Kornilia Hatzinikolaou, Lecturer of Developmental Psychopathology, School of Early Childhood Education, Aristotle University of Thessaloniki
Developmental Psychopathology emerged in the mid-1970s (Sameroff, 1975; Sameroff and Chandler, 1975) and was established as a distinct research field during the 1980s. It is the “study of the origins and course of individual patterns of behavioural maladaptation” (Sroufe and Rutter, 1984, p.14). This new domain had to manage a series of challenging issues, such as: defining the expression of psychopathology in children; the appropriateness of the existing mental health criteria for infants, toddlers and children; the creation of new intervention programmes and the assessment of the effectiveness of established interventions with such early ages; the investigation of systems responsible for atypical development, among others.
These fundamental questions could be better tested, both in theory and research, by making use of the knowledge on infant and toddler behaviour that Developmental Psychology had gathered since 1970s. This research was strongly influenced by the ethological tradition of meticulous observation of behaviour through frame-to-frame analysis of video and the interconnected theory of Innate Intersubjectivity (Trevarthen, 1974, 1979; Trevarthen and Hubley, 1978). Trevarthen and his colleagues built a new and more recognizable picture of the human infant through the theory of innate intersubjectivity: that is, motivated to communicate with other people and well-equipped to do so from birth. Intersubjectivity has been used in philosophy, psychology and other social sciences to refer to the sharing of subjective states between persons. Trevarthen himself, in a recent chapter for a book published in Greek that included the work of Greek researchers which was based on his theory, describes intersubjectivity as the sharing of minds (Trevarthen, 2016).
Impact of research on infant typical development on the establishment of Developmental Psychopathology
Thus, today, there is robust evidence that infants demonstrate well-organised patterns of communicative behaviour from the very beginning (e.g. Kugiumutzakis, 1985, 1998; Kokkinaki, 1998; Kokkinaki and Kugiumutzakis, 2000; Mazokopaki and Kugiumutzakis, 2008; Semitekolou, 2005), which are intentional in nature (Reddy, 1991), expressive of the infant’s own emotions and attentions and influenced by the emotions, intentions and attentions of their communicative partners. Moreover, infants seem to be capable of a non-reflective form of sympathy even as early as their second month of life (Hatzinikolaou, 2002; Hatzinikolaou and Murray, 2010).
Many of these themes were taboo for traditional Psychology. Infants were conventionally seen as lacking higher cognitive skills and for this reason could not be included in therapeutic interventions which required them. If infants are not capable of perceiving and experiencing others’ emotions, as it was traditionally thought, how they could be included in bidirectional models attempting to explain child psychopathology? Thus the recognition of the infant and young child as a person with her own rights, hopes and intentions provided Developmental Psychopathology with a more extended and fruitful field for study.
Moreover, the theoretical advances in the field of Developmental Psychopathology, such as the transactional model for understanding the process of the establishment of psychopathology (Sameroff and Chandler, 1975), were in agreement with theories of Developmental Psychology that supported the bidirectional model for explaining the construction of experience and the promotion of human development, such as the theory of Innate Intersubjectivity. It may also be worthwhile to mention that infancy research allowed the meeting of both fields, Developmental Psychology and Developmental Psychopathology, with the battle for human rights in society, and, particularly, with the movement of children’s rights, which had long supported the belief that the human infant is a person with intentions and volition, and therefore with basic human rights which should be recognised and protected.
All this new knowledge of infants’ early communicative abilities was gradually appealing to more and more researchers, and infancy became once again an exciting field of research to work in. For example, the better understanding of early communicative abilities has allowed a more thorough investigation of the passage from typical development to psychopathology. In order to investigate this process, often infants developing in at risk families and/or communities were extensively studied, such as infants of postnatally depressed mothers (Field, 1984, 1995; Field, Healy, Goldstein, Perry, Bendell, Schanberg, Zimmerman and Kuhn, 1988; Hatzinikolaou & Murray, 2010; Murray, 1992; Murray, Kempton, Woolgar and Hooper, 1993; Murray, Fiori-Cowley, Hooper and Cooper, 1996; Murray and Cooper, 1997; Murray, Arteche, Fearon, Halligan, Goodyer and Cooper, 2011).
