Infant Mental Health Journal, Vol. 3 No.

4, Winter 1982

Toward a Synactive Theory of Development:

Promise for the Assessment
and Support of Infant Individuality
Heidelise Als, PhD

ABSTRACT: A theoretical model to understand and assess the individual infant is presented.
Its focus is on the dynamic, continuous interplay of various subsystems within the organism: the
autonomic system, the motor system, the state organizational system, the attentional-interactive
system, and the self-regulatory system. The organism forges ahead negotiating emerging
developmental agenda while simultaneously seeking to attain a new level of modulated,
functional competence. Developmentally salient aspects of the environment are actively sought
as fuel in this process. This synactive model of development promises to be helpful in identifying
specific ingredients of the early developmental process and in structuring specific supports for
preventive and ameliorative work when difficulties in differentiation and regulation are
identified. An assessment procedure to systematically identify difficult areas of modulation
integration is briefly described and examples of environmental structuring are given.

Clinical work with infants necessitates a theory from which to understand the
..
individual organism and hidher development. While research is the process of
identifying and quantifying regularities and patterns, the tension of clinical
work lies in the task of identifying the individuality and specificity with which a
particular small infant negotiates this common developmental process. Much
work over the last decade has increased our knowledge about the infant’s
remarkable sensory, cognitive, and social capacities. Now we are at the
threshold of developing methods to document how an individual infant
integrates these capacities and negotiates hislher unique and specific develop-
Heidelise Als is Assistant Professor of Pediatrics (Psychology) at the Harvard Medical School and
Director of Clinical Research at the Child Development Unit, Children’s Hospital Medical Center, 300
Longwood Avenue, Boston, MA 02115. Reprint requests should be directed to Dr. Als at that address.
This work was supported by grants HD 10889 from the National institute of Mental Health and by grant
3122 from the Grant Foundation, New York. Part of this work was executed at the facilities of the Mental
Retardation Research Center, Children’s Hospital Medical Center, Boston, Massachusetts.
The author wishes to acknowledge her indebtedness to Dr. T. B. Brazelton, Chief of the Child
Development Unit at Children’s Hospital Medical Center, to her colleagues, Drs. B. M. Lcster and M .
Yogman, co-investigators on a project of preterm infant development, and to Dr. F. H . Duffy for his
continued guidance from a neurologist’s perspective. Special thanks go to the infants and their families who
make our observations and studies possible, and who have contributed so generously to our understanding
of the early developmental process.
0613-9641/82/1600-0229$02.75 229 0 1982 Human Sciences Press
230 Infant Mental Health Journal

ment by bringing the capacities to bear on the surrounding environment. We

shall discuss a process-oriented theory of development and a recently
developed, behavioral assessment of newborn organization based on this
formulation. We shall draw inferences as to the clinical care possible in support
of optimal development.

A SYNACTIVE FORMULATION OF INFANT DEVELOPMENT

The conceptualization of development presented here focuses on how the

individual infant appears to handle the experience of the world around
him/her. The infant’s functioning is seen in a model of continuous intra-
organism, subsystem interaction and the organism, in turn, is seen in con-
tinuous interaction with the environment. We have termed this view of
development synactive, since at each stage in development and each moment
of functioning, the various subsystems of functioning are existing side by side,
often truly interactive, but often in a relative holding pattern, as if providing a
steady substratum for one of the system’s differentiation process. The systems
we are speaking of include the autonomic system, the motor system, the state-
organizational system, the attention and interaction system, and a self-
regulatory, balancing system. The functioning of all these systems is reliably
observable without technical instrumentation.
The autonomic system is observable via the pattern of respiration, color
changes, tremulousness, and visceral signals such as bowel movements,
gagging, hiccoughing, etc. The motor system is observable in the posture, tone
and movements of the organism. The state-organizational system is observable
in the kind and range of states of consciousness available to the organism, from
asleep to aroused states, and in the pattern of state transitions exhibited. The
attention and interaction system is exemplified in the organism’s ability to
come to an alert, attentive state and to utilize this state to take in cognitive and
social-emotional information from the environment and in turn elicit and
modify the inputs from the environment. The regulatory system is exemplified
in the observable strategies the organism utilizes to maintain a balanced,
relatively stable and relaxed state of subsystem integration or to return to such
a state of balance and relaxation. If the infant’s regulatory capacity is exceeded
and the infant is unable to return to an integrated, balanced subsystem state,
another parameter of functioning is identifiable in the kind and amount of
facilitation from the environment that is necessary to aid the infant’s return to
balance.
The questions posed about the organism in this synactive model of develop-
ment always are: How well differentiated, and how well modulated, are the
various subsystems, given varying demands placed on the organism and given
the varying developmental tasks the organism attempts to master from hidher
intrinsic motivation? Where are the thresholds of functioning beyond which
smoothness and balance become stressed coping behaviors, and eventually
costly, bare subsistence protections or even counterproductive maladaptations?
 Heidelise Als 231

