641_96-303 4/24/97 12:36 PM Page 171

(Black plate)

Infant Mental Health Journal, Vol. 18(2) 171 181 (1997)

1997 Michigan Association for Infant Mental Health

CCC 0163-9641/97/020171 11

Evaluation into the Relationship: Reflections on New Trends in

Evaluation, Assessment, and Classification
ANTOINE GUEDENEY

Service de Psychopathologie du Jeune Enfant, Institut de Puericulture de Paris, 26 Blvd Brune,

75014 Paris, France
SERGE LEBOVICI

Faculte de Medecine de Bobigny, France

ABSTRACT: From a clinical and psychoanalytically informed point of view, the process of evaluation is
mainly concerned with the formation of a working alliance with the infant. Assessment is, therefore, considered
as a process that cannot be applied in a systematic way, regardless of the situation. On the contrary, it is based
upon transference and countertransference, which guides the clinician, along with the infants behavior and reactions, during the consultation. From this perspective, evaluation should always have some therapeutic impact.
Paradoxically, this therapeutic action is linked with the suspension of diagnostic process for a period of time.
The prognosis and treatment planning is mostly based upon the evaluation of change during the expended assessment period. The more serious the situation, the longer the assessment to determine why the infant is at risk,
what are the positive aspects of the situation, and what are the ways to reach the infant through the relationship
with the parents.
RESUMEN: Desde un punto de vista clnico y psicoanaltico, el proceso de evaluacin se ocupa primordialmente de la formacin de una alianza de trabajo con el infante. La evaluacin es, por lo tanto, considerada como
un proceso que no se puede aplicar en forma sistemtica, sin prestar atencin a la situacin. Por el contrario, ese
proceso se basa en la transferencia y contra-transferencia que gua al clnico, junto con la conducta y las reacciones que el infante muestra durante la consulta. Desde esta perspectiva, la evaluacin debe tener siempre algn impacto teraputico. Paradjicamente, esta accin teraputica va unida a la suspensin del proceso de
diagnstico por un perodo de tiempo. La prognosis y el plan de tratamiento se basan por la mayor parte en la
evaluacin del cambio durante el perodo de evaluacin usado. Mientras ms seria es la situacin, ms largo es
el perodo de evaluacin con el fin de determinar por qu el infante est a riesgo, cules son los aspectos positivos de la situacin, y culos son las maneras de llegar al infante a travs de la relacin con los padres.
RSUM: Dun point de vue clinique et dun point de vue psychanalytique, le processus dvaluation sintresse principalement la formation dune alliance de travail avec le bb. Lvaluation est donc considre

The authors gratefully acknowledge the help of Rachael Henry, University of Wollongong, Australia, and
Gisele Danon, l Aubier, Fontenay-les Roses for editing, translating, and reviewing help. This work has greatly
benefitted from the reports of the WAIMH Study Group on psychoanalytically oriented parent infant therapy,
chaired by B. Cramer and including D. Daws, R. Debray, B. Golse, N. Guedeney, M. Maury, M. Morales- Huet,
M. R. Moro, F. Palacio-Espasa, M. Soule, and A. Watillon-Naveau. Correspondence should be addressed to the
first author at Service de Psychopathologie du Jeune Enfant, Institut de Puericulture de Paris, 26 Blvd Brune,
75014 Paris, France.
171

641_96-303 4/24/97 12:37 PM Page 172

172

(Black plate)

