INDICES
OF
THE
CHILD’S
EARLIEST
ATTACHMENT
TO
HIS
MOTHER,
APPLICABLE
IN
ROUTINE
PEDIATRIC
EXAMINATION
Henri Parens, M.D.
Department of Psychiatrti, Child Section, Medical College of Pennsylvania, Philadelphia
ADDRESS FOR REPRINTS: Eastern Pennsylvania Psychiatric Institute, Children’s Unit, Henry Avenue
and Abbottsford Road, Philadelphia, Pennsylvania 19129.
PEDIATRICS, Vol. 49, No, 4, April 1972
DIAGNOSIS
AND
TREATMENT
NOWLEDGE about the psychological
as-pects of early child development is
now a regular component of basic clinical knowledge for pediatricians. In the past 25
years this newer knowledge has become
documented, refined, and translated into
every-day pediatric competence. The
prac-ticing pediatrician and his academic col-leagues will be as deficient without this un-derstanding as applied in clinical care as if they were deficient in up-to-date knowl-edge about immunizations, adequate nutri-tion, or the recognition and care for the common infections and infectious diseases of childhood. Children do not grow out of developmental deviations any more than they grow out of the need for adequate nu-trition. This note is a reminder, not only of all the competent care pediatricians pro-vide, but of the risk they take for their pa-tients when they arc ambiguous or less than rigorous about the earliest signs of maternal deprivation or other causes of developmen-tal deviation in the first year of life.
Five years after a first adoption, a middle class couple privately adopted Fay at the age of 1 month. Within weeks, the natural mother sued for the return of her child, and the case remained in litigation from within the second month of Fay’s life to 16 months of age, when the court legalized the adop-tion.
Mrs. G., the adopting mother, cared for her child’s physical and physiological needs well. However, during this entire 15 months, because she feared she might lose
Fay at any point, Mrs. G. took particular
pains to limit tile amount of emotional
con-tact she, her husband, and their adapted
son had with Fay. Unfortunately, the child
adapted to these conditions too well: she developed very restricted emotional ties to
her family.
The parents were highly conflicted, be-cause, while they attempted to protect themselves against the loss of their infant, they also felt that Fay was not reacting to them as a normal child. They were not cog-nizant of the source of the child’s abnormal
responsiveness. During the child’s first year
of life, and during the two that followed, the parents consulted their physician sev-eral times on this matter. He recommended that they await further development and that, if their child continued to show devi-ant behavior by the age of 3 years, they should seek further help. Although the physician’s advice was given with good
in-tentions, he apparently had not recognized
the specificity of Fay’s developmental devi-ation, a response to maternal deprivation. This developmental arrest, detectable in the first year of life, required immediate inter-vention to limit the effects of the depriva-tion and to prevent its elaboration into sub-sequent phases of development. Until the deprivation was recognized, the parents could not understand the consequences of their effort to limit their emotional contact because of their fear that the child would be taken away from them. This uncertainty about Fay’s future did not lessen her need for affection and stimulation, though it may have made it more difficult for the parents to involve themselves in the loving care of their child. Intervention in the first year of life might have corrected and prevented the developmental deviation.
read-DIAGNOSIS AND TREATMENT 601
ily accounted for by this history of emo-tional or maternal deprivation. She repre-sented a classical case of the findings of Spitz,1 Mahler2 and others, who have de-scribed such deviant development in conse-quence of inadequate personal relationships with parents
(
deprivation of satisfying hu-man object relationship)
during the firstand second years of life.
Because of man’s marked helplessness at birth, the object-the parenting person-is all the more important to the child.
Psycho-analysts and pediatricians
(
Freud, A.,3Freud, 5,4,5 Spitz,1 Mahler,2 Winnicott,#{176}
Rib-ble,7 Jacobson,8 Provence and Lipton9 and others
)
have stressed that the importance of that human parent object is twofold: 1. the biological, because the infant would not sur-vive without parental ministrations; and 2. the psychological, because from the emo-tional relations with these essential human objects come the stimulation and affection(libido) that will induce and sustain the unfolding of the child’s psychic organiza-tion, the character of his ego-his psychic apparatus for self-regulation and adapta-tion-and that of his superego-from which come his particular conscience, morality, and ideals.