Which subsystem is differentially vulnerable at which level of environmental

and endogenous demand? How severe is its infringement on, and kindling of,
other systems’ imbalance by virtue of its own current disorganization? How
much or how little does it take in terms of environmental modification to
induce the reinstitution of a more balanced, integrated state?

THE DEVELOPMENTAL TASK OF THE HUMAN ORGANISM

From our work with healthy fullterm newborns examined with the Brazelion
Neonatal Behavioral Assessment Scale, * and in direct observation of newborns with
their mothers over the first 3 month^,^.^ we learned that the differentiation of
the attentional-interactive system is the most rapidly changing, apparently
newly emerging, salient agendum of the human Autonomic
stability in terms of, for instance, respiratory control, temperature regulation,
and digestive visceral functioning, is relatively quickly restabilized after the
birth process, as are smoothness of movements and adaptation of well
regulated, smooth balance between flexor and extensor posture.‘j The same
holds true for state organization in terms of the range of states available and
their transitions. Most healthy full-term newborns have no difficulty
achieving a robust crying state and can return to a sleep state quite readily.
The issue most newborns seem to attempt to get under control in the first weeks
after birth is the increasing stabilization of the alert state in their movement
from sleep to aroused crying states and back to sleep state. While in the two-
day-old infant the alert periods are still much more difficult to come by and are
embedded in long stretches of sleep and episodes of crying, by two and three
weeks these periods of alertness have become increasingly reliable and
solidified. By one month to six weeks many infants spend an hour or more in
an alert, socially and cognitively available state.

THE SOCIAL ENVIRONMENT OF THE HUMAN NE WBORN

It appears that the newborn is not the only one grappling to solidify these
periods of alert availability. The infant’s social partners, from the first post-
natal contact with the baby tend to be sensitive in aiding the newborn in
stabilizing these periods. O n the first contact mothers and, presumably, fathers
will prod their newborn in both vocal and tactile ways to open hidher eyes,
even at the cost of eliciting crying. Once the newborn opens at least one eye,
the parent will typically acknowledge this initial connection and mutual
recognition by an affectively positive, heightened vocal pattern, accompanied
by an animated facial expression, praising the newborn for the
accomplishment: “Hi! There you are-that’s right-I knew you were in
there. . . . Hi!” The parent may say it over and over again in a drawn out
loving manner.g T h e parent’s behavior in turn, appears to facilitate and
232 Infant Mental Health Jownal

