Volume 5, Issue No.1 - January 2000
 

President's Corner:  Cultural Factors During the Perinatal Period and Infancy

The next meeting of the World Association for Infant Mental Health will take place at the end of July in the year 2000 in Montreal, Canada. This is a multi-cultural city, where there are immigrants from all over the world. One of the themes of the conference is “Diversity”. This is one of the great challenges in the field of mental health and plays an important role in the perinatal period and infancy.

There are three major areas where cultural factors are of particular importance:

1) Cultural variations in care of the mother (and family) during pregnancy, in care of the newborn and baby and in child-rearing practices.

2) Culture-bound syndromes or difficulties. That is, some manifestations of distress or difficulties are manifested in a culturally specific way, take for instance susto in Latin America, of Amae in Japan.

3) Dealing with immigrant families or groups of families, usually this means underprivileged populations moving to an industrialized country. There may be language challenges, cultural differences,  and how to provide services to these groups in a relevant and meaningful way.

These concerns may appear at first look as somewhat sophisticated and not very relevant to the work of everyday clinicians, but there are important issues that I will try to illustrate.
This issue is very important for questions of child-rearing, and I will try to refer to some of the situations that we encounter in our clinical work in the “ real world.”

--Breast Feeding. Breast feeding is practiced  fairly openly in many traditional cultures. This means that the mother in these countries may breast feed her baby on demand and in a public place. An immigrant mother may find it difficult to do, if she lives in a culture where this is considered inappropriate. For instance, in several places in the U.S. a mother is expected to go to a bathroom to breast feed her baby. The breast is considered somewhat as a sexual organ, rather than as a feeding organ. A mother may feel frustrated by those constrictions, or discouraged from doing what she would intuitively do. This also would apply to feeding the baby on demand, rather than having to follow some sort of  “schedule” of feeding her baby every three hours.

--Bottle feeding.  It appears that in several Latino cultures infants are bottle fed for a rather long period of time, compared with what is common in the U.S. We have seen this concern often in the interface between a Mexican family, for instance, and a well-intentioned health professional who is very concerned that a two-year old toddler is  “allowed” to  still bottle feed.  There are concerns about cavities and about teeth deformities.  Families continue using the bottle despite the advice to stop it.  Culturally, the family may place greater emphasis on giving the toddler something to be soothed than have concerns about cavities and continue using the bottle despite the advice. Perhaps it would be better to give the suggestion to make sure to brush the teeth rather than discontinue the bottle.

--Separations.  Recently, a health professional asked to refer a little girl who was 1 ½ years old and appeared very frightened of any separations from her mother. She felt that this was very unusual as she felt terrified when the mother was asked to join an adult group and the little girl was expected to stay in a toddler group where she had never been.  The family was of Asian origin. As it is common in many cultures, the infant had no experience of being left with strangers and had not been separated from her mother for any considerable length of time. The staff at the center had not thought about this, but later on they understood the mother’s reluctance to leave her baby crying and frightened. What they had perceived as excessive closeness, was understood better in the context of the practices in the country of origin.

--Sleeping Arrangements.  Families in perhaps three quarters of the world practice “co-sleeping” i.e. the mother sleeps in the same bed with the baby.  Mothers might feel puzzled or frustrated if advised to put the baby to sleep in his or her own bed.  They would wonder what is the purpose of that, particularly if they breast  feed during the night.  We have encountered situations in which a nurse or health care professional with the best intention tells a mother that the baby “ should “ sleep in separate bed, and that this is the standard practice. This is presented as though this was advice based on science.  Parents at times feel confused  about what to do. Their family and culture says one thing and “ science” says the opposite. This could be conceived as clash between traditional beliefs and “modern medicine”. In the case of co-sleeping there is no scientific basis for the recommendation of sleeping separately.

These are a few of the challenges that face clinicians, researchers and families in increasingly complex and multicultural societies. We invite your comments and reactions and would like to incorporate them in these pages.

--submitted by Martin Maldonado MD, President of KAIMH
 

At the December educational and business meeting of KAIMH, Dr. Marion O'Brien from the University of Kansas gave a very informative presentation on the NICHD Study of Early Child Care.  Dr. O'Brien is a co-investigator in this multi-site longitudinal study of child care and its effects on development.  For those of you who could not attend the meeting, a summary of the presentation is given below.