Infant Mental Health Journal

comme un processus qui ne peut tre appliqu dune manire systmatique, quelle que soit la situation. Bien au
contraire, elle est fonde sur le transfert et le contre-transfert qui guide le clinicien, ainsi que le comportement et
les ractions du bb, durant la consultation. De cette perspective, lvaluation devrait toujours avoir un impact
thrapeutique. Paradoxalement, cette action thrapeutique est lie la suspension du processus de diagnostic
pendant un certain temps. La planification du pronostic et du traitement est pour la majeure partie base sur
lvaluation du changement durant la priode allonge dvaluation. Plus la situation est srieuse et plus est
longue lvaluation de manire dterminer pourquoi le bb est risque, quels sont les aspects positifs de la
situation, et quelles sont les manires datteindre le bb travers la relation avec les parents.
ZUSAMMENFASSUNG: Die Herstellung eines Arbeitsbndnisses mit dem Kind ist das Wesentliche bei der
Untersuchung sowohl aus klinischer als auch psychoanalytischer Sicht. Unabhngig von der jeweiligen Situation, mu man daher jede Untersuchung als einen Proze verstehen, der nicht regelhaft verlaufen kann. Ganz im
Gegenteil bentzt der Untersucher die bertragung und Gegenbertragung, die gemeinsam mit dem Verhalten
und den Reaktionen des Kleinkindes den Kliniker leitet. Dadurch kann bereits jede Untersuchung zugleich
einen therapeutischen Anteil haben. Durch die therapeutische Handlungen wird jedoch der diagnostische Proze
unterbrochen. Die Prognose und die Planung der Behandlung ergibt sich vor allem durch die berprfung der
Vernderungen whrend der Untersuchungsphase. Je ernster die Situation ist, desto lnger bentigt man, um
festzustellen, warum das Kind in Gefahr ist, um positive Aspekte der Situation zu erheben und um Wege zu dem
Kind mit Hilfe einer Beziehung zu den Eltern zu finden.

Without a precise and comparative definition and a broad international consensus, on

the scope and role, evaluation and assessment have, nonetheless, become key words in the
field of infant mental health. Infant mental health is a new discipline in which knowledge
has grown exponentially in the last two decades. Through systematic observations, research, and clinical interventions, a more sophisticated understanding of the factors that
contribute to disorders of infancy and early childhood and the need for early intervention
has emerged. Therefore, timely assessment and accurate diagnosis have become key components of effective intervention. However, the recent emphasis on evaluation, assessment, and classification issues raises a few observations. There is a concern that
classification deals with syndromes, whereas assessment and intervention deals with individuals. Therefore, classification is a potentially conflictual area with respect to clinical
intervention and to cross-cultural issues (Guedeney, 1996b).
Clearly, mental health in infancy shares common aspects throughout the world. Disorders of infancy do exist as entities (Sameroff & Emde, 1989; Zero to Three, 1994). However, some features of infant mental health in infancy, being multidisciplinary, having a
developmental orientation, having an orientation toward prevention, and emphasizing the
relationship, challenges the medical tradition of diagnosis (Emde, Bingham, & Harmon,
1994). Because evaluation and treatment planning have strong cultural correlates, classification is a common denominator that does not easily take cultural specificity into account. Therefore, classification should not be linked too strongly with evaluation, as the
latter is much broader process. Otherwise, evaluation is at risk of becoming a standard-

641_96-303 4/24/97 12:37 PM Page 173

(Black plate)

A. Guedeney and S. Lebovici

173

ized and legal procedure, used for labeling and designed to reduce treatment costs
through the definition of a standardized treatment of choice. On the contrary, evaluation
with parents and infants should remain a process based mainly on the relationship between the clinician and the family designed to understand and intervene in a specific situation. The future of the discipline of infant mental health is concerned with these issues,
as was adult psychiatry earlier with the development of DSM-III (Wilson, 1993). Currently there is no ideal, cross-cultural standard evaluation, just as there is no ideal diagnostic classification. Evaluation and classification should be strongly linked with
underlying theory related to causality, and to developmental stages, and have the ultimate
goal of developing appropriate interventions.
DIFFICULTIES IN CLINICAL APPROACHES TO ASSESSMENT AND DIAGNOSIS
In the introduction to DC: 0 3 (Zero to Three, 1994), it is stated that it is the responsibility of any clinician who is charged with doing a full diagnostic work-up and planning
an appropriate intervention program to take into account all the relevant areas of a childs
functioning, using state-of-the-art knowledge in each area. These areas include:
presenting symptoms and behaviors;
developmental history past and current affective, language, cognitive, motor, sensory, family, and interactive functioning;
family functioning and cultural and community patterns;
the infants constitutional-maturational characteristics; and
affective, language, cognitive, motor, and sensory patterns.
In addition, it is important to consider the familys psychosocial and medical history, the
history of the pregnancy and delivery, and current environmental conditions and stressors. (Zero to Three, 1994, p. 13). In planning such a complete and ideal evaluation,
based on the model of the medical assessment and diagnostic procedure, the issues are:
How do we begin? Should such a procedure be applied in all situations? Is it really suitable to the field of infant mental health? What is the impact of the sex or ethnic background of the clinician? Is the process of evalution best achieved with a team? If so, who
should have the final responsibility for the evaluation? On which basis are the assessment
tools to be chosen for each of the items on this list? Are these tools validated for different
of populations and what situations? Have they been adapted for clinical use? Finally,
what is the red wire, that is, the path that the clinician must follow to achieve a significant assessment and evaluation procedure?
SUGGESTED APPROACH TO HISTORY TAKING, UNDERSTANDING
PRESENTING SYMPTOMS, AND CLINICAL INTERVIEWING
To follow the list described above, first we have to deal with the presenting symptoms
and behaviors and to take a developmental history. This approach may involve a medical
procedure, in addition to a psychologically oriented one. For example, a family with both
parents presenting as manic depressive came in with an 18-month-old infant asking for an
awakening program, although the child was sleeping less than 4 hours in 24. Because the
parents presented with this information, the clinician needs to be sensitive to these issues.
Asking questions about development without information about the emotional back-

