As hearing health care professionals, we champion the need for auditory access and early intervention in the first three years of a child's life to grow his neural connections. From seven months’ gestation to age 2, an infant's brain grows from 25 percent to 75 percent of its eventual adult size. This rapid growth is accompanied by increased complexity from the wiring of neurons (synaptogenesis) during this critical period.
This dense branching is affected by the influence of the baby's environment and attachment relationships. Early experiences shape which neural pathways will be strengthened and which will be pruned away. The baby's early environment matters, and early relationships are essential for a baby's brain growth and the effects on subsequent development. It is critical for hearing health care professionals to recognize the importance of a child's relationship with his caregivers, and our families benefit when we partner with professionals who are specialists in infant mental health. Infant mental health field is the “healthy social and emotional development of a child from birth to 3 years, and a growing field of research and practice devoted to the promotion of healthy social and emotional development, prevention of mental health problems, and treatment of the mental health problems of very young children in the context of their families” (“Early Childhood Mental Health.” ZERO TO THREE: National Center for Infants, Toddlers, and Families 2014http://www.zerotothree.org/child-development/early-childhood-mental-health/?referrer=https://www.google.com/#2).
Babies develop and learn through a primary attachment relationship with their caregivers. They give a signal when they are in need, and they learn they receive help when their caregiver is sensitive to these cues and responds appropriately. This serve and return interaction creates the essential piece of safety and trust that allows the baby to venture into the environment to explore, develop, and learn.
This lasting and deep emotional connection between an infant and caregiver, which we identify as attachment, is critical for infant development. When there are significant disturbances to this attachment relationship, the baby is at risk for impairment in his development and in his social and emotional functioning that can have serious consequences later in life. Because babies cannot speak, it is important to clinicians to spend time observing and talking about their behaviors and helping their primary attachment figures understand what their behavior may mean.
It is critically important to assess the parent-infant relationship for children with hearing loss because the quality of attachment in infancy has a powerful influence on the course and outcome of a baby's progress. In the early months of hearing loss, parents might believe they cannot connect with their child because the child cannot hear their voices. A parent may also be grieving the diagnosis while attempting to manage new hearing aids or technology.
We, as providers, must familiarize ourselves with some of the warning signs of poor attachment so we can then support the family in establishing a secure one. We can also coach parents in ways that will strengthen the attachment and allow the baby to thrive.
Asking questions can be helpful diagnostically and therapeutically when working with families and infants with hearing loss. As we learn to become better observers of infant behavior, caregiver behavior, and the exchange between the two, we can address concerns before they become obstacles in the most important relationship in an infant's growing brain. Observations of caregivers and babies can begin in the waiting room and continue throughout the audiology appointment or therapy session. It is wise to gather information from the pediatric audiologist and speech-language pathologist who are familiar with the characteristics of a healthy attachment. It is important that the observation also include activities that involve free play between the infant and caregiver and a structured task, such as stacking blocks, rolling a ball, or feeding a doll. Standardized assessments and questionnaires are helpful in formulating diagnoses and treatment plans but cannot replace the insights gained from thoughtful observations and questions geared toward understanding the quality of an attachment (Child Development: A Practitioner's Guide. New York: Guildford Press 2010).
These 10 questions guide an observation when working with children with hearing loss and their families to improve outcomes and build better relationships. With infants, it is best to begin with a focus on the caregiver.
1. How does the caregiver physically handle the infant?
Now that newborns are screened for hearing loss, it is not uncommon to meet a family only a week or two after a child's birth. Quality information can be gained from simply observing how the parent brings the child into the session. Does the parent attempt to hold the infant when he becomes fussy or signals that he wants out of the car seat, or does she leave the baby in the car seat and attempt to appease him through other means? Does the infant settle and appear comfortable in the caregiver's arms, or does the physical touch appear rigid or mechanical?
