Mental health of adolescent mothers.

OBJECTIVE: To propose an assessment and intervention model for adolescent mothers that evaluates the influence of physical, cognitive, affective, and interpersonal development on such areas of psychological dysfunction as unprotected sexual activity, substance abuse, and psychopathology. METHOD: More than 100 studies were reviewed to identify correlations between discrete developmental events and evidence of psychological dysfunction in adolescent mothers. RESULTS: The adolescent's nascent developmental skill in one domain of functioning (e.g., cognitive) frequently exerts a synergistic effect on other areas of functioning (e.g., affective). This synergy increases the likelihood of psychological dysfunction. In turn, psychological dysfunction affects the emerging relationship between the adolescent mother and her infant. CONCLUSION: The interaction between the nascent developmental status of the adolescent caregiver and her psychosocial environment enhances the probability of a maladaptive exchange between mother and infant. A model designed to overcome the adolescent's developmental limitations and promote adaptive interaction with the infant may avert dyadic interpersonal failure.

Use of developmental principles to decipher the narrative of preschool children.

The narratives of preschool children differ from the narratives of adults in several respects that are of clinical relevance. First, children's narratives reflect their immersion in the sensory dimensions of experience. Second, children use distinctive forms of language. Third, although the child's memory capacities are comparable with those of the adult, the child's proximity to the pivotal interpersonal events of early life leads to the forceful insinuation of these events into the narrative. Fourth, during the preschool years certain behaviors associated with defensive operations, previously used to achieve adaptive developmental goals, may now be used pathologically to disguise the presence of conflict. Fifth, during play situations, children rely heavily upon symbolic fantasies to enact key experiences. Sixth, the distinction between appearance and reality has not yet consolidated for young children. Seventh, although children are avid storytellers who generate "scripts" with elaborate characters and plots, their ability to engage in symbolic thought is still undergoing maturational change. The unique developmental features of childhood narrative warrant the use of specific strategies to effect diagnosis and treatment.

Treatment strategies for a case of concurrent pervasive developmental disorder and cerebral gigantism.

A 4-year-old girl presented for a psychiatric evaluation with reported episodes of clumsiness, aggressiveness, lack of relatedness, and temper tantrums. Her evaluation disclosed multiple developmental deficits, including cognitive, affective, and social lags. Given her individual history and her specific constellation of symptoms as well as a familial history indicative of developmental impairment, the child was diagnosed as having pervasive developmental disorder. This diagnosis reflects the expanded nosology for autism, as specified in DSM-III-R. Subsequently, after a genetic evaluation, the child was found to have an organic central nervous system deficit in the form of cerebral gigantism, a neural disorder. The recognition of an organic impairment in this case contributed to an understanding of the pervasive developmental disorder symptomatology and facilitated the formulation of an appropriate therapeutic protocol that addressed both developmental and neurological components.

Kiddie-Infant Descriptive Instrument for Emotional States (KIDIES): use in children with developmental disorders.

The Kiddie-Infant Descriptive Instrument for Emotional States (KIDIES) was used to overcome the limitations of microanalytic facial observations and subjective assessments in the diagnosis of childhood developmental disorders. The KIDIES quantifies eight behavioral and eight affective dimensions by evaluating facial, vocal, gestural, and postural displays. In a sample of 42 subjects, KIDIES ratings distinguished between children with pervasive developmental disorder and a comparison group with mixed developmental diagnoses, and demonstrated sensitivity to emotional changes as a result of environmental shift. The results suggest that the KIDIES has potential as a reliable instrument for evaluating emotional and behavioral patterns in young developmentally disordered children.

Assessment and psychotherapeutic intervention for an HIV-infected preschool child.

Pediatric acquired immunodeficiency syndrome (AIDS) is becoming more common. Moreover, human immunodeficiency virus (HIV) positive status in multiple family members is common and complicates disease management. Practitioners treating these children are often unaware of the effect of the virus on the child's psychological, cognitive, and emotional functioning. In addition, children with AIDS frequently come from families facing pressing social problems, including homelessness, poverty, and drug addiction. HIV-positive children thus confront such diverse issues as the deterioration of developmental skills, social ostracism, and the possibility of imminent death, placing them in a socioemotional crisis. This paper presents a comprehensive psychotherapeutic intervention for such children.

