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Data from a multi-method, longitudinal study involving a community sample (N = 120) of pregnant women aged 18–42 were used to examine disrupted maternal representations of the child as a mechanism ...

The development of maternal representations of the child during pregnancy guides a mother’s thoughts, feelings, and behavior toward her child. The association between prenatal representations, particularly those that are disrupted, and toddler social-emotional functioning is not well understood. The present study examined associations between disrupted prenatal representations and toddler social-emotional functioning and to test disrupted maternal behavior as a mediator of this association. Data were drawn from 109 women from a larger prospective longitudinal study (N=120) of women and their young children. Prenatal disrupted maternal representations were assessed using the Working Model of the Child Interview disrupted coding scheme, while disrupted maternal behavior was coded 12-months postpartum from mother-infant interactions. Mother-reported toddler social-emotional functioning was assessed at ages 12 and 24 months. Disrupted prenatal representations significantly predicted poorer toddler social-emotional functioning at 24 months, controlling for functioning at 12 months. Further, disrupted maternal behavior mediated the relation between disrupted prenatal representations and toddler social-emotional problems. Screening for disrupted representations during pregnancy is needed to facilitate referrals to early intervention and decrease the likelihood of toddler social-emotional problems.

This chapter begins by describing the approach used in the Taming Sneaky Fears program to explain the abstract concept of cognitive distortions to four- to seven-year-old children, i.e., by externalizing anxiety (calling it Sneaky Fears) and by referring to the Tricks (or cognitive distortions) that Sneaky Fears play (Not Telling the Truth, Exaggerating, and Only Showing the Bad Things). It describes how cognitive coping strategies traditionally used with older children are adapted to accommodate the cognitive abilities of four- to seven-year-old children, i.e., by learning How to Be the Boss of My Brain and using the Stop sign and the Trick Stoppers (Ignore Sneaky Fears, Think Brave Thoughts, and Talk to an Adult). The chapter provides step-by-step guidelines on how to communicate these abstract concepts and cognitive coping strategies to four- to seven-year-old children and their parents in one parent session (P-Session 2) and two child sessions (C-Sessions 3 and 4).

This chapter offers a historical timeline of the various phases of development and refinement of the Taming Sneaky Fears program, a group Cognitive Behavior Therapy program developed specifically for four- to seven-year-old children diagnosed with an anxiety disorder, and their parents. The chapter describes the development of the parent and child components of the Taming Sneaky Fears program. It summarizes the various research endeavors and the research evidence documenting the efficacy of the Taming Sneaky Fears program in the treatment of various anxiety disorders, including social anxiety disorder and selective mutism, in four- to seven-year-old children. The chapter proposes future directions for research to further refine the Taming Sneaky Fears program.

This chapter provides an overview of anxiety disorders in young children. It discusses the concept of anxiety versus anxiety disorder and describes classification and associated features of the different anxiety disorders commonly seen in young children. The chapter presents information on epidemiology of anxiety disorders in young children, as well as evidence for the comorbidity of anxiety disorders with other anxiety and non-anxiety disorders, with a special emphasis on the comorbidity between selective mutism and social anxiety disorder. Given that few data are available to document prevalence rates of anxiety disorders in four- to seven-year-old children, the chapter summarizes the evidence in children of all ages with anxiety disorders and provides specific information pertaining to four- to seven-year-old anxious children whenever such data are available. The chapter also reviews the etiological risk factors for the development of anxiety disorders, with a special emphasis on selective mutism.

This chapter describes intervention and management programs for which empirical evidence is available to treat four- to seven-year-old children with anxiety disorders, excluding the Taming Sneaky Fears program, which is described at length in subsequent chapters. The primary focus of intervention in most of extant treatment studies is on the caregivers of young anxious children and/or dyadic approaches involving the young anxious children and their caregivers. The chapter reports on the somewhat limited empirical evidence supporting these approaches and highlights their strengths and shortcomings. A special emphasis is placed on interventions that focus on the management of selective mutism and social anxiety disorder in four- to seven-year-old children. Finally, the chapter offers suggestions for further empirical exploration.

This chapter emphasizes the pivotal role that parents play in the success of the Taming Sneaky Fears program with young children. It describes how child group therapists provide and seek feedback on each child’s progress during a brief meeting with each child’s parents at the mid-point in the Taming Sneaky Fears program, i.e., immediately following Session 4 or immediately prior to the start of Session 5. It focuses on parental strategies for managing struggles with oppositional and non-compliant behavior, bedtime, and nighttime waking that young anxious children often display (foci of parent sessions (P-Sessions) 4 and 5). It offers a rationale for providing three review sessions for parents (P-Sessions 5–8), as well as step-by-step instructions for implementing these sessions. Finally, the chapter provides step-by-step guidelines for implementing the last, ‘graduation’ session for both parents and children (P-Session 8 and C-Session 8).

