AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
PAULA ZEANAH: So here's where we're starting. I want to go ahead and introduce my speakers. My name again is Paula Zeanah, and I'm going to be starting off the program today. I wear several hats these days. My biggest hat is as the director of the nurse family partnership program for the State of Louisiana. I'm going to be mentioning that and talking about that a little bit today.
I've also served as an infant and mental health and mental illness consultant to the Office of Public Health in Louisiana for almost 10 years. I've also served as an infant mental health and mental health consultant to the Office of Public Health in Louisiana for almost 10 years.
I'm also ‑‑ my background is in clinical psychology. I'm on the faculty at Tulane in child and adolescent. I also do some work with medically ill children at Tulane. And I also have background as a pediatric nurse. I worked as a pediatric nurse for about the first 15 years of my career. And since then, became a psychologist, and now am very happy that I'm in a position where I get to mix psychology and primary care, really. I actually thought about becoming ‑‑ doing work in maternal child health and decided not to get that degree, but lo and behold, here I am.
Anyway, I'm very happy to be here. I don't how many of you all know ‑‑ have some knowledge of infant mental health? The field of infant mental health? So a number of you do, okay.
The second person I want to introduce is Jean Valliere. And Jean Valliere is currently an assistant professor of the School of Public Health at Louisiana State University Health Sciences Center. And she is now serving as a coordinator of mental health and Maternal Child Health with the Office of Public Health. She received her degree in social work for the University of Michigan.
She has worked with young children zero‑to‑six and their families since 1976. She has a long history and much, much experience in this field. She's worked with developmental disabilities, infant mental health, forensic, infant maltreatment, child care consultant, child care consultation, at‑risk teen parents, expectant and parenting youth in the juvenile justice system in Louisiana.
She received her training in infant mental health, because as most of you know, infant mental health training basic training programs yet, through Dr. Charles H. Zeanah, who happens to be my husband, and has written a book on ‑‑ called Handbook of Infant Mental Health, and has been a leader in the field.
And she also holds specialization in infant mental health from the LSU‑Harris Infant Mental Health Training Program, where she has served as a faculty and senior supervising clinician.
As I mentioned, she is now a mental health consultant coordinator for Maternal Child Health in Louisiana. She is a consultant to the State of Texas, Department of Rehab Services, where she is focused on consultation and training for early intervention as cross‑disciplines.
She has served as the director of the Permanency Infant and Toddler Preschool Program in Orleans Parish, which is a forensic infant evaluation and maltreatment program. The director of the Starting Secure Child Care Consultation Program at LSU. And she's presented, you know, locally and nationally on many topics regarding infant mental health, young children with disabilities. So we're very glad to have Jean and all her expertise here.
I have to add that Jean also likes to dance. And we just want to add a little, you know ‑‑ I won't go into the rest of the part you didn't want me to add.
Brian Stafford, over here, is a graduate of Tulane University, School of Medicine, School of Public Health and Tropical Medicine. He has an M.D. and an M.P.H. from Tulane. He completed training in pediatric, adult, child and adolescent psychiatry at the University of Kentucky. And completed advanced training in cultural psychiatry at the University of Cape Town in South Africa. He also did an infant and early childhood psychiatry at the Tulane Institute for Infant and Early Childhood Mental Health.
He has recently left Tulane. We're very sorry that he left. He left right after Katrina. He did some work with Katrina, but he'd already planned to leave. He didn't leave because of Katrina. He is currently a faculty member in the Department of Pediatrics in Child Psychology of Denver Children's Hospital. There he leads a team of mental health professionals that are collocated within a Pediatric Residency Training Clinic. He's the medical director of the Postpartum Depression Intervention Program at the Kempe Center.
So we're glad to have these two along with us. So that's the group that you're going to hear from today. Our plan is, um, to talk about a mental health systems service system and how to do that. And we're going to use a lot of examples from what we've done in Louisiana.
But we are going to start with really talking about what is infant mental health? All of us here that are going to be presenting have done a lot of training, both with mental health and non-mental health professionals. And I know for myself, every time I hear, kind of go through the didactics I learn something else. So we're going to really talk about where we're coming from, from a theoretical perspective, and to give a good, hopefully at least an introduction to you all about what attachment theory is about and why this is all so important. So we're going to spend a little bit of time talking about that before we get into the systems.
And then we're going to talk about a framework for addressing infant mental health and social‑emotional development in a variety of health and other types of settings. We will probably, like I said, take a break probably after we talk about attachment and so forth.
UNKNOWN SPEAKER: (Inaudible.) You've got handouts on the table. At the end of your program, are those pages. So if you y'all want to take notes for this session, there is some lined paper in there ‑‑ at the end there. I'm sorry interrupt.
MS. ZEANAH: That's okay. That's fine.
UNKNOWN SPEAKER: People were looking around for the notepads and they're not on the table.
MS. ZEANAH: Oh, I see.
UNKNOWN SPEAKER: Yeah.
MS. ZEANAH: Okay. Again, I apologize we don't have the handouts. We're happy to get them to you. Like I said, it was very long, you'll see. And as we go through this, I would like you to just kind of sit back and listen and maybe jot a few things down. But we want to really sort of start with basics. What is infant mental health? What in the world are we talking about?