The parent is psychologically important to the infant from birth, and it is necessary that the parents, especially the mother, be
emotionally engaged with the infant from
birth on. From what we can deduce, on the other hand, the importance of the object is
not experienced psychologically by the
in-fant at birth; it is rather, that progressively the object becomes valued psychologically by the child as affectionate attachments are established between adult and child.
Because this engagement of the mother is so important, we must observe the mothers we see, the emotional atmosphere in which they foster their child’s attachment to them, and help to insure an optimal psychological beginning for him. But how can one ascer-tam that this valuation of the mother is pro-ceeding well enough? And how soon can one tell? In the child with normal psychic endowment, the healthy development of his
relation to his mother evolves and passes through phases which have been especially well formulated by R. Spitz in his The First
Year of Life.’ These phases and milestones
can be observed and assessed. Where the
assessment of these developmental
mile-stones has not already been incorporated
into the pediatrician’s routine examination,
they can and should be included. Many
pe-diatricians have become knowledgeable about developmental screening. Where
in-dices of adequate development are not
oh-served, there should be no delay in explor-ing the nature of child-mother attachment for etiologic determinants of a developmen-tal lag.
The human neonate is not capable of psychological responsiveness to the minis-trations of his mother; his responses are physiologic and reflexive. From about 4 weeks to 3 months, induced probably by an
Innate Releasing Mechanism
(
Lorenz1#{176}) and gratifying experiences of care in the en-vironment, the infant will smile at his mother(
and others)
.
This smile, however, is “nonspecific” or “undifferentiated,” for the infant will then smile at any assemblage, animate or inanimate, that resembles the hu-man face(
not the profile)
.
The index, then, this nonspecific smiling response, wouldin-dicate that we have just passed from a phase
when there was no social response to an-other human, to the next phase, where a socially-related responsiveness to another human emerges. A nonspecific smiling re-sponse would either not appear or would not become differentiated in a child with primary autism. If the pediatrician has as-certained that the infant smiles at its mother, then he need not be alarmed if a 4-month-old child does not smile at him. This infant may well have moved along into the phase of specificity in smiling to which the nonspecific smiling response opens the way.
This second phase in the development of the emotional relation to the parents, is characterized by the progressive emergence of the child’s perception of the specificity of
the object (mother
)
.
Now the infant beginswho frequently appears in his visual field, who assuages his complaints and gratifies
his needs. With this he begins to
discrimi-nate faces. Behaviorally he indicates his rec-ognition of the specific mothering figure with whom he has formed an attachment. This includes the feeling tone, the voice, the manners of his mother which he has in-vested emotionally. \Ve begin to see that the smile stops being automatic. Now the infant smiles broadly at his mother while he closely examines, frowns, or even begins to
cry at the presentation of an unkown face. Hence the smile becomes “specific”; and we now also have the emergence of reactiorvi
to strangers.
This development is progressive from the ages of 4 to 8 months. Generally at about 6 months of age, in the average child-and one may extend this by several months in some undisturbed children-one should be able to count on the child giving clear evi-dence of preferring his mother to other peo-plc, i.e., that she has become valued psy-chically, and this can easily be discerned by
the specific smiling response to her and
non-smiling resporlies to strangers.
Another very important normative index which appears at this time, and substanti-ates the normative or healthy psychic vaIn-ation of the mother, is separation anxiety.
This response, as well as the stranger re-sponse, can often be demonstrated by ask-ing the mother to leave the room. It is a complex interaction, however. Some
chil-dren between the ages of 6 and 12 months who have clearly established a good rela-tionshi1) with their mother may show no separation anxiety or stranger responses
when in their own home. The patterns of
response can be understood if the reactions to the appearance are compared to those of her reappearance. Thus, one 6-month-old
did not show anxiety when her mother left her at home with older sister; but the
child’s joy on mother’s reappearance
re-vealed clearly the child’s attachment to her mother. Also, many children do not express a stranger response when the mother is present.
In the physician’s office, however
(
astranger situation), asking the mother to leave the room ordinarily induces some anxiety in the 6- to 10-month-old. The com-plex of a strange office, the pediatrician as a relative stranger, and the perception of mother leaving the room, being absent, is a combination of influences that are
norma-tively evocative of anxiety for the healthy
6-month-old child. Where no anxiety is evi-dent, clarification should be sought.