641_96-303 4/24/97 12:37 PM Page 174

174

(Black plate)

Infant Mental Health Journal

ground runs the risk of providing the clinician only with answers. It is important to learn
about the kind of relationship the parent has with his/her infant without the clinician indicating an opinion about what can be accepted or not. Gathering specific facts about the
family may be less useful than doing a careful analysis of a particular moment of experience that embodies the essence of the central problem. Most psychoanalytically trained
clinicians prefer to let the parents describe the situation in their own terms and display
their concern and troubles without following a standard interview procedure (Debray,
1995; Wattillon-Naveau, 1990). As the parents share the problem and its origins in their
own way, it is also possible to better understand the emotions that accompany their story
(Daws, 1993). The strong emotions may be linked with the feelings experienced by the
baby in difficult situations. Thus, understanding transference and countertransference aspects are essential to the evaluation process (Seligman, 1993). From this perspective, the
clinician carrying out the evaluation should have previously worked through with his or
her own emotional states gained through a personal psychoanalytic experience. At times,
the use of structured assessment planning may be helpful in making sure certain areas
have not been forgotten (M. J. Cordeiro, July 1996, personal communication.)
Because evaluations do include observations as a crucial part of the process, some
comments on the observational method are relevant as part of the evaluation process
(Rustin, 1989): How one finds a place for oneself in the family during the observation
process, ones identification with different persons in the family, ons response to anxiety
and uncertainty and a large measure of helplessness, and ones exposure to some of ones
own personal problems as a consequence of the emotional impact of the observation are
important (Rustin, 1989, p. 8). This situation is especially true in case of child abuse.
Finally, It is critical that the information be gathered in the service of an active ongoing effort, together with the parents to organize the experience of the family and to
construct an account of the familys experience with the baby (Hirshberg, 1993,
p. 174).
PARENT AND FAMILY FUNCTIONING
The role of family functioning and the parents psychopathology related to the childs
behavior is one of the most difficult parts of the evaluation. The child being assessed is
only the foreground of the total picture. It is, therefore, important to identify the background against which it is framed (Barrera, 1994). It is now clear that parental psychopathology and family functioning play a large part in infant disorders, much more
than maternal psychopathology alone (Rutter, 1995). Further, the parent who appears to
be more characterological is not always the one who may be contributing most to the
problem. Sometimes, in fact, this parent may be protecting the other, and may, in turn, be
more accessible to change than his or her partner. It is common to the child psychiatric
experience to see parents present themselves in a characterological way, seemingly
searching for judgment and forgiveness at the same time. It may take some time and patience before the clinician will be taken for a journey into the family history. The clinician
will be trusted only if s/he represents more hope for the child than fear and guilt for the
parents. Identification of ghosts in the nursery (Fraiberg, 1980) or transgenerational
repetition (Lebovici, 1993) can be done only through a collaborative process between
parents and clinician and not by labeling, diagnosing, and assessing procedures. This sen-

641_96-303 4/24/97 12:37 PM Page 175

(Black plate)