This chapter provides an overview and rationale for using the concepts of feeling recognition and management early in the Taming Sneaky Fears program, i.e., during one parent session (P-Session 1) and three child sessions (C-Sessions 1, 2, and 5). It offers detailed, step-by-step guidelines on how to implement these sessions and teach four- to seven-year-old children and their parents: (1) feeling recognition (or How to Be a Feeling Catcher by doing a Body Scan in P-Session 1 and C-Sessions 1 and 2 and by using the Feeling Thermometer in P-Session 1 and C-Session 5); and (2) relaxation strategies (or How to Be the Boss of My Body by using Spaghetti Arms and Toes in P-Session 1 and C-Session 1 and Balloon Breathing and Imagery in P-Session 1 and C-Session 2). The chapter suggests adaptations for four- to seven-year-old children with selective mutism and social anxiety disorder and their parents.

This chapter describes five new screening and assessment tools developed or refined by our group to assist clinicians and researchers working with four- to seven-year-old anxious children. The Preschool Screen for Child Anxiety Related Emotional Disorders (Pre-SCARED) is a parent report to screen and identify anxiety symptoms in four- to seven-year-old children that is derived from the Screen for Child Anxiety Related Emotional Disorders (SCARED). The Mutism Accommodation Scale is another parent report questionnaire that assesses the degree to which parents could unintentionally accommodate their children’s mutism. The chapter also describes three new clinician-administered tools our group created to help clinicians and researchers distinguish between selective mutism and social anxiety disorder in four-to seven-year-old children: the Talking Behavior Assessment Tool, the Selective Mutism Versus Social Anxiety Disorder Criteria Checklist, and the Steps to Talking. The chapter presents the currently available research evidence in support of these screening and assessment tools, including psychometric properties of the instruments where available.

This chapter describes the theoretical framework, requirements for implementation, and overview of the Taming Sneaky Fears program. It discusses adaptations of traditional Cognitive Behavior Therapy concepts and strategies to accommodate the cognitive abilities of four- to seven-year-olds. Feeling recognition becomes How to Be a Feeling Catcher with the Body Scan and Feeling Thermometer; progressive muscle relaxation and diaphragmatic breathing become How to Be the Boss of My Body with Spaghetti Arms and Toes and Balloon Breathing (with Imagery as an additional relaxation strategy); anxiety is externalized as Sneaky Fears; cognitive distortions become Tricks that Sneaky Fears play (children learn How to Be a Trick Catcher and catch those Tricks: Not Telling the Truth, Exaggerating, and Only Showing the Bad Things); cognitive coping strategies become How to Be the Boss of My Brain with the Stop sign and Trick Stoppers (Ignore Sneaky Fears, Think Brave Thoughts, and Talk to an Adult); and progressive desensitization becomes How to Climb Bravery Ladders.

This chapter focuses on how clinicians and researchers can help parents of four- to seven-year-old children advocate for daycare and school supports. It offers suggestions on how clinicians and researchers can work with daycare and school professionals to support young children with anxiety disorders and their parents. It emphasizes that although all young children with anxiety disorders can benefit from strong support from professionals working in daycare and school settings, those with separation anxiety disorder, selective mutism, and social anxiety disorder may especially benefit. The chapter provides suggestions for the type of information and training clinicians and researchers might provide to daycare and school professionals to equip them with the necessary knowledge and skills to help young anxious children and their parents implement within the daycare or classroom setting the strategies they learn in the Taming Sneaky Fears program. The chapter also provides suggestions on how to engage and support daycare and school professionals while they implement Bravery Ladders within daycare, classroom, or school settings.

This chapter describes how the Taming Sneaky Fears program explains to four- to seven-year-old children and their parents the abstract concept of progressive desensitization or gradual exposure (i.e., How to Climb Bravery Ladders to overcome fears). The concept is discussed with parents in one parent session (P-Session 3) and reviewed extensively in subsequent parent sessions while it is described to the children in two child sessions (C-Sessions 6 and 7). The chapter proposes specific adaptations for selective mutism and social anxiety disorder and emphasizes the usefulness of Bravery Ladders when working with young children with these disorders. The chapter also reviews the approach presented to parents (P-Session 3) on the management of excessive worries in young children.

This chapter provides a description of screening and assessment tools that researchers have used with four- to seven-year-old children who present with various anxiety symptoms. The chapter summarizes the psychometric properties, advantages, and limitations of these instruments. It highlights the need to use some of the instruments described in this chapter with caution with young children in clinical settings due to the somewhat limited empirical evidence to justify their use. The chapter emphasizes the importance of assessing anxiety symptoms in four- to seven-year-old children using age-appropriate interviews and tools, with a special focus on the current assessment approaches that pertain to selective mutism and social anxiety disorder. The chapter highlights the need for further empirical exploration of age-appropriate screening and assessment tools of anxiety symptoms in young children.

The prototype hypothesis suggests that attachment representations derived in infancy continue to influence subsequent relationships over the life span, including those formed with one's own children. In the current study, we test the prototype hypothesis by exploring (a) whether child-specific representations following actual experience in interaction with a specific child impacts caregiver-child attachment over and above the prenatal forecast of that representation and (b) whether maternal attachment representations exert their influence on infant attachment via the more child-specific representation of that relationship. In a longitudinal study of 84 mother-infant dyads, mothers' representations of their attachment history were obtained prenatally with the Adult Attachment Interview (AAI; M. Main, R. Goldwyn, & E. Hesse, 2002), representations of relationship with a specific child were assessed with the Working Model of the Child Interview (WMCI; C.H. Zeanah, D. Benoit, & L. Barton, 1986), collected both prenatally and again at infant age 11 months, and infant attachment was assessed in the Strange Situation Procedure (M.D.S. Ainsworth, M.C. Blehar, E. Walters, & S. Wall, 1978) when infants were 11 months of age. Consistent with the prototype hypothesis, considerable correspondence was found between mothers' AAI and WMCI classifications. A mediation analysis showed that WMCI fully accounted for the association between AAI and infant attachment. Postnatal WMCI measured at 11 months' postpartum did not add to the prediction of infant attachment, over and above that explained by the prenatal WMCI. Implications for these findings are discussed.

