Vol. 14, No. 2
Newsletter of the World Association for Infant Mental Health April - June 2006
Watch, Wait, and Wonder: An Infant-Led Approach to Infant-Parent Psychotherapy who are worried about their infants greatest concern, the actual focus of Nancy J. Cohen, Mirek Lojkasek, & and their relationships with them treatment is on the parents or other are increasingly seeking help. When caregivers (Lojkasek, Cohen, Muir, Hincks-Dellcrest Centre and Univer- infants are brought to mental health 1994). We have been refi ning an clinics, they obviously cannot use intervention called Watch, Wait, and words to express their anxieties and Wonder over the past 12 years which Originally published in 2003 in distress. Symptoms typically appear is innovative because it shifts the IMPrint, 35,17-19. IMPrint is the as functional problems in the infant focus of therapy to the infant, requir- newsletter of the Infant Mental involving feeding, sleeping, and be- ing the parent to follow the infant's Health Promotion Project, The haviors such as extreme tantrums or spontaneous and undirected activity Hospital for Sick Children, Toronto, diffi culty being soothed. While not (Muir, Lojkasek, & Cohen, 1999). In Ontario, Canada. apparently relational, these problems this article we will describe the theo- commonly refl ect diffi culties in the retical underpinnings and techniques From birth, infants are busy growing relationship between parent and in- of Watch, Wait, and Wonder, and and developing in their capacity to fant. For example, sleeping problems fi ndings from our research comparing show their feelings, to express them- may refl ect the infant's separation the outcome of this form of treatment selves both verbally and through anxiety resulting from an anxious with a more traditional psychother- their gestures and feelings, to think, apy with the mother with the infant and to relate socially. We now know that early relationships affect how well infants develop. When prob- Mother: Joey has never slept through Attachment Theory and Its
lems develop in an infant's early the night. He doesn't know the Association with Infant-Parent
relationships they are linked with meaning of the word sleep. We later problems in social relationships, haven't had a good night in the 11 John Bowlby (1988) suggested emotional health, thinking, and months since he's been born. We that attachment security develops problem solving. Due to this, parents can't get him to sleep during the through the experience that infants day and we can't get him to sleep have with their mothers in relation to during the night. So during the day I their mothers' emotional responsiv- was ready to call the orphanage and ity and physical proximity. There during the night my husband was is considerable evidence that for 5 Attending and Repsonding dealing with him and ready to call secure attachments to form, parents to Infant cues.
the orphanage. I kind of reached a must perceive their infants' emo- point where I said I can't go in there tional signals accurately, respond 8 Editorial Position Open anymore because he's making me to them sensitively, display affec- 9 By the Red Cedar very angry. You give so much but he tion, accept their infants' behavior doesn't give anything back.
and feelings, and be physically and 10 President's Perspective A particular challenge in mental psychologically available when their 12 Literature Monitor health interventions for infants is that infants are distressed. Development although it is the infants who are of appears to proceed more optimally University Outreach & Engagement, Kellogg Center, Garden Level, MSU, East Lansing, MI 48824-1022 Tel: 517-432-3793 Fax: 517-432-3694
for infants who are securely attached. Watch, Wait, and Wonder Technique
These infants are able to regulate their Watch, Wait, and Wonder directly emotions and have a sense of inner involves the infant in therapy. For half confi dence and effi cacy (Goldberg, of the session, the parent is asked to: 2000). Feeling safe, securely attached • get down on the fl oor with the infant infants can express their curiosity • follow the infant's lead and are eager to explore their envi- • not initiate any activities him/herself ronment. Securely attached infants • be sure to respond when the infant Production Editor: enjoy more pleasure and harmony in initiates but not to take over the activi- their relationship with parents, which fosters infants' openness to other • allow the infant freedom to explore; Editorial Board: relational experiences. In contrast, whatever the infant wants to do is infants who are not securely attached okay as long as it is safe have mothers who are unpredictable • remember to watch, wait, and and either provide minimal or incon- sistent care or may even be frighten- ing to their infants. An insecurely We mark the Watch, Wait, and Wonder Graziella Fava-Vizziello attached mother interprets her infant's play space with a heavy duty plastic normal bids to gain access to her and mat and always arrange the same toys to explore and master the environment in the same order. These are toys that negatively, thus promoting insecurity the infant can manipulate and include Cynthia Garcia-Coll in the infant. It is important to keep both construction toys and represen- in mind that we recognize that in such tational toys. Typically, some of the situations the mothers themselves toys are chosen to promote emotional have had caregiving experiences that and relational themes central to the were not optimally responsive to their infant's presenting symptoms. For in- emotional needs. In the Watch, Wait, stance, an infant with eating problems and Wonder psychotherapy, we help is often drawn to the feeding utensils the parent and infant discover for such as bowls and spoons, and an themselves a new way of relating and infant with sleeping problems to the aim to prevent a repetition of inter- dolls and doll bed.
generational transmission of insecure Tuula Tamminen The therapist's role in Watch, Wait, From the Red Cedar: and Wonder is less interactive than in Hiram E. Fitzgerald Following from attachment theory, an other forms of psychotherapy. Just as intervention consistent with attach- the mother is asked to watch, wait, and The Signal is a quarterly publication ment theory would need to meet a wonder with her infant, the therapist of the World Association for Infant number of criteria: sits slightly off to the side of the area Mental Health. Address correspon- • provide emotional and physical ac- defi ned by the mat and watches, waits, cess to the parent, dence to Paul Barrows. and wonders, refl ecting on the interac- • focus directly on parent sensitive tions of parent and infant. The thera- responsiveness to the infant's behavior pist shows interest and curiosity about and emotional signals, the relationship and inner life of the All opinions expressed in The • place the parent in a non-intrusive parent-infant dyad, and supports and Signal are those of the authors, not stance, which allows for the provi- validates the parent's experience. This necessarily those of WAIMH's. sion of a space in which the infant parallels the task of the parent since Permission to reprint materials from can work through relational struggles the parent is also placed in the position The Signal is granted, provided ap- through play and interaction with the of being curious about and accepting propriate citation of source is noted. Suggested format: The Signal, 2005 • provide a therapist who can function Vol. 14, No. 2, WAIMH.
