association for Affiliates Corner March 2012

Infant Mental Health, Inc.

Our challenges in moving forward are By Grace A. Whitney, PhD, MPA, IMH-E(IV)®, In addition to membership and conference growing from a Board of passionate Director, CT Head Start Collaboration Office registration fees, our key funding streams have been federal, state, and private volunteers to a paid staff, expanding our Margaret C. Holmberg, PhD, IMH-E(IV)®, grants. US Department of Health and Board to include people with affluence President, CT Association for Infant Mental Human Services funding has come to and influence, finding ways to infuse the Health CT-AIMH a) from the Substance Abuse infant mental health Competencies into and Mental Health Service Administration the policies and practices of those agencies and programs that provide services to through a local system of care and state The Connecticut Association for Infant work force collaborative, infants/toddlers and their families, and finding multi-year funding sources that Mental Health, Inc. was formed out of a b) from the Office of Head Start through task force on early childhood development support the infrastructure of the Board and the State Collaboration Office, and c) sponsored by our Child Health and from the Children’s Bureau through our committees. Development Institute in 2002. We Department of Children and Families. Each followed the suggestions from WAIMH for of these federally funded efforts includes For additional information please see our establishing an affiliate and developed CT-AIMH in their work plans. Funding from web site: www.ct-aimh.org By-laws, formed a Board of Directors, our State Department of Developmental established membership dues, and held Services was received to support our first meeting and conference in reflective supervision work this year. A 2004. We became a 501c3 (US non-profit) private foundation, the Child Health and organization in 2009 and adopted the Development Institute of the Children’s Competency Guidelines for Culturally Fund, has been a long-time supporter Sensitive, Relationship-Focused Practice and source of funds. These collaborations Promoting Infant Mental Health® in 2009 have allowed us to move our workforce from Michigan-AIMH. In 2010 we engaged development initiatives forward, a professional to help us develop a promoting the Competency Guidelines Business Plan following the strategic plan and Endorsement process. developed by the Board and hired a part time Endorsement Coordinator. To promote the Competency Guidelines

we established a Competency Planning Our membership has grown from 30 to Consortium in 2008. This group has 180 persons from diverse professional and become the Professional Development educational fields. Our contact list now Advisory Committee and is currently numbers 350. engaged in a visioning process to plan for growing our Competency and Prior to 2010 we held two professional Endorsement Activities. development activities a year with 80-100 people attending. Since adopting the What has worked to get us to our current Competency Guidelines and offering the status? Conneticut Champions who have

Endorsement our educational activities spoken on our behalf at critical meetings, have increased. With funding specifically financial support from federal grants and for workforce development we have state agencies as we have been written offered a series of training on infant/ into their work plans, private foundation toddler and family development related support, learning and sharing through to the Competencies and introductory connections with other states and the sessions on reflective supervision. In 2012 WAIMH¸ and a growing interest in and with funding from federal, state and local evidence for the importance of early grants we will be offering another training relationships and emotional regulation. series and will provide four-year-long reflective supervision opportunities for mixed groups of Part C, Early Head Start and child welfare staff.

6 THE SIGNAL JANUARY–MARCH 2012 Obituary Michel SOULE

first day care unit for autistic and psychotic child mental health, which was followed children. He developed liaison work with by legions of paediatrician, psychologists the NICU, one of France’s top ones for very and child psychiatrist. At last, in 1985, he low birth weight premature babies. He was named honorary Professor of Infant was fascinated by the work developed in Psychiatry at René Descartes University the IPP with foetuses and family, in one of (Paris V). He was extremely pleased with the earliest foetal medicine department, this recognition, even if it was quite late in led by Fernand Daffos, the French pioneer life. He had a great ability to connect with of antenatal diagnosis and intervention. children and adolescents, as he had kept There, he helped the Daffos team reflect something from his own childhood. He on ethical issues in this very new field, was curious and playful, loved to listen and and explored the effect of ultrasound to tell stories, to make jokes. He could not echography on parents’ minds. live without reading, without learning, and

Professor Michel Soulé died in Paris, without music, particularly opera. He loved

February 2012, aged 85, from a long Michel Soulé will be remembered for a to travel, particularly in Italy, where he neurological disease which had kept this lot of reasons, but the one of organising went as often as he could. He was a close very active man confined to a wheel chair prevention and early services for infants friend of Graziela Fava and many Italian for several years. Michel Soulé would have in the community is a very special one child psychiatrist and psychoanalysts. He loved to attend his own , but he indeed. He was able to recruit the help of stayed quite often in Trento to teach and would have liked it to be a feast, or even a brilliant, young magistrate, Simone Veil, work with the Fava’s, and he went more better, a ‘bal costumé’. Like Huckleberry who became a very prominent politician than 40 times to Venice. Finn, he would have loved to hear what and health minister to help him organize was said of him, who was moved, who the first district based prevention and Of special importance, Michel Soule was was not attending. He would have been early intervention network for infants and particularly helpful with the young child pleased to see that in this Montparnasse families. psychiatrists of my generation or a bit we were very numerous, even older. He told us how to teach and enlisted though the temperature was minus 10 In addition, ,Michel Soulé organized us in his clinical and scientific adventures. C. Almost everyone he had been able to a yearly meeting for infant, child & Though he did not speak English, he teach, to enlighten and to put to work was adolescent mental health professionals, was very interested in the international there - members of a large, heterogeneous over 25 years ago. He meant it as a landscape and was well known in South crossroad between disciplines, where family. America, as well as in all French speaking people came to learn, to reflect on new countries. Michel Soulé took great interest Michel Soulé was a very special figure in issues, to share resources , as well as to be in WAIPAD and was a member of the the field of French speaking Child and amused and distracted from daily clinical organising committee in the Lugano Adolescent Psychiatry. He came from a work. What he established was beautiful WAIPAD congress, along with Bob Emde, family of mathematicians and scientists - a special mixture of pleasure and work, Bertrand Cramer, Hiram Fitzgerald, Serge and started by preparing for admission with around 800 people attending each Lebovici, Charley Zeanah, Kathryn Barnard. to top engineering schools. He had a session. Many of these “Journées de la clearly organized, scientific mind, as well Guidance” were memorable. The first one We will remember his strength in front of as a psychologically oriented one. This was in 1973, focused on infant’s functional his increasing handicap, of his willingness was obvious when dealing with him as syndromes. It led to the writing of a still to live, to understand, to learn, without a boss. He quickly moved to medicine, famous book by Michel Soulé, Michel Fain abdication. I miss him, we miss him. then to paediatrics, then to child and Leon Kreisler on early psychosomatics. psychiatry. He often said that when he Another meeting was about parents in did so his mother asked him, “ But what the NICU; another introduced T. Berry Antoine Guedeney have we done to you?.”: He had Freudian Brazelton ‘s work to the French public; psychoanalysis with Serge Lebovici, another examined foetal medicine then became a training member of the issues; and yet another was one on the Paris Psychoanalytical Society. After his effect of an autistic child on the parent’ residency, he was not named full professor, s mental life. Michel Soulé was definitely most probably because he was much the first psychoanalytically oriented child too smart for his mentors. He therefore psychiatrist to raise the issue of autism in organized doe himself his own place France. for working , researching and training, as did Serge Lebovici and Léon Kreisler, In summary, Michel Soulé was quite a his friends and colleagues, for the same leader, a fantastic teacher, and a great reasons. The place was the Institut de organizer. He wrote a classic teaching Puériculture de Paris, in the 14 th district, book on child psychiatry, gathering with a clinic for infants and children, in a contributions from all over France. He paediatric hospital. There, he opened the organized the first course in infant and

7 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH JANUARY–MARCH 2012 Reflections on filicide

