For additional material related to the content of this chapter, please see Chapter 2, Chapter 3 , and 6.

Vignette

Rosaria is tightly swaddled as the midwife hands her to her mother. Following a 36-hour labor, her mother is exhausted but grateful to hold her baby for the first time. Rosario instinctively nestles into the crook of her mother’s arm and turns her head toward her breast. Awkwardly, she attempts to find her mother’s nipple, but when she finds it, she is too tired to suckle. She calmly rests there by her mother. Over the next few hours, she learns to breastfeed, looks toward her mother’s adoring face, and turns to her mother’s soft voice. In 24 hours her mother takes her home. Rosario joins a household with four older siblings, her grandmother, and another family. She breastfeeds every 2 to 3 hours, and she lets her siblings gawk and poke at her, when she is alert, and cries when she gets drowsy. Her mother returns to work after 2 weeks at home. At that point, Rosario is cared for primarily by her grandmother and siblings. Her parents work long hours to provide the financial resources for their family, limiting their time with Rosario and her siblings. Nonetheless, Rosario continues to thrive in her loving family.

“There is no such thing as a baby, only a baby and an adult.” Winnicot

Introduction

Following birth, infants do not stand alone but continue to be part of an ex utero external dyadic regulatory system. Parents provide resources to supplement the infant’s capacity to regulate homeostasis. Infant crying, sucking, wriggling, lidded eyes smiling are the external behaviors that signal the need for a caregiver to respond by providing the support the infant needs. These events influence what happens next in the child’s life. In many ways the development in the first year of life has the steepest trajectory of developmental changes and brain growth of any other developmental epoch. The rapid changes integrate infants into their social world and simultaneously allow them to begin to function autonomously, if only in limited domains. However, social conditions and governmental policies can influence the earliest stages of infant development. Infants need at least one responsive caregiving adult; nonparental guardians can fit the bill under circumstances, as we have seen in the opening vignette.

This chapter discusses the multiple developmental processes that occur during the first year of life. For each developmental process, possible normal variations and indications for clinical concern are described. The theoretical foundation of the chapter is the transactional model ( ), which asserts that infants, caregivers, and their environment mutually determine the child’s developmental and behavioral outcome (see Chapter 2 ). Seen in these terms, child development is more than a two-way street; it is an intimate and complex interaction. Caregiving, through good times and adversity, impacts the child’s neurophysiology and structural changes in the brain; the social environment becomes embedded in biology.

Neurologic Indicators of Neonatal Maturity

State Organization/Sleep

Healthy full-term infants display a regular series of distinct states over time. The study of behavioral states in infants has attracted wide interest as an indicator of the functional integrity of the central nervous system (CNS) during the fetal, neonatal, and infant periods of development ( Table 6.1 ). Maturational changes in neonatal state periodicities have been correlated with later neurodevelopmental outcome; earlier maturation of electrophysiologic and behavioral patterns of quiet sleep in the newborn period predict higher performance on cognitive tests at preschool and school age ( ).

Table 6.1
Neonatal State Classification Scale
Adapted from Brazelton, T. B. (1984). Neonatal Behavioral Assessment Scale (2nd ed.). Heinemann.
State Characteristics
Quiet sleep Regular breathing, eyes closed; spontaneous activity confined to startles and jerky movements at regular intervals. Responses to external stimuli partially inhibited, any response is likely to be delayed. No eye movements, and state changes are unlikely after stimuli or startles than in other states.
Active sleep Irregular breathing, sucking movements, eyes closed. Rapid eye movements detected underneath the closed lids. Infants also have some low-level and irregular motor activity. Startles occur in response to external stimuli and can produce a change of state.
Drowsiness Eyes may be open or closed; eyelids often flutter; activity level variable and interspersed with mild startles. Drowsy newborns are responsive to sensory stimuli with delay, and state change frequently follows stimulation.
Alert inactivity A bright alert look, with attention focused on sources of auditory or visual stimuli; motor activity is inhibited while attending to stimuli.
Active awake Eyes open, high motor activity, thrusting movements of extremities, and occasional startles set off by activity; reactive to external stimulation with increased startles or motor activity. Discrete responses are difficult to note because of general high activity level.
Crying Intense irritability in the form of sustained crying, and jerky limb movement. This state is difficult to break through with stimulation.

Sleeping and waking states in infancy reflect the competency of the CNS, and they modulate the infant’s interactions with the external environment. An infant’s behavior differs, depending on whether the infant is in a sleep, drowsy, or alert state, as described in the vignette. A visual stimulus that captures the attention of a quietly awake infant does not elicit a response from an aroused, crying infant. Cyclic activity of the autonomic nervous system mediates the infant’s responsivity to the external environment and regulates numerous homeostatic functions. Neonatal behavioral and psychophysiologic measures of state organization highlight maturational differences between preterm and term infants that could affect their responses to caregiving (see Chapter 34 ). Overall, sleep regulation and consolidation represent critical developmental processes that occur in the first years of life.