We explored the relation between maternal mind-mindedness (i.e., a mother's tendency to verbally refer to her infant's mental world through use of infant-directed mental state terms) and maternal attachment. Mothers (N = 76), classified prenatally as Autonomous, Dismissing, Preoccupied, and Unresolved using the Adult Attachment Interview (AAI), simulated speaking to their 6-month-old infants in positive and negative emotion contexts. Mothers' utterances were coded for frequency of use of emotion and cognition-related mind-minded terms. Results indicated a significant negative relation between coherence of mind scores on the AAI and emotion mind-mindedness in the positive emotion context. When differences between insecure attachment categories and mind-mindedness were explored, results indicated that mothers with Preoccupied attachments were significantly more likely to use emotion-related terms than mothers with Dismissing attachments and that these differences were most pronounced in the negative emotion context. A similar pattern was found for mothers with Unresolved attachments compared to those with organized (Autonomous, Dismissing, Preoccupied) attachment classifications, however use of emotion mind-minded terms did not differ by emotional context. Future research directions highlighting the importance of exploring the unique contribution of Preoccupied, Dismissing and Unresolved attachment and emotional context in the exploration of mind-mindedness are discussed.

The present study is a reanalysis of a preexisting study examining the usefulness of the Atypical Maternal Behavior Instrument for Assessment and Classification (AMBIANCE; Bronfman, Parsons, & Lyons-Ruth, 1999) measure as an indicator of efficacy in reducing disrupted caregiver behavior in two brief interventions. The current study examines the rate of change in the display of disrupted caregiver behavior over the course of an attachment-based intervention (Modified Interaction Guidance) in a group of 11 caregiver-infant dyads referred to a tertiary care clinic for feeding problems. The AMBIANCE was utilized as an indicator of change in disrupted behavior following an assessment feedback session and three intervention sessions. Results showed a significant decrease in the total display of disrupted caregiver behaviors, as well as a change in classification from disrupted to not-disrupted, after receiving both feedback from the assessment and the first treatment session. A qualitative analysis of the data further revealed different patterns of change between caregivers. These findings provide preliminary empirical support suggesting that a reduction of disrupted caregiver behavior can be observed relatively quickly after the commencement of the Modified Interaction Guidance intervention.

Infant disorganized attachment is a significant predictor for later psychopathology. The Working Model of the Child Interview (WMCI; C.H. Zeanah, D. Benoit, & M.L. Barton, 1986) elicits and classifies caregivers' perceptions and subjective experience of their child and relationship with the child, which are related to concurrent and future attachment to the caregiver. However, when the WMCI was first developed, the disorganized attachment classification had not been fully developed, so the original WMCI did not include a classification that is linked to disorganized attachment. We adapted the WMCI coding scheme to include items similar to those identified by K. Lyons-Ruth, E. Bronfman, and E. Parsons (using the Atypical Maternal Behavior Instrument for Assessment and Classification, or AMBIANCE, 1999), which reflect disrupted caregiver behaviors associated with disorganized attachment. This resulted in a new WMCI-Disrupted (WMCI-D) scale and classification, disrupted. WMCI-D was used to code 35 WMCIs administered prenatally. A prenatal disrupted classification was significantly associated with caregiver unresolved classification on the Adult Attachment Interview (M. Main, N. Kaplan, & J. Cassidy, 1985), infant disorganized Strange Situation classification (M.D.S. Ainsworth, M.C. Blehar, E. Waters, & S. Wall, 1978), and disrupted caregiver behaviors toward the infant (using AMBIANCE; K. Lyons-Ruth et al., 1999), at infant age 12 months. These data suggest WMCI-D can capture disrupted caregiver internal representations, and identify dyads at risk for disorganized attachment and caregivers with unresolved mourning/trauma. These data also provide evidence for the convergent and predictive validity of the WMCI-D Scale.

The aim of the current study was to increase understanding of how victimization history impacts the longitudinal course of depression and anxiety in a sample of 55 adolescents emerging into parenthood. Adolescents were interviewed about their victimization experiences during their second trimester of pregnancy, and interviews were subsequently classified according the Maltreatment Classification Scale (Barnett, Manly, & Cicchetti, 1993). Adolescents reported on their symptoms of depression and anxiety prenatally and 6 and 12 months postpartum. Growth curve modeling revealed that, on average, there was a steady linear decline in depression and anxiety symptoms across the transition to parenthood, with a rate of change of 25% and 20%, respectively, from the prenatal assessment to 12 months postpartum. Sexual abuse history attenuated the likelihood of a decrease in depressive symptoms over time. Neglect history was associated with higher prenatal levels of anxiety, as well as a steeper decline in anxiety symptoms over time. Future research is needed to determine the role of poly-victimization in predicting the onset and change of depression and anxiety symptoms. Findings from the current study have the potential to aid in the design of preventative and intervention efforts to reduce risks of mental health difficulties in adolescent parents.