I started doing training with nurses, public health nurses a number of years ago with infant mental health and they would kind of look at me like, okay, they were very nice and cooperative people, you know, very interested. But at the end of the training, they said, "I had no idea what you were going to be talking about and I really wasn't sure." So we always think that a starting definition is a good idea.
When we talk about infants, we're talking about the child from zero‑to‑three. And as from Neurons to Neighborhood says, that starts too late and ends too early. It doesn't mean everything happens in the first three years, but a lot does. So we want to stick with that age. For the most part, that age period.
Primary caregiver. I'm just saying, you know, is just the person who takes the primary responsibility for the child. We're going to use that term interchangeably with parent or mother or whatever, but we probably all recognize that it's not always the biological parent who is the primary caregiver.
Finally, the definition of infant mental health. And again, I have to say, when I started doing the training, I was using a lot of my husband's materials, including his book to get material out, and I realized there was no definition. I said, "Charlie, how can there not be a definition of infant mental health?" Everybody uses this term, but, you know, does everybody mean the same thing?
So over the last two or three years, there's been some discussion about it. This is the definition that comes from zero‑to‑three. Which is an organization that really targets all kinds of programs and clinical training and so forth in infant mental health. And they define it as a state of emotional and social competence in young children who are developing appropriately within the interrelated context of biology, relationships and culture. We're going to go down just a little bit further.
Again, infant mental health, as a field, focuses on context, and especially the relationship context. Now this makes a lot of intuitive sense, but it has practical implications because most of us were taught to look at an individual. You know, we look at the mother or we look at the baby. We don't look at that space between them that's the relationship.
How many of y'all are parents? Okay. And I assume most of you were parented somehow or another, right? We all have some experience with parenting, right? And how many of us have said, "How can my two children ‑‑ my children be so different?" Well, perhaps it has something to do with relationship fit and whatever other context we're going on. So we really want to focus on the relationship context.
Development, especially social and emotional. This has been an area that has just zoomed up in the amount of knowledge that we have about the social and emotional development of children. When I was growing up in nursing, we talked a lot about gross motor and fine motor development and, you know, cognitive development, but nothing about social‑emotional development. Now we know that there's a lot going on with young babies from the very, very beginning.
Competence. Not just problems, but competence. What does it mean to be a competent six‑month‑old or 12‑month‑old or 18‑month‑old? What do we mean in terms of social and emotional competence?
Risk and protective factors. What puts kids at risk to go off track and what protects them? Psychopathology, this is a term that, for many people, the whole term of infant mental health is sometimes people don't like to hear that term because it's associated with bad mental health stuff.
But the fact is, babies are not just at risk for problems. Some of our babies are truly distressed and they're truly hurting and they are truly distressed and they need treatment. So we can't say that they're just happy, little things. In some ways, I mean, we come from mental health so we see this all the time, but there's a lot of examples out there. We're not going to have a chance to go into all of that. Where, in fact, there is frank psychopathology in these very young children. So we need to learn more about that, and what does that mean in terms of normal development and so forth?
What does all that mean for assessments, diagnosis and interventions? We're talking about children who can't tell us what's wrong with words. So we have to look at behavior. We have to look at interaction. We have to look at assessment in a different way than we've done before, and we have to consider a whole lot of factors other than what is necessarily reported.
And then there's prevention as well. We want to get in early. I think a lot of us are in this field because we see little babies as the chance to really make a difference. This is the hope. These are fresh, young human beings and we don't want to see bad things happen and we want to prevent bad things from happening.
So infant mental health is a multi‑disciplinary endeavor, and it requires input from all of us. The field has benefited from ‑‑ from nursing, from psychology, from psychology, from social work, from psychiatry, all kinds, pediatrics, all kinds of disciplines have been involved in helping shape how we understand what the early experience is like for young children.
I also just want to add here that, given that all of us, one way or the other, have had some experience with being parented or being a parent, this stuff is very valuating. I don't think ‑‑ you know, I think all of us probably have ideas about what a good parent is and what good parent is or what it isn't and what children need and so forth. And so I say that right up front, because it seems like we can agree on the words sometimes, but when you get into the actions and the down and dirty what happens every day between that mother and that child or in that family, it becomes very difficult sometimes to separate our own personal values our own professional values from what we are seeing or doing. So I want to put that in there, because I really think we need to keep that focus. Although it's not a focus of this talk today.
Why does it matter? One of the things that has become evident over the last few years is that, if you're going to pick one thing to predict later development in, it would be attachment. The relationship that that infant has with their caregiver is, right now, at least current state of the art; the best predictor of later development is that pattern of attachment between the infant and the caregiver. Very interesting. It's not how early do they walk, you know, or how soon do they talk necessarily, unless they're delayed. And there's some exceptions, of course. But if you want to look overall on how kids are going to do, you need to look at that relationship. And you can look at that relationship, both in terms of observable interactions, which we do all the time, but it's not just what you see. It's how people experience that interaction. So we all have been in relationships, whether it's our relationship with our child or with some other person, where you feel comfortable, you feel cared about, you feel like you can relate to that person. They understand you, right? And that feels really different than being with somebody that you think doesn't have those same kind of qualities, right? And so there's a subjective experience that the parent, as well as the child have, in terms of their relationship that we need to be paying attention to.
