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The Routledge Handbook of Attachment: Assessment
Steve Farnfield, Paul Holmes
Mothers and infants
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Airi Hautamäki
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Chapter 3
Mothers and infants
Screening for maternal relationships
at risk with the CARE-Index
Airi Hautamäki
Introduction
The Infant CARE-Index was originally devised for the purpose of research and is
the oldest and best validated of the Dynamic-Maturational Model (DMM) methods
for the assessment of attachment. Patricia Crittenden developed the CARE-Index
under the direction of Mary Ainsworth together with the assistance of John Bowlby,
both of whom viewed her set of videotapes of troubled mother–infant dyads (Crittenden 1981). At a time when research was largely focused on subjects drawn from
typical community samples, the CARE-Index was instrumental in extending the
assessment of attachment to at-risk populations (i.e. families in perpetual crises,
dyads troubled by abuse or neglect). The CARE-Index was the first of the DMM
assessments and, although not explicitly stated in the early papers, introduces the
basic constructs on which Crittenden’s model is built: attachment as adaptation to
context and attachment patterns as self-protective strategies organised to maximise protection under dangerous or threatening conditions (Crittenden 2008).
Ainsworth et al.’s (1974) original rating scale defined ‘sensitivity’ as a multistep process including the ability (1) to perceive and to interpret the infant’s signals
accurately and (2) to respond to the signals promptly and appropriately. Inevitably
parents vary with regard to how they receive and respond to their infant’s signals
(Claussen & Crittenden 2000): one parent might perceive the signal, but does not
find it relevant nor react to it, another might not even perceive the signal. Thus,
sensitivity refers to the parent’s ability to read the child’s behavioural signals (smiling, crying or arching the back, for example) as well as to select and to provide the
appropriate response (Crittenden 2008). Crittenden defines adult sensitivity in play
as ‘any pattern of behavior that pleases the infant and increases the infant’s comfort
and attentiveness and reduces its distress and disengagement’ (Crittenden 2010: 8).
Ainsworth’s (Ainsworth et al. 1978) original work stressed the impact of maternal sensitivity on the security of the infant’s attachment, but the variance in attachment accounted for by maternal sensitivity turned out to be modest (Belsky 1997).
The effect of paternal sensitivity on infant attachment security was even less (De
Wolff & Van IJzendoorn 1997). This ‘gap’ indicates that the quality and/or the
context of the assessment of sensitivity could be improved (Belsky & Fearon
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38
Airi Hautamäki
2008) which, in turn, presupposes a better understanding of why and how parental
sensitivity contributes to attachment, as expressed by the evolving working models of self and relationships (Thompson 1997).
A number of approaches have been taken to bridge the transmission gap (how
attachment security is transmitted). For example, Fonagy et al. (2002) have elaborated the concept of sensitivity in terms of mentalising, and Meins et al. (2001)
in terms of mind-mindedness. These concepts refer to the caregiver’s readiness
to treat the infant as an intentional individual with a mind of his own. Crittenden
(2010) has elaborated the dyadic construction of interpersonal meaning in terms
of the functional meaning of the behaviour for each individual, that is, the same
behaviour can mean different things and have various functions in different dyads.
Belsky and Fearon (2008) stress that in correlational studies the children’s susceptibility to rearing influences may also moderate the sensitivity–attachment link.
However, meta-analytic studies of experimental intervention programmes
designed to increase mothers’ sensitivity, do show that even short-term interventions can be successful and that interventions improving mothers’ sensitive
responsiveness to infant cues are most likely to show improvement in the attachment patterns of their babies (Bakermans-Kranenburg et al. 2008; van den Boom
1994). Likewise, interventions that have broadened the concept of sensitivity to
include both maternal representations and caregiving behaviour also show that
targeting maternal sensitivity has a positive impact on the attachment pattern of
the infant (Cicchetti et al. 2006; Svanberg et al. 2010). Therefore, there is strong
experimental evidence in regard to the impact of maternal sensitivity on infant
attachment. As interventions often focus on infants with high levels of negative
emotionality, they may be the group who are the most susceptible to changes in
maternal behaviour (Belsky & Fearon 2008).
