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Clinical Assessment in Infancy Utilizing Structured Playroom Situations
Clinical Assessment in Infancy Utilizing Structured Playroom Situations Theodore J. Gaensbauer, M.D., and Robert J. Harmon, M.D.
Abstract. This paper describes our experience with structured playroom laboratory situations which have proven to be useful in the evaluation of social-emotional development in infants. We believe a reliable and valid clinical instrument for infants should (I) be standardized, (2) involve direct observation, (3) assess multiple lines of development, (4) represent an efficient use of time, (5) be amenable to objective measures, and (6) allow as much as possible for the expression of spontaneous and typical patterns of behavior. Major elements of the observation session include (I) free play involving the mother and her infant, (2) comparisou of the infant's response to a similar approach by the mother and an unfamiliar person, (3) a developmental testing situation during which the infant's responses to mild frustration and his or her motivation to master the environment can be observed, and (4) a brief maternal separation and reunion. In addition to normal infants from middle and low socioeconomic backgrounds, clinical populations with which the authors have worked include abused and/or neglected and premature infants. Typical reactions of normal infants during each of the segments as well as behaviors which may be cause for clinical concern arc described. Joumal ofthe American Academy oj Child Psychiatry, 20:264-2S0, I9SI
In recent years enormous effort has been directed toward facilitating the well-being of infants and young children at high risk for disturbances in their psychological and social development. Unfor-
Dr. Gacnshauer is Assistant Professor, Department of Psychiatry, University o] Colorado School of Medicine, Denver. Dr. Hannon is Assistant Professor, Division of Child Psychiatry, University of Colorado School of Medicine, Denver. Drs. Gacnsbaucr and Harmon are supported by Rescardi Career Development Awards l-K04-lfY-214-3 and l-KOI-MH-00281-01 respectioel». Dr. Hannon is also supported by Research. Grant l-iWI-MH34005-0i from the National institute of Health. Portions of this tuorl: were supported by grants to both authors [rom the Grant Foundation Endowment Fund of the Dcoelopmental Psychobiological Research Group of the Department of Psychiatry, University oj Colorado Health Sciences Center, Denver, and from BRSG RR-05357 awarded by the Division of Research Resources, National institute of Health. Reprints may be requested from Dr. Gaensbauer, Department of Psychiatry, C268, University of Colorado Health Sciences Center, 4200 Fast Ninth Avenue, Denver, CO 80262. 0002-7138/H 1/2002-0264 $01.44 © 1981 American Academy of Child Psychiatry.
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tunately, t his e ffo rt has bee n serious ly hamper ed by the lack o f conve nient and rel iable methods for me as uri ng these areas of fun ctioning in pr ever bal child re n . To d ate , the assessment of an in fant's social a nd emotional develo pme nt has la r gely de pe nde d on clin ical expe rie nce. W hile the brilli ant observations of clinicianr esea rchers suc h as Bo wlby (195 1), Esca lona a nd Heider (195 9), Ma hler et al. (1975) , Murp hy ( 1956, 1976), Sander (1975), Spitz (1945, 1946, 1965), and othe rs have provided a foundation for mak ing suc h assessme nts , a co m pre he nsive instrume nt fo r the psychiatri c eva luation of infants has been lacking. The need for suc h an instru ment was ar ticulated ove r a de cade ago by Cytry n (1968), who describe d a num ber of variabl es pertinent. to suc h an evaluation, including drive organization, inter perso na l relatio ns with th e mot her an d other people , affecti ve responses, fr us tratio n tolerance, cogn itive functioning, and co pin g strategies in r esponse to stress but gav e no clear outline as to how suc h assessme n ts m ight be carried o ut. In t his paper, we will desc ribe ex pe r iences with playroom laboratory parad igms t hat we have fo und use ful in evaluating in fan ts' socia l-emotional development. T he situa tio ns comprising t hese parad igms we re chosen with researc h and clinical interests in m ind sin ce o u r r esearch programs have involved co m par ing the pat terning of soc ial-e mo tional res po nses in normal infan ts with clin ically at -r isk populatio ns, inclu din g abused/neglected in fants and pre m ature in fants. B AC KGRO UN D
We bel ieve d tha t an ad eq uate eva luative instrument should in volve direct observation. Though many instru ments u tilized by pediatricians and chi ld psych iatr ists have invo lved parental re po r ts (T homas et al., 1968; Carey, 1970; Broussard and H artner, 1971 ), a n u m b er of studie s h a ve s ugges te d that p a r en tal r eports do not
consiste ntly provide an acc ura te picture of par e nting practices or of the sta te of the rel atio nshi p with the child (A insworth , 1973). Second, we beli eved t hat a n assessmen t instru me nt sho uld be standard ized in su ch a way as to allow for compar isons between infants . T he need for standardization re lates to t he co m plexity and variability of infant behavior. Exte nsive research has doc ume n ted great variation in in fant be havior, depe ndi ng o n context a nd st imul us conditions (Sro ufe et al., 1974). In order to d raw an y co ncl usions abo ut pa rti cul ar be haviors shown by a par ticular in fant, or to
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compare these to a normative standard, the stimulus conditions must be sufficiently consistent across infants to make valid comparisons. This principle corresponds to the relatively constant stimulus conditions that prevail in the psychiatrist's office or during psychological testing. Only after developing a set of ideas about "average expectable behavior" in a consistent context can one apply one's diagnostic barometer with confidence to the unique presentation of a particular patient. This point was articulated many years ago by Winnicott (1941), whose "set situation" was one of the early examples of a structured clinical assessment procedure for infants. Third, an adequate instrument should tap a broad variety of behaviors and assess multiple lines of development. In any comprehensive clinical examination a broad range of psychological functioning must be explored in order to obtain a balanced overall picture of the patient. In an interview situation, a variety of important areas are probed with detailed questioning and a thorough mental status exam. Similarly, an adequate infant examination must cover a range of qualities relevant to the infant's overall psychological functioning. The com plexities of social-emotional development and the fact that pathology is not likely to show itself in the same form or under the same conditions in every case provide additional arguments for assessing multiple facets of development. While the research literature on infancy covers almost all aspects of infant development, studies have usually focused on single dimensions and have limited their experimental protocols accordingly. It was our assumption that a number of experimental situations could be linked together to allow the infant to show his potentialities in multiple sectors. In seeking to elicit a range of functioning, a further consideration was that the infant would not always provide such information spontaneously. This provided a further argument for a standardized and structured paradigm. Since the infant is dependent to such a large extent on the outside environment for orientation, it seemed most practical to structure the observation session actively, with various stimulus conditions being brought to the infant, rather than depending on spontaneous behavior in an unstructured setting. Fourth, we felt such an instrument should represent an efficient use of time and be amenable to objective measures. The need for efficiency was a consideration in deciding to utilize a playroom laboratory situation rather than going into the home. The laboratory setting also makes systematic and reliable observations of the in-
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fant's behavior possible. Since the infant cannot tell us what he is experiencing, accurate observation of overt behavior constitutes the primary means of gaining insight into the infant's world. Although this has left room for the important contributions of the intuitively perceptive clinician, it has also created an undesirable potential for inappropriate or misleading adultomorphizing (Spitz and Wolf, 1946). The more objective observations are, the more convincing the conclusions are likely to be. A particular advantage of the laboratory setting is that the session can be videotaped or filmed, making it possible to go back over the observations many times. In this respect, research interests have served to facilitate our clinical understanding. We have utilized a number of research instruments with high interrater reliability to assess specific aspects of infant emotional and social behavior (Morgan et al., 1976, 1977; Durfee et al., 1977; Gaensbauer et al., 1979). The use of such rating instruments has served to discipline our observations and to sharpen our sensitivity to the meanings of the behaviors observed, while making the conclusions potentially verifiable by independent observers. Fifth, such an instrument should, as much as possible, allow for natural and spontaneous behavior on the part of the infant and the caretaker so that characteristic patterns of behavior may emerge. Even though situations must be structured to ensure that a range of abilities are tapped, within this structure both mother and infant are encouraged to deal with the various situations in the way that seems natural to them. METHOD
The situations we will describe have been utilized in a somewhat different order and with varying emphasis, depending on the purpose of the particular study and the population being studied. Rather than describe a single paradigm we will describe specific clements which have been common to all of our paradigms. Specific paradigms are summarized in the appendix with a brief outline of the purposes of each particular study. For each of the clements described we will outline the assessment criteria and the specific data upon which judgments of normal and deviant behavior were based. Our conclusions are based on the considerable research literature available and on our own samples of 60 normal infants assessed in groups of 20 at 12 to 13, 15 to 16, and 18 to 19 months of age; approximately 80 infants ranging in age from 3 to
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34 months who had experienced severely disturbed parenting (for purposes of comparison we will focus on a group of 14 from this sample who were between 12 and 21 months of age, tested with their biological mothers, and living with their biological parents at the time of the observation); 109 12-month-old infants from a high risk, low-SES population; and 30 low-birthweight (less than 1500 grams), premature infants compared with a control group of 30 fullterm infants at 12 months of age. Variables we have examined in these various populations include the patterning of discrete emotions (Gaensbauer et al., 1979; Gaensbauer, 1981), affiliative and attachment behavior (Harmon et al., 1979), and the quality and persistence of spontaneous play (Harmon et al., 1979, 1981; Jennings et al., 1979). Interrater reliabilities using raters unaware of the hypotheses of the studies or of the identity of the infants ranged from 0.52 to 0.92 with a mean of 0.73 for scales of discrete affect, from 0.60 to 1.00 with a mean of 0.89 for ratings of affiliative and attachment behavior, and from 0.84 to 1.00 with a mean of 0.94 for ratings of free play. In the following discussion we will describe only the findings that bear directly on the issues of clinical assessment. LABORATORY PARADIGMS
Free Play Period with Mother and Infant
The situation we used in the initial phase for all of our playroom studies was a free play period involving the mother and the infant. It varied in length, depending on the particular study, but was utilized to observe a number of common phenomena. The initial two minutes were described to the mother as a warm-up period; she was instructed to make the infant comfortable and to put him or her in a good mood. Even in these first minutes one can begin to distinguish those mothers who have the capacity to "tune in to their infants" and to observe the degree to which mother and infant can involve themselves in mutually pleasurable activity. In general, mothers let their child take the initiative, while they facilitated and expanded on the child's play in a contingent manner. This way of relating contrasted with those mothers who were more directive, intrusive, or unable to respond appropriately at the child's level. Some mothers seemed almost oblivious to the child's activity, exhibiting "parallel play" rather than reciprocal interaction. Often it was the child who revealed the