The present study assessed the stability of atypical caregiver behaviors over six years. The sample included 81 mother-child dyads (27 children with cystic fibrosis, 27 with congenital heart disease, and 27 healthy controls). Attachment was assessed using the Strange Situation paradigm when the child was one year old. Atypical caregiver behaviors were assessed in the Strange Situation paradigm at one year and again in a reunion episode at seven years of age using the Atypical Maternal Behavior Instrument for Assessment and Classification (AMBIANCE). Stability of atypical caregiver behaviors over six years was established. Atypical caregiver behaviors assessed when the child was one year old were related to infant-caregiver disorganized attachment and were not associated with secure infant-caregiver attachment. The current study identifies that atypical caregiver behaviors remain stable over time which suggests that they could be targeted during interventions aimed at preventing or treating disorganized child-caregiver attachment relationships and associated negative outcomes.

Atypical maternal behavior has consistently been identified as a precursor of disorganized infant-mother attachment, but to date, no research has examined the role of atypical paternal behavior in the development of disorganized infant-father attachment. This study aims to enhance our understanding and conceptualization of infant-father attachment by examining the role of fathers' unresolved states of mind and the display of atypical paternal behavior in the development of disorganized infant-father attachment. Thirty-one middle-class couples participated in this study. Maternal and paternal Adult Attachment Interviews (C. George, N. Kaplan, & M. Main, 1996) were completed prenatally and at infant age 6 months, respectively. Infant-mother and infant-father dyads participated in the Strange Situation paradigm (M. Ainsworth, M. Blehar, E. Waters, & S. Wall, 1978) when the infants were 12 and 18 months of age, respectively. The Atypical Maternal Behavior Instrument for Assessment and Classification (E. Bronfman, E. Parsons, & K. Lyons-Ruth, 1999) was used to assess maternal and paternal behavior during the Strange Situation. Maternal states of mind regarding attachment predicted infant-mother attachment relationships, and paternal states of mind predicted infant-father attachment relationships. Atypical maternal behavior was associated with infant-mother disorganized attachment; however, atypical paternal behavior did not predict infant-father disorganized attachment. Thus, it is possible that other factors, yet to be uncovered, might contribute to the development of infant-father disorganized attachment.

The prototype hypothesis suggests that attachment representations derived in infancy continue to influence subsequent relationships over the life span, including those formed with one's own children. In the current study, we test the prototype hypothesis by exploring (a) whether child-specific representations following actual experience in interaction with a specific child impacts caregiver-child attachment over and above the prenatal forecast of that representation and (b) whether maternal attachment representations exert their influence on infant attachment via the more child-specific representation of that relationship. In a longitudinal study of 84 mother-infant dyads, mothers' representations of their attachment history were obtained prenatally with the Adult Attachment Interview (AAI; M. Main, R. Goldwyn,E. Hesse, 2002), representations of relationship with a specific child were assessed with the Working Model of the Child Interview (WMCI; C.H. Zeanah, D. Benoit,L. Barton, 1986), collected both prenatally and again at infant age 11 months, and infant attachment was assessed in the Strange Situation Procedure (M.D.S. Ainsworth, M.C. Blehar, E. Walters,S. Wall, 1978) when infants were 11 months of age. Consistent with the prototype hypothesis, considerable correspondence was found between mothers' AAI and WMCI classifications. A mediation analysis showed that WMCI fully accounted for the association between AAI and infant attachment. Postnatal WMCI measured at 11 months' postpartum did not add to the prediction of infant attachment, over and above that explained by the prenatal WMCI. Implications for these findings are discussed.

The Working Model of the Child Interview (WMCI; C.H. Zeanah, D. Benoit,M.L.Barton, 1986) assesses caregiver internal representation of his or her child and the relationship with the child, with a relatively new coding system for representations associated with disorganized attachment-WMCI-Disrupted (WMCI-D; A. CrawfordD. Benoit, 2009). In the present study, we investigated the stability of the WMCI-D classification using a sample of 62 mothers who completed the WMCI twice as part of their involvement in a randomized trial comparing an attachment-focused parent group to home visiting. Demographic information and measures of maternal sensitivity, parenting stress, and infant attachment also were obtained in the randomized trial. There was significant concordance between WMCI-D classifications over 8 months (from pretest to follow-up) (90% agreement; κ = .79), with 61% of mothers remaining disrupted, 29% remaining not-disrupted, 8% becoming disrupted, and 2% becoming not-disrupted. Compared to mothers with not-disrupted representations, mothers classified as disrupted had lower socioeconomic status, more parenting stress, and infants with less attachment security, ps.05. These results suggest that the WMCI-D classification is stable over 8 months during infancy. The findings are consistent with research demonstrating stability for disorganized/unresolved/disrupted classifications, the validity of the WMCI-D classification, and the lack of intervention impact on disorganized attachment.