support the infant’s alertness. From a brief initial glance, the infant may go to
widen hidher eyes, raise the eyebrows, soften and raise the cheeks, and shape
the mouth into an “ooh” configuration. The partners mutually support and
drive each other to prolong this episode. One of them will then reset or break
the intensity. For instance, the infant may avert hidher gaze and move into a
yawn or a sneeze, thus resetting the intensity of the interaction at a lower level
by utilizing subtle attentional regulation strategies. Or the infant may avert
and move into a fussy, crying or drowsy state, thus utilizing state shifts to reset
the interaction. The baby may not avert but may stay locked on the parents’
face, become tense and perhaps spit up or move into hiccoughs or gags or even
the strain of bowel movement, thus reacting at an autonomic visceral level in
resetting the interaction. The baby may begin to extend or even flail hidher
arms and start to squirm, thus utilizing motoric shifts in the resetting of the
interaction. If the infant is able to sustain alertness for a substantial period,
keeping respective subsystems of functioning in balance, the parent may be the
one resetting the intensity of the interaction by pulling the baby close and
nuzzling and kissing the baby, or by stroking and patting, thus changing the
cyclical attentional interchange.
It is curious that such emphasis appears to be placed on these early
attentional episodes of the infant embedded in affectively supportive and highly
positive inputs from the parent, given that later this alertness will be much
more easily available. From a species evolutionary perspective, this early
valuing of the attentional interactive connection gains an added dimension. It
appears that it is uniquely human, and it takes on significance as we identify a
correlation between an increasingly complex and simultaneously flexible social
system with an increasingly complex affective communication system in the
order primate from the nocturnal prosimians via the old and new world
monkeys to the great apes and man.10.11.12.13 The essence of humanness, and in
fact of survival of the human species, appears to be in man’s enormously
complex social and emotional interaction capacity that is the prerequisite for
the super systems of material culture technology that we have constructed and
are dependent on for survival. Highly differentiated capacities for collaboration
and cooperation of species members are necessary to make complex adaptation
workable. It appears that from the beginning of extrauterine life the newborn is
specifically launched onto the species specific, collaborative, communicative
track and is in turn supported and affectively rewarded by caregivers as a social
interactor. The attentional interactive capacity of the newborn and young
infant becomes a salient parameter of newborn functioning. It appears to be in
current ascendancy and is highly valued and supported by those around the
baby.
THE NE WBORN’SA TTENTIONAL INTERACTIVE CAPACITY
AND THE FUNCTIONING OF OTHER SYSTEMS

Not all newborns are equally able to increasingly build up this interactive
attentional capacity. For some, this is a difficult task that impinges on the
 Heidelire Alr 233

infant’s other functional subsystems. For example, in a study of thin-for-height

newborns’’ these infants showed great reluctance to come into alertness,
moving into hypertonic, flexed high-guard arm position with fisted hands,
while becoming pale, showing tachypneic and irregular respiration and pained
and drawn facial expressions. Eventually, with calm support they would
gradually open their eyes, but then the hypertonic high-guard-fisted-defended-
ness shifted abruptly into motoric flaccidity and tuning out, the color paled
further, and breathing became slow and irregular. The mustered attention was
of a glassy-eyed, barely focused kind that came at great cost to the autonomic
and motoric regulation.
The identification of this pattern of relatively poor subsystem differentiation,
where as one system attempts to accomplish a task, the other systems are
drawn into the reaction exemplifying the relative cost to the total system, is one
avenue toward understanding the current standing of the infant in terms of
subsystem differentiation.

ASSESSING THE INFANT’S FUNCTIONING

FROM A SYNACTIVE PERSPECTIVE

On the basis of our observations of this subsystem synaction, we have

formulated the following parameters to be identified when assessing an
individual infant’s functioning:
1. the infant’s currently emerging developmental agendum and a situation
to test the degree of ascendency of this agendum;
2. the infant’s current level of subsystem balance and smooth integrated
subsystem functioning, regardless of the agendum identified as in
acendency ;
3. the threshold of disorganization indicated in behaviors of defense and
avoidance, at varying subsystem levels of functioning as the
developmental agendum in ascendency is tested;
4. the degree of relative modulation and regulation of the various
subsystems in accomplishing the new task;
5. the degree of differentiation and effectiveness in rebalancing the
subsystems in the accomplishment of the task;
6. the degree of environmental structuring and support necessary to bring
about optimal implementation of the new task; and
7. the degree of environmental structuring and support necessary to bring
about return to smooth, well-integrated,
- baseline functioning.
This approach to assessment is thought to be appropriate throughout the life
span of the organism. At each stage of development, newly salient agenda are
being negotiated on the backdrop of previously accomplished subsystem
differentiation and modulation. Figure 1 is a schematic attempt to visualize the
conceptualization of the synactive perspective of development, applied to the
fetal and neonatal stages.
234 Infat Mental Health Journal