as a secure base for the dyad working During the second half of the session, through their relational diffi culties.
the parent is asked to talk about what Watch, Wait, and Wonder meets all of he/she observed about the infant's these criteria.
activity and his/her experience during the session. The main idea of this is to April - June 2006 put the parent in a position to become home. We have a new duvet and I regulation. In some other cases, refer- more knowledgeable about the infant throw him on the soft bed and he just ral was triggered by factors that got in and not feel it is necessary to intervene loves it. I realized that he was inviting the way of the mother's capacity for or to rely on the therapist for advice or infant care such as feelings of failure insight. The infant, too, can use play in the attachment process, maternal and activity to master diffi culties in The most important thing I learned depression, and in a few cases risk or relation to the parent. Although some was how sensitive Joey was to my allegations of abuse. Problems were parents talk about their early relation- moods and emotions. If I was angry longstanding beginning in the infant's ships with their own parents, this is or stressed, then he would be also. It earliest months of life. Assessments not necessary for therapy to work. was as though he could feel stress in were done before treatment began When used with infants, it is best to my arms and hear it in my voice even (pre-treatment), at the end of treatment start Watch, Wait, and Wonder no when I was trying not to show it. He (post-treatment), and six months after earlier than the age of 4 to 6 months would cry and whine and couldn't treatment ended (follow-up). when infants can regulate emotional relax. No wonder he couldn't fall and behavioral states to some extent asleep because he was being held by At the end of the relatively brief treat- and are mobile to explore.
someone who wasn't relaxed. Now ment (averaging 14 sessions over ap- we are much happier and I have more proximately 5 months), we found that understanding not only of Joey but of both psychotherapeutic interventions Mother: We were really expecting the myself. I try to really listen to Joey had positive effects on infants and therapist to say we looked at all the even though he doesn't talk yet. I their mothers. Specifi cally, at the end evidence and test results and I know get down on the fl oor with him and of treatment both forms of psycho- that Joey is like this and because he's try to allow myself to be led into his therapy resulted in reducing infants' like this we can do this. It turned out world. I guess in a way it's like hav- presenting problems, increasing moth- that I did all the work! Once a week, ing a totally new baby or maybe it's ers' confi dence that they could manage for 1 hour, Joey and I would play on fi nding him like I never found him to these problems, and decreasing stress the fl oor with toys that were provided. begin with. I can honestly say I went associated with parenting. As well, The therapist would sit quietly to through a stage where I regretted that at the end of treatment mothers were the side without any involvement. I he ever came into my life. We fi nally observed to be less intrusive and to en- was not to initiate any play. I was got our baby. He was missing. It feels gage in less confl ict with their infants to follow Joe's lead and watch, wait, more like a family now.
in infant-mother play interactions. and wonder. Then for the second half This suggests that there are some com- hour the therapist and I would talk Research on Watch, Wait, and Wonder
mon benefi cial effects of treatment about what had happened during the We completed a study comparing regardless of technique. At the same play time. What did I see in Joey's Watch, Wait, and Wonder to a more time, we found some differences in the behavior? What did I think he might traditional Psychodynamic Parent-In- outcomes of the two treatments. In be trying to do? How did I feel when fant Psychotherapy often used in clinic particular, infants in the Watch, Wait, he acted in this particular manner? settings (Cohen, Muir, Lojkasek et al., and Wonder group were more likely She never told me to do things differ- 1999; Cohen, Lojkasek, Muir, et al., in to shift toward a more organized or ently. Instead, she asked me questions press). In Psychodynamic Parent-In- secure attachment relationship than in- and helped me fi gure out some of what fant Psychotherapy, it is assumed that fants in the group whose mothers had mattered to Joey by helping me notice in therapy the parent explores early psychodynamic psychotherapy. The his actions and behavior that I may relationships with his own parents and, infants in the Watch, Wait, and Wonder have overlooked. She gently urged me through this process, gains insight into group also showed greater improve- to think more about particular things current relationships with the infant ments in cognitive development and he had done. After some time, things and family. The work in this approach increased capacity to become engaged he had done many times before began is between the parent and the thera- in the cognitive tasks. Although we to take on a new meaning and I was pist. The presence of the infant in the do not know whether improvement in better able to understand his needs. therapy sessions provides the motiva- cognitive functioning resulted from For example, every week he went over tion for change. positive changes in attachment secu- to a bean bag chair and jumped or fell rity or organization, attachment theory into it laughing. First, I thought he This study involved mothers and their does suggest that improved cognitive was saying Look see what I can do. 10 to 30 month old infants who were developmental functioning should be Aren't you jealous of me? Then three primarily referred for problems mani- an outcome of increased attachment weeks later it hit me. I understood fested as functional symptoms in the security. Moreover, at the end of he was repeating a game we play at infant or in behavioral or emotional treatment, mothers of children in the World Association for Infant Mental Health Watch, Wait, and Wonder group were secure connection. Due to the need to become more knowledgeable about signifi cantly less depressed and re- fi nd a way to establish a more secure her own infant and not feel the same ported more satisfaction and effective- relationship with the mother, when need to rely on the knowledge of the ness in their parenting than mothers left to his own devices the infant will therapeutic "expert". It also allows in the group receiving psychodynamic inevitably approach her. We have ob- her to refl ect on and deal with those served that at this point the infant will anxieties that are aroused while trying quickly bring forward the core issues to follow her infant's lead, which are When followed six months later, in his relationship with his mother often manifested in her diffi culties in