I throw these in. I'm not going to go through them one by one, but these are important. This comes from the book that I absolutely love. From Neurons to Neighborhood, written ‑‑ edited by Jack Shonkoff and Deborah Phillips. If you haven't seen it, it should be like, you know, required reading, even though it's ‑‑ I shouldn't say even though it's policy. What they have done is they have pulled together all kinds of very good research and they've been selective in the research they've used to talk about what we know about little kids and what that should mean for policy. And they synthesize a lot of their research in these concepts. And that, you know, the nature‑nurture thing, we know that human development is a combination of, not just biology, but also experience, and that experience impacts biology. We're learning that with depressed moms and their babies and so forth, as well as trauma. Their culture, and again, values influences every single expect of development.
Self‑regulation is something that you can see extremely early on with a newborn infant? How well they're able to regulate their physiology and their reactions to their environment. It is very important, you know, how we regulate our behaviors and our thoughts and our feelings as to how we function later on in life. I'm sure you know people who do that better than others, you know. So we got to get that down early.
And that children are not act ‑‑ they're not passive recipients. They make a difference. So we know that when that newborn baby arrives in that household, that household is forever changed. So that they are there and impacting the environment and they also have their own needs to explore and to learn and to master.
Healthy human relationships, the building blocks of human development. I've kind of already said that. The broad range of individual differences and the broad range of what is normal makes it difficult sometimes to figure out between ‑‑ I love this middle one ‑‑ between normal variations, maturational delays, transient disorders and persistent impairment. And you can see all those variations within very young children. So I think it's important to make those kinds of distinctions.
And the development occurs in a series of transitions, continuities and discontinuities. Sometimes it goes smoothly, sometimes we backtrack and move forward. It's not always smooth. So we kind of need to keep that in focus as well.
Vulnerability and resilience. We all have varying degrees of those, and those are impacted by risk and protective factors. And it can obviously, we believe anyway, the development can be altered by the intervention that shift the balance between risk and protection.
So given that little, brief overview of what infant mental health is, I'm going to jump into attachment theory and do this little tutorial. I mean, I hope you will bear with me. If you already know this stuff, I hope you'll bear with me. For those of you who aren't as familiar, I hope it's helpful in clarifying.
We know that adverse care‑giving environments, this is not a new thing. Sometimes it feels like it's a new discovery, but it really isn't. We've known that at least since the beginning of the 20th century and, really, centuries before that, that children who were living in very poor environments did not do well, like, some of them would die.
In the mid‑1900s, mid‑20th century, there was a bunch of work that was going on ‑‑ this is a very brief history of attachment ‑‑ during World War II when there were a lot of children who were orphaned by the bombings, and they were put in orphanages and so forth.
So Renee Spitz and the Robertsons looked at these children and discovered that these children, although they were in orphanages and they were getting ‑‑ they were warm. They were being fed. They had clothing. They got their physical needs taken care of. They did not look so good and there was a higher death rate among those children. And their work, you know, they really were the ones who laid the groundwork for saying, "They need to have their parents. They need somebody around to take care of them emotionally as well."
I'm going to date myself, but when I was in nursing school, it hadn't been that long that visiting hours were really open for parents, and this was a direct result of this. It used to be, and I'm sure there were problems in terms of, you know, infections and all that kind of stuff. You know, restrictions ‑‑ or very severe restrictions on how often parents could visit their children in the hospital and so forth.
The work of Renee Spitz and the Robertsons and all called these children's reactions where they would really withdraw and not interact. They might quit eating and they might actually, like I said, get sick. And, in some occasions, would die of hospitalism.
At the same time, about the same time period, there were a lot of ecological studies that were going on. Those were animal behavior studies. And (inaudible) Rand is the one who had the ones where he taught the goslings to follow him. He was the one who talked about critical period.
Harry Harlow is the one who talked about monkeys and the wire ‑‑ I never can say this clearly ‑‑ the wire monkey mothers vs. The regular monkey mothers and the babies that were ‑‑ baby monkeys that were raised by the wire monkey mothers had significant growth problems, behavior problems that that went into adulthood as well. They ended up being more abusive to their own offspring, having sexual problems, all kind of things. So it was very important information.
And so, as a result of all this kind of work that was going on, um, it really the looked like there's something about the infant of the mammal species, I suppose, where they're biologically primed to become attached to caregivers. John Bobie came along, is a psychoanalyst, a psychiatrist in England. And he was doing psychoanalytic theory therapy and so forth, and he was working with juvenile delinquents. And he noticed in his group of young men that he was working with that every single one of them had some sort of loss in their earlier life. Their mother had abandoned them or there had been somebody that had died or something. And so this kind of led him to look at the issue of loss and early experience concern. He's the one who kind of pulled together this whole idea of attachment.
His theory was that attachment, um, is one of four behavioral control systems that operate to motivate behavior. Remember, he is an analyst. So he's into drives and motivations and all that sort of stuff. And he identified the attachment system as the one ‑‑ this is really important to pay attention to here ‑‑ it motivates the infant to seek proximity to the attachment figure, with the internal goal to seek felt security, feel secure inside, but it's also protective. If that infant isn't close to the mother then, or the caregiver, then that infant isn't going to be physically safe either. So it's really a motivational system for both physical and internal security. And a lot of people use this term kind of loosely.