MODEL OF THE SYNACTIVE

ORGANIZATION OF BEHAVIORAL DEVELOPMENT

Isolerfe

Figure 1

Looked at from above, four concentric cones are seen, representing from the
innermost going outward, first the autonomic system in its basic position
suring up the organism’s baseline functioning. Around it, is the motor system,
unfolding from early embryonic stages with recognizable flexor posture, limb
and trunk movements, and becoming increasingly differentiated in its
explication. Around it, as a third cone, lies the state-organizational system, the
unfolding of distinct states of consciousness from a diffuse quasi-sleep to
increasingly differentiated sleep, wake, and aroused bands of consciousness.
Around this cone lies the gradual differentiation of the awake state into more
elaborated, subtly branched and finely tuned nuances of affective and cognitive
receptivity and activity, shaping the social and inanimate world and in turn
negotiating one’s developmental progression in the process. These cones are
continuously in simultaneous contiguity if not interaction with one another,
influencing and supporting one another or infringing on one another’s relative
stability. The within-subsystem differentiation each system is pushing for
depends on the other subsystems’ support and relative intactness. The
 Ha‘&lisc A h 235

organism with its intraorganism subsystem synaction is at all stages embedded

in an environment it has evolved to expect for its species appropriate
ontogenesis. It is shaping and selecting from this environment as it is also
challenged and impinged upon by this environment at all times. l5sL6

THE PRETERM ORGANISM

SEEN IN A SYNACTIVE DEVELOPMENTAL PERSPECTIVE

We shall use the preterm organism as an example to further explain this

synactive formulation of development. From 24-27 weeks postconceptual-age
on, the, human fetus can be kept alive in an extrauterine environment due to
the advances of medical technology. The infant is biologically expecting 13- 16
more weeks of in-utero existence, with respiratory, cardiac, digestive, and
temperature control aided by the maternal bloodflow and placental
functioning. Total cutaneous somasthetic input from the amniotic fluid is
expected. Kinesthetic input from the contingently reactive amniotic sac,
prevents full extensor patterns and assures flexor inhibition and maintenance
for the typical head-trunk extremity adjustments and movements of soft
modulated limbs, trunk, and head movement, so vividly described by Milani
Comparetti” and Birnholz.I8 Maternal diurnal rhythms presumably
entraining the infant’s own gradually differentiating states of consciousness are
expected. The infant is expecting presumably muted sensory inputs to the
primary senses of vision and audition, readying himlher for the experience of
the extrauterine world. The preterm infant is not an inadequate fullterm
organism, but a well-equipped, competently adapted organism appropriately
functioning at hislher stage and in a particular environment. Suddenly, the
infant is in a vastly different environment, the passage to which has irreversibly
triggered subsystem functioning in an environment only poorly matched to the
infant’s expectations. Instead of the maternal organism, medical technology
attempts to take care of respiratory, cardiac, digestive, and temperature
control functions. The motor system, the state-organizational system and
sensory functioning intimately dependent on an adaptive environment are
largely left to their own devices. The center in our schematic model of Figure 1,
the autonomic functioning, is currently the primary focus of medical care. As
the preterm organism reactivates after a period of “shut down” and
“holding,” trying to get back on track with his earlier accomplished develop-
mental differentiation, we need to ask with what supports and in what
situations is the infant already able to bring about smooth and balanced
functioning which will be critical for realization of new pathways. The freeing
up of the strands of the next developmental agenda in the offing must occur on
the background of well integrated functioning in order to set and maintain the
path of development in a positive direction. This is necessary to avoid the
unwitting reinforcement of the disturbing, defense behaviors that are
236 I n f d Mmtd Heallh Journal

concomitants of the discrepant organism-environment fit and that can easily

lead to a vicious cycle of increasing distortion and disorganization.1g From this
perspective, it is not surprising that the number of autistic children and
children with organizational, impulsivity, and attention deficitsz0is made up of
a disproportionately high number of prematurely born infants.
The . developmental agendum that we have identified for the fullterm
newborn, namely to increasingly free up the ability to maintain an alert state,
may not yet be the appropriate issue for the preterm infant. The mutual
regulation of autonomic functioning with motoric balance and equilibrium, in
a well-defined sleep state may be the salient agendum for a while, before
further state differentiation becomes possible.