Thus, for those involved in offering services to troubled families, a tool, like the
CARE-Index, to assess parental sensitivity, in terms of risk, planning for interventions and as a means of understanding the process of intervention, is a crucial first
step (Crittenden 2010).
What the CARE-Index assesses
The CARE-Index is a play-based method for assessing dyadic synchrony; that is,
the ‘dance’ between parent and child or quality of adult–infant interaction. It was
developed to assess the risk to relationships, screen for developmental risk, guide
intervention and assess the outcomes of interventions (Crittenden & DiLalla 1988;
Farnfield et al. 2010). The focus on the assessment of risk to relationships rather than
individuals (usually mothers) makes it a unique screening tool (Crittenden 2010).
The assessment process
The infant method is used with children from birth to 15 months and the toddler
method with children aged between 16 and 48 months (Crittenden 2005, 2010).
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Mothers and infants: screening for maternal relationships at risk
39
The parent is asked to ‘be or play with your child as you would usually’ and the
interaction is videotaped for approximately 3–5 minutes. The parent decides the
nature of play and use of toys. Because the procedure induces low stress in the adult
and none in the child, it offers less information on child attachment than the stressbased Strange Situation (Ainsworth et al. 1978). But as the CARE-Index allows
the adult to be a more active participant, it offers more information on the parent’s
contribution to the child’s strategy (Farnfield et al. 2010). It can be used with adults
who are not attachment figures (e.g. distant relatives) and foster and prospective
adoptive parents. The videotaping does not require a laboratory setting and can be
conducted by one person just about anywhere. The procedure is not invasive and
can be repeated several times, using short time intervals without compromising its
validity (Crittenden 2010). As well as screening for risk, it is useful for intervention
studies and programme evaluation (Cramer et al. 1990; Svanberg et al. 2010).
Because the focus of the CARE-Index is on specific relationships and not on
individual characteristics, the behaviour of each person is scored from the perspective of the other. For example, the behaviour of a baby who is looking away and
squirming is coded as ‘difficult’ from the mother’s perspective, and the behaviour
of a mother who pokes the baby is coded ‘controlling’ from the baby’s perspective. Because sensitivity is a dyadic construct, rather than a quality possessed by
the parent independently, the infant’s temperament becomes an integral part of the
procedure so that a mother is sensitive only to the extent that she is responsive to
the unique features of her infant. And because sensitivity is a characteristic of a
specific relationship, the same parent may display different degrees of sensitivity
with different children (Crittenden 2010).
Coding the CARE-Index
In contrast to Ainsworth’s global and uni-dimensional scale of attachment (Ainsworth et al. 1971), Crittenden’s (2010) system has two negative points to the
non-sensitive end of the sensitivity dimension: over- and under-engagement with
the infant, coded as controlling and unresponsive, respectively. The coding procedure focuses on seven aspects of adult and infant behaviour, of which four assess
affect (facial expression, vocal expression, position and body contact, expression
of affection) and three assess cognition, i.e. temporal order and interpersonal contingencies (the response of one party to the behavioural signals of the other): turntaking, control of the activity, developmental appropriateness of the activity. Each
aspect of behaviour is scored separately, for the adult and the infant, and the scores
added to generate three scales for the adult (sensitivity, control and unresponsiveness) and four for the child (cooperation, compulsivity, difficulty and passivity
for infants, and cooperation, compulsivity, threatening and disarming coercive
behaviour for preschoolers) (Crittenden 2010).
The CARE-Index incorporates the concept of ‘reparation’ (Tronick 1989); that
is, the ability of the dyad to repair breaches or breakdowns in their interaction. In
sensitive dyads breakdowns are repaired relatively quickly accompanied by the
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40
Airi Hautamäki
transformation of negative affect into positive affect. Dyads which are assessed
as at risk show sustained periods when there is either conflict or no connection
together with negative affect (anger or withdrawal).
