Definition:
Perinatal Psychiatry psychiatry infant was held in Cannes. All the big names (pediatricians, child psychiatrists, psychoanalysts) were present; the French psychiatrists discovered it interesting leads and could expose the work they undertook.
Subsequently, a conceptual and practical link was made between the first of maternal conditions surrounding the birth and their perceived impact on the developing baby. The interest in further work Brazelton, competency infant has to rediscover the attachment theory of Bowlby and then develop with Stern theories of interaction between the newborn and its entourage.
Psychoanalysts postkleiniens were formed in infant observation according to the method of Bick and gradually building a baby psychopathology. The French child psychiatrists, following Lebovici have rooted their practice in this discovery of the psychic world of the child in his family history (transgenerational mandate) while they were interested in parentalisation phenomenon.
NPP was thus created and the term was spent at conferences to finally take its credentials with the title “Perinatal Psychiatry” Book of Lebovici and Mazet published by PUF in 1998.
The field of NPP extends from pregnancy to the end of the first year of the child. The evolution of knowledge today is the question of the need to look more precisely but also more acute and continuity over the first 6 weeks of life that would, somehow, time of psychiatry neonatal. This period is still unknown and mysterious. We believe it is to be considered without detaching ahead and post.
For pediatricians and gynecologists and obstetricians, time of perinatal care is divided into a prenatal period covering the pre-conception stage until birth (excluding voluntary interruption of pregnancy) and postnatal period to 28 days or until the end of the hospital where newborns are hospitalized.
History and background:
Psychiatry looked at this time of life through mental pathologies of mothers who have emerged as specific: postpartum psychosis, postpartum depression. If in other countries, particularly in the UK it is the adult psychiatrists have maintained that interest and who are responsible for mother-baby units in France, however (as in Switzerland and Belgium) are the Child psychiatrists who have taken this field on their own and focusing on the relationship and on the effects of maternal disease on the baby. The look has moved on from mother-between (mother-baby, parent-baby) to go up in the generational line and then back down again to really discover the baby. We can say that in France we are at this stage and it is, compared to the international PPN, particularly original. The look of the caregiver turns back, the baby to the parents and through them to the grandparents. NPP also initiates a rise time of life. Since one or two decades she became familiar with the beautiful 9 month, found that of 3 months and begins to question one of less than 40 days, time which corresponds in part to that of the leave pregnancy for the mother and for which she is at home, often alone with him. The disarray that has engulfed the mother and father facing this infant the confusing events is largely unknown. It would now be desirable (and we are working on it) to look into this Constituent perinatal suffering family struggling to draw on the resources of families dispersed. These sufferings are normally a resolution but can become pathogenic in this period lived on, confused, invaded by the body and its productions, subject to a sense of “draining” and psychic exhaustion in which time and space , psychic and bodily limits are diluted.
Maternal and paternal psychopathology has a specificity that is the source of questions, research focused on this life time. The strong link between being a parent and baby to the observed overhaul capabilities, the fragility but also the richness of this period psychiatrists have mobilized in order to provide care that takes into account these factors. But Disorder parent, if he embraces his child’s history, also presents considerable strength for the baby, whose impact would be simplistic to think that he is direct, systematic, linear, unicausal. In light of this complexity, we find this life time a large number of professionals who are real babies psychiatrists partners. Are invited around the cradle those around the woman childbearing, those awaiting the baby, professionals soma, psyche, representatives of the company. NPP is a place of intense and essential transdisciplinarity.
The confrontation of diverse approaches in the image of those who play in the baby and parents where everything psychic is expressed preferentially by the body, forcing everyone to return on his own body and his own emotions.Understanding what is built is based on observation and apprehension proven even before the use of the word.
Subject of perinatal psychiatry and therapeutic means:
Frame:
NPP is to the changes experienced by a couple when the project to become a parent is realized: the transformations experienced by the mother and the father-in pregnancy, representations during this time and the relationship that lives on the fetus, the time of birth and the changes that take place at that time, finally the baby’s psychological development, including somatic dimension in developmental and psychodynamic dimension in relation to the environment. It considers that there is a continuity between the different stages and reflects responses in preventive, therapeutic, it implements.
It has developed tools apprehension and understanding in reference to various theories: experimental neuroscience, baby skills, attachment, psychoanalysis and systemic theories to the study of the interrelationship and interaction .
NPP speaks at the presumption of risk for the baby when parental pathology exists and a disease or suffering of the baby. Its function is preventive and therapeutic.
We focus in this work on the immediate period after birth, neonatal period we will call and looking to the end of the first year for lack of current data on the first 6 weeks of life. We do not address the issue of somatic problems, pathologies of pregnancy, childbirth, the baby, which alone merit the development of a product, knowing that the NPP will contribute. Finally, we do not treat drug prescription with characteristics particular during pregnancy and when breastfeeding.
First therapeutic tools:
It is those who pass by the parents and especially the mother, and those who wear wrap the baby parents interrelations are from the observation Bick, who even considering the baby are in line with Pikler.
