Maternal/caretaker-child interactions

While the study of maternal-child feeding interactions relating to nutritional outcome has been limited, research linking mother-infant relations to psychological health and child intelligence is vast, heterogeneous, and spanned by many levels of analytic re solution (Hopkins and Kalverboer, 1983). This research has been both extensive (large sample) and intensive (small sample) and can be classified into unidirectional studies, looking at influences operating from mother to infant (M-l), infant to mother (I-M) or bidirectional (both ways). The recent trend is towards intensive fine-grained (micro) analyses investigating interactional processes. In both non-nutritional and the few existing nutrition studies, the inborn characteristics of children are increasingly recognized as contributing to the nature and quality of the mother-child relationship (Hopkins and Kalverboer, 1983; Pollitt and Wirtz, 1981). This relationship may, in turn, have an influence on the expression of the child's temperament.

Fig 7. Conceptual framework of factors influencing positive deviance and of programme types.

Lists of Interactions Related to Growth

Four tabular lists are provided below in sufficient detail as not to require a parallel narrative explanation. They are divided into mother-to-infant and infant-to-mother

general non-feeding interactions; and mother-to-infant and infant-to-mother feeding specific interactions. For simplicity of presentation, bidirectional interactions are put on both M-I and lM lists. A few variables linked to nutritional status through core relations with a third variable have been included and are so labelled. The reader should be aware that major methodological problems make it difficult to generalize from the findings of many of the studies reported. These difficulties include:

1. Selection of small samples of mother-infant pairs who are not necessarily representative of the population, but who were willing to co-operate in in-depth studies. Small sample size leads to loss of statistical power.
2. Units of recorded behaviour that differ from study to study. There is an inevitable arbitrariness to the ways in which units of behaviour are defined and subdivided for microanalysis. When many minute behavioural elements are recorded and then reconstituted statistically into scales or by factor analysis, the resulting theoretical constructs. called by such names as "nutritional cluster" (Pollitt and Wirtz, 1981), may or may not correspond to the topics discussed by others. Many documents fail to list the items that they combine into their scales, thus making it impossible for the reader to judge the validity of their conclusions.
3. Impossibility of inferring the direction of causal relationships. Most studies demonstrate associations between growth and behaviour. None the less, they are not designed in a manner that permits a clear determination of the role played by these behaviours.
4. Different age-groups from study to study. While the mother's repertoire of responses may be fairly stable, the infant's is constantly changing. The same term (e.g. verbal communication) describes different interactions when referring to younger versus older infants.

The reader will also note that the number and types of interactions linked to infant and youngchild growth are very extensive. Seen together they appear to encompass almost all aspects of mothering. The question inevitably arises: how is it possible to get a handle on these many interactions and categorize them in a way that permits their incorporation in health-education activities. The discussion that follows the set of lists will address these questions.

The list provided below refers to M-l and I-M non-feeding and feeding interactions shown in the literature as being associated with better nutritional status.

M-1 Non-feeding Interactions Linked to Growth in Infancy and Early Child hood

1. Meeting physical and emotional needs, and responding to them appropriately, in order to contribute to the well-being of the infant (Cravioto and Delicardie, 1976; Bithoney and Rathbun, 1983; Graves, 1976; Morley et al., 1968).
2. Frequent physical interaction: flexible holding, adjusting posture, rocking and bouncing (Pollitt and Wirtz, 1981; Price, 1977; English, 1978; Alvarez et al., 1982).
3. Positive affect: smiling and friendly mood rather than hostile and dominating (Auba and Alvarez, 1983; Alvarez et al., 1982; Pollitt et al., 1975; Cravioto and Delicardie, 1976; Zeitlin et al., 1989).
4. Attention: looking at the infant and establishing eye contact (Cravioto and Delicardie, 1976; Alvarez et al., 1982).
5. Verbal communication: includes talking to, cooing, when in physical contact or across distance (Pollitt et al., 1975; Cravioto and Delicardie, 1976; Graves, 1976).
6. Appropriate pace of interaction: not too slow or irregular, not too intense or hectic, avoiding both overstimulation and apathy (Bithoney and Rathbun, 1983; Fleisher, 1979).
7. Reciprocal relationship permits and encourages the baby to start and control interactions, "conversations," and games. Child's cues must be responded to, contingently (Graves, 1976, 1978; Pollitt et al., 1975; Cravioto and Delicardie, 1976).
8. Socialization/safety instructions/prohibitions: verbal instructions and physical demonstrations of what is wrong before the fact, instead of harshly punishing wrong behaviour after it occurs; reward of positive achievements. Otherwise, the inability to control may be one of the reasons for the caretaker's physical dominance over the child (Pollitt et al., 1975; Cravioto and Delicardie, 1976).
9. Creation of a stimulating physical environment for the infant through toys, pictures, and books (Sheffer et al., 1981).