A. Guedeney and S. Lebovici

175

sitive approach is particularly important for high-risk, hard-to-reach families who will
not collaborate in a routine assessment because it provides little hope for help based on
their previous experience with overworked, noncaring, bureaucratic agents (Seligman,
1993). A sensitive outreaching to the parents (Fraiberg, 1980) and the initial transference
are crucial aspects of the assessment. How this approach is handled and how the initial
transference develops leading to an alliance with the parent will, in fact, determine
whether an assessment can be done (Fraiberg, 1980, p. 31).
In addition, there is a clear need for easy-to-use, validated tools to assess the condition
of parents, especially in the postpartum period, such as a postnatal grief scale (Toedter,
Lasker, & Alhadeff, 1988) or, in some circumstances, anxiety linked with antenatal diagnosis (Guedeney, 1996c), or with having a high-risk infant (Meyer, Zeanah, Zachariah
Boudikis, & Lester, 1993). Leon (1992) has emphasized the importance of not using standardized procedures in perinatal grief situations, even if it is essential that a protocol be
prepared. What Stern (1995) has described as the Motherhood Constellation also calls
for specific attention and evaluation. Because of the sensitivity of the mother, extensive
knowledge of parental psychology is needed. In some cases, treatment may be needed at
the same time as the evaluation is begun; therefore, clinical tact may be more important
than using the latest questionnaire.
CROSS-CULTURAL ISSUES AND EVALUATION
The process of assessment often assumes an objective reality that can be observed
and documented in a reliable fashion. However, it is crucial to be familiar with cultural
aspects of the parent infant interaction to assess it properly. At the same time, it may be
even more important to recognize that we do not have complete access to the others culture, and therefore may need help to be empathetic to these aspects of the evaluation. To
view a childs individuality with no consideration of his or her group affiliation, is to deny
the reality of culture (Barrera, 1994; Moro, 1994). For example, understanding the concept of amae is crucial for any clinician working with Japanese parents and infants
(Watanabe, 1992). Thus, assessment procedures, materials, instruments, and interactions
are all embedded in particular world views, expectations, values, and behaviors. When
these world views, expectations, and behaviors reflect those of the assessors and the family, the likelihood that valid information will be obtained and interpreted accurately is
high. When they do not, the potential for error is equally high (Barrera, 1994).
CAREGIVER INFANT RELATIONSHIPS AND INTERACTIVE PATTERNS
Understanding the caregiver infant relationship and interaction patterns are important,
yet difficult. This assessment cannot be free of theoretical underpinnings, even if it presents itself as purely descriptive. For example, the Parent Infant Assessment Global Assessment Scale included in the Diagnostic Classification of Mental Health and
Developmental Disorders of Infancy and Early Childhood (DC: 0 3) is such a descriptive tool, which provides the clinician with a global rating of the pattern of the relationship (Zero to Three, 1994). Moreover, the concept of fantasmatic interaction (Kreisler
& Cramer, 1981; Lebovici, 1988), however arguable in its formulation, was put forward
to capture the link, from a psychoanalytically perspective, between the overt manifest be-

641_96-303 4/24/97 12:37 PM Page 176

176

(Black plate)