effects of both psychotherapeutic into the play; for example, the infant's being sensitive and responsive to her interventions on presenting complaints desire for closeness when physical infant's emotional cues. and maternal and child functioning accessibility was previously restricted. were maintained (Cohen et al., 2002). Watch, Wait, and Wonder involved Stern (1995) suggests that there are a Moreover, in some respects, further enhancing the mother's capacity to number of "ports of entry" into help- gains were observed after treatment respond to her infant's activity with a ing parents' and helping other infants' ended in that, at follow-up, there was reciprocal gesture, by placing her in a relationship problems; for example, continued improvement in infant non-intrusive stance which allows for the overt infant-parent interactional symptoms and observational measures the evolution of the infant's potentiali- behavior or parent representations. of maternal intrusiveness and dyadic ties or "true self" (Winnicott, 1976). We recognize that both treatments that reciprocity observed during mother- We speculate that when the mother we studied aim to improve maternal infant play. Although this general observes her child without being able sensitive responsiveness, but each conclusion applied to both treatment to intrude, her assumptions about approached this in a different way and groups, the pathway for change for the herself, her infant, and her relationship that both were successful. Thus, "all two treatments had a different time- with the infant are challenged. More roads lead to Rome" (Stern, 1995) but line. As reported above, greater gains importantly, the interaction feels dif- taking some roads takes less time than were made from the beginning to the ferent and more pleasurable. Since as end of treatment in the Watch, Wait, part of the process the mother begins and Wonder than in the psychody- to feel more competent in reading her namic psychotherapy group on some infant's cues, she gains confi dence Bowlby J. (1988). A secure base: Parent-child attach-ment and healthy human development. New York: measures. In the parent-infant dyads to work things out with her infant receiving psychodynamic psychother- on their own, resulting in enhanced apy, these gains were also observed confi dence as a caregiver. Thus, it Cohen, N.J, Muir, E., Lojksek, M., Muir, R., Parker, C.J., Barwick, M.B., & Brown, M. (1999). Watch, but not until six months after treatment is the involving of the infant directly Wait, and Wonder: Testing the effectiveness of a new ended. At the same time, an advantage and the mother's non-intrusiveness approach to mother-infant psychotherapy. Infant Mental Health Journal, 20, 429-451. persisted in the Watch, Wait, and Won- that might account for the difference der group from the end of treatment to between Watch, Wait, and Wonder and Cohen, N.J, Lojkasek, M., Muir, E., Muir, R., & Parker, C.J. (2002). Six month follow-up of two six-month follow-up in that mothers in the more traditional psychodynamic mother-infant psychotherapies: Convergence of this group reported a further increase psychotherapy. Although the infant is therapeutic outcomes. Infant Mental Health Journal, in comfort in dealing with the infant involved in psychodynamic psycho- Vol 23, 361-380.
problems that brought them to treat- therapy, the primary focus is on feel- Goldberg, S. (2000). Attachment and development. ment and a further decrease in their ings and thoughts about relationships. London: Arnold.
ratings of parenting stress. This focus may delay changes as the Lojkasek, M., Cohen, N.J., & Muir, E. (1994). Where mother needs to work through her is the infant in infant intervention? A review of the literature on changing troubled mother-infant relation- What might account for the different earlier relationships before her new ships. Psychotherapy: Theory, Research and Practice, timeline for changes to appear in the insights can infl uence the relationship 31, 208-220.
two treatments? In trying to under- with her own infant Muir, E., Lojkasek, M., & Cohen, N. (1999). Watch, stand this, we return to attachment Wait, & Wonder: A manual describing a dyadic theory. We think that Watch, Wait, The therapist in Watch, Wait, and infant-led approach to problems in infancy and early childhood.
and Wonder maximizes the require- Wonder engages in a parallel process ments for forming a secure attachment of watching, waiting, and wondering; Stern, D.N. (1995). The motherhood constellation: A unifi ed view of parent-infant psychotherapy. New relationship. The instructions to the that is, the therapist does not inter- York: Basic Books. mother to allow her infant to take vene by modeling or directing for the the lead increases maternal sensitive mother or interpreting the infant's Winnicott, D.W. (1976). The capacity to be alone. In D.W. Winnicott (Ed.), The maturational processes and responsiveness and makes the mother activity. Due to this, and to the the facilitative environment. London: Hogarth Press.
uniquely physically accessible to her expectation that the mother observes For inquiries about training in Watch, Wait, and infant, creating the potential for a her infant's activity, she is enabled to Wonder contact Edythe Nerlich (Program Coordina-tor): or April - June 2006 Attending and responding to infant cues as an essential focus for effective early This small window of opportunity to implicitly used in bodily communica- most effectively infl uence brain devel- tion with babies. opment means that I feel pressure to The outcome of the encounter with teach therapeutic handling as fast as Mary was that I subsequently went to In this article, for clarity I refer to possible. In the past I found that ba- Innsbruck on one of her courses and the caregiver as mother because it bies often got upset during treatment, then organized a similar course for her is more often the mother with whom especially when I focused primarily on to teach in the UK. Then, because of I work, but I also work with fathers, how to change the way they moved, my desire to understand and com- grandparents and other carergivers. and I felt uncomfortable about their municate better with families around The baby's details have been altered distress. I was also very torn between the time of diagnosis, I completed a so that he is not recognizable. the emotional needs of the family, who counseling degree. Some years later had often just received the news that I completed an MA in psychoanalytic Winnicott (1988), quoting a col- their baby may develop cerebral palsy, observational studies (Tavistock/ league, John Davis, said, "[I]n the and getting started with physiotherapy UEL). It was from this point that I felt newborn physiology and psychology for the infant. I felt that I wasn't re- more confi dent to follow my intuition are one." This intertwining of psyche ally doing my job if I spent more time about how to work with babies and and soma indicates the necessity listening to both family and baby.
