Monthly Archives: November 2012

Infant Parent Mental Health Weekend: Murray and Cooper

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Part I

The last weekend in the IPMH fellowship, we were treated to researchers on postnatal depression (PND) from the U.K., Lynne Murray  and Peter Cooper. In this summary, I cannot do justice to the rich presentation and discussions that followed. What I will do instead is to note some of the main points and then illustrate them with descriptions of some of the wonderful film examples Lynne and Peter showed us. At the end I will include references to some of the studies so that those who are interested may read about the research in greater detail. http://www.reading.ac.uk/pcls/people/lynne-murray.aspx

On Friday, Lynne Murray lectured on the effects of PND on the child. She pointed out that PND occurs at a time when the infant is maximally dependent on the mother and also highly sensitive to the caregiver’s communications. Depression influences the communications that the caregiver gives the baby. The baby picks up for example whether the caregiver’s eyes are open or closed, whether her gaze is direct or indirect. By 8 weeks old, the baby is ready for “proto-conversations” – a variety of gestures and expressions that indicate the baby’s affect and intention and that demand contingent responses to maintain engagement. 

When a mother is clinically depressed, she may fall into two broad patterns of insensitivity, either remoteness and disengagement, or hostility and intrusiveness, and in turn the infants may avoid contact and become depressed themselves. Boys are more vulnerable, perhaps because they intrinsically tend to need more support. 

Murray showed a film of the first pattern of interaction with a depressed mother and her 12-week old baby. The mother says to her baby, “Oh, poor baby! I feel so sorry for you sitting there (in an infant seat) all by yourself! You’re struggling to get out!” In this example, the mother seems to perceive her baby as feeling as trapped as she herself might feel. Perhaps because she is weighted down by her own negative affect state, the mother cannot respond to the baby’s cues of widening eyes and open mouth, and so the baby gives up and withdraws. Naturally, the mother gets discouraged. A cycle gets going in which mother and baby both feel helpless. 

In a film exemplifying the second pattern, the mother seems a little speeded up and anxious. She behaves in an pushy manner and cannot seem to sit back and attend to the baby’s cues. As the baby pulls away, the mother pushes forward. The mother changes the play agenda all the time; she decides the baby is fed up with a toy without any evidence from the baby’s behavior, and she takes it away, abruptly substituting another. This interaction also ends up in a discouraging experience for both mother and baby.

Two experimental paradigms demonstrate the effect on the baby of an interruption of maternal responsiveness. The first is Ed Tronick’s still face procedure in which the mother is instructed to interrupt her play with her baby and become unresponsive for a period of 1-2 minutes; the babies in these experiments are powerfully affected by the loss of their mother’s responsiveness. The second is a study by Lynne Murray that illuminated the refinement of the contingency response pattern between young infants and their mothers (Murray & Trevarthen, 1985). When babies were shown their mothers’ images on a television screen as the mothers were reacting to them in real time, the babies responded to them as if they were their interactive partners. Then when the mothers’ images were played back to them with the timing manipulated so that there was no contingency with the babies’ gestures (same mother, same baby, but gestures played back a little later than they were made), the babies’ gaze dropped off, the smiling stopped, and the baby became confused and distressed. 

What are the ways that non-depressed mothers behave that support their babies’ psychological growth and development? The mother of a 3-month old facilitates the baby’s attention by closely monitoring the baby’s expressions to maintain the baby’s attention on an object, varying the experience enough to keep the baby’s interest. This is difficult for a depressed mother to do because she has difficulty picking up the baby’s cues. The non-depressed mother will also facilitate the baby’s potential by holding the toy at the right distance and keep the baby in the right position so that the baby can get the maximum benefit out of the toy. The non-depressed mother of a 12-month old will for example pick up toys to make them available to the child – indicating what the baby can do with it without taking over, steadying the toy so that the baby can achieve his own goals. In an example of a non-depressed mother sharing a book with her baby, the mother put her thumb under the page so that the baby could more easily turn the page himself. 

Both the general patterns displayed by PND mothers – without intervention – can end up in persisting interaction difficulties, and in different kinds of negative outcomes in the developing child. Examples of these outcomes are a depression in IQ and school achievement, behavior regulation problems in childhood, and depressive disorders in childhood (Murray et al, 2010).

References:

Murray L & Trevarthen C (1985). Emotional regulation of interactions between two-month olds and their mothers, In T A Field & N A Fox, Social Perception in Infants, Norwood, N.J., Ablex Publishers, pp. 177-197.

Murray J (2010). The effects of maternal postnatal depression and child sex on academic performance at age 16 years: A developmental approach, Child Psychol & Psychiat, 51(10):1150-1159.

 Photo – Joshua Sparrow, M.D., Nov. 2012 

Read this blog in Spanish.

 

 

 

Growing Flexibility in Your Older Child

 

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A while ago the mother of a 9-year old girl told me a story about going to the bookstore with her daughter to buy her a book in a series that the girl – we will call her Josie – loved. They had planned this happy errand ahead of time, and they both were looking forward to it. 

Josie loved to read and could really get lost in a book. She sometimes used books as a refuge when life got hard, for example when she felt slighted or excluded by friends at school, especially at recess. Although her classmates could actually be critical or rejecting, it was also true that Josie lacked some of the flexibility that allows children to brush off casual meanness or to not take something personally. It was not exactly that Josie could not “pick up social cues”, because she could imitate for me with remarkable astuteness the body language of girls on the playground who turned their backs and circled the wagons as she approached.  She even “understood” that sometimes friends had private communication that derived its value from belonging to those girls alone and could not be shared – at least not at the moment. But her feelings would be hurt, and she would get stuck on the unfairness of it all. Then she would either tell the teacher, which would not gain her points in the playground society, or she would isolate herself in a book, reading in a corner of the school yard. Of course, this broke her mother’s heart, and mine too. 