Another example of how research on infant communicative abilities has advanced knowledge on early onset developmental disorders is the contribution of joint attention research to the understanding of autism. Joint attention to an external object is an ability demonstrated well before the end of the first year and indicates infant’s awareness of others’ attentions (e.g. Reddy, 2005). In autism, joint attention presents an atypical development (e.g. Dawson, Toth, Abbott, Osterling, Munson, Estes and Liaw, 2004). Measures of joint attention developed for the purposes of understanding early communicative abilities, early attention awareness and the development of self- awareness in typical development have also been used to assess self- and other- awareness in autism (Mundy, Gwaltney and Henderson, 2010).
The theory of Innate Intersubjectivity provided the theoretical context for the aforementioned and many more studies which investigated early typical and atypical development of communication, by considering that both actors, the infant and the caregiver, played active roles. Such studies introduced “a communicative infant”, who would be capable to “speak” for herself and, thus, allow further explorations in Developmental Psychopathology and its clinical applications. Infants were now recognised as persons with their own preferences, intentions, and emotions and with the ability to perceive the emotions and the intentions of their communication partners and respond to them in appropriate ways. In other words, the “communicative infant” came to promote a more solid bridge between Developmental Psychology and Developmental Psychopathology.
The study of infancy in the context of Developmental Psychopathology
The developments in the domain of Developmental Psychopathology attracted the attention of clinical psychologists, who worked on new interventions and carried out research including young children in clinical trials. In consequence, more taxonomic categories referring to young children were included in the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013) and in the ICD-10 Classification of Mental and Behavioral Disorders (WHO, 1992). In 1994, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised (DC: 0-3R) was published by the American Organization Zero to Three (Zero to Three, 1994). This is a developmentally based diagnostic manual that provides clinical criteria for mental health and developmental disorders that may be initially manifested in infancy and toddlerhood.
This multiplying evidence on infant and toddler mental health provided for the clinicians the tools to identify more infants and toddlers with developmental difficulties, and health and social services attempted to respond to the increasing demand in infant and toddler mental health services. However, it was quickly understood that prevention and early intervention cost less than treating the actual mental health problem after it has established itself (Allen, 2011; American Academy of Child and Adolescent Psychiatry, 2011). The establishment and the development of the domain of Early Intervention in infant mental health were largely based on infancy research carried out from 1970s onwards, as well as on research carried out in the context of Developmental Psychopathology itself. Without the developments in both fields that pointed towards the bidirectional construction of human experience since birth, planning and delivering appropriate and effective services could not take place.
Developmental Psychopathology research on infancy intensifies the demand for appropriate Early Intervention Programmes
If infants were still considered as creatures driven by instincts, unable to communicate with the external world, ‘lost in their fantasies’, as traditional psychology theories had presumed, how could we involve them in early intervention programmes, which treat infants as active agents in re-structuring their experience with others and with their environment in order to achieve a more functional and happy everyday life? Or, how could appropriate services be offered to those populations that mostly need it, if no research on risk and protective factors, on the peculiarities of families with mental health problems, on resilience, and on the duration of the effects of specific interventions, among others, had included infants and toddlers in research samples?
Although Early Intervention still fights to establish itself as a public health issue, many prevention and early intervention programmes have already been proven effective in limiting potential risk factors for psychopathology, and in enhancing the supportive function of protective factors decreasing the probability of the manifestation of infant and toddler mental health disorders. Some examples of such programmes are the Triple P-Positive Parenting Program (e.g. Thomas and Zimmer-Gembeck, 2007), The Incredible Years Parenting Programs (e.g. Menting, de Castro and Matthys, 2013; Webster-Stratton, Reid and Stoolmiller, 2008), Parent-Child Interaction Therapy (e.g. Thomas and Zimmer-Gembeck, 2011), and Video Interaction Guidance (VIG) (Kennedy, Landor and Todd, 2011). The case of the latter, however, is an example of how current research on infant typical and atypical development of communicative abilities based on the Theory of Innate Intersubjectivity was translated into an effective Prevention and Early Intervention Programme.