families. I no longer felt that it was of considering the psyche in early When I heard a lecture by Mary Quin- "wrong" to approach the treatment physiotherapy intervention and this ton, by then an elderly physiotherapist on an emotional level, but that this is the theme I would like to discuss from Switzerland, this all started approach is fundamental to the success further. I am a neurodevelopmental to change. Although not trained in of the whole treatment. physiotherapist working with preterm psychology, she had a very intuitive infants from about 26 weeks gestation approach. She would say "Follow the It is well recognized that the emo- to nine months of age. I usually see baby's lead!" "Listen carefully to what tional state affects muscle tone. Tustin babies fi rst of all in NICU (Neonatal his body tells you through your hands" (1981) talked about the "second skin Intensive Care Unit) and then later at (Quinton, 2002). She taught that of muscular tension" that babies may home and in baby clinics, thus provid- through our hands and bodies (as well use to "hold themselves together" ing continuity for families at this as watching the baby's expression) we when under psychological or physi- often stressful time.
could feel how the baby accepted new cal stress. This is very evident on Recent advances in neuroscience have movements and positions. In the same the NICU where babies go stiff when shown the importance of early experi- way that psychotherapists undergo handled too much or too quickly, as if ence on brain development (Schore, personal therapy, Mary believed trying to protect themselves. We are 2001 a & b). It has also been shown that physiotherapists should have a familiar with toddler tantrums when that when a baby has an area of brain thorough understanding of movement the muscle tone increases, and the tod- damage, there is a certain amount in their own body to enable them to dler goes stiff and cannot be placed in of neuroplasticity in the brain so use the "inner eye" (Quinton, 2002) to a push chair. But even more remark- that other cells can take over certain understand the baby's movements. I able, the movements of babies differ functions (Wigglesworth, 1989, Had- have since read Allan Schore's work, according to what they are focusing ders-Algra, 2001). This neuroplas- where he writes about non-verbal attention on. Brazleton described how, ticity is greatest between 34 weeks "right hemisphere-to-right hemisphere just by observing one segment of a gestational and eight months of age, affective transactions" that are beneath limb, the observer could tell whether hence the need for the physiotherapist levels of awareness (Schore, 2003). the baby was looking at a person or a to develop a rapid rapport with infant Schore quotes neuroimaging studies toy (lecture March 2004). and mother. It is the specifi c han- showing areas of the right hemisphere dling from day to day by the family, that light up in the brains of mothers When a baby is born at 24 weeks ges- facilitating and repeating good quality and infants during these transactions. tation, the experience of being cared movement in the baby that creates the I think that this unconscious, emotion- for in NICU is very different from the optimal synaptic connections. al intelligence is something that Mary experience in utero. With the baby World Association for Infant Mental Health that proceeds to full-term, as the fetus sequence movements in order to move helpful for the physiotherapist to ad- grows bigger there is fi rm even pres- fl uently from one position to another. dress, either directly or indirectly, the sure all over the body and the fetus However, they sometimes will allow internal world of the mother. hears the mother's heart beat, breath- me to facilitate a movement, such as ing and tummy rumblings that Maiello rolling, if I "hold" them with my eyes Some babies with disabilities fi nd it (1996) called the "sound object" - the throughout the movement by mov- hard to give clear cues, making it more fi rst object relation. However, for the ing with them and maintaining eye diffi cult for parents to respond appro- preterm baby in NICU this is mainly priately. Babies with signifi cant neu- missing, although later, if well enough, rological disability may fi nd moving the baby may be nursed in skin to skin When trying to infl uence how babies or being moved extremely frightening contact (known as kangaroo care) for move and improve motor patterns as their own motor control during periods of the day. when cerebral palsy has been diag- movement is unpredictable. Apart nosed, it is important to use activities from the fact that we all have our own In utero, as the mother moves, the that are functional and meaningful characteristic ways of moving, anxiety fetus experiences the motion, being (Mayston 2000). The central ner- can cause some mothers to move gently buffered by the amniotic fl uid. vous system is task-dependent in its too quickly for the baby to feel safe. However, the preterm baby in an in- organization (Flament et al., 1993) and Here, the mother's movement is an ex- cubator is motionless apart from when so motivation for movement, with a tension of the prosody of speech. It is being handled by nurses and doctors, positive emotional engagement, would not only the facial expression and the often for extremely invasive (though seem to be desirable. Also, given tone and pitch of the mother's voice, life saving) procedures. Instead of that distress tends to cause increased but also the speed and range of her being well fl exed in a curled position, muscle tone as mentioned above, it is movement and the fi rmness of touch the baby in NICU is not supported by important that babies enjoy therapy. that inform the infant's experience of fi rm boundaries as in utero, although Affect attunement (Stern, 1985), her affect attunement. When working many NICUs now try to compensate which provides a framework for affect with a parent and baby facing these by providing a nest. Even with the regulation, is an important aspect of unknown and often terrifying experi- best NICU care, bright lights and physiotherapist-infant communication ences, I ask myself, "Where would loud noises are sometimes inevitable. and also provides a model for mothers be the best place to start?" Whereas, These factors may all contribute to who may be struggling to understand I used to be much more planned in the lack of felt safety for the preterm their babies' cues. my approach I now tend to go into or critically ill baby. Experience tells the situation simply trying to feel and me that this can have an effect on the The mother's and baby's mind and understand something of what is hap- quality of movement.