His other motivational systems included the exploratory system. And I'm sure y'all have heard the term mastering motivation. The babies are motivated to learn about the world.
Another system is the affiliative system which motivates them just to be with others, but it isn't necessarily activated during times of distress. And then the fear weariness system, which is basically fight or flight.
The attachment system and the exploratory system work in concert. So, for example, if the baby is feeling pretty secure and pretty safe. He's going to feel okay about going out and exploring the environment, right? I mean, this hopefully makes sense. If he's not feeling safe, either emotionally or physically, he's going to go back and try to find that caregiver and say, "Mommy. Mommy. Take care of me. I need you to protect me." So he's not going to be exploring. So they kind of work like this, up and down with each other. So it's very important to keep that in mind when we think about what the implications are of this in terms of later development.
Again, it's a control system. The goal is to seek proximity to feel safe and secure. When the infant is secure, he's motivated to explore the world, and infants are biologically predisposed to become attached. It's actually pretty rare that humans are not attached.
Charlie's been doing some work in Romania in orphanages with pretty dire circumstances. It's very rare, even in that circumstance, to find a child who doesn't have some kind of attachment. Now, does that mean it's a good attachment or the right kind of attachment? That's the question.
So what does this mean? Okay. What does attachment mean? We over the time of our experience and being with a caregiver, we as human beings develop a working model, an idea in our mind and perhaps, you know, other places too, about what it's like to be with somebody when we're in distress.
Okay. Let me give you a simple example about what a working model is. Think about birthday parties. You know, we've all been to many birthday parties, probably, right? And we know ‑‑ what does a birthday party involve? How do you know it's a birthday party as opposed to an anniversary party or a graduation party?
UNKNOWN SPEAKER: Candles.
MS. ZEANAH: Candles?
UNKNOWN SPEAKER: Music.
MS. ZEANAH: Music? Songs. You sing that happy birthday song. I mean, there's certain things that distinguish a birthday party from other kinds of parties. Even though we've been to lots of different birthday parties. Some were at bowling parties. Some were just, you know, little. Some may be giant extravaganzas. But we have in our mind what a birthday party is like. And over time, babies develop an idea about what it's like to be with a caregiver when they're in times of distress. And that working model of what I need to do, how am I going to get responded to? What is my caregiver going to do? All of those kinds of things come into this working model of attachment. It will impact how the person feels about himself, about the other. Like I said, what you have to do. I'm going to show you some examples of this later. All of these really get formed in the first year of life. So think about the myriad of interactions that go on between the baby and the caregiver that first year of life. Through each of those interactions, the baby is beginning to put together this picture of what it's like for this attachment.
Initially the model accommodates new information. People can have more than one attachment, but it does leave us with a certain model of what relationships are like and it will guide new information coming in. So we can have other relationships, but we fit that into whatever our old model has been.
And you will see that infants will recreate situations of relating that they're used to with other people, with new people. They will assume that other people are going to treat them the way they were treated before. And new social partners selected in terms of working models. So this has implications all the way ‑‑ you know, all throughout life.
I want to spend a few minutes talking about just sort of how this develops over time. Because, again, I think one of the things that I see happening is that people equate attachment right off the bat, and I think terminology ‑‑ I think we need to think about what are we really talking about and what's going on? And I want to go through sort of developmentally, what we know about the developmental attachment at this point in time. We're just going to go through this pretty quickly, but I think it's important where you are programmatically. So where does it begin? When does attachment start? How do you begin it?
And there are have been some studies that have been done that have looked at prenatal conceptions about that ‑‑ that parent has with the baby. In fact, Charlie did some of this work. And nursing, actually, has done a fair amount of work about how they ‑‑ how the women adjust to pregnancy and so forth.
But for most women, I'm using the term attachment here loosely, because really what we're talking about here is awareness of the infant and feeling love and closeness to the baby grows over the course of pregnancy. And for a lot of women, it's when quickening or when they start feeling that baby movement that it becomes really more real, the pregnancy becomes more real to them.
But there are a few people who, for the very, very beginning, before they even really have any showing or anything like that they feel a strong attachment to the baby right away, but not all mothers feel that right away. And there's a few women who even, after the baby is born, may not feel that love. It's important to keep that in mind. It can be kind of a red flag, but it's important to keep in find that not all women immediately feel love. And as a society, we kind of expect that. But usually, over the period of a few weeks, the mother should have experienced that.
Usually the mother's attachment is greater than the father's throughout the pregnancy. Although we don't have a lot of research on fathers during pregnancy. So there's not a whole lot of data about this.
During the first couple of months, from the baby's side, again, this first line is a quote From Neurons To Neighborhood, "The newborns are wired for feelings and ready to learn." They are able to do so many things that, again, when I was in nursing school, we didn't really pay attention to all the things that they're doing. Certainly their physical features. Most of us who see babies that are walking down the street will stop and look, if not talk to them. We're drawn to those babyish features. If you think about baby puppies or baby kittens, or whatever, they're cute, and that probably has some kind of biological reason for it. Because as we get older, some of us lose that cuteness and people aren't necessarily drawn to us physically. But certainly with little babies, cuteness brings, makes us attracted to them.