Approximately 1300 children in 10 locations across the U.S. were recruited at birth in 1991 to participate in the study. The sample was diverse and demographically similar to the US population but children of teen mothers and high-risk infants were not included in the sample. The Kansas sample was drawn from Lawrence and Topeka.

Data were collected when the children were 1, 6, 15,  24, and 36 months of age.  Measures used included standardized assessments of  the children's development, observations of behavior and interactions at home, the lab, and in child care settings, and questionnaires filled out by parents.  Quality of child care was determined based on 1) "regulable" characteristics such as group sizes, ratios of children to adults, and teacher training and also by 2) observations of caregiver sensitivity and responsivity.  Since this was not an experimental study, analyses of the effects of child care were designed to control for selection factors, child factors, and family factors known to affect developmental outcomes.

By six months of age, over 55 percent of the sample was receiving 10 or more hours of child care.  By 36 months, this percentage had risen to almost 75 percent.  The care across all settings tended to receive ratings of fair or good, with only 17 percent of care being rated as excellent.  When examining center-based care alone, it was found that only 9 percent of care was rated as excellent.

Both family factors (such as the quality of home environment) and child care factors (such as positive caregiving and language stimulation) consistently and significantly contributed to better cognitive and language outcomes at 36 months.  The higher the quality of the care, the better prepared the child was for school-related tasks.

In terms of social behaviors, family factors were found to be more important then child care factors. For example attachment security was more related to the quality of the home environment than to the experiences of child care.  However, children with insensitive mothers in poor quality child care had the highest risk for insecure attachment.  The quality of child care was related to having fewer problem behaviors, but child care factors only accounted for 1-3 percent of the variance in social development compared with family factors which accounted for 18-20 percent of the variance.

Child care settings that met minimum standards set by the American Academy of Pediatrics and the American Public Health Association had children with fewer behavior problems, and better social development, school readiness, and language comprehension.

Dr. O'Brien concluded that the results show that child care is not "bad" for children, that families are still the primary influence on a child's development, and that quality of care matters, especially sensitive and responsive caregiving in child care and at home.

The children in this study are currently in third grade and are still being followed.  The raw data from the first phase of the study to 36 months of age will be available January 1st in a public use data set.  Contact Dr. O'Brien for further information (mobrien@falcon.cc.ukans.edu).

--submitted by Ann Murray, Newsletter Editor
 

The next meeting (the sixth) on infant mental health, sponsored by Menninger and the Kansas Association for Infant Mental Health, will be on May 5 and 6th, 2000 here in Topeka. We have a wonderful program as follows:

     Massimo Ammaniti (University of Rome) will talk about his work on early mother-father infant relationships, shortly after birth, and psychological difficulties during pregnancy.

     Marie Rose Moro (Hopital Avicenne, Paris, and Medecines sans Frontieres) will talk about transcultural issues during the perinatal period (mother, father, infant) and working in infant mental health with immigrant families.

     Maria Ramsay (Montreal Childrens Hospital , McGill University) will talk about very early feeding difficulties in infants, and intervention approaches to feeding difficulties in infants.

There will be other people from Menninger also participating. Do plan to join us.

--submitted by Martin Maldonado, President of KAIMH
 

Alicia Lieberman is a psychologist who works in San Francisco and is in charge of a study on the effects of violence on young children at San Francisco General Hospital. She is author of numerous articles dealing with issues of attachment and with parent/ infant psychotherapy. Her book “ The Emotional Life of the Toddler” is a precious resource both for parents and professionals to understand “ from inside” the  internal life of the very young child. She is also one of the editors of the “ CASEBOOK" of  infant mental health problems published recently by Zero to Three.  Dr. Lieberman is a friend of the Kansas Association for Infant Mental Health, and has participated in our annual conference, eliciting much praise for her moving presentations on her clinical work. She is very warm and humble person, a delight to listen to and one of the main advocates for the poor and marginalized families in the area of infant mental health.

1. Who was your most influential teacher?  I actually had two teachers that were equally influential, although in very different ways.  Selma Fraiberg literally gave me my life's work. Before studying with her, I had planned to become an adult psychotherapist, but after a year of learning infant-parent psychotherapy everything else paled in comparison.  Mary Ainsworth gave me a visceral appreciation for attachment theory that is essential to the way I work.

