1. Social and Emotional Impact after Neonatal Intensive Care Penny Glass, Ph.D. Developmental Psychologist Children’s National Medical Center

2. Objectives: Understand the early pattern of typical social/emotional development Understand the early pattern of typical social/emotional development Identify factors which impact social/emotional development during and after the NICU Identify factors which impact social/emotional development during and after the NICU Understand the role of the professional in supporting social/emotional development Understand the role of the professional in supporting social/emotional development

3. NORMAL PATTERN OF SOCIALIZATION Roots of Attachment – Roots of Attachment – Development of Trust Development of Trust Independence/Autonomy Independence/Autonomy Importance of Peers Importance of Peers

4. Attachment: Environmental Predisposition Attachment: Environmental Predisposition Imprinting in humans??

5. Early Attachment – what the infant brings Inborn social prediliction Inborn social prediliction Innate releasers (Bowlby) Innate releasers (Bowlby) Root/suck/cling/cry Root/suck/cling/cry Visual regard Visual regard + Physical dependency + Cute + own temperament + own temperament

6. Biologically predisposed for social vs nonsocial human voice human voice empathic distress empathic distress interactional synchrony interactional synchrony

7. Social Predisposition and Sensory Motor Integration Interactional synchrony.. to human voice to human voice

8. Social Predisposition mutual exchanges & magic moments

9. Predisposition for social vs nonsocial searches for facial features (eyes!) searches for facial features (eyes!) face/voice discrimination face/voice discrimination (parent/non-parent) (parent/non-parent) reciprocal vocal play reciprocal vocal play

10. Attachment, Trust, and Contingency – who the infant chooses Biological mother facilitates attachment… but is not essential Biological mother facilitates attachment… but is not essential More important: More important: sensitivity sensitivity contingent responsiveness contingent responsiveness emotional involvement emotional involvement Power of the smile

11. Mama? She can’t compete!

12. Attachment takes time…. From initial eye contact… to shared experiences and social reciprocity…… Physical dependence and development of language

13. Temperamental style Easy Easy Difficult Difficult Slow to Warm Slow to Warm Match/Mismatch Match/Mismatch Chess & Thomas Chess & Thomas

14. Temperament as emotional reactivity & self regulation Approach/withdrawal to new situation Approach/withdrawal to new situation Sensitivity to stimulation Sensitivity to stimulation Intensity of response Intensity of response Predominant mood (+ or -) Predominant mood (+ or -)

15. Emotional reactivity & self regulation Activity level, regularity of biorhythms Activity level, regularity of biorhythms Distractibility Distractibility Persistence in pursuing a goal Persistence in pursuing a goal Adaptability to change Adaptability to change

16. Stepping toward Independence & Autonomy Power of walking Power of walking Touching base parent as base of emotional support Touching base parent as base of emotional support self-regulation self-regulation mastery motivation mastery motivation Empathy: Empathy: From crying to caring From crying to caring From parent to others From parent to others 2-year old dilemma!

17. Attachment and Separation Anxiety response to separation/reunion response to separation/reunion Secure Secure Insecure ambivalent Insecure ambivalent Insecure avoidant Insecure avoidant Disorganized Disorganized …and temperament …and temperament

18. Attachment and Peers Task of the 3 year old Practice with “pair-dates” expands to group play expands to group playNeeds: desire (biology/temperament) skills (lang. dependent 1. art of conversation 2. negotiate a social contract, taking turns 3. compromise and playing pretend

19. Social and Emotional Impact during/after NICU Factors which Impact Parent Child

20. “High Risk” Newborn physical separation physical separation vulnerable appearance vulnerable appearance “6 sticks of butter” “6 sticks of butter” disruption of biological clock disruption of biological clock change of itinerary change of itinerary

21. Loss of Identity as Parent Nurse…Therapist….Teacher Nurse…Therapist….Teacher Force feeding and later food refusals Force feeding and later food refusals Not doing enough….or doing too much Not doing enough….or doing too much Later social isolation Later social isolation

22. Parents often try to compensate for NICU experience

23. Prolonged Physical Dependency parent fatigue parent fatigue effects our social interaction effects our social interaction parent depression parent depression

24. Interference with Play physical limitations and type of toys physical limitations and type of toys play is a social thing (language!) play is a social thing (language!) teaching vs play time teaching vs play time parents searching for the “magic toy” parents searching for the “magic toy”

25. Sensory Deficits auditory, visual, tactile auditory, visual, tactile reciprocal interaction reciprocal interaction communication communication

26. Multisensory toys: - heighten arousal, not attention to what is important - delay object relations - increase irritability

27. “Risks” of Therapeutic Interventions Physical intrusion Physical intrusion personal body space: personal body space: physical discomfort physical discomfort parent’s protective role parent’s protective role Multiple therapists and too many adults Multiple therapists and too many adults Loss of parenting role Loss of parenting role Loss of peers? Loss of peers?

28. “Risks”of Therapeutic Intervention Impact of excess reinforcement Impact of excess reinforcement loss of internal motivation loss of internal motivation becomes overly dependent on adult becomes overly dependent on adult distracting from task goal distracting from task goal Never teach a child to do something that you later must teach him (her) not to do. Never teach a child to do something that you later must teach him (her) not to do.

29. Problem of Limits in Child with Special Needs Over-acceptance of inappropriate behavior Over-acceptance of inappropriate behavior Inhibition and brain damage Inhibition and brain damage Who loves a terror and a tyrant? Who loves a terror and a tyrant? Not even the parent Not even the parent

30. Beyond the NICU Family Issues Family Issues Financial burden Financial burden Siblings Siblings Adult relationships Adult relationships Facing the future Facing the future Community Support Community Support Early Intervention Early Intervention Neighbors and friends Neighbors and friends Cultural Expectations Cultural Expectations

31. Summary The social/emotional pathway for a NICU graduate may be different, but it can be just as strong. The social/emotional pathway for a NICU graduate may be different, but it can be just as strong. The parent’s primary role as protector, a source of safety and comfort in times of distress, is altered in the NICU and beyond. The parent’s primary role as protector, a source of safety and comfort in times of distress, is altered in the NICU and beyond. As professionals, we need to be aware of the potential impact of our therapeutic approaches on social/emotional development of the child and family As professionals, we need to be aware of the potential impact of our therapeutic approaches on social/emotional development of the child and family

32. Selected References Fetal Development: A Psychobiological Perspective. Jean-Pierre Lecanuet, William Fifer, Normal Krasnegor, & William Smotherman, eds. Hillsdale, NJ: Lawrence Erlbaum, 1995. Fetal Development: A Psychobiological Perspective. Jean-Pierre Lecanuet, William Fifer, Normal Krasnegor, & William Smotherman, eds. Hillsdale, NJ: Lawrence Erlbaum, 1995. Attachment and Loss, J. Bowlby. New York: Basic Books, 1969. Attachment and Loss, J. Bowlby. New York: Basic Books, 1969.