I-M Non-feeding Interactions Linked to Growth in Infancy and Early Childhood

1. Infant's response to handling and stimulation: the infant must not be overly agitated, distressed when handled, easily exhausted and always crying even without provocation (Lester, 1979; Fleisher, 1979; Powell and Low, 1983).
2. Close and cuddly physical interaction when held, although the infant must not be constantly clinging to the caretaker (Graves, 1976, 1978; Bithoney and Rathbun, 1983; Powell and Low, 1983).
3. Positive affect: smiling, happy, and interested infant rather than apathetic, depressed, miserable, or irritable (Powell and Low, 1983).
4. Communication, according to the different developmental stages, includes: a normal, not highly stressful sound of cry (measured acoustically) during neo-natal period; alertness of neonate, who opens his eyes during feed; cries and increasingly whimpers during feeding as infant grows older, as well as talks and vocalizes; more appropriate gestures corresponding to age; interpretation of sounds and gestures; communication occurs both when the infant is in physical contact with his caretaker and across distance, such as opposite side of the room (Pollitt and Wirtz, 1981; Pollitt et al., 1977; Graves, 1976; Powell and Low, 1983).
5. Reciprocal relationship in which the infant responds contingently to the caretaker's approach (instead of avoiding it or looking away), and to the intent of caretaker's action or communication (although in younger infants this response will tend to be more reflexive than deliberate) (Graves, 1976; Powell and Low, 1983).
6. Attachment: infant reacts to separation appropriately for his developmental stage (Gordon and Jameson, 1979; Graves, 1976, 1978), and is "securely attached" according to a defined scale (Ainsworth et al., 1978).

M-l Feeding Interaction Linked to Growth in Infancy and Early Childhood

1. Breast/bottle-feeding interactions (Pollitt and Wirtz, 1981; Pollitt et al., 1977): permits the infant to control nipple insertion and removal (e.g. mother doesn't interrupt feeding to clean the baby or because she decides that the baby has had enough, and doesn't continuously tilt or rotate the nipple in her baby's mouth) (Pollitt and Wirtz, 1981); enables the infant to control feeding schedule (i.e. feeding on de mend except for sleepy or sick babies who must be encouraged to eat more often, or full babies who respond to gastric or other discomfort by eating to the point of regurgitation); allows neonate to breast-feed more frequently (DeCarvalho et al., 1983).
2. Consumption of other foods: more regular meals, better quality (nutrient density and variety), and larger quantity of food is offered; nourishing foods are not to be replaced by sweets and candies in order to placate the infant's hunger; the child must not be left to self-feed exclusively, but must be helped by the mother; the child must be encouraged to eat, while avoiding a power struggle; food hygiene must be practiced (Pollitt, 1975; Guthrie et al., 1982; Zeitlin and Johnson, in progress).
3. Positive affect: feeding the infant is a happy time for the mother (Alvarez et al., 1982; Auba and Alvarez, 1983).
4. Appropriate pace of interaction: not marked by jerky or hectic rhythms that may induce nervous vomiting (Fleisher, 1979).
5. Reciprocal relationship of the mother and child during meal time (Fleisher, 1979).

I-M Feeding Interactions Linked to Growth in Infancy and Early Childhood

1. Breast/bottle-feeding behaviours: the infant sucks vigorously and keeps the nipple in his mouth longer (Pollitt et al., 1977).
2. Appetite for supplementary foods: the infant more frequently finishes the portion of food that the caretaker tries to feed him/her (Zeitlin, 1989).
3. Development of wholesome diet: the infant or young child may refuse new foods, as he goes through the weaning period, but should progressively get used to them. The child should not get into the habit of eating sweets, but should eat more nutritious snacks (Pollitt, 1975; Guthrie et al., 1982).