Pregnant adolescents are a group at high risk for exposure to traumatic experiences. The present study aimed to examine if Trauma-Focused Cognitive Behavior Therapy (TF-CBT) typically applied to Posttraumatic Stress Disorder (PTSD), could also be applied to unresolved states of mind in a sample of socially at-risk pregnant adolescents. Forty-three adolescents who were in their second trimester of pregnancy and who also had positive indices of unresolved states of mind or symptoms of PTSD were randomly assigned to either the treatment as usual (parenting classes) or intervention (parenting classes + TF-CBT) group. Adolescent mother-infant dyads were then re-assessed at infant ages 6 and 12 months on a broad range of measures, including those specific to attachment, as well as to PTSD, and adolescent behavioral adjustment. Twenty-six of the 43 (60%) recruited subjects completed all components of the study protocol. Although there were no significant effects of the TF-CBT intervention on maternal attachment, infant attachment, PTSD diagnosis and adolescent behavioral adjustment, several study limitations restrict our ability to draw firm conclusions about the efficacy of TF-CBT for use in pregnant adolescents with complex trauma. The discussion offers insight and guidance for clinical work and future intervention research efforts with this vulnerable population.

Attachment theory is one of the most popular and empirically grounded theories relating to parenting. The purpose of the present article is to review some pertinent aspects of attachment theory and findings from attachment research. Attachment is one specific aspect of the relationship between a child and a parent with its purpose being to make a child safe, secure and protected. Attachment is distinguished from other aspects of parenting, such as disciplining, entertaining and teaching. Common misconceptions about what attachment is and what it is not are discussed. The distinction between attachment and bonding is provided. The recognized method to assess infant-parent attachment, the Strange Situation procedure, is described. In addition, a description is provided for the four major types of infant-parent attachment, ie, secure, insecure-avoidant, insecure-resistant and insecure-disorganized. The antecedents and consequences of each of the four types of infant-parent attachment are discussed. A special emphasis is placed on the description of disorganized attachment because of its association with significant emotional and behavioural problems, and poor social and emotional outcomes in high-risk groups and in the majority of children who have disorganized attachment with their primary caregiver. Practical applications of attachment theory and research are presented.

We explored the relationship between vocal expressiveness in song and maternal attachment representation. Mothers (N = 36), classified as Autonomous, Dismissing, or Preoccupied, sang a play song of their choice in their 6-month-old infants’ presence and absence. Raters ( N = 50) who were na¨ to maternal attachment classifications listened to excerpts of each song rendition and rated mothers’ emotional involvement. Mothers, regardless of their attachment classification, sang more expressively in their infants’ presence than otherwise. Unique patterns of vocal expressiveness were associated with different maternal attachment classifications, but only under conditions of infant distress. Unlike Autonomous and Preoccupied mothers, who sang less playfully to distressed than to nondistressed infants, the playfulness of Dismissing mothers’ performances was unrelated to infant affect. These findings support the hypothesis that maternal attachment influences the nature of emotive vocal communication, but only under conditions of infant distress. © 2002 Elsevier Science Inc. All rights reserved.

Several studies have demonstrated associations between alexithymia, adult attachment styles, personality traits, and relationship adjustment. Only two studies, however, have explored associations between alexithymia and attachment representations. As part of a larger investigation of maternal and infant attachment, the current study explored this association in a sample of 97 pregnant women; in addition, measures of alexithymia and domains of the five-factor model (FFM) of personality were compared in predicting attachment security, assessed with the Adult Attachment Interview Coherence of Mind mind scale, and perceived relationship adjustment. Alexithymia negatively predicted coherence of mind; the domains of the FFM did not add significantly to the prediction. The Openness-to-Experience domain predicted relationship adjustment better than alexithymia. Contrary to findings from studies that assessed adult attachment styles, coherence of mind was unrelated to relationship adjustment and the FFM. The results suggest that alexithymia does not uniquely predict relationship adjustment beyond the domains of the FFM.

Van IJzendoorn’s (1995) model of the intergenerational transmission of attachment was tested with data from 96 mother-infant dyads assessed prenatally, and at 6 and 12 months. In spite of efforts to explain or reduce the transmission gap by measuring all three components in the same study, improving or altering definitions of sensitivity, and considering infant dyadic contributions, the results remain surprisingly consistent with the original meta-analysis: only a limited portion of the link between maternal and infant attachment is transmitted via maternal sensitivity/responsiveness. In support of the notion that the link between unresolved maternal attachment and infant disorganization is mediated by processes other than maternal responsiveness, omission of unresolved and disorganized cases enhanced links between responsiveness and infant attachment and slightly reduced the transmission gap. Accumulating data indicate that 1) maternal attachment contributes to infant attachment through routes other than maternal responsiveness and 2) maternal sensitivity/responsiveness contributes to infant attachment independent of maternal attachment. New models of the transmission process that take account of this information are needed.