Thus, the NPP is transdisciplinary, the baby and his parents’ place of midwives encounter, nurses, gynécoobstétriciens, pediatricians, psychiatrists … posed the question of how is the mystery of life and how occur the “avatars” in the relationship. This model multifactorial, never closed, is based on a vital trust between professionals so that everyone asks the other, not to return the puzzle but to unravel the whole. This mutuality is a condition for creating a therapeutic alliance with parents and their babies to get into their interpersonal world.
Clinical child psychiatrists:
It is that the narrative discourse and related bodies, combining description, testimony and recollection. How to make this clinic is not swallowed up by the parental story so rich at this time of life story that masks the observation and alters the description of the interrelation capabilities and even more those of the perception of the term body of the baby?
NPP is certainly that of the past which is in this new story in the presence of a baby, it is also in the commissioning of a new story that can not be said that through the body of the children, especially as he is young. In this body unfolds the story of its construction, it is the theater of psychic baby lived.
The richness of the NPP has the obligation, to cradle, to integrate these different approaches. Child psychiatry has to develop outreach tools where the clinic is essential. The Bick teaching transmitted by colleagues as Genevieve and Michel Haag based very clearly on this basis. The observation of the infant is the node, it is understood as a containing attention gateway to understanding and caring Action friendly building and the sensitivities of individuals. The study of interactions and analysis of forms of attachment are not excluded from this observation that also takes account of felt and experienced observer. This is a witness position participant at a time of life when the baby as her parents are in projection and powerful mechanisms that include regression too.
Role of the Psychiatrist:
The child psychiatrist, facing the future parents are attentive to their psychological state. He is concerned with becoming their sense of risk and simultaneously a possible chance of mobilization. He knows the factors of decompensation but also the promise of renewed structural capacities. It is also attentive to the fetus (still too neglected because thought to be relatively protected), then for the baby because of the richness of exchanges and their impact on development at this age. The effects of the baby maternal pathology are undoubtedly underestimated because they speak preferably be in the presence of the baby or when speaking to the mother of the woman. This pathological dimension is often overlooked in our adult psychiatric colleagues when not fully invaded the psychic field.However, the child psychiatrist is particularly sensitive because it remains in connection with the baby and the baby of the mother. He is attentive to the consequences of maternal disease on the baby’s psychological development in a sort of pathological interactive loop. His position is, however, open, receptive to become descriptive (like it could be in the contemplation of a landscape), setting aside theories to approach each dyad in the richness and creative novelty of early relationships. The descriptive attitude sets aside, at first, tracking clues, that is to say the identification of negative criteria (signs and symptoms) basic education in medicine. NPP aims to let each baby and his parents discover their own terms of trade, their support, their place in the family history so that it can build harmoniously in its double line.
Parental presence:
A major component is the possibility for the father and mother to be together around the cradle, to become parents for that child. For many of our consultants, this “simple” fact is too complex, requires structuring links in another form as adhesive identification.
Part of the parents who come to us have altered solidarity opportunities that unfortunately our institutional difficulties meeting to consider the father and mother in their individuality and complementarity around the cradle. The psychiatrist is the question of his position both open to the creativity of each specific constellation while recognizing inefficiencies and ways to find resolution.
Participant observation includes the perception of the various interactions (biological, behavioral, emotional, fantasy, symbolic) and the baby’s skills. The concern is that of its psycho-building in its bases and its various functions, or places of expression, which are the psychomotor development, cognitive and language. The mechanisms involved are numerous and we can apprehend observing the baby, certainly in the immediate environment, but also being sensitive to her story through that of her parents. We consider early interrelations, the importance of projective mechanisms, intersubjective and intrapsychic manifested by the body, the phenomena of transgenerational transmission, the study of parental psychopathology and its impact, attachment representations of the parents (or models inner working) and their effect on the attachment being of the baby.
Theories:
We do not take detailed theories concerning early interactive skills, or tuning or finally attachment and its representation in adults. They are all essential and complementary. Their current interest is in the bridges between them, the links between these concepts open to a better understanding of how the baby.
The main points to remember are the close relationship between the baby and the adult who provides care, their mutual skills, the ability to have access and to engage tuning that supports transgenerational transmission. The questions that arise before a baby is: how occurs the passage of a representational world of an adult than a child, by what genius baby’s world is organized and makes sense in this story that it extends?.
Attachment:
It refers to the five criteria Bowlby: exchange of smile strength of portering, warmth of the embrace, soft feel and interaction during breastfeeding Anzieu which adds consistency rhythms. This need for reactive attachment baby in the mother’s early experiences relationship with her own mother and representations it is made. It is against this background that it relies to offer the child a clean secure base let create modalities for interaction with a personal style made of invariants and deviations.
Interaction:
It has a good physical support, it is sensory and motor (tonic). Bullinger shows how, through the concept of tonic regulation, a meaning is given to tonicoémotionnels states, which will constitute the outer face of the body envelope.