They are able to have some discrimination. They actually can identify their caregiver, their parent, in terms of what they hear. They can distinguish mother's voice from father's voice from other women's voices. They can identify mother's smell. There's certain kinds of sensory types of behaviors that the babies seem to be wired for that seems to cross babies where they're able to identify who that mother is.
And the caregiver's job, at this point in time, is to help that baby. Because you can imagine they're being bombarded with all kinds of sensory stimulation. It's to really help them begin to sort out the stimulation coming in, but as well as the internal stimulation that they're feeling and figure out what's what. What does it mean when I feel this way in my stomach? Does it mean I'm hungry? Or maybe if my mom brings me milk every time I feel this way, that means I'm hungry. They begin to sort out the internal and external stimuli.
And it's really the quality of the care giving that's going to assist or interfere with the infant regulating states and emotions. And so, from the very, very beginning, the caregiver's job is to help the baby learn to modulate their reactions to and their responses to their environmental stimuli. And they can do that, obviously, in a variety of ways.
When cues and signals are responded to contingently. In other words, in a very close period of time. So let's say a baby starts to cry, a newborn baby starts to cry, and you've heard people say, "Well, just let him cry." Well, if you let him cry for 20 minutes or 10 minutes or even three minutes, the cue between what made the baby cry and then what happens when they begin to cry and get more and more upset, gets mixed up. If the mother responds really quickly and responds in a way that's sensitive and actually is correct in what her judgment of what the baby needs, the baby begins to learn. When I feel this way, this happens, and these things happen. They begin to learn about their affect, their state and how people are going to respond to them.
And when they're insensitive, over time they learn that they really can't count on somebody else. Their behavior has to change to make the environment respond to them, and it real three interrupts their own sense of competence that they are able to get what they need and let people know what they need.
Two‑to‑seven months. This is a lovely time for babies. They're fun. They're beautiful. Usually they're settled down in terms of routine. They're more predictable. They're pretty easy to take care of. When I worked as a nurse practitioner, I loved doing the four‑month baby checks, because the babies just, they loved me. I thought it was me, but it was really them. I mean, they're just fun to take care of and very social beings.
And at this point in time, they are still able to ‑‑ they are able to differentiate among who's whom. They can tell who's who. They may seem more comfortable with a primary caregiver, but they're basically pretty social and they're not reticent to go with someone that they don't know and so forth.
Now, you will hear parents say, but I know my baby knew me as opposed to somebody else at age three months or whatever. I still think ‑‑ I mean, I don't not believe them, and I don't want to undermine that belief that that parent has, because that parent needs to believe that they're important to that baby. But in general, at least what we know now, the way we've been able to do the research now, they haven't necessarily developed what we would call an attachment relationship yet, but they're still working on it based on all those interactions that are going on every day.
Seven‑to‑12 months a major capacity comes on board, and that's mobility, which means the baby is able to move around and not necessarily be dependent on the caregiver to get what he needs or to go where he wants to go. There's also the cognitive ability. So memory kicks in a little bit more. A little bit more problem solving, reasoning and improved ways of communicating needs and so on and so forth. So there's a lot happening just in terms of bio‑behavioral shift going on at this time. And the infant is also given these other things. In the context of this other development going on, has to figure out new ways of communicating with the caregiver in getting his or her needs met.
This is the time when what we call preferred attachment becomes evident, and it is evident through a number of different of ways. Stranger Anxiety being one. So the child gets very upset when somebody new come in or hides or hides their face or doesn't want to go with a new person. That's showing that the baby really is able to differentiate from mom, from somebody else and so forth. And it's a good thing. That's a good thing. Although a lot of parents think it's not a good thing.
Separation anxiety is also what I would call a good thing. Not all babies have it. Some have it more than others, but it means that I know that I need you. I know that you're the person I can count on to take care of me when I'm in distress, and I'm going to be upset if you leave me. That's what separation anxiety is about.
Now, because some babies will have more of it than others. If they don't have it, it doesn't necessarily mean there's a problem. But if they do have it, you can tell your parents, "This is a good thing. This means he knows who you are and he counts on you and that's a good thing." Even though it's sometimes hard to leave the house.
All that is part of the development of this idea of felt security harbored to measure. The development of trust versus mistrust. This is what Erickson was talking about. One of the things about attachment has really been able to explicate. More specifically, how does that trust begin? How does that evolve over the first year? He was definitely on to something.
At this point in time, babies will have a hierarchy of preferred caregivers. So you can say, if mom's not available, okay, I know aunt will be my next person to go to. If she's not available, I will go my sister. If she's not available, I will go to my dad. And they will have a hierarchy of caregivers for whom they prefer. But usually, if they have the choice, they will go to their number one person first.
Next phase, toddler-hood. Obviously, again, they're more motorically dependent and they're beginning to talk. So again, there is a change in how the parent and the child have to negotiate their needs and how they have to interact with each other. This is when you see children who will hear a noise or something like that comes back in, grabs the mom by the leg, gets a little pat on the back, and then goes back out again. That's what we're talking about, a secure base. Just touching base with that mom makes me feel better. I can go back out and I can explore again.
And safe haven, again, is using that ‑‑ the attachment figure itself as a secure base, safe haven. Again, the system gets activated in times of distress. So that's important to keep in mind. So you can see, when you're distressed, when the baby is distressed, who are they going to turn to? Who are they going to look to? If they don't have somebody to turn to and to look to, then we're going to get concerned. But being close to the caregiver makes them feel secure inside.