By Sam Tyano and Miri Keren ensure social stability (Mull & Mull, 1987). is the most prone: among children and Tel Aviv University Medical School, Indeed, cultural-bound priorities, still in adolescents, are most likely to Geha Mental Health Center, Israel the early 21st century, give legitimization occur in the first year of life; the second for filicide (Oberman, 2003). For instance, peak is during later adolescence (Overpeck “A four-year-old girl had in parts of Northern India, adults prioritize et al, 1998). Abuse and filicide are on the well-being of family rather than the disappeared for two months and the same spectrum: more than 80% of survival of individual members (Miller, homicides in very young children were was found dead in a suitcase at 1981). In some societies, infants with actually fatal child abuse. the bottom of a river. The girl’s visible deformities and twinships are Among those under the age of 5 years, father admitted to having killed legitimately killed (Mull & Mull, 1987; 61% were killed by their own parents, half her and, the girl’s mother is Larme, 1997). Female gender is also a by their mothers (30%), and half by their culture-bound risk factor for fathers (31%). The majority of homicides suspected of having asked him to (Fuse & Crenshaw, 2006). Some societies, of children older than three years are do so.” such as in rural parts of India, seem to committed by a person unrelated to prefer sons, but the reason behind this the child. Based on these statistics the “A three-year-old boy was preference is economic: “Too many girls, conclusions reached are that filicide is a drowned by his mother, a single too much dowry” (Diamond-Smith et al, real problem and that the first three years parent. Until then, this boy filled 2008). Culture-bound beliefs, such as evil are critical for early detection of infants the mother’s world. She had spirits that can grab the souls of newborns, who are at high risk for at the hands may make infanticide a legitimate act, as of their parents. planned to commit , but it has been described in Bolivia (DeHilari did not do so.” et al, 2009). Other common reasons for Risk factors for filicide killing infants were social, such as family “A one-year-old infant girl was size and poverty. These authors found that Early detection necessitates knowing the killed and hidden in a forest by both communities of their sample gave risk factors. her father. Her parents were legitimization to that were divorced. “I knew this would be the result of biological and social reasons. Killing infants because of social reasons - Age of child the solution for all my problems,” only, was rarely justified. In the late 1960’s, the author, Resnick the father said. (1969), suggested differentiating between While the rationale for engaging in “” (within the first 24 hours infanticide varies widely by culture, of life) , “infanticide” (within the first 12 Introduction commonalities emerge, especially among months of life), and filicide (older children). less-industrialized places. Contrary to The interdiction to kill one’s own child is Neonaticide being typically committed by current Western thinking and studies (that not a universally shared value. young, poor, and unmarried mothers with will be reviewed below), filicide is not The first published “near-filicide” of our little or no prenatal care. A more recent always an unpredictable crime committed ancestor, Abraham, was ready to review (Hatters-Friedman et al, 2005) by mentally ill parents: Oberman (2003) his son, Isaac, as the ultimate proof of his reported a high frequency of denied or showed that parents who commit filicide unconditional commitment to God. But concealed pregnancies (in spite of the fact often cannot raise children under the God did not allow it to happen… that these mothers tend to live with their circumstances dictated by their specific own parents) among maternal perpetrators position in place and time. To most Western minds, the thought of of neonaticide. Mothers who committed a parent killing his/her child evokes a infanticide were described as young, Besides the cultural and socio-economic deep sense of horror and outrage, as it is unemployed and having a high frequency motives, little is known about the viewed as a betrayal of the assumption of psychiatric disorders (Haapasalo & circumstances and factors that lead to that parental love is one of the tenets Petaja, 1999). filicide. This lack of knowledge makes of civilization. Therefore, parental, and prevention difficult. While it is obvious that especially maternal, filicide is regarded filicide is one of the rare conditions where - Child’s characteristics as a crime committed by “crazy” people. prevention is the only treatment, this lack While reviewing the literature, it turns A study which took place in Japan of knowledge is especially disturbing. out that many societies have practiced (Haapasalo & Petaja, 1999) found not infanticide, including Greeks, Chinese, only a high frequency of psychiatric Japanese, India, Brazil, England, Italy, and Prevalence of filicide among disorders among mothers who murdered France, among others. Infanticide has western societies their infants, but also a high frequency been the most widely used method of of physical anomalies among the child population control during much of human A recent survey in the United States victims. This is consistent with the well- history (Harris, 1997) and fully reviewed by (Hatters-Friedman et al, 2005) reported known link between physical handicap and Brockington (1996). “Legitimate” motives that was the fourth leading cause child abuse. for infanticide include the desire to control of death among children from ages 1-4 the size and composition of the family, years, and the third one among children maximize reproductive success, and from ages 5-14 years. The first year of life

8 THE SIGNAL JANUARY–MARCH 2012 - Gender death (i.e. the “Shaken Baby syndrome) distinction between two types of psychotic Empirical studies have made clear the women (Kunst, 2005): Among the children who were murdered fact that in most cases of filicide, multiple under five years of age in the United States factors act together to cause the parent 1. The disorganized type, characterized by in the last quarter of the 20th century, to kill his/her own child (Saisto et al, 2001; extreme personality fragmentation that is 61% were killed by their parents, equally Schwartz & Isser, 2000). These include the combined result of a biologically-based by mothers and fathers (30% by mothers, financial difficulties, social isolation, single chronic mental illness and a destructive 31% by fathers). Twice as many fathers motherhood, work-related stress, housing early environment (such as severe neglect as mothers committed filicide-suicide problems, and a childhood of abuse and/ and abuse). This parent’s crime is the result (Hatters-Friedman et al, 2005). In a Quebec or trauma, marital problems and jealousy, of bizarre acting out where the infant is sample (Bourget & Gagne, 2005), paternal alcohol abuse, physical illness, depression, not perceived as human, but rather as a filicide was found to be more common mood disorders, psychosis. lifeless part-object into which the mother than maternal filicide after the age of one projects unwanted, threatening parts of year (neonaticide is very rarely committed her fragmented ego. by fathers and most infanticides are 2. The organized type, distinguished committed by mothers). Filicidal parents who are not by a premorbidly more integrated ego defined as mentally ill (reflected in quite good educational Despite these findings, paternal filicide has achievements, work and interpersonal attracted limited research and is even less functioning), that becomes temporarily but well-understood than maternal filicide. Neonaticide is caused mostly by this severely fractured. The crime is organized Also, 60 cases of male parent filicides were group of mothers, usually very young into “logic”, though pathological and investigated : 23% of the children were mothers who cannot cope with social distorted. Their childhood history is less under the age of 1 year, 26% between 1 stress factors Haapasalo et al, 1999; chaotic than the disorganized group’s one, and 5 years, 22% between 6 and 10 years, Stanton et al, 2000; Bourget et al, 2007). but, based on Kunst’s sample of filicidal and 29% were more than 10 years old. The absence of mental illness, as defined mothers, all the women had a history of Siblings were murdered in 23% of the by the law, meaning psychosis or affective intrafamilial sexual abuse and depressed, cases. 60% of the homicides committed by disorder, does not imply the existence of inconsistent maternal care. Unlike the fathers were followed by suicide, especially a healthy personality. As has been shown first group, these filicidal mothers are very in the instances involving multiple sibling (Putkonen et al, 1998), there is a high rate invested in their child, but in a pathological victims. 18% of the sample also killed their of personality disorders, with very low ego way. They look to their children to be for spouses at the time of the filicide. The most organization, among these mothers who them objects of transformation, of repair common means of homicide was the use commit neonaticide. Similarly, among 16 of themselves (Bollas, 1987). Such women of a firearm (34%), followed by beating cases of neonaticide (Spinelli, 2001), nearly seek a mother in their own child. Again, (22%). The use of knife, strangulation, blunt all of the women reported symptoms the filicidal act comes when environmental instrument, intoxication, and drowning of belle indifference, depersonalization, stresses, such as marital stress or were much less common, in decreasing dissociative hallucinations, and separation, severe financial problems, and order. Recent rupture of the marital intermittent amnesia at delivery. Most poor support, combine with the mother’s relationship had occurred in 40% of the of the cases reported were preceded by psychological vulnerability and lead her cases; family violence was indicated in and 56% of of the to feel increasingly alienated from the 40% of the cases; drugs and/or alcohol use sample had a history of sexual abuse. world around. The mother’s unbearable were uncommon. The presence of severe Accidental filicides, i.e.fatal abuse, is more anxiety turns into depression and psychopathology was observed in 60% frequent among parents with personality fantasies of ultimate annihilation where of the fathers: major depression (52%), disorders and intense psychosocial stress at the child is entrapped because of her schizophrenia and other psychoses (10%), the time of the fatal abuse, than psychosis enmeshed, undifferentiated relationship and acute substance intoxication (5%). and depression (Stanton et al, 2000). with him/her. It is in that state of mind Fathers are often perpetrators of fatal- Among the psychopathic, narcissistic, that these mothers start to build “the” abuse filicide, with a childhood history retaliatory individuals, the aim is sadistic plan. A mother’s statement, illustrates this of abuse, especially in paternal filicides (Glasser, 1986). The child was never really catastrophic dynamic very well: “I didn’t kill involving infants under the age of 1 year. wanted and is killed either as an accidental my son, I killed myself” (Kunst, 2005, p. 36). These fathers are rarely psychotic. result of severe abuse or in the parent’s Retaliating filicides are rare among deliberate, vengeance towards his/her This distinction of the two groups mothers and typically reflect personality spouse. This group of parents, though of women is important in terms of disorders with a high incidence of suicide psychologically disturbed, but not mentally understanding the phenomenon of filicide attempts. ill (Pappietro et al, 2005), are typically and in planning for intervention. Indeed, in found guilty of . Kunst’s experience, the women described Parental motivations for as “organized” are often treatable patients who can use psychotherapy to understand committing filicide Filicidal parents who are the core complexities and fantasies that led them to commit the crime. The major motivational factors for filicide defined as mentally ill include (Gagne, 2002; Resnick, 1972; In this second group of parents who suffer d’Orban, 1979; Pitt & Bale, 1995; Farooque from schizophrenia, bipolar disorder, or & Ernst, 2003): Clinical implications psychotic depression, the violence is very a. Mental illness different in nature. It is self-preservative, b. Retaliation Early detection aimed at protecting oneself and/or the c. Rejection of an unwanted child child from perceived threat (Fonagy & The knowledge of motivating factors d. Mercy killing Target, 1995). There is a suggestion of a causing a parent to kill a newborn, a e. Chronic abuse that lead to accidental

