WAIMH Handbook of Infant Mental Health, Early Intervention, Evaluation, and Assessment / Edition 1

by Joy D. Osofsky, Hiram E. Fitzgerald

Overview

Keynote: This 4-volume set offers comprehensive coverage of children's psychological development during the critical early years of life. Infancy—which is defined as the period from birth to 18 months of age—is the single most critical stage in cognitive and socioemotional development. The comprehensive WAIMH Handbook of Infant Mental Health offers the first thorough interdisciplinary analysis of the biopsychosocial factors that impact normal and abnormal infant mental development. Assembled under the auspices of the leading international organization in infant development—the World Association of Infant Mental Health—this ground-breaking four-volume reference offers a state-of-the-art overview of the field by the world's leading researchers, clinicians, and scholars.

Product Details

ISBN-13:	9780471189442
Publisher:	Wiley
Publication date:	12/28/1999
Series:	WAIMH Handbook of Infant Mental Health , #2
Edition description:	Volume 2
Pages:	600
Product dimensions:	7.40(w) x 10.37(h) x 1.70(d)

About the Author

Joy D. Osofsky is the editor of WAIMH Handbook of Infant Mental Health, Volume 2, Early Intervention, Evaluation, and Assessment, published by Wiley.

Hiram E. Fitzgerald is Associate Provost for University Outreach and Engagement, University Distinguished Professor of Psychology, and Adjunct Professor in Human Development and Family Studies at Michigan State University.

Read an Excerpt

1

Toward a Theory of

Early Relationship-Based

Intervention

Robert N. Emde, Jon Korfmacher,

and Lorraine F. Kubicek

Introduction

This chapter offers a contribution toward a theory of intervention in infancy that is relationship-based. We begin with a set of assumptions about successful mental health interventions. We then discuss developmental motives in the context of the caregiving relationship and interventions, enhancing adaptive caregiving interactions, and the role of the interventionist in a network of relationships. Following this, we discuss a model for evaluating infant mental health programs. We conclude with thoughts for the practitioner of infant mental health.

Assumptions

Successful mental health interventions throughout the life span are characterized by four features. First, they are experience- focused. Successful interventions consider the meaning of interventions for the individual at both the psychological and interpersonal levels. From a humanistic perspective, individual meaning is taken into account not only to minimize suffering and self- destructive behavior, but also to make it possible for satisfying and productive adaptations. Second, successful interventions are developmentally-oriented. They go beyond immediate symptom relief and are concerned with enabling individual adaptive developmental processes over time.

Third, successful mental health interventions throughout life are relationship-based. Interventions depend upon a sense of trust and availability as experienced over time with the intervener. Fourth, and less widely appreciated, successful interventions involve the influence of relationships on other relationships. Individual psychotherapies, for example, are based on therapist-client relationships. Such relationships are designed to influence two domains of other relationships: (1) problematic internalized (psychologically-represented) relationships that are conflictual or inadequate and (2) problematic interpersonal relationships outside the therapeutic encounter that deal with loving and other aspects of living. Other mental health interventions, such as family therapy, group psychotherapy, or casework, are often explicitly designed to make use of an interventionist relationship influencing a network of relationships in the family or in the workplace.

Successful mental health interventions in early life highlight special aspects of these four features. First, in these interventions, the experience of both the child and the adult caregiver is of central concern. Research has repeatedly targeted the individuality of the infant's experience, not only in terms of temperament (Chess & Thomas, 1986; Carey, 1970, 1972), but also in terms of interaction with caregivers and the infant's mastery of the environment (Bell, 1968; Osofsky & Danziger, 1974; Sameroff & Chandler, 1976). Even though the interventionist cannot access infant experience directly through language, it can be appreciated from emotional expressions and gestures that communicate needs and intentions. The experience of caregivers can be accessed through language, as well as behavioral observations. Such experience is often a target of mental health work, especially in the practice of parent-infant psychotherapy (see the special issue of the Infant Mental Health Journal, Summer 1998).

Second, the developmental orientation highlights a special emphasis of successful interventions in infancy: They are necessarily prevention-oriented. Because early developmental processes are rapid and involve the beginnings of pathways for adaptation and because early vulnerabilities hamper such pathways, the mental health interventionist is concerned with preventing future problems and strengthening future adaptations, in addition to dealing with current individual stresses and symptoms.

This brings us to the third feature, namely, the special aspects of the relationship-based nature of successful early interventions. Availability and trust of the intervener as experienced by the caregiver is a primary goal of intervention that, in turn, may enhance the relationship between caregiver and infant. Unlike adult psychotherapy, the client of an infant mental health intervention is not necessarily the adult caregiver but the caregiver-infant relationship itself. A focus on the early caregiving relationship is important because this experience for the infant is crucially different from subsequent life relationships. It is formative. All aspects of the infant's development are subsumed within it. Without the caregiver-infant relationship, there would be no infant (Tyson, Emde, Galenson, & Osofsky, 1985; Winnicott, 1960). Disturbances and problems in infancy are immersed in disturbances and problems of the caregiver-infant relationship (Sameroff & Emde, 1989a).

Thus, this chapter focuses on how the service provider may influence the caregiver-infant relationship by diminishing stresses and conflicts and by strengthening developmental processes in both partners and their interactions. In other words, this chapter places emphasis on the provider's relationship to the caregiving relationship. Such a focus is consistent with much of the emphasis of Fraiberg (1980) and of the practice of parent-infant psychotherapy and brings us to the fourth special quality of successful interventions in early mental health, namely, the influence of relationships on relationships. Not only must successful early intervention target the caregiver-infant relationship itself, but it also must be multifaceted, attending to a network of other social relationships that support the caregiver-infant relationship. Moreover, in addition to current relationships, the intervener also attends to parental influences represented from the past, influences of relationships that go across three or more generations. Fraiberg and colleagues (Fraiberg, Edelson, & Shapiro, 1975) drew attention to such psychodynamic influences in interventions in the classic essay entitled "Ghosts in the Nursery." Subsequently, such influences have been given added coherence from recent attachment theory and research (Fonagy, Steele, Moran, Steele, & Higgitt, 1993; Fonagy, Steele, & Steele, 1991; Main, 1993).

Developmental Motives, the Caregiving Relationship, and Intervention

Psychoanalytic contributions of the past 40 years have increasingly emphasized that the child's early motives are developmentally-based, pre-adaptor social interactions, and can, by implication, provide a framework for mental health interventions. The work of Spitz (1959, 1965), Bowlby (1969, 1973, 1980), Fraiberg (1980), and Mahler, Pine, and Bergman (1975) emphasized that early development is contained within caregiving relationships and that the child's developing autonomy occurs along with the young child's developing interconnectedness with others. Bowlby's ethnological considerations articulated that the human infant is born pre-adapted by evolution for social interactions and that attachment and exploration develop within the context of supportive and consistent caregiving interactions, points that were also enumerated in the theorizing of Spitz (Emde, 1983a). Fraiberg broadened considerations of motivation important for the interventionists by bringing cognitive perspectives from Piaget. Fraiberg also pointed to the rapid development of the infant and founded approaches in infant-parent psychotherapy, wherein the infant was present during psychodynamic explorations with mother. Fraiberg's often quoted phrase "it's a little bit like having God on your side" (Fraiberg, Shapiro, & Cherniss, 1980, p. 53), considering the rapid development of the infant over the course of the early postnatal months, pointed to a positive developmental impetus that could be experienced, appreciated, and acknowledged as part of mother's caregiving. Such an impetus could be used by the therapists to help bolster the mother's self-esteem and, by implication, an empathic appreciation of this experience could add incentives to the mother's own development.

This leads us to consider some of the salient developmental processes in infancy that are made use of in intervention. Although these processes require nourishment from the caregiving environment, they represent potential and active strengths in each individual infant. In earlier publications, we summarized extensive multidisciplinary research regarding a set of basic motives of infancy (Emde, 1988a, 1988b; Emde & Robinson, in press). Such motives are inborn tendencies, manifest in earliest infancy, and fostered by caregivers who are emotionally available-- that is, responsive to the infant's emotional signals of need, states, and interests. Since these basic motives continue throughout life, they can also be thought of as developmental motives (Emde, 1990). In other words, as Fraiberg began to envision, these motives are aspects of developmental processes that become consolidated during the experiences of early caregiving and can also be mobilized in interventions.

Activity is a first basic motive. The infant is active, exploratory, and motivated to master the world and realize developmental agendas-- given that there is a consistent caregiving environment (Emde, Biringen, Clyman, & Oppenheim, 1991). Self-regulation, a second basic motive, refers to the fact that there is an inborn propensity for regulation of behavior, as well as for physiology. Self-regulation of behavior is indicated by cycles of sleep, wakefulness, and attentiveness, as well as the longer term built-in propensity for the young individual to attain species-important developmental goals, such as self-awareness, representational thinking, and language, in spite of a variety of perturbations and variations. Social-fittedness is identified as a third basic motive. Infants are motivated and pre-adapted by evolution for initiating, maintaining, and terminating human interactions. Much research has documented the biological preparedness for the dynamic complexities of human interaction that exist in early infancy, providing there are caregiving experiences to foster its development (Papousek & Papousek, 1979; Stern, 1985).