Unlike many other observational methods which count the frequency of a particular behaviour, the CARE-Index focuses on patterns of interaction and emphasises the use of categorical judgements regarding the function of behaviours in the
‘dance’ of the dyad. This is of particular importance with the regard to falsification of behaviour by both adults and toddlers with the result that some displays
of emotion may have more than surface significance. For example, smiles do not
necessarily express genuine pleasure or affection. A mother might try to hide her
infant’s displeasure and her own hostility with false positive affect, or a child may
display positive affect when she, in fact, feels rejected and sad. In the latter case
the function of the display of cheerfulness may be to cheer up a withdrawn mother
and increase her emotional availability to the child (compulsive care giving).
Alternatively the apparent helplessness of a toddler may actually mask a coercive strategy aimed at maximising adult attention by emphasising vulnerability
over aggression (passive aggression).
Identifying the overall function of behaviour helps us recognise patterns of
adult–child interaction; the most common combinations are given in Table 3.1
(Crittenden 2010; Hautamäki 2010).
The CARE-Index was developed to differentiate high-risk dyads from low-risk
dyads and has a tendency to over-identify risk. For this reason, whenever a dyad
is identified as being at risk, a more thorough assessment with additional methods
should be carried out, for example a second CARE-Index, a family history should
be taken or another attachment assessment method should be conducted. Crittenden (2010) also stresses that because the suitability of the CARE-Index for applied
use has not yet been studied as fully as its research utility, and because highly
trained coders are needed, diagnostic conclusions based on the procedure should
be drawn with caution, and only in conjunction with other information.
Comparable procedures
Comparable assessments are those involving the parent and child doing something
together under mildly stressful conditions (e.g. Fivaz-Depeursinge & CorbozTable 3.1 The most common pairs of patterns of adult–child interactions as
assessed by the CARE-Index
Carer
Infant
Toddler
Sensitive
Controlling
Cooperative
Difficult or Compulsive
compliant
Passive, difficult or
Compulsive caregiving
Cooperative
Threatening-disarming or Compulsive
compliant
Threatening-disarming or Compulsive
caregiving
Unresponsive
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Mothers and infants: screening for maternal relationships at risk
41
Warnery 1999; Marschak 1960). Like the CARE-Index, the Lausanne Triadic
Play (LTP) has a relational focus, but it looks at the development of the infant’s
communicative competence with both parents simultaneously in a triangular
family process, the goal of which is ‘to preserve threesome relatedness in the
midst of affectively loaded situations, such as harmony, uncertainty, and conflict’
(Fivaz-Depeursinge & Corboz-Warnery 1999: 25). Thus the observation in the
LTP combines a family systems and an attachment theory perspective although it
does not code for attachment behaviour per se. The Marschak Interaction Method
(MIM) is a structured technique consisting of a series of tasks that elicit a variety
of behaviours. The aim is to observe and assess the structure, engagement, nurture
and appropriate challenging in the parent’s relationship to her child (Marschak
1960).
Even though the MIM-constructs may be paralleled with the affective and
cognitive aspects in the CARE-Index, the CARE-Index is more focused on the
dyadic construction of interpersonal meaning, that is, the same behaviour can
mean different things and have various functions in different dyads. Neither does
appearance always reflect reality. Displays of behaviour may be falsified, for
example when the infant learns to deny negative affect in compulsive or inhibitory patterns of infant adaptation. The affective displays may also be distorted, as
when toddlers learn to exaggerate some signals and minimise others in coercive
patterns of adaptation (Crittenden 2010).