9 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH JANUARY–MARCH 2012 toddler, or an older child, is a prerequisite Conclusion De Hilari. C,, Condori, I., Dearden, K.A. for any early intervention planning. The (2009) When is deliberate killing of above reported data imply, for instance, Obviously, only a minority of parents who young children justified? Indigenous that a psychotic mother is at heightened become psychiatrically ill and/or have interpretations of infanticide in Bolivia. risk of killing her newborn, especially environmental stressors kill their child. Social Science & Medicine 68, 352-361. if other factors add to the burden of Similarly, most parents who experienced d’Orban, P.T. (1979) Women who kill their motherhood, such as being a single parent, neglect and/or abuse in their own children. British Journal of Psychiatry having a low IQ and a history of drug childhood do not kill their children, in 134, 560-571. abuse. For these women, there is a specific spite of their deficient parenting skills. need for social and psychiatric support Therefore, one must try to comprehend the Farooque, R., Ernst, F.A. (2003) Filicide: during pregnancy and the first year of life. phenomenon of filicide as a complex one, A review of eight years of clinical The same stands for teen-agers, isolated, where psychodynamic factors should be experience. Journal of the National and poor first mothers. Psychiatrists also included in the constellation of risk factors Medical Association 95, 90-94. need to remember that a very depressed identified in individuals at risk for filicide Fonagy, P., Target, M. (1995). Understanding woman may be at risk of killing an older [28]. the violent patient: the use of body child, especially if she has other risk factors. and the role of the father. International Thoughts of infanticide should be directly “The eye sees only that which the mind is Journal of Psycho-analysis 76, 487-501. probed by general practioners and prepared to comprehend”, has brilliantly other health professionals, among non- announced Henri Bergson, French Fuse, K., Crenshaw, E.M. (2006). Gender psychotic, postpartum depressed mothers philosopher and recipient of the Nobel imbalance in infant mortality: a cross- because they tend to spontaneously Prize for Literature in 1927. The central task national study of social structure and disclose their suicidal thoughts, but not for those who seek to eliminate filicide female infanticide. Social Science & their infanticidal ones (Barr & Beck, 2008). is first to understand the lives of those Medicine 62, 360-374. In spite of the high proportion of child who commit this crime and the unspoken Gagné, P. (2002). Maternal filicide in homicides committed by fathers, the messages conveyed by their society and Quebec. Journal of American academy tendency to overlook filicidal risk culture. It is important also to recognize of Psychiatry and the Law 30, 345-351. among men, is still high. The possibility the serious nature of perinatal mental of homicidal tendencies in depressed disorder, its link to abnormal personality Glasser, M. (1986) Identification and fathers, especially when suicidal ideation is and to consequent relationship problems its vicissitudes as observed in the present, should be assessed systematically. with the parent and infant and to plan perversions. International Journal of Almost half of the filicidal women and risk reduction strategies in primary and Psych-Analysis 67, 9-16. men had had previous contact with health secondary services where staff are trained Haapasalo, J., Petaja, S. (1999) Mothers who professionals before the time of offense in infant and perinatal psychiatry. killed or attempted to kill their child: (Bourget et al, 2005). Life circumstances, childhood abuse,

and types of killing. Violence and To-date, the most effective early detection Victims 14, 219-239. is still a case-by-case approach which necessitates a high degree of vigilance References Harris, M. (1997). Cannibals and kings: the and general awareness of homicidal risk. origins of cultures. New York: Random The findings of the above cited Finnish Barr, J.A., Beck, C.T. (2008) Infanticide House. study (Putkonen et al, 2009) suggest that secrets. Qualitative study on Hatters-Friedman, S., McCue Horwitz, prevention of filicide is not the task of postpartum depression. Canadian S., Resnick, P.J. (2005) psychiatry alone; health care and society Family Physician 54, 1716-1717.e5. by mothers: A critical analysis of the must work together. Bollas, C. (1987). The shadow of the object. current state of knowledge and a

New York: Columbia University Press. research agenda. American Journal of Existing programs Psychiatry 162, 1578-1587. Bourget, D:, Gagné, P. (2005) Paternal In the USA and other Western countries, Filicide in Québec. Journal of the Hatters-Friedman, S., Hrouda, D.R., Holden, programs usually center on American Academy of Psychiatry and C.E., Noffsinger, S.G., Resnick, P.J. (2005) 1. Developing comprehensive the Law 33, 354-360 Filicide-suicide: Common factors in parents who kill their children and reproductive health programs, Bourget, D., Grace, J., Whitehurst, L. (2007) themselves. Journal of American including giving access to A review of maternal and paternal Academy of Psychiatry and the Law 33, family planning and filicide. Journal of the American 496-504. 2. Improvement of social support Academy for Psychiatry and the Law networks 35, 74-82. Kirscher, M.K., Stone, M.H., Sevecke, K., 3. Targeting at-risk families, Steinmeyer, E.M. (2007) Motives Brockington, I. ( 1996 ). Infanticide in such as those with high levels of for maternal filicide: results from a Motherhood and Mental Health . domestic violence study with female forensic patients. Oxford University Press ,pp. 430-468 4. Clinical interventions International Journal of Law and 5. Legal sanctions Diamond-Smith, N., Luke, N., McGarvey. Psychiatry 30, 191-200. One of the evidence-based efficient (2008) “Too many girls, too much Kunst, J.L. (2005) Fraught with the urmost interventions is home visitation by trained dowry”: son preference and daughter danger: The object relations of mothers nurses during pregnancy and the first aversion in rural Tamil Nadu, India. who kill their children. Bulletin of the two years of life reduced rates of child Culture, Health, & Sexuality 10, 697- Menninger Clinic 66, 19-38. abuse and neglect among first-born 708. children of unmarried adolescents of low socioeconomic status (Olds et al, 1986).

10 THE SIGNAL JANUARY–MARCH 2012 Larme, A.C. (1997). Health care allocation Rodenburg, M. (1971) Child murder and selective neglect in rural Peru. by depressed parents. Canadian Social Science & Medicine 44, 1711- Psychiatric Association Journal 16, 1723. 41-49. Miller, B. (1981). The Endangered Sex: Saisto, T., Salmela-Aro, K., Nurmi, J.E., Neglect of female children in rural Halmesmaki, E. (2001) Psychosocial North India. Cornell University Press, disappointment with delivery Ithaca. and puerperal depression: A longitudinal study. Acta Obstetricia et Mull, D.S., Mull, J.D. (1987). Infanticide Gynecologoca Scandinavica 80, 39-45. among the Tarahumara of the Mexican Sierra Madre. In N. Scheper-Hughes Schwartz, L.L., Isser, N.K. (2000) Endangered (ed.) Child survival: Anthropological children: Neonaticide, infanticide and perspectives on the treatment and filicide. New York: CRC Press. maltreatment of children. Reidel, Spinelli, M.G. (2001) A systematic Dordrecht, Holland, pp. 113-134. investigation of 16 cases of Oberman, M. (2003). Mothers who neonaticide. American Journal of kill: Cross-cultural patterns in and Psychiatry 158, 811-813. perspectives on contemporary Stanton, J., Simpson, A,, Wouldes, T. (2000) maternal filicide. International Journal A qualitative study of filicide by of Law and Psychiatry 26, 493-514. mentally ill mothers. Child Abuse and Olds, D., Henderson, C.R., Chamberlin, R., Neglect 24, 1451-1460. Tatelbaum, R. (1986) Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics 78, 65-78. Overpeck, M.D., Brenner, R.A., Trumble, A.C., Trifiletti, L.B., Berendes, H.W. (1998) Risk factors for infant homicide in the United States. New England Journal of Medicine 329, 1211-1216. Papapietro, D.J., Barbo, E. (2005) Commentary: Toward a Psychodynamic Understanding of Filicide—Beyond Psychosis and Into the Heart of Darkness. Journal of the American Academy of Psychiatry and the Law 33, 505-508. Pitt, S.E., Bale, E.M. (1995) Neonaticide, infanticide and filicide: A review of the literature. Bulletin of the American Academy of Psychiatry and the Law 23, 375-386. Putkonen, H., Collander, J., Honkasalo, M.L., Lonnqvist, J. (1998) Finnish female homicide offenders 1982-1992. Journal of Forensic Psychiatry 9, 672-684. Putkonen H, Weizmann-Henelius G, Lindberg N et al. (2009) Differences between homicide and filicide offenders: results of a nationwide register-based case-control study. BMC Psychiatry, 9,27doi Resnick, P.J. (1969) Child murder by parents: A psychiatric review of filicide. American Journal of Psychiatry 126, 325-334. Resnick, P.J. (1972) Infanticide. In J.G. Howells (ed.), Modern perspectives in psycho-obstetrics. Oliver & Boyd, Edinburg, pp. 410-431.