He cites Wallon for whom repetition Activity develops representative cores, support points for new emotions that will gradually diversify. These contributions concerning tonics and emotional aspects, like that of sensoritonique balance between the biological, physical, social and cognitive dimensions are essential to understand the baby. Ajuriaguerra described the “tonic dialogue” interaction between the baby and the person wearing design that we find Winnicott and is obviously paramount, what we experience daily in the mother-baby units. In this situation, trade, prolonging those perceived by the fetus during pregnancy, seek vestibular flow, tactile, olfactory, auditory and visual. The modulations produced by adults give meaning to the inevitable variations. The baby has the ability, in a state of attunement, reproduce the emotional state of the adult transmitted along sensory fashion by transposing it into another sensory modality: this is what Stern calls transmodality. Modeless perception contributes to forming a sense of self and the other emerges.
Piaget emphasizes the continuity between the biological and the psychological. We believe understand it as a material on which subjectivity is constructed. Ajuriaguerra relied on this dual understanding of development rooted on physiological bases but also on the concepts of emotion and tone.
Psychomotor:
It has thus developed based his theory on the joints between the body and the development of the psyche as the first cognitive expression and indispensable basis to intelligence. Sensorimotor is central in PPN and psychomotor are key partners.
Winnicott is the baby’s development in the relationship with the mother (the care giver), which provides three functions: holding as facilitator of sensorimotor integration; handling of facilitator of autonomy; personalization and object relationship as the basis of all human relationships.
It is the primary maternal preoccupation which gives the mother an increased sensitivity to the baby’s body and to his own. We find the sensorimotor, tonic dialogue, at the base of attachment and object relations that occur in interactions.One originates in another without that we can separate them. Winnicott emphasizes the importance of appropriate parental care. Sensorimotor quality of the envelope, the tonic quality porting ensure a sense of continuity to the child which gradually emerge feeling the separation of “self.” This final phase requires the establishment of a founding internal security of a quality narcissism.
The sleeve is the vector relationship between the adult and baby.
The latter feels his feelings following rhythms and variations of these rhythms, repetitions associated with proven. It detaches structures as invariant elements but also differences to proven connects varied tones. For it to reach this performance requires certain safety conditions, predictability.
The adult mothering plays this function by drawing in him a sensitivity to match that of the infant. Between mother and baby, the attunement adopts a style, color emotional communication between them. These interrelations have first representation and motor expression. The knowledge links are emotional ties expressed through the body. According to Fonagy, the concordance of states between the caregiver and the child allows internalization of the mental state of adults in the context in which this occurs. On this basis, it can gradually understand the mental states (mood and cognitive) of the caller and develop what Fonagy calls reflective function that characterizes access to intersubjectivity.
This aspect in PPN is exciting because it is a source of fascination at the beauty of what is happening since we agree to place ourselves in an observant attention.
We simultaneously discover the therapeutic possibilities available from this attentive presence. This wonder is not without silent grief face tuning failures, failure to respect the needs and archaic proven that we see and that resonate strongly in our view of the state of receptivity in which we are.
The baby needs that containing maternal function of the primary object, function which maintains a necessary continuity through the presence of a mother physically present and despite his absences or relational distances. The baby can, in the presence of the mother, live exchanges across his body by the intracorporeal identifications mechanism described by Haag.
Tonicoposturale regulation:
The regulation tonicoposturale according Bullinger perfectly integrates the theories of Haag. It describes the need for primary background object introjected the baby to form the first markers of internal strength. This joins the interpenetration of looks and visuomanuelle link. The young child, to start the hand towards the object and keep his attention to it, needs this inner strength. The tone of the mother supports the child through a postural adjustment and harmonious dialogue tonic.
This harmony is reached quickly by thymic alterations of the mother; we then understand how maternal thymie expressed through his body and postural and tonic modulations. Through this channel, the baby perceives the nature of mood variations and internalizes.
Mother-baby relationship:
Every relationship between a mother and her baby is unique, with its own detachable rhythmic structures by the child in the middle of all sensitivosensorielles perceptions in a particular emotional context. Mothering weave this interactive body language to build a sense of “belonging together”. The healthy baby in a sufficiently satisfactory relationship, thanks to the maturation of the sensorimotor system, launches the “conquest of new and existing capabilities.” He learns by itself, shows the way to adult, initiates interesting exchanges. His motor skills are the source of his mental activity, they are a reflection, language that is built in line sensorimotor development. a spiral is observed between motor activity, the progressive differentiation of sensations and mental activity. In the middle of a magma apparent internal tensions, confused emotions, primitive anxieties and dislocations appear gradually diversified attitudes. The child repeats, the only express and interaction, seems to become master and make his personal coloring. This progressive mastery associated with a form of emergence of consciousness is very subtle, it asks from the viewer a great knowledge of the child (his parents and the relationship they have them) obtained through to attention and respectful observation of relational terms and climate.
The child builds, develops his mental space through his body “at this age everything goes through the body to be gradually developed into a mental space; all major functions, cognitive, emotional, relational, take root and build from that preverbal sensorimotor behavioral functioning of the baby. “
The existence of the NPP has the consideration of hazards occurring in these processes. Vagaries of multiple origins and the importance of fundamentally changing the construction of the baby but not irreparably. NPP is based on this new knowledge to create flexible, diversified and multidisciplinary responses to meet the needs of children and their parents. The project is to change the course of events, not to a normalized or normative history, but to a structuring personal history. Forms of therapeutic responses that are in place are based on the experience of child psychiatry sectors and take account of specific factors related to the age of children.