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usual nature of the mother-infant interaction most clearly. If unused to reciprocal play, the infant was likely to disregard the mother and play in the independent manner to which he or she was accustomed, despite active efforts on the mother's part. Following the initial warm-up period of two minutes the mother was signaled to take a seat in a chair approximately eight feet away from the toy pile. At this point the initiative for interaction passed to the infant, who had a choice of playing with the mother or the toys. In our normal samples infants involved themselves with both. The mother was used as a "secure base" (Ainsworth, 1973) from which to explore; the infant would maintain a dialogue with her, intermittently checking with her visually or verbally) or through direct initiative inviting her to share in the play. Mahler et al. (1975) have described a similar phenomenon, terming it "emotional refueling." The animated atmosphere of mutual enjoyment which characterized most of our normal sample was in striking contrast to the mother-infant pairs who were alienated from each other or who lacked the capacity for mutual enjoyment. In a recent study of emotional expression, a grou p of twelve 12- to 19-month-old abused/ neglected infants, when compared with a normal group, showed both significantly decreased amounts of pleasure as well as significantly less interest in physical, verbal, and/or visual contact with their mothers (Gaensbauer, 1981). In an earlier study involving 36 normal children, Harmon et al. (1979) found that infants showing low interest in the mother (defined by the lack of bids for attention directed toward the mother during a free play period) tended to show negative reactions to being approached by her, failed to show evidence for a "secure attachment" to her (see below), and did worse on measures of cognitive competence. At the other extreme from the excessively independent child is the depressed or anxious infant who is unable to leave the mother's proxi m it.y or whose capacity to explore is limited (Airrswo rt.h et al., 1971; Gaensbauer and Mrazek, 1981). The free play situation also allows the infant's competence in relation to the inanimate world to be assessed in terms of his or her capacities for exploration, initiative, persistence, and level of cognitive maturity. Does the infant show confidence in the novel situation, explore items in depth, combine items in creative ways, and persist in the face of obstacles? Or is the play immature, stereotyped, and characterized by frequent seemingly random moves from object to object?
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Qualitative differences in play are documented utilizing detailed scoring systems which assess the different kinds of play and levels of cognitive complexity observed over the infancy period. From 12 to 18 or 19 months, infants move from less cognitively mature play, such as passive exploration (looking, passive contact, or mouthing), to more active manual investigation of toys, to increasingly appropriate use of specific toys, such as combining toys in creative ways, and finally, to thematic or pretend play (Harmon et al., 1980). Com pared with the normal sam pIe the 14 abused/neglected infants not only showed less positive affect, less proximity to their mothers, and less social play (confirming findings from the study of emotional expression), but also showed marked disturbances in the quality of their play. They showed less overall mobility and active exploration, more passive exploration, and much less "high level" play such as combining items or thematic play. They also tended to play with fewer objects, reflecting inhibitions and tendencies toward stereotyped, repetitive play. In contrast, the premature infant populations showed a different trend. Although showing cognitive play of equal maturity once corrections were made for gestational age, pre matures, in comparison with fullterm infants, were less mobile and active in moving about the room and spent more time in close proximity to and in contact with the mother. These findings, in conjunction with interview data and observations at other points in the laboratory session, lend support to the impression that these infants have a closer and perhaps "overprotected" relationship with their caregivers (Beckwith and Cohen, 1978; Goldberg, 1978; Harmon, 1979).
Stranger and Mother Approaches The second situation common to all of our studies involved an approach of the infant by an unfamiliar person, a "stranger," followed by a similar approach and pickup by the mother. Based on our earlier work and previous studies of other researchers on infants' emotional responses to a "stranger's" approach, we anticipated that most infants would show some degree of wariness, ranging from intense fearfulness and avoidance to very mild shyness and coy behavior (Gaensbauer et al., 1976; Harmon et al., 1977; Bretherton and Ainsworth, 1974). A negative reaction, however, is by no means constant; some infants are immediately friendly (Rheingold and Eckerman, 1973). From the clinical point of view, we believe that the most important information to be gained from this segment derives from the comparison of the in-
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Iant's affective responsivity to the stranger with his or her responsivity to the mother. Both common sense and several systematic studies led us to expect that the infant's response to the mother would be more positive than, or at least as positive as, the response to someone whom he or she has just met (Klein and Durfee, 1976; Harmon et al., 1979). In the Harmon study, the finding of a more negative affective response to the mother than to the stranger was the most powerful predictor of low scores on the Bayley Scales of Infant Development and competence in playas well as being highly associated with decreased involvement with the mother. Our recent study of 60 normal infants illustrated the rarity of this pattern; only 6 (l 0%) of 60 infants showed a distinctly more positive reaction to the stranger. By contrast, out of the sample of 14 abused/neglected infants, 6 (35%) showed a more negative affective response to the mother. Strikingly, in the study of emotional expression referred to earlier, the only times that the sam pic of abused/neglected infants showed more pleasure than the group of normal infants involved situations in which the infants were interacting primarily with the stranger (Gaensbauer, 1980). The stranger approach also provided an opportunity to observe the extent to which the mother is used as a source of security. Most noteworthy from a clinical standpoint are those infants who are obviously distressed or wary of the stranger, but who do not look to the mother for comfort. Developmental Testing We used a structured developmental testing situation for a number of purposes. In this situation, the infant sat on the mother's lap across a table from the examiner, who presented the infant with a series of structured tasks. Like most other workers in the field, we used the well-standardized Bayley Scales of Infant Development to obtain an estimate of the infant's cognitive development. Scores I'ro m the abused/neglected sa m plc were, as a group, well below the
norms established for this test, providing evidence for the destructive effects of abuse and neglect on ego functioning and cognitive development (Gaensbauer et al., 1981; Martin, 1976). Other test instruments may readily be used to evaluate a variety of specific mental abilities (Uzgiris and Hunt, 1975). The testing situation provided measures not only of the infant's mental capacity but also demonstrated the infant's capacity to cooperate in play and his willingness to follow the directions of others. The structure of the situation also allowed the experi-
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menter to examine a number of specific aspects of the infant's behavior. For example, a peek-a-boo game served as a direct measure of the infant's social responsivity and capacity for a pleasurable engagement. Several elements of the testing situation provided an opportunity to observe the infant's frustration tolerance. Moving from one task to the next involved a potential frustration for the infant. In several studies these mild frustrations were purposefully standardized. For example, a ten-second delay between each of the first five items was structured into the situation. We also introduced a "barrier" task, in which a desired toy was placed in a box with a seethrough plexiglass top. The infant's degree of confidence about the fulfillment of his wishes and his sense of initiative were nicely illustrated during this phase. Due to problems of standardization in our initial studies, we did not utilize objective measures in this situation, and can therefore only speak from clinical experience. Children generally showed some mild protest behavior and/or visual or physical pursuit of the items during the pause between items. At the same time they demonstrated a capacity to delay and immediately took up the next item once it was presented. Our experience with the abused/ neglected infants suggested that extreme responses at either end of the frustration continuum were cause for concern. There were infants who passively accepted the comings and goings of toys with no protest or pursuit at all, revealing their sense of helplessness and resignation. There were also children who showed highly disruptive temper outbursts, throwing toys and/or withdrawing from the situation completely by turning away or squirming to get down. A mild verbal prohibition Cno-no") was also administered at some point in the testing. This was particularly informative in cases of abuse. An almost pathognomonic sign of harsh discipline is the child who, in response to a very mild prohibition, freezes in posture, looks extremely sad or fearful, or fails to recover for a prolonged period. A most dramatic instance of this was a 16month-old infant who responded to the examiner's encouraging hand gesture directing him to put several cubes in a cup with a terrified look, crying, and visible cringing, as if he anticipated being struck across the face. This infant had been hospitalized several months earlier with a skull fracture. Responses such as these have not been seen in normal samples. The infant's intrinsic motivation to have an effect on and to master his environment (White, 1963) was also assessed in the testing
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situation. For the premature sample a separate session involving a series of nine tasks was utilized. What is assessed is not simply whether the child solves the task, but his or her persistence in working at the problem. Preliminary data indicated that premature infants have a longer latency before becoming involved in tasks than do fullterms and show a narrower range of affect during testing. They also have been generally less persistent at more complex tasks, preferring tasks related to noise and visual effects to more cognitively demanding tasks involving combinational abilities and the solving of "barrier" problems (Doyle, 1979; Harmon, 1979). A description of the tasks is provided in the appendix to this paper. Though we did not em phasize maternal variables in our research instruments, the mother's capacity to facilitate the infant's performance could be observed during the testing situation. Typically, mothers helped the child to focus and structure the task by providing an organizing presence without intruding upon the child or taking over. One can observe the extent to which the mother can allow the child to perform at his or her own level without her own self-esteem being so tied up with the performance of the child that her expectations become unrealistic or she provides inordinate help. The potential for power struggles between parent and child often became evident in this portion of the session. Separation and Reunion Sequences The last portion of the evaluative session consisted of a brief separation and reunion sequence. First, the mother was instructed to leave the room for 3 minutes, departing as if she were leaving the child with a babysitter. A number of studies have provided evidence that the quality of the infant's "attachment" to the mother may be revealed in the infant's response to this event (Ainsworth et £11., 1978). In these studies the most revealing element in the sequence has been considered to be the infant's reunion behavior (Sroufe and Waters, 1977). Even if they were not distressed, infants considered to be "well attached" greeted the mother promptly with a positive acknowledgment and more often than not sought close proximity. If distressed, they immediately and unambivalently sought comfort from her (Ainsworth et £11., 1971). Our own studies indicated that there was, in general, a prompt recovery from any distress soon after the mother's return; usually within several minutes the infant's good mood was restored (Gaensbauer et £11., 1979).