To examine the characteristics and outcomes of children with gastrostomy and gastrojejunostomy tubes inserted before age three years, and to identify the factors that predict removal of the enterostomy tubes within 12 months of insertion.Case review of a consecutive sample of 325 medical records.A tertiary care paediatric hospital that is situated in a large metropolitan area.All outpatients and inpatients from birth to 36 months of age who had an enterostomy tube inserted from 1994 to 1996.No direct intervention was provided. In the subgroup of 203 patients with a follow-up period of at least 12 months after tube insertion, children whose tubes were removed within 12 months of insertion were compared with children who continued to receive tube feedings for 12 months or longer.At the time of tube insertion, the median age of patients was six months; 47% of the children for whom data were available were failing to thrive. Although 66 (21%) of 321 patients for whom data were available had their tubes removed, only 25 of the 203 (12%) patients with a follow-up period of 12 months or more had their tubes removed within 12 months of insertion. Children whose tubes were removed less than 12 months after insertion differed from children whose tubes were not removed with respect to medical diagnosis (no children with cerebral palsy had their tubes removed versus 33% of children with cancer who had their tube removed). Most children with failure to thrive at the time of tube insertion were also failing to thrive at the time of tube removal.Children with cerebral palsy are not likely to have enterostomy tubes removed within one year of insertion.

Les manifestations de comportements atypiques et de ruptures de communication lors d'interactions parents-enfant, mesurees par un instrument d'evaluation et de classification des comportements maternels atypiques (AMBIANCE, Atypical Maternal Behavior Instrument for Assessment and Classification), a ete precedemment mis en rapport avec l'attachement desorganise chez le jeune enfant, lequel est a son tour lie a la survenue de la psychopathologie. La presente etude examine l'utilite de AMBIANCE comme indicateur de l'efficacite de deux types d' interventions breves visant a reduire les comportements atypiques et les ruptures de communication pendant des interactions lors du jeu. 28 dyades meres-enfant ont participe a l'etude(14 par type d'intervention). Tous les enfants avaient des difficultes alimentaires. Une des interventions, du type de la guidance interactive, visait a entrainer les meres a repondre avec sensibilite aux besoins de leur bebe (intervention centree sur le jeu). L'autre intervention visait a entrainer les meres a l'usage de nouvelles techniques d'alimentation (intervention centree sur l'alimentation). Les resultats ont montre une diminution significative des scores a l'AMBIANCE dans le groupe centre sur le jeu, entre l'avant et l'apres intervention, mais non dans le groupe de l'intervention centree sur l'alimentation. Il existait une diminution significative des ruptures de la communication a la suite de l'intervention dans le groupe centre sur le jeu, mais pas dans le groupe centre sur l'alimentation. 73% des meres du groupe-jeu et 17% des meres du groupe-alimentation, initialement classees comme « a communication rompue» ont obtenue un classement dans la categorie «a communication non rompue» a l'evaluation post-intervention. Cette etude est limitee par la faible difference dans le moment de l'evaluation des echantillons pour chaque type d'intervention, et par l'usage d'echantillons tout-venant. Cependant, ces resultats preliminaires vont dans le sens de l'utilite d'AMBIANCE comme outil d'evaluation de l'efficacite clinique de la guidance interactive.

Soixante-dix meres de milieu defavorise et leurs bebes de 15 mois ont ete evalues a domicile et en laboratoire pour examiner si les compte rendus des meres faisant etat de detresse et de violence domestique etaient associes a l'attachement enfant-mere et la motivation de developpement de l'enfant. Comme on l'avait predit, les meres faisant l'experience d'une violence domestique plus serieuse avaient plus de chances d'avoir des enfants ayant des attachements deorganises envers elles. Il n'y avait aucune association entre les experiences de violence domestique ou de detresse et la motivation de developpement de l'enfant. Les recherches a venir devraient evaluer la correlation entre la violence domestique chez les modes de soin adultes et les attachements enfant-mode de soin.

This study tests the hypothesis that infants with failure to thrive (FTT) are at risk for a clinical disturbance of attachment (defined as a combination of: (1) nonautonomous caregiver state of mind with respect to attachment, measured by the Adult Attachment Interview (AAI); (2) nonbalanced caregiver representation of the infant, measured by the Working Model of the Child Interview (WMCI); (3) problematic play interactions; and (4) problematic feeding interactions). Participants were 57 infants (30 FTT, 27 non-FTT) and their primary caregivers, recruited from outpatient pediatric clinics. Caregivers were interviewed with AAI and WMCI and observed interacting with their infants during play and feeding. Results show that more infants with FTT than infants without FTT met some of the criteria for risk for a clinical disturbance of attachment —nonautonomous AAI and nonbalanced WMCI classifications, and less dyadic reciprocity during feeding. However, there were no group differences in play. Future directions for research are discussed.