Pathologies:
What types of conditions are these treatments? How are within the baby pathological interactional dysfunction?Bullinger sheds light on these processes in the toddler when he describes the operation of an “archaic loop”. When interactional dysfunction, whether due to the mother, the baby or both, we perceive a violation dialogue capabilities expressed in the tonicoémotionnelle synchronization. The balance between regularity (vigilance, sensory flow, the human environment, representations), the tonic regulation (in the physical exchanges) and how these capabilities for dialogue and tonicoémotionnelle sync up what Bullinger called “archaic loop” on which (and which) is based (gets entangled) cognitive loop. The tonicoémotionnels and cognitive aspects are completely linked.
Maternal depression:
Thus, maternal depression can make inadequate synchronization tuning that builds on the tonic dialogue. The emotional sharing is poor in these cases and the baby can develop joint attention necessary for cognitive development. It can not be indifferent to the mother thymie which is expressed as much through the tone used in the postural adjustment in the exchange of gestures and sounds. The tonic dialogue, combined with a poor exchange of look, not centered on the fovea, draws a specific interaction. One of the first signs of pain in the baby is her toned expression associated with frequent avoiding eye (signs of emotional withdrawal before signs of a diagnostic set). This issue of maternal depression is quite central in PPN, although the issue of deficiency, negligence and discontinuity is ultimately more problematic and more delicate in the therapeutic approach.
The maternal inadequacy to the baby’s psychic needs in this depressive constellation creates dysfunctions in the attunement. Emotional withdrawal in trade, the lack of shared pleasure, the operational dimension, “frozen”, care, taking a technical dimension, do not feed the nascent psyche of the child. The port is often inadequate, poor interactions, succinct gestures, speech not only reduced but with melodic and rhythmic characteristics that do not allow to support the exchange, so that the baby will often turn away. These mothers react painfully little to the protests of their baby that they can console as anything they had no comforter. The mother is present but its interior is deadly object, the child turns away or appropriates, which endangers real potential of psychic life.
Depression baby:
The baby may be too depressed, this expression can be the result of maternal depression (which is not however the only issue). The interactive removal and loss of enjoyment expressed through psychomotor poverty with somatic disorders and attachment disorders are the first manifestations which nature can be raised through a fine descriptive observation also drawing against the transfer of the observer. The narcissistic foundations of children are deeply affected and threatened its further development.
Psychotic mother:
In situations where the mother is psychotic, despite a strong influence of psychotic mechanisms in the interactions, we can see initially (1-2 months) maintenance of the seemingly beneficial maternal function for the baby. The total dependence of the baby and the close relationship it establishes meet adequate maternal capacity to its needs.Sometimes it is a failure of our clinical knowledge of the baby during this period leaves us think. We still have to work on this specific time the first 40 days of the baby. As soon as the baby begins to show an outline of individualization (during the appearance of the smile, the separation of the head from the body of the mother of increased arousal beaches) appear disturbances. The individuation (the draft), the biggest of interactions requests reveal many disturbances: inadequate response and reverse the mother to the demands of the child, projection delirium or maternal fantasies, primary seduction, excitement, mental or intrusion withdrawal. The child expresses his suffering by avoiding eye contact, hyper- or hypotension, visual vigilance, support research on caregiver (in a therapeutic setting).
The child “learns” to know the maternal conditions and adapt. He expressed or represses its needs based on the mental state of his mother. It becomes “thrifty,” “hypermature” if the relationship is not too disorganizing, intrusive, unpredictable.
The child in this case is in danger, anxieties become intrusive when inaménageables close or successive jilting. These disturbances are sometimes offset by the relationship to the father if he can recognize the condition of the mother and the impact that it has on her baby. It is not uncommon, however, that despite a discourse on the reality of maternal illness, the father denies it every day and leaves, too happy, the child alone with her.
Disruptions in relationships between parents and baby, stimulus defects, deficiencies, affect children’s functioning.These are the most frequent and no less complex to support and treat.
Deficiencies of mothering:
When we talk about mothering shortcomings, we group the emotional deprivation and stimulation deficiencies. They are never alone, the little child can be stimulated in a narcissistic symbiotic relationship with the mother who does not perceive its existence outside of it or be, conversely, in a love deficiency.
The mothering object is absent here, but not by depression if not often invested by parents themselves deficient, without support on personal emotional childhood experiences.
They can tap into enough good parenting images to identify with their baby parts that would open the way to their real baby.
More commonly associated with these deficiencies are found inadequacies, lack of continuity, overstimulation and submersion of the baby by parental projections that cause many bodily and somatic manifestations.
Parents can observe the baby’s pace in the interaction during its cyclical withdrawals. The young child also meets these overflows or dyschronies by these withdrawals, a psychic vacuum, disinvestment of the drive exploration function.