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Responses that we considered cause for concern were again those at either extreme of the continuum. At one extreme were infants who showed no evidence of missing the mother or who expressed continuing anger by "snubbing" and "avoiding" her on her return. At the other extreme were infants who were highly distressed and not easily soothed, or who showed persisting anger by resisting the mother's efforts to comfort them. A series of studies summarized by Ainsworth et al. (1978) and Sroufe and Waters (1977) have demonstrated the validity of this classification based on reunion behavior. "Avoidant" and "resistant" patterns of reunion behavior were shown to be associated with less sensitive, less accepting, and more intrusive caretaking in the home (Ainsworth et al., 1978). As a group the "well attached" infants showed greater competence both in problem solving and in social relations (Sroufe and Waters, 1977; Matas et al., 1978; Arend et al., 1979). Our own experience has certainly supported the clinical relevance of these findings. Of the 14 infants in the 12- to 21-month-old abused/ neglected sample, 11 were either resistant or avoidant based on Ainsworth's classification. Observation of the mother's response to the introduction of a stress in the infant-caretaker relationship, such as a brief separation, can be extremely informative. If the infant cries, the mother cannot help but feel to some extent responsible. She may interpret this distress in a positive vein, indicating her importance to the infant, or she may react negatively, feeling overly guilty or angry and attempting to minimize the child's "dependence" on her. During the reunion, mothers were quite aware of the infant's reaction. A positive greeting from the infant was quite pleasing to the mother. In contrast, infants who ignored their mother's presence evoked remarks of disappointment such as "I might as well not have come back. He didn't miss me." (Gaensbauer and Sands, 1979). A depressive mother who relied on her infant to cheer her up became tearful during the reunion and plaintively asked her infant to forgive her for having previously left him. Another mother, whose self-esteem depended on her belief in the infant's need for her, was so distraught at her infant's avoidance of her upon her return that she needed immediate psychiatric intervention. In severely disturbed mother-infant pairs, where little capacity for the resolution of conflict was present, angry interchanges and intense distress continued for the remainder of the session and beyond (Gaensbauer et al., 1981; Gaensbauer and Mrazek, 1981). In the last phase of the sequence, 2 minutes after the mother's
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ret ur n, the stran ger was instructed to leave th e room for 3 minutes. Aga in , a co m par ison may be mad e bet ween the st ra nger and th e mother. In the sa m ple o f th e 14 abused/n egle cted infants disc usse d abov e, 3 of th em showed more po sitive greeting behavior to the stra nge r than to th e mother ; one showed a full ran ge of "a ttachment" behavior to th e stra nge r rather th an to th e mother, including sea rc h behavio r a nd di stress followin g the se par atio n, a nd positive greeting a nd p ro ximity seekin g o n reunion (Gae nsbauer e t aI., 1981 ). In co ntras t to th e ab use d sa m ple , o nly 3 o f 60 in fan ts in th e normal sa m ple show ed more positive gree ting to th e strange r; all 3 o f these infants we re highly avoid ant o f the mother, an d showed a disturba nce in attachment behavi or accor d ing to Ainsworth's classification s. T he most dramatic occurrence of a discrimination in favor of the st r an ger in the premature sa m ple involved an infant who had experienced very activ e a nd inv ol ved paternal caregiving. Because of the mother's concern ab out the infant's preference for the strange r, as well as her awareness o f her own di fficulty in "wa r m ing up" to t he infant followin g the difficult ea rly months, a follo w-up visit was sche d uled. At 15 months the infant had de veloped a clear a nd appropriate attachment to his mother , as indica ted b y his dis tress res po nse s whe n the stra nge r picked him up as we ll as wh en t he mother left th e r oom durin g the separati on. The o p po rtu n ity to obse rve this shift was very meaningful to th e mot he r, serv ing to co nso lidate her growin g co n fide nce abo u t the ch ild's su rv ival and valida ting her increa sin g e mo tio nal in ves tm ent in t he c hild . DI SC USSIO N
In utilizin g these vario us situa tions, re gard less of the orde r in wh ich th e y were presen ted , we ex posed the infa nt to a series of st im uli, tapping a broad range of emotional a nd soc ial behavior. Many , if not most of the facets of the ideal ps ychiatric e valuatio n as o u tline d by Cytryn (19 68) have been incorporat ed in some manne r. Clinicia ns can obs erve the range of emotion al responding, the o rga nizatio n of social behaviors, the quality of th e rel ationship betwee n mother and infant, th e d egree of co m pe te nce in relation to t he e nv iro n me nt, th e ca pacity to sus tai n orga n ized e ffo rt, and the ability to play coo pe ra tively . At th e sa me tim e , we would not wish to im ply that th e elements d escribed here are the o nly useful ones. As ca n be seen fr om th e a p pe nd ix, we ha ve made usc of vario us situa tio ns in different ways, d epending o n th e population to be
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st ud ied and the particular d e velopmental a reas o f greate st interest. A few e xamples of situation s t hat other in vestiga tors ha ve e ffectively utilized include a fee d ing situatio n (Bro dy, 1956 ; Ainsworth a nd Bell , 1969), coo pe rat ive tasks requirin g the participation of both mother and in fant (Ma tas e t al. , 197 8 ; Als, 1981 ), and un structured face-to-face pl ay (Ste rn , 1971; Brazelton et al. , 1974; Tronick c t al. , 1979). Regardless o f th e particular situatio ns chose n, we would r ecommend tha t th e y be adequa tely str uc tu r ed so th at a basis for co m parison a mo ng individual in fants is present. Even th ough thi s kind o f eva lua tio n ca n be extre me ly useful, seve ral cave a ts arc in orde r. First, the age of th e in fant must be conside re d . There is consid erable e vid e nce from stu d ies in our own lab oratory, as well as in ot he r laboratories, that fr om a group standpoint, social and affect ive responses to the kind s of stimulus situations utilized here are co ns iste n t over the 12- to 18-month age ran ge (Sroufe and Waters, 1977; Vaughn et al. , 197 9 ; Gaensbauer, 1981). In our opinion th e patterns of response d escribed in this paper a re m ost informative in infants between the ages o f 9 and 21 months. Though the situa tio ns themsel ves arc re leva nt to infants yo u nge r than Y months, th e cogn itive immaturity a nd d ecreased mobility o f yo u nge r in fants wo uld necessitate so mew ha t different assessm ent cr ite r ia . Beyond the age s of 21 to 24 months, man y infan ts ha ve d e veloped su fficie n t evoca tive memory a nd language a bility so that situati ons suc h as a str a n ge r approach o r a threeminute maternal separati on a re no longer hi ghl y e motion ally cha rge d e vents. T he methodology d escribed here requires not o nly training and ex pe r ie nce in the use o f th e paradigms d escribed , but exte ns ive clinical e x pe r ie nce wit h th e populations under study, suc h th at o ne has a tho rough understanding o f the ran ge o f normal beha viors to be ex pec ted. In addition , the infant-centered e valuation d escribed here is best utilized in co n ju nc tio n with a com plete e valuatio n of th e par ents, so that the infant's behavior may be placed within the o verall car e ta king context. It is best to be conservative about drawin g inferences from a single se t of observations , co ns ide r in g the co nsta n tly changing and e volving character of d evelopmental processes. T he exa m ple o f t he p remature infant who see me d to prefer th e male stranger to the mothe r at 12 m onths of age but was avoida nt o f the st r a nger at 15 month s of age und erlines th e importance of be ing aware o f cha nges in the d e velopmental process. At the same lime , a single extre me reaction in th e co nte xt of otherwise normal beha vior ma y be highl y info r m ative. T he in fant who visibly cr inged at the exa m iner's gest ure had been in a fo ster home for
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several months; except for this striking reaction, repeated twice during developmental testing, he showed normal "attachment behavior" to his parents and no other evidence of developmental disturbances. Except in dramatic instances such as the one just described, we generally did not utilize the laboratory situation to make direct inferences about specific experiences in the home. We tended to interpret deviant reactions as indicators, rather than as hard evidence, of potential disturbances in the caregiver-infant relationship. They give cause for further examination, corroborate impressions gained from psychiatric evaluation of the parents, and help to focus attention on specific areas of parent-child interaction to be addressed.