Affective monitoring is identified as a fourth basic motive. There is a propensity from early infancy to monitor experience according to what is pleasurable or not pleasurable. The infant's affective expressions guide the caregiver to what is needed and when. One only needs to be reminded of the messages conveyed by an infant's cry, an interested alert expression, or a bright smile. During the middle of the first year, a major development takes place from the infant's point of view, that of social referencing. The infant begins to monitor emotional expressions of significant others in order to guide behavior when confronted by a situation of uncertainty. Accordingly, if a mother smiles, the infant is encouraged to approach a stranger or unfamiliar moving toy; if mother looks fearful or angry, there is reluctance or retreat (Emde, 1992).

Cognitive assimilation is designated as a fifth basic motive. From the beginning, an infant has a tendency to explore the environment, seeking what is new in order to make it familiar. Such a motive is related to that of activity but brings emphasis to a more directed tendency for the child to "get it right" about the environment. It makes use of what Piaget referred to as "cognitive assimilation" that in his cognitive theory was considered "a basic fact of life" (Piaget, 1952). This motive also incorporates the construct of mastery motivation, wherein the child experiences pleasure in performing newly-acquired behaviors and skills (Harmon & Murrow, 1995; MacTurk & Morgan, 1995).

Perhaps it is because the previously mentioned motives are universal features of normal development that they are generally assumed by developmental theories while not being specified as motivations. Still, when they are experienced by an infant with an emotionally available caregiving figure, we believe they become elaborated into important developmental structures prior to three years of age. Among these structures are what we consider early moral motives. We now believe important aspects of moral development occur earlier than previously thought, and they occur in a broader domain. Early moral inclinations can be observed prior to the preschooler's awareness of "Oedipal" urges and conflictual struggles within triangular family relationships (Emde, Johnson, & Easterbrooks, 1987). Most central to this chapter is our belief that developmental motives become early moral motives in infancy and in toddlerhood as a result of repeated everyday experiences within the caregiving relationship.

According to our theory, morality con- tains positive aspects (referred to as "do's" in early moral development) as well as negative aspects (referred to as "don'ts" in early moral development). The "do's" are prominent in the infant's early experience and seem to follow naturally from the basic motives described previously. For example, a propensity for social interaction, the basic motive of social-fittedness, involves reciprocity in exchanges. Inclinations of this sort result in rules being internalized for turn-taking. These rules are learned in the course of games and other social interactions with caregivers (Bruner, 1986; Kaye, 1982; Stern, 1985) and represent early forms of reciprocity that are included in all moral systems. Similarly, the basic motive of cognitive assimilation, of getting it right about the world, leads to the internalization of many rules which become accepted by the child in the course of everyday life.

Toddlers typically develop further moral inclinations during the second year. When confronted by another's distress, a one and one-half-year-old may respond empathically-- also experiencing distress and attempting to comfort, soothe, or share something with the distressed other (Zahn-Waxler, Radke-Yarrow, & King, 1979; Zahn-Waxler, Robinson, & Emde, 1992). Toward the end of the second year, children sometimes show anxiety when internal standards are violated. When faced with a familiar object that is changed, flawed, or dirty, the child may evidence distress, and there may be a tendency to repair or make it better (Kagan, 1981), another form of "getting it right."

The infant's sense of initiative takes on a new level with the onset of walking, which has further implications for early moral development. This was characterized by Erikson (1950) as a stage of "autonomy versus shame and doubt" in the toddler's experience. The internalization of prohibitions or "don'ts" occurs through repeated interactions with caregivers wherein rules of safety and family culture are imposed. Correspondingly, the toddler develops a sense of the semantic "no" (Spitz, 1957) and a developing sense of "good" and "bad" (Mahler et al., 1975; Sander, 1985). Such a process involves not only negative features but also aspects of the "do's" in terms of the toddler's wanting to get it right and in terms of processes of social referencing. The child, through repeated interactions, learns strategies of negotiation in the midst of emotional communications with caregivers, as well as the consequences of these strategies (Emde et al., 1987; Kochanska, Casey, & Fukamoto, 1995; Kochanska & Askan, 1995; Kuczynski & Kochanska, 1995). Dunn and Kendrick (1982) also documents the importance of interactions that include conflicts with caregivers and siblings, over such issues as possession, sharing, or destruction, for the internalization of expectations and rules about how to negotiate or cope with these situations. Much of what the child first learns in this area is "practicing knowledge" (Reiss, 1989), knowledge that is activated when particular people come together in family or group routines.

We have placed strong emphasis on these moral motives because they are extremely important aspects of successful social development. Many needy children, however, have not been provided the consistent caregiving routines and practices to support such early moral motives. We believe the assessment of the child's moral motives in the context of the family, for example, to reciprocate, repair, and follow rules, and the engagement of these motives within the family, in the context of mealtimes, bedtimes, play, and other daily routines, are an untapped resource for intervention. In the next section, we provide more detail regarding caregiving interactions and routines that may or may not engage these motives and implications for intervention.

Enhancing Adaptive Processes in Caregiving Interactions and Routines

The caregiver-infant relationship is founded, at least in part, on the recurring, day-to-day interactions in which infants and caregivers engage. An important aspect of these early social interactions is their organization or structure. Their structure leads to, and then comes to depend upon, expectations that infants and their caregivers share about their own and each others' behavior. We hope to show that intervention opportunities can occur at fine-grained levels of interaction. First, we consider the need for consistent, adaptive patterns of behavior which both promote coordination in interaction and facilitate interactive repair when miscoordination occurs. The importance of these processes for positive developmental outcomes is highlighted. Next, we consider the negative developmental consequences of inconsistent and/or maladaptive patterns of interactive behavior. Moving from fine-grained analysis of interaction, we additionally consider behavior patterns within the larger context of the family system and discuss the beneficial effects of family routines on family functioning and child outcomes.

Caregiving Interaction

Research on infant-caregiver interactions during the past 25 years has made it clear that, from the earliest days of life, the infant is capable of highly predictable behavioral responses to outside stimuli and is an active participant in social interactions with his caregivers (Lewis & Rosenblum, 1974; Schaffer, 1977; Stern, 1977; Tronick, 1982). This research has also made it clear that despite these often impressive abilities, the infant has much to learn before he can contribute, in a more equal and socially appropriate way, to the maintenance and regulation of his interactions with others.

Social interaction is a complex process which requires individuals to coordinate their separate actions into a joint, organized activity (Duncan & Fiske, 1977; Kendon, 1982; Lewis, 1969; Schaffer, 1984). The ability to achieve coordination in interaction is closely tied to the experience of consistency. When similar patterns of behavior are repeated over time, both infant and caregiver are likely to develop expectations and rules, that are largely unconscious, about what behaviors are expected of them and what behaviors they can expect from their partner. Once such a set of mutual, reciprocal expectations is established, it increases the likelihood that the pattern will be repeated when infant and caregiver are engaged in similar kinds of social exchanges (Bruner & Sherwood, 1977; Duncan, 1991; Duncan, 1997; Duncan & Farley, 1990; Kubicek, 1981; Kubicek, 1992; Schaffer, 1984; Stern, 1977). In this way, dyads begin to establish their own characteristic patterns of interacting over time.

The profound influence of the infant- caregiver relationship on the infant's learning about self and other is intimately tied to these characteristic patterns (Sameroff & Emde, 1989a; Stern, 1985; Tronick, 1989). What the infant learns about turn-taking, reciprocity, repair, emotional regulation, and social referencing will be strongly influenced by the nature of these formative patterns of interaction with the caregiver. Such patterns will not only affect the infant's expectations regarding interactions with the caregiver, but will likely generalize and influence the infant's expectations regarding interactions with others as well (Tronick, 1989).

Although characteristics of the infant clearly affect these interaction patterns from the start (an influence which increases with age), because of the infant's dependence, characteristics of the caregiver have a more predominant influence in the earliest years. Both research and clinical practice indicate that certain caregiver characteristics are likely to foster patterns that are beneficial to the infant's development, whereas others are likely to foster patterns that are harmful. We consider each of these situations in turn.

If a caregiver is sensitive, responsive, and consistent, the expectations an infant develops about self and others are likely to nurture development of the basic motives of infancy. That is, an infant who consistently experiences a nurturing caregiving environment is more likely to be motivated to explore the environment, develop adaptive means for self-regulation, develop social competence, be more aware and attuned to the emotions of significant others and rely on them as a guide for his or her own behavior, and take pleasure in mastering the environment.

Of course, this is not meant to imply that all infant-caregiver interactions will be synchronous, well-coordinated, or affectivity positive even if the caregiver is sensitive, responsive, and consistent. Although researchers have used these terms to describe the communicative "dance" that develops between a caregiver and an infant, we now know that these terms tend to apply only to the "best" exchanges between caregivers and infants (Tronick & Gianino, 1986). Even among well- functioning dyads, everyday communication is likely to involve many missed cues and misunderstandings relating to the mistiming or misreading of signals and different goals (Biringen, Emde, & Pipp-Siegel, 1997; Tronick & Cohn, 1989; Kubicek, 1992; Golinkoff, 1983, 1986). The resulting mismatches or violations of expectations may create stress and generate negative emotions. The challenge for the dyad is to develop effective strategies to repair these mismatches or violations, through self-directed or other-directed regulatory behavior. Fortunately, caregivers and even very young children typically work together to repair their communicative errors, so that their exchanges can continue, especially when interactions are characterized by sensitivity, responsivity, and consistency.