DESCRIPTION OF THE ASSESSMENT

OF PRETERM INFANTS’ BEHAVIOR (A.P.I.B.)

In an attempt to systematically identify the infant’s relative standing in terms

of differentiation and modulation of behavioral subsystems, we have
formulated over the last eight years the Assessment of Pretenn Infants’ Behavior
(A.P.I.B.).’l The instrument is appropriate not only for preterm, but also for
otherwise at risk infants and for well fullterm infants. It is a substantial
refinement and extension of the Brazelton Neonatal Behavioral Assessment Scale
(B.N.B.A.S.),’ in that it provides an integrated subsystem profile of the
infant’s current levels of smooth, well-balanced functioning in the face of
varying developmental demands. Toward this goal, in the A.P.I.B., the
maneuvers of the B.N.B.A.S. are used as graded sequences of increasingly
vigorous environmental inputs, moving from distal stimulation presented
during sleep to mild tactile stimulation, to medium tactile stimulation paired
with vestibular stimulation, to more massive tactile stimulation paired with
vestibular stimulation. The social-interactive-attentional package is
administered in the course of the examination whenever the infant’s behavioral
organization indicates the infant’s availability for this sequence. It receives
priority in the examiner’s attempts to facilitate the infant’s organization. The
systems sheet of the assessment permits one to read off which tasks are handled
with ease by the infant in terms of maintaining well regulated, balanced
functioning of all subsystems; which tasks begin to stress the infant and
trespass the balance and modulation of various subsystems yet can be handled
with enough environmental facilitation; and which tasks are clearly inappro-
priate for the infant at this time. In this fashion, developmentally appropriate
goals can be established for the individual infant and facilitations can be
instituted in the infant’s care so that the infant is not overtaxed or, less likely,
underchallenged.
Aside from the systems sheet, the A.P.I.B. provides detailed information on
each individual item presented, as is the case in the B.N.B.A.S., yet the scales
are expanded to document the behavior of the immature, as well as the mature
 Hei&Lisc A h 23 7

T abl e 1

S t r e s s R eac t i ons o f t h e Organism by Subsystem

1. Autonomic and V i s c e r a l s t r e s s s i g n a l s i n c l u d e , among o t h e r s :

a. seizures
b. r e sp i r a t o r y pauses, t achypne ic r e s p i r a t i on
c. c o l o r changes t o m o t t l e d , webbed, c y a n o t i c , g r e y , f l u s h e d
d. gag9 i n g , g a sp i ng
e. s p i t t i n g up
f. h i cccu g h i ng
9. s t r a i n i n g as i f o r a c t u a l y p r o d u c i n g a bowel movement
h. t r e m o r i n g and s t a r t l i n g ; t w i t c h i n g
i. c cugh i n g
j- sneezing
k. yawn ing
1. sighing

2. Motoric s t r e s s s i g n a l s include:

a. m o t o r i c f l a c c i d i t y o r " t u n i n g out "

1) trunkal f l a c c i d i t y
2) e x t r e m i t i e s f l a c c i d i t y
3 ) f a c i a l f l a c c i d i t y (gape f a c e )
b. motoric hypertonicity
1 ) w i t h hyperextensions:
of l e g s ( s i t t i n g on a i r ; l e g b r a c i n g )
o f arms ( a i r p l a n i n g ; s a l u t e s )
o f trunk (arching; o p i s t h o t m u s )
f inger sp 1ays
f a c i a l grimacing
trngue extensions
p r o t e c t i v e maneuvers such as hand on f a c e maneuver,
h i g h guard arm p o s i . t i o n , and f i s t i n g

2) w i t h hyperf Iexions:
o f t r u n k and e x t r e m i t i e s ( f e t a l t u c k )

c. frantic, diffuse activity

3. State-related stress signals include:

a. d i f f u s e sl e e p or awake s t a t e s w i t h w hi m peri ng sounds,

f a c i a l t w i t c h e s and d i s c h a r g e s m i l i n g
b. eye f l o a t i n g
C. strained fussing or crying
d. staring
e. active averting
f. p a n i cke d o r w o r r i e d a l e r t n e s s
9. g 1 assy-e yed , s t r a i nea a I e r tn ess
h. r a p i d s t a t e osci 1 l a t ions
I . i r r i t a b i l i t y and d i f f u s e a r c u s a l
j. crying
238 Infant Mental Hwlth Journal