Cultural differences
According to Geertz (1973) the core of culture is a set of control mechanisms
– plans, rules and instructions – for the governing of behaviour. The control
mechanisms connected to protecting humans from danger in their specific cultural
niche are particularly relevant in the context of parental sensitivity and attachment (Hautamäki 2010). Every culture has scripts about how to live safely in
one’s environment. The parents’ most important task, independent of culture, is
to keep their offspring alive and safe (von der Lippe & Crittenden 2000). Parents
transmit to their children a set of control mechanisms, or what people in a certain
cultural context have learned about ways of staying safe. Their infants organise
their attachment behaviours in ways that increase the probability of their parents
providing protection from dangers, and decrease the probability of parents rejecting them (von der Lippe & Crittenden 2000). For example, if the cultural niche
demands the suppression of negative affect (anger, fear and the desire for comfort),
infants tend to develop a Type A (avoidant) attachment to meet this requirement.
In such a cultural context, the Type A strategy may be considered normative in the
sense that it promotes adaptation and is the predominant one (Hautamäki 2010;
Hautamäki et al. 2010). Thus, inter-cultural differences in parental sensitivity and
child attachment reflect the history of dangers in the culture in question.
Even though these cultural differences lead to variation in parental sensitivity
vs. unresponsiveness and control, coders of the CARE-Index should not adapt the
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42
Airi Hautamäki
items to different cultures. Instead they should apply the items similarly across
cultures (Crittenden 2005). When the results show different patterns of scores, for
example higher unresponsiveness scores in a particular culture (Hautamäki 2010;
Kemppinen 2007) the social and psychological meaning of the difference should
be analysed in terms of how historical and current conditions of danger and safety
have impacted on the culture’s values, in particular, in regard to child rearing
(Crittenden 2005).
The Infant CARE-Index has been applied to an array of cultures, for example:
Hautamäki 2010; Kemppinen et al. 2006a; Killen 2006; Künster et al. 2010; Pleshkova & Muhamedrahimov 2008; Simó et al. 2000; Svanberg et al. 2010; Ward
& Carlson 1995.
Infant CARE-Index: developmental considerations
The CARE-Index is well grounded in infant development and the ways in which
parental sensitivity has to change to meet developmental changes in the child.
Accurate coding of the infant system must focus on the stages and processes by
which the adult and the infant create dyadic synchrony (the dance), cognitive contingencies (responses to the other’s signals) and affective attunement (the mother’s ability to pick up and mirror the infant’s feelings), from birth to 15 months
(Crittenden 2010).
The infant period (0–15 months): from physiological
regulation to reciprocal communication around objects of
joint attention
The central question in the first three months is: ‘Can the adult enable the infant
to remain in an alert and relaxed state for increasingly long periods of time?’
(Crittenden 2010: 46). When the baby is developing an emergent sense of self,
the adult’s task as the ‘self-regulating other’ (Stern 1985) is one of physiological
regulation. At best, parents regulate the baby’s arousal in a way that keeps the
infant alert, but not over-excited. Sensitive parents take up face-to-face positions
to communicate with their babies, as nothing catches the young infant’s attention
better than a mother’s attentive and responsive face. A cooperative baby will gaze
at his mother, coo and gesticulate. Control is indicated by maternal actions which
are experienced by the baby as intrusive, i.e. negatively contingent. Unresponsive
mothers do not provide the baby with self-relevant stimuli around which to organise his behaviour and learn the to-and-fro of social interaction. Tronick’s (1989)
‘still-face’ experiment (when the mother is asked to suddenly blank her expression
when looking at her baby) shows the difficulties confronting babies whose carers
lack contingent responsiveness.
During the 3–6 month period the central question is learning to take turns (Crittenden 2010: 49): ‘Can the adult help the infant to find and expect repetitive dyadic
sequences in which they each have a part?’
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Mothers and infants: screening for maternal relationships at risk
43
From 6–9 months the central issue is: ‘Can adult and infant establish a dyadic
pattern and then vary the components of the pattern?’ (Crittenden 2010: 52).
Several important developmental processes broaden the scope of parent–child
interaction at this stage. The child forms person-specific ties with one or two attachment figures, which also means he is wary of unfamiliar people. As the infant has
learned turn-taking, longer and more varied play sequences can be created.