To illustrate, consider the following sequence, videotaped during an evening home visit with a family (Kubicek, 1992). The family had finished dinner, and the father and toddler had gone into the living room, as they often did, to play with some puzzles. The father sat down in a large chair, and his son sat on the floor a few feet in front of him. The child initiated an exchange with an apparent request to the father to place a bunny puzzle piece in the puzzle board, a request that the father initially misunderstood. The turn exchanges that follow illustrate the kind of additional "interactive work" and cooperation that is required of both caregiver and child to maintain their exchange and eventually resolve their misunderstanding. Although this child was 15 months old at the time, he had relatively few words and relied heavily on non-language behaviors to communicate. The following was observed:

The child vocalizes to his father (" eh" ) as he bounces the bunny puzzle piece in the air. Father points to the bunny space in the puzzle board and sings, "Hippity hoppity hippity hoppity hippity hoppity back in his spot?" Next, the child holds the bunny piece out to Father, who responds, "Put him back in his spot?" The child frowns and repeats his initial vocalization (" eh" ), but this time in a more fretful, insistent tone, and bounces the bunny piece in the air. Father repeats, "Hippity hoppity hippity hoppity." At this point, the child interrupts his father by getting up and walking over to his father's chair and placing the bunny piece on the arm of the chair. Father now seems to understand and replies, "Want me to do it?" The child smiles and immediately points to the space in the puzzle board. Father bounces the bunny piece in the air as he sings, "Hippity hoppity hippity hoppity hippity hoppity back in his spot!" Both smile and break into laughter.

This vignette helps to highlight an important finding regarding caregiver-child interactions. Even in well-functioning dyads, interactions frequently involve the expression of negative as well as positive emotions. What is important for healthy development, and illustrated here, is that both parent and child learn to regulate their emotions in response to one another and express them in adaptive ways (Sameroff & Emde, 1989a). For example, in this vignette, the child expresses some anger/ frustration as he attempts for the third time to communicate what he wants his father to do. He frowns and vocalizes in a more fretful and insistent tone as he bounces the bunny piece in the air. Despite his distress, the child copes well and continues to engage his father, an adaptive response which was likely motivated by earlier successes in similar situations. For his part, the father does not become angry or impatient with the child but instead, calmly makes another attempt to understand what his son wants. Both are eventually rewarded with success and share a hearty laugh before going on to their next game.

When caregivers and their children are able to regulate their emotions adaptively and negotiate needed communication repairs successfully, such early exchanges can provide a foundation for positive development. Through repeated experience in these day-to-day interactions with sensitive caregivers, the child begins to learn important lessons about the world and about how interaction works. Specifically, he learns adaptive rules for turn-taking, social reciprocity, and emotion regulation, begins to develop expectations about behavioral regularities and interactive sequences, and learns to repair errors or misunderstandings in interaction which allow him to maintain engagement in the face of stress. These experiences also help the child to develop a positive affective core (Emde, 1983b) and to view the self as effective and the caregiver as reliable and trustworthy (Tronick, 1989).

Less adaptive exchanges, on the other hand, may have negative consequences for development. Problems can arise when caregiver characteristics such as immaturity or inexperience (Brooks-Gunn & Chase-Lansdale, 1995; Osofsky, Hann, & Peebles, 1993), depression (Field, 1995; Tronick & Field, 1986), drug use (Mayes, 1995; Zuckerman & Brown, 1993), or stress related to chronic poverty (Halpern, 1993; Norton, 1990) lead to insensitive, nonresponsive, and inconsistent care. Under such conditions there can be disorganization, with maladaptive expectations about self and others that are likely to undermine the development of the basic motives summarized earlier in the chapter.

Consider, for example, the following interaction sequence, also videotaped during an evening home visit, of a family participating in a recent longitudinal study. Following dinner, the mother and the father and their two-year-old son went into the living room to play with some toys the researcher had brought. The mother and father sat on the floor leaning against the couch, and their son sat a few feet in front with his back to them. The child was absorbed in playing with a shape sorter which required matching color-coded keys to doors in order to remove animal blocks from the sorter. For the first part of the vignette, father repeatedly tickles and gently pokes at the child, despite the child's repeated protests that escalate in intensity. Failing to stop his father, the child eventually gets up and moves across the room. Shortly after, the child invites his father to play. First the father ignores the child, then repeatedly asks what the child wants before helping him open the door. In contrast to the previous vignette, the turn exchanges that follow illustrate how disruptive it can be for a child when a caregiver is unable or unwilling to respond in a sensitive way to his requests and thwarts, passively and/or actively, his attempts to repair.

Father gently pokes at the back of the child's neck as he sits trying to open the sorter door. The child says, "No," and continues to play. Next, the father successively pokes the child in three different spots on his back and the child says, "No, no!" in a louder voice. The father persists, and the child turns and looks at his father and says, "No!" even more loudly and attempts to push his father's hand away. He then turns back to the sorter, and father resumes his teasing. The child turns to his father and screams "No!" in a high pitched voice and then moves to the other side of the room where he plays with another toy. A few minutes later, the child, with keys in hand, approaches Father and invites his help saying, "Daddy do it, Daddy do it." Father stares with a blank face. The child says, "Daddy do" and places the keys on his father's hand. When Father fails to respond, the child picks up Father's limp hand and tries to put the keys inside it, repeating, "Daddy do, Daddy do it," several times while looking at his father. The child slaps at Father's hand, then screams and pulls the keys while Father holds on. The child eventually gets the keys and again asks, "Daddy do it," then begins to cry as he tries to put the keys back in his father's hand. Finally, the father asks, "What do you want?" The child sighs, then says, "Daddy do it." There are several more turns in which Father repeats, "Do what?" each time the child says "Daddy do it." The child eventually points to the sorter door and says, "Daddy do." Father asks, "Do you want me to open the door?" and the child says, "Yep." Father begins to explain how to open the door, and the child watches.

In this example, the father intentionally creates conflict/disruption by teasing his son and ignoring the child's request to stop, despite the child's increasing distress. Rather than helping the child regulate his emotion, the father contributes to dysregulation. After repeated attempts, the child's only recourse is to remove himself from the situation. After calming himself, the child returns to his father who ignores his attempts to repair, once again escalating the child's distress until he cries. Even then, the father persists in several question-answer exchanges before helping the child with the sorter. This leads to a brief period of joint play, but one that clearly lacks the shared joy evident in the previous example.

When child and caregiver are unable to regulate emotions adaptively and negotiate needed repairs successfully, the characteristic patterns of interaction they develop are likely to undermine, rather than support, positive development. Through repeated experiences in these kinds of day- to-day interactions, the child is more likely to see the world as insensitive and uninviting. As Tronick (1989) warns, this could lead to the establishment of a self-directed style of regulatory behavior to control negative emotions. The need to control negative emotions may take precedence over other developmental goals. Such experiences are likely to interfere with the development of a positive affective core (Emde, 1983b), and the child may begin to view the self as ineffective and the caregiver as unreliable (Tronick, 1989). Due to such destructive effects on the child's overall development, intervention is warranted.

The preceding discussion suggests that one appropriate entry point for intervention with the caregiver and infant is with their interactive behaviors. Several models of early intervention have followed such an approach. Interaction guidance (McDonough, 1991, 1992, 1995) is one such exam- ple. The interventionist guides the caregiver to strengthen healthy patterns of interactional behavior with her infant, often using reflective review of videotaped interaction. Intervention, in other words, takes place within the context of the caregiver- infant relationship, rather than focusing on problems in the infant or the caregiver themselves. Similarly, a major goal of the parent-infant mental health model developed by Kathryn Barnard and colleagues (Barnard et al., 1987) is to influence the caregiver-infant relationship through social interaction and communication as well. There is strong emphasis on enhancing caregiver-infant interaction by developing the caregiver's awareness of infant cues, encouraging the caregiver to vocalize, respond contingently, provide appropriate stimulation, and develop appropriate expectations about infant abilities. In addition, curricula such as the Partnership in Parenting Education (PIPE) (Dolezal, Butterfield, & Grimshaw, 1994; Butterfield, 1996) emphasize guiding parents in how to set the stage for positive interaction by helping them become more sensitive and emotionally available. Through demonstrations and interactive sessions, using the infant as "teacher" and talking through the infant, parent educators focus on emotional communication, mutual regulation between caregiver and infant, and relationship-building skills.

Routines

Another entry point for intervention may be in encouraging the development and maintenance of meaningful family routines. Family routines are patterned interactions that occur with predictable regularity in the course of everyday living. Routines help to organize family life, reinforce family identity, and provide members with a shared sense of belonging ( Wolin & Bennett, 1984).

At least one reason why adherence to routines may be associated with these positive outcomes is that family routines can provide an ongoing context for strengthening the parent-child relationship by providing regular opportunities for parent and child to come together around a common goal and develop patterns of interaction that are adaptive and likely to enhance development. Through repeated participation in shared, meaningful activities such as greetings, mealtimes, bedtime routines, and social games, with sensitive and responsive caregivers, children begin to internalize basic procedures for emotional regulation and morality and learn the values and practices of their family and culture (Bossard & Boll, 1950; Fiese, Hooker, Kotary, & Schwagler, 1993; Reiss, 1981; Rogoff, Mistry, Goncu, & Mosier, 1993).