In the bookstore, on the way to the display table featuring this new book, Josie spied a large glossy nonfiction volume about dog breeds. Grasping it up and clutching it to her chest, she begged her mother to buy it for her. Josie’s mother was taken off guard. She tried to reason with Josie – “Josie, don’t you want the new book in the series?” She checked the price of the dog book and determined that it was, as she had expected, quite expensive. “No,” Josie responded with emotion, “I want this, Mom. Please get it for me! This is what I want!”  Josie’s mother suggested that they first go take a look at the display table with the new book, but Josie took this as a rejection and stamped her foot, refusing to budge. “This is what I want, and if I can’t have this, I don’t want anything!” 

Josie’s mother had that sinking feeling that she sometimes gets when she and Josie are at odds with each other. Why couldn’t Josie be reasonable and see that she was changing course mid-stream? Why did she have to take their lovely plan for an afternoon together and turn it into another sad fight?  For her part, Josie (as she told me later) was thinking, “Doesn’t my mom want me to have something that I really want? Does she only want me to have something that she picks out for me? I could learn all about dog breeds from this book! Maybe I will start a dog breeding business, and this book could be the inspiration for a great enterprise! My mom just doesn’t listen to me.” 

In fact, Josie’s mom tried again to persuade Josie to be reasonable about checking out the new book, and Josie dug in even deeper. Finally, they left the store without any book at all, both miserable. Josie’s mom asked me what suggestion I could give her about how to avoid this unhappy stand off in the future. 

I thought of the blog posting I had just written about growing flexibility in younger children and wondered how some of those ideas could be applied to a child Josie’s age. It is usually harder to work on something like this with an older child. One reason is that a 9-year old having a tantrum in a public place is more humiliating for a mother than is the case with a 4-year old. Also, you can’t pick up a 9-year old and carry her to the car. 

Another important underlying reason is that a 9-year old has repeated this unfortunate pattern with you thousands of more times than the 4-year old has had time in his shorter life to do, and the pattern is more established, easier to slip into. Remember the metaphor of rain on a flat plain (Granic & Patterson, 2006). (This excellent article has “antisocial” in the title, but it includes general principles of family development that apply to all families and kids.) At first the raindrops fall randomly on the flat surface, but then some of them happen to fall near one another and a little depression forms in the dirt. After that, the depression draws more raindrops into it because it is downhill, and before long a rivulet of water is formed. Decades later the rivulet may have turned into a river. Whereas the 4-year old may be at the rivulet stage, the 9-year old may be at the stage of a small stream. It is easier to make a pile of dirt to dam the rivulet than it is to divert a stream. 

Yet another reason is that the 9-year old hasn’t had the benefit of all the time to practice flexible reactions that the 4-year old will have had if he begins to learn them at 4. She has been working with methods that don’t serve her well all this time, and that has taken a toll on her whole repertoire of skills for getting along in the world. A crude analogy is that sometimes when you injure your foot, you adjust your walk to minimize the pain of stepping on the sore foot and in the process put strain your back, causing back pain, and that can cause you to stiffen your neck, giving you a headache, etc. 

But take heart! 9-years old is not too late! Let’s think about what Josie’s mother might do to help things turn out differently next time.  First of all, in the example of the 4-year old I stressed the child’s state of regulation. Here I would also like to stress the mother’s state. Remember that she and Josie had set out to have a fun time together, so when Josie abruptly went off course, she too felt disrupted. Her next reaction was to anticipate the inevitability of a standoff. With this unhappy thought in her mind, she experienced disappointment, frustration, even a sense of loss. She must also have felt controlled by Josie, even though she was actually in the grips of a pattern that she and her daughter had created together. So the first step is to attend to her own state (remember the admonition in the airplane to put the oxygen mask on yourself first and then put it on your child). She can try to calm herself, recognize the pattern and tell herself that it doesn’t have to turn out that way this time. Sometimes I tell parents to “channel” me, because I want them to feel less alone in this situation.

Next, she can try to imagine Josie’s mind. To do that, she can approach Josie in a similar way to the boy in the 4-year old example. She might say something like, “Oh, let me see that (dog breeding) book! That looks so neat! You know, I think the idea of breeding dogs is amazing. It makes me happy just to think of it.” (Here she would be matching Josie’s emotional state in addition to her intention.). Then she might say, “Bring that book with you, and let’s go see the other book too. Then we can consider all of our options!” I use the word “our” instead of “your” here, because it softens the idea of the choice that is coming up, emphasizing that Josie will not have to make a difficult choice alone. Josie’s mother will also have to slow down. You cannot rush through this kind of process. She will have to be willing to let Josie look at both books at the same time, flip through the pages of each, imagine what it would be like to be the proud owner of a book about dog breeds and what it would be like to enter the fantasy world of the series book. It will be hard, but with her mother’s help, next time she may be prepared to let go of one cherished (even if unrealistic) idea in order to choose another more realistic alternative. She will be building agency (the sense of being able to choose effectively) as well as flexibility.

Of course, it might not work. Remember the metaphor of the stream. You can throw rocks in the way of a rushing stream, but one or two will not stop the flow. You have to do it again and again. But it can be done. Next time, I will consider building flexibility in your adolescent! 

Granic, I & Patterson, G (2006). Toward a comprehensive model of antisocial development: a dynamic systems approach, Psychological Review, 113 (1) 101-131.