We have found these indices to be most useful in our work. The nonspecific smiling
response emerges by 3 or so months; it is
followed by the progressive emergence of the specific smiling response and reactions
to the stranger. These culminate between 6
and 8 months in a stable specific smiling
re-spouse and separation anxiety. When a
4-month-old has not yet smiled, when a 6- to 10-month-old exhibits no separation
anxi-ely, sound pediatric practice requires us to know why. Excessive stranger and separa-tion anxieties in a 16-month or older child are also of concern in pediatric assessment. However, that would take us into the next epoch of child development-about which the pediatrician should be equally knowledgeable.
The earliest period of development of the child’s relation to his mother is emphasized in this essay, because basic capacities of the child’s psychic organization and functions depend on it. As was tragically illustrated by the clinical vignette, the establishment of the child’s relation to his mother is not automatically secured. Where derailment of normal development is seen, early interven-tion is strongly urged and can be most promising.
REFERENCES
1. Spitz, R. : The First Year of Life. New York: In-ternational Universities Press, 1965.
2. Mahier, M. S.: On Human Symbiosis and the Vicissitudes of Individuation, V. I : Infantile Psychosis. New York: International
Univer-sities Press, 1968.
DIAGNOSIS AND TREATMENT 603
4. Freud, S. : Inhibitions, Symptoms and Anxiety. Standard Edition 20. London: Flogarth Press, (1926) 1959.
5. - An Outline of Psychoanalysis. Standard
Edition 23. London: Hogarth Press, (1940)
1964.
6. Winnicott, D. WI. : The Maturational Processes and the Facilitating Environment. New York: International Universities Press, 1965. 7. Ribble, M. A.: Rights of Infants. New York:
Columbia University Press, 1943.
8. Jacobson, E. : The Self and the Object World. New York : International Universities Press,
1964.
9. Provence, S. and Lipton, R. C. : Infants in Insti-tutions. New York: International Universities
Press, 1962.
10. Lorenz, K.: Comparative behaviorologv. In: Tanner, J. M., and Inhelder, B., ed. : Discus-sions on Child Development. Volume I. New York: International Universities Press, pp. 108-117, 1953.
IS THE WEARING OF OVERSHOES DETRIMENTAL TO A CHILD’S HEALTH?
The author of the letter below, published in 1831, vehemently proscribed the use of
over-shoes as an article of clothing for children. He
wrote:
OvERSHOES FOR CHILDREN
To the Editor of the Boston Med. and Surg. Journal
Sir,-It is a subject of regret that there is so great a demand, in this part of the country, for children’s India-rubbers; and as your Journal is probably taken by every physician in New England of any distinc-tion, I am desirous of enlisting, through its pages, their influence against so pernicious a custom. Are not parents sensible that they cannot well do their children a greater unkindness, than thus cautiously to protect their feet from external dampness, and parboil them in perspiration? The feet of children
should be well bathed in the coldest water every morning throughout the year, and they should then be protected by nothing thicker, warmer, or more
impervious to water, than leather shoes. If, in wet weather, the soles of these shoes are soaked through,
no injury can come of it, if the child have never been
made tender and susceptible of cold by practice I feel it is a duty to discourage. On the contrary, he
will run and sport about more briskly, and lay the foundation of a firmer constitution, and more
vigor-ous and uniform good health.
I have noticed several families of children whose feet are thus habitually guarded, and find them look-ing puny and pale, kept at home from school oftener
l)y colds, than other children by bad walking, and in
sickness offering much less resistance to disease than those whose systems have been fortified by more
hardy management. Let a child, after three or four
years of age, be accustomed to reasonable exposure of every kind, and exercise as much as he will, and he will be better and happier in his early ears, and grow up with a vigor of health and elasticity of mind which I have seldom seen surmounting a pair of children’s India-nibbers.
Yours, most respectfully,
THE CHILDREN’S FRIEND’
The views expressed by the writer of this letter were those of John Locke ( 1632-1704)
who in his Thoughts Concerning Education,
published in 1692, had this to say about chil-dren’s feet.
I will also advise his Feet to be wash’d every Day
in cold Water, and have his Shoes so thin that they
might leak and let in Water Whenever he comes near it.
. .
NOTED By T. E. C., Jn., M.D.
REFERENCES
1. Overshoes for Children, Letter to the Editor. Boston Med. Surg. j., 4:81, 1831.