Assessing the relationship between affective responsivity and social interaction in children with pervasive developmental disorder.

An investigation of children with pervasive developmental disorder (PDD) was conducted using a new instrument, the Kiddie-Infant Descriptive Instrument for Emotional States (KIDIES). The KIDIES rates several affective and behavioral dimensions based on facial, vocal, gestural, and postural cues. The study's goals were to determine whether the KIDIES could detect individual differences in responsivity among the PDD subjects; to ascertain the KIDIES' sensitivity in identifying group differences between PDD subjects and control children with other developmental disorders. Children were videotaped during episodes with three partners: the mother, a familiar female teacher, an unfamiliar male doctor. Episodes were scored using the KIDIES. PDD subjects were most severely impaired during the Mother episode in comparison to the controls. Equally as striking was the within-episode heterogeneity among PDD subjects. During the Teacher episode, PDD subjects were twice as variable in interpersonal response as the controls.

A developmental model for risk avoidance in adolescents confronting AIDS.

Epidemiologic studies indicate that HIV infection is on the rise within the adolescent population. Much of this increase has been attributed to the teenager's developmental proclivity for risk-taking behavior. Intervention programs designed to curtail high-risk behaviour among adolescents have focused primarily on educational methods alerting teenagers to modes of disease transmission. Among these programs, demonstration and role-playing techniques have shown promise, but have not significantly modified behavior patterns. In contrast, a new developmental technique known as previewing advocates the use of representation and enactment to promote risk deterrence. Previewing may serve as a productive alternative to traditional interventions, since it directly addresses the adolescent's cognitive limitations with regard to the prediction of behavioral outcomes. This paper recommends a prevention model using previewing that is designed to lower the incidence of AIDS transmission among adolescents.

PIP: Experimenting with new behaviors, especially behaviors which are associated with risk, is part of growing up. This aspect of adolescence in the current context of incurable and spreading HIV infection, however, jeopardizes the medium-term health and long-term survival of many youths who have unprotected sexual intercourse. Epidemiologic studies indicate that HIV infection is on the rise within the adolescent population. The number of teens diagnosed with AIDS doubles every fourteen months. The majority of HIV-infected teens, however, do not know they are infected and lead asymptomatic, sexually active lives. Heterosexual contact in urban areas may account for as much as 15% of infections among teens. Programs aiming to reduce the level of unprotected sexual intercourse and other behaviors posing risk for HIV infection and transmission typically teach individuals about modes of disease transmission and how to protect themselves. This approach has not been very successful in changing behavior. This paper describes the new developmental technique known as previewing as a potential alternative intervention approach. Significant imminent events in a teen's life are first mentally represented, then rehearsed with peers to experiment with the probable outcomes of behaviors. Previewing focuses adolescents upon future aspirations, works to strengthen teens' ability to accurately predict the consequences of actions, and tries to provide adolescents with practical skills needed to engage in safe sex in real-life situations. A case study of a 15-year old girl is used in describing the technique.

Substance abuse in adolescent mothers: strategies for diagnosis, treatment and prevention.

Adolescent drug addiction and alcohol abuse are on the rise in this country. Teenagers of all races, socioeconomic groups and both genders have become avid experimenters with a full spectrum of substances, including alcohol, marijuana, stimulants, cocaine and hallucinogens. A diagnosis of addiction requires familiarity with the normative trends of adolescent behavior, as well as deviations from these trends. Moreover, an adolescent mother with a drug addiction problem confronts the additional burden of fostering adaptive developmental patterns in her infant. Treatment techniques such as previewing, which empowers through the representation and enactment of future outcomes, have helped addicted teenage mothers relinquish drug use and adopt more mature caregiving behaviors.

Sadness and suicidal tendencies in preschool children.