Recently, a young mother who had been coming to the clinic weekly for six weeks had to be prompted to remove her child from the car seat when he became agitated. While holding him, his head continued to bob, and it was clear that she was uncomfortable with him in her lap. In contrast is the young mother who knows intuitively to hold her baby close to her chest or in a position on her lap where she can engage the baby through eye contact or conversation. Convey to caregivers that how they lift, carry, and hold a child reflects their emotional state. Research supports that babies feel safest when the parent is calm, tender, and relaxed rather than angry, frustrated, or stressed.
2. Is the caregiver talking to the infant? How does she talk to the baby?
“Motherese,” the language that some refer to as “baby talk,” is typical of most adults when they encounter a young baby. The high-pitched melodic songlike pattern is engaging for most infants, and some adults automatically respond in that way. If a young mother has never heard that type of cooing or singsong inflection, she is not likely to do it herself. All too often, a caregiver might use a phone or tablet to attempt to engage a child rather than realizing that a baby's favorite toy is actually the primary caregiver.
A nonverbal conversation can happen with a newborn. What is the tone of the caregiver's voice? Even a child with hearing loss can hear the suprasegmentals or the pitch and can understand the difference between a tone that is harsh or indifferent and one that demonstrates tenderness, concern, and adoration. This is an excellent opportunity to teach the family the impact of hearing loss and the need to focus on the variety of sounds that can be heard even with significant hearing loss when the infant is well amplified.
3. How is the parent talking about the baby?
How the parent describes the personality and interactions with the infant gives us more information on how the parent views the infant. A parent who describes the infant as spirited, independent, expressive, and determined is creating a much different story than a parent who says his baby is difficult to please, crabby, manipulative, and always upset. These two babies grow up hearing different messages about themselves and their needs from their parents.
A mother stated in a recent therapy session that her child was always fussy, difficult to take care of, and screamed constantly in the car. She said she hesitated to take her daughter anywhere because “I can't have any fun if she is with me.” When probed further by the therapist, the young mother was unable to describe any activity that her daughter enjoyed and reiterated that her baby was always in a bad mood. Infants may not understand the words a mother is saying, but they certainly have the ability to sense if there is stress or frustration from their caregiver in response to their cues for help.
4. How does the primary caregiver respond when there is another primary caregiver present?
Observing the infant in relationship with other primary caregivers can also give significant information about the quality of attachment and the infant's personality and temperament. An infant can respond differently to different caregivers. Is the father calmer in his approach when the infant cries? Is the mother better able to help the infant explore the environment but struggles with helping the infant calm down when he is upset? Without observing the infant with his other primary caregivers or asking about the infant's interactions with them, we could be seeing only one part of the infant's experience in a relationship, which may not accurately represent the infant's attachment.
5. What is the general status of the baby?
It is important to explore the birth history or early health history of every child because an infant's well-being can affect his attachment. Infants born prematurely or who have extended NICU stays may have early life experiences that leave them stressed, unregulated, or unsafe. The likelihood of a disturbance in attachment is high if prenatal care was limited or the baby struggled to gain weight after birth. Our experience with infants in state custody or the foster care system is that they are certainly at much greater risk for poor attachment, and it is critical to address strategies for establishing a healthy bond with a foster family as soon as possible.
6. How present is the parent in the session?
How mindful is the caregiver of what is happening in the booth? Making new earmolds? One of the greatest improvements in our access to information through smartphones and tablets also creates one of the greatest challenges for parents to respond consistently to an infant's cues and behaviors. Parents and caregivers can often miss the “magic of everyday moments” when changing diapers, sitting at the dinner table, during bath time, and so on by remaining engrossed with their phones or television.
These moments in session and at home provide parents a critical opportunity for singing, talking, reading, and simply remaining present in the moment with their baby. How is the appropriate use of technology being modeled in your clinic and in sessions? What are you observing in the waiting room between parents and infants?
7. How does the parent respond to the baby?
Intentionally focusing on the interaction between the parent and child gives more information about the quality of attunement and responsiveness to each other. It is important for providers to spend time observing how responsive a parent is to her baby. Is the parent able to see the baby's needs and read his signals? Can the caregiver maintain eye contact, smiling, sharing perceptions, and attention? How responsive is the parent to the baby? Is he able to recognize the baby's needs and read her signals? Is any behavior observed from the infant or parent that may make it difficult for the parent to respond to the infant's cues?