L'objectif de cette etude est de veritier si des problemes de comportements alimentaires specifiques, chez les nourrissons souffrant de troubles d'alimentation post-traumatiques, laissent prevoir les resultats du traitement. Dans cette serie de cas, vingt-quatre enfants âges entre sept semaines et trente-quatre mois ont ete traites en trois etapes pour leurs troubles alimentaires post-traumatiques. Les trois composantes du traitement etaient constitutees (1) de changements physiologiques et environmentaux pour regulariser les cycles de faim-satiete et promouvoir de bonnes routines et habitudes alimentaires, (2 ) d'un suivi nutritionnel et (3) d'une therapie du comportement (gavage). Les nourrissons souffrant de troubles alimentaires post-traumatiques qui demontraient un refus passif d'avaler la nourriture mise dans leur bouche en ne mastiquant pas, ne sucant pas ou ne bougeant pas la nourriture dans leur bouche pendant plus de cinq secondes etaient moins susceptibles de respondre au traitment que les nourrissons souffrant de ces troubles qui ne presentaient pas ces comportements. De plus, un plus grand nombre de nourrissons souffrant de troubles alimentaires qui n'ont pas reagi au traitement presentaient des problemes anatomiques et mecaniques des voies aeriennes superieures, telle que la fistule tracheo-oesophagienne, ou de maladies pulmonaires telle que la dysplasie broncho-pulmonaire que les nourrissons souffrant de troubles d'alimentation post-traumatiques qui ont reagi positivement au traitement. Les decouvertes ont un impact direct sur l'evaluation et le traitement des troubles post-traumatiques alimentaires dans la petit enfance.

The stability and predictive validity of Classifications of mothers' representations of their infants as determined by the Working Model of the Child Interview (WMCI) were examined. Concordance between mothers' representations of their infants assessed prenatally and again one year later and infant Strange Situation (SS) attachment classifications at 12 months was also examined. WMCI classifications were stable over 12 months in 80% of mothers, compared to 51 % expected by chance alone. Pregnancy WMCIs predicted infant SS classifications in 74% of cases, compared to 54% expected by chance. Concordance between 11-month WMCI and 12-month SS classifications was 73 % (vs. 55% expected by chance). Problems with the skewed distribution of the sample, the low concordance between pregnancy and 11 months for one of the three classifications, and future directions for research are discussed.

Parental perceptions and subjective experience of infants have long been considered important in clinical work with infants and families. Using three different samples of infants, we compare mothers' represen- tations of their infants in clinically referred and nonreferred groups, using the Working Model of the Child Inter- view (WMCI). Twenty-four mothers of infants with failure to thrive (and 25 matched controls), 17 mothers of toddlers with sleep disorders (and 20 matched controls), and 13 mothers of infants seen in a general infant psy- chiatry clinic participated. Compared to their nonclinical counterparts, mothers of infants with clinical problems had representations of their infants that were significantly more likely to be classified distorted or disengaged. Infant gender, age, and birth order were independent of maternal classifications. We conclude that the WMCI is a useful structured interview to categorize mothers' perceptions and subjective experience of their infant and re- lationship with the infant. Mothers' WMCI classifications are associated with the clinical status of the infant. RESUMEN: Las percepciones de la madre y la experiencia subjetiva de los infantes han sido consideradas im- portantes, desde hace tiempo, en cuanto al trabajo clinico con infantes y familias. En este estudio, presentamos los resultados de una entrevista clinica acerca de las representaciones que las madres tienen de sus infantes y las comparamos con las representaciones de otras madres de infantes que no pertenecen al mismo grupo. Partici- paron veinticuatro madres de infantes con problemas de crecimiento (y sus 25 parejas de control), 17 madres de infants con trastornos para dormir (y sus 20 parejas de control), y 13 madres de infantes que habian sido vistos en una clinica de siquiatria infantil general. Comparados con sus contrapartes no clinicas, las madres de infantes

This article describes and illustrates a semistructured interview, the Working Model of the Child Interview, designed to describe parents’ internal representations of their infants. The interview has both a specific theoretic foundation and growing empiric support for its validity. Although the interview provides only one component of assessment, it may make a useful contribution to the clinician‘s understanding of a disordered infant-caregiver relationship. Individual differences in parents’ responses are illustrated with excerpts from interview transcripts.

Empirical research supporting the contention that insecure attachment is related to internalizing behaviors has been inconsistent. Across 60 studies including 5,236 families, we found a significant, small to medium effect size linking insecure attachment and internalizing behavior (observed d = .37, 95% CI [0.27, 0.46]; adjusted d = .19, 95% CI [0.09, 0.29]). Several moderator variables were associated with differences in effect size, including concurrent externalizing behavior, gender, how the disorganized category was treated, observation versus questionnaire measures of internalizing behavior, age of attachment assessment, time elapsed between attachment and internalizing measure, and year of publication. The association between avoidant attachment and internalizing behavior was also significant and small to moderate (d = .29, 95% CI [0.12, 0.45]). The effect sizes comparing resistant to secure attachment and resistant to avoidant attachment were not significant. In 20 studies with 2,679 families, we found a small effect size linking disorganized attachment and internalizing behavior (observed d = .20, 95% CI [0.09, 0.31]); however, the effect size was not significant when adjusted for probable publication bias (d = .12, 95% CI [-0.02, 0.23]). The existing literature supports the general notion that insecure attachment relationships in early life, particularly avoidant attachment, are associated with subsequent internalizing behaviors, although effect sizes are not strong.