2. Which patient has had most effect on your work?  A woman who found herself unable to feel love for the baby she was pregnant with.  As we explored her feelings, it emerged that she equated this baby with her younger brother, whose birth had enraged her because it exacerbated her parents' emotional distance from her.  The treatment of this woman made me really understand the baby's role as a transference object for the parents, and taught me that uncovering the past can lead to substantial healing in the present.  Before treating this patient, I knew these principles in theory, but I had not realized how compellingly true they can be.

3. What would be your advice to a new qualified child therapist?  First, find yourself a good supervisor so you can continue a disciplined process of learning.  Second, do not cling to theory, but open yourself to alternative formulations.  Third, be authentic; children need deep and true relationships. Fourth, don't forget to be loving.

4. What is your greatest fear?  Only my husband knows my greatest fear, and I would like to keep it that way. My second greatest fear is dying with a feeling that I have not done enough to make things better within my reach.

5. What are you currently reading?  I usually read several things at the same time, and choose what to read in the moment according to my mood. I am currently reading "St. Augustine" by Gary Wills, "The Gifts of the Jews" by Thomas Cahill, and "Daughter of Fortune" by Isabel Allende.  It is a heady mixture.

6. What is the movie that has had the most impact on you?  "1984", based on the novel by George Orwell. I saw it when I was about 12 years old, living in Paraguay during a very harsh military dictatorship, and very scared of the government.  This movie made me realize that totalitarianism was not confined to my country. It terrified me. I still carry images of this movie in my head.

7. What is your greatest regret?  I would rather keep it private out of respect for others.  My second greatest regret is feeling physically and emotionally divided between the United States, where my everyday life unfolds; Israel, my spiritual home, where I lived for 5 pivotal years and where my family of origin resides; and Paraguay, where my gut feeling of belonging still is.

8. Who is the greatest love of your life?  I have two great loves: my husband, David, and my son, Michael.  Each of them makes me feel a love so unique and different that I cannot say that one is greater than the other. I guess that my inner life is organized in pairs, given that I also said that I had two equally influential teachers... No wonder I practice dyadic psychotherapy!

--submitted by Martin Maldonado, President of KAIMH

May 5-6, 2000: 6th Infant Mental Health Conference at the Menninger Foundation. (See announcement in this newsletter).    Location:   Topeka, KS. Contact:  1-800-288-7377.

July 16-19, 2000:  XIIth Biennial International Conference on Infant Studies. Location:  Brighton Centre, Kings Road, Brighton, UK.  Contact:  icis2000@cogs.susx.ac.uk or www.isisweb.org/conf.htm or telephone: +44(0)1273 678448

July 26-30, 2000:  7th Congress of the World Association for Infant Mental Health.  Location:  Montreal, QC, Canada.  Contact:  waimh@ums1.Ian.mcgill.ca or (514) 398-3770.
 

It is time to renew your membership for KAIMH.  There will be a separate mailing with dues information.  Please also encourage others who are not on our mailing list to join using the form on the back of this newsletter.

Also, check our out web site at www.kaimh.org.  The collection of slides and the Spanish section have been greatly expanded.  If you are willing to make presentations about infant mental health issues around the state, please fill out the member survey form on the web site so that your areas of interest and expertise can be listed.  You can also email me if you have announcements for the web site or the newsletter (admurray@ksu.edu).
 
 

A recent book entitled The Myth of the First Three Years has been reported on by the news media and has created confusion about the significance of the early years. ZERO TO THREE has developed the following response to help put the book into perspective for parents, policymakers, professionals and others who care about babies and toddlers. As you will see, there is no myth about the importance of the first three years.

The Myth of the First Three Years, by John Bruer, is an attempt to redress some popular misconceptions about the importance to brain development of a child’s earliest experiences. The book is an extension of “Education and the Brain: A Bridge Too Far,” a scholarly article by Bruer that appeared in the November 1997 issue of Educational Researcher. Bruer, who is president of the James S. McDonnell Foundation, which awards $18 million annually for biomedical, educational, and international projects, has no formal training in either neuroscience or child development. But his “Bridge Too Far” article provided an astute examination of the ways in which recent findings in neuroscience have been blown out of proportion and used to imply that we know how to increase the neural connections in a child’s brain and ultimately, the child’s intelligence.  Take the so-called “Mozart effect,” for example, the notion that playing classical music, especially Mozart, will boost a child’s IQ. This idea was popularized in the press and capitalized on by entrepreneurs selling Mozart CDs for babies and parents, but it has no clear foundation in science.