At 9–12 months the central question is: ‘Can the adult and the baby turn their
attention from each other and toward an object that they both enjoy?’ (Crittenden
2010: 55). Parent and child can now divert their attention to playing with a third
object so that the issue becomes one of ensuring reciprocal communication around
objects of joint attention.
The central issue from 12–15 months of infant age is incorporating language in
play. ‘Can the adult use language in simple ways that enable the baby to regulate
play without exclusive reliance on non-verbal forms of communication?’ (Crittenden 2010: 58). Three groups of children can be discerned by one year of age
(Crittenden 2010: 55, 58):
•
•
•
Cooperative infants: Those who have learned to listen to adult language, because they find it meaningful, and produce sound sequences of their own with
the expectation that it will elicit a sensitive response.
Difficult and passive infants: Those who are angry and desirous of comfort
and still emphasise non-verbal communication and do not find it meaningful
to attend to what adults say.
Compulsive: Those who use language according to meanings offered by
others, i.e. they do not vocalise spontaneously. Instead, they tend to echo and
mirror what is demanded of them.
In terms of attachment strategies these are Types B, C and A, respectively.
Contingency
From birth, babies develop strategies for eliciting the best possible care from their
attachment figures. The combinations of parent–child behaviours given in Table
3.1 can be construed in terms of the degree to which parental behaviour is contingent on the signals of the infant and the emerging attachment behaviour of the
infant. Sensitive mothers are positively contingent and their babies are on the road
to secure attachment. Controlling, covertly hostile mothers provide negative or
punitive contingencies (e.g. they respond to their baby’s distress angrily or by
laughing). If the parent is controlling and shows false positive affect, the infant
will either protest by showing non-compliance, or inhibit the display of negative
affect, and look alert, but with an empty gaze. If the baby engages in a struggle
then she is on the road to a Type C attachment.
However, by 6 months of age, some infants become alert and vigilant, i.e. they
learn to selectively inhibit some behaviours (e.g. crying, pushing with the arms).
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44
Airi Hautamäki
If difficult behaviour has been punished consistently and strongly by the parent,
infants, with further cortical maturation, will exhibit the beginnings of compulsive
behaviour (Crittenden 2010: 50).
When maternal unresponsiveness is pervasive, the infant is likely to shut down
and display passive, i.e. uninvolved and listless behaviour, which will elicit even
less attention from an already unresponsive adult. The infant is not yet able to generate attention-getting and pleasing affective behaviour (Crittenden 2010: 51). For
this reason, at 3–6 months, it is probable that an unresponsive parent is paired with
a passive baby. This is detrimental for the relationship, in which both feel unloved
by the other, and for the development of the baby, who neither learns to recognise signals around which to organise his interactive behaviour nor self-efficacy.
However, when the maternal unresponsiveness is at average, the infant is likely to
display difficult behaviour to catch the attention of the inconsistently responding
caregiver (Fuertes et al. 2010).
Compulsivity
One of Crittenden’s major contributions to the observation and understanding of
early years development in the context of maltreatment is her work on compulsivity. Compulsive behaviour is characterised by inhibiting forbidden negative
affect (which forms the basis of avoidant Type A1-2 behaviour) and, crucially
for compulsivity, turning negative affect into displays of false positive affect. For
example, smiling with sad eyes or responding to adult intrusions with a strained
‘happy’ voice tone. Parallels may be drawn to Winnicott’s (1965: 17) concept of
‘false self’.
The affective response to aversive body contact is the most difficult to falsify
so that infants only gradually develop compulsive behaviour, if required, and
there is frequently a shift from difficult to compulsive behaviour with displays of
compulsivity being achieved earlier or later in different modalities. For example,
inhibition of vocal protects (crying) and looking away from the attachment figure
are relatively easy to master, whereas tolerating aversive touch is more difficult to
achieve (Crittenden 2010: 53).