Infant Mental Health Journal

havior and interaction, and the underlying fantasy in the caregivers mind. The identification of such a specific symptomatic sequence (Cramer & Palacio-Espasa, 1993) became a
major goal of a psychoanalytically oriented assessment with parents and infants, maybe
even more so than the qualitative and global assessment of the interaction. One of the
most striking aspects of parent infant clinical work is the ability of the baby to follow
the script of the relationship (Stern, 1985). In such a way, the infants behavior becomes the best guideline during the process of evaluation.
The DC: 0 3 classification system (Zero to Three, 1994) makes a distinction between
disorders and relationship problems, which is not easy to make clinically, because the
clinical process specifically embodies the selection of a significant feature with an etiological mechanism (for instance, sleep disorders with separation-individuation process).
Another important and practical issue in infant evaluation is to determine to what extent
the physical disorders of the infant should be taken into account in the evaluation of psychopathology. The clinician has to make a choice between the descriptive attitude, not
necessarily exploring for links, and the possibility of certain links between the onset or
the persistence of a problem and the relationship disorders (for example, chronic otitis
media or eczema and attachment disorders). This second method of thinking has been developed in France in the Paris school of psychosomatics (Debray, 1995; Kreisler, 1981).
Finally, it is important to emphasize that no assessment procedure or classification system
is free of a theoretical position, even if it presents itself as purely descriptive (Golse,
1994). During the process of evaluation, the clinician makes use of his or her own set of
personal experiences, theories, and beliefs.
Technical means, such as the use of videotape equipment, for analyzing the relationship and the behaviors to see what is really happening between the partners in the interaction has greatly improved our ability to look for Who does what to whom and when
(Stern, 1995). However, the assessment of the relationship remains mostly in the domain
of opinion and transference, even if some recent progress appears significant (Crowell &
Fleishmann, 1993). What ideas help in our clinical assessment of relationships? Clearly,
implications of the attachment concept has played an increasingly important role in our
clinical evaluations (Hirshberg, 1993; Holmes, 1993; Rutter, 1995). The Strange Situation
paradigm is an extraordinarily fruitful laboratory assessment of attachment (Ainsworth,
Blehar, Waters, & Wall, 1978). It has stimulated research and intervention programs
aimed at modifying the patterns of attachment and mothers sensitivity (van Izjendoorn,
Joffer, & Duyvesteyn, 1995). But the Strange Situation paradigm is not very useful as a
clinical instrument because it precludes the dialogue with the parents that is essential in
obtaining an accurate picture of the babys functioning. In a procedure such as the
Strange Situation, the parents own perceptions and emotions are not elicited and the
parents behavior is carefully dictated by the need for standardization (Greenspan &
Liberman, 1980). In a psychodynamically oriented evaluation, it is important to be able to
justify why a certain assessment procedure is used, thus taking countertransference aspects into account as part of assessment procedure. Most parent infant assessment situations present with a great deal of chaos and stir up a lot of strong feelings, before a sort of
coherence emerges from the different sources of material (Daws, 1993). Therefore, the
temptation is great to desire more objective testing to get a better grip on the situation, before sufficient time has been spent integrating the experience in the clinicians mind,
which will then mirror the integrative process in the parents mind. This does not mean

641_96-303 4/24/97 12:37 PM Page 177

(Black plate)

A. Guedeney and S. Lebovici

177

that testing and assessment scales are not useful. Rather, one has to know their range of
use and validity to integrate the material into an understanding of relationship and the
working alliance.
INFANTS CHARACTERISTICS
Several methods are available to assess the infants participation to the interaction. The
Neonatal Behavioral Assessment Scale (Brazelton, 1984) was the first scale designed to
assess the relational abilities of a newborn. More recently, emphasis on maturationalconstitutional characteristics of the infant have led to the description of new diagnostic
categories, such as Regulatory Disorders (Greenspan & Liberman, 1980; Sameroff &
Emde, 1989). Their validity and reliability remains to be established, as does their link
with the relationship. For example, do regulatory disorders exist prior to any relationship
disorders or are they a consequence of relationship disorders? These are important issues
related to the use of these categories in the process of evaluation. Similarly, the use of
Multi-System Developmental Disorder (MSDD) is a new opportunity and a new category
in the DC: 0 3 (Zero to Three, 1994), compared to DSM IV (American Diagnostic Association, 1994). In MSDD, the relationship difficulty is not viewed as a relatively fixed,
permanent deficit but as open to change and growth. Therefore, during the evaluation
process, an effort will be made to observe the child for a substantial period of time, together with the caregivers, in a supportive, safe, not overly stimulating setting, where
spontaneous interaction and play are possible and encouraged. Observing a childs response to intervention over a period of time is the most useful way to gauge relationship
potential (Zero to Three, 1994, p. 43). Another infant disorder where improved assessment and evaluation is obviously needed is infant depression. Despite the frequent use of
the term with the idea that it is a key notion in evaluation, infant depression remains
poorly defined and assessed. Infant depression may be hard to recognize because of the
feelings of helplessness it may evoke in the observer (Guedeney, 1996a).The concept of
sustained withdrawal reaction has been proposed to build a screening scale to be used in
well-baby clinics (Guedeney, Vermillard, Roge, Benjellal-Zamoun & Fermanian, 1996b).
Finally, another improtant notion to be taken into account in the process of the evaluation
is the great number of transition periods in infancy, as sources of progress and potential
germs of pathology. Thus, an important task of the evaluation becomes the identification
of these distinct periods of disorganization and regression (Van de Rijt-Plooij & Plooij,
1993).
THERAPEUTIC APPLICATIONS OF EVALUATION
The invitation to the parents (Fraiberg, 1980) is, in fact, the step to therapeutic intervention. Paradoxically, this effect can be linked with the suspension of any diagnostic
procedure. We explore the parents history about the child, and we ask them to share their
understanding and look at their infant. Looking together becomes the motto, without
jumping too quickly to conclusions, despite the parents often urgent need for reassurance
and advise. At the same time, they feel some relief in being able to bring their story to us,
and for having had the courage to decide to look for professional help for their infant.
Therefore, they are willing to take the risk of our insight into their own history and at-