11 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH JANUARY–MARCH 2012 Membership meeting

World Association for Infant Mental Health WAIMH 13th World Congress Cape Town, South Africa

Thursday April 19, 16.45 – 17.30 Chair Antoine Guedeney, President of WAIMH

Agenda

1. Call to order

2. President's remarks

3. approval of Minutes of the 2010 Membership Meeting, Leipzig, Germany

4. Financial Report

5. Report on Board Activities since Leipzig, 2010

6. Central Office Report

7. action plan for 2012 – 2014

8. WAIMH 14th World Congress, Edinburgh, Scotland

9. AOB

10. Closing of the meeting

Welcome to the WAIMH Membership Meeting

Antoine Guedeney President of WAIMH

Honorary President Distinction

12 THE SIGNAL JANUARY–MARCH 2012 President’s Perspective

By Antoine Guedeney

WAIMH is on the Move!

WAIMH really is on the move, and on all extend. WAIMH is “on the move,” we have used video We have implemented major by-laws changes, conferencing for our board meetings, allowing as well as the transfer of the WAIMH office from us to have meetings when needed at low cost to East Lansing, Michigan USA to Tampere, Finland. the association. This is by now fully realised and efficient. We The Infant Mental Health Journal (IMHJ) is have also revised and updated the WAIMH also on the move. Hiram Fitzgerald, Editor- website. and China as they develop affiliates groups or in-Chief, has moved the IMHJ into one of the societies committed to infant mental health. The Signal is on the move. Revitalized by Editor more important publications in the field with and President-Elect, Miri Keren (Israel) and with a large panel of Associate Editors from around This is my last presidential address and offers assistance from Deborah Weatherston (USA), the world and streamlining submissions me the opportunity to tell you how pleased The Signal is becoming an important member electronically. The new format and cover are and privileged I have been to work with such benefit. Members are invited to submit articles really attractive and, of real importance, the an incredible group of people who are now for the readership at large. We invite all affiliates IMHJ can accommodate more papers in each long time friends. I have had constant help from to use The Signal to disseminate information issue and can plan for special issues. WAIMH Miri Keren, President-Elect (my almost sib as we about the history of their associations, as well members are invited to submit ideas for special were born same day in the same city!) and I will as special trainings, conferences or advocacy issues and, if accepted, will undergo the same continue to work with her and with the board events. The Signal is also a place where WAIMH peer review process as the regular issues. Hope with great pleasure as Past President. I had the can celebrate the life and work of colleagues is high that the IMHJ will soon get into Medline; constant support and help from Past President, who have made important contributions to the mean rejection rate now is 69%, which is Tuula Tamminen, from Honorary President, Bob the field, but who are no longer living, such as about the same as Child Development. The Emde and previous Executive Director, Hiram Salvador Celia from Brazil, arguably the first IMHJ is the official publication ofAI W MH and is Fitzgerald, benefiting from their experience WAIMH member to be statued in the city where owned by the Michigan Infant Mental Health and wisdom. Palvi Kaukonen, WAIMH Executive he organized la ‘Semana do Bebe’, the week Association (MI-AIMH). MI-AIMH, with assistance Director, is a great asset for WAIMH, assisted of the infant or Michel Soulé, a great figure of from a selection committee, will choose the next by Kaija Puura, Associate Director, with both infant mental health in France (see his obituary Editor-in-Chief by 2014 when Hiram Fitzgerald of them carrying high level responsibilities in this issue). It is the place where members steps down from that position. as they carry out the work of WAIMH. The can publish original clinical work, specific WAIMH office in Tampere is fantastic, with Development of training within WAIMH is also experiences or book reviews. Minna Sorsa, Administrative Assistant, always “on the move,” with several new initiatives. One ready to assist even in “off” hours. The board WAIMH members recently held an important is the first AIW MH Training Village to be carried has been extremely hard working, during board election. As President, I want to thank out in Capetown, just before the Pre-Congress congress meetings and in between. I do thank the candidates who were nominated and day. It will be one-day training, offered by Kaija all of them for their work. It was with particular congratulate the selection of Karlen Lyons-Ruth. Puura, Palvi Kaukonen, Deborah Weatherston pleasure that we greeted Martin Saint André and Because this is a member-based organization, and myself, at the Children memorial Maree Foley as representative of the affiliates we hope that each WAIMH member will paediatric hospital. Astrid Berg and the South to the board and we have appreciated their participate with enthusiasm in upcoming African Affiliate organized a test meeting last responsiveness and initiatives to strengthen the elections. The next important vote will take year during the WAIMH Conference committee’s bonds between WAIMH and affiliates societies. place in Capetown. Miri Keren will step up to site visit and it was quite successful. The idea was Thanks to Kai von Klitzing for organizing a very her role as President of WAIMH. At that time, the to use the WAIMH Congress as a way to attract successful congress in Leipzig, which puts us board will select a new Present-Elect. We have and support infant mental health workers who in a good financial condition and to Neil Boris sent a tentative inquiry to all WAIMH members may not be able to attend the WAIMH Congress and the whole program committee who made so that candidates be known and give their in Cape Town, but would be able to attend a it so scientifically and clinically pertinent and so programs and presentation so the members of Training Village. It is one way that WAIMH can attractive. the board will be able to vote select the new give back to the growing infant mental health President-Elect at the April 2012 board meeting. community. In the future, we could look for Finally, I must say how much I learned in being sustained sponsorships for such events. a WAIPAD then a WAIMH member for 23 years The position of President-Elect is an important now. I started as executive at large for Serge one. The WAIMH Presidency is an honour as well A second training development was the Lebovici, my mentor and the first French as an exciting and demanding responsibility. invitation extended to Miri Keren and myself president of WAIPAD. I barely could speak fluent Generally, candidates have been on the board to participate in the perinatal section of the English then and I had to follow and transcript for some time and are very familiar with the World Psychiatric Association WPA. Together, the conversation between impressive people organisation. Quite often, they have successfully we used our attendance at this conference in like Bob Emde, Joy Osofsky, Hiram Fitzgerald, organised a world congress or a regional Buenos Aires to respond to the invitation of Peter de Chateau, and many others all of whom conference in connection with WAIMH. They the Argentinian affiliate association (SAPI), to were quite helpful and became close friends. have had leadership experience as head of an participate in a 2-day meeting at no cost to the Being in the board of WAIMH has helped me a academic department or research team and affiliate. In the past, WAIMH board members lot in my personal career and lead me to high have international experience and respect. The have largely done this work as missi dominici, responsibilities in research and university as well President-Elect sits on the board for 4 years offering their expertise and training abilities as allowing me to visit extraordinary people and before becoming President, allowing for a great to groups who requested it. WAIMH leaders places around the world, and I am very grateful deal of collaboration with the current president will take every opportunity to participate in to the organization for all this. and insuring continuity for the leadership of the other societies meetings (Marcé, IACAPAP, etc), association. increasing our training opportunities within our Now, get ready for the next WAIMH grand world or regional congresses. Our next goal is rendezvous! See you all in Cape Town or, if not, Of additional interest and showing that clearly to continue to expand training in India in Edinburg, 2014.

13 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH JANUARY–MARCH 2012 Editor’s Perspective

By Miri Keren, M.D.

When cry becomes lethal…

In the literature review on the filicidal parent's motives to kill their infant, as it has been described in this Issue, " due to abuse" is mentioned. Baby Shaken Syndrome is one of the causes for such accidental death.

By chance, in parallel to the preparation of this Issue, two cases of Baby Shaken Syndrome, one of them lethal, were reported in the news, and created very strong reactions in the Israeli media. It reminded me of a similar case we had at our Infant Mental Health Conference last year. A 26-year-old father could not stand his baby's inconsolable cry in the midst of the night and shook her so badly the baby was left with mild to moderate brain damage. He was discharged from the police under the condition that he participate with his wife in our unit for intensive treatment. There were no indicators of chronic abuse towards the baby.

As opposed to the public "black and white" reaction, we had no choice but to try to overcome the almost automatic identification with the victim…a 4 month- old beautiful baby, the first child of a young, immigrant couple… and to develop a more complex view of the case. Not surprisingly, the team member who volunteered to be their therapist was our social worker (Selma Fraiberg was indeed a social worker…)! We enrolled both parents and their baby in an intensive treatment plan we have put in place for neglectful/ violent parents. The plan includes two weekly sessions. The first is a parent-infant group interactional therapy and the second is an individual triadic (mother-infant-father) session. Our adult psychiatrist diagnosed the father with impulsive and antisocial traits, but did not see him as a violent man.