From about 9 months some infants with very withdrawn, unresponsive parents develop compulsive caregiving behaviour which entails inhibiting their own
desire for comfort, focusing excessively on the parent, and presenting an overbright cheerful demeanour in order to elicit and maintain attention from their
parent (Crittenden 2010: 56).
Toddler CARE-Index (15–48 months): from parent–toddler
conflict to goal-corrected partnership
The Toddler CARE-Index is adapted to fit the more complex psychological
and interpersonal functioning of preoperational children. On the basis of growing cognitive, language and perspective-taking abilities, the toddler develops
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Mothers and infants: screening for maternal relationships at risk
45
expectations of a goal-corrected partnership; i.e. to create joint plans, negotiate and
compromise about them with significant others (Bowlby 1982).
The central issue for 2-year-old children is: ‘Can the adult assist the toddler to
transform (1) action into linguistic communication, especially story-like behavioural sequences and (2) non-verbal affect into accurate verbal statements about
feelings and desires?’ (Crittenden 2005: 41).
In the transition from sensorimotor representation to the representational use of
language, verbal negotiation of differences in plans becomes possible for the toddler.
Stern (1985: 161) emphasises that affective attunement (which starts when the baby
is born) is a stepping stone toward language: ‘It treats the subjective state as the referent and the overt behavior as one of several possible manifestations or expressions
of the referent.’ Language provides a new way of being related to others by sharing
personal knowledge with them, as the child develops his sense of a verbal self (Stern
1985). Language can either help the toddler to articulate his personal experience and
feelings or alienate him from his self-experience depending on how parents incorporate language in their interactions with their children, for example helping the child
to interpret his genuine feelings and intents by empathically mirroring and expanding
his utterances into short statements. The Type C coercive strategy is connected to linguistic limitations and the belief that words do not necessarily mean what others seem
to express by them. If the parents have been inconsistent, as is the case in struggling,
‘inept’ dyads, the child has learned that parents do not necessarily do as they tell him.
Hence the child does not learn to trust promises about the future, and to negotiate
with language. Instead, he refines his coercive strategy, alternating forcefully exaggerated and split negative affect (anger/desire for comfort) (Crittenden 2005).
With a covertly hostile caregiver, the child experiences the mismatch of affect
to speech. When, for instance, the carer’s false positive affect is accompanied by
predictable, sometimes hostile, language, the child learns to focus on the content
of speech and behaviour, is not sensitised to the carer’s or his own true underlying
feelings and may become estranged from his own personal experience. This is the
basis for the Type A strategies.
Crittenden (2005: 9) defines adult sensitivity in play as any pattern of behaviour
that supports the toddler’s opportunities to explore the activity with interest and
spontaneity and without inhibition or exaggeration of negative affect. Two issues
are essential: whether the adult is able to establish a hierarchical relationship, in
which the toddler both can explore safely and seek comfort, and, if the adult can
help the toddler to regulate affect in a way that it communicates the feelings of the
toddler without disturbing the relationship further.
Two developmental advances require a different way of coding toddlers’ interactions (Crittenden 2005). First of all, because toddlers can split the internal regulation of feelings from their external display, new ways of influencing the behaviour
of parents in desired directions are possible. Hence the ambivalent-resistant, Type
C pattern becomes organised as a coercive strategy (Crittenden 1994). Toddlers
using the Type C coercive strategy can split mixed negative affects into an angry
and threatening display package, on the one hand, and a vulnerable fearful and
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46
Airi Hautamäki
desirous of comfort package on the other. The toddler is able to use coy behaviour
to disarm parental anger and elicit nurturance; for example, stamping on the cat’s
tail then giving Granny a cute little smile accompanied by a shimmy. The split
here is within negative affect so that one emotional state may dominate (e.g. anger
over vulnerability) or displays of anger and desire for comfort may be alternated.
By contingently alternating affective displays the toddler can catch and maintain
the attention of unpredictable parents and regulate their response. Parallels can be
drawn to Mahler et al.’s (1975) analysis of 18–21-month-old toddlers’ increasing
attempts to coerce parents to function as external extensions to their egos and to
react with splitting mechanisms.
