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 Preface

During the week I was writing this preface, several events indicated that the field of infant mental health is
finding new inroads that previously would have been unimaginable. It began with an e-mail from a law school
faculty member, who told me that she had heard a legislator give a pitch to a diverse group of judges and
legislators about supporting early childhood development. Then, a prominent businessman called about a
group he was organizing to talk about how best to support young children. When a juvenile court judge called
me to consult about a case involving a young child that was keeping him up at night, and a psychiatry faculty
member told me that she had received a grant from a foundation to support her infant mental health
consultation in primary care, it dawned on me that any one of these conversations would have been
astonishing when this book was first published in 1993.
Today, the landscape of the field is different. Infant mental health concerns are actively being addressed by
state government officials, funders, and many judges, educators, and child health and child protection
professionals, as well as by clinicians in diverse fields. In Louisiana, for example, integration of infant mental
health principles and practice has followed concerted efforts to broaden outreach to key stakeholders beyond
mental health professionals. For the past 20 years, two Tulane faculty members have conducted 36-hour
trainings in infant mental health for non-mental-health professionals twice a year, rotating throughout
different regions of the state. For the past 4 years, we have provided training in infant mental health and
related topics to 62 established and emerging leaders in Louisiana from diverse professional backgrounds
through the Tulane Early Childhood Policy Leadership Institute. We designed this annual program to
cultivate informed early childhood champions, equipped with the necessary tools to advocate for the needs of
Louisiana’s youngest citizens. What is notable about both of these training approaches is how readily
discussions of early experiences—positive and negative—resonate with people without a professional mental
health background. Similar efforts supporting infant mental health are widespread throughout the country.
The fourth edition of the Handbook continues the basic structure and twin themes of development and
context that provided the foundation for the first three editions. In keeping with the growth of research in the
past decade, this edition incorporates far more coverage of the biological underpinnings of development in
early childhood than did previous editions. Major new developments in our understanding of risk processes
(and in some cases mechanisms) are highlighted throughout the risk section (Part II). New approaches to
assessment, the considerable advances in our understanding of early childhood psychopathology, and a
burgeoning number of evidence-based treatments are also highlighted.
Finally, the increasing application of infant mental health principles and practices is evident across diverse

8
settings beyond the mental health clinic. Translating these principles and practice is an important imperative
for the field. Nevertheless, as the field of infant mental health has won broad acceptance, questions and
controversies are arising about limits in the scope of practice beyond mental health settings. Part VI of this
volume describes a number of models of consultation to child care and primary care, and incorporation of
infant mental health into home visiting. But questions remain about whether the activities of teachers,
primary care providers, and home visitors (not to mention early interventionists, child protection workers,
judges and attorneys, etc.) constitute infant mental health practice. The boundaries and practice expectations
of various non-mental-health disciplines are not always clear.
Many people were involved in seeing this book to completion. First and foremost, the authors, many of
whom are my personal heroes, agreed to undertake their contributions even though they are all incredibly busy
and overcommitted. Each chapter that arrived in my inbox felt like a gift and taught me a great deal. I am
forever indebted to the generativity and scholarship of these authors. I credit them and the work they review
as providing the substantive basis for the field that is now approaching broad acceptance.
Seymour Weingarten and the group at The Guilford Press are responsible for initiating the Handbook
originally and supporting it through four editions. Kitty Moore nurtured each edition from conceptualization
through final product with unfailing support and plenty of sage advice. Carolyn Graham also has cheerfully
assisted with this and all of the previous editions. Judith Grauman, Managing Editor, and Laura Specht
Patchkofsky, Senior Production Editor, shepherded this edition through the entire production process.
Third, I remain prouder than ever of the faculty, staff, and trainees at Tulane—those who are authors in
this volume, as well as those who are not. They are ever the best—regularly informing and inspiring me. Their
work has accomplished more than I could have imagined—locally, regionally, nationally, and internationally.
Being on the inside, I witness every week small, unrecognized feats of commitment to the well-being of young
children and their families that my colleagues undertake through service, research, and training.
And finally, as always, I thank Paula, Emily, Matt, Katy, Sue, and Mel for everything. And Henry, Clare,
and Ruby—thanks for reminding me why this work is so important and so enjoyable.

CHARLES H. ZEANAH, JR.