Within the parent-infant group sessions, as a sense of basic trust slowly emerged among the parents, the father felt confident enough to tell what happened. As opposed to the usual horrified reactions heard in the general public, the other parents identified with the father's extreme reaction to the baby's persistent cry. Each of them started to tell the group how much they fear their baby's cry. Almost by definition of the reason for their enrollment in this high risk parents’ group, all of the parents have complex childhood attachment histories. The persistent cry, a central attachment signal, evokes in all of them helplessness, followed by anger and rage, as they perceive the baby ias persecutory. Shaking the baby in despair and rage becomes the end-point of this psychological chain of events.

The therapist’s ability to sort out parental despair and fear as separate from the violent act, is, I think, the first step in our duty, often imposed on us by the court, to try and treat violent parents. We do not have the luxury to simply put them far away from us, by labeling them "simply crazy" or "horrific" as the media has. It seems to me that we as infant parent therapists are trained to treat these parents as victims of trauma and domestic violence rather than perpetuators of abuse. As the baby's cry may become the trigger for a filicidal act, the parent's treatment can start only with the establishment of a secure base that will give him/her tools for regulating his/her strong negative affects engendered by fear, loneliness, and helplessness in face of their crying infant, exactly what they missed in their own past. At the end of a two-year therapeutic process, the father who participated in treatment with us concluded by saying: "Only now I understand how much being a parent is not something to take for granted". He and his wife have decided to have their second child.

14 THE SIGNAL JANUARY–MARCH 2012 Book review

Clinical Skills in Infant Mental Health: may be considered- psychoanalytic theory, offering many examples of emotional The First Three Years, 2nd Edition (2011) object relations theory, attachment processing, the development of symbolic theory, neurobiology and brain research. capacities and empathy. Essential tasks Authors: Sarah Mares, Louise Newman, and Of additional interest, there is a succinct of parenting are clearly presented, with Beulah Warren overview of infancy, including the attention to the challenging behaviors ACER Press, Victoria, Australia exploration and significance of early that toddlers may present and the need emotional and psychosocial experiences for careful developmental and family As interest in infancy and early parenthood to development, the identification of assessments and supportive interventions. grows, professionals who work in a variety disorders of infancy and disruptions to of ways with very young children and their the parent-child relationship, as well as Careful discussion of special issues appears families are eager for practical information discussion of current models for early in the final chapters where the authors about the relatively new field of infant intervention. There are also references for address trauma, gender identity, perinatal mental health. It was not so long ago further reading and vignettes that illustrate mental illness, parental substance abuse, that Selma Fraiberg coined the phrase, key concepts. and high-risk caregiving environments that “infant mental health” and introduced threaten the social and emotional health developmental and clinical practitioners Later chapters introduce a bio-psychosocial of infants and young children. There are to the early identification and treatment and developmental perspective for levels of intervention that practitioners of the parent-child relationship (Fraiberg, infant mental health assessments. The can provide to reduce these risks, from 1980). Fraiberg understood that an infant’s approach invites careful consideration prevention to early intervention and long capacity for love and learning begins in the of infant, family and contextual factors. term care. The authors discuss a range of first years of life. She also understood that Principles to keep in mind include the evidence-based practices and conclude how a parent cares for a very young child assessment of both capacity and risk; the with a discussion about training and the has a significant impact on the emotional understanding that parents want what preparation of professionals to provide an health of that child. Most importantly, is best for their babies or toddlers; that array of infant mental health services. she helped us understand that history is a relational approach is essential; and that development is transactional. The In sum, the book is an extraordinary guide not destiny. Parents have the capacity for those who want to build infant mental to change the ways in which they relate invitation to consider effective clinical assessment includes practical guidelines health services into their local or state to and care for a baby; babies have the systems. It is beautifully written and offers capacity to change, too. From Fraiberg’s for interviewing families, observing parent- infant interactions, and carrying out. vignettes to illustrate theory and clinical perspective, it is our shared responsibility practice. Most importantly, the authors as professionals to support parents during developmental assessments of each infant to assure an understanding of the risks and offer hopefulness for change through pregnancy and in the first years of life to supportive interventions that take into promote healthy social and emotional the strengths of those referred for services. The authors include many examples from account, the infant, the parent and the development and to reduce the risk of early developing relationship. relationship disturbances, disorders of their clinical experiences with very young infancy, abuse and neglect. children and their families that enrich the Clinical Skills in Infant Mental Health: The reader’s capacity to consider a broad range First Three Years, 2nd Edition, written by of things when assessing risks in infancy Reference Sarah Mares, Louise Newman, and Beulah and early parenthood. Fraiberg, S. (Ed.)(1980). Clinical studies in Warren, Australian clinicians well-known In later chapters, Mares, Newman & for their work in Sydney, offers a guide infant mental health. New York: Basic Warren discuss problems that are often Books. to professionals all over the world who arise in infancy and result in referral to a with families in effort to reduce the risks professional for assessment, consultation that Fraiberg described and to restore and intervention services. The most emotional health in infancy and early problematic include regulatory difficulties parenthood. The knowledge and skills (sleeping, feeding, crying), relationship addressed should be seen as “a treasure disturbances, and trauma that place that should be returned to babies and development and caregiving at high their families as a gift from science” risk. The authors offer guidance to (Fraiberg, 1980, p. 3). It is a volume offering practitioners to help them determine what theoretical and skill-based information to therapeutic approaches might increase inform research and practice with children parental confidence in caregiving and birth to three and their families. strengthen the quality of the infant-parent The first chapters introduce the reader to relationship. the multi-disciplinary field of infant mental After focusing on infancy, the authors health, with attention to both research and present developmental changes clinical practice during pregnancy and in throughout the second, third and fourth the first three years. The authors offer a year of life. They examine emotional and theoretical framework within which infant behavioral milestones and challenges, mental health principles and practices

15 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH JANUARY–MARCH 2012 Mothers with Severe Psychiatric Illness and their newborns: a hospital-based model of perinatal consultation

By Ana Almeida and Gaëlle Merminod, University Hospitals of Geneva ZERO TO THREE Corner Daniel S. Schechter, University Hospitals of Geneva and Columbia University College of Physicians Surgeons Women with severe psychiatric illness face numerous risks and challenges during pregnancy and as parents. Mental health Women with severe psychiatric illness, such professionals can help these mothers and their infants by supporting as schizophrenia, experience increased the attachment relationship and by providing the external supports risks and vulnerability during pregnancy that are necessary for successful parenting. In this article from the Zero and the postpartum period. The risks are particularly high if the woman has had to to Three Journal (Vol.29, No.5), the authors describe a hospital-based stop taking her stabilizing medications intervention in Geneva, Switzerland, and contrast the stories of two because of the risks to the baby and if mothers with schizophrenic illness in terms of the risks and resilience of she lacks sufficient social supports (Miller, each mother in her capacity to care for her infant. 1997). A recent epidemiologic study of over 1 million live births in Denmark over a 25 year period supported the theory that women with psychotic disorders are at substantially higher risk for perinatal loss and morbidity (King-Hele et al., 2009) than are women without psychotic disorders. At the University Hospitals of Geneva, stress, and at best, save lives (Schechter This increased risk was not necessarily we foster alliances between infants and & Willheim, 2009). Another component due to their psychiatric illness itself but their parents, medical staff and parents, of treatment involves helping to rather to psychosocial impairment that is and medical staff and infants with a contemplate and interpret their baby’s associated with chronic psychiatric illness developmentally and relationally focused communication. It is important to note and that results in insufficient prenatal perspective. These human bonds are the that this psychotherapeutic work is distinct care, unstable living conditions, and lack most precious, yet vulnerable lifelines from child protective services and should of integration into social support networks for mothers, many of whom who have be clearly presented as such. This is to say including a medical home (King-Hele et al., experienced disturbed attachments, that we as clinicians attempt whenever 2009). In addition, women with chronic abandonment, violence, lack of social possible to maintain a therapeutic alliance psychotic disorders are more prone to support, or immigration stress. Because with mothers that holds their and their lead unhealthy lifestyles that often involve these women often feel abandoned baby’s perspectives in mind while not nicotine dependence, poor nutrition, and and burdened, if not menaced, by the neglecting safety issues. To maintain this greater risk for violence exposure (Hauck, world around them, it is hard to let longer-term investment in the mother and Rock, Jackiewicz, & Jablensky, 2008). their own babies connect to them, even baby’s well-being, we recommend that though those babies are hardwired to a separate team of mental health/child The problem is not as rare as one might try (Stern, 1985). In addition to these protection specialists, whose job it is to hope. Every year in the U.S., 4,100 to social risk factors, chronic psychiatric report over the short-term to the family 8,200 women experience postpartum illness may involve psychosis (i.e., loss of court system directly, do a distinct forensic psychosis. New onset psychosis during reality testing, thought disorder, gross evaluation to determine whether parental the peripartum period is most commonly disturbances in affective responsivity, rights should be upheld, suspended associated with bipolar disorder poor social functioning), medications to pending observation, or terminated. At (Sharma & Mazmanian, 2003). Careful treat their psychosis and other difficulties, times, we do find it essential to offer our evaluation, diagnosis, and treatment and the potential side effects of those clinical opinions one way or the other of maternal psychiatric illness together medications. Given these vulnerabilities to the forensic evaluators. When this is with family planning counseling prior to and risks, women with psychiatric illness necessary, as it often is, we often have one any conception would be optimal in an face enormous challenges to succeeding member of our team who is known to the ideal world. In reality, this is often not as parents in a complex urban society mother discuss this frankly but sensitively possible. And so, preventive intervention (Hipwell, Goossens, Melhuish, & Kumar., with her, with an attempt to ally with her and sensitive alliance-building with 2000). fundamental wishes to keep her child psychiatrically ill parents, baby, and other alive and protected from danger. Another caregivers from the first moments of For women with severe psychopathology, member of our team known to the mother presentation is paramount to provide the a key part of the treatment involves remains available should the mother newborn with the opportunity for optimal recognizing their capacities and their decide that the therapist who spoke with development (Hauck et al., 2008). desires, however ambivalent, to form the forensic evaluators can no longer be relationships that can at the least reduce trusted. This is an advantage in working