Translating the Theory of Innate Intersubjectivity into an Early Intervention Programme: The case of Video Interaction Guidance (VIG)
VIG is a method which promotes sensitive and attuned interactions and is intrinsically linked to Trevarthen’s theory of Innate Intersubjectivity and Mediated Learning. The model was developed by Harrie Biemans and his colleagues in The Netherlands during 1980s (Biemans, 1990). As an empowerment method, VIG promotes sensitive and attuned interactions by supporting clients to identify and recognise their communicative strengths. The working definition of the concept of “communicative strengths”, so central to VIG’s theory and practice, was based on infancy research and, particularly, on those principles which have been found to promote successful intersubjective communication between mothers and their very young infants. The identification and recognition of such communicative strengths empowers and motivates clients not only to further develop these strengths, but also to make good use of them in order to support less successful communicative moments and to re- establish intersubjectivity when the latter has been interrupted by communicative failures.
The principles that Trevarthen’s Theory of Innate Intersubjectivity and Mediated Learning have pointed out as paramount for the promotion of sensitive communications are central to Video Interaction Guidance’s theory and practice. In the VIG context these are known as the “Principles of Attuned Interactions and Guidance” and they can be summarised as follows: 1) Being attentive, 2) Encouraging initiatives, 3) Receiving initiatives, 4) Developing attuned interactions, 5) Guiding, and 6) Deepening discussion. ‘Being attentive’ refers to the skill of deliberately paying attention to what the other is doing, thinking and feeling and the skill to communicate this interest to the other through friendly postures, with provision of space and time for the other to express herself. A milestone of a sensitive and meaningful communication is the ‘encouraging of other’s initiatives’, which may be promoted through active listening and warm tone of voice, and identifying and naming the initiatives of the other.
Similarly important is the ‘receiving of the other’s initiatives’, which is communicated through confirming body movements and short verbal affirmations, returning eye-contact and nodding, or sometimes by repeating what the other has just said. These three principles provide the basis for the fourth principle, the ‘development of attuned interactions’. An attuned interaction is characterised by receiving and responding appropriately to the other’s communicative messages, by waiting for your turn, by giving and taking short turns, by collaborating, and of course having fun together. When an attuned interaction has been built, ‘guiding’ may be the next step. By guiding, what is meant is ‘scaffolding’ (Wood, Bruner and Ross 1976) – that is, the extending of the other’s experience and understanding, the provision of adequate help and the offer of tangible choices. Finally, an attuned interaction creates the appropriate intersubjective space for the ‘deepening of the conversation’, the exploration of new meanings, the collaborative problem-solving, the naming of disagreements and the managing of conflicts.
Colwyn Trevarthen has been personally involved in the development of Video Interaction Guidance, since the time that VIG was brought from the Netherlands to Scotland in the beginning of 90s. Trevarthen has admitted that “the interesting thing about Video Interaction Guidance is the shared discovery of creative or constructive communication in relationships that are in trouble” (Sound Cloud: User3720942, 2013), and that in the context of VIG, both trainers and clients “only really join attention to things that have made a contribution towards better relationships. I think that’s an excellent principle; a principle that Video Interaction Guidance can teach to any kind of therapy.” (Sound Cloud: User3720942, 2013).
In order to achieve its aims, VIG makes use of video-recorded interactions. More specifically, a trained VIG guider video-records the client’s interaction with her/his communicative partner. After reviewing and micro-analysing the video-recorded interaction, the guider selects exemplary moments of positive communicative exchanges between the two partners. Those selected moments of interaction make up a number of video clips, which are then presented to the client during the so-called shared review.
The primary aim of the shared review that takes place between the VIG guider and the client is to provide a safe environment for the selected video-recorded positive moments of communicative exchanges to be watched and discussed. As shared reviews are also based on the Principles of Attuned Interactions and Guidance, a secondary but nevertheless important aim is to provide a model for the client of how those principles may be applied to communication with others. The guider has been specifically trained to incorporate the principles into her/his way of communicating with others. Of course, working on the Principles of Attuned Interactions and Guidance is a life’s work; for this reason, all accredited VIG guiders and supervisors are encouraged to take a life-long-learning stance in relation to VIG.
The impact of the video on the client is noticeable. Although, initially, some clients may express shyness or surprise, they quickly recognise the reasons why the guider selected those particular clips to share; through sensitive and attuned conversations, the client reaches an understanding of the structural and dynamic characteristics of the communicative exchanges with another person (e.g. infant, child, partner, colleague or therapist).