ApPENDIX
This appendix describes two examples of the use of a structured experimental situation for clinical assessment in infancy. The first one-session situation was designed to study the regulation of affective expression in normal and abused/neglected infants. The second two-session paradigm was designed to study attachment, cognitive-motivational development, and affective development in term and pre term infants. One-Session Paradigm 1. Mother and infant enter: "Make infant comfortable" 2. Infant free play with mother present 3. Stranger enters, stranger approach a. Talk to mother minute b. Talk to infant minute c. Give-and-take minute d. Pick up infant 1 minute 4. Mother approach (similar to stranger approach) a. Give-and-take b. Pick up infant 5. Developmental testing with mild frustrations 6. Stranger and infant engage in interactive play 7. Mother leaves-separation 8. Mother returns-reunion 9. Stranger leaves 10. Stranger returns
2 minutes 5 minutes 4 minutes
2 minutes
15-30 minutes 1 minute 3 minutes 2 minutes 3 minutes 2 minutes
Two-Session Paradigm 1. Mother and infant enter: "Make infant comfortable" 2. Infant free play with mother present 3. Stranger enters, stranger approach
2 minutes 2 minutes 4 minutes
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5.
6. 7. 8. 9. 10.
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a. Talk to mother minute b. Talk to infant minute c. Give-and-take minute d. Pick up infant I minute Mother approach (similar to stranger approach) a. Give-and-take b. Pick up infant Free play a. Record the first 2 minutes (min. 0-2) (Min. 0-1 begins when the mother has left the infant alone on the Hoor to play with the toys and moved to her chair for interview.) b. Tape off during minutes 3-7 c. Record minutes 8-22 Stranger and infant engage in interactive play Mother leaves-separation Mother returns-reunion Stranger leaves Stranger returns
2 minutes
2 minutes
5 15 1 3 2 3 2
minutes minutes minute minutes minutes minutes minutes
Mastery Motivation Testing Session A. Tasks Nine tasks are given in the same order to each infant for a 3-minute trial. The tasks are divided into three conceptual clusters: (1) Effectance production, or tasks which allow the infant to produce interesting effects (surprise box, toaster, forest); (2) problem solving, or tasks in which the infant seeks a toy from behind a barrier (barn door, object permanence, barrier box); and (3) practicing emerging skills, or tasks in which infants put one object into another (pegs in boat, dropa-ball, and shape sorter). Our key measure on these tasks consists of the percentage of time each infant engages in persistent goal-directed behavior (Jennings et aI., 1979). B. Administration of object permanence scales (Uzgiris and Hunt, 1975). C. Administration of Bayley Scales of Mental Development
These two paradigms and the particular sequences of events have been designed to study specific aspects of development in specific populations as described above. Other sequences may be relevant, depending on the interest of the clinician or researcher. Our major emphasis is not on a specific sequence, but rather on the importance of a structured systematic approach for the clinical assessment of infants.
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REFERENCES AINSWORTH, M.D.S. (1973), The development of infant-mother attachment. In: Review of Child Deoelopment Research, Vol. 3, eel. B. M. Caldwell & II. N. Riciutti. Chicago: University of Chicago Press, pp. 1-94. - - - , & Brr.t., S. M. (1969), Some contemporary patterns of mother-infant interaction in the feeding situation. In: Stimulation in l~'arly lnjiwcy, cd. A. Ambrose. New York: Academic Press, pp. 133-170. - - - - - - , & STAYTON, D. (1971), Individual differences in strange situation behavior of one-ycar-olds, In: The Origins of Human Social Relations, cd. H. R. Schaffer. New York: Academic Press, pp. 17-52. - - - , BU:HAR, M. C., WATERS, E., & wxu, S. (1978), Patterns ojAttachmcnt. Hillsdale, NJ: Lawrence Erlbaum. ALS, 1-1. (1981), A new model of assessing the behavioral organization in prctcrrn and fullterm infants. This journal, 20:239-263. AREND, R., GOVE, F. L. & SROUFE, L. A. (1979), Continuity of individual adaptation from infancy to kindergarten. Child Deoelpm., 50:950-959. BECKWITH, L., & COllEN, S. E. (1978), Prctcrm birth. Infant Behao. Deoelpm., 1:403-411. BOWl.BY, .J. (1951), Maternal care and mental health. Presentation at the World Health Organization, Geneva. BRAZEl.TON, 'I'. B., KOSLOWSKI, B., & MAIN, M. (1974), The origins of reciprocity. In: Tile Origins of Behavior, cd. M. Lewis & L. A. Rosenblum. New York: Wiley, pp. 49-76. BRETHERTON, I., & AINSWORTH, M. (1974), Responses of one-year-olds to a stranger in a strange situation. In: The Origins of Fear, cd. M. Lewis & L. A. Rosenblum. New York: Wiley, pp. 13/-164. BRODY, S. (1956), Patterns of Mothering. New York: International Universities Press. BROUSSARD, E., & HARTNER, M. S. S. (1971), Further considerations regarding maternal perception in the first born. In: Exceptional Infani, Vol. 2, cd . .J. Hellmuth. New York: Brunncr/Mazcl, pp. 432-449. CAREY, W. B. (1970), A simplified method of measuring infant temperament..J. Pediai., 77: 184-194. CYTRYN, L. (1968), Methodological issues in psychiatric evaluation of infants. This Journal, 7:510-521. DOYl.E, A. F. (1979), Existence of mastery motivation in infants. Unpublished dissertation, Smith College School 1,)1' Social Work. DURFEE,.J. '1'., KLEIN, R. P., FIVEL, M. W., BENNETT, C. A., & MORGAN, G. A. (1977), Infant social behavioral manual. jSAS Catalog of Selected Documents in Psychology, 7:38 (ms. no. 14(7). ESCALONA, S., & HEIDER, G. M. (1959), Prediction and Outcome, New York: Basic Books. GAENSBAUER, T . .J. (1981), Regulation of emotional expression in infants from two contrasting caretaking environments. This Journal (in press). - - - , EMilE, R. N., & CAMPOS,.J. (1976), Stranger distress. Percept. Mot. ShiLL" 43:99-106. - - - , & MRAZEK, D. (1981), Differences in the patterning of affective expression in infants. This Journal (in press). - - - , - - - , & EMilE, R. N. (1979), Patterning of emotional response in a playroom laboratory situation.ln/emt Behau. Deuelopm., 2: 163-178. - - - , - - - , & HARMON, R . .J. (1981), Behavioral observations of abused and/or neglected infants. In: Psychological AjijJroaclles to tile Understanding and Prevention of Child Abuse, cd. N. Frudc. London: Concord Books (in prcparat.iou). - - - , & SANDS, K. (1979), Distorted affective communications in abused/neglected infants and their potential impact on caretakers. Thisjournal, 18:236-2:)0. GOLilBERG, S. (1978), Prematurity: effects on parent-infant interaction . .J. Pediai. Psychol., 3: 137-144. HARMON, R . .J. (1979), Play mastery and attachment in term and pre term infants. Read at the