Clinical Implications

The infant’s control of state, responsiveness to environmental input, and sleep-wake patterns show wide individual variations. A crying infant who quiets down when picked up and a drowsy one who becomes wide-eyed at the sound of mother’s voice delight caregivers. Infants who cannot sustain an alert, receptive state unless assisted by an adult who swaddles them or gently restrains their hands may challenge adult caregivers. Methods to assist such infants in maintaining alertness include swaddling them and minimizing extraneous sounds or images when the infant is trying to focus.

Clinical supervision of sleep disorders requires an understanding of the normal developmental and individual variability in children’s sleep patterns. Newborns typically sleep 16.5 hours per day, 6-month-olds sleep approximately 14.25 hours, and 1- to 2-year-olds sleep approximately 13 hours a day including naps ( ). The clinician can help parents devise strategies that gradually mold the infant’s innate biologic rhythms into socially convenient patterns (see Chapter 70, Chapter 92 , which specifically discuss clinical interventions and sleep). New parents may require help with distinguishing active or rapid eye movement (REM) sleep occurring every 50 to 60 minutes with waking. Infants moan, groan, move around, and may even open their eyes while in REM sleep, which uninformed parents may interpret as a signal to feed or intervene, leading to waking up a sleeping baby and delaying the development of sustained sleep.

Sensory Maturation

Sensory systems undergo rapid changes during the last trimester of pregnancy and the first several months after birth. An orderly sequence characterizes the functional development of the sensory systems of infants in utero ; the tactile and auditory systems develop early. The visual system is the last sensory system to start functioning during gestation and the least well developed at birth. Sensory abilities in infants mature rapidly during the first year of life. The newborn’s vision is optimal at 19 cm, a visual acuity of about 20/120. By 8 months of age, visual acuity improves to 20/30, nearly as good as normal adult acuity.

Clinical Implications

Parents subliminally monitor their infant’s responses to sensory input and modulate input to enhance the infant’s responsiveness. A mother may move her head slowly back and forth until the infant’s expression signals that her face is in focus. Parents slow the tempo of their speech and elongate and amplify words, often called parentese, to maintain infant’s attention. Research shows positive brain-related changes in response to parentese versus normal adult speech cadence ( ).

The Brazelton Neonatal Behavioral Assessment Scale (NBAS) was developed by T. Berry Brazelton and colleagues in the early 1970s to measure newborn behavior, to identify and understand normal variability, and to know the impact of prematurity and drug exposure on behavioral functioning ( ). The NBAS has been shortened to the Newborn Behavioral Observation (NBO) tool to train clinicians to be observers of newborn behavior, respond effectively to newborn needs, and be utilized as a clinical relationship-building tool ( ).

Colic is a common condition that is likely related to temperamental characteristics of low sensory threshold to stimulation. Colic typically resolves in a predictable time course by 3 months with or without medical therapy in most cases. The most important role of the health care professional in colic is to educate, reassure, and support families ( ).

Clinicians may need to provide explicit guidance for families whose infants are unusually hypersensitive or unresponsive, which is common among premature or small-for-gestational-age infants. Sounds and sights that are attractive to most infants are aversive to hypersensitive infants. Although most infants prefer to track a moving face that is making sounds, hypersensitive infants may avert their gaze, vomit, or startle when confronted with simultaneous visual and auditory stimulation. With these infants, stimulation can be adaptively offered to one sense at a time. Extraneous stimuli, such as bright lights and loud music, should be decreased. When parents express concern that their infant does not seem to hear or see, the infant should be formally assessed.

SOCIAL-emotional development

Attachment

Attachment describes the enduring and specific affective bond that children develop with caregivers. The infant’s behavior signals, including crying, fussing due to hunger or cold, quiet alert, and sleepy, are learned through trial and error. These behaviors allow caregivers to respond effectively to meet the infant’s needs leading to feelings of safety and security. Maternal depression, other mental health problems, alcohol and drug use, and domestic violence can interfere with understanding and responsiveness, which may be experienced by the infant as a stress or adversity (see Chapter 5 ). As we saw in the opening vignette, the primary caregiver may not be one of the parents. It may be other family members or childcare providers who interact with the child regularly.

The infant also contributes to this dyadic relationship. An alert infant who reacts readily to parents’ faces and responds promptly to consoling maneuvers enhances parents’ positive feelings and a sense of competence. A drowsy, relatively hypotonic infant who provides less satisfying feedback may diminish parents’ emotional satisfaction.

Security of attachment is predicted by (1) caregivers’ current representations of their own childhood experiences as expressed by their attachment experiences and (2) caregivers’ sensitive responsivity to their infants’ cues during the first year of life. Self-understanding of their upbringing enhances the adult’s ability to be good parents. Clinicians can support parents’ self-understanding by asking key questions ( ).