The baby can not anticipate relational terms, care will be given. Maternal ability pareexcitation is rarely offered to him, so he can not really integrate. The usual function of pareexcitation relies on the ability of the mother to regress during the neonatal period, as an early identity crisis necessary allowing it to access the buried parts of his psyche link with his own childhood and his relationship to his mother. This decline, which however is not complete, makes it able to offer its psychic apparatus capable of metabolizing to contain emotions, the baby lived and respond appropriately.
What characterizes these interactions is the unpredictability in the discontinuity, leaving the child in a state of insecurity. This discontinuity is often marked by physical proximity combined with jilting without a proper distance is found for the light of exchanges supported by a “good port”.
The body treatments fail, enveloping not, sometimes they avoid areas sexualized in a phobic attitude or too insistent giving the feeling of fascination by a flood sexualization.
verbal exchanges following the emotional states of the parents of the couple’s relationship. They can become raw and violent.
The baby has to be built in the middle of what looks like chaos, it may seem very attached to his mother, trying to please him, and developing strategies to survive. He quickly returns aggressiveness against him and sets up rhythmic movements to cope. Frequently, the observation reveals atonic children, with a particularly poor exploratory activity, the body seems no investment without perception of discomfort and pain where it is.
Attachment disorders sign objectively installing these relational terms. The insecure-avoidant attachment that emerges reveals the poverty of the development of thought, affect, the story, the capacity for reverie, that of being alone next to an adult. The infant sometimes cancels its creative movement in this type of relationship with parents concerned about where the environment is lacking.
Child abuse:
The abused child has no internal security, so that he can rely on his inner feelings when interacting with reassuring messages. It remains vigilant, monitoring the physical world, it can and let go in the game and later pretend, and when roughing it lets discover a terrifying internal world. When parental violence, the child is under a double influence, that of the violence of one and the terror of the other. The world is doubly frightening.
Abuse, violence reach the ability to play, to stage his emotions and ideas, connect with external events. With a poor mentalizing, the child tends therefore to repeat.
Very often we see in these very young children the draft representations, but they are inadequate, overall, inflexible and quickly bypassed. The inner psychic life is restricted, self-experience is discontinuous.
The observation of these babies is difficult because parents take center stage, their story “fascinating” fact-screen attention that we must bring to these young children. A very careful and continuous monitoring allows an assessment of its violations and its needs. The illusion would be to believe that a simple change of environment could modify and remove events. But the child has constructed these relational forms, it has already internalized them. The pathology of the link request to the containing of attention, support parenting skills (even if brief), a reassuring continuity so that changes can emerge.
Treatment:
PPN care in several areas of intervention.
Pregnancy:
For pregnant women (chapter we will deal quickly and that could lead to another job), the approach is diverse, and function of the symptoms and pathologies. Midwives are the first contacts with general practitioners, gynecologists and obstetricians. Psychiatrists and child psychiatrists are involved either in continuity of previous care (women already followed by a psychiatrist), or indirectly through recovery or analysis of practice, either second the demand for professionals concerned with pregnancy.
When the pregnancy is progressing without aggravation or without disturbance from the usual course, the midwives are able to support the woman and the couple. However, as soon as particular concerns appear, it is not uncommon that psychiatrists are interviewed, consulted. This is the case when non-limiting early insomnia, associated with obsessive dimension vis-à-vis the symptom, when fatigue or muscle invasive somatic pain in particular. It is the same when depression, delusions, identity disorder, depersonalization, all psychotic manifestations worsen, addiction that future parents fail with midwives to control sufficiently.
Finally, vulnerability situations require additional bracing to facilitate the connection with the future baby.
Treatments are usually ambulatory, in collaboration with relevant and chosen by the couple partners.
Midwives must adapt their follow these mothers taking into account their anguish, their representation of pregnancy, the baby, the potential projection or not in the future, death anxiety and in the third quarter of anticipation of the post-birth with presentation of early childhood professionals (pediatric nurse medical and child protection [PMI] for example). Around 6-7 months of pregnancy, sometimes before we realize hospitalization directions (full-time, day, partial) in the mother-baby units where midwives involved. These hospitalizations allow some women to calm a massive anxiety, sleep again, to soothe, to see their pain decrease. The relationship of trust that is built so greatly facilitates the preparation for birth, return home or a mother-baby hospitalization to discharge from hospital. The results are clearly better in these cases compared hospitalizations decided during the stay at the maternity ward. They provide continuity and consistency in the care, support in the before and after regarding perinatal care.
Postpartum:
After birth, the most conventional process is that psychotherapeutic interviews developed by Palacio-Espasa. If the therapeutic process is the space between the mother and the baby is through the mother is diagnosed. This is to change the mother’s investment in the only baby in the sector and not all the psychic functioning of the mother. Mental representations of the mother, her relationship with her own mother and the baby are affected. Very frequently, therapeutic work on the relationship does not give rise to interpretation on the transfer. The therapist helps the mother to recognize the events, children’s expressions and their impact in itself both in terms of perceptions, emotions that her mental representations. He then reached the issue of maternal identifications and projections whose baby is the support in a generational dynamic. This notion of identification is particularly sensitive to this period of life when the primary maternal preoccupation reflects these essential regressive identifications which also affect caregivers also, but to a lesser extent.