Routines are considered an almost universal attribute of family life that cuts across ethnic background and socioeconomic status (Bossard & Boll, 1950; Boyce, Jensen, James, & Peacock, 1983). Nevertheless, few details are known about the actual day-to-day practices of families with infants and young children, particularly those with low incomes. The scant literature that is available, however, suggests that the lives of many families living in poverty lack adequate structure and predictable routines (Aponte, 1976; Halpern, 1993). Norton (1990) has intensively studied the early experiences of a longitudinal sample of inner city, low-income children of adolescent mothers, noting deficits in caregiving routines and the structuring of experience through language, as well as consequent problems in the children's future-oriented sense of time. Similarly, Escalona (1987) has described a relative lack of structure in the daily lives of the poorest infants in her economically disadvantaged longitudinal sample of premature infants and has found an association between this relative lack of structure and impairments in cognitive development.

Two studies have highlighted the beneficial effects of family routines on child social and cognitive outcomes in low-income Head Start preschoolers. Keltner (1990) found that adherence to family routines was predictive of preschool social competence. Churchill and Stoneman (1997) found that for girls, family routines were associated with higher scores on standardized cognitive tasks and teacher ratings of peer interaction. Preliminary results from our own ongoing longitudinal study (Kubicek & Emde, 1998) of an ethnically diverse group of Early Head Start research families suggest that there is meaningful variation in the number and kind of routines these families follow. We plan to explore the relation between differences in the practice of family routines in this low-income sample and a number of outcome assessments in the toddler and preschool periods.

These results suggest a promising area in need of more systematic research aimed at identifying strengths in existing routines as well as documenting areas of impoverishment and difficulty so that culturally appropriate interventions can be developed. Such an approach has been used therapeutically to help families cope with problems relating to transitions such as adolescence or remarriage as well as mental health issues such as children's fears or obsessions or parental alcoholism (Imber- Black, Roberts, & Whitney, 1988).

Emotional Availability and the Role of the Interventionist in a Network of Relationships

Overlaying structure and everyday routines in the early caregiving relationship is the construct of emotional availability. Regulation of the emotional communicative system is a central task facing parent and infant. Initially, the emotional availability of caregiver to child provides the main basis for regulation. Being emotionally available can be thought of as communicating an openness toward the other's feelings and expressed needs (Biringen & Robinson, 1991; Sroufe, 1995). Emotional availability reflects a quality of the developing relationship that is continuous, in that expectations include a responsiveness that will bring interest and pleasure, as well as relief from distress (Emde, 1980). Variations in emotional availability and caregiver sensitivity are extensive. Not only are there deficits that can be considered maladaptive, but there are excesses. Infants can become disorganized by too much excitement or distress and communicative signals can also become aversive for caregivers. Managing caregiver arousal to infant signals is, therefore, a challenge in sustaining availability to infants and may need support from interventionists.

It is relevant to our theory of intervention that, through repeated experiences with emotionally available caregivers, the child, especially during the second year, learns skills of self-control, emotional regulation, and negotiation, as well as empathy in helping others. Pride and shame typically develop during the child's second year, and the interventionists can enhance attunement to the child of the caregiver by highlighting a toddler's new skills and emotional reactions. As could be seen in the exchanges described in the previous section, the experience and expression of positive emotions are also vital aspects of communication and regulations that are adaptive. An intervention that focuses on interactions between caregiver and child must be attuned to the emotional tone of the interaction as well as the specific behaviors. Promoting positive engagement is, in fact, a focus of the approaches noted in the previous section (Barnard et al., 1987; Dolezal et al., 1994; Butterfield, 1996; McDonough, 1991, 1992, 1995). For some parents, intuitive bases for emotionally available engagement are not present, and they may need assistance in experiencing what "getting it right" feels like in interactions (Emde & Robinson, in press). An important principle of intervention in this area is that, once having experienced a positive response from the infant, parents experience inherent rewards that continue to motivate positive interactions (Emde, 1980).

A relationship-based theory of intervention also addresses the emotional availability of the interventionist. This involves broadening our focus, from the emotional availability seen within the caregiving dyad to the emotional availability between the interventionist and the caregiving dyad. The interventionist's emotional availability includes not only the ability to resonate with the emotions of the infant-caregiver relationship in a way that can facilitate relief of distress and encouragement of positive emotional communications and engagement, but it also refers to the openness to empathic communications in a broader sense. Communicating an understanding of painful past experiences and how they might motivate actions in the present can convey an open presence to caregiver that is appreciated. Equally important is a perspective over time. Maintaining a consistent supportive alliance encourages a hope- fulness about the possibility of alternative positive outcomes both now and in the future. When an interventionist is able to help a parent view a child's developmental motives more clearly and see that "ghosts" from the past that distort perception need not be influential (Fraiberg et al., 1975), there are new opportunities for appreciation of the child's individual experience and growth.

The interventionist's emotional availability also extends to a larger network of relationships, including those in family, community, and staff of programs that work with the caregiver or child, such as Early Head Start or day care. Indeed, all interventions, from short-term to long-term and from crisis-focused to analytic, involve the influence of relationships on other relationships. This leads to at least two implications. First, if we acknowledge and assess these influences, we may further strengthen our interventions by discovering other supportive relationships and conflicting ones that can use attention. In the model described by Barnard and colleagues (1987), for example, intervention during pregnancy focuses on the caregiver's social skills and relationships with others in her life, with the assumption that the caregiver's ability to parent a child will be based, at least in part, on the caregiver's ability to maintain satisfying relationships with other adults. Second, our efforts may often be misplaced. That is to say, in our infancy work, we make use of our relationship to the mother, but what seems most important is the relation we have to the mother-infant relationship. Thus, our efforts may need to be concentrated on fostering that relationship instead of focusing on the mother or on the child.

When we think of interventions as the influence of relationships on relationships, we realize that there are different levels we may address within developing systems. It is often strategic to choose a level for working that offers maximum leverage, depending on the unique concerns and experiences of the family. For example, we may have long-term goals to influence the internalized relationships that are represented in the child, such as to improve "working models of attachments" , or similar goals to influence the internalized relationships within the mother's representational world, an approach seen most commonly in parent-infant psychotherapy models (Fraiberg, 1980). Other targeted goals might include improving father-child and mother-father relationships within the family in the course of our interventions. Similarly, other goals might address enhancing other supportive relationships for the mother and, thereby, improve her relationship with her infant-- goals that are often prioritized in family support programs. As noted previously, we may target a more direct and immediate level for our goal-setting that concentrates on bettering the repeated interactions between mother and infant in order to make such interactions more satisfying. In all instances, it seems clear that our intervention relationship is in relation to one or more other relationships which we hope to influence for the better.

We need more thinking to address these points. Family systems approaches currently come closest to addressing these matters, but with a few exceptions (Byng-Hall, 1995; Scharff & Scharff, 1987), they seldom consider relations to internalized representations of relationships and seldom consider development. What is needed is intervention theory which probes further in this area and can specify schemes for assessing leverage points in developing systems-- one that can yield opportunities for influencing the effects of relationships on relationships and their consequences for intervention in particular circumstances.

Evaluation of Infant Mental Health Programs

A theory of mental health services for very young children and their families should also provide a guide for evaluation of the services. Obviously, a comprehensive overview of evaluation issues in infant mental health cannot be conducted here. In this remaining section, however, we will address four important and interrelated facets of evaluation that parallel points earlier addressed: (1) measuring the experience of families in intervention programs; (2) considering the dynamic development of the intervention; (3) examining the relationships that interventionists form with families; and (4) examining the network of relationships within a program, including the program's relationships to the evaluator. Each of these points lead to a general conclusion: Given the many different entry points into the caregiving system available to programs and interventionists, examining the processes by which interventionists achieve outcomes is just as important as examining the outcomes themselves.

Experience of Participants

A key to examination of intervention process is recognition that people, including infants, have unique and individual experiences with a program. Understanding the variable experiences that families have within the program and understanding the meaning that is attached to that experience is crucial. Although the need for this has been repeatedly addressed (Emde, 1988c), there are few empirical examinations of this issue. The simple outcome question "Does it work?" that is often asked in evaluation studies is overly reductionistic, denying the large range of experiences that families have in an infant mental health program. By being so focused on outcome, one may lose sight of the crucial question of "How does the intervention work for whom under what circumstances" ?

Families enter a mental health intervention with different motivations and expectancies. We too readily assume that because families initially agree to be part of an intervention program, they will be knowledgeable consumers and enthusiastic participants, understanding fully what they are getting into and endorsing our attempts to help them. But it may be that caregivers agree to enter an intervention program because they were pressured by another family member or support agency to join or because they want to see changes in circumstances around them, without having to explore changes in themselves. Once in a program, families will have different experiences, based in part upon their differing motivations and expectations, but also according to variation in program factors, such as the relationship that forms with the interventionist (see following) and the critical events that occur during the course of treatment. In short, participant characteristics at the onset and their experiences within the program will influence the meaning that they attach to the treatment that they receive.

It is possible to study this experience, although it involves a more in-depth focus on participants than outcome studies typically provide. One may chart, for example, the quantity of contact that families have with their interventionist to examine the different "dosages" of treatment (Howard, Moras, Brill, Martinovich, & Lutz, 1996). Olds & Korfmacher (1998) demonstrated in a nurse home-visiting program for first-time mothers that mothers with lower feelings of self-control received more visits than mothers with stronger senses of control. Mothers, in a very basic way, had different experiences based upon this level of psychological resources, and this differential experience likely contributed to the low rates of child maltreatment seen at later time periods in the home-visited, lower-resource group when compared to mothers who did not receive home visits (Olds, Henderson, Chamberlin, & Tatelbaum, 1986).