body are continually interacting and pening for mother, baby and anyone infl uencing each other, so another area else involved and then respond to what Of course, all babies need to be to consider is the mother's well-be- I feel. Physiologically I think this well-supported and moved reason- ing and how the mother moves. This involves using both my right and left ably slowly. I sometimes work with is not just an adjunct to treatment but brain and allowing right hemisphere- full-term babies for teaching purposes, is essential if the mother is to be free to-right hemisphere communication and if I put a baby down on a mat and available to "take in" (Bion 1962) with the dyad (Schore, 2003). Some- on the fl oor, the change of position the baby's feelings and process them, times I start by listening to the mother and environment will sometimes feel thus providing physical and emotional and helping her to explore her feelings frightening for the baby. However, if "containment" for the baby. This en- about the diagnosis and the diffi culty I maintain eye contact while keeping ables the baby to start to engage with of "not knowing" exactly what the my hand on the baby's chest, the baby the environment. As the baby takes future holds. Although I take longer does not get upset and so I presume an interest in the outside world, for before thinking about the baby, this they feel safely "held". With some example through eye contact or turn- helps the mother to feel more settled preterm babies, this is even more ing to a voice, the available mother and so to be able to start thinking pronounced, perhaps because they can work to facilitate useful and good about the baby with me. have missed out on the natural, safe, quality movement. It may be hard for in utero movement and have had the the mother to do this if she has just On the other hand, if the baby is possibly more frightening experi- been through the traumatic experience screaming and unable to settle, or if ence of sudden and less supported of a premature birth and subsequent the mother is particularly upset by the movement in NICU. At around nine life threatening illness of her baby baby's apparent unresponsiveness, I to twelve months I have found that followed by distress about a diagnosis may begin by refl ecting with her about some preterm babies are unable to of probable disability. Therefore it is the baby – often thinking aloud or April - June 2006 "speaking for the baby". I may voice I thought I noticed a slight stilling As a physiotherapist I wanted to feel how it feels to be without the sup- in his grumbling. I said, touching Bouzid's muscle tone and facilitate portive walls of the uterus and how him fi rmly, "I'm going to lift you up his integration of the sensation of the perhaps it is less frightening when I slowly and put you on my lap." I sat various parts of his body. I wanted "to cup my arms around her on my lap. I down on the fl oor with my knees bent paint in" (Quinton, 2002) this sym- talk slowly, looking at the baby with and slowly took him from his mother, metrical position of his body lying in a gentle responsive gaze, and trying keeping him well supported in my midline, by pressure with my hands to respond to the subtle changes of arms and placed him on my lap. I on his buttocks pressing up through muscle tone and facial expression.
kept his arms and legs gathered in, his spine. I also wanted to provide supporting his shoulder girdle slightly a contained and stable position from Sometimes on NICU I can help forwards, trying to provide a feeling of which he could make eye contact with parents to read their baby's cues or safety. I placed my hand on his chest. others and communicate by facial demonstrate a positive response; for His eyes were moving around but not expression. I gave tactile input to his instance, having the mother move making contact with me.
arms to draw his attention to them and from one side of her baby to the other I talked softly to him and his sobs drew his shoulder girdle forward so and watching how the baby, even as lessened. The containment of his that he had the possibility of seeing his young as 34 weeks, turns purposefully body provided a point of fi xation from arms and hoped that he might also as- towards her voice when she talks to which he could use his eyes. There sociate these two perceptions. He had him. Holding the baby in a well-sup- were a few moments when he was just the possibility of bringing his hands to ported way facing mother may enable able to meet my eyes and I said, "Well the baby to make eye contact. Helping done, you found me!" and eventually parents to understand that behaviors I saw the ghost of a smile. I stroked This position on my lap felt to me such as yawning and looking away Bouzid's left hand and arm fi rmly like a "gathering together" of Bou- may indicate that a baby is overloaded and said, "Hello Bouzid, this is your zid, providing a "background of and just needs some time out, will help arm." I stroked his right hand and arm safety"(Sandler, 1960) before Bouzid parents respond appropriately. If these and said, "And you have another arm himself was able to achieve sensory cues are overlooked, then the behavior here. Can you feel this one? Can you integration. Haag. (2000) describes the may escalate and the baby go stiff and see it?" (bringing it within his line of importance of the sensory contact of arch back in anger. This may develop the spine combined with visual contact into a habit of arching back which is in her work with autistic children, unhelpful for motor development and I decided to start my intervention in saying that it provides a "background is also likely to feel rejecting to the this way because I wanted to reveal place," an experience of a "back- Bouzid's personality and help Mother ground with a fl oor." Her descrip- to get to know him. I wanted her tion gives the sense of a support that In the following brief extract from a to see that Bouzid wanted to com- moulds itself to the body so that there session with a baby who I will call municate, that he would still to my is less fear of falling through. I think Bouzid, I decided to start the work by voice and that by making him feel of the position in which I held Bouzid thinking with and about the baby. At secure he was able to take in more as providing "a secure base" (Bowlby, this time Bouzid was 12 weeks old of his surroundings. This would be 1973) in a physical and emotional and his mother was isolated and de- similar to Stern's aim to "change sense, from which the infant can move pressed. Research by Murray (1997) the parents' representations" (Stern, out and then return to. about predictive factors for post-natal 1998). My expectation of a response depression found that having an infant from Bouzid, perhaps enabled him to I fi nd this way of working very who was irritable or who had a poor respond, and myself to see the tiniest demanding because of the intense motor ability signifi cantly increased beginning of a smile. Kohut. (1977) involvement with the experience of risk of depression in the mother. describes how we respond to infants as baby and mother. However, I also fi nd Bouzid's mother had come from Paki- if they had already formed a self. As that it is more effective and reward- stan to marry, lived with her husband's often happens, I found myself talking ing than the way I used to work and it family and spoke little English. I to Bouzid as if he could understand. would now be impossible to go back. sensed that although the family were Norman (2001) describes infants' un- In addition to helping develop better outwardly accepting of the diagnosis derstanding of the emotions expressed motor patterns it is very satisfying of disability, there was also a feeling in the non-lexical aspect of language to facilitate better communication of disappointment. and the value of talking to babies in between infant and mother, which is As I spoke softly to Bouzid, who infant psychotherapy. crucial to their relationship and to the was grizzling in his mother's arms, baby's longer term development. World Association for Infant Mental Health Flament D, Goldsmith P, Buckley C. and Lem- Schore, A., (2001b). The effects of an emo- I would like to thank staff at BTPP in Birming- on R., (1993) Task dependence of responses tional trauma on right brain development, af- ham and Maria Rhode at the Tavistock Clinic, in fi rst dorsal interosseous muscles to magnetic fect regulation and infant mental health. Infant London for teaching me about these topics. brain stimulation in man. Journal Mental Health Journal, Vol 22, 201-69.