This paper highlights factors associated with suicidal behavior in children who are approximately 3-6 years old. Similar suicidal risk factors found in older children, such as depression, preoccupations with death, and family instability involving child abuse and other forms of parental psychopathology, are associated with suicidal impulses of preschool children. Assessment of these risk factors should be included in pediatric and mental health evaluations of such young children. Clinical vignettes are offered in this text.

The ability of adolescents to predict future outcome. Part I: Assessing predictive abilities.

Because adolescents are generally viewed as "risk-takers," an assessment of planning and decision-making skills during the teenage years may reveal why this developmental group tends to engage in dangerous behaviors. One area in which these abilities have significant consequences for future outcome is pregnancy, a condition that requires a decision to either give birth or abort. Previewing, a process by which caregivers introduce infants to the physical sensations of imminent developmental change and the implications of such change on their relationship, may affect the adolescent's ability to predict upcoming change. This paper explores previewing skills during the adolescent years and how this capacity affects the teenager's orientation toward future outcomes.

PIP: Previewing, a future-oriented psychotherapeutic intervention, can assist pregnant adolescents in deciding whether to give birth or have an abortion. Such an intervention involves an assessment of the sophistication of the adolescent's decision making and planning skills and the use of techniques for weighing consequences. Adolescents who have been taught to predict outcomes will be better equipped to make decisions about risky behaviors. Previewing is more commonly used to introduce infants to the physical sensations of the next developmental stage and to promote a secure parent-child attachment relationship. However, adolescence also requires mastery of a set of development milestones, including establishing a sexual identity, making decisions about a career, asserting autonomy, and envisioning having one's own family. Risk-taking behaviors are developmentally expected during adolescence and help the teenager assert an identity that is separate from that of family members. At the same time, adolescents are often incapable of understanding the consequences of their actions or the likelihood of an unwanted outcome such as pregnancy. Also characteristic of adolescents who have not had adequate attachment relationships in childhood is an external locus of control, in which consequences are conceived as unrelated to personal actions. Previewing can assist the adolescent in developing an internal locus of control and a future orientation by rehearsing the risks associated with carrying a pregnancy to term--e.g., emotional unpreparedness for parenthood, economic stress, conflict with family and peers, curtailment of individual goals in terms of education and employment--and the perceived benefits--e.g., alleviating loneliness, obtaining a stronger commitment from the father--and then selecting the best alternative.

The ability of adolescents to predict future outcome. Part II: Therapeutic enhancement of predictive skills.

The assertion of autonomy, a developmental challenge of adolescence, helps predict the teenager's attitude toward pregnancy and parenthood. Significantly, the ability to predict the future relationship with the infant has direct implications for the achievement of an adaptive outcome. Indeed, the interpersonal outcome of the parent-infant relationship may be predicted by the adolescent's behaviors with her infant. A prospective orientation may offer an important vantage point for improving this relationship. For example, the ability to predict future outcome helps identify potential conflict, such as abuse. When applying a prospective approach during the prenatal period, the adolescent's past relationship with her own mother and her motivations for becoming a parent will be explored in order to predict the future dyadic relationship. For adolescents who are already parents, an assessment of the dyad's contemporaneous interaction may further predict future interpersonal exchange. Moreover, orienting the adolescent parent toward the future may identify areas of potential conflict, as well as foster more adaptive dyadic exchange.

PIP: The relationship between the adolescent mother and her infant is complicated by the fact that both face the same developmental challenge--assertion of autonomy. If the adolescent's own mother cannot tolerate her daughter's moves toward individuation and autonomy and provides inadequate modeling of nurturing behavior, the infant is at risk of being abused. A prospective approach focused on the adolescent's past and current relationship with her mother, combined with her capacity to envision how future developmental gains will impact on her evolving relationship with her infant, can be used by psychotherapists to predict the quality of the mother-infant relationship. If the adolescent has had an abusive or conflicted relationship with her own mother, she may repeat this pattern and introduce conflict into her relationship with her child. Also germane are the adolescent's motivations for becoming pregnant; those who view motherhood as a means of breaking away from their own mother's control or of achieving intimacy may fail to promote their infant's adaptive maturation. Here-and-now factors that should be assessed by the therapist include the mother's proficiency in reading her infant's cues, the nature of the infant's attachment to the mother (insecure, ambivalent, or secure), the fit between the infant's temperament (difficult, easy, or slow to warm up) and the mother's, and the extent to which her expectations of her infant's abilities are age-appropriate. Orienting the adolescent mother toward the future involves instilling the ability to plan and motivation to seek further interaction. For example, the therapist can teach adolescent mothers previewing techniques, in which the mother deduces from intuition and education about child development that her infant is on the verge of acquiring a new skill, devises interactional exercises aimed at rehearsing this skill, and, in the process, enhances the intimacy and permission for autonomy in the dyadic relationship.