9
 Contents

Title Page

Copyright Page

About the Editor

Contributors

Preface

PART I. DEVELOPMENT AND CONTEXT

1 Infant Mental Health: The Science of Early Experience

Charles H. Zeanah, Jr., and Paula Doyle Zeanah

2 Pregnancy and Infant Mental Health

Arietta Slade and Lois S. Sadler

3 Neurobiology of Fetal and Infant Development: Implications for Infant Mental Health

Anne E. Berens and Charles A. Nelson

4 Genetic and Epigenetic Processes in Infant Mental Health

Andrew R. Dismukes, Elizabeth A. Shirtcliff, and Stacy S. Drury

5 The Neurobiology of Stress and Adversity in Infancy

Stephanie F. Thompson, Cara J. Kiff, and Katie A. McLaughlin

6 Infant Social and Emotional Development: Emerging Competence in a Relational Context

Katherine L. Rosenblum, Carolyn J. Dayton, and Maria Muzik

7 Emerging Executive Functions in Early Childhood

Jennifer M. McDermott and Nathan A. Fox

8 Wounds from the Past: Integrating Historical Trauma into a Multicultural Infant Mental Health Framework

Chandra Michiko Ghosh Ippen

PART II. RISK AND PROTECTIVE FACTORS

10
9 Poverty, Early Experience, and Brain Development
Luciane R. Piccolo and Kimberly G. Noble

10 Postnatal Depression and Young Children’s Development

Lynne Murray, Sarah Halligan, and Peter Cooper

11 Parental Substance Abuse

Neil W. Boris, Kimberly Renk, Amanda Lowell, and Ellen Kolomeyer

12 Prematurity: Identifying Risks and Promoting Resilience

Prachi E. Shah, Joy Browne, and Julie Poehlmann-Tynan

13 The Effects of Violent Experiences on Infants and Young Children

Daniel S. Schechter, Erica Willheim, Francesca Suardi, and Sandra Rusconi Serpa

14 Neglect

Kathryn L. Humphreys, Lucy S. King, and Ian H. Gotlib

PART III. ASSESSMENT

15 Caregiver Report Measures of Early Childhood Social–Emotional Functioning

Leandra Godoy, Annie Davis, Amy Heberle, Margaret Briggs-Gowan, and Alice S. Carter

16 Assessing the Relational Context of Infants and Young Children

Julie A. Larrieu, Melissa A. Middleton, Anna C. Kelley, and Charles H. Zeanah, Jr.

PART IV. PSYCHOPATHOLOGY

17 Hyperactivity, Impulsivity, and Inattention in Young Children

Mary Margaret Gleason and Kathryn L. Humphreys

18 Autism Spectrum Disorder

Marianne L. Barton and Julia Chen

19 Sensory Overresponsivity

Timothy W. Soto, Vivian M. Ciaramitaro, and Alice S. Carter

20 Communication Disorders in Infants and Toddlers

Meredith Saletta and Jennifer Windsor

21 Intellectual Disabilities

Robert M. Hodapp and Elisabeth M. Dykens

22 Sleep Disorders
Judith Owens and Melissa M. Burnham

23 Eating and Feeding Disorders in Early Childhood

Miri Keren

24 Developmental Emergence of Disruptive Behaviors Beginning in Infancy: Delineating Normal–Abnormal Boundaries to

Enhance Early Identification

11
 Dorota Biedzio and Lauren Wakschlag

25 Depression in Early Childhood

Joan L. Luby and Diana Whalen

26 Posttraumatic Stress Disorder in Young Children

Devi Miron and Whitney Sturdy

27 Attachment Disorders in Early Childhood

Julianna Finelli, Charles H. Zeanah, Jr., and Anna T. Smyke

28 Relationship-Specific Disorder of Early Childhood

Charles H. Zeanah, Jr., and Alicia F. Lieberman

PART V. INTERVENTION

29 Child–Parent Psychotherapy: A Trauma-Informed Treatment for Young Children and Their Caregivers
Alicia F. Lieberman, Miriam Hernandez Dimmler, and Chandra Michiko Ghosh Ippen