Moreover, in the context of the shared review, the client has the opportunity to micro-analyse the interaction together with VIG guider, which allows the client to fully realise the power of the “now moments” (Stern, 2004) that may be lost and forgotten during the natural flow of an interactive exchange. The client is also in the position to understand the influence of her/his subtle communicative patterns on the other, as well as to realise that interactive coordination and emotional attunement are achieved through sensitive listening and appropriate responding to the other’s needs, wishes and intentions.
The average number of video-recordings and the subsequent shared reviews is around 3 to 4, depending on the client and the client’s initial demand. The termination of the VIG process is negotiated between the guider and the client, but usually the VIG process is concluded when the client feels that a good level of sensitive and attuned communication has been achieved with her/his communicative partner (Kennedy et al., 2011).
Applications of Video Interaction Guidance
Video Interaction Guidance has been used for prevention as well as for (early) intervention purposes. It has been applied to many different populations, such as postnatally depressed mothers and their infants (Vik and Hafting, 2006; Vik and Bråten, 2009), premature infants (Tooten, Hoffenkamp, Hall, Winke, Eliëns, Vingerhoets and van Bakel, 2012), children with early language and communication difficulties (Anderson, Jones and Flack, 2014), autistic children and their parents (Gibson, 2011; Nikopoulos and Keenan, 2011), deaf-blind children and their educators (Janssen, Riksen-Walraven and van Dijk, 2003), preschool teachers and their students (Fukkink and Tavecchio, 2010), bank managers and their staff (Doria, 2013), to mention just a few.
In 2012, the British National Institute of Health and Clinical Excellence recommended VIG as an effective evidence-based intervention to be used by professionals who work on promoting social and emotional well-being in under-5s (NICE, 2012). Over the last 20 years, the method has spread to other countries and continents, such as to Latin America (e.g. Mexico, Ecuador), Europe (the Netherlands, UK, Greece, The Czech Republic, France, etc.), Hong Kong, Malaysia, Canada, USA and Australia. Most importantly, VIG has been proved especially effective with high risk groups (Kennedy, et al., 2011).
Infant Intersubjectivity: More steps forward
Currently, neurosciences are attempting to understand and explain the “social brain”. However, the neural substrates of human intersubjective interactions are still an unknown land. In order for the social neurosciences to walk on this unknown land, it may be necessary to combine the use of descriptive behavioural sciences and neuroscience techniques.
For example, the simultaneous collection of data through video-recorded face-to-face interactions between infants and caregivers and with fMRI might provide rich information on the abilities of the young “social brain” to reach for and get emotionally involved with a sensitive other. Such a combined methodological approach would provide the opportunity for each method to be tested on whether it accurately studies what it is meant to study, by comparing the data stemming from the one method with the data stemming from the other method. In other words, a researcher’s description of early face-to-face infant-caregiver interactions in behavioural terms could be compared with the interpretation of fMRI data. If both methods agree on what is happening during this face-to-face interaction, their value in describing and interpreting early communicative exchanges will be tested. The need for the neurosciences to investigate natural real-time social encounters including at least two people, in order to demystify the social brain, has been previously underlined by other researchers, such as Schilbach and his colleagues (2013).
If such advances in developmental neurosciences can be used to study issues such as early intentional behaviour, early development of self-consciousness, and early expressions of infant sympathy, as those are described and understood in the context of the theory of Innate Intersubjectivity and the Innate Motive Formation, new insights may be brought to explanations of Autism, Regulatory Disorders, Attention Deficit/Hyperactivity Disorder, or Developmental Coordination Disorder. Then we will be in a better position to review and evaluate early intervention programmes addressing these disorders, as well as to construct new, more informed and evidence- based ones.
Finally, the effectiveness of Video Interaction Guidance on promoting sensitive communication and sympathy to different populations and in variable settings indicates that the translation of the Innate Intersubjectivity Theory into service provision was clearly successful. Thus, it may be worth to think of a more systematic transfer of knowledge between the Innate Intersubjectivity Theory and VIG’s principles and methodologies. Concerning VIG, the development of evaluation procedures which will be able to explain the mechanisms through which it achieves such positive results would be an important step forward for this so promising method.
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