16 THE SIGNAL JANUARY–MARCH 2012 in therapist-pairs with these families. We Raiza and Yousef son was given to his father who at that also try to continue our therapeutic work point assumed full-custody and legal beyond the time when court decisions In the Maternity Hospital, the neonatal guardianship, and the son had weekend are made—which itself is often a period staff requested an evaluation of a mother– visits with Raiza. of enormous stress for parents, extended baby relationship 1 day postpartum family, and baby. If a mother and baby because of the staff’s concern regarding During meetings with the multidisciplinary are separated, often one member of the the mother’s erratic behavior. Nurses had team, Raiza had consistently appeared to therapist-pair will continue to follow the noticed that Raiza, a 44-year-old Algerian be easily irritated, often talking nonstop baby in her new setting and the other, will woman, had appeared to be overly without taking a breath, and showing work with mother on issues of separation, intrusive with her baby boy, Yousef, one signs of physical agitation that caused loss, and planning for her own future. moment, and very “odd” and elusive to the her to leap up from her chair, dramatically staff the next. Yousef was placed on the leave the room, and then return. She In order to assess an infant–parent Developmental Pediatrics Unit pending tended to jump from one subject to relationship at high risk, it is important to further evaluation. A colleague in the adult another often with vague, idiosyncratic try to elicit the strengths and capacities psychiatry liaison service diagnosed Raiza references that were difficult to follow of the parent and infant, and the family’s with schizoaffective disorder, a form of despite her excellent command of the internal and external supports over psychotic disorder typified by delusions, French language. In the relation to Yousef, multiple visits. The discovery of mother hallucinations, profound ambivalence, she seemed to confuse herself with Yousef, and baby’s ability to form a loving mood swings, and erratic behaviour. Raiza speaking of dry skin and lathering her own attachment is a treasure to guard. But had been stable for several years without arms and face with skin cream but also the ability to form a loving attachment any treatment—yet to maintain this level applying it to Yousef’s behind and legs tin within a structured hospital setting does of functioning, she had a very routinized such large quantities that a white visible not necessarily mean that a psychiatrically life with little social contact. She was layer that oozed from the diaper. At times, ill parent will be able to manage without on long-term disability and had a city- it appeared that she forgot about her baby, a substantial network of resources upon appointed case-manager to manage her relinquished eye contact with him, and discharge. Her baby may even need to finances. Behind inconsistent interaction focused with his nurses only on her own be placed, temporarily or permanently, with hospital staff was clear mistrust to the grievances. in a child protective center and/or foster point of “paranoia.” Raiza at certain points And yet at other moments Raiza clearly family (Hipwell et al., 2000). Our work believed that the Swiss medical system was involves establishment of a sense of had a capacity to share an admiring glance robbing African mothers of their children with her baby, speak sweetly to him, or continuity and coherence in the lives of to make the children “Swiss” and work for psychiatrically vulnerable mothers and sing him a song. However, she described the “white people.” She denied any mental Yousef (i.e., “her mental representations of the thoughtful integration of multiple illness or need for treatment. points of view by members of various him”) with a paucity of detail, and with no professional disciplines: the obstetric team, Raiza was not married to Yousef’s father, regard for his individuality: “What can I say social workers, mental health professionals, Boris, who was an illegal immigrant and of him… he is a baby and all babies that pediatricians, nurses speech/occupational/ did not speak the local French language. age are alike.” She also described Yousef via physical therapists, vocational skills Yousef is the only child of this couple, attributions that one would normally apply educators, and others. but Raiza had previously had an 11-year- to the description of an older child: “He is a old son out of a relationship with a man wise young man—he knows what you are In situations when termination of parental who had long since disappeared from all up to.” She had a definite idea that was rights seems imperative, we again want her life. Boris had three children living in unmovable regarding her baby. When we to emphasize that it is still beneficial to war-torn Bosnia whom he had left behind tried to introduce a bit of curiosity about work with parents and infant to prevent to seek political refuge in Geneva. The him, she was not curious with us. It was as subsequent tragedies. Indeed, parents couple knew each other for less than 1 if the discovery of her baby from any other often “replace” a removed child, and many year. The pregnancy, while unexpected, perspective was too threatening. infants grow up with the scars of adverse went well despite the fact that mother had Another worry among hospital staff was early experiences in the child protective completely avoided obstetric care. system. The efforts of the mental health the sudden panicked thoughts Raiza could professional , whether or not the parent Raiza had been painfully rejected by her have about her baby. A nurse could be remains active in the daily life of the child, family for having had her first child as a talking with her calmly when suddenly should include mental health outreach, single-mother and so moved to Geneva. the sleeping Yousef’s gurgle would be family planning, and violence prevention/ Raiza remained guarded about her family. interpreted by Raiza as evidence that he safety planning as important treatment Yet she suggested that she had nothing was suffocating. She would jostle him and goals (Miller, 1997) Working with foster good to say about her parents or siblings. hoist him up in her arms abruptly to make parents and their infants, and assessing A history of verbal and possibly physical sure he could breathe, startling him and their tolerance of an ongoing relationship abuse was suspected but never completely making him cry. When we tried to reflect between the child and biological mother confirmed by Raiza. with Raiza on these moments, she denied when she is stable, can optimize the that she had really thought he would She was hospitalized at the main subsequent development of the child die, saying, “He was waking up and I just psychiatric hospital in Geneva when (Marshall, Reeb, Fox, Nelson, & Zeanah, wanted to help him by holding him.” We her older son was only 2 years old. At 2008). To illustrate, we present below understood but did not interpret to Raiza that time, she was diagnosed as having two contrasting situations involving that these incidents likely marked Raiza’s a schizophrenic disorder. Raiza was mothers with chronic disabling psychiatric own sense of suffocation by her baby’s assigned a case-manager, and this older conditions. needs and the closeness he required.