The Importance of Bonding

Mother-child interaction during the first four hours following birth may have a particular beneficial effect by bonding the mother to her infant. Some evidence indicates that if the infant is put immediately to the breast and if the mother and baby have close physical contact at this time, the quality of all the mother's later interactions with the baby will be improved. The direction of this effect appears to be M-I. Both common sense (entire populations of mother/infant pairs do pretty well without this experience) and the literature make it evident that neo-natal bonding is not critical except perhaps for some mothers who are at a high risk of forming poor relationships with their infants. Klein and Stern (1981) found in examining 51 cases of child abuse, for example, that 24 per cent of the abused infants had been of low birth weight and had had an average hospital stay of 41 days, preventing normal early parenting.

It could be, however, that such early bonding would account for small but significant differences in mother-infant behaviour for most infants. As an example of such small differences, Pollitt and Lewis (1980a, 1980b) reported data from two studies showing that children who had been breast-fed tested on average one IQ point higher than those who had been bottle-fed. Effects of this size produced by neo-natal bonding would be difficult to detect.

The second period of bonding, commonly referred to as attachment, is primarily I-M and occurs, as noted earlier, between two and seven months. The breaking of this bond by changing the child's primary caretaker(s) between the ages of about 6 and 36 months tends to throw the child into a state of depression similar to that of hospitalized children (Bowlby, 1965). Malnutrition frequently follows. The reasons for this depression are not entirely a mystery. The caretaker is the child's source of stability. At the same time, the child, who is just learning to express itself in words and gestures, may build up an intimate personal communication system that only the primary caretakers understand and share. Given to an unfamiliar caretaker, this child is like an adult lost in a strange country without an interpreter. Basic trust is broken and the child is afraid to trust again for fear of another abandonment. The child tends to show rejecting behaviour towards the new caretaker(s) and long-term developmental probe lems frequently develop. The mending of such broken bonds may require extreme measures such as permitting the infant to physically cling to its new caretaker(s) and/or sleep in bed with the caretakers for weeks or months. Special strategies for repairing these bonds in older adopted children are under investigation.

Among infants with many shifting caretakers in day-care centres or extended families, the child may become more attached to the stability of the environment or the daily routine than to a single individual. Such infants may respond to a radical change in routine or environment with as much distress as others display to the loss of an individual caretaker.

Dixon and co-workers (1982) found that among the Gusii in Kenya, the majority of severely malnourished children in their study community had lost their mothers as primary caretakers and had also experienced neo-natal problems interfering with the early bonding experience. They suggest that the child's state at birth led to neo-natal bonding failure, as the malnourished, small-for-gestational-age (SGA) neonate was less able to interact with his caretaker. This early failure predisposed the vulnerable mother to leave the child in another's care or otherwise neglect him, resulting in a poorly bonded, depressed, and malnourished child.

Typologies of Faulty Interaction

Woolston (1983) describes three types of mother-child interactions that lead to male nutrition or non-organic failure-to-thrive in the United States. The extent to which this typology applies to other cultural contexts should be investigated. These are presented in table 4. Type 1, reactive attachment disorder of infancy, may correspond most closely to the concept of "benign neglect" defined by Cassidy ( 1980), a situation where the mother believes that she is being benevolent but is in fact neglectful. "The mother both undernourishes and under stimulates her infant. One would expect the mother to be emotionally unavailable, the infant to show developmental delays and an abnormal response to proximal interactions with others, and mother-infant interaction to be characterized by a paucity of warmth and nurturance."

We propose that a variant of this type occurs in developing countries where the mother is underinvesting in a child, while lacking the resources (time, food, future income, social support) to bring him up properly. The mother, herself, may not be psychologically abnormal but may feel personally conflicted and depressed over her relationship with the child, to whom she may behave warmly when not too emotionally stressed.

Anecdotal reports suggest such ambivalence in Pakistan. It is considered normal in Pakistani villages for a new mother to cry after giving birth to a daughter. These tears are believed to express both sorrow for herself that she has not delivered a son, and grief for the fate of the little one, who must endure the unhappiness of a woman's lot in life (Dr. Satnam Mahmood, personal communication. 1973).

Table 4. Three syndromes leading to malnutrition in infancy

NFTT type I (reactive attachment disorder of infancy) Infants

1. Significant developmental delays in motor, language and adaptive areas.

2. Lack of developmentally appropriate signs of social responsivity as defined by DSM-I II in reactive attachment disorder of infancy.