of Physiology 464, 361-378.
Schore, A., (2003). Affect regulation and the Bion, W., (1962). Learning from Experience, Mayston, M.J., (2000). Motor learning now repair of the self. London: WW Norton and London, Heinemann requires meaningful goals. Physiotherapy Company Ltd.
Bowlby, J., (1973/1998). Attachment and Loss Stern, D., (1985). The interpersonal world of Vol. 2, Separation, anger and anxiety, London, Murray, L., and Cooper, P., (1997). Prediction, the infant. New York, Basic Books.
detection and treatment of postnatal depres-sion. Archives of Diseases in Childhood, Haag, G., (1997). "Psychosis and autism." Stern, D., (1998). The motherhood constella- In: M. Rustin, M. Rhode, A. Dubinsky and H. tion. Karnac Books, London.
Dubinsky (eds) Psychotic States in Children, Norman, J., (2001). The psychoanalyst and the London, Duckworth baby: a new look at work with infants. Inter- Tustin, F. (1981/1989). Autistic states in chil- Haag, G., (2000). "In the footsteps of Frances national Journal of Psychoanalysis, dren London: Routledge Tustin: further refl ections on the construction of the body-ego". Journal of Infant Observa- Wigglesworth, J.S., Plasticity of the develop- tion, June: 7-22 Quinton, M., (2002). Concepts and Guide- ing brain. In Pape, K. and Wigglesworth, J. S., lines for Baby Treatment. Albuquerque, NM, (eds) Perinatal Brain Lesions. Contemporary Hadders-Algra, M. (2001). Early brain dam- Clinician's View.
Issues in Fetal and Neonatal Medicine. Ox- age and the development of motor behaviour Sandler, J., (1960). The background of safety. ford, Blackwell Scientifi c Publications.
in children: clues for therapeutic intervention. International Journal of Psychoanalysis, Neural Plasticity 8, 31-49 Winnicott, D., (1967). Mirror role of mother and family in child development. In D. Win- Kohut, H., (1977). The Restoration of the Self. Schore, A., (2001a). The effects of a secure nicott 1971. Playing and Reality. London, New York, International Universities Press attachment relationship on right brain devel- Tavistock Publications. Maiello, S., (1995). The sound object: a opment, affect regulation and infant mental hypothesis about pre-natal auditory experience health. Infant Mental Health Journal, Winnicott, D., (1988). Human nature. and memory, Journal of Child Psychotherapy, Vol. 22 , 7-66 London, Free Association Press.
Vol. 21 (1) pp.23-41 Editor Needed: The Signal
After six years of superb service, Paul Barrows is ending his tenure as editor
of The Signal. Continuing the tradition started by past editor Charley Zeanah, Paul expanded The Signal's scope beyond that of an ordinary newsletter, including citation quality articles with special emphasis on clinical issues/ interventions and prevention programs, international perspectives, as well as WAIMH news, presidential columns, and windows to published literature. Now, we need to have a successor to continue this tradition. Individuals interested in serving a three to fi ve-year term as editor of The Signal should contact the WAIMH Central Offi ce for more information. April - June 2006 of those concerned with promoting the to all articles published in the IMHJ, optimal development of infants, as well addresses for all Affi liates, copies of as the prevention and treatment of mental The Signal, copies of WAIMH minutes, disorders in the early years; aspects of WAIMH fi nancial reports, and access to research, education, and interventions member information. in the above area Executive Director's Collaborations with other organiza-
Annual Report WAIMH pursues its goals by engaging tions; establishing task forces
in a number of activities, the most visible Building relationships with other orga- Hiram E. Fitzgerald nizations to strengthen international and interdisciplinary collaborations, Historically, WAIMH has not issued an World congresses and regional
annual report to its membership. This has Study groups and committees; and
been a mistake and since the mistake is Regional Meeting: July 2007, Riga, carrying out special projects.