The second developmental advance entails the ability to create a split between
negative and positive affect by inhibiting negative affect and displaying positive
affect. The inhibited negative affect is replaced by parent-pleasing, false positive affect to prevent adult rejection and elicit adult approval. This is the compulsive strategy, outlined above, which takes four forms: compulsive caregiving
(role reversal); compulsive attention; compulsive compliance; and compulsive
performance.
Toddlers using the Type B strategy have parents who can establish a hierarchical relationship in which the child can explore safely, and in times of need, seek
comfort (Crittenden 2005). The child is open not only about positive but also his
negative affects, without exaggerating them, and negotiates directly with his or
her parents in situations of conflict, in the firm belief of the protective availability
and goal-corrected partnership with the attachment figure (Crittenden 2004).
Validity and reliability of the CARE-Index
The Infant CARE-Index is the best validated of the DMM assessments. There are
several studies of low-risk populations and prospective longitudinal studies (Kemppinen et al. 2006a; Kemppinen et al. 2007; Simó et al. 2000; Ward & Carlson
1995). Also several studies of various risk conditions have been done, for example
handicapping conditions (Crittenden & Bonvillian 1984; Robert-Tissot et al. 1996);
drug-exposed infants (Linares et al. 1999); maternal psychiatric disorder (Cassidy
et al. 1996; Kemppinen et al. 2006b); maltreated infants (Crittenden & DiLalla
1988; Leadbeater & Bishop 1994); and prematurity (Müller-Nix et al. 2004). Discriminating between a set of medical and social factors, Fuertes and colleagues
found that the socio-economic situation of the family had the strongest impact on
maternal sensitivity and the cooperative behaviour of premature infants (Fuertes
et al. 2012). Economic hardship is connected to more harsh and/or detached parenting that, in turn, may be mediated by the reproductive strategies that the parents
have developed in their families of origin (Belsky 2007). There are only two studies of the toddler CARE-Index (Crittenden 1992; Künster et al. 2010).
Coding a CARE-Index is essentially a pattern recognition skill, and as such it
requires extensive training as well as seeing many interactions and receiving feedback on one’s judgements. Qualified coders need to code 100–150 interactions
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Mothers and infants: screening for maternal relationships at risk
47
before becoming reliable. In order to retain reliability, coder drift, by coding in
small groups drifting away from the standard, must be prevented. Coding must
also occur blindly, the coder being naive to all external information about the dyad
(Crittenden 2010).
How can the CARE-Index be used to plan
interventions with dyads at risk?
For the purpose of screening for risk, both the pattern of the interaction (see Table
3.1) and the scale score of maternal sensitivity can be used (Kemppinen et al.
2007; Linares et al. 1999; Simó et al. 2000). Scores on parental sensitivity range
from the highest value of 14 (the dyadic synchrony is described as ‘mutual delight,
joy in one another; a dance’) to a low value of 0 (‘total failure to perceive or
attempt to soothe infant’s distressed state; no play’) (Crittenden 2010: 21). On the
basis of the scale score of parental sensitivity, the degree of risk to the relationship
can be estimated, and when this is incorporated with the pattern of the interaction
it can help professionals design the optimal intervention.
Svanberg and colleagues (Svanberg et al. 2010) assigned subjects to risk groups
on the basis of the scores on maternal sensitivity. For the sensitive enough group
(scores on maternal sensitivity ranging from 8–12), one home visit was offered
including positive feedback to the mother by means of showing examples in the
videotape of sensitive responses to her infant. The health visitor also offered guidance such as a leaflet on the early emotional development of the child. For dyads
in the struggling group (sensitivity scores ranging from 4–7) and the high-risk
group (sensitivity scores ranging from 0–3) the intervention was designed around
the unique needs of the dyad. The struggling group was offered a series of four
reflective video feedback sessions, using their own CARE-Index, highlighting
brief flashes of sensitive interaction (Svanberg et al. 2010). The aim was to help
mothers read and respond to infant signals and to increase reflection on potentially
distorted representations of both herself and her baby. The reflective discussions
focused on four main topics: developing mindfulness; acknowledging ambivalence; helping the mother to make links from her own childhood to current parenting; and developing awareness of the impact of separations. Dyads in the high-risk
group were offered the same reflective videotape feedback, and, in addition, various forms of parent/infant psychotherapy (Svanberg et al. 2010).