Tabl e 2

S e l f-R e q u l a tory B ehavi ors o f t h e Organ ism by Subsystem

1. Autonomic s t a b i l i t y i s evi denced by:

a. smooth resp ir a t i o n
b. good, s t a b l e c o l o r
c. stable digesticn

2. M o t o r i c s t a b i l i t y i s evidenced by:

a. smooth, w e l l modulated p o s t u r e and we 1 r e g u l a t e d tcne

b. synchronous smooth movements w i t h e f f c ient motor i c
s t r a t e g i e s such as

hand c l a s p i n g
f o o t clasping
finger folding
han d- t o-mout h maneuvers
g ra s p i n g
suck s e archi ng and sucki ng
hand h o l d i ng
tucking

3. S t a t e s t a b i l i t y and a t t e n t i o n a l r e g u l a t i o n a r e evi denced by:

a. c l e a r , ro b u s t sl eep s t a t e s .
b. rhythmical robust c r y i n g
c. good s e l f q u i e t i n g and/or c a s o l a b i l i t y
d. robust, focused, shiny-eyed a l e r t n e s s w i t h i n t e n t and/or
a7 imated f a c i a l expressi on, e.g.

1) frowning
2) cheek s o f t e n i n g
3) mouth p u r s i n g t o "ooh" face
4) cooing
5) a t t e n t i o n a l smi 1 i n g

fullterm, organism. Moreover, particular attention has been given to the

reliably readable body language of the developing organism and a catalogue of
specific regulation behaviors has been established that can be helpful in
understanding the infant's current functioning. The signals of stress and
signals of stability can be grouped into autonomic/visceral stress signals,
motoric stress signals, and state-related stress signals on the one hand and
signals of autonomic/visceral stability, signals of motoric stability, and signals
of state-organizational stability, on the other hand. The conceptualization
underlying this approach is that stimulation if inappropriately timed or
inappropriate in quality and intensity will cause the organism to move away
from it and protect itself. Stimulation if appropriately timed or appropriate in
quality and intensity will cause the organism to seek it out and move towards
 H&Lire Als 239

it, while maintaining a balanced level.22~23.24.25 Table 1 catalogues stress

behaviors by varying levels of defense reaction, from the autonomic level to the
motoric and state organizational level. Table 2 catalogues self regulatory
behaviors of the organism by various subsystems. All these behaviors are
readily and reliably identifiable in the observation of infants. T h e formulation
of this dual antagonist integration of avoidance and approach as applied to the
newborn infant’J6.27-28can be helpful in identifying the infant’s current
thresholds of balanced, well-modulated functioning and can facilitate the
individualization of caregiving and interaction with an infant.

IMPLICA TIONS FOR CAREGIVING

O n the basis of this synactive approach to development, individualized

environmental structuring to maintain maximal development and to reduce
developmental defense and sparsity becomes possible. Using the preterm
infant as an example, various treatment modifications are suggested depending
on the baby’s current sensitivities. It must be kept in mind that these are as yet
suggestions and their efficacy must be systematically tested. Many others may
be apparent as we become more attuned and creative in the understanding of
the preterm organism. For some babies, complete elimination of nearly all
stimulation may be necessary and strict stress precautions may be appropriate,
depending on the infant’s level of sensitivity and fragility of current subsystem
integration. This would include elimination of touching and handling, as much
as procedures to ensure physiological survival permit , while assuring maximal
postural containment and complete sensory shielding. This might be provided
ideally by a parent or other caregiver softly encasing head, trunk, and
extremities of the infant in the isolette or crib in an ongoing fashion. Such
containment presumably has an advantage over physical containment via
blanket rolls, etc., in that it can be continuously and assuringly reactive and
adjusting as the infant increasingly stabilizes him- or herself autonomously.
For most preterm infants a protected location for the baby’s incubator remains
important for extended periods. Auditory inputs can be significantly reduced
by felt stripping on drawers and pails; decrease in ambient conversation and
laughter, elimination of radios, and modelling of quiet behavior for others in
the area are possible. Visual inputs can be individualized. Bright overhead
light can be shielded through a blanket hood over the isolette ceiling or a
bassinette hood for an open crib. Stable visual patterning without clutter can
be achieved on the incubator walls through stationary decal on porthole doors
and one distinct facial configuration. Thus, a visual stimulus within the baby’s
visual field is ensured without being overwhelming. Olfactory inputs can be
controlled. Pungent smells can be eliminated whenever possible. LOW
concentration of the mother’s perfume can be used on a gauze pad in the
infant’s isolette or crib, or a gauze pad saturated with maternal breast milk can
240 I n f d Mental H d t h J o d