641_96-303 4/24/97 12:37 PM Page 178

178

(Black plate)

Infant Mental Health Journal

tachment experiences. Through their child, they feel that they are taking the risk of showing us some of their unconscious functioning which nobody does easily. The assessment
procedure developed by Selma Fraiberg (1980) is the best application of the idea that the
more serious the situation, the more extended the assessment process. The extended assessment period allows for identification of ego strengths as well as weaknesses in
parental personality, and for identification of positive aspects of parent infant interaction
that are so needed as a basis for intervention and the development of a therapeutic alliance. Extended assessment may enable us to know why the baby is having difficulties,
and therefore gives us ideas about the most helpful interventions. The assessment process can have tremendous therapeutic value if the parents are integrally involved in it
(Brazelton, 1981; Parker & Zuckerman, 1990; Renard & Rabouam, 1996).
Clinical Example: Triplets
In this clinical example, evaluation was used as the main therapeutic strategy. The family came in great distress because of Ninas feeding difficulties. Nina, age 2, would cling
to her bottle, as her parents would bitterly fight about who was right. The father who said
one should let her do what she felt like and the mother, a former pediatrician, who had
worked in humanitarian associations throughout the world, was concerned with the stagnation of her weight. Both parents were considering divorce because of Nina who was, in
fact, worrisome because of her withdrawal and depressive state, and because of her failure to thrive. The family had recently expanded with the natural birth of triplets, a girl
and two boys. Despite their expertise on organization, both parents were exhausted and
overwhelmed by the situation. They came to the first meeting with Nina alone. It was decided to have subsequent meetings with the whole family.
This was an awful experience for the clinician, as the room was filled with cries, fights,
anger, and tears, and with a lot of baby equipment and toys. As it was obviously impossible to assess the situation as a whole, the clinician came up with the idea of trying to
focus attention on one child at a time to assess his or her specific strengths or vulnerabilities. An evaluation session was planned for each child in the order chosen by the parents,
and was accomplished during two meetings with the parents, the child and the assessment
team, which was composed of a psychometrician, and a speech and language therapist,
both trained to work together and with young infants. Their task was to establish a good
relationship with the parents and to provide the child with different stimuli and relationships, rather than have the child go through specific developmental testing. Between the
evaluation sessions, the consultant would continue with the whole family, and discuss the
results of each of the evaluations. This procedure allowed for a reduction of the high level
of anger, anxiety, and stress in the family, and, therefore, contributed to the therapeutic effect. It allowed the clinician to understand and to cope with their traumatic life, and to
take his time with a difficult situation, without having to diagnose or to intervene too
early. It enabled the parents to take the needs and characteristics of each child into account, and to plan an intervention strategy for each of them. Also, this allowed for the
evaluation of the different relationships of each infant with the others and with the group.
The most distressing aspects in some of the children such as head banging, withdrawal,
sleep disorders, food refusal, tantrums, and difficulty in playing progressively disappeared. At times, the sessions allowed for insight into the parents childhood and provided
some links with actual relationship difficulties with the children and between the parents.