And again, as they move on to out to 36 months, they begin to talk. They begin to say no. They begin to assert their will in various ways. And, you know, it's a balancing act. But again, how that relationship is developed is going to help them in their learning how to become more independent and have healthy dependence, because we don't want them to be completely independent at age three. And we need them to learn about cooperation and so forth.
So there are various, um, classifications of attachment. I'm going to go through these fairly quickly. The classifications are just descriptions of attachment relationships. They are not necessarily evidence of psychopathology. So I want that to be clear. Okay?
The first one is secure, and the secure attachment you probably heard about. The infant knows the caregiver is available. He can count on that caregiver. He uses the caregiver as a secure base. After they've been separated, the infant has been away from the caregiver for a while, the infant will go to the caregiver, seek comfort, is able to be calmed down pretty quickly. It's not that these babies are happy all the time or they don't cry or they don't show distress. They are able to turn to the caregiver and get relief and get comfort and then go back on with whatever they're going to be doing. Again, they can express negative affect. That's not discouraged. That's allowed by the caregiver. They're clear and they get comforted. And in low‑risk samples, you're going to see this in about 50 to 65 percent of the babies.
Now, we measure attachment through something called the strange procedure, and I'm not going to talk about that today. But you'll see higher ‑‑ you'll see lower amounts of secure attachment in higher risk samples. We measure this usually at about age one. The caregiver is warm, attuned, consistent, quick to respond, especially early on and is a pretty good reader of what the child needs.
I think I already said that. Okay. Another classification, another type of attachment classification is called insecure avoidance. I think these kids really are kind of interesting. Because these are the kids who don't look distressed when they in distress. So they act like there's no problem that mom is not there or that they're upset about something. Interestingly, if you do like pulses, if you measure the child's pulse on these babies, you will see that their heart rates are up. I don't know if they've done cortisol levels on these kids, but the cortisol goes up. The stress hormone goes up on these babies, even though they're looking cool, calm and collected, okay? So this is really important. They are saying, "I'm cool. I'm okay. I don't need you. I'm just fine. Thank you very much." Okay?
They don't react a whole lot when reunion comes back. We look, not at just separation, but what does the child do when the caregiver leaves him or her, but really, more importantly, what does the child do when the caregiver comes back? That's what we're really concerned about.
And a lot of times, these kids will either not really pay very much attention to the caregiver returning or they'll keep playing with their toys. They will act like it's no big deal. They may act like they're angry, and they may be unresponsive to the caregiver trying to make a bid for their attention. But they also may be social to a stranger. They may actually turn to a stranger, as opposed to their caregiver in times of distress, which is interesting. And again, 15 to 20 percent you can see in low‑risk samples.
Here the caregiver is a person who really doesn't like that baby to need her too much. She really wants that baby to be independent, to be on his own, a person who really does (inaudible), and the baby gets that message early on and it acts accordingly. And this caregiver, again, may be baby that they're so independent, proud of that.
The third kind I'm going to mention is insecure resistant or insecure ambivalent. You can hear both of those terms used. These are the kids who, when the mother leaves, gets way distressed. I mean, a lot of kids get distressed. So I don't want to give too much credence to the separation, but they are very, very loud in their separation. But when the mother comes back into the room, he can't be comforted very easily. He cries. He can't get settled. He can't calm down. The mother doesn't ‑‑ they don't have a way that they reunite and re-experience each other in a positive way and then go on.
And in this ‑‑ these kind of babies are often clingy, demanding, they need a lot of stuff. They're kind of whiny. They're unhappy children. And they often are angry towards the caregiver. And we believe that this shows that these infants are ambivalent. They're not sure. Is that caregiver going to be available for them or not? So they have to figure out, what do I have to do to get this caregiver to respond to me? And so they are very focused on what the caregiver is doing and very much paying attention to her and they're not exploring a whole lot. Okay?
Resistant, another part of this. They are not soothed. They can be overwhelmed or preoccupied. This is really kind of a hyper-activation of the attachment system, so that you see some of the attachment behaviors really an extreme. And again, these are kids that are hard ‑‑ sometimes hard for caregiver to deal with and vice versa.
Here the caregiver is unpredictable. Attentive, but maybe out of sync. The caregiver may care about what's going on with the baby, but just can't read the cues very well and doesn't understand what the baby needs. Has a hard time understanding that and really plays into the baby's fear. If you do this, I'm going to leave you, and that kind of stuff and kind of threatening, those kinds of things with babies and stuff.
The last one is something called disorganized attachment. This is another relative, it's not new, but it's a newer version of attachment classification. And one that is probably the most worrisome if we see these. You'll see children on reunion freezing or still or just not moving when the caregiver returns to them. They seem afraid. You'll see them do weird things. Like you may see the baby going towards the parent with their eyes closed. They have mixed messages for the caregiver. Sometimes they look depressed. And babies ‑‑ we do believe babies can be depressed or they lack facial expressions. Or affectively, they just seem not really there.