Amount of contact, however, is most likely a proxy measure for more complicated aspects of "dosage." These other qualitative characteristics of the experience include how emotionally engaged family members are within sessions or the actual content of the intervention (e.g., topics discussed or use of specific techniques, such as videotape feedback). These characteristics can be examined quantitatively, using scales and checklists (Greenspan et al., 1987; McBride & Peterson, 1997). Different studies, for example, have empirically demonstrated that parent's engagement in the intervention predicts program outcome (see Heinicke, 1993, for one review). The young child's experience as intervention participant is less well studied (Liaw, Meisels, & Brooks-Gunn, 1995, is an exception), although there is ample evidence from the child care literature (Howes & Smith, 1995) that child activities and relationships in a center-based setting can be reliably measured.

Qualitative methods are also important evaluation tools and may in fact be the best way to measure complex aspects of a patient's experience. Focus groups (Gilkerson & Stott, 1997) and narratives of case studies (Kitzman, Cole, Yoos, & Olds, 1997) provide detailed accounts of how both participants and helpers find value or struggle with challenges within interventions. Qualitative and quantitative methods can be used together in the search for important program elements. For example, a study using preliminary data from an evaluation of an Early Head Start program examined how children from low-income families responded to a structured and enriched Montessori environment, using both weekly rating scales filled out by teachers and ethnographic field notes from an anthropologist (Korfmacher, Spicer, & Emde, 1998). The combined data highlighted individual variation across children in their response to the classroom environment, changes in the child's response across time, and the importance of the period of transition from the infant to the toddler classroom. The study also highlighted to the investigators how study of a common theme is enriched by comparing and contrasting qualitative and quantitative data.

Development of the Intervention

As the previous example demonstrates, the experience participants have in an intervention is not static. Infant mental health programs deal with young children and families that are undergoing rapid developmental adaptation. In turn, we can assume that children and families will respond in different ways over the course of the intervention. They will have different levels of engagement, and they will focus on different issues. Psychotherapy research with adults, for example, shows that improvements in feelings of well-being are apt to occur earlier in the treatment cycle, followed by symptom relief and only later by changes in behavioral adaptation patterns (Howard et al., 1996).

The relationship family members have with their infant mental health provider and the relationship the provider has with the parent-infant relationship will change over time. Given this, infant mental health programs themselves should not be considered static entities. They too must change over time, altering themselves to fit to the individual needs of families as the families embark on different longitudinal pathways.

As families and the programs that serve them develop and change over time, so must evaluation and measurement of the program itself be able to adapt. Examining how the experience and meaning of treatment changes for families and how these changes affect outcome requires a means of collecting process data from multiple time periods and requires sophisticated approaches toward analyzing data. New methods of measuring individual differences in development (Howard et al., 1996; Speer & Greenbaum, 1995) provide opportunities for studying change in response to intervention. These techniques have not yet been used to study changes in experiential aspects of the intervention itself, such as the therapeutic relationship, although such an approach is certainly possible if programs collect such data at multiple time points.

A final point about the developmental orientation of program evaluations in infant mental health is crucial. Given that the goals of most programs are future-oriented, for example, to improve social emotional competence after early childhood and to enhance school readiness, longitudinal follow-up is essential. Long-term follow-up of interventions early in the life cycle have demonstrated important effects over a decade later for both children and their parents, such as promoting school achievement (Barnett, 1995), reducing child maltreatment (Olds et al., 1997), and reducing child and parent antisocial behavior (Olds et al., 1997, 1998).

Therapeutic Relationships

An important element of the individual experience in an intervention is the quality of the relationship formed with the therapist or service provider. Therapeutic or helping relationships are frequently shown to be strong predictors of positive adult psychotherapy outcomes (Orlinsky, Grawe, & Parks, 1994; Orlinsky & Howard, 1986), as well as early childhood intervention research (Osofsky, Culp, & Ware, 1988; Lieberman, Weston, & Pawl, 1991).

The concept of the helping relationship has been measured mostly in terms of contributions by the participating parent or caregiver, measuring, for example, program "taking" (Osofsky et al., 1988), achievement of treatment goals (Barnard et al., 1988), or commitment (Korfmacher, Adam, Ogawa, & Egeland, 1997). Such constructs are basic measures of the treatment alliance. It must be acknowledged that, although a premium is placed on the helping relationship in early childhood programs, as has been noted repeatedly in this chapter and elsewhere (Olds & Kitzman, 1993), this relationship is very difficult to measure. Individuals within the helping relationship-- the client and the provider-- construct psychological meanings of the relationship that are based on their own personal history and interpretation of events, and they will perceive the relationship in ways different from each other and from an outside observer (Orlinsky & Howard, 1986). There are also specific features of a given individual helping relationship. That is, the match between therapist and patient is frequently shown to be an important program element in adult psychotherapy (Beutler, Machado, & Neufeldt, 1994) and is assumed to be so in early childhood interventions as well (Korfmacher, 1998).

Additionally, since the relationship is dynamic, the quality of the match and the meanings individuals attach to the relationship will change over time. A productive and meaningful alliance comes from a therapist and a client finding a level where they work well together. Just as we have noted in the parent-child relationship, there are periods in the helping relationship of disruption and repair. How the service provider and the family member negotiate these times is an important and untapped area of study. For example, sequential analyses, as are used in psychotherapy research, are ways to examine the reactions of clients to interventionist actions (Lambert & Hill, 1994) within a session. The function of so-called "critical events" (Fraser & Haapala, 1987; Peterson & McBride, 1999), on which the quality of the intervention can shift, also plays a role here. For example, the Early Head Start study noted previously highlights how important transitions between classrooms are for young children in center-based programs (Korfmacher et al., 1998). The previously mentioned techniques have as yet had minimal application in infant mental health programs, but they are promising in allowing for the tracking of individual infants and families using services over time.

In summary, although there is converging evidence to support the importance of the helping relationship in infant mental health programs, we do not yet understand what are the critical dimensions of the helping relationship to study or how to examine them best. Although our theory and our practice highlight how crucial it is to attend to these relationships, in an evaluation context, the helping relationship is a moving target. This aspect of early childhood intervention research needs increased attention, with development of qualitative and quantitative measures better able to capture it and its complexity.

Evaluating a Network of Relationships

The problems of measuring helping relationships in early childhood intervention are compounded by a point made previously in this chapter. In early childhood interventions, the provider not only develops a relationship with the parent (the relationship most analogous to the adult psychotherapy alliance), but also develops a relationship with the infant and additionally hopes to influence the relationship between the parent and the infant. These different relationships, as well as relationships that the provider may develop with other family members in the context of assisting the parent-child dyad, are all being played out simultaneously and developmentally.

In most cases, these other relationships are not being measured. Although we know that the therapist's alliance with the parent may predict a positive outcome, how does one measure the therapist's relationship to the infant, and how does this intersect with the relationship developing with the parent? This topic is unexplored in early childhood intervention, although research on the relationships between parents and day care providers may offer a model of study (Elicker, Noppe, Noppe, & Fornter-Wood, 1997).

To add to the complexity noted previously, there is one more relationship to discuss-- the relationship between the program and the researcher. Strict advocates of the scientific method may emphasize a need for evaluators to keep an objective distance from the program that they study. According to this view, researchers should act unobtrusively around the intervention, silently observing and measuring, interviewing families, and videotaping children, but not relating their impressions of measurements until well after the intervention is concluded. Attempts to provide feedback to programs are seen as "experimenter effects," threats to the study's internal validity, and, therefore, discouraged.

Although these concerns of losing objectivity and empirical rigor are valid in some evaluation contexts, there needs to be acknowledgment of the cost that this rigor can bring. Empirical research establishes artificial constraints to programs, setting boundaries and limitations that disrupt the natural flow of families into program and services. A randomized trial, for example, will alter the motivation of participants in joining a study/intervention, putting off some families who do not want the uncertainty of assignment but also encouraging others who have no interest in the study but the commonly-used financial incentives for taking part in the research.

Although program evaluations that are tightly experimentally-based (i.e., efficacy trials) by their nature do not allow for an active dialogue between the researcher and the clinician, such trials are but one evaluation tool. The model of continuous improvement analyses, for example, where evaluators feed back information to programs and providers during the course of the intervention in order to promote changes or improvements, is increasingly being promoted. It is but one example of "action research" methods (Lewin, 1947; Whyte, 1984) that assume a more dynamic and collaborative relationship between evaluator and program. These alternative assessment approaches should be seriously considered for interventions that are in their own period of growth and development or that exist in a community or context where a strict efficacy trial is not feasible. Such strategies fit well within the relationship-based framework of intervention that has been proposed in this chapter.

Conclusion: A Need for Theory in an Increasingly Active Field

We began the chapter with the viewpoint that a contemporary useful theory of mental health interventions in infancy has certain common features. Successful mental health interventions are experience-focused, developmentally-oriented, and relationship-based. Moreover, they involve the influence of relationships on other relationships. Interventions in infant mental health build on developmental motives within the context of the caregiving relationship. Such interventions enhance adaptive processes in caregiving interactions and routines so as to enhance the experience of both caregiver and child with positive expectations in everyday routines, as well as for development itself. Enhancing emotional availability in the caregiving relationship involves attention to emotional regulation, exchanges of signals, and consistency over time in interactions between infant and caregiver. Correspondingly, the interventionist also becomes emotionally available in relation to this relationship, with expressions of empathic concern and appreciative interest. Evaluation of infant mental health programs attends to each of these features of the relationship- based theory of intervention. Such evaluation also highlights the network of relationships involved in work that targets improved developmental outcomes for infants and toddlers.