641_96-303 4/24/97 12:37 PM Page 179

(Black plate)

A. Guedeney and S. Lebovici

179

The mother began to understand that she tended to ruin every opportunity she could have
for pleasure or achievement, in relation to her envy of a very strong and powerful mother.
This had been true in her professional career, and was reenacted in the sessions. Initially
severely depressed, she finally agreed to take antidepressant drugs and to begin psychotherapy. The father also began with personal therapy, being struck with his difficulty
to apply authority. Through a detail in the relationship with the most oppositional child,
he began to understand that his lack of intervention could be as aggressive as the violent
and humiliating responses he had suffered from his father. After some initial fears, all
children appeared to be free of severe developmental disorders, and follow-up confirmed
positive developmental progress for each of them. The family continues to come for consultation for one long session every 3 months but it is now possible to talk about
each one at a time and about the family as a group without too much confusion.
CONCLUSIONS
Psychoanalytic thinking, particularly in France, has not been closely linked with the
concept of evaluation, although it can be argued that evaluation is, in fact, necessary prior
to any psychoanalytical work, be it with adults or with parents and infants. The primary
importance of transference does not fit well with the idea of evaluation, as the latter may
appear as a way to take some distance from the parents or with the child. Also, the psychodynamic point of view emphasizes the importance of individuality with each family
having its own flavor, with a history, a style and a culture of its own, which may not be
easily captured within a structured assessment process. Most of what we are looking for
in a comprehensive evaluation process comes from details, and repetition, terrible and
exacting details (Fraiberg, 1980, p. 165). On the other hand, the field of infant mental
health calls for specific multidisciplinary, developmentally oriented assessment procedures, with respect to the primary importance of parent infant relationship. Developments in the field of assessment procedures has already changed our way of evaluating
and treating parent infant relationships. As our knowledge of specific situations grows,
we see the need for more specific assessment tools and procedures, validated in clinical
practice, rather than standardization and homogenization.
REFERENCES
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological
study of the strange situation. Hillsdale, NJ: Erlbaum.
American Diagnostic Association (1994). Diagnostic standard manual IV. Washington, DC: Author.
Barrera, I. (1994). Thoughts on the assessment of young children whose sociocultural background is unfamiliar
to the assessor. Zero to Three, Bulletin of the National Center for Clinical Infant Programs 14, 9 13.
Brazelton, T. B. (1981). Assessment as a method for enhancing infant development. Zero to Three, Bulletin of
the National Center for Clinical Infant Programs, 2, 1 8.
Brazelton, T. B. (1984). Neonatal behavioral assessment scale. London: Spastics International.
Cox, J., & Holden J. (1994). Perinatal psychiatry. Use and misuse of the Edinburgh Post Natal Depression
Scale. London: Gaskell.
Cramer, B., & Palacio-Espasa, F. (1993). La pratique des psychotherapies mere-bebes: Etudes clinique et technique. Paris: Presses Universitaires de France.
Crowell, J. A., & Fleishmann, M. A. (1993). Use of structured research procedures in clinical assessment of infants. In C. H. Zeanah (Ed.), Handbook of infant mental health (pp. 210 222), New York: Guilford.

641_96-303 4/24/97 12:37 PM Page 180

180

(Black plate)