be used for a pleasing olfactory experience. Change in environmental stimuli,

e.g., gentle music, mobile, change in visual stimuli should be introduced only
when the infant is changing into a more alert state. Sleep state should not be
interrupted for the sake of changing these stimulations. Should certain stimuli
prove stressful or counterproductive, they would be eliminated or postponed.
Quiet protected contained time is of great importance.
The direct caregiving procedures to the infant can also be individually
modified to reduce the stress signals of the baby and increase the stability
signals whenever possible. Vital sign taking, including taking the baby’s
temperature, blood pressure, respiratory and cardiac rates, can be timed to the
baby’s state transition from quiet sleep to higher states. The caregiver can
delay these activities when the baby is soundly asleep or quietly alert. When
the infant is drowsy or aroused, the caregiver can first position the baby so that
autonomic and motoric stress signals are at a minimum. This can be done for
instance by helping the infant into a more flexed position and stabilizing
respirations by holding the infant’s hands and feet and encasing the baby with
the caregiver’s arm. While talking softly in a reassuring voice, the caregiving
ministrations can be performed by giving the baby enough facilitation and rest
during the process so that the infant can return to a relatively stable baseline.
When the vital sign taking is complete the caregiver can make sure that the
infant is positioned in such a way that motor arousal and autonomic reactivity
are contained and stabilized as much as possible. The goal of this intervention
is to decrease the stress of these manipulations and increase the infant’s
positive functional strategies. The same approach can be taken when the more
intrusive special procedures such as postural drainage, suctioning, and chest
vibration are being performed. The goal is always to reduce stress signals and
enhance stabilization signals.
This goal also applies for feeding procedures. The baby should not be
interrupted when in deep sleep or when quietly alert. Babies on the respirator
who are gavage fed can be facilitated in a flexed position by diaper rolls for
better hip flexion and knee, shoulder and elbow flexion if the containment by
the caregiver is not possible. Containment can then be provided along the back
of the trunk and against the soles of the feet with diaper rolls. A soft, graspable
terrycloth roll for both hands can facilitate the sucking and trunkal-flexion
configuration. Yet the parent’s or nurse’s finger may be placed in the baby’s
hands and may accomplish this even more effectively. As soon as possible, a
pacifier to suck during gavage feeding can be gently offered when the baby is
relaxed facially. After gavage feeding, a reorganization period for stabilization,
as described above, can be ensured.
After discontinuation of the respirator babies can also be fed when the state
is appropriate for feeding. The baby can be cradled in the parent’s or care-
giver’s arm with the baby’s face about eight inches from the caregiver’s face.
The caregiver should sit in a relaxed position in a rocking chair with feet on a
footstool to provide a comfortable cradle with hidher lap. The baby should be
facing away from a direct light source and the ambient noise and light level
 Hn&I~icA Is 241