Joint viewing of the videotape and reflective video feedback sessions play an
integral part in interventions with troubled families and studies that have used video
as a part of an intervention with parents and their young children have reported
promising results (Svanberg et al. 2010; Bakermans-Kranenburg et al. 1998,
2008; Holmes & Farnfield 2014). In real life parents must respond immediately,
caught by the heat of the moment, to the signals of their infants. When parents are
viewing their own interaction with their infant, they can observe without having to
act. The opportunity to analyse and to reflect on one’s own action helps the mother
to recognise problems and blocks in her own ways of responding, for example
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48
Airi Hautamäki
repeating tragedies from her own past (Fraiberg et al. 1975), and to generate new
ways to respond (i.e. mentalising: see Chapter 13; see also Lieberman et al. 2005).
Viewing other mothers and babies may also increase a mother’s repertoire of
things to try. This provides mothers an opportunity to develop their observational
skills on less personally threatening observation material (Crittenden 2008).
The pattern recognition skills of the interventionist
The CARE-Index does not only offer information in regard to the level of dyadic
synchrony, but also in regard to the nature of the dys-synchrony. The CAREIndex assessment is based on categorical judgements of the function of behaviours
in dyadic interaction, particularly on finding functionally equivalent behaviours,
and offers information about how these behaviours form a self-protective pattern
(Crittenden 2010). For example, an unresponsive mother who feels she is unlovable signals this to her baby by not seeking eye contact with her infant, even averting her gaze, and by minimising close physical contact with him (Ainsworth et al.
1978). Gaze aversion can, in terms of Schore (1994: 379) be considered ‘an external manifestation of shame’. The baby responds by passivity but might then learn
that by gurgling positively when his mother draws near he can brighten her affect
and retain her attention. Seeing the functional purpose of self-protective strategies
in the parent and the child helps to engender compassion for both participants in
the dyad (Crittenden 2008).
The therapist needs pattern recognition skills to discern the nature of the
dys-synchrony of the dyad. Are there biases to toward using affect or cognition
to regulate behaviour? What kind of distortions are there in child-protective and
comforting behaviour and in information processing? The relation of adult to
infant scores can be analysed. A combination of non-sensitive and non-cooperative items offers information about how the mother and the child perceive each
other. Incongruity in the adult and child scores, for example apparently sensitive
adults with compulsive infant, as well as covertly hostile adults with apparently
cooperative infants, should alert the observer to ask whether the sensitive and
cooperative items have been misinterpreted (Crittenden 2010).
Items related to affect should be contrasted with those related to temporal contingency. A marked difference in the appropriateness of affective and cognitive
scores offers information for tailoring the intervention (Crittenden 2010). Affectively attuned adults who struggle to structure activities and respond to infant
cues are able to learn how to interpret their infant signals better by observing their
own videotaped interactions. Appropriately cognitively contingent adults who
are covertly hostile or affectively unresponsive present a more serious challenge.
The intervention has to deal with the adult’s feeling of being a mother or father
carrying the care-taking responsibility of a needy infant. Infant–caregiver psychotherapy is often needed (Crittenden 2010).
Thus, with the help of the CARE-Index the therapist can observe and draw
inferences in regard to the unique patterns of the relation of the non-sensitive
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Mothers and infants: screening for maternal relationships at risk
49
adult to the non-cooperative infant or toddler, which helps to focus the intervention. Further research will help to match CARE-Index patterns to developmental
psychopathology and environmental conditions as well as improving the selection
of appropriate interventions to meet the needs of a particular dyad.
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