We return to the concerns of the practitioner. A topic we have not yet addressed is diagnosis and assessment. A relationship-based model of intervention, however, has begun to influence thinking in this area. Diagnosis, in the practice of infant mental health, is regarded as an ongoing process. It is not a fixed designation, but it needs to be repeated over time because of dynamic influences of development and because of the changing contexts of different caregiving and other relationships. The process of diagnosis consists of two aspects: The assessment of individuals in context and the classification of disorders.

The assessment of individuals involves a variety of evaluations of an individual's functioning and symptoms within the context of a network of family relationships, as well as evaluations of culture and stresses that are both biological and environmental. In light of the multidisciplinary nature of early intervention activities, practitioners of early intervention are likely to be diverse and multiple paradigms and methods of assessment may be applied (Brazelton & Cramer, 1990; Fraiberg, 1980; Gaensbauer & Harmon, 1981; Greenspan, 1981, 1997; Stern & Stern-Bruschweiler, 1987; Shonkoff & Meisels, in press)

The diagnostic process moves from assessment to considerations of classification. The classification of disorder involves linking to a system of ordering knowledge about symptom patterns and syndromes that can provide information about etiology, prognosis, and intervention outcomes. Such classification has a major function of allowing for communication among professionals, and it is important to bear in mind that we classify disorders, not individuals (Rutter & Gould, 1985).

No current classification exists for infancy and toddlerhood that has been shown to be reliable or valid. A recent advance has been the publication of Diagnostic Classification: Zero to Three; Diagnostic classification of mental health and developmental disorders of infancy and early childhood (DC: 0- 3; Zero to Three, 1994), representing the work of a national task force of clinicians. The new system is intended to supplement DSM- IV (American Psychiatric Association, 1994), providing adequate coverage of early age. Relevant to our model, this diagnostic classification system recommends assessment prior to classification and incorporates a multiaxial system that not only allows for the features of assessment, but pays special attention to the evaluation of the caregiver relationship. A special axis exists in the DC: 0- 3 system which deals with relationship disorder, following the recommended use of a parent-infant relationship global assessment scale which provides anchor points for clinical judgments.

In conclusion, recent research has provided a considerable amount of knowledge about developmental processes in infancy and their dependence on an emotionally available caregiving relationship experience. Recent clinical practice has provided an accumulated conviction that relationship-based assessments and interventions are what lead to successful outcomes. Additionally, attention is now being directed, both in program evaluation and in mental health interventions, to influences across a network of relationships. In the increasingly active field of mental health interventions, we are now aware that effects result from the influence of relationships on other relationships. Insights about this are more recent, and research is needed. Because of a lack of empirical knowledge, this chapter can only point to a framework rather than a theory in this area. It is our hope that future research on the topic of a theory of infant mental health intervention will build on forthcoming inquiry and investigation to develop a more specific model.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: Au- thor.

Aponte, H. J. (1976). Underorganization in the poor family. In J. D. Guerin (Ed.), Family therapy: Theory and practice (pp. 432- 448). New York: Gardner Press.

Barnard, K. E., Hammond, M. A., Sumner, G. A., Kang, R., Johnson-Crowley, N., Snyder, C., Spietz, A., Blackburn, S., Brandt, P., & Magyary, D. (1987). Helping parents with preterm infants: Field test of a protocol. Early Child Development and Care, 27, 256- 290.

Barnard, K. E., Magyary, D., Sumner, G., Booth, C. L., Mitchell, S. K., & Spieker, S. (1988). Prevention of parenting alterations for women of low social support. Psychiatry, 51, 248- 253.

Barnett, W. S. (1995). Long-term effects of early childhood programs on cognitive and school outcomes. The Future of Children, 5(3), 25- 50.

Bell, R. Q. (1968). A reinterpretation of the direction of effects in studies of socialization. Psychological Review, 75, 81- 95.

Beutler, L. E., Machado, P. P. P., & Neufeldt, S. A. (1994). Therapist variables. In A. E. Bergin & S. I. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 229- 269). New York: Wiley.

Biringen, Z., Emde, R. N., & Pipp-Siegel, S. (1997). Dyssynchrony, conflict, and resolution: Positive contributions to infant development. American Journal of Orthopsychiatry, 67, 4- 19.

Biringen, Z., & Robinson, J. (1991). Emotional availability in mother child interactions: A reconceptualization for research. American Journal of Orthopsychiatry, 61, 258- 271.

Bossard, J., & Boll, E. (1950). Rituals in family living. Philadelphia, PA: University of Pennsylvania Press.

Boyce, W. T., Jensen, E. W., James, S. A., & Peacock, J. L. (1983). The family routines inventory: Theoretical origins. Social Science Medicine, 17, 193- 200.

Bowlby, J. (1969). Attachment and Loss: Vol. I. Attachment. New York: Basic Books. Bowlby, J. (1973). Attachment and Loss: Vol. II. Separation, Anxiety and Anger. New York: Basic Books.

Bowlby, J. (1980). Attachment and Loss: Vol. III. Loss, Sadness and Depression. New York: Basic Books.

Brazelton, T. B., & Cramer, B. G. (1990). The earliest relationship. Reading, MA: Addison-Wesley.

Brooks-Gunn, J., & Chase-Lansdale, P. L. (1995). Adolescent parenthood. In M. H. Bornstein (Ed.), Handbook of parenting, Vol. 3 (pp. 113- 149). Mahwah, NJ: Erlbaum.

Bruner, J. S. (1986). Actual minds, possible worlds. Cambridge, MA: Harvard University Press.

Bruner, J. S., & Sherwood, V. (1977). Peekaboo and the learning of rule structures. In J. S. Bruner, A. Jolly, & K. Sylva (Eds.), Play: Its role in development and evolution (pp. 277- 285). Harmondsworth, England: Penguin.

Butterfield, P. M. (1996). The Partners in Parenting Education Program: A new option in parent education. Zero to Three, 17(1), 3- 10.

Byng-Hall, J. (1995). Rewriting family scripts: Improvisation and systems change. New York and London: Guilford.

Carey, W. B. (1970). A simplified method for measuring infant temperament. Journal of Pediatrics, 77, 188- 194.

Carey, W. B. (1972). Clinical applications of infant temperament. Journal of Pediatrics, 81, 823- 828.

Chess, S. & Thomas, A. (1986). Temperament in clinical practice. New York and London: Guilford.

Churchill, S. L., & Stoneman, Z. (1997, April). Family routines and temperament as a predictor of child outcomes: Differences by sex of child. Poster presented at the biennial meeting of the Society for Research in Child Development, Washington, DC.

Dolezal, S., Butterfield, P. M., Grimshaw, J. (1994). Listen, listen, listen. Denver, CO: How to Read Your Baby.

Duncan, S. D., Jr. (1991). Convention and conflict in the child's interaction with others. Developmental Review, 11, 337- 367.

Duncan, S. D., Jr. (1997). Early parent-child interaction grammar prior to language acquisition. Language and Communication, 17(2), 149- 164.

Duncan, S. D., Jr., & Farley, A. M. (1990). Achieving parent-child coordination through convention: Fixed-and variable- sequence conventions. Child Development, 61, 742- 753.

Duncan, S. D., Jr., & Fiske, D. W. (1977). Face-to-face interaction: Research, methods, and theory. Hillsdale, NJ: Erlbaum.

Dunn, J., & Kendrick, C. (1982). Siblings. Cambridge, MA: Harvard University Press.

Elicker, J., Noppe, I. C., Noppe, L. D., & Fornter-Wood, C. (1997). The parent- caregiver relationship scale: Rounding out the relationship system in infant child care. Early Education & Development, 8, 83- 100.

Emde, R. N. (1980). Emotional availability: A reciprocal reward system for infants and parents with implications for prevention of psychosocial disorders. In P. M. Taylor (Ed.), Parent-infant relationships (pp. 87- 115). Orlando, FL: Grune & Stratton.

Emde, R. N. (1983a). Rene A. Spitz: Dialogues from infancy. Selected papers (with commentary). New York: International Universities Press.

Emde, R. N. (1983b). The pre-representational self and its affective core. The Psychoanalytic Study of the Child, 38, 165-192.

Emde, R. N. (1988a). Development terminable and interminable I: Innate and motvational factors from infancy. International Journal of Psycho-Analysis, 69, 23-42.

Emde, R. N. (1988b). Development terminable and interminable II: Recent psychoanalytic theory and therapeutic considerations. International Journal of Psycho-Analysis, 69, 283- 296.

Emde, R. N. (1988c). Risk, intervention, and meaning. Psychiatry, 51, 254- 259.

Emde, R. N. (1990). Mobilizing fundamental modes of development-- an essay on empathic availability and therapeutic action. Journal of the American Psychoanalytic Association, 38, 881- 913.

Emde, R. N. (1992). Social referencing research: Uncertainty, self, and the search for meaning. In S. Feinman (Ed.), Social referencing and the social construction of reality in infancy (pp. 79- 94). New York: Plenum

.

Emde, R. N., Biringen, Z., Clyman, R. B., & Oppenheim, D. (1991). The moral self of infancy: Affective core and procedural knowledge. Developmental Review, 11, 251- 270.

Emde, R. N., Johnson, W. F., & Easterbrooks, M. A. (1987). The do's and don'ts of early moral development: Psychoanalytic tradition and current research. In J. Kagan & S. Lamb (Eds.), The emergence of morality (pp. 245- 276). Chicago: University of Chicago Press.