This present student examines maltreatment experiences reported by 55 high-risk pregnant adolescents in response to a slightly adapted version of the Adult Attachment Interview (AAI; George, Kaplan,Main, 1996 ). Previous research has suggested that the rates of unresolved states of mind regarding trauma in response to the AAI may be underestimated due to the lack of direct questions and associated probes regarding physical, sexual, and emotional abuse. We address this concern by including behaviorally phrased questions and probes regarding maltreatment experiences into the original format of the AAI and examine the concordance between reports of maltreatment experiences in response to the AAI and the Childhood Trauma Questionnaire (CTQ). Maltreatment experiences in response to the AAI were evaluated using the Maltreatment Classification Scale developed by Barnett, Manly, and Cicchetti (1993). We also examine the association between unresolved states of mind and dissociation using the Adolescent Dissociative Experience Scale. Results revealed a significant concordance between reports of maltreatment in response to the AAI and CTQ measures. Reports of maltreatment were prevalent in this sample: across the AAI and CTQ measures, 96% of pregnant adolescents reported some form of emotional abuse, 84% physical abuse, 59% sexual abuse, and 88% reported neglect. Sexual abuse history uniquely predicted unresolved status in response to the AAI. Self-reports of dissociation were significantly associated with unresolved states of mind. Results suggest that the inclusion of behaviorally focused questions and probes regarding maltreatment in the AAI protocol can further contribute to the clinical and theoretical value of this tool.

Attachment classifications in mothers and their 1 -year-old infants were independently and concurrently assessed using the Adult Attachment Interview and the Strange Situation Procedure. Overall concordance was significant (k = 0.62), with strong links apparent between mothers classified dismissing and infants classified avoidant and between mothers classified autonomous and infants classified secure. Mothers' classified preoccupied were not more likely to have infants classified resistant. Mothers' perceptions and interpretations of the emotional distress of an infant observed in a 4-minute videotape were related to both infant and mother attachment classifications. These results are compatible with the suggestion that attachment classifications reflect differences in internal working models of relationships. Other measures of maternal psychosocial adjustment were not related to infant attachment classifications.

Some of the controversies surrounding the definition and classification of failure to thrive (FTT) are briefly described. Phenomenologic aspects of FTT are reviewed as well. In addition, treatment methods reflecting the considerable heterogeneity of clinical presentation with respect to the infants with FTT, their mothers, their families, and the FTT infant-mother relationship are described. Finally, methodologic problems limiting studies currently available are reviewed, and future directions for research are suggested.

The purpose of this paper is to present a structured method to assess and manage feeding problems in children under three years of age and a newly developed instrument to assist in the assessment and monitoring of these feeding problems. Simple management strategies and practical suggestions are described, derived from clinical experience and a pertinent review of the literature. Because feeding problems are so prevalent (affecting up to 35% of infants), the use of structured parent questionnaires, interviews and observation scales is important when assessing and managing these problems.

Attachment theorists assume that maternal mental representations influence responsivity, which influences infant attachment security. However, primary studies do not support this mediation model. The authors tested mediation using 2 mother-infant samples and found no evidence of mediation. Therefore, the authors explored sensitivity as a moderator, studying the (a) interaction of mental representation and sensitivity as it predicts infant attachment security and (b) level of sensitivity in mothers whose infants' attachment security is either concordant or discordant with their own. The interactional analyses were not significant. But the match-mismatch data showed that when mother-infant attachment strategies were discordant, maternal sensitivity was more consistent with infant than maternal attachment strategy. These findings are congruent with an interpretation of sensitivity as a moderator that can block transmission of attachment strategy.

The current meta-analysis examines the links between unresolved representations of attachment, anomalous parental behavior, and disorganized attachment relationships in 12 studies including 851 families. We found moderate effect sizes for the associations between unresolved states of mind and anomalous behavior (r = .26), unresolved states of mind and infant disorganized attachment relationships (r = .21), and anomalous behavior and disorganized attachment relationships (r = .34). Sample characteristics, observational context, and observational measure were not associated with differences in effect sizes. Only a small part of the association between unresolved states of mind and disorganized attachment relationships was explained by the mediation of anomalous parental behavior (.26* .34 = .09). Other factors yet to be uncovered must mediate the influence of unresolved states of mind on infant disorganized attachment; thus, further exploration of infant, parental, ecological, and genetic factors are warranted.

Although central to attachment theory, internal working models remain a useful heuristic in need of concretization. We compared the selective attention of organized and disorganized mothers using the emotional Stroop task. Both disorganized attachment and emotional Stroop response involve the coordination of strongly conflicting motivations under conditions of emotional arousal. Furthermore, much is known about the cognitive and neuromodulatory correlates of the Stroop that may inform attempts to substantiate the internal working model construct. We assessed 47 community mothers with the Adult Attachment Interview and the Working Model of the Child Interview in the third trimester of pregnancy. At 6 and 12 months postpartum, we assessed mothers with emotional Stroop tasks involving neutral, attachment, and emotion conditions. At 12 months, we observed their infants in the Strange Situation. Results showed that: disorganized attachment is related to relative Stroop reaction time, that is, unlike organized mothers, disorganized mothers respond to negative attachment/emotion stimuli more slowly than to neutral stimuli; relative speed of response is positively related to number of times the dyad was classified disorganized, and change in relative Stroop response time from 6 to 12 months is related to the match-mismatch status of mother and infant attachment classifications. We discuss implications in terms of automatic and controlled processing and, more specifically, cognitive threat tags, parallel distributed processing, and neuromodulation through norepenephrine and dopamine.