mine, I aim to correct it in this column. Latvia; World Congress: August, 2008, Among the special projects currently under development are those concerning WAIMH Mission Statement and
training programs, WAIMH organiza- Publication of The Signal, its quarterly
tional structure, WAIMH publications, During the past year, President Tuula Affiliate participation in WAIMH Tamminen asked the Board of Directors Beginning in 2007, The Signal will be governance, and policy issues. We will to look anew at WAIMH's mission state- published on-line, with copies available report committee recommendations in ment and its organizational goals. This as a PDF via the WAIMH listserv and The Signal so that all members are in- examination resulted in an affi rmation through the WAIMH web page, formed and Affi liate organizations can of the mission statement contained in have active discussions prior to voting the by-laws, but presented in a more Sponsorship of the Infant Mental
Health Journal in partnership with its
Michigan Affi liate

The World Association for Infant Men- Looking Within to Expand
Heading into its 28th year of publication tal Health (WAIMH) is a not-for-profi t Without: Study of WAIMH's
with over 1000 subscribers, the IMHJ is professional organization that exists the leading international and interdis- When WAIMH was formed in 1992, it for scientifi c and educational purposes. ciplinary scientifi c journal focused on merged the organizational structures of A central aim is to promote the mental social-emotional development, preven- two parent organizations. From the In- well being and healthy development of tion, and clinical interventions during ternational Association of Infant Mental infants throughout the world, taking into infancy and early childhood, Health, WAIMH acquired its Affi liate account cultural, regional and environ- structure, and from the World Asso- mental variations, and to generate and Supports existing and new regional
ciation of Infant Psychiatry and Allied disseminate scientifi c knowledge. and/or national affi liates
Disciplines it acquired a management Within the context of its mission state- During 2006 WAIMH welcomed four structure. Fourteen years have passed ment, WAIMH seeks to facilitate new Affi liates, one located in the United by and the WAIMH Board of Direc- increased knowledge about mental States (Nebraska), and two in Europe tors decided that it was time to review development and disorder in children (Portugal and Latvia) and one in New WAIMH's organizational structure to see from conception to three years of age; the Zealand. Affi liates now represent 20 whether it best represented the growth application of knowledge about scientifi - countries as WAIMH's infl uence con- that has taken place in WAIMH since cally based services for care, intervention tinues to grow and adapt to increasingly 1992. Many more Affi liate organizations and prevention of mental disorder and diverse cultures. have been developed, world congresses impairment in infancy; the application of have moved to biennial offerings, the knowledge about evidence-based ways Maintains an information repository
journal has moved from four to six to support the developmental transition issues annually, and overall WAIMH to parenthood, as well as the healthy The site for accessing World Congress has grown. So, during the next several aspects of parenting and caregiving en- programs and IMHJ Special Issues of months the WAIMH Board will review vironments; the international cooperation Congress abstracts, obtaining an index its structure with the goal of fi nding a World Association for Infant Mental Health way to involve greater participation in WAIMH's activities. More about this President's
will appear in The Signal in the com-ing months.
The 2006 Congress was one of the most successful in WAIMH's history. Over have increasingly clear involvement in 1100 people assembled at the City of The World Association for Infant WAIMH's structure and activities. The Science museum and convention center Mental Health had the most wonder- EC set up a working committee to pre- to enjoy over 800 presentations embed- ful and successful congress in Paris pare a new plan of the organizational ded within symposia, workshops, poster in July. The scientifi c program was structure and to identify all needed workshops, a record number of posters very rich indeed, and there were 1200 changes in our by-laws. We aim to be (400), plenary sessions, clinical teach-ins participants from 39 countries from ready by the next WAIMH Congress and video sessions. Innovations for 2006 different parts of the world. The Local in 2008 in Yokohama, Japan.
included master lectures and plenary Committee, chaired by professors This evolution, this maturation process interfaces. These innovations were so Antoine Guedeney and Bernard Golse, of WAIMH is, in my opinion, ex- successful they will be incorporated worked effi ciently and skillfully to tremely important so that WAIMH into the standard offerings at future produce an event rich with cultural will be able to face all new challenges congresses. We learned two important experiences and strong support for in promoting infant mental health lessons in Paris. First, video sessions the congress. The Program Com- throughout the world.
need to be scheduled in theater style mittee, chaired by Elisabeth Fivaz- rooms with greater seating capacity. Depeursinge, worked in a creative There are also other important Second, poster workshops need to be way and introduced a new program changes going on in WAIMH. So restricted to 8 posters and scheduled in format, called Interfaces, which were far, our Central Offi ce has always separate rooms, not in hallways. These remarkably well received. In these been at Michigan State University lessons learned will be evident in our interfaces an authentic video-material and our Excecutive Director, profes- programming for 2008 in Yokahama. of a clinical case was fi rst presented sor Hiram Fitzgerald, has taken care Our on-line submission worked without and after watching the video-tape, two of the responsibilities of running the error and enabled posting of the program persons representing different views offi ce. This has meant a huge amount and abstracts on the WAIMH web page in the fi eld of infant mental health of work, skill, local investments, without diffi culty. However, the CD ver- described their understanding of the and extreme motivation. WAIMH sion of the program and abstracts used in case. Interfaces were clinically very is deeply grateful for all this! Dr. Melbourne was missed in Paris. We will rich and the discussions offered inter- Fitzgerald has informed the EC that return to this practice in Yokahama. The esting learning possibilities for all of BCA professional company was superb: he will step down after the Yokohama us. The new format was well accepted an exceptionally competent professional Congress and the EC has decided by the audience, and WAIMH will company with effi cient and extremely that the Central Offi ce will move to certainly continue to develop these! pleasant and cooperative staff. The local the University of Tampere, Finland. organizing committee selected splendid Also keynote lectures, workshops and The Finnish Ministry of Education social events. Although all evaluation posters were top-level "gold-pieces" has provided funding to set up and to forms have not been analyzed to date, of state-of-the-art clinical knowledge start running such an offi ce and the the results will be shared in this column and research fi ndings.
complicated process of moving the in future issues. The WAIMH board also offi ce has already started. But until the established a variety of work groups Once again, I want to thank all those 2008 Yokohama Congress, the Central and I will report on their progress in who invested so much energy and time Offi ce will stay in Michigan and for this excellent congress. In addi- Hiram Fitzgerald will continue as the tion, I wish to express my gratitude to Executive Director, assisted in Finland WAIMH OFFICE
all participants for the exceptionally by associate Executive Director, Palvi Effective August 2008, the WAIMH open, friendly and warm atmosphere Kaukonen. This new arrangement will offi ces will move from Michigan State people created together. The Paris help with the transition process.