Infants vary in temperament and their behavior can make it difficult for a parent to feel joy in being able to meet their needs. A parent may be experiencing isolation and ongoing grief issues about a hearing loss diagnosis that makes it more difficult to see the infant. A therapist in a recent staff meeting noted that a family was struggling to keep hearing aids on their daughter. “Jane's mother did not respond to her infant's attempts to capture her attention such as fussing, waving her arms, and squirming. The mother also missed other behavioral cues from Jane* that indicated she was interested in a toy. Her mother has not been observed to initiate play with Jane but will imitate the therapist when prompted. She did not engage Jane in face-to-face play or respond to Jane's cues for attention during therapy.” (*Not her real name.)
8. How equipped is the parent to help the baby regulate distress?
It is important to observe how well a caregiver is able to calm the baby. It was clear that Jane's mother was not able to help Jane regulate her distress. Through observation, the therapist noted that Jane did not maintain eye contact with her mother and was observed to pull away from her attempts to comfort. She did place the baby on a blanket, and Jane calmed when she was placed away from her mother.
This prompted more questions, such as why Jane was unable to calm down in her mother's arms. How does this affect the mother's ability to feel successful in caring for her child? A strong attachment between an infant and caregiver is one of the best protective factors against future stress. A parent being a careful observer of his infant's behaviors while also having routines and flexible strategies to respond to the infant's distress supports attachment.
9. To what degree can the parent reflect on the meaning of the baby's behavior and emotions?
The therapist reported that Jane's mother had difficulty seeing the world from Jane's perspective. Her mother did not appear to enjoy her time with Jane and seemed burdened by the difficulty she had in taking care of her. What was keeping this mother from understanding and empathizing with her daughter? How could we support the mother in gaining more appropriate developmental expectations for her daughter? How did this mother's views affect her daughter's progress in therapy?
10. What are your goals in working with a family when there is concern about the quality of attachment between the infant and caregiver?
The first goal is always to provide the parent with developmental information. Talking to a parent and sharing that other babies are fussy and that other parents experience this same frustration in meeting their baby's needs often helps decrease some of the isolation a caregiver may feel. Providing strategies to help the mother calm Jane while also bringing the mother's attention to some of Jane's behaviors as clues to understanding if Jane wants comfort or to explore will increase the mother's success in meeting Jane's needs.
Another goal in therapy for a family concerned about attachment is to find a joyful activity they can experience together. Having a wide array of developmentally appropriate, simple activities is a great starting point for a parent and baby to duplicate at home. Structuring an office space that is peaceful and calm allows a parent and child to be supported in experiencing joy in their interactions. It also serves as a model for how to provide that safe place outside the clinic.
Utilizing these questions will give a more clear understanding of the relationship between a baby and his parent. Consultation is an essential piece of infant mental health, and discussing these observations and relationships with your colleagues can also give more clarity about the relationship dynamics present. These observations and discussions help create thoughtful interventions for a child and his parents that are possible to address in therapy.
In some relationships, the attachment needs more support and continues to be a barrier for the child to make progress. The next step for a family not responding to intervention to strengthen their attachment is to seek a referral with an infant mental health specialist. Many states have an association for infant mental health that can provide a registry of specialists (“Members of the Alliance.” Michigan Association for Infant Mental Health 2015http://mi-aimh.org/alliance/members-of-the-alliance/). The health care authority in most states should also have lists of appropriate infant mental health providers by area and local universities with early childhood programs.
Focusing on the development of a strong safe attachment between a caregiver and child is an essential part of intervention. We clinicians often enter sessions with our own agenda and can miss many opportunities to support the relationship between a parent and baby. Taking the time to be intentional about observations and remaining curious about each baby's attachment with his parents can only strengthen the services we provide.