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Annual Meeting of the American Academy of Child Psychiatry, 1979. - - - , GLICKEN, A. D., & GAENSBAUER, T. j. (1981), Development of free play behavior in infancy (unpublished manuscript). - - - , MORGAN, G. A., & KLEIN, R. P. (1977), Determinants of normal variation in infants' negative reactions to unfamiliar adults. This journal, 16:670-683. - - - , SUWALSKI, j. D., & KLEIN, R. P. (1979), Infants' preferential response for mother versus an unfamiliar adult. This [ournal, 18:437-449. JENNINGS, K. D., HARMON, R. j., MORGAN, G. A., GAITER, J. L., & YARROW, L. J. (1979), Exploratory playas an index of mastery motivat.ion. Develpm. PsychoI., 15:386-394. KLEIN, R. P., & DURFEE, .l- 't. (1976), Infants' reactions to unfamiliar adults versus mothers. Child Deuelpni., 47:1 ISJ4-1 196. MAHLER, M. S., PINE, F., & BERGMAN, A. (1975), The Psychological Birtli of the Human Infant. New York: Basic Books. MARTIN, II. P., cd. (1976), The Abused Child. Cambridge, Mass.: Ballinger. MATAS, L., AREND, R. A., & SROUFE, L. A. (1978), Continuity of adaptation in the second year. Child Deoelpm.; 49:546-556. MORGAN, G. A., HARMON, R. j., & BENNETT, C. A. (1976), A system for coding and scoring infants' spontaneous play with objects. jSAS Catalog of Selected Documents in Psychology, 6:10" (ms. no. 13",,). - - - , IIARMON, R.j., GAITER,j. L.,jENNINGS, K. D., GIST, N. F., & YARROW, L.j. (1977), A method of assessing mastery in one-year-old infants. ./SAS Catalog of Selected Documents in Psychology, 7:68 (ms. no. 1,,17). MURPHY, L. B. (1956), Methodsfor the Study ofPersonality in Young Children; Vol, I. New York: Basic Books. - - - , & MORIARITY, A. E. (1976), Vulnerability, ColJing and Grounh . New Haven: Yale University Press. Rm:INGoJ.[), H., & ECKERMAN, C. (1973), Fear of the stranger. In: Advances in Child Development and Behauior , Vol. 8, eel. H. W. Reese. New York: Academic Press, pp. 186-222. SANDER, L. (197,,), Infant and caretaking environment investigation and conceptualization of adaptive behavior in a system of increasing complexity. In: Explorations in Child Psychiatry, cd. E. j. Anthony. New York: Plenum, pp. 129-166. SPITZ, R. A. (1946), Anaclitic depression. The Psychoanalytic Study of the Child, 2:313-342. - - - (1945), Hospitalism. The Psychoanalytic Study of the Child, 1:53-74. - - - (196,,), The First Yea1' ofLije. New York: International Universities Press. - - - , & WOLF, K. (1946), The smiling response. Genet. Psychol. Monogr., 34:"7-12,,. SROUFE, L. A., & WATERS, E. (1977), Attachment as an organizational construct. Child Deoelpni., 48: 1184-1199. - - - , - - - , & MATAS, L. (1974), Contextual determinants of infant affective response. In: TIll' Origins ofBehauior, cd. M. Lewis. New York: Wiley, pp. 49-72. STERN, D. N. (1971), A micro-analysis of mother-infant interaction. Thisjournal, 10:501-517. THOMAS. A.. CHESS. S., & BIRCH, 1-1. (1968), Temperament and Behaoior Disorders in Children, New York: New York University Press. TRONICK, E., ALS, H., & ADAMSON, L. (1979), Structure of early face-to-face communicative interactions. In: Before Speech, ed. M. Ballowa. Cambridge: Cambridge University Press, pp. 349-372. UZGlRIS, I., & HUNT, J. (197,,), Assessment in Infancy. Urbana, IL: University of Illinois Press. VAUGHN, B., EGELAND, B., & SROUFE, L. A. (1979), Individual differences in infant-mother attachment at 12 and 18 months. Child Deuelpm., 50:971. WHITE, R. W. (1963), Ego and reality in psychoanalytic theory. Psychological Issues, Monograph II. New York: International Universities Press. WINNICOTT, D. W. (1941), The observation of infants in a set situation. Int . .J. Psycho-Anal., 22:229-249.
Abstract. This paper describes our experience with structured playroom laboratory situations which have proven to be useful in the evaluation of social-emotional development in infants. We believe a reliable and valid clinical instrument for infants should (I) be standardized, (2) involve direct observation, (3) assess multiple lines of development, (4) represent an efficient use of time, (5) be amenable to objective measures, and (6) allow as much as possible for the expression of spontaneous and typical patterns of behavior. Major elements of the observation session include (I) free play involving the mother and her infant, (2) comparisou of the infant's response to a similar approach by the mother and an unfamiliar person, (3) a developmental testing situation during which the infant's responses to mild frustration and his or her motivation to master the environment can be observed, and (4) a brief maternal separation and reunion. In addition to normal infants from middle and low socioeconomic backgrounds, clinical populations with which the authors have worked include abused and/or neglected and premature infants. Typical reactions of normal infants during each of the segments as well as behaviors which may be cause for clinical concern arc described. Joumal ofthe American Academy oj Child Psychiatry, 20:264-2S0, I9SI
In recent years enormous effort has been directed toward facilitating the well-being of infants and young children at high risk for disturbances in their psychological and social development. Unfor-
Dr. Gacnshauer is Assistant Professor, Department of Psychiatry, University o] Colorado School of Medicine, Denver. Dr. Hannon is Assistant Professor, Division of Child Psychiatry, University of Colorado School of Medicine, Denver. Drs. Gacnsbaucr and Harmon are supported by Rescardi Career Development Awards l-K04-lfY-214-3 and l-KOI-MH-00281-01 respectioel». Dr. Hannon is also supported by Research. Grant l-iWI-MH34005-0i from the National institute of Health. Portions of this tuorl: were supported by grants to both authors [rom the Grant Foundation Endowment Fund of the Dcoelopmental Psychobiological Research Group of the Department of Psychiatry, University oj Colorado Health Sciences Center, Denver, and from BRSG RR-05357 awarded by the Division of Research Resources, National institute of Health. Reprints may be requested from Dr. Gaensbauer, Department of Psychiatry, C268, University of Colorado Health Sciences Center, 4200 Fast Ninth Avenue, Denver, CO 80262. 0002-7138/H 1/2002-0264 $01.44 © 1981 American Academy of Child Psychiatry.