Emde, R. N., & Robinson, J. L. (in press). Guiding principles for a theory of early intervention: A developmental- psychoanalytic perspective. In J. P. Shon- koff & S. J. Meisels (Eds.), Handbook of early childhood intervention. New York: Cambridge University Press.

Erikson, E. (1950). Childhood and society. New York: Norton.

Escalona, S. (1987). Critical issues in the early development of premature infants. New Haven, CT: Yale University Press.

Field, T. (1995). Psychologically depressed parents. In M. H. Bornstein (Ed.), Handbook of parenting, Vol. 4 (pp. 85- 100). Mahwah, NJ: Erlbaum.

Fiese, B. H., Hooker, K. A., Kotary, L., & Schwagler, J. (1993). Family rituals in the early stages of parenthood. Journal of Marriage and the Family, 55, 633- 642.

Fonagy, P., Steele, M., Moran, G. S., Steele, H., & Higgitt, A. (1993). Measuring the ghost in the nursery: An empirical study of the relation between parents' mental representations of childhood experiences and their infants' security of attachment. Journal of the American Psychoanalytic Association, 41, 957- 989.

Fonagy, P., Steele, M., Steele, H. (1991). Maternal representations of attachment during pregnancy predict the organization of infant-mother attachment at one year of age. Child Development, 62, 880- 893.

Fraiberg, S. (1980). Clinical studies in infant mental health: The first year of life. New York: Basic Books.

Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. Journal of American Academy of Child Psychiatry, 14, 387- 421.

Fraiberg, S., Shapiro, V., & Cherniss, D. S. (1980). Treatment Modalities. In S. Fraiberg (Ed.), Clinical studies in infant mental health: The first year of life (pp. 49- 77). New York: Basic Books.

Fraser, M., & Haapala, D. (1987). Homebased family treatment: A quantitative-qualitative assessment. Journal of Applied Social Sciences, 12, 1- 23.

Gaensbauer, T. J., & Harmon, R. J. (1981). Clinical assessment in infancy utilizing a structured playroom situation. Journal of the American Academy of Child Psychiatry, 20(2), 264- 280.

Gilkerson, L., & Stott F. (1997). Listening to the voices of families: Learning through caregiving consensus groups. Zero to Three, 18(2), 9- 16.

Golinkoff, R. M. (1983). The preverbal negotiation of failed messages: Insights into the transition period. In R. M. Golinkoff (Ed.), The transition from prelinguistic to linguistic communication (pp. 57- 78). Hillsdale, NJ: Erlbaum.

Golinkoff, R. M. (1986). "I beg your par- don?" : the preverbal negotiation of failed messages. Journal of Child Language, 13, 455- 476.

Greenspan, S. I. (1981). Psychopathology and Adaptation in Infancy and Early Childhood. New York: International Universities Press.

Greenspan, S. I. (1997). The growth of the mind. Reading, MA: Addison-Wesley (with Beryl Lieff Benderly).

Greenspan, S., Wieder, S., Lieberman, A. F., Nover, R., Robinson, M., & Lourie, R. (Eds.). (1987). Infants in multirisk families. Madison, CT: International Universities Press.

Halpern, R. (1993). Poverty and infant development. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health. New York: Guilford.

Harmon, R. J., & Murrow, N. S. (1995). The effects of prematurity and other perinatal factors on infants' mastery motivation. In R. H. MacTurk & G. A. Morgan (Eds.), Advances in applied developmental psychology: Vol. 12. Mastery motivation: Origins, conceptualizations, and applications (pp. 237- 256). Norwood, NJ: Ablex.

Heinicke, C. M. (1993). Factors affecting the efficacy of early family intervention. In N. J. Anastasiow, S. et al. (Eds.), At-risk infants: Interventions, families, and research (pp. 91- 100). Baltimore, MD: Brookes.

Howard, K. I., Moras, K., Brill, P. L., Martinovich, Z., & Lutz, W. (1996). Evaluation of psychotherapy: efficacy, effectiveness, and patient progress. American Psychologist, 51, 1059- 1064.

Howes, C., & Smith, E. W. (1995). Relations among child care quality, teacher behavior, children's play activities, emotional se- curity, and cognitive play activity in child care. Early Childhood Research Quarterly, 10, 381- 404.

Imber-Black, E., Roberts, J., & Wheling, R. A. (1988). Rituals in families and family therapy. New York: Norton.

Kagan, J. (1981). The second year: The emergence of self-awareness. Cambridge: MA Harvard University Press.

Kaye, K. (1982). The mental and social life of babies: How parents create persons. Chicago: University of Chicago Press.

Keltner, B. (1990). Family characteristics of preschool social competence among black children in a Head Start program. Child Psychiatry and Human Development, 21(2), 95- 108.

Kendon, A. (1982). The organization of behavior in face-to-face interaction: Observations on the development of a methodology. In K. R. Scherer & P. Ekman (Eds.), Handbook of methods in non- verbal behavior research (pp. 441- 505). Cambridge: Cambridge University Press.

Kitzman, H., Cole, R., Yoos, L., & Olds, D. (1997). Challenges Experienced by Home Visitors: A Qualitative Study of Program Implementation. Journal of Community Psychology, 25, 95- 109.

Kochanska, G., & Aksan, N. (1995). Motherchild mutually positive affect, the quality of child compliance to requests and prohibitions, and maternal control as correlates of early internalization. Child Development, 66, 236- 254.

Kochanska, G., Casey, R. J., & Fukamoto, A. (1995). Toddlers' sensitivity to standard violations. Child Development, 66, 643- 656.

Korfmacher, J. (1998). Examining the service provider in early intervention. Zero to Three, 18(4), 17- 22.

Korfmacher, J., Adam, E., Ogawa, J., & Egeland, B. (1997). Adult attachment: Implications for the therapeutic process in a home visitation intervention. Applied Developmental Science, 1, 43Ð 52.

Korfmacher, J., Spicer, P., & Emde, R. (1998, July). Examining the child's experience in an Early Head Start Program. Poster presented at Head Start Fourth National Research Conference, Washington, DC.

Kubicek, L. F. (1981). Organization in two mother-infant interactions involving a normal infant and his fraternal twin brother who was later diagnosed as autistic. In T. Field, S. Goldberg, D. Stern, & A. Sostek (Eds.), Interaction in high-risk infants and children (pp. 99Ð 110). New York: Academic.

Kubicek, L. F. (1992). Organization of parent-child repair and non-repair sequences in routine interactions at 15 and 21 months. Unpublished doctoral dissertation, University of Chicago.

Kubicek, L. F., & Emde, R. N. (1998, July). Similarities and differences in the family routines of an ethnically diverse group of Early Head Start research families. Head Start Fourth National Research Conference, Washington, DC.

Kuczynski, L., & Kochanska, G. (1995). Function and content of maternal demands: Developmental significance of early demands for competent action. Child Development, 66, 616- 628.

Lambert, M. J., & Hill, C. E. (1994). Assessing psychotherapy outcomes and processes. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (p. 72- 113). New York: Wiley.

Lewin, K. (1947). Action research and minority problems. Journal of Social Issues, 2, 34- 36.

Lewis, D. K. (1969). Convention. Cambridge, MA: Harvard University Press. Lewis, M., & Rosenblum, L. A. (Eds.). (1974). The effect of the infant on its caregiver. New York: Wiley.

Liaw, F., Meisels, S. J., Brooks-Gunn, J. (1995). The effects of experience of early intervention on low birth weight, premature children: The Infant Health and De- velopment Program. Early Childhood Research Quarterly, 10, 405- 431.

Lieberman, A. F., Weston, D., & Pawl, J. H. (1991). Preventive intervention and outcome with anxiously attached dyads. Child Development, 62, 199- 209.

MacTurk, R. H., & Morgan, G. A. (1995). Advances in applied developmental psychology: Vol. 12. Mastery motivation: Origins, conceptualizations, and applications. Norwood, NJ: Ablex.

Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant: Symbiosis and individuation. New York: Basic Books.

Main, M. (1993). Discourse, prediction, and recent studies in attachment: Implications for psychoanalysis. In T. Shapiro & R. N. Emde (Eds.), Research in psychoanalysis: Process, development, outcome (pp. 209- 244). Madison, CT: International Universities Press.

Mayes, L. C. (1995). Substance abuse and parenting. In M. H. Bornstein (Ed.), Handbook of parenting, Vol. 4 (pp. 101- 126). Mahwah, NJ: Erlbaum.

McBride, S. L., & Peterson, C. (1997). Home-based early intervention with families and children with disabilities. Who is doing what? Topics in Early Childhood Special Education, 17, 209- 233.

McDonough, S. C. (1991). Interaction guidance: A technique for treating early rela- tionship disturbances in parents and children. In J. Gomes-Pedro (Ed.), Bebe XXI. Lisbon, Portugal: Condor.

McDonough, S. C. (1992). Treating early relationship disturbances with interaction guidance. In G. Fava-Vizziello & D. N. Stern (Eds.), Models and techniques of psychotherapeutic intervention in the first years of life. Milan: Rabbaello Cortina Editore.

McDonough, S. C. (1995). Promoting positive early parent-infant relationships through interaction guidance. Child & Adolescent Psychiatric Clinics of North America, 4(3), 661- 672.