30 The Circle of Security

Joe Coyne, Bert Powell, Kent Hoffman, and Glen Cooper

31 Attachment and Biobehavioral Catch-Up

Mary Dozier and Kristin Bernard

32 Reflections on the Mirror: On Video Feedback to Promote Positive Parenting and Infant Mental Health

Marian J. Bakermans-Kranenburg, Femmie Juffer, and Marinus H. van IJzendoorn

33 Parent–Child Interaction Therapy

Monica Stevens and Amanda N’zi

34 Foster Care in Early Childhood

Anna T. Smyke and Angela S. Breidenstine

PART VI. APPLICATIONS OF INFANT MENTAL HEALTH

35 Infant and Early Childhood Mental Health Training: Updates, New Directions

Sarah Hinshaw-Fuselier, Paula Doyle Zeanah, and Julie A. Larrieu

36 Infant Mental Health in Primary Care

Mary Margaret Gleason

37 Child Care and Early Education as Contexts for Infant Mental Health

Allison Boothe Trigg and Angela W. Keyes

38 Infant Mental Health and Home Visiting: Needs, Approaches, Opportunities, and Cautions

Paula Doyle Zeanah and Jon Korfmacher

39 Investing in Early Childhood Development and Infant Mental Health

Geoffrey A. Nagle

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Author Index

Subject Index

About Guilford Press

Discover Related Guilford Books

13
 PART I

DEVELOPMENT AND CONTEXT

Two overarching concerns of infant mental health are the twin themes of development and context, and these
are the topics of this initial section. In keeping with the essence of infant mental health, these themes
underscore how infants become who they are gradually by developing within multiple contexts, with which
they transact over time, influencing contexts and being influenced by them. Contexts range from the intrinsic
contexts of the infant’s own genetics and neurobiology to the external contexts of parents, families, culture,
class, and historical epoch.
For clinicians, of particular interest are those contexts that are mutable. These become the focus for efforts
to reduce risk processes, mobilize protective processes, and enhance infant competence. The most crucial and
experience-near of these mutable contexts is the primary caregiving relationship of the young child. The
relationship itself, of course, is powerfully affected by all of the other contexts. Because of its importance to the
young child, the primary caregiving relationship (or relationships) is the major focus of assessment and
intervention in infant mental health.
In Chapter 1, Zeanah and Zeanah assert that infant mental health is the clinical science of early experiences;
that is, increasing evidence suggests that for good or for ill, experiences shape the developing brain and
potentially all other developmental domains. Therefore, infant mental health clinicians become crucial in the
effort to change young children’s developing trajectories from maladaptive to adaptive by changing the
relationships they have with caregivers. In this chapter, they consider how infant mental health is defined,
review its guiding principles and empirical foundations, and present a public health model to characterize
different levels and types of interventions, from health promotion to preventive interventions to treatment.
To begin considering context, in Chapter 2, Slade and Sadler review the psychology and psychopathology
of pregnancy, emphasizing it as the first psychological and biological context for infant development and
where the relationship with the baby begins. They remind us that the personal, relational, and social contexts
of the pregnancy all matter greatly to a woman’s psychological experience of and acceptance of the pregnancy.
These distinct circumstances establish the context for the emerging relationship with the baby. Slade and
Sadler consider crucial features of prenatal representations of the baby, such as reflective functioning,
mirroring, and empathy, and the early development of the caregiving system. Throughout, they emphasize
pregnancy both as a vital developmental phase for the woman and as a period of clinical importance, and they
highlight some approaches that have been useful interventions during pregnancy and in the perinatal period.
In Chapter 3, Berens and Nelson review the neurobiology of brain development from embryology through
myelination of circuits. They identify numerous influences on that process and highlight the importance of
neural plasticity. Human brain development depends on input that in some cases is linked to sensitive periods,
and they consider how conditions of adversity may compromise brain functioning and brain development—
and they note the urgency of providing children with healthy caregiving environments as early as possible to
ensure healthy brain development. They conclude by reminding us that although the human brain develops
over several decades, a concentration of “sensitive periods” early in life explains why experiences during
pregnancy and early infancy have substantial implications for the subsequent emergence of adaptive and