The dyadic system is malleable, it can play between receipt of the baby’s projections and transformation through open enough mother. This openness is maintained by the regressive identification and transformation is possible through the link stored in the mother, between primary and secondary process. The mother plays an organizing function of the internal world of the child from the attention given to it. It thus gives a representation to the child tried, she draws the contours of affect in the relationship it creates, processes rooted in the bodily relationship. When the mother can not perform this function either too risky defense against regression or by pathological projective identification, either through lack of matchmaking ability, is the caregiver willing to dyad attention this function. It turns on a filter function between the two aimed to protect the mother projections and infantile impulses by providing infant tested under more nuanced forms and also protecting the child returns unprocessed emotions nursery. The caregiver comes as a receptacle helping to transcode the story written. Sharing emotions through the caregiver that helps both partners to internalize this function through progressive common recognition.
Therapeutic Observation:
In NPP, following the course of the psychoanalytic infant observation Bick and therapeutic effects of the method that has been recognized and theorized by Houzel, therapeutic observation has developed as a privileged instrument approach in infants. This technique requires a lot of quality in health care and in particular those of expectation, attention, ability to tolerate projections and not to protect the defenses systematically related to knowledge that would justify too quick explanation, too immediate. It requires the ability to be permeated by the atmosphere of these highly emotional moments of life without brutal intervention to get out.
The space opened by the caring and respectful presence alleviates caregiver projections on the baby, deflects off the caregiver negative and aggressive elements, supports the parents in his office with an identification of the parent to that person. Similarly, we find that the baby relies on the psychological care of it. The observer makes sorting, reduces, transforms and clarifies the content of interactions, making the relationship more harmonious.
Treatments differ according interactional pathologies and their origin. In PPN, responses are predominantly ambulatory, made in the form of therapeutic interviews, joint consultations, therapeutic observation at home or at the place of the child’s life, working in direct and indirect network with professionals early childhood care psychomotor. The Mother Baby hospitalizations have increased in recent years full-time, weekly and daily.
Families deficient:
Interactional dynamics differs parenting difficulties. In the case of deficient families, parental failure is in the foreground, with a poorly integrated parenting that is expressed by a discontinuity of trade, too close during interactions not meeting the emotional needs and rhythm of the baby, finally failure body treatments. Infants are insecure, living in a chaotic world and develop strategies to survive, but these defenses affect their development. They are atonic or hypertonic vigilant, have little exploratory activity in the world of objects and their bodies.
Quickly they exhibit attachment disorders well observed in disorders of affect regulation.
Treatment, well described by Lamour, is first in supporting parents: work at home, therapeutic observation. The stability of the frame, maintaining the link, support on parenting skills, using parallel made socially and daily (socio-familial caregivers, for example) make possible relational changes.
During the first 2 months, devices related to the IMP, as the one set up by Rochette in Lyon, can be preventive of a seemingly repetitive and inevitable development.
These ritualized passage thereby supporting the work of birth by a metabolic-processing complex experienced postpartum through the group. “These groups support the psychic work of mother and mental growth of the baby in creating the conditions for a fantasy and identificatory stimulus via the group including through départicularisation phenomena of experience, dissemination of anxieties and diffraction on caregivers “.
It is very difficult to cope with the frequent crises that these families are going through. They undermine networking, and consistency is always to maintain and even restore, aided by the analysis of projections and experiences then acted by professional divisions; This to prevent jilting, breaks and repetitive separations inflicted on these children.
All other forms of treatment may be considered according to the recorded events: mother-baby groups, psychomotor tracking …
Psychotic mother:
Babies whose mother is psychotic and have no substitutes intra-family (father, grandmother …) are subject to another form of interaction. During the first 40 days of life of the child, it is not uncommon that the mother offers quality container by providing a fusion that satisfies both partners. The signs start appearing as soon as the baby begins to awaken, to enter into a relationship with a draft of individuation.
Observers have shown that visual interactions are difficult in these cases. The mother does not enter the exchange of gaze or look elsewhere, the baby then responds quickly by avoiding to protect the maternal inner world. We find favor and that the baby relies on the familiar look of care during hospitalization or during therapeutic interviews. In the absence of mutual exchange of words which combine modulation is not related to the context, it is often repetitive and does not agree to trade passing through other channels. Most often, the voice interactions are poor. Porterage, personal interactions are not in harmony with the other interactions since it is another thing to have the baby against itself. The baby slides on his mother’s lap, head tilted out of the arms. The child must adapt and often it does. He knows how to wait, be passive, be molded to his mother not to be intrusive for it but at what cost! The caregiver deploys its background function or envelope to mitigate these phenomena. Sometimes, conversely, the Close is intolerable and the baby is placed remotely. In this case, the alert is quicker and leads to a more intense care decision relay or extreme placement.
The question that arises is that of the subsequent emotion recognition by the baby and care work is done around this dialogue emotions through psychic attention in the therapeutic observation.