Assessing the patterns that prevent teenage pregnancy.

Adolescence is a time of rapid developmental change and emotional upheaval as teenagers strive to assert their autonomy. In a similar vein, pregnancy--even under optimal circumstances with an adult mother--has been labelled a developmental crisis. Pregnancy during the teenage years has a synergistic effect, magnifying maturational changes in both the teenage girl and her infant. Recommended intervention strategies in cases of adolescent pregnancy should address not only the imminent mother-infant relationship, but the dyad's future transformations. One intervention technique is previewing, which is derived from the rhythms of adaptive exchange between mature mothers and their infants. The aim of previewing with adolescent parents is to help the teenager become more attuned to the infant's imminent developmental skills and to heighten their rapport.

Using maternal representational patterns to evaluate postpartum depression.

This paper has reviewed postpartum depression through the use of a case history. As exemplified by the case, a key factor contributing to the onset of postpartum depression appears to be the caregiver's representations of her own experience with caregivers. In general, mothers whose representations of their childhood experience are positive appear psychologically equipped to transfer these emotions to the infant and to assume caregiving tasks with enthusiasm. In contrast, mothers whose representations of their caregiving experience are negative are apathetic about engaging the infant in interaction and hesitant about accepting the maternal role. While several etiologic factors have been linked to postpartum depression, representational deficits may provide a more comprehensive explanation of the origins of the disorder because such deficits encompass not only the mother's capacities, but also influence the interactional patterns mother exhibits with the infant. The case history describes a mother who represented a conflicted relationship with her own caregiver. Initially, her representations of her own mother were vague and unclear. Through inquiry, however, she gained access to her own experience--or, at least, to her representation of it--and began to understand how her own memories had negatively affected her ability to interact adaptively with her infant son. Treatment focused on three areas: Overcoming the mother's depressed affect; providing behavioral support for the infant's developmental efforts; and, re-invigorating the dyadic relationship. To accomplish these goals, the mother was taught observation techniques and intuitive behaviors. These techniques enabled her to view the infant in an objective fashion, devoid of distorted representations from her own childhood that reflected her attitude toward her caregiver. Helping the mother attain this new perspective enabled her to generate more adaptive representations, to acknowledge infant development more positively, and to initiate an adaptive dyadic exchange.

Previewing: a preventive strategy that promotes adaptive development.

The phenomenon of previewing, evident from observations of mother-infant interaction, represents a unique process for understanding the evolution of relational patterns in individuals. Previewing refers to the process whereby mothers first anticipate developmental acquisitions in their infants and subsequently convert these expectations into behaviors designed to acquaint the infant with the experience of new maturational skill and the implications these skills will have on the dyadic relationship. Previewing signifies a distinctive means of approaching the etiology of human behavior because it integrates the subjective perceptions experienced by the mother with the objective behaviors that are an outgrowth of these internal representations. Understanding the previewing process may offer therapists a new technique for diagnosing, treating, and preventing psychopathology. The diagnostic potential of previewing lies in the fact that the therapist can contrast the mother's subjective perceptions with her behavioral manifestations and with the objective developmental changes exhibited by the infant. In addition, by encouraging the mother to predict how upcoming developmental events will affect the interpersonal relationship she shares with the infant, the therapist gains access to unrehearsed material that has not yet been subjected to the defensive operations. As a treatment technique, previewing fosters the predictive capacities of both mother and infant, thereby instilling feelings of mastery over the interpersonal challenges posed by developmental change.