17 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH JANUARY–MARCH 2012 Ten days postpartum, Raiza became medical advice. Meetings between this sensitive center that is meant for increasingly anxious about why the law guardian and Raiza ended with temporary shelter, but in fact becomes Developmental Pediatrics Unit would not Child Protective Services deciding to often a placement for several months. let her take her baby home if he was not place Yousef in foster care and terminate Raiza did not show up for her outpatient physically sick. After not visiting all day, Raiza’s parental rights. During the visits with us. Follow-up at Yousef’s shelter Raiza showed up in the evening on the multidisciplinary meeting at which this indicated that Raiza had visited initially unit and abruptly took Yousef out of his decision was announced, Raiza hurled on a sporadic basis but stopped after bassinet. She covered him in a blanket and insults at the medical staff, became several weeks and that Yousef was waiting stormed out of the unit. When the nurses agitated, got up to leave, and then sat . tried to stop her, she screamed loudly down again spontaneously and remained in a threatening way at them. As Boris quiet and preoccupied, muttering to As a postscript to this story, 2 months later approached her to keep the elevator door herself. Raiza was wandering around the lobby open so she would have more time to talk of the Children’s Hospital one morning to the nurses, she shoved him back and It was painful for us as parents to see appearing agitated and lost. She was pulled the door closed. Hospital security Raiza’s suffering in these circumstances. hardly recognizable, with a new hair was called but could not arrive quickly The countertransference was one of guilt, color and style, wearing large glamorous enough, and the mother disappeared into as we if we indeed had done exactly what sunglasses and fashionable, flowing, and the night with the baby. The staff called Raiza feared. We felt helpless for lack of colorful, if not somewhat mismatched the police and an adult psychiatrist to our capacity to appeal to logic or for this clothes. She approached Dr. Schechter make an at-home crisis evaluation. At the parent to exercise insight and invoke saying, “Doctor, I am so glad to see you… time of the assessment, Raiza was calm problem solving. Using this awareness of I don’t know where my baby is. I heard he and Yousef, sleeping, remained unharmed. our own reaction to her, we reassured Raiza was adopted but they tell me nothing. I Raiza reported that if police said that in this intense and disorganizing suffering just want to know where he is and that Yousef must go back to the hospital, she that we understood how much she loved he is safe.” She proudly pulled out her cell trusted that there was a real medical her baby and that we would do everything phone and showed Yousef’s picture. “This reason for it. She allowed the police to possible to help her maintain a link with is the last picture I have… see that he can remove the baby and was not brought to Yousef no matter what the outcome would sit by himself now! He is so handsome, the hospital herself. It was as if Raiza had be. no?” Just as Raiza had disappeared, she had reappeared in a new guise and been reassured by the police intervention Boris meanwhile, was in a precarious and remained calm. engaged the doctor to cope with her social situation since he was in Switzerland loss, receive confirmation that she had Following this event, Yousef was moved illegally. He visited often at first, with an produced a lovely child, and to assist her directly in front of the nurse’s station and attitude of total support for Raiza (perhaps communication with the city social services monitored when his mother visited. Raiza either with ignorance of or denial of the department so that she could find out that seemed more compliant with nursing degree of her psychiatric disturbance and her baby was indeed in safe hands without requests and apologized for her rash thus colluding with her in the denial of her compromising the foster family’s right to judgment. Nevertheless, after a day or pathology). But after Raiza shoved him and maintain anonymity. two, she again began to resist nursing took Yousef out of the hospital as nurses suggestions that her baby might be crying pleaded with her, he little by little showed for reasons other than hunger—even as understanding of Raiza’s difficulties and, she could keep her baby on her breast for simultaneously, greater estrangement Rose and Europa from her. At the same time, he too had a exceedingly long periods, beyond nutritive A local gynecologist worried that this sucking. She also had the need to awaken strong tendency to mistrust the medical staff and remained angry and abrupt. He Italian-immigrant mother whom we her baby to change him and lather his shall call Rose had presented for care in bottom with diaper cream. seemed unaware that his temper was intimidating. He refused categorically her 22nd week of pregnancy. A midwife By the third day following the police event, that the baby should be placed out of his noted that she seemed “odd and hard to Raiza again seemed mistrustful of the care—even though in Switzerland he had follow.” The gynecologist referred Rose nursing staff and easily irritated. Yousef no paternal rights as an illegal immigrant for evaluation by the Adult Psychiatry was more dysregulated, hypervigilant, and with no proof of paternity. He threatened Consult-Liaison Unit at the Maternity frequently spitting up due to excessive members of the medical team, causing Hospital, which led to Rose’s immediate feeding. The pediatricians limited visiting security to be called when he visited. The hospitalization where she remained until hours to allow time for Yousef’s own presence of the the security officers in the delivery. After an uncomplicated birth, sleep and feeding rhythms to develop response to both parents’ behaviour made her baby girl, Europa, was hospitalized in without Raiza’s intrusion. Raiza seemed them more hypervigilant and suspicious the Developmental Pediatrics Unit. Rose more organized and focused on Yousef of the medical team’s intentions. However, returned to the Adult Psychiatry Inpatient when she visited. As with the limitations Raiza remained responsive to limits set— Unit. imposed by the police, she seemed to rise almost as if she had been reassured by the We learned that Rose’s own mother to the challenge during the briefer visits. presence of security; while Boris tended suffered from a psychiatric illness that She, nevertheless, continued to deny any to become agitated and provocative with required intermittent hospitalization. difficulties and refused psychiatric care guards and staff alike. Not surprisingly, However, Rose had very positive early even though this was a condition for the day Yousef was transferred to the and consistent contact with her maternal increasing her visiting hours. Child Protective Services residence, the grandmother until she was an adolescent parents separated, and the residence’s staff A law guardian was appointed for Yousef and began to “have fun with boys.” Rose reported that Boris made no further visits herself had never worked. She was 34- by Child Protective Services, to whom to Yousef. a report had been made when Raiza years-old. Despite a history of multiple took Yousef from the hospital against Yousef was placed in an attachment- sexual pursuits since age 14, she denied

18 THE SIGNAL JANUARY–MARCH 2012 physical or sexual abuse. She did not know hurdles of coming to accept that Europa in becoming a mother while having one with any certainty the identity of Europa’s had a father but that the father would of these chronic disabling psychiatric father. likely never recognize Europa as his child conditions. Rather, we hope that we can (and that Rose would likely not recognize learn to see what prevents Raiza and We observed that during visits with the father by appearance!), 2½ months of Yousef from developing a good-enough her daughter Rose appeared adjusted, mother–baby hospitalization allowed us to attachment despite the external supports attentive to Europa’s signals, respectful of build a very positive and reciprocal alliance and constraints that are imposed. And her sleep rhythms and feeding needs. The with Rose and Europa. In contrast to the we hope that we can learn to se see what pediatric nurses noted that Rose was very case of Raiza and Yousef, Rose accepted permits Rose and Europa, despite the careful with her daughter during bathtime, that “something was not right with her mother’s significant psychiatric morbidity, speaking and singing appropriately to her mind” (officially termed “schizoaffective to maintain a loving attachment and make little girl throughout. Europa was a quiet disorder”). She thus gladly accepted the most use of external supports and baby who cried when hungry but calmed psychiatric follow-up for herself and dyadic constraints that are imposed. Rose’s lack quickly in Rose’s arms. When awake, Rose psychotherapy, home visitation, and of judgment in her relationships with men appreciated her attentiveness. case management with a law guardian poses a risk for Europa in terms of potential Rose, in contrast to Raiza, idealized her in the interest of Europa. Until a suitable trauma such as sexual abuse. And yet, daughter and saw herself in her daughter. housing arrangement could be found Rose is able to accept that, for this reason, Yet Rose was also able to see her daughter for Rose in a supervised living facility, it may be best not to live alone with her as an individual: She was delighted to she allowed Europa to move to the same baby at this time—while still maintaining discover Europa’s face, and to acknowledge attachment-sensitive child protective unit a positive relationship with her under the that her daughter was nonetheless unique. where Yousef had been sent. Yet Rose guidance and supervision of professionals. maintained daily regular contact and Rose said, “She has her mother’s feet but A secure attachment to her maternal her hands are all her own.” demonstrated that she could keep her own mental health appointments. We grandmother surely provided a foundation During the second postpartum week, thus felt confident that Europa and Rose for Rose to accept and make use of Rose awakened on the psychiatric ward would benefit from the best each could help and to pass this appreciation of crying for the nurse. She told staff that she contribute to their mutually satisfying human relationships on to Europa even “had nightmares that Europa is crying and relationship. In addition, we believed that as a newborn. In contrast, Raiza’s early calling for [me] but [I] cannot get there… Rose and Europa’s emerging attachment deprivation, and repeated trauma in the [I] cannot tell her it will be all right.” We would lay the foundation for openness context of having no secure attachment, viewed this as further evidence of an to subsequent attachments with others together with the particular nature of her evolving attachment—of what Winnicott such as case managers, early childhood subsequent psychopathology, prevented called “ primary maternal preoccupation” staff, or mental health professionals, who her from working with others and with (Winnicott, 1956/1958, p. 300) even would further nurture and enrich Rose and Yousef for their mutual benefit. though mother and daughter were not Europa’s development as a new family.. Another very common and unfortunate allowed to sleep in the same room. Staff fear for prospective adoptive parents decided to bring Europa’s crib over to of infants such as Yousef is that these Rose’s ward. The nightmares stopped. What do each of these babies may share the schizophrenic or Europa woke up twice per night to feed bipolar genetics of their parents. As much and fell quickly asleep again along with her vignettes teach us? as the complexity of modern medical mother. science seems to bring us toward greater As infant specialists, we are relationship- uncertainty rather than less, one helpful One concern that remained was that Rose based and attachment-focused. We trend is the realization that caregiving continued to wonder whether in fact she understand the potential effects of environments matter very much and that might have produced Europa without protection and risk conferred by a genetics are not the only determinants a father because she did not know who particular attachment relationship of behavior (Caspi et al., 2003; Meaney & the father was. During the pregnancy (Coates & Schechter, 2004). And, in fact, Szyf, 2005). The genetic risk of developing Rose had said that a man she passed on psychiatric patients often have histories schizophrenia in adoptees whose the street on the way to her obstetric of interpersonal violent trauma, as in the biological mothers had schizophrenic- appointment might have been the father, case of Raiza, with compromised early spectrum disorders compared to a control but after Europa’s birth Rose said that attachment. Such a background often group of adoptees of nonschizophrenic maybe she “alone conceived the baby like predicts a mistrust of caregivers, medical mothers was slightly elevated but not the Madonna.” This statement was made or otherwise. Yet, when we hear that statistically significant in a large Finnish despite the fact that Rose was taking anti- a mother has paranoid schizophrenia, epidemiologic study (Tienari et al., 2003). psychotic medication, and as with many schizoaffective disorder, bipolar disorder, such women, sacrificing breastfeeding to or has a “severe personality disorder,” For mothers such as Raiza and Rose, do so. do we sometimes assume, based on a it is to the greatest advantage to their worst-case scenario stereotype, that an On the positive side, Rose seemed to infants and subsequent generations infant and mother with such difficulties rally and become more organized when to reduce their burden of stress during are best separated? Indeed, the case of she spoke about her baby than when and following pregnancy because Rose and Europa illustrates that a psychotic she spoke about her own life history. stress as been shown to play a role in mother with supports in place can fulfill In particular, Rose disorganized around the vulnerability to and exacerbation of her infant daughter’s developmental needs discussion of her tendency to fall in love at least some schizophrenic-spectrum sensitively and enjoy her own maternal quickly, passionately, and prolifically with disorders (Corcoran, Mujica-Parodi, Yale, competence. a number of men whom she did not know Leitman, & Malaspina, 2002; Malaspina et al., 2008). Infant mental health specialists well, thereby placing herself and her This is not to say that we should ignore the need to further research the effects of baby at considerable danger. Despite the elevated risk and perinatal stress implicit