However, in The Myth of the First Three Years, a book written for a popular, mass audience, Bruer crosses his own bridge and then burns it, taking his correct observation that the neuroscience of early childhood is, in a sense, in its own infancy, and leaping to the extreme conclusion that what happens to a child in the early years is of little consequence to subsequent intellectual development. He also suggests that intervening in the lives of very young children at risk for poor outcomes in school and adulthood will have little or no effect. Nothing could be further from the truth.

We are particularly concerned that readers will come away from this book confused about what babies need and what parents can do to encourage development, and that policymakers will see Bruer’s argument as an excuse to ignore the growing interest and demand for policies and services that support babies, toddlers, and their families.

The Myth of Boosting Baby’s Brain

ZERO TO THREE agrees with some of Bruer’s assertions. He is right that science has just begun to sort out how the trillions of nerve cells in a child’s brain are organized during the first three years of life to allow a child to learn to talk, read, and reason. The application of these new and exciting findings has sometimes been exaggerated, particularly by the media, or used inappropriately to make claims about what parents, educators, and policymakers should or should not be doing.

Much of the confusion centers on the notion that the first three years are a “critical period,” defined as a window of opportunity for laying down circuits in a child’s brain or learning a particular set of skills that closes irrevocably after a set amount of time. What we know from early research is that critical periods exist in children only for some very basic capacities, such as vision, and to a lesser extent for learning language. For example, it has been well-documented that young children can learn a second language much more easily—and often with better pronunciation and grammar—than can adolescents or adults.

We agree with Bruer that a child’s brain is not even close to being completely wired when the third candle on the birthday cake has been blown out. In fact, brain research suggests the opposite conclusion: Important parts of the brain are not fully developed until well past puberty, and the brain, unlike any other organ, changes throughout life. The human brain is capable of learning and laying down new circuitry until old age. But this does not mean that the first three years are unimportant.

Why the Early Years Are So Important

While scientists have so far only confirmed a few “critical periods” in the development of the human brain, there is no doubt that the first three years of life are critical to the growth of intelligence and to later success in adulthood. We know from rigorous psychological and sociological research, and from compelling clinical experience, that early childhood is a time when infants and toddlers acquire many of the motivations and skills needed to become productive, happy adults. Curiously, Bruer turns a blind eye to the immense and crucial social and emotional development that begins during a child’s first three years, which provides a foundation for continued later intellectual development.  The importance of the first three years is no myth, and parents and policymakers must not be misled by Bruer’s book.

Following are a few examples that underscore why and how a child’s intellectual development rests on social and emotional skills learned in the early years:

1. Development of Trust

Every person needs to learn to trust other human beings in order to function successfully in society. It is crucial that this sense of trust begins to grow during the earliest years. While it is certainly possible to learn this later, it becomes much more difficult the older a child gets. Years of living in an interpersonal environment that is unresponsive, untrustworthy, or unreliable is difficult to undo in later relationships. Trust grows in infancy in the everyday, ordinary interactions between the child and the significant caregivers. A baby learns to trust through the routine experiences of being fed when she is hungry, and held when she is upset or frightened. The child learns that her needs will be met, that she matters, that someone will comfort her, feed her, and keep her warm and safe.  She feels good about herself and about others.

Children whose basic needs are not met in infancy and early childhood often lack that sense of trust, and have difficulty learning to believe in themselves or in others. We know this from a multitude of scientific studies, including the research of Alan Sroufe and Byron Egeland, at the University of Minnesota. In a long-term study that followed infants through toddlerhood and into adulthood, Sroufe and his colleagues found that when children were reared within relationships they could count on, they had fewer behavior problems in school, had more confidence, and were emotionally more capable of positive social relationships.

2. Development of Self-Control

From the time a child begins to walk, we can see the progress she is making in mastering an important skill: self-control. Babies do not come into the world knowing that nobody likes it
when they bite and hit, or grab toys and food from them; they need help from adults to understand that these impulses are not socially acceptable. John Gottman, of the University of
Washington, among others, has demonstrated that children who get no help monitoring or regulating their behavior during the early years, especially before the age of three, have a greater
chance of being anxious, frightened, impulsive, and behaviorally disorganized when they reach school. Further, these children are more likely to rely on more violent or other intimidating means to resolve conflicts than their peers who have successfully begun the long process of learning self-control.