Most families require several months before they learn to identify and respond effectively to their infant’s needs for food, rest, or social interaction. By 3 months of age, the child and caregivers achieve social synchrony manifested by reciprocal vocal and affective exchanges. Adult displays of pleasure are followed by smiling, cooing, and movement in the infant.

The next important step in the attachment process is the development of a clear preference for primary caregivers. By 3 to 5 months of age, an infant stops crying more readily for familiar caregivers than for strangers. Infants usually smile sooner and more brightly for their parents than for other adults, and this clear behavioral preference enhances the parents’ formation of positive emotional ties to their infant.

Initially, attachment figures provide a sense of security through their physical presence. Later in the first year, infants internalize their relationship with attachment figures, leading to an internal model of security. By 18 months of age, infants can conjure an image of the attachment figure in their mind (memory), which helps comfort them when the parent is not present.

The creation of a secure relationship of attachment requires consistent availability of adults who are affectionate and responsive to the child’s physical and emotional needs. The adults are often the infant’s parents, but, as in the vignette, may be other caregivers, based on circumstances. Other factors include mutuality and synchrony, stimulation, positive attitude, and emotional support. Without a secure home base, infants cannot move outward effectively.

Children given the opportunity to develop a secure relationship are better able to build positive relationships with peers and unrelated adults and to cope with stress than children without a home base.

The research method commonly used to describe infant attachment is the strange situation ( ). The purpose of this classic paradigm is to assess the quality of an infant’s attachment to parents and to evaluate an infant’s capacities for coping with stress when a parent leaves the infant’s presence and then returns. Attachment theory describes four categories of response at the time of reunion with the caregiver ( Table 6.2 ).

Table 6.2
Categories of Attachment Based on the Strange Situation Classificationa
Category Description
Secure attachment
  • 1.

    Reunites with the caregiver and uses the caregiver to become calmed

  • 2.

    Returns to play quickly

Implication: The child’s signals have typically be responded to in a respectful, caring manner. This pattern is associated with development of later positive social relationships.

Avoidant attachment
  • 1.

    No overt response to the return of the caregiver

  • 2.

    Continues play as though the caregiver did not leave and return

Implications: This pattern suggests the child’s signals are rarely perceived or responded to in an effective manner. Avoidant attachment predicts later difficulty relating to peers and the emergence of a poorly developed sense of self.

Ambivalent attachment
  • 1.

    Turns to the mother upon reunion, but become fretful and not easily soothed

  • 2.

    Does not return to play

Implications: This pattern predicts a later level of uncertainty and anxiety in social situations.

Disorganized attachment
  • 1.

    Chaotic and/or self-destructive behavior upon reunion

  • 2.

    Does not return to play

Implications: This pattern is ascribed to recurring situations when a parent repeatedly causes a state of fear in a child, by expressing excessive anger, withdrawing, or creating a setting in which the child is offered no hope of comfort or safety, or no relief from distress.

a The category is defined by the child’s behavior on reunion after a brief separation.

Clinical Implications

The clinician should attempt to identify parental problems, such as depression, excessive drug and alcohol use, and/or past or concurrent adversity (see Chapter 5 ), which can interfere with sensitive responses that are needed for secure attachment. A two- and three-generation family history often has important implications for the preventing or mitigating intergenerational transmission of mental health conditions.

Clinicians are able to observe and reinforce parent behaviors that promote attachment. When a parent attends to the infant’s signals and interest, engages in a shared moment of communication, and shows enjoyment in the infant’s face and voice, clinicians should acknowledge the parent’s responsiveness. Conversely, if parents exhibit a monotone with their baby, impatience with diaper changes, or emotional disconnection, clinicians should inquire about the parents’ feelings and practices in an effort to detect whether the family may require enhanced support. Clinicians can model responsive joyful interactions with the child to coach parents unobtrusively and respectfully to explore the relational capacity of the child. Clinicians may consider using a digital application, such as , developed for new parents with weekly segments for the first 6 months to promote parent and infant emotional wellbeing.

When mothers do not respond to their infant’s attempts to get their attention, often called a mismatch, the infant responds with distress as indicated by crying, turning away, and jerky movements. This infant response is normal, inevitable, and occurs commonly while parents are driving, cooking, or speaking on the phone. Mismatches are “repaired” when caregivers eventually respond to their infant’s distress. After repair, young infants often show joy in the reconnection, likely indicating a sense of trust. This sequence is one of the origins of empathy development. Alternatively, when mismatches are not repaired most of the time, the infant’s secure attachment may be undermined, and neurophysiology may be disrupted.

Separation

Negotiation of separation, both psychological and physical, poses a continuous challenge to parents and children. In Mahler’s theory, separation refers to the internal processes by which the child evolves a satisfying identity as an individual, distinct from the parents ( ). Physical separations may enhance or impede the child’s ability to develop a comfortable individuality. Responsive caregivers encourage the infant’s security and independence. A complementary process of acceptance of the child’s internal separation occurs within the parents. Some parents accept an infant’s total dependence and have difficulty tolerating a toddler’s striving for an independent identity.

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