Case Studies in Infant Mental Health Case Studies in Infant Mental Health: Risk, Resiliency, and Relationships Joan J. Shirilla & Deborah J. Weatherston, Editors Washington, D.C. Published by: ZERO TO THREE 2000 M Street NW, Suite 200 Washington, DC 20036-3307 (202) 638-1144 Toll-free for orders: (800) 899-4301 Fax: (202) 638-0851 Web: http://www.zerotothree.org Cover design: Will Works, Parkton, Maryland Text design and composition: Susan Lehmann, Washington, D.C. Library of Congress Cataloging-in-Publication Data Case studies in infant mental health: risk, resiliency, and relationships/ Joan J. Shirilla, Deborah J. Weatherston, editors. p. cm. Includes bibliographical references. ISBN 0-943657-57-1 (pbk.) 1. Infants—Mental health. 2. Infant psychiatry. I. Shirilla, Joan J., 1951- II. Weatherston, Deborah. RJ502.5 .C37 2002 618.92’89—dc21 2002004005 Copyright 2002 by ZERO TO THREE. All rights reserved. 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For Holly This case study book was completed with the award of a grant from The Gerber Foundation to the Infant Mental Health Program at the Merrill-Palmer Institute of Wayne State University, Detroit, Michigan. The editors and authors wish to express their gratitude for the Foundation’s longstanding commitment to the well-being of infants and their families. is a national nonprofit organization whose mission is to promote the healthy development of our nation’s infants and toddlers by sup- porting and strengthening families, communities, and those who work on their behalf. We are dedicated to advancing current knowl- edge; promoting beneficial policies and practices; communicating research and best practices to a wide variety of audiences; and pro- viding training, technical assistance, and leadership development. Foreword This volume is a wonderful collection of case studies as well as a thoughtful and useful discussion of the nature and heart of infant mental health practice. It is well worth reading and pondering by both beginning and experienced practitioners. Contributors beauti- fully capture the remarkable experience of working with babies and those who are caring for them. In doing so, they allow us to readi- ly join in the complicated journey each family and practitioner make together. Throughout the book run an explicit, deep appreciation and an understanding of the work of Selma Fraiberg. Indeed, this volume should be considered a direct descendant of The Child Develop- ment Project, which Selma Fraiberg began in Ann Arbor, Michigan, in 1973, and which I joined a year later. It is poetically proper, as well as logical, that this book should emerge from the Merrill- Palmer Institute and that so many of the contributors are leaders in the Michigan Association for Infant Mental Health. Mrs. Fraiberg would love it. She was born and raised in Detroit, got her social work degree from Wayne State University, and Michigan was always her true home. To understand these case studies as the well-deserved tribute to Selma Fraiberg that they are, one must understand that Selma Fraiberg was a remarkable woman. She was a thoughtful and criti- cal integrator of knowledge, read passionately, and pursued her interests with vigor and imagination. Along the way she produced a number of wonderful and creative ideas. Among them was one that was truly seminal, and it is because of it that this particular volume exists. That idea had its own interesting origins. In 1960, Selma Fraiberg and Gerald Freedman were asked, in their roles as consultants to the family service society of New vii Case Studies in Infant Mental Health Orleans, to design a program for blind children ages 3 to 14. As it was to evolve, the agency asked just the right people. Mrs. Fraiberg was a social worker and psychoanalyst, and Dr. Freedman was a neurologist and psychoanalyst. How could one design such a pro- gram, they wondered, if one didn’t know what is different about the early development of a child with visual deficits from that of a sight- ed child? And how much might we learn about the development of sighted children from this contrasting perspective? Mrs. Fraiberg and Dr. Freedman were disturbed by the atypical patterns they saw among children with visual deficits—for example, stereotyped movements, odd mannerisms, and a lack of differentia- tion of self and other. Equally concerning were what they felt were notably tenuous connections of these children to others. A thorough literature search revealed their assessments as typical of other researchers. However, newly emerging literature suggested that blind- ness itself was probably not the factor predisposing these children to worrisome developmental patterns. Rather, issues of emotional stim- ulation and incentives for development played a major role. Careful interviewing and fastidious filming and observation of the babies were the beginning of what was to be a long, interesting journey for Mrs. Fraiberg. In 1963, the two researchers moved to different universities. Their mutual interest in the topic continued, but along separate paths. Mrs. Fraiberg continued her observation- al studies and, in 1965, received a grant to expand her efforts. The families selected for the research and also those referred who could not be part of the research protocol were visited at home for pur- poses of guidance, with the understanding that what was learned would be shared with the families as it seemed useful. The families within the research group were also observed and filmed. Beginning in 1960, Mrs. Fraiberg and her colleagues engaged in a lively and remarkable exchange of knowledge and ideas with a dazzling group of psychologists and psychiatrists who were similar- ly intrigued with the exquisitely detailed study of early develop- ment. This cast of players included (in order of appearance) Sibylle Escalona, Peter Wolff, Therese Gouin Decarie, Jean Piaget, Eric Lenneberg, Rene Spitz, Sally Provence, Robert Emde, David Met- calf, Mary Ainsworth, Arthur Parmelee, Justin Call, Daniel Stern, and Ken Robson. The soberness of their deliberations and the joy in each other’s company in this context was enormously productive. Mrs. Fraiberg reported that Piaget threw his beret in the air and cheered when he saw, on film, one of the blind children achieving stage six on his scale of development (demonstrating, by searching for it, that he understood that something out of his awareness exist- ed)—an achievement that is a challenge to develop without vision. viii These studies made an enormous contribution to the under- standing of the development of blind infants and illuminated understanding of the development of sighted infants as well. This new knowledge, coupled with the extremely successful intervention with the young blind infants and their families, provoked Mrs. Fraiberg’s seminal idea. It went something like this: If beginning as early as possible is so successful in preventing prob- lems with these families and these babies, why wouldn’t it be possible to work in a similar way where there are other impediments to an infant’s development? It should not matter whether the impediments stem from a different source intrinsic to the baby or from impediments within the parents. Mrs. Fraiberg reached this conclusion because she understood that early experience is crucial to development. She pointed to her work with blind babies and their families as the defining impetus that led to the establishment of The Child Development Project in Ann Arbor, Michigan, in 1973. This was the first program that took as its sole focus work with infants and parents together, in order to improve and enhance the overall ego development of the baby in whatever ways seemed necessary. Since 1973, programs for infants, toddlers, and families have steadily proliferated. They all have the goal of supporting and enhancing the children’s development in a positive way. They also see an improvement in aspects of the child’s home environment as being of primary relevance to this goal. But how this is understood and implemented, and how the service is designed and delivered, varies enormously. The State of Michigan, in the form of a very far-sight- ed Betty Tableman, chose to support interested mental health prac- titioners from community mental health agencies across the state to receive training from The Child Development Project. This resulted in an unusually effective dissemination of interest and skills. Practi- tioners in Michigan have remained closely tied to the original pres- ence and impact of The Child Development Project, even as the project itself moved to the University of California, San Francisco, in 1979. This volume reflects these enduring connections. The work described in these 12 case studies embraces many of the essential elements of The Child Development Project in a splendid way. One of the most striking and valuable aspects of these collected stories is their realistic untidiness. We are able to hear the true voices of many different people, whether baby, toddler, parent, or practitioner. The stories have not been conceptualized or edited into some homogeneous way of presentation, of being, or of seeing.