19 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH JANUARY–MARCH 2012 our preventive interventions in terms of full-time faculty at the Columbia University Malaspina, D., Corcoran, C., Kleinhaus, K. reducing toxic stress, improving outcomes, College of Physicians and Surgeons. After R., Perrin, M. C., Fennig, S., Nahon, D, and interrupting cycles of trauma and completing his National Institutes of et al. (2008). Acute maternal stress psychiatric illness. The development Mental Health Clinical Research Career in pregnancy and schizophrenia in of inpatient mother–baby units and Award project on maternal posttraumatic offspring: a cohort prospective study. transitional programs that provide support stress and interactive behavior with BMC Psychiatry, 21(8), 71. upon discharge and that are staffed by toddlers at Columbia, he assumed the Marshall, P. J., Reeb, B. C., Fox, N. A., infant mental health experts, can play position of chief of Pediatric Psychiatry Nelson, C. A., & Zeanah, C. H. (2008). a crucial role in an cost effective and Consult-Liaison and Parent-Infant Research Effects of early intervention on EEG successful intervention for the benefit of all Units at the University Hospitals of power and coherence in previously concerned (Hipwell et al., 2000). Geneva, Child and Adolescent Psychiatry institutionalized children in Romania. Serviceand the University of Geneva, Development and Psychopathology, Faculty of Medicine. He remains adjunct 20(3), 862–880. Acknowledgments assistant professor in developmental The authors wish to thank Professor neuroscience and behavior and director of Meaney, M. J. & Szyf, M. (2005). François Ansermet and the staff of the Child Research, Center of Psychoanalytic Environmental programming of stress University Hospitals of Geneva and of Training & Research at Columbia University, responses through DNA methylation: Piccolo for their unwavering support of the Department of Psychiatry. He is co-editor Life at the interface between a dynamic work described in this article. We also wish of the forthcoming Cambridge University environment and a fixed genome. to thank the patient–families, including Press book Formative Experiences: The Dialogues in Clinical Neuroscience, those anonymously described in this paper, Interaction of Parenting, Culture, and 7(2), 103–123. Developmental Psychobiology. for what they have often so poignantly Miller, L. J. (1997). Sexuality, reproduction, taught us about their experiences, needs, and family planning in women with wishes, and fears. schizophrenia. Schizophrenia Bulletin, References 23(4), 623–635. Schechter, D. S., & Willheim E. (2009). When Authors Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., Harrington, H., et al. (2003). parenting becomes unthinkable: Ana Almeida, FMH, is a Swiss double- Influence of life stress on depression: working with traumatized mothers and boarded child psychiatrist and pediatrician Moderation by a polymorphism in their toddlers. Journal of the American who directs the Perinatal Team of the the 5-HTT gene. Science, 301(5631), Academy of Child & Adolescent Pediatric Psychiatry Consult-Liaison Unit 386–389. Psychiatry, 48(3), 249–253. and serves as a member of the Postpartum Sharma, V., & Mazmanian, D. (2003). Sleep Depression Preventive Research Team Coates, S.W., & Schechter, D. S. (2004). Preschoolers’ traumatic stress post- loss and postpartum psychosis. Bipolar in the Child and Adolescent Psychiatry Disorders, 5(2), 98–105. Service within the Department of 9/11: Relational and developmental Pediatrics at the University Hospitals of perspectives. Psychiatric Clinics of Stern, D. N. (1985). The interpersonal world Geneva. Dr. Almeida has also researched North America, 27(3), 473–489. of the infant. New York: Basic Books. parental stress during medically-assisted Corcoran, C., Mujica-Parodi, L., Yale, Winnicott, D. W. (1956). Primary maternal reproduction. Sheis currently committed S., Leitman, D., & Malaspina, D. preoccupation. In D. W. Winnicott (Ed.), to further development of relationship- (2002). Could stress cause psychosis Collected papers: Through paediatrics based programs for mentally ill parents, in individuals vulnerable to to psycho-analysis (pp. 300–305). their children, and foster families in schizophrenia. CNS Spectrums, 7(1), London: Tavistock, 1958. Geneva. 41–42. Gaëlle Merminod, FSP, is a Swiss clinical Hauck, Y., Rock, D., Jackiewicz, T., & psychologist who specializes in perinatal Jablensky, A. (2008). Healthy babies mental health and the psychological for mothers with serious mental illness: evaluation and treatment of children with A case management framework for developmental disorders. Ms.. Merminod is mental health clinicians. International a senior psychologist on the Perinatal Team Journal of Mental Health Nursing, 17(6), Copyright 2009, ZERO TO THREE. of the Pediatric 383–391. All rights reserved. For permission to reprint, go Psychiatry Consult-Liaison Unit and serves to www.zerotothree.org/reprints. Hipwell, A. E., Goossens, F. A., Melhuish, E. as mental health consultant to “Piccolo” an C., & Kumar, R. (2000). Severe maternal attachment-based emergency infant and psychopathology and mother-infant toddler residence in Geneva for children attachment. Development and awaiting child protection decisions, Psychopathology, 12(2), 157–175. placement, and adoption, thereby ensuring continuity of care for those King-Hele, S., Webb, R. T., Mortensen, infants who are transferred from University P. B., Appleby, L., Pickles, A, & Abel, Hospitals of Geneva to this holding center. K. M. (2009). Risk of stillbirth and neonatal death linked with maternal Daniel S. Schechter, MD, is an American mental illness: a national cohort study. child and adolescent psychiatrist, Archives of Disease in Childhood: Fetal researcher, and psychoanalyst who moved and Neonatal Edition, 94(2), 105–110. from New York to Geneva, Switzerland, in April 2008 after serving for 6 years as

20 THE SIGNAL JANUARY–MARCH 2012 From the Kauppi Campus -News from WAIMH Central Office

By Pälvi Kaukonen, Kaija Puura and Minna Sorsa

Dear WAIMH members, we will meet each other WAIMH Congress two Training Village seminars will soon at the 13th World Congress of WAIMH in Cape be arranged for local practitioners. Town, South Africa. This is the first AIW MH congress ever spanning to Africa. We are looking forward to An important part of the Congress is the biannual the congress and the beautiful Cape Town! WAIMH Membership Meeting. All WAIMH members participating in the Congress are welcomed to join The congress programme will be a rich one the meeting on Thursday 19th April, 16:45-17:15. that caters for all needs with 67 symposia, The Agenda of this meeting is included on page xx 58 workshops, 18 clinical teach-ins, 8 video in this Signal. presentations, 14 Master Classes, 150 posters and 13 poster workshops from all over the world. The new Board member elected to the WAIMH There will be two Pre-congress Workshops, one on Board of Directors is Professor Karlen Lyons-Ruth Diagnostic Classification for Infant Mental Health from Harvard Medical School, U.S. Congratulations and one on Infant Rights. Additionally, before the to Karlen! Altogether 18,5% of eligible WAIMH members voted in this election. The vote tally is consistent with previous experiences since 1992. It would be good, if the members’ participation rate was higher. Ideas for improving the voting activity may yield out of discussions at the Board and Membership Meetings and discussion with Affiliates at the Affiliate Council Meeting in Cape Town.

The current President Antoine Guedeney is stepping down to the position of Past President and the current President-Elect Miri Keren will commence her presidency in Cape Town.

A new President-Elect will be elected from among the Board of Directors. Two Board members, Kai von Klitzing and Campbell Paul, have expressed

their interest in becoming a new President Elect. We have sent all WAIMH members a tentative enquiry in order to find out the support each candidate has among the members. The Board will then elect the new President Elect in Cape Town, taking into account the tentative enquiry and the opinion of the Nominating Committee.

You have received an e-mail with a link, which redirects you to the enquiry, and just tick your favourite President-Elect candidate, and submit your vote.

Last but not least, please renew your 2011 membership into a current membership online at the WAIMH website www.waimh.org.

21 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH JANUARY–MARCH 2012 22 THE SIGNAL JANUARY–MARCH 2012