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tunately, t his e ffo rt has bee n serious ly hamper ed by the lack o f conve nient and rel iable methods for me as uri ng these areas of fun ctioning in pr ever bal child re n . To d ate , the assessment of an in fant's social a nd emotional develo pme nt has la r gely de pe nde d on clin ical expe rie nce. W hile the brilli ant observations of clinicianr esea rchers suc h as Bo wlby (195 1), Esca lona a nd Heider (195 9), Ma hler et al. (1975) , Murp hy ( 1956, 1976), Sander (1975), Spitz (1945, 1946, 1965), and othe rs have provided a foundation for mak ing suc h assessme nts , a co m pre he nsive instrume nt fo r the psychiatri c eva luation of infants has been lacking. The need for suc h an instru ment was ar ticulated ove r a de cade ago by Cytry n (1968), who describe d a num ber of variabl es pertinent. to suc h an evaluation, including drive organization, inter perso na l relatio ns with th e mot her an d other people , affecti ve responses, fr us tratio n tolerance, cogn itive functioning, and co pin g strategies in r esponse to stress but gav e no clear outline as to how suc h assessme n ts m ight be carried o ut. In t his paper, we will desc ribe ex pe r iences with playroom laboratory parad igms t hat we have fo und use ful in evaluating in fan ts' socia l-emotional development. T he situa tio ns comprising t hese parad igms we re chosen with researc h and clinical interests in m ind sin ce o u r r esearch programs have involved co m par ing the pat terning of soc ial-e mo tional res po nses in normal infan ts with clin ically at -r isk populatio ns, inclu din g abused/neglected in fants and pre m ature in fants. B AC KGRO UN D
We bel ieve d tha t an ad eq uate eva luative instrument should in volve direct observation. Though many instru ments u tilized by pediatricians and chi ld psych iatr ists have invo lved parental re po r ts (T homas et al., 1968; Carey, 1970; Broussard and H artner, 1971 ), a n u m b er of studie s h a ve s ugges te d that p a r en tal r eports do not
consiste ntly provide an acc ura te picture of par e nting practices or of the sta te of the rel atio nshi p with the child (A insworth , 1973). Second, we beli eved t hat a n assessmen t instru me nt sho uld be standard ized in su ch a way as to allow for compar isons between infants . T he need for standardization re lates to t he co m plexity and variability of infant behavior. Exte nsive research has doc ume n ted great variation in in fant be havior, depe ndi ng o n context a nd st imul us conditions (Sro ufe et al., 1974). In order to d raw an y co ncl usions abo ut pa rti cul ar be haviors shown by a par ticular in fant, or to
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compare these to a normative standard, the stimulus conditions must be sufficiently consistent across infants to make valid comparisons. This principle corresponds to the relatively constant stimulus conditions that prevail in the psychiatrist's office or during psychological testing. Only after developing a set of ideas about "average expectable behavior" in a consistent context can one apply one's diagnostic barometer with confidence to the unique presentation of a particular patient. This point was articulated many years ago by Winnicott (1941), whose "set situation" was one of the early examples of a structured clinical assessment procedure for infants. Third, an adequate instrument should tap a broad variety of behaviors and assess multiple lines of development. In any comprehensive clinical examination a broad range of psychological functioning must be explored in order to obtain a balanced overall picture of the patient. In an interview situation, a variety of important areas are probed with detailed questioning and a thorough mental status exam. Similarly, an adequate infant examination must cover a range of qualities relevant to the infant's overall psychological functioning. The com plexities of social-emotional development and the fact that pathology is not likely to show itself in the same form or under the same conditions in every case provide additional arguments for assessing multiple facets of development. While the research literature on infancy covers almost all aspects of infant development, studies have usually focused on single dimensions and have limited their experimental protocols accordingly. It was our assumption that a number of experimental situations could be linked together to allow the infant to show his potentialities in multiple sectors. In seeking to elicit a range of functioning, a further consideration was that the infant would not always provide such information spontaneously. This provided a further argument for a standardized and structured paradigm. Since the infant is dependent to such a large extent on the outside environment for orientation, it seemed most practical to structure the observation session actively, with various stimulus conditions being brought to the infant, rather than depending on spontaneous behavior in an unstructured setting. Fourth, we felt such an instrument should represent an efficient use of time and be amenable to objective measures. The need for efficiency was a consideration in deciding to utilize a playroom laboratory situation rather than going into the home. The laboratory setting also makes systematic and reliable observations of the in-
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fant's behavior possible. Since the infant cannot tell us what he is experiencing, accurate observation of overt behavior constitutes the primary means of gaining insight into the infant's world. Although this has left room for the important contributions of the intuitively perceptive clinician, it has also created an undesirable potential for inappropriate or misleading adultomorphizing (Spitz and Wolf, 1946). The more objective observations are, the more convincing the conclusions are likely to be. A particular advantage of the laboratory setting is that the session can be videotaped or filmed, making it possible to go back over the observations many times. In this respect, research interests have served to facilitate our clinical understanding. We have utilized a number of research instruments with high interrater reliability to assess specific aspects of infant emotional and social behavior (Morgan et al., 1976, 1977; Durfee et al., 1977; Gaensbauer et al., 1979). The use of such rating instruments has served to discipline our observations and to sharpen our sensitivity to the meanings of the behaviors observed, while making the conclusions potentially verifiable by independent observers. Fifth, such an instrument should, as much as possible, allow for natural and spontaneous behavior on the part of the infant and the caretaker so that characteristic patterns of behavior may emerge. Even though situations must be structured to ensure that a range of abilities are tapped, within this structure both mother and infant are encouraged to deal with the various situations in the way that seems natural to them. METHOD
The situations we will describe have been utilized in a somewhat different order and with varying emphasis, depending on the purpose of the particular study and the population being studied. Rather than describe a single paradigm we will describe specific clements which have been common to all of our paradigms. Specific paradigms are summarized in the appendix with a brief outline of the purposes of each particular study. For each of the clements described we will outline the assessment criteria and the specific data upon which judgments of normal and deviant behavior were based. Our conclusions are based on the considerable research literature available and on our own samples of 60 normal infants assessed in groups of 20 at 12 to 13, 15 to 16, and 18 to 19 months of age; approximately 80 infants ranging in age from 3 to
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34 months who had experienced severely disturbed parenting (for purposes of comparison we will focus on a group of 14 from this sample who were between 12 and 21 months of age, tested with their biological mothers, and living with their biological parents at the time of the observation); 109 12-month-old infants from a high risk, low-SES population; and 30 low-birthweight (less than 1500 grams), premature infants compared with a control group of 30 fullterm infants at 12 months of age. Variables we have examined in these various populations include the patterning of discrete emotions (Gaensbauer et al., 1979; Gaensbauer, 1981), affiliative and attachment behavior (Harmon et al., 1979), and the quality and persistence of spontaneous play (Harmon et al., 1979, 1981; Jennings et al., 1979). Interrater reliabilities using raters unaware of the hypotheses of the studies or of the identity of the infants ranged from 0.52 to 0.92 with a mean of 0.73 for scales of discrete affect, from 0.60 to 1.00 with a mean of 0.89 for ratings of affiliative and attachment behavior, and from 0.84 to 1.00 with a mean of 0.94 for ratings of free play. In the following discussion we will describe only the findings that bear directly on the issues of clinical assessment. LABORATORY PARADIGMS
Free Play Period with Mother and Infant
The situation we used in the initial phase for all of our playroom studies was a free play period involving the mother and the infant. It varied in length, depending on the particular study, but was utilized to observe a number of common phenomena. The initial two minutes were described to the mother as a warm-up period; she was instructed to make the infant comfortable and to put him or her in a good mood. Even in these first minutes one can begin to distinguish those mothers who have the capacity to "tune in to their infants" and to observe the degree to which mother and infant can involve themselves in mutually pleasurable activity. In general, mothers let their child take the initiative, while they facilitated and expanded on the child's play in a contingent manner. This way of relating contrasted with those mothers who were more directive, intrusive, or unable to respond appropriately at the child's level. Some mothers seemed almost oblivious to the child's activity, exhibiting "parallel play" rather than reciprocal interaction. Often it was the child who revealed the
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usual nature of the mother-infant interaction most clearly. If unused to reciprocal play, the infant was likely to disregard the mother and play in the independent manner to which he or she was accustomed, despite active efforts on the mother's part. Following the initial warm-up period of two minutes the mother was signaled to take a seat in a chair approximately eight feet away from the toy pile. At this point the initiative for interaction passed to the infant, who had a choice of playing with the mother or the toys. In our normal samples infants involved themselves with both. The mother was used as a "secure base" (Ainsworth, 1973) from which to explore; the infant would maintain a dialogue with her, intermittently checking with her visually or verbally) or through direct initiative inviting her to share in the play. Mahler et al. (1975) have described a similar phenomenon, terming it "emotional refueling." The animated atmosphere of mutual enjoyment which characterized most of our normal sample was in striking contrast to the mother-infant pairs who were alienated from each other or who lacked the capacity for mutual enjoyment. In a recent study of emotional expression, a grou p of twelve 12- to 19-month-old abused/ neglected infants, when compared with a normal group, showed both significantly decreased amounts of pleasure as well as significantly less interest in physical, verbal, and/or visual contact with their mothers (Gaensbauer, 1981). In an earlier study involving 36 normal children, Harmon et al. (1979) found that infants showing low interest in the mother (defined by the lack of bids for attention directed toward the mother during a free play period) tended to show negative reactions to being approached by her, failed to show evidence for a "secure attachment" to her (see below), and did worse on measures of cognitive competence. At the other extreme from the excessively independent child is the depressed or anxious infant who is unable to leave the mother's proxi m it.y or whose capacity to explore is limited (Airrswo rt.h et al., 1971; Gaensbauer and Mrazek, 1981). The free play situation also allows the infant's competence in relation to the inanimate world to be assessed in terms of his or her capacities for exploration, initiative, persistence, and level of cognitive maturity. Does the infant show confidence in the novel situation, explore items in depth, combine items in creative ways, and persist in the face of obstacles? Or is the play immature, stereotyped, and characterized by frequent seemingly random moves from object to object?
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Qualitative differences in play are documented utilizing detailed scoring systems which assess the different kinds of play and levels of cognitive complexity observed over the infancy period. From 12 to 18 or 19 months, infants move from less cognitively mature play, such as passive exploration (looking, passive contact, or mouthing), to more active manual investigation of toys, to increasingly appropriate use of specific toys, such as combining toys in creative ways, and finally, to thematic or pretend play (Harmon et al., 1980). Com pared with the normal sam pIe the 14 abused/neglected infants not only showed less positive affect, less proximity to their mothers, and less social play (confirming findings from the study of emotional expression), but also showed marked disturbances in the quality of their play. They showed less overall mobility and active exploration, more passive exploration, and much less "high level" play such as combining items or thematic play. They also tended to play with fewer objects, reflecting inhibitions and tendencies toward stereotyped, repetitive play. In contrast, the premature infant populations showed a different trend. Although showing cognitive play of equal maturity once corrections were made for gestational age, pre matures, in comparison with fullterm infants, were less mobile and active in moving about the room and spent more time in close proximity to and in contact with the mother. These findings, in conjunction with interview data and observations at other points in the laboratory session, lend support to the impression that these infants have a closer and perhaps "overprotected" relationship with their caregivers (Beckwith and Cohen, 1978; Goldberg, 1978; Harmon, 1979).