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maladaptive behavior.
In Chapter 4, Dismukes, Shirtcliff, and Drury review the implications of contemporary research in genetics
and epigenetics on infant mental health. They illustrate various ways that cellular and molecular regulatory
processes transact with environmental conditions across development, with a focus on experiences in the
earliest years of life. This is one of the most promising areas of contemporary research on mechanisms
involved in determining the kinds of trajectories that propel young children toward adaptive or maladaptive
outcomes. They highlight some of the vital questions about how caregiving relationships, and interventions
designed to enhance them, may have different effects on different levels of genetic and epigenetic processes,
and why better understanding these effects will enhance our ability to intervene more successfully.
In Chapter 5, Thompson, Kiff, and McLaughlin summarize what is known from research on the
neurobiological systems that respond to stress in infancy—including endocrine pathways such as the
hypothalamic–pituitary–adrenal axis and autonomic nervous system pathways including the sympathetic and
parasympathetic nervous systems. After considering normative responses within expectable environments,
they then consider how adverse experiences have uniquely powerful effects on stress response systems. They
remind us that efforts to develop “biomarkers” of early adversity may provide more specificity in identifying
young children most at risk for the emergence of psychopathology, predictive or causal pathways, and tracking
effectiveness of interventions. They conclude by considering developmental changes in stress responses,
evidence of individual differences and protective effects, and potential buffering or moderating effects on these
systems.
Following these chapters’ attention to biological context, in Chapter 6, Rosenblum, Dayton, and Muzik
move to the level of the infant–caregiver relationship and the development of emotional and social
competence within the first 3 years of life. Highlighting complex transactions between infant and parent
across multiple interrelated contexts, they emphasize the centrality of the parent–infant relationship as the
crux of the dynamic developmental interplay of transactions impacting infant development. They note that
social–emotional competence emerges from the interplay of complex transactions across maturational,
environmental, biological, and interpersonal contexts. Infant mental health embraces assessing and
intervening with the infants and caregivers within this relational context and provides multiple opportunities
for enhancing infant development.
Moving from the social and emotional to the cognitive domains of infants and young children, McDermott
and Fox, Chapter 7, consider how early experiences affect the subsequent emergence of executive functions, an
increasingly important set of cognitive skills linked to later academic success and social competence. Although
executive functions are measured more reliably after early childhood, increasing evidence documents that
antecedent experiences may enhance or impede the healthy development of these cognitive abilities. The note
that there remains much to be learned in this important area, especially regarding which experiences at which
times are most importance for which skills. Research progress in these areas will be critical to developing more
effective interventions.
In Chapter 8, Ghosh Ippen reminds us about the considerable importance of cultural differences for not
only infant development but also the transactions that occur between families and infant mental health
clinicians. She illustrates how everyday experiences in the lives of young children and their caregivers may be
shaped in part by historical traumas that invisibly but powerfully affect how caregivers understand and
respond to their children. She makes a compelling case for clinicians to become better at bringing cultural-
historical experiences into the clinical arena through careful listening and observing to enhance our ability to
connect meaningfully with families of young children. She concludes by encouraging us to affirm the strengths
and values in families’ cultural histories and to support their efforts to draw on ancestral wisdom as guides to
understanding and responding to the needs of young children.

15
 CHAPTER 1

Infant Mental Health

The Clinical Science of Early Experience

Charles H. Zeanah, Jr.

Paula Doyle Zeanah

Infant mental health emerged as an important and visible clinical undertaking during the latter decades of
the 20th century. In the late 1960s, two important papers appeared—one from basic developmental research
and the other from psychoanalysis—each of which anticipated the subsequent emergence of contemporary
infant mental health. R. Q. Bell (1968) published a paper asserting that infants have powerful effects on their
caregivers, in contrast to the prevailing view of parent-to-child effects that dominated thinking at the time.
This point of view anticipated much of the work on infant competence and abilities (e.g., Brazelton, 1973), as
well the power of infants to elicit responses from their caregivers (e.g., Stern, 1977). In a second paper
published at nearly the same time, Escalona (1967) transcended the nature–nurture debate by declaring that
what matters is not so much infant characteristics or environmental characteristics but rather the infant’s
experience (our emphasis) of the world. This focus on experience anticipated our current understanding of
brain development, in which experience sculpts the details of circuitry that build on a basic, genetically
programmed blueprint (see Berens & Nelson, Chapter 3, this volume). More importantly, this emphasis also
highlighted the essence of the clinical efforts to appreciate the experience of the young child in relational
contexts.
Now in the early 21st century, infant mental health stands as a broad-based, multidisciplinary, and
international effort to enhance the social and emotional well-being of young children, and includes the efforts
of clinicians, researchers, and policymakers. Still, some express puzzlement or even aversion to the term
“infant mental health.” The idea of an “infant,” with its associations of innocence, beginnings, and hope for a
better future, does not seem to fit with “mental health,” and its associations of maladjustment, stigma, and
major mental illness. Is it reasonable to think of infants as having mental health problems? Or, does it make
more sense to think about them as being at risk for later emerging problems? There are also questions about
infant mental health as a profession. In a multidisciplinary field, how is core knowledge versus specialized
knowledge determined? Are infant mental health interventions qualitatively different from mental health
interventions for older children and adolescents? And how are infant mental health approaches similar to and
distinct from those of other, closely related fields that engage in services, education, and/or research for young
children and their families, such as pediatrics, early childhood education, or developmental psychopathology?
Finally, as the field has grown, the implications of the science of infant mental health for policy, legislation,
and service delivery have become more urgent and more complex.
We begin by defining infant mental health and considering its scope. We suggest that the centrality of the
relational framework of infant mental health distinguishes it from work with older children and adolescents.
We review some of the major empirical foundations of the field, highlighting the implications of these
foundations for an infant mental health perspective. Finally, we emphasize the need for comprehensive

16
approaches to intervention and highlight some evidence-based programs. Throughout, we emphasize
experience in the early years as a central focus of this work.