Norton, D. (1990). Understanding the early experience of black children in high-risk environments: Culturally and ecologically relevant research in regard to support for families. Zero to Three, 10(4), 1- 7.

Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L. M., & Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen year follow-up of a randomized trial. JAMA: Journal of the American Medical Association, 278, 637- 643.

Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78, 65- 78.

Olds, D. L., Henderson, C. R., Cole R., Eckenrode J., Kitzman H., Luckey D., Pettitt L., Sidora K., Morris P., & Powers J. (1998). Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA: Journal of the American Medical Association, 280, 1238- 1244.

Olds, D. L., & Kitzman, H. (1993). Review of research on home visiting programs for pregnant women and parents of young children. The Future of Children, 3(3), 53- 92.

Olds, D. L., & Korfmacher, J. (1998). Maternal psychological characteristics as influences on home visitation contact. Journal of Community Psychology, 26, 23- 36.

Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome in psychotherapy-- noch einmal. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 270- 376). New York: Wiley.

Orlinsky, D. E., & Howard, K. I. (1986). Process and outcome in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (pp. 311- 381). New York: Wiley.

Osofsky, J. D., Culp, A. M., & Ware, L. M. (1988). Intervention challenges with adolescent mothers and their infants. Psychiatry, 51, 236- 241.

Osofsky, J. D., & Danziger, B. (1974). Relationship between neonatal character and mother-infant interaction. Developmental Psychology, 10, 124- 130.

Osofsky, J. D., Hann, D. M., & Peebles, C. (1993). Adolescent parenthood: Risks and opportunities for parents and infants. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp. 106- 119). New York: Guilford.

Papousek, H., & Papousek, M. (1979). Early ontogeny of human social interaction: Its biological roots and social dimensions. In K. Foppa, W. Lepenies & D. Ploog (Eds.), Human ethology: claims and limits of a new discipline (pp. 456- 489). New York: Cambridge University Press.

Peterson, C. A., & McBride, S. L. (1999, April). Home-visiting: Parent and provider perceptions of critical events. Paper presented at the Biennial Meeting of the Society for Research in Child Development, Albuquerque, NM.

Piaget, J. (1952). The origins of intelligence in children (2nd ed.). New York: International Universities Press.

Reiss, D. (1981). The family's construction of reality. Cambridge, MA: Harvard University Press.

Reiss, D. (1989). The represented and practicing family: Contrasting visions of family continuity. In A. J. Sameroff & R. N. Emde (Eds.), Relationship disturbances in early childhood-- A developmental approach (pp. 191- 220). New York: Basic Books.

Rogoff, B., Mistry, J., Goncu, A., & Mosier, C. (1993). Guided participation in cultural activity by toddlers and caregivers. Monographs of the Society for Research in Child Development, 58(8, Serial No. 236).

Rutter, M., & Gould, M. (1985). Classification. In M. Rutter & L. Hersov (Eds.), Child and adolescent psychiatry: Modern approaches (pp. 304- 321). London: Blackwell Scientific Publications.

Sameroff, A. J. & Chandler, M. (1976). Reproductive risk and the continuum of caretaking casualty. In F. D. Horowitz (Ed.), Review of the child development research: Vol. 4 (pp. 187- 244). Chicago: University of Chicago Press.

Sameroff, A. J., & Emde, R. N. (Eds.). (1989a). hood: A developmental approach. New York: Basic Books.

Sameroff, A. J., & Emde, R. N. (1989b). Relationship disturbances in context. In A. J. Sameroff & R. N. Emde (Eds.), Relationship disturbances in early childhood: A developmental approach (pp. 221- 238). New York: Basic Books.

Sander, L. (1985). Toward a logic of organization in psychobiological development. In K. Klar & L. Siever (Eds.), Biologic response styles: Clinical implications. Monograph Series of the American Psychiatric Press.

Schaffer, H. R. (Ed.). (1977). Studies in mother-infant interaction. New York: Academic.

Schaffer, H. R. (Ed.). (1984). The child's entry into a social world. New York: Academic.

Scharff, D. E., & Scharff, J. S. (1987). Object relations family therapy. New Jersey and London: Jason Aronson.

Shonkoff, J. P., & Meisels, S. J. (Eds.) (in press). Handbook of early childhood intervention (2nd ed.). New York: Cambridge University Press.

Speer, D. C., & Greenbaum, P. E. (1995). Five methods of computing significant individual client change and improvement rates: Support for an individual growth curve approach. Journal of Consulting and Clinical Psychology, 63, 1044- 1048.

Spitz, R. A. (1957). No and yes: On the genesis of human communication. New York: International Universities Press.

Spitz, R. A. (1959). A genetic field theory of ego formation. New York: International Universities Press.

Spitz, R. A. (1965). The first year of life. New York: International Universities Press.

Sroufe, L. A. (1995). Emotional development: The organization of emotional life in the early years. Cambridge, England and New York: Cambridge University Press.

Stern, D. (1977). The first relationship. Cambridge, MA: Harvard University Press.

Stern, D. (1985). The interpersonal world of the infant. New York: Basic Books.

Stern, D., & Stern-Bruschweiler, N. (1987). The mother's representation of her infant: Considerations of its nature. Unpublished manuscript.

Tronick, E. Z. (1982). Social interchange in infancy. Baltimore, MD: University Park Press.

Tronick, E. Z. (1989). Emotions and emotional communication in infancy. American Psychologist, 44, 112- 126.

Tronick, E. Z., & Cohn, J. F. (1989). Infant-mother face-to-face interaction: Age and gender differences in coordination and the occurrence of miscoordination. Child Development, 60, 85- 92.

Tronick, E. Z., & Field, T. (1986). Maternal depression and infant disturbance: Vol. 34. New directions for child development. London: Jossey-Bass.

Tronick, E. Z., & Gianino, A. (1986). Interactive mismatch and repair: Challenges to the coping infant. Zero to Three, 6(3), 1- 6.

Tyson, R. L., Emde, R. N., Galenson, E., & Osofsky, J. D. (1985). The origins and fates of psychopathology in infancy: a panel discussion. In J. D. Call, E. Galen- son & R. L. Tyson (Eds.), Frontiers of infant psychiatry: Vol. 2 (pp. 480- 489). New York: Basic Books.

Whyte, W. F. (1984). Learning from the field: A guide from experience. London: Sage.

Winnicott, D. W. (1960). Ego distortion in terms of true and false self: The maturational processes and the facilitating environment. New York: International University Press.

Wolin, S. J., & Bennett, L. A. (1984). Family rituals. Family Process, 23, 401- 420.

Zahn-Waxler, C., Radke-Yarrow, M., & King, R. A. (1979). Child rearing and children's prosocial initiations toward victims of distress. Child Development, 50, 319- 330.

Zahn-Waxler, C., Robinson, J., & Emde, R. N. (1992). The development of empathy in twins. Developmental Psychology, 28, 1038- 1047.

Zuckerman, B., & Brown, E. R. (1993). Maternal substance abuse and infant development. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health. New York: Guilford.

Zero To Three. (1994). Diagnostic classification: 0- 3 Diagnostic classification of mental health and developmental disorders of infancy and early childhood. Washington, DC: Author.

Table of Contents

Toward a Theory of Early Relationship-Based Intervention (R. Emde,et al.).

Relationships for Growth: Cultivating Reflective Practice inInfant, Toddler, and Preschool Programs (L. Gilkerson & R.Shahmoon-Shanok).

The Assessment of Infants and Toddlers with Medical Conditions andTheir Families (K. Minde).

Infant Mental Health Assessment Through Careful Observation andListening: Unique Training Approaches (D. Weatherston).

Preventive Infant Mental Health: Uses of the Brazelton Scale (J.Nugent & T. Brazelton).

The Assessment and Diagnosis of Infant Disorders: DevelopmentalLevel, Individual Differences, and Relationship-Based Interactions(S. Greenspan & S. Wieder).

Clinical Assessment of Infant Psychopathology Challenges andMethods (M. Cordeiro).

Evaluating Mother-Infant Psychotherapies: "Bridging the Gap"Between Clinicians and Researchers (B. Cramer & C.Robert-Tissot).

Advanced Training in Infant Mental Health: A MultidisciplinaryPerspective (K. Frankel & R. Harmon).

Assessing the Risks and Strengths of Infants and Families inCommunity-Based Programs (S. Landy).

Training Mental Health and Other Professionals in Infant MentalHealth: Conversations with Trainees (J. Pawl, et al.).

Intervention-Centered Assessment: Opportunity for Early andPreventive Intervention (J. Thomas, et al.).

Observation, Reflection, and Understanding: The Importance of Playin Clinical Assessment of Infants and Their Families (E. Tuters& S. Doulis).

Assessment of Temperament in Infancy (J. Worobey).

Meeting a Desperate Need: One Man's Vision of Training for theInfant Family Field (F. Stott & L. Gilkerson).

Preparing Infant Mental Health Personnel for the Twenty-FirstCentury Practice (S. McDonough)

Indexes.

Editorial Reviews

"...an impressive collection of information..."...will serve as amajor resource for clinicians, researchers, scholars and studentsof human development in the years to come." (Int Jnl of AdolescentMedicine & Health, 13th January 2000)

From the Publisher

...an impressive collection of information...will serve as a major resource for clinicians, researchers, scholars and students of human development in the years to come.

Internationl Journal of Adolescent Medicine & Health

...an impressive collection of information...will serve as a major resource for clinicians, researchers, scholars and students of human development in the years to come.

International Journal of Adolescent Medicine & Health