Stranger and Mother Approaches The second situation common to all of our studies involved an approach of the infant by an unfamiliar person, a "stranger," followed by a similar approach and pickup by the mother. Based on our earlier work and previous studies of other researchers on infants' emotional responses to a "stranger's" approach, we anticipated that most infants would show some degree of wariness, ranging from intense fearfulness and avoidance to very mild shyness and coy behavior (Gaensbauer et al., 1976; Harmon et al., 1977; Bretherton and Ainsworth, 1974). A negative reaction, however, is by no means constant; some infants are immediately friendly (Rheingold and Eckerman, 1973). From the clinical point of view, we believe that the most important information to be gained from this segment derives from the comparison of the in-
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Iant's affective responsivity to the stranger with his or her responsivity to the mother. Both common sense and several systematic studies led us to expect that the infant's response to the mother would be more positive than, or at least as positive as, the response to someone whom he or she has just met (Klein and Durfee, 1976; Harmon et al., 1979). In the Harmon study, the finding of a more negative affective response to the mother than to the stranger was the most powerful predictor of low scores on the Bayley Scales of Infant Development and competence in playas well as being highly associated with decreased involvement with the mother. Our recent study of 60 normal infants illustrated the rarity of this pattern; only 6 (l 0%) of 60 infants showed a distinctly more positive reaction to the stranger. By contrast, out of the sample of 14 abused/neglected infants, 6 (35%) showed a more negative affective response to the mother. Strikingly, in the study of emotional expression referred to earlier, the only times that the sam pic of abused/neglected infants showed more pleasure than the group of normal infants involved situations in which the infants were interacting primarily with the stranger (Gaensbauer, 1980). The stranger approach also provided an opportunity to observe the extent to which the mother is used as a source of security. Most noteworthy from a clinical standpoint are those infants who are obviously distressed or wary of the stranger, but who do not look to the mother for comfort. Developmental Testing We used a structured developmental testing situation for a number of purposes. In this situation, the infant sat on the mother's lap across a table from the examiner, who presented the infant with a series of structured tasks. Like most other workers in the field, we used the well-standardized Bayley Scales of Infant Development to obtain an estimate of the infant's cognitive development. Scores I'ro m the abused/neglected sa m plc were, as a group, well below the
norms established for this test, providing evidence for the destructive effects of abuse and neglect on ego functioning and cognitive development (Gaensbauer et al., 1981; Martin, 1976). Other test instruments may readily be used to evaluate a variety of specific mental abilities (Uzgiris and Hunt, 1975). The testing situation provided measures not only of the infant's mental capacity but also demonstrated the infant's capacity to cooperate in play and his willingness to follow the directions of others. The structure of the situation also allowed the experi-
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menter to examine a number of specific aspects of the infant's behavior. For example, a peek-a-boo game served as a direct measure of the infant's social responsivity and capacity for a pleasurable engagement. Several elements of the testing situation provided an opportunity to observe the infant's frustration tolerance. Moving from one task to the next involved a potential frustration for the infant. In several studies these mild frustrations were purposefully standardized. For example, a ten-second delay between each of the first five items was structured into the situation. We also introduced a "barrier" task, in which a desired toy was placed in a box with a seethrough plexiglass top. The infant's degree of confidence about the fulfillment of his wishes and his sense of initiative were nicely illustrated during this phase. Due to problems of standardization in our initial studies, we did not utilize objective measures in this situation, and can therefore only speak from clinical experience. Children generally showed some mild protest behavior and/or visual or physical pursuit of the items during the pause between items. At the same time they demonstrated a capacity to delay and immediately took up the next item once it was presented. Our experience with the abused/ neglected infants suggested that extreme responses at either end of the frustration continuum were cause for concern. There were infants who passively accepted the comings and goings of toys with no protest or pursuit at all, revealing their sense of helplessness and resignation. There were also children who showed highly disruptive temper outbursts, throwing toys and/or withdrawing from the situation completely by turning away or squirming to get down. A mild verbal prohibition Cno-no") was also administered at some point in the testing. This was particularly informative in cases of abuse. An almost pathognomonic sign of harsh discipline is the child who, in response to a very mild prohibition, freezes in posture, looks extremely sad or fearful, or fails to recover for a prolonged period. A most dramatic instance of this was a 16month-old infant who responded to the examiner's encouraging hand gesture directing him to put several cubes in a cup with a terrified look, crying, and visible cringing, as if he anticipated being struck across the face. This infant had been hospitalized several months earlier with a skull fracture. Responses such as these have not been seen in normal samples. The infant's intrinsic motivation to have an effect on and to master his environment (White, 1963) was also assessed in the testing
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situation. For the premature sample a separate session involving a series of nine tasks was utilized. What is assessed is not simply whether the child solves the task, but his or her persistence in working at the problem. Preliminary data indicated that premature infants have a longer latency before becoming involved in tasks than do fullterms and show a narrower range of affect during testing. They also have been generally less persistent at more complex tasks, preferring tasks related to noise and visual effects to more cognitively demanding tasks involving combinational abilities and the solving of "barrier" problems (Doyle, 1979; Harmon, 1979). A description of the tasks is provided in the appendix to this paper. Though we did not em phasize maternal variables in our research instruments, the mother's capacity to facilitate the infant's performance could be observed during the testing situation. Typically, mothers helped the child to focus and structure the task by providing an organizing presence without intruding upon the child or taking over. One can observe the extent to which the mother can allow the child to perform at his or her own level without her own self-esteem being so tied up with the performance of the child that her expectations become unrealistic or she provides inordinate help. The potential for power struggles between parent and child often became evident in this portion of the session. Separation and Reunion Sequences The last portion of the evaluative session consisted of a brief separation and reunion sequence. First, the mother was instructed to leave the room for 3 minutes, departing as if she were leaving the child with a babysitter. A number of studies have provided evidence that the quality of the infant's "attachment" to the mother may be revealed in the infant's response to this event (Ainsworth et £11., 1978). In these studies the most revealing element in the sequence has been considered to be the infant's reunion behavior (Sroufe and Waters, 1977). Even if they were not distressed, infants considered to be "well attached" greeted the mother promptly with a positive acknowledgment and more often than not sought close proximity. If distressed, they immediately and unambivalently sought comfort from her (Ainsworth et £11., 1971). Our own studies indicated that there was, in general, a prompt recovery from any distress soon after the mother's return; usually within several minutes the infant's good mood was restored (Gaensbauer et £11., 1979).