University to the University of Tampere, Congress was a real WAIMH meeting! Finland. The transition team, consisting In conclusion, I think that WAIMH of folks from each respective offi ce, has In Paris the Executive Committee of is going through a very active devel- been meeting electronically and face-to- WAIMH also held its annual meet- opmental phase and at the same time face in Paris. All is moving along well ing and we took the most important a general professional interest in the and we anticipate a smooth transition in steps in developing our association fi eld of infant mental health is rapidly 2008. More about this move will be in- towards a true world-wide organiza- increasing and widening. This means cluded in future issues of The Signal.
tion. The most profound decision was that WAIMH is building towards a that WAIMH will change its organiza- successful future! tional structure so that Affi liates will April - June 2006 The Beacon Club Endowment Fund
Contribution is tax deductible for US members.
WAIMH is a tax exempt 501 (c) (3) educational organization.

Help us extend information about infant mental health to our colleagues throughout the world who temporarily lack the resources necessary to maintain memberships in pro-fessional societies.
As developing countries gradually make the transition to vibrant economies, such investments on behalf of infants and families will be repaid three-fold.
As a member you can:
The Beacon Club
Endowment for International Development • Sponsor WAIMH memberships and Infant Mental Health Journal subscriptions for individuals from developing Reaching out to fulfill WAIMH's mission A beacon is a signal that gives notice, summons, and • Designate the recipient of this membership or allow encourages. The WAIMH Beacon Club Endowment Fund WAIMH to designate the recipient was started in July 1993 as a result of frequent requests from scientists and clinicians from developing countries inÀ uence of infant mental health research to asking for complimentary memberships and subscrip- countries now developing new approaches to issues of tions to the Infant Mental Health Journal. Outreach is an important part of WAIMH's mission; the Beacon Club Endowment Fund was formed to honor as many of these requests as possible.
• Make it possible to build capacity for promoting the well- being of infants and their families Past Beacon Scholarship recipients include:
Armenia Bangladesh
• Apply to WAIMH's Central Of¿ ce to receive a Beacon Romania Russia Yugoslavia Yes! I want to support the Beacon Club
I'm sponsoring a Beacon Club Scholarship for (choose one): _$150 USD 1-year membership for one person _I want WAIMH to designate the recipient
_$250 USD 2-year membership for one person _I want to designate the recipient myself (Please
_$350 USD 3-year membership for one person provide the recipient's information below) Name of Recipient Payment: Check (US af¿ liate bank) Expiration Date _ Amount Send applications and requests for scholarships to:World Association for Infant Mental Health (WAIMH), Kellogg Center, Garden Level, East Lansing, MI 48824-1022, USAPhone: 517-432-3793 Fax: 517-432-3694 E-mail: Web: World Association for Infant Mental Health Eluvathingal, T.J. et al (2006) Abnor- Risk of Persistent Pulmonary Hy- mal Brain Connectivity in Children pertension of the Newborn The New After Early Severe Socioemotional England Journal of Medicine Volume Akker, Olga van den & Redshaw, Deprivation: A Diffusion Tensor Imag- 354:579-587 February 9 Number 6 M. (2006) Editorial: Depression in ing Study. PEDIATRICS, Vol. 117 Maternal use of a selective serotonin- the perinatal and postnatal period (6), pp. 2093-2100. Conclusion: Our reuptake inhibitor (SSRI) after the continues to challenge researchers study demonstrates in children who 20th week of pregnancy increases the and practitioners worldwide.
experienced socioemotional depriva- risk of persistent pulmonary hyper- Journal of Reproductive and Infant tion a structural change in the left tension of the newborn (PPHN) by a Psychology, 24 (2): 83-85 uncinate fasciculus that partly may factor of six. In a case-control study* underlie the cognitive, socioemotional, performed in four North American Akman, I. et al., (2006) Mothers- and behavioral diffi culties that com- cities during 1998–2003 an SSRI had postpartum psychological adjust- monly are observed in these children. been used at this stage of pregnancy ment and infantile colic. Archive of by 14 of 377 mothers whose infants Disease in Childhood 91: 417-419. Senior, R. et al., (2005) Early experi- developed PPHN (3.7%) and six of Postpartum maternal depressive ences and their relationship to mater- 836 matched control mothers (0.7%), symptoms and insecure attachment nal eating disorder symptoms, both (adjusted odds ratio 6.1). Neither SSRI style are associated with infantile lifetime and during pregnancy. British use before 20 weeks nor use of other colic. Screening and early inter- Journal of Psychiatry, 187, 268-273. antidepressants at any time was as- vention of postpartum depression sociated with increased risk of PPHN. might promote the health of both the Chambers, C.D. et al., (2006) Selec- (Archives of Disease in Childhood mother and infant.
tive Serotonin-Reuptake Inhibitors and July 2006, pp.626) WORLD ASSOCIATION
University Outreach & Engagement
Kellogg Center, Garden Level
Michigan State University
East Lansing, MI 48824-1022
Tel: (517) 432-3793
Fax: (517) 432-3694

Web site:
April - June 2006


N° 02 2012 Fr. 12.– LE MAGAZINE DES MÉDIAS „Il faut parler aux jeunes" La guerre des Comment Raymond Loretan magazines fémininsAu moins quatre titres vont Les médias suisses voit l'avenir de la TV se partager la Suisse romande cherchent leurs marques


ConditionOsteoarthritis of the knee Osteoarthritis of the kneeThis booklet provides information and answers to your questions about this condition. Arthritis Research UK produce and print our booklets entirely from charitable donations. What is osteoarthritis of the knee? Osteoarthritis is the most common form of joint disease, and the knee is one of the most commonly aff ected joints. In this booklet we'll explain how osteoarthritis of the knee develops, what causes it and how it can be treated. We'll also give some hints and tips to help you manage your arthritis and suggest where you can fi nd out more.