3. The Source of Motivation

Another pillar of intellectual development and success in school is motivation. Infants and toddlers develop this through day-to-day interactions with responsive caregivers. Responding to
the needs of the child is a powerful process that builds confidence and an inner sense of curiosity. This motivates the child to learn and has direct effects on success in school. The more confident a child is, the more likely she is to take on new challenges with enthusiasm.

The Emotional Foundations of Learning

Trust, self-control, and motivation form the bedrock of a child’s intellectual development. Intelligence and achievement in school do not depend solely on a young child’s fund of factual knowledge, ability to read or recite the alphabet, or familiarity with numbers or colors. Rather, in addition to such knowledge and skills, success rests on children, of whatever background, coming to school curious, confident, and aware of what behavior is expected. Successful children are comfortable seeking assistance, able to get along with others, and interested in using their knowledge and experience to master new challenges.
Bruer is right that there is no magic bullet for making kids smart. But by erroneously focusing exclusively on intellectual achievement, he fails to recognize that all aspects of development affect one another, and that children cannot learn or display their intelligence as well if they have not developed emotionally and socially. The task for parents and other caregivers who want their children to succeed in school is not to force development. Rather, it is to try to ensure that the moment-to-moment events of daily life give babies and toddlers the sense of security, encouragement, and confidence that are the foundation of emotional health. It is this that will ultimately allow them to learn at home, in school and throughout life.

Dangers of the Book

We are concerned that readers will draw the wrong conclusions. Many parents are likely to be confused by Bruer’s message, which contradicts what they may know instinctively about the importance of the first three years. The book may let other parents off the hook—particularly those parents who aren’t willing or able to devote the time and attention that is needed to provide a nurturing environment for babies and toddlers.

Moreover, some parents will be offended by Bruer’s assertion that “mothers who behave in acceptable American middle-class fashion tend to have securely attached children. The challenge is to get more non-complying, mostly minority and disadvantaged, mothers to act in this way.” We know that there are plenty of poor, minority parents doing a marvelous job of raising their children in securely attached relationships. Whether by design or accident, Bruer stigmatizes minority racial and ethnic groups by defining them as the exception to the rule. And just what is “acceptable American middle-class” parenting? We know of no such thing as a homogeneous approach to parenting and attachment.

Policymakers may come away from Bruer’s book with the misconception that efforts to help young children are a waste of money and time. Indeed, it appears that this may be Bruer’s intent. For example, he attacks the very modest funding provided for such programs as Early Head Start, a desperately needed initiative that is a drop in the bucket relative to other government programs. Early Head Start was conceived on the basis of ample evidence for the value of early intervention—evidence that was gathered long before the hoopla began over neuroscience, but that Bruer conveniently omits from his book.
Pioneering work done in the 1970s by Sally Provence, at the Child Study Center at Yale University provides just one example. Over a period of several years, Provence studied two groups of families with young children who were at risk for poor outcomes in school and adulthood. One group was offered free medical care and high quality day care, which included help in learning to be more responsive parents. The other group received no assistance. Provence found that when the children of both groups reached school age, those who received help missed far less school than the others, were able to learn and retain information more easily, and were more motivated. Their families had fewer children and the births were spaced farther apart.

Efforts to help all children achieve the basic skills of trust, motivation, and self-control needed for later intellectual and emotional development should not be aimed at creating super-babies, or giving anxious parents one more thing to worry about, or overambitious parents one more reason to push their children. Our aim should be to ensure that all children reach school age with a solid foundation for learning and relating to others, and that all parents know what they can do to help their children develop. In the last decade, the United States has made important progress in recognizing the needs of young children. Businesses have made efforts to create family-friendly policies. Government has made efforts to provide services to families. Parents are increasingly interested in how best to encourage and prepare their children. Taking to heart many of the negative messages of The Myth of the First Three Years can only set back those efforts. Our nation’s youngest citizens deserve better.

(ZERO TO THREE is a national non-profit organization founded more than 20 years ago by leading pediatricians, researchers, and child development specialists to share new knowledge on how children develop in the early years. ZERO TO THREE focuses on the first three years of life because this is the time of greatest human growth and development. The organization’s award-winning web site—cited by Newsweek magazine and The New York Times as an excellent resource for parents—is located at:  zerotothree.org)
 

For more information about the Kansas Association for Infant Mental Health, e-mail or call (785)532-1492.
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