3. Onset of failure-to-thrive (FTT) before X months of age.

Mothers

1. Perceive their infants as sick.

2. Psychopathology characterized by depression and social isolation.

Mother-infant interaction

1. Few interactions indicative of pleasure and mutual social responsivity.

2. Infants prefer distal to proximal interaction.

3. Infants show apathy and/or active withdrawal in proximal and feeding interactions.

NFTT type 2 (simple calorie-protein malnutrition)

Infants

1. No or minimal developmental delays.

2. Developmentally appropriate signs of social responsivity.

3. Onset of FTT before 12 months.

Mothers

1. Perceive their infants as sick.

2. No characteristic psychopathology or psychosocial disruptions.

Mother-infant interaction

1. Frequent interactions indicative of pleasure and mutual social responsivty.

2. Infants prefer proximal to distal interactions.

3. Infants co-operative and vigorous in proximal and feeding interactions.

NFTT type3 (pathological food refusal)

Infants

1. No or minimal developmental delays.

2. Developmentally appropriate signs of social responsivity.

3. Onset of FTT between 6 months and 16 months.

Mothers

1. Do not perceive their infants as sick.

2. Psychopathology characterized by depression and hostility.

Mother-infant interaction

1. Few interactions indicative of mutual social responsivity and pleasure.

2. Infants prefer distal to proximal interactions.

3. Infants show angry withdrawal and active avoidance in proximal and feeding interactions.

Source: Woolston, 1983.

Type 2 represents simple calorie-protein malnutrition. The mother provides adequate stimulation for her infant but, as a result of misinformation or lack of re sources, does not provide adequate nutrition. One would expect the mothers to appear within normal limits on psychological testing, the babies to show no abnormalities except in growth, and the mother-infant interaction to be within normal limits.

This would appear to be the model most commonly addressed by nutritionists in developing countries, where a large proportion of infants are malnourished when measured by international standards. Inadequate cultural beliefs and practices account for misinformation, and poverty for lack of resources. As infants become more severely malnourished their capacity for normal interaction is, at least temporarily, reduced.

In type 3, pathological food refusal. "the infant is struggling to create autonomy from the mother. One would expect the mothers to be angry or depressed, the babies to show specific behavioural disturbances focused on food refusal but without developmental abnormalities, and the mother-infant interchange to be characterized by negative and angry interchanges."

Yet another type that may be common in developing countries, but is not often seen in industrialized countries and is not described by Woolston, has been termed breast addiction. Towards the end of the first or during the second year of life, the child refuses solid foods and insists on breast-feeding on demand. One American mother of a 16-month-old going through this phase nicknamed her daughter "Draculina" (connoting humorously that she felt attacked by a vampire trying to feed on her blood). From personal discussions with mothers in the United States, Nigeria, and Indonesia, whose infants displayed this pattern, the writer suggests that mother and infant are again locked in a power struggle in which the infant is trying to protect its exclusive rights to access to the comfort of the mother's body and to her attention against perceived competition from siblings or adults or from the mother's desire to terminate breastfeeding.

Discussion of Mother/Caretaker-Child Interactions

Figure 8 is a model showing that close and affectionate interactions between the mother and child (box 1) may promote growth both through greater maternal responsiveness to the child's needs (box 2) and by a direct physiological effect on the child (box 3). We have already introduced potential mechanisms for such physiological effects. This diagram also indicates that certain practices, behaviours, and technologies and their corresponding belief structures (box 6) may be more adaptive to resource scarcity than others, independently of the quality of the mother's psychological interactions with her infant.

Findings that Can Be Applied to Educational Messages

Messages conveyed to mothers encouraging them to hold, hug, play with, talk to, and kiss their babies frequently are important. Such advice may seem to some policy makers to be too obvious or simplistic or to insult the natural mothering abilities of their constituents. Yet many cultures have rules against "spoiling" infants which justify not responding to their cries and leaving them isolated for long periods. Some mothers apply these rules harshly, believing that it is for the good of the child. The rules are part of the obsolete ideology (referred to as adaptation type 3) that the infant must be taught to accept its subordinate rank in the family. The message "holding your baby will not spoil him" may be necessary.

Fig. 8.

Even where the culture reinforces attentive mothering, women who have recently migrated from extended family homes or whose personal support networks are weak or unstable for other reasons may need additional external encouragement to be attentive.