Here we look at these are more likely to occur when the caregiver has had a lot of unresolved losses. So many, many pregnancy losses or other kinds of losses in their life have experienced some kind of trauma. This may be their own physical abuse or sexual abuse or other kinds of trauma. They may be a substance abuse ‑‑ substance abuser. Bi‑polar affective disorder and so forth. And these are the situations where maltreatment is more likely to occur.
So I don't know what programs y'all are working with. But in the program that I work with, we see a lot of mothers who fit into these categories and we work very hard to get them tuned in. Because they're so preoccupied with their own life distresses that they experience, it's very hard for them to tune into what's going on with the baby. And their own experience of being in a relationship may have been disordered as well. So they don't even know how to interact appropriately. 15 percent low‑risk samples. You'll see a lot higher in high‑risk samples. And again, they're more likely to maltreat.
Okay. I want to stop there for a second and see if anybody has any questions about these classifications or comments or anybody want to add anything?
UNKNOWN SPEAKER: I would like to add one thing.
MS. ZEANAH: Okay.
UNKNOWN SPEAKER: I think, you know, these classifications are important, but I think one thing, which you alluded to, is in my experience that babies have different relationships with different caregivers. He could be disorganized with one caregiver and secure with another. So these relationships (inaudible).
MS. ZEANAH: Thank you. Thank you very much for saying. That's really important when we're talking about assessment and treatment. Because so many times when we're in a clinical setting, we see the child with one caregiver, and we may miss the boat if we don't see them in other types of settings with other types of caregivers. So thank you very much. It's a really, really important comment. Okay.
UNKNOWN SPEAKER: As well as the number of caregivers that the baby will actually get attached to (inaudible).
MS. ZEANAH: Say that again.
UNKNOWN SPEAKER: Babies just can't have endless caregivers. That's why we run into so many problems with babies who are in foster care. We need the primary caregivers to be consistently in the child's life. We cannot substitute one primary caregiver for another, for another, for another.
MS. ZEANAH: We see that ‑‑
UNKNOWN SPEAKER: (Inaudible.)
MS. ZEANAH: Yeah. I mean, I said they do have a hierarchy and they do ‑‑ they still need a limited number of caregivers for them. And we do see this a lot of times, in the program that I work in, where nobody really takes emotional responsibility for that baby. The baby is physically cared for and passed around, but nobody is kind of really taking on the ownership. We call it who's the momma in this household? You know, who's the real psychological mother for this child? Any other comments? Yes.
UNKNOWN SPEAKER: You know, for so many years in working with children with autism, we looked at attachments and refrigerator mothers ‑‑
MS. ZEANAH: Right.
UNKNOWN SPEAKER: ‑‑ that sort of thing and how can you or how far have we come as far as differentiating between biological and neurological factors with children who attach throughout the relationship that the caregivers experience?
MS. ZEANAH: Okay. That's a very good question. The question is, you know, she's worked autistic kids and how do you differentiate sort of biological, neurological problems that these kids and other children might have from the care giving experience?
We do know that even kids with autism and kids with mental retardation will have different attachment relationships. You can measure their attachment relationships with those children. And we know that, for example, children with autism will do better if they have a secure relationship with their caregiver. So even in those circumstances, the relationship is going to impact the outcome for that child and how they're functioning. I don't know if that answers your question.
UNKNOWN SPEAKER: It looks a little different, but when you take a look at patterns of behavior that the child exhibits towards the parent, they do play out as being attachment behavior. And sometimes what you really have to do if you're working with those kinds of (inaudible) is help the parents see how the child is demonstrating their attachment to them.
We do find that most kids on the autistic spectrum do have fairly healthy attachments to their parents. They may look a little different in how they show that because of neurological differences and what have you. The only kids for whom we definitely see problems are kids that have severe neurological disorders. Their hardwiring is so completely different that we don't see the same biological processes, engage and respond differently.
UNKNOWN SPEAKER: We don't see the same biological (inaudible) severe attachment disorders, who aren't neurologically impaired from those who are (inaudible).
MS. ZEANAH: You know, that's a question for my husband, actually. Because he's got all these great videotapes and worked with these Romanian orphans who actually, some of them, look autistic. They're called institutionalized autism ‑‑ institutionalized autism.
They look very autistic because of their very, very deprived, you know, environment. They will quickly get into relationships, you know, clear relationships. And even the children who are in the orphanages, you know, and many of them have a lot of neurological deficits because they've had poor prenatal care, bad nutrition, the whole, you know, lots of illnesses. They can't see right and they can't hear right. They've got everything going wrong for them, but they can still identify attachment patterns in these children, even in those kinds of conditions. When they've had both the physical and the environmental insults to them.
So, I mean, the other thing this makes me think about that I didn't mention, is that these patterns, sometimes people say, "Well, is this just American middle‑class kids?" No. These have been studied around the world. Now, I can't say studied in every single environment. These classifications seem to kind of hold up across different environments and different cultures, which I think is important.
It kind of speaks to the pre-wiring. You know, to stay safe and healthy, you've got to have somebody taking care of you when you're a human infant. So it's a pretty high‑level need to figure out how to do that, one way or the other. These patterns are ones that kind of ‑‑ these are ones that they cope with various experiences. Yes?
UNKNOWN SPEAKER: What about a baby that's a preemie or has significant medical problems and has to go into the hospital immediately so the parents are not able to become the primary caregiver. In those cases, what happens in the attachment process? Does it change once the baby is born?