Intervention paradigms for parents: the application of previewing.

Because of increasing signs that the mother-infant dyadic relationship is not always as idyllic as we would like to believe, a number of therapeutic approaches have been developed to explore conflicts within the dyad. These approaches range from a psychoanalytic approach to a behaviorist approach to a family-therapy approach. When considered individually, none of these models comprehensively integrates both the mother's and the infant's objective behavioral manifestations and subjective representations. The concept of previewing, however, provides an integrated vision of the dyad's behaviors and representations. Furthermore, previewing addresses issues posed by imminent development. Principles of previewing were applied to two cases to: (1) demonstrate that the infant's future development would not threaten mother-infant intimacy, and (2) instill in the mother representational skills for coping with the perceived threat of the infant's increasing autonomy. As such, previewing can be used as a technique for preventing and resolving incipient psychopathology.

Forging a transference relationship with a self-destructive preschooler.

A three-and-a-half-year-old boy was referred for treatment because of his inability to engage adequately in school activities and his absorption in fantasy and episodically charged and homicidal wishes. A few months after therapy was initiated, the boy revealed fantasies of a self-destructive nature. Through the development of the transference relationship, the patient was able to elaborate further, understand the implications of such fantasies, and validate his perceptions regarding feelings that were until then suppressed and isolated.

Emergence and resolution of ambivalence in expectant mothers.

Little has been written about the perceptions of expectant mothers with previous histories of psychiatric disturbance and their affective oscillations during pregnancy. This paper discusses the case of a 22-year-old primigravida with a history of schizoaffective disorder who was referred to our mother-infant psychotherapy service. Despite the patient's initial defensive style, she was asked to discuss several dreams that she had had since learning about her pregnancy. A wealth of information about the patient's unconscious ambivalence and destructive wishes toward her unborn infant emerged. The patient was also unable to engage in any predictive imagery about the future of her infant or to anticipate intuitively what the experience of mothering would be like. This paper reveals that pregnant women with a history of psychological disturbances often have highly aberrational fantasies and ambivalent impulses toward their unborn infant, and some of these fantasies threaten to manifest in the form of abusive behavior after the birth. Techniques for predicting how new mothers with previous psychiatric histories will interact with their infants after birth are outlined. It is hoped that this treatment may avert child abuse.

The emergence of psychopathology in a previously adaptive mother-infant dyad.

A mother and her six-week-old infant began attending group therapy sessions designed to raise awareness of developmental events. The mother consistently displayed a high degree of responsiveness and sensitivity to the infant's needs; in fact, her behavior served as a model of adaptive interaction for the entire group. After six months of sessions, when the infant manifested full-blown weaning patterns, the mother reported symptoms indicating a major depressive episode, such as pervasive dejection and rejection, listlessness, and anxiety attacks. After several individual sessions, during which discussion focused on the etiology of these emotions, the depression remitted and the mother was able to resume previous adaptive interaction designed to promote the infant's development. This case study reveals that highly adaptive parents may be susceptible to depression when developmental events that signify imminent separation from their infants or a similar dramatic change in their relationship occur.

Self-mutilation in a new mother: a strategy for separating from her infant.

A primiparous mother, aged 25 years, first presented for treatment when her infant was three months of age. A comprehensive case history disclosed that the mother had experienced two prior full-fledged psychotic episodes requiring hospitalization. During treatment, the mother underwent an abortion and burned her face with kitchen chemicals. This case history reveals a pattern of self-mutilating behavior whenever the mother is confronted with events threatening imminent separation or individuation.

Treatment of an abused preadolescent and the role of parental self-reporting.

This report describes treatment strategies used in the case of child physical abuse. It especially focuses on the strategy of encouraging the parents to report themselves to the Bureau of Child Welfare (B.C.W.). In so doing, the sense of therapeutic alliance, self-esteem, and re-establishment of appropriate parent-child relationships were enhanced. Furthermore, this flexible therapeutic design resulted in the beginning of successful treatment of this family's maladaptive interactions.