Little research has been done on behaviours that are specifically adaptive to resource scarcity. The study in Mexico reported by Zeitlin and Johnson (in progress) indicated that the mother's active, persistent feeding of toddlers appeared to overcome constraints of low nutrient density of the food and anorexia associated with high rates of infection. Many mothers believed that 12-month-old infants should be able to feed themselves independently. Messages conveying the idea that children at this age cannot eat enough by themselves, and that mothers should actively feed them, appeared appropriate.

Although useful educational messages are expected to develop from the results of further research into mother-child interactions, not all beneficial mother-child interactions can be transferred through education alone. When a mother engages in less than optimal forms of emotional interaction with her child because she herself is under stress or emotionally unprepared to satisfy the child's needs, a social-marketing approach that attacks individual behavioural elements may or may not be productive. Preaching to a depressed mother to "smile and be cheerful with your baby" could make the situation worse. On the other hand, the attempt to act cheerful with one's children even when feeling depressed is a part of good parenting. Social support that reduces the stresses in the mother's life in addition to providing her with minimal child-care counselling may be sufficient to revert the pathological interactions to normal ones.

Findings that Can Be Applied to Programme Design

Mothers who interact poorly with their infants need help. Current methods of treating interactions that are overtly pathological are very expensive. A recent estimate of the per family per year cost of intensive interventions to protect the physical and psychological development of infants in high-risk families in the United States was $850 (Greenspan, 1982).

Table 5 (Rathbun, 1979) shows all of the members of the failure-to-thrive team in a Boston area hospital. Each child exhibiting growth failure is assessed by the entire team and a multifactorial intervention is planned. The expense of assembling such professional teams to serve all high-risk children would obviously be prohibitive in most developing countries. Yet Alvarez in her recommendations to the 1985 International Union of Nutrition Sciences Workshop on Positive Deviance (Zeitlin and Ghassemi, 1986) suggested that pairing in a "buddy" system of competent low-income mothers or grandmothers (positive deviants) with high-risk mothers could be used to reduce pathological parenting. In the United States, in the New England towns of Braintree, Lawrence, Lowell, Waltham, and Taunton-Fall River, the Massachusetts Society for the Prevention of Cruelty to Children (MSPCC) runs such a pairing system in a project entitled the Good Start Program. The Ford Foundation also supports such a programme pairing teenage parents with mature parents in New York City and in Boston under the name Alliance for Young Families. If community-based, these pro"rammes can be inexpensive and have the potential to reduce interactional disorders, family stress and loss, poor infant feeding, and developmental delays.

Table 5. Multidisciplinary management of FFT

Problems	Area of assessment and treatment	Treatment resource	Facility
1. Inadequate nutrition	Nutritional rehabilitation	Nutritionist	Hospitalization
2. Attendant medical problems	Stabilization of medical problems	Paediatrician
3. Developmental delay	Developmental stimulation	Developmental specialist (e.g. paediatrician, psychologist, physical therapist)	Infant stimulation programme, physical therapy and social work services
4. Family stress and loss	Social intervention	Social worker
5. Interactional disorder	Infant behavioural status, maternal level of functioning, quality of parent-infant interaction	Child psychiatrist, psychiatric nursel social worker	Mental health services
6. Long-term growth sequellae	Nutrition counselling, close pediatric follow-up, frequent weighings	Nutritionist, paediatrician, nurse	Outpatient paediatric practitioner, visiting nurse, community nutrition service

Source: Rathbun, 1979.

Early childhood interventions that teach mothers to stimulate their infants' psychological development should also have a beneficial effect on growth status. A nutrition/health component in these programmes should enhance this effect.

Findings in this section also support existing recommendations that:

1. Childbirth routines should be changed (if necessary)to permit the neo-natal bonding experience (Jelliffe and Jelliffe, 1978). The infant should be put to the breast immediately after birth or as soon after as the mother's condition permits. Although such bonding may not be needed by all mothers, it is physiologically natural, it helps to establish breast-feeding, and it may serve to prevent abnormal interaction patterns from developing in mothers who are at high risk of neglecting or abusing their children.
2. Practices of abruptly sending older infants and newly weaned toddlers to live with "grannies" or in other fostering arrangements away from home should be discouraged. Day care that permits the older infant to return home each night is better than foster care.