need to be subdued. When appropriate, the caregiver could talk softly to the
baby to encourage a quiet, modulated, alert state with a relaxed face. He/She
would hold onto the baby’s hand and allow the infant’s feet to tuck into the
crook of the caregiver’s other arm to inhibit unnecessary motor arousal. In this
supported flexor position, the nipple could be introduced. For babies who are
gavage fed, a pacifier can be used in association with the feed. Burping can be
done gently with the baby against the nurse’s shoulder to promote flexion,
cuddling, and visual alertness. Resting periods should be interspersed as
necessary and extraneous interruptions should be avoided as much as possible.
Depending on the baby’s robustness, soft talking may be added to looking at
the baby and smiling. Overload must be carefully avoided. For some babies, it
may be necessary to avert one’s gaze during feeding while the infant is sucking
and only look at the infant during sucking pauses, if at all. The baby’s signals
should be used to titer the complexity of the input. It may be inappropriate for
some babies to be taken out of the isolette for feedings. They may do better
gently supported in the isolette, without additional tactile and sensory input.
Diaper changing and cleaning need to be timed to the baby’s state transi-
tion. Being placed in supine can be stressful for many preterm babies. There-
fore, diaper changing and cleaning should be accomplished as much as possible
in a prone and side position. Stabilization should be assured and then during
the procedure flexion can be facilitated by letting the baby hold onto the
nurse’s finger, by letting the baby suck if necessary, and by aiding postural and
autonomic restabilization after the procedure. Calm, soothing talk can accom-
pany the procedure for some infants. For others this may be too much input.
All social interaction must be in keeping with the baby’s state transitions.
The baby should not be interrupted if in quiet sleep. Once in a quiet alert state,
social interaction can proceed in a graded fashion, first from a distance and
with soft gentle talking and lowkeyed animation. If the baby responds well the
complexity of talking and facial expression can be gradually increased; anima-
tion in the baby’s face is the goal, with reciprocation of social signals on the
baby’s part.
The baby should be continuously monitored for autonomic and motoric
stress signals during these interactive sequences. The interaction will be
reduced in complexity or terminated as necessary, if the baby shows stress. An
aroused or otherwise stressed baby always needs to be stabilized and reorgan-
ized before the caregiver leaves the baby.

IMPLICATIONS FOR PARENT SUPPOR T

Parents are vital participants in the baby’s development. As our model in

Figure 1 indicates, they are temporarily subsidized by the isolette and medical
technology in facilitating the premature transition from in-utero to extra-utero
parenting. That this is a temporary subsidy only must be kept in mind by all
professional personnel. The parents are the key facilitators of the infant’s
242 Infant Mend Health J o u d

development and need to be seen in their critical role of appropriate stimulus

barrier between the infant and the world at large. The infant’s behavioral orga-
nization in the synactive formulation outlined here is often intuitively obvious
to the parent. Yet often the parents do not dare trust their intuition and the
infant’s signals of communication. They defer to the professional to whom they
abruptly and totally had to relinquish their child, and they gather that the
legitimacy of questions and discussion is now established by the professional.
Discussion tends to revolve around blood gasses, oxygen levels, equipment,
etc. The parent often becomes good at verbal intercourse on this level. Yet he
or she wonders how the infant is feeling; whether the baby is in pain; and
whether the baby is panicked, overwhelmed, desperate. The baby is seen by
the parent communicating all those messages quite clearly. This is an oppor-
tunity to assure the parents of the significance of the baby’s communication, of
the accuracy of their understanding of these communications, and of their
importance in responding to these communications. When the parents can
recapture the baby as theirs and in need of their protection and their growing
trust in the infant’s integrity and autonomy, then the clinician has done the job
well of supporting infant and parents in this mutual development task.

SUMMARY

We have outlined a formulation of development that identifies five subsystems

of functioning in continuous contiguity and interaction: the autonomic system,
the motor system, the state-organizational system, the attentional-interactive
system, and the self-regulatory-balancing system. The organism negotiates the
integration and continuous differentiation of these systems in continuous inter-
play with the environment. Assessment of the organism’s functioning therefore
lies in the identification of the currently salient and emerging developmental
task and its relative support by, or disruption of, the other subsystems in their
balance and modulation. Signals of stress and signals of self regulation can be
detected at each system level in the identification of the organism’s current
degree of smooth, well-regulated functioning. This kind of assessment of the
infant’s current level of organization seems important for our preventive and
supportive structuring of the environment and for the identification of an
infant’s individual progression. This permits us to provide opportunities for
the parents and others working with the infant to take pleasure in the infant’s
competence and their own competence, no matter how difficult or different the
infant may be.

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