The development of representations of impulses, the organization affects and setting direction emotions are the basis of the therapeutic action. During hospitalization mother-baby, caregivers attach to this function contenante around the baby and mother so that he develops his skills and his mental functioning is organized through personal exchanges.Psychomotor made a joint work with a pediatric nurse or a referring nurse dyad for a progressive work of recognition and support for the baby’s individuation through massage workshops or workshops “baby” with moms. The father, when it may be present, is involved in these efforts triangulation.
Maternal depression:
When moms are plunged into a depression, the first time is that the baby’s protection and its “revitalization” narcissistic by referring caregivers. Mom asked most often relay the baby looking elsewhere. The delicacy is that to restore the link to the two partners. The mother is in a sometimes complete withdrawal vis-à-vis his baby, “at best” the attunement is discordant. The child is the absolute minimum and retires from interaction, as he retired from his body becoming sluggish.
When we intervene early or a relay has been provided by the family, the baby quickly shows skills, revives with pleasure and is often ready to reconnect with his mother whenever the state of the latter improves.
Pathogenic parent-baby:
Finally, we have to deal with parent-infant relationships are pathogenic whatever we do without possible or desirable placement of the child. Work on the relationship continues, but clearly not enough. Direct action with the baby parallel to the therapeutic work on the relationship, the care given to the mother, is then necessary. In this area, the assessment of baby’s operation is an essential component of therapeutic and preventive work. The baby is our barometer of the relationship, we are listening, we pay attention to him. This assessment requires a very precise clinical order not to lose sight of the overarching objective of development of the baby. Breast-state, the speech of women, adults and their behavior around too often screen that happens between parents (mother) and baby. Our eyes and our attention is often diverted, distorted our assessment and therapeutic work undermined.
Baby’s suffering:
baby suffering from the signs are the more subtle the baby is young. During the first 2 months, fusion period, it is rare to understand the signs of the infant and the relationship that we inaccessible. We have to build a clinic the first 2 months in order to ensure better prevention.
The body and body language of the baby are the true voice of this possible suffering experienced in the relationship.The evaluation of signs based on reading the comments before any judgment, any criteriology. In these observations, we draw as many elements specific to worry that both supporting relationship and the baby in their resources and skills. Therefore, we prefer to focus the narrative assessment scales that sometimes seal the individual capacity.Assess the capabilities of the infant, the relationships he has with his parents and his environment, evaluate parenthood are an integral part of the PPN-assess soignerprévenir is a triad that works simultaneously and whose terms can not be easily separated.
We hope that the therapeutic approach based on the development of the baby on its own resources should be strengthened in PPN. The Institute of Loczy showed how the baby’s autonomous motor activity is important for evolution, and how the psyche and soma entanglement is imposed on us at this age of life. We do not isolate these babies are hospitalized or consult with their mothers (parents), but we offer them time for respectful interactions of this free motor activity in their mother’s attention and / or under the attention of caregiver. This our interest very early in its autonomous motor activity, its time and its rhythms, to smooth presentation of objects, environment conducive to generating an internal security quality is done to help her sensorimotor development, source of his mental construction.
The observation of the baby promotes his free activity which develop his feelings and emotions, will differentiate invariant representations which emerge. The baby is interested in his own experiences, he sees his ability to control and internalize this confidence in the security offered to him. It will rely secondarily on this emerging confidence in his abilities.
In the case of disorders, relationship mother-baby disorganization, experience Pikler Loczy to be taken into consideration. Relays that rely on these infant capabilities can be implemented sequentially or in the mother-baby units, outpatient care on time psychomotor example, but also as therapeutic nurseries whose concept is to develop. It is however clear that the aim of his term care and do not establish an ideal relationship but to allow a viable relationship for both partners, albeit atypical.
Temporary investment:
When too serious disorders in the parental relationship, the mother-baby units are required to work under temporary placement of orders issued by the judge for child. The term is usually entrusted to the Welfare of Children (ASE).Sometimes it contains a form of injunction care in these units and setting a clear framework. But sometimes after a hospitalization time in these same units as the pathogen dimension of the relationship and its effects on the baby become apparent, requiring a report by child psychiatrist and possibly an investment decision by the judge.
Once the investment made, we asked about the particularly toxic effects (and that we find on the older children in child psychiatry) maintaining some mothers relationships overrun by psychotic mechanisms on their baby. We have implemented a form of meetings we call “therapeutic mediations” that occur in the mother-baby unit in the presence of a nurse. These therapeutic mediations provide a container and a function of protective shield to the relationship mother (father) -bébé. The child builds on the caregiver in the meeting with the parent. The caregiver restores the events of the baby to the parents as accessible and recognizable to them, and in turn reduces parental projections.
This work was developed according to specific therapeutic indications in accordance with the law or ESA. It has a dual function: to allow the meeting between the parent (s) (s) and baby mitigating maximum pathogenic effects, continuing care to the relationship so that parental representation is not, in children, source an anxiety or pathogenic process that continues well beyond the time of the meeting.