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Responses that we considered cause for concern were again those at either extreme of the continuum. At one extreme were infants who showed no evidence of missing the mother or who expressed continuing anger by "snubbing" and "avoiding" her on her return. At the other extreme were infants who were highly distressed and not easily soothed, or who showed persisting anger by resisting the mother's efforts to comfort them. A series of studies summarized by Ainsworth et al. (1978) and Sroufe and Waters (1977) have demonstrated the validity of this classification based on reunion behavior. "Avoidant" and "resistant" patterns of reunion behavior were shown to be associated with less sensitive, less accepting, and more intrusive caretaking in the home (Ainsworth et al., 1978). As a group the "well attached" infants showed greater competence both in problem solving and in social relations (Sroufe and Waters, 1977; Matas et al., 1978; Arend et al., 1979). Our own experience has certainly supported the clinical relevance of these findings. Of the 14 infants in the 12- to 21-month-old abused/ neglected sample, 11 were either resistant or avoidant based on Ainsworth's classification. Observation of the mother's response to the introduction of a stress in the infant-caretaker relationship, such as a brief separation, can be extremely informative. If the infant cries, the mother cannot help but feel to some extent responsible. She may interpret this distress in a positive vein, indicating her importance to the infant, or she may react negatively, feeling overly guilty or angry and attempting to minimize the child's "dependence" on her. During the reunion, mothers were quite aware of the infant's reaction. A positive greeting from the infant was quite pleasing to the mother. In contrast, infants who ignored their mother's presence evoked remarks of disappointment such as "I might as well not have come back. He didn't miss me." (Gaensbauer and Sands, 1979). A depressive mother who relied on her infant to cheer her up became tearful during the reunion and plaintively asked her infant to forgive her for having previously left him. Another mother, whose self-esteem depended on her belief in the infant's need for her, was so distraught at her infant's avoidance of her upon her return that she needed immediate psychiatric intervention. In severely disturbed mother-infant pairs, where little capacity for the resolution of conflict was present, angry interchanges and intense distress continued for the remainder of the session and beyond (Gaensbauer et al., 1981; Gaensbauer and Mrazek, 1981). In the last phase of the sequence, 2 minutes after the mother's
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ret ur n, the stran ger was instructed to leave th e room for 3 minutes. Aga in , a co m par ison may be mad e bet ween the st ra nger and th e mother. In the sa m ple o f th e 14 abused/n egle cted infants disc usse d abov e, 3 of th em showed more po sitive greeting behavior to the stra nge r than to th e mother ; one showed a full ran ge of "a ttachment" behavior to th e stra nge r rather th an to th e mother, including sea rc h behavio r a nd di stress followin g the se par atio n, a nd positive greeting a nd p ro ximity seekin g o n reunion (Gae nsbauer e t aI., 1981 ). In co ntras t to th e ab use d sa m ple , o nly 3 o f 60 in fan ts in th e normal sa m ple show ed more positive gree ting to th e strange r; all 3 o f these infants we re highly avoid ant o f the mother, an d showed a disturba nce in attachment behavi or accor d ing to Ainsworth's classification s. T he most dramatic occurrence of a discrimination in favor of the st r an ger in the premature sa m ple involved an infant who had experienced very activ e a nd inv ol ved paternal caregiving. Because of the mother's concern ab out the infant's preference for the strange r, as well as her awareness o f her own di fficulty in "wa r m ing up" to t he infant followin g the difficult ea rly months, a follo w-up visit was sche d uled. At 15 months the infant had de veloped a clear a nd appropriate attachment to his mother , as indica ted b y his dis tress res po nse s whe n the stra nge r picked him up as we ll as wh en t he mother left th e r oom durin g the separati on. The o p po rtu n ity to obse rve this shift was very meaningful to th e mot he r, serv ing to co nso lidate her growin g co n fide nce abo u t the ch ild's su rv ival and valida ting her increa sin g e mo tio nal in ves tm ent in t he c hild . DI SC USSIO N
In utilizin g these vario us situa tions, re gard less of the orde r in wh ich th e y were presen ted , we ex posed the infa nt to a series of st im uli, tapping a broad range of emotional a nd soc ial behavior. Many , if not most of the facets of the ideal ps ychiatric e valuatio n as o u tline d by Cytryn (19 68) have been incorporat ed in some manne r. Clinicia ns can obs erve the range of emotion al responding, the o rga nizatio n of social behaviors, the quality of th e rel ationship betwee n mother and infant, th e d egree of co m pe te nce in relation to t he e nv iro n me nt, th e ca pacity to sus tai n orga n ized e ffo rt, and the ability to play coo pe ra tively . At th e sa me tim e , we would not wish to im ply that th e elements d escribed here are the o nly useful ones. As ca n be seen fr om th e a p pe nd ix, we ha ve made usc of vario us situa tio ns in different ways, d epending o n th e population to be
27 6
Theodore) . Gaensbauer and R obert). Harmon
st ud ied and the particular d e velopmental a reas o f greate st interest. A few e xamples of situation s t hat other in vestiga tors ha ve e ffectively utilized include a fee d ing situatio n (Bro dy, 1956 ; Ainsworth a nd Bell , 1969), coo pe rat ive tasks requirin g the participation of both mother and in fant (Ma tas e t al. , 197 8 ; Als, 1981 ), and un structured face-to-face pl ay (Ste rn , 1971; Brazelton et al. , 1974; Tronick c t al. , 1979). Regardless o f th e particular situatio ns chose n, we would r ecommend tha t th e y be adequa tely str uc tu r ed so th at a basis for co m parison a mo ng individual in fants is present. Even th ough thi s kind o f eva lua tio n ca n be extre me ly useful, seve ral cave a ts arc in orde r. First, the age of th e in fant must be conside re d . There is consid erable e vid e nce from stu d ies in our own lab oratory, as well as in ot he r laboratories, that fr om a group standpoint, social and affect ive responses to the kind s of stimulus situations utilized here are co ns iste n t over the 12- to 18-month age ran ge (Sroufe and Waters, 1977; Vaughn et al. , 197 9 ; Gaensbauer, 1981). In our opinion th e patterns of response d escribed in this paper a re m ost informative in infants between the ages o f 9 and 21 months. Though the situa tio ns themsel ves arc re leva nt to infants yo u nge r than Y months, th e cogn itive immaturity a nd d ecreased mobility o f yo u nge r in fants wo uld necessitate so mew ha t different assessm ent cr ite r ia . Beyond the age s of 21 to 24 months, man y infan ts ha ve d e veloped su fficie n t evoca tive memory a nd language a bility so that situati ons suc h as a str a n ge r approach o r a threeminute maternal separati on a re no longer hi ghl y e motion ally cha rge d e vents. T he methodology d escribed here requires not o nly training and ex pe r ie nce in the use o f th e paradigms d escribed , but exte ns ive clinical e x pe r ie nce wit h th e populations under study, suc h th at o ne has a tho rough understanding o f the ran ge o f normal beha viors to be ex pec ted. In addition , the infant-centered e valuation d escribed here is best utilized in co n ju nc tio n with a com plete e valuatio n of th e par ents, so that the infant's behavior may be placed within the o verall car e ta king context. It is best to be conservative about drawin g inferences from a single se t of observations , co ns ide r in g the co nsta n tly changing and e volving character of d evelopmental processes. T he exa m ple o f t he p remature infant who see me d to prefer th e male stranger to the mothe r at 12 m onths of age but was avoida nt o f the st r a nger at 15 month s of age und erlines th e importance of be ing aware o f cha nges in the d e velopmental process. At the same lime , a single extre me reaction in th e co nte xt of otherwise normal beha vior ma y be highl y info r m ative. T he in fant who visibly cr inged at the exa m iner's gest ure had been in a fo ster home for
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several months; except for this striking reaction, repeated twice during developmental testing, he showed normal "attachment behavior" to his parents and no other evidence of developmental disturbances. Except in dramatic instances such as the one just described, we generally did not utilize the laboratory situation to make direct inferences about specific experiences in the home. We tended to interpret deviant reactions as indicators, rather than as hard evidence, of potential disturbances in the caregiver-infant relationship. They give cause for further examination, corroborate impressions gained from psychiatric evaluation of the parents, and help to focus attention on specific areas of parent-child interaction to be addressed.
ApPENDIX
This appendix describes two examples of the use of a structured experimental situation for clinical assessment in infancy. The first one-session situation was designed to study the regulation of affective expression in normal and abused/neglected infants. The second two-session paradigm was designed to study attachment, cognitive-motivational development, and affective development in term and pre term infants. One-Session Paradigm 1. Mother and infant enter: "Make infant comfortable" 2. Infant free play with mother present 3. Stranger enters, stranger approach a. Talk to mother minute b. Talk to infant minute c. Give-and-take minute d. Pick up infant 1 minute 4. Mother approach (similar to stranger approach) a. Give-and-take b. Pick up infant 5. Developmental testing with mild frustrations 6. Stranger and infant engage in interactive play 7. Mother leaves-separation 8. Mother returns-reunion 9. Stranger leaves 10. Stranger returns
2 minutes 5 minutes 4 minutes
2 minutes
15-30 minutes 1 minute 3 minutes 2 minutes 3 minutes 2 minutes
Two-Session Paradigm 1. Mother and infant enter: "Make infant comfortable" 2. Infant free play with mother present 3. Stranger enters, stranger approach
2 minutes 2 minutes 4 minutes
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4.
5.
6. 7. 8. 9. 10.
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a. Talk to mother minute b. Talk to infant minute c. Give-and-take minute d. Pick up infant I minute Mother approach (similar to stranger approach) a. Give-and-take b. Pick up infant Free play a. Record the first 2 minutes (min. 0-2) (Min. 0-1 begins when the mother has left the infant alone on the Hoor to play with the toys and moved to her chair for interview.) b. Tape off during minutes 3-7 c. Record minutes 8-22 Stranger and infant engage in interactive play Mother leaves-separation Mother returns-reunion Stranger leaves Stranger returns
2 minutes
2 minutes
5 15 1 3 2 3 2
minutes minutes minute minutes minutes minutes minutes
Mastery Motivation Testing Session A. Tasks Nine tasks are given in the same order to each infant for a 3-minute trial. The tasks are divided into three conceptual clusters: (1) Effectance production, or tasks which allow the infant to produce interesting effects (surprise box, toaster, forest); (2) problem solving, or tasks in which the infant seeks a toy from behind a barrier (barn door, object permanence, barrier box); and (3) practicing emerging skills, or tasks in which infants put one object into another (pegs in boat, dropa-ball, and shape sorter). Our key measure on these tasks consists of the percentage of time each infant engages in persistent goal-directed behavior (Jennings et aI., 1979). B. Administration of object permanence scales (Uzgiris and Hunt, 1975). C. Administration of Bayley Scales of Mental Development
These two paradigms and the particular sequences of events have been designed to study specific aspects of development in specific populations as described above. Other sequences may be relevant, depending on the interest of the clinician or researcher. Our major emphasis is not on a specific sequence, but rather on the importance of a structured systematic approach for the clinical assessment of infants.
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