MS. ZEANAH: Okay. That's a good question. The question is premature babies and babies who have been in the hospital for a long time after birth, what happens to them, their attachment situation?
Brian, do you want to the answer that?
DR. STAFFORD: Sure. I think, you know, part of it is the babies are in a pre‑attachment period, for the most part. We're talking about behavioral patterns. You know, that means six or seven months (inaudible). Most of those babies are home by then.
But the thing that's actually kind of interesting is, what has that experience meant to that caregiver? Because many parents have ESP, when their baby is born prematurely or (inaudible) being told that they're not going to survive. Many parents have (inaudible).
That's also true for autism. One of the biggest mediators is how well that parent has resolved that diagnosis. They've been given the diagnosis and then they've been able to kind of share with someone about what that's meant to them and regulate the whole experience themselves, those are the babies who feel secure attachments, even though they have autism. It's the same thing with the babies that are premature. A lot of them depend on the support the caregiver gets and also how they see this baby and how that experience was met.
MS. ZEANAH: Good question. Yes?
UNKNOWN SPEAKER: This is about the caregiver responding promptly and consistently to the cues of the infant. Where does the thought fall on when it's time to learn how to self‑console?
MS. ZEANAH: Right. Good question. I mean, this is one of those nitty‑gritty, every day problems that you have to deal with. When do you let them self‑console. I tell you what, some of the research that's out there shows that quick responsiveness to babies in the first three months of life, the first quarter of their first year of life, by that, I mean, within a few seconds. We're not talking two minutes. We're talking very, very quick responses. Those babies are going to be less whiny, less angry, less demanding at age one year. Okay?
So that gives you ‑‑ if that's helpful. So really early on, these babies are learning very, very early on, from the first view weeks of life, that how that parent responds is going to make a difference. If they learn early, early on, my mother's going to be there and take care of me, then it sets the stage for better behavior later on. Now, yes, babies, and I'm going to talk out both sides of my mouth, because if you look at what newborns are able to do, some newborns have the capacity to console themselves. And they are able to figure out a way to suck their thumb or figure out a way to be uncomfortable and then settle back down again. And we could spend a whole lot of time talking about that. It's really kind of fascinating, but it still needs to be fairly quick because babies escalate pretty quickly. I don't know about you guys, but when I get really upset, I kind of lose any rational thinking here. I guess it's kind of true for babies too. You get so upset that you can even think straight, not like they're thinking like we do, but you want to kind of intervene early so they can begin to learn this issue of self‑regulation.
Now, over time, you know, is there a hard‑and‑fast answer to that? I don't think so. You have to kind of learn what the baby brings to you, what the baby's temperament is and so forth. If the parent doesn't do this 100 percent of the time, it doesn't mean they're going to have insecure attachment. But most of the time we're talking about, most of the time, is the mother pretty sensitive? Is the mother pretty consistent in responding to that baby early on? And it will pay off in the long run, because those babies will be easier to take care of.
UNKNOWN SPEAKER: I will add one caveat though. You have to be especially careful with babies who may have been substance exposed, because they can be very poorly organized and they tend to be easily over-stimulated and tend to be unable to handle more than one channel of stimuli at a time.
If you really ‑‑ you can find a mutuality, a reciprocal relationship gone bad early on with moms who have had substance abusing problems or whatnot when they're babies, because these babies tend to be more demanding, more ‑‑ what they really are is just miserable and disorganized. But it's interpreted, you know, as being difficult. And we often see they let the baby cry, don't spoil the baby kind of thing here. And this goes for some babies too who temperamentally are just, you know, born a little bit that way.
You have to be very careful, because what you're going to do is set up a very maladaptive pattern of contingent responsiveness. What does this baby actually have to do before they get some response out of the mother?
MS. ZEANAH: Yeah.
UNKNOWN SPEAKER: So that's, you know, one thing I just wanted to add. We've run into lots and lots of problems there. All babies are not the same.
MS. ZEANAH: So, you know, it sounds so simple, to me, this stuff makes so much intuitive sense. But when it gets down to the every single day interaction between moms and babies, there's a lot of stuff going on that's impacting the ability to do that. We're going to talk a little bit more about that later. Okay. Now, any other pressing questions?
Okay. Now you get to have a little test. We're going to show some very brief videos and your job is to figure out which attachment classification are you going to be seeing? These are real, live families. These are not beautifully, you know, developed videos. They've been used a lot too. So the quality is not so great. They're very short. Mostly you're going to be seeing reunions. And these are kids ‑‑ most of these kids are coming into clinics for evaluation and treatment. And this is part of the normal assessment that has happened at some of our infant clinics in Louisiana, also previously in Rhode Island.
So everybody ready? Is the baby ‑‑ you're going to see the baby playing, and the person sitting in the room with the baby is the stranger. So in this particular paradigm, there's a series of comings and goings between the mother and a stranger and so forth.
At this point in this interview, in this paradigm, this is a strange situation. You're going to see the baby's mother has left ‑‑ they're only out for a short period of time ‑‑ the mother has left and the strange is sitting there with the baby. And in a few seconds, you're going to see the mother return. And I want you to notice what the baby is doing before the stranger ‑‑ before the mother comes in. What happens when the mother comes back in, and then I want you to think about what attachment classification you think this is.