In some situations, the placement has no objective reasons and yet the concerns are there; they are developmental for the baby, or current preventive face negligence, serious discontinuities and high risk of abuse. We envision an innovative formula which we call “therapeutic nursery” which is based on developing our practice (bipartite project pédopsychiatrie- PMI).
Young children who would benefit from this formula are sufficiently frequent in situations of relational disorders, discontinuity in the tuning, malfunctions in the establishment of the attachment process, care deficiencies, microruptures attention, maladjustment.
These inadequacies in the responses cause problems in children that appear minimally from 2-3 months, highlighted by a descriptive observation and participant fine, below the usual food signs, gastroesophageal reflux, the excessive crying, insomnia and body tension. From its fourth month, the only baby has signs that observation in the mother-baby hospital unit allows: no gathering of two hémicorps, poverty of investment objects, avoidance in trade and more clearly from 6-8 months lack of investment lower body. These children have been able to build a sense of security, locked in their exploration by autoagrippement, they do not play with their feet, or rocking, or possibility of staying to move on carpet, they are tied in a seat and already in excessive phenomena projections. The object relationship is poor, we see a hypo- or hypertonic, passivity, eating disorders, sleep, incessant crying or rather a lack of expression. To 9-12 months, the child already presents a delay acquisitions or hyperactivity detrimental to the discovery of objects and the cognitive, psychomotor retardation often touching the lower body.
Such situations occur even when a treatment is initiated but is inadequate outpatient or sequential periods. The baby is left with his parents over long periods without mediators. Such care would continue to therapeutic nursery to protect the baby on longer time, in a context allowing it to carry his own experience of motor skills, build proxy continuous quality links and Secures. To continue building the relationship with parents, beyond home visits by the referring professional, it is expected that parents be present half a day per week in the nursery to share life with their child and the team in an experience that is lived in common.
Job stability:
The work on the stability is achieved by allowing the child to experience the balance and imbalance safe.
For these babies have often experienced tensions as inherent in their bodily sensations (inadequate port, discordant care not comply with the requirements of the moment …), it is interesting to arouse in them the ability to do good, to miss a few without punishment or without serious consequence, repair disappointment, pain or sorrow products, the ability to do for himself rather than to brighten another or mitigate its aggressiveness. The organization of such a nursery reflects these objectives: the environment must be stable, it must be down there without getting hurt, experiment motor safely. Areas of “loneliness” under the benevolent gaze of adults, appointed to promote the work of thought in particular by the use of motor skills for self (mobility, game engine, handling, experimentation …).Apprenticeships are secondary and are not involved in their earliest forms, the children are there without idea of stimulating activities to accumulate as educational form of cognitive abilities or advance knowledge.
Emotions:
The attention to the emotions of the child, whether in the form of withdrawal, anger, gastrointestinal symptoms, sleep disorders etc. helps mitigate and transform them into thinkable element but without interpretation, only a capacity to receive them, not away from it, to welcome the grief, depression, lack as in real life. Singing, breathing, human voice can be mediators to say all the emotions, discover, experience beauty.
Containing function:
The containing function of the nursery is quite essential for these children lived painful (they do not even recognize the pain). They are often in the discontinuity, suspended in a vacuum psychic and sometimes physical through porting knowing what is going on psychologically expressed through the body and vice versa. Regulate tensions, events estates, fight against discontinuity require the deployment of a quality capacity to function and this is being set up by the presence, continuity, offering fulcrum, the body every day: explore the inside and the outside physics is to explore proven, emotions, letting go. Settle in places is possible in the time and the reassuring repetition providing a stable investment is finally understanding the flow of time in its predictability. Before incorporating psychically experience, he must live in a safe environment that encourages experimentation, allersretours, assumptions, non-destructiveness of facts and emotions, will allow movement between knowing and not knowing without being destroyed. This function of capacity will need time to act positively to prevent babies cling to their past experiences as the only possible, as only lived to which they cling in repetition, in the need they feel to grip on the same destructive known for their development. The use of rigid defenses, repeating patterns of attachment, freezing of sensory and motor skills is a major obstacle that can not be changed in this context and with the participation of parents to recognize their child as their own in this new relational modality.
Conclusion:
NPP is early in its development, it must continue exploration of the field of knowledge of the baby, especially in its first 40 days. Emotional interaction is expressed through minimal signals, perceived only through observation by professionals uniquely trained in this technique. Each dyad, a particular body language and a discovery for the professional. Whenever the question of what happens to this baby there with this mother, this father, this specific environment.
How to support the parent in its relationship to the baby, how to give confidence to the baby in his own skills?
NPP is complex, it is faced with recognition and care brought to the relationship that develops between a baby and its parents, and sometimes the need to consider the baby’s sensitivity, he expressed his anguish through her body. We must be able to bring this baby a feeling of well-being, restore security, support its capacity and return them to their parents so they can feel supported by their children.
Fueling the relationship and find a place to free activity ask to be based on a careful and respectful observation from the caregiver who acquires knowledge of the inner workings of the dyad which he is responsible. Give the child the possibilities of a secure attachment to his parents support parents so they can receive this child, foster relationship in its creative arrangements would bet the PPN.