Infant Mental Health Journal

Debray, R. (1995). Principes de consultations et therapies des bebes atteints de troubles somatiques. Devenir 7,
25 34.
National Center for Infant Clinical Programs. (1994). Diagnostic classification: Manual (DC: 0 3). Arlington,
VA: Author.
Daws, D. (1993). Through the night. London: Free Association Books.
Emde, R. N., Bingham, R. D., & Harmon, R. J. (1993). Classification and the diagnostic process. In C. H.
Zeanah (Ed.), Handbook of infant mental health (pp. 225 235). New York: Guilford.
Fraiberg, S. (1980). The first year of life. Clinical assessment of the infant and his family. In Clinical studies in
infant mental health (pp. 23 48). London: Tavistock Publications.
Hirshberg, L. M. (1993). Clinical interviews with infants and their families. In C. H. Zeanah (Ed.), Handbook of
infant mental health (pp. 173 190). New York: Guilford.
Holmes, J. (1993). John Bowlby & attachment theory. London: Routledge.
Golse, B. (Ed.). (1994). Bebe soigne, bebe observe. Geneve, Paris: Medecine et Hygiene & Eshel.
Greenspan, S. I., & Liberman, A. F. (1980). Infants, mothers and their interaction: A quantitative clinical approach to developmental assessment. In S. I. Greenspan & G. H. Pollock (Eds.), The source of life: Psychoanalytic contributions towards understanding personality development (Vol. I, Infancy and early
childhood). (pp. 271312). Bethesda, MD: NIMH.
Guedeney, A. (1996a). From early withdrawal reaction to infant depression: A baby alone does exist. A french
perspective on infant depression. Infant Mental Health Journal (submitted).
Guedeney, A. (1996b). International and cross cultural perspective on diagnostic classification of mental health
and developmental disorders in infancy and early childhood. In Zero to Three, Washington DC: National
Training Institute.
Guedeney, A. (1996c). Antenatal diagnosis: What sometimes remains to be done after the birth of a normal
child. Journal of Child Psychotherapy (in press).
Guedeney, A., Vermillard, M., Roge, J., Benjellal-Zamoun, H., & Fermanian, J. (1996).The Baby Alarm Distress
Scale (BADS). A scale for assessing sustained withdrawal reaction in infancy. A pilot study. Infant Mental
Health Journal (submitted).
Kreisler, L. (1981). L enfant du desordre psychosomatique. Toulouse: Privat.
Kreisler, L., & Cramer, B. (1981). Sur les bases cliniques de la psychiatrie du nourrison. La psychiatrie de lenfant 24, 1 15.
Lebovici, S. (1993). On intergenerational transmission: From filiation to affiliation. Infant Mental Health Journal 14, 260 272.
Leon, I. G. (1992). The psychoanalytic conceptualisation of perinatal loss: A multidimensional model. American Journal of Psychiatry 149, 1464 1472.
Meyer, E. C., Zeanah, C. H., Zachariah Boudikis, C. F., & Lester, B. M. (1993). A clinical interview for parents
of high risk infants: Concept and applications. Infant Mental Health Journal 14, 192 207.
Moro, M. R. (1994). Parents en exil. Paris: Presses Universitaires de France.
Parker, S. J., & Zuckerman, B. S. (1990). Therapeutic aspects of the assessment process. In J. Meisels & J.
Shonkoff (Eds.), Handbook of early childhood intervention (pp. 350 369). New York: Cambridge University Press.
Renard, L., & Rabouam, C. (1996). Le role del evaluation dans l intervention psychotherapeutique aupres des
jeunes enfants. In A. Geudeney & S. Lebovici (Eds.), Interventions psychotherapeutiques parents-jeunes
enfants (p. 1624). Paris: Masson.
Van de Rijit-Plooij, H. H. C., & Plooij, F. X. (1993). Distinct periods of mother infant conflict in normal development: sources of progress and germs of pathology. Journal of Child Psychology and Psychiatry 34,
229 245.
Rustin, M. (1989). Encountering primitive anxieties. In L. Miller, M. Rustin, M. Rustin, & J. Shuttleworth
(Eds.), Closely observed infants (pp. 8 21). London: Duckworth.
Rutter, M. (1995). Clinical applications of attachment concept: retrospect and prospect. Journal of Child Psychology and Psychiatry 36, 549 571.
Sameroff, A. J., & Emde, R. N. (1989). Relationship disturbances in early childhood. A developmental appraoch. New York: Basic Books.
Seligman, S. (1993). Why what you feel matters. Countertransference reactions in intervention relationships.
Whaim Newsletter 1, 1 6.

641_96-303 4/24/97 12:37 PM Page 181

(Black plate)

A. Guedeney and S. Lebovici

181

Stern, D. N. (1985). The interpersonal world of the infant. New York: Basic Books.
Stern, D. N. (1995). The motherhood constellation. New York: Basic Books.
Toedter, L., Lasker, J., & Alhadeff, J. (1988). The perinatal grief scale: Development and initial validation.
American Journal of Orthopsychiatry 58, 435 449.
van Ijzendoorn, M. H., Joffer, F., & Duyvesteyn, M. G. C. (1995). Breaking the intergenerational cycle of insecure attachment: A review of the effects of attachment-based intervention on maternal sensitivity and infant
security. Journal of Child Psychology and Psychiatry 36, 225 248.
Watanabe, I. (1992). Difficulties in Amae: A clinical perspective. Infant Mental Health Journal 13, 26 33.
Watillon-Naveau, A. (1990). Alice ou les avatards de la relation mere-fille. Devenir 1, 46 59.
Wilson, M. (1993). DSM-III and the transformation of american psychiatry. A history. American Journal of Psychiatry 150, 399 410.
Zero to Three (1994). Diagnostic classification of mental health and developmental disorders of infancy and
early childhood. Arlington, VA: National Center for Clinical Infant Programs.