DEFINING INFANT MENTAL HEALTH

The generally accepted definition of infant mental health describes it a characteristic of the child: “the young
child’s capacity to experience, regulate, and express emotions, form close and secure relationships, and explore
the environment and learn. All of these capacities will be best accomplished within the context of the
caregiving environment that includes family, community, and cultural expectations for young children.
Developing these capacities is synonymous with healthy social and emotional development” (Zero to Three,
2001).
We also must consider what we mean by the term “infant.” In pediatrics, “infant” usually refers to the first
year of life. In mental health, there is a tradition that “infant” refers more broadly to the first 3 years. In this
chapter and book, however, we use an even broader conceptualization. First, as famously declared in From
Neurons to Neighborhoods (National Research Council and Institute of Medicine, 2000), focusing
disproportionately on birth to 3 years “begins too late and ends too soon” (p. 7). Therefore, prenatal
experience ought to be included within our conceptualization of infant mental health. There is now
considerable evidence regarding prenatal influences on many clinical problems in early childhood (see Kim,
Bale, & Epperson, 2015; Robinson et al., 2008). We also extend the upper age limit from 3 to 5 (or so) years, as
much research and many clinical programs extend somewhat beyond the first 3 years.
In addition, infant mental health may be defined as a multidisciplinary professional field of inquiry,
practice, and policy concerned with alleviating suffering and enhancing the social and emotional competence
of young children. Infant mental health is multidisciplinary because the complex, interrelated nature of
human development and its deviations requires expertise and conceptualizations beyond the capabilities of
any particular discipline. For the same reason, it is likely that the field of infant mental health will remain a
pluralistic subspecialty within a number of different disciplines, rather than an integrated and distinct
discipline itself, although some graduate programs conferring degrees in infant mental health have appeared.

GUIDING PRINCIPLES OF INFANT MENTAL HEALTH

Given that infant mental health encompasses foundational research and clinical practice from across
disciplines, it is important to consider basic guiding principles that underlie the clinical practice of infant
mental health. These include a relational framework for assessment and intervention, a focus on strengths in
infants and families, and a prevention orientation.
Infant–caregiver relationships are the primary focus of assessment and intervention efforts in infant mental
health, not only because infants are so dependent on their caregiving contexts but also because infant
competence may vary widely in different relationships. From an infant mental health perspective, a clinical
focus on parental behavior or on infant behavior is not an end in and of itself but rather an effort to change the
relationship.
Infant mental health is a strengths-based discipline. This means that clinicians work to identify strengths
from which to build competence and address problems. One could rightly argue that all mental health
professionals ought to work from a strengths-based perspective, but it seems especially important in a field
whose focus is on the crucial and vulnerable beginnings of parent–child relationships. Our children are
extensions of ourselves, and when they do not thrive, we experience it as a reflecting profoundly on us as
parents, especially in their early years. Nevertheless, being strengths-based does not mean ignoring liabilities
(Zeanah, 1998). Clinicians must identify problems in young children and in their parents unflinchingly in
order to address them effectively. Furthermore, there is often a complex interrelationship between strengths
and weaknesses, so that strengths may not only be obscured by weaknesses but may also be mobilized to
ameliorate weaknesses.

17
 The well-known “ghosts in the nursery” construct of Selma Fraiberg highlights that parents’ own
experiences often unwittingly intrude into their relationships with their infants (Fraiberg, Adelman, &
Shapiro, 1975). Identifying and interrupting parents’ relationship reenactments with infants of their own
previous unresolved relational conflicts are often a central focus of infant mental health intervention efforts. In
keeping with the strengths-based focus of infant mental health, Lieberman, Padrón, Van Horn, and Harris
(2005) noted that there are also “angels in the nursery.” They assert that “angels in the nursery—care-receiving
experiences characterized by intense shared affect between parent and child in which the child feels nearly
perfectly understood, accepted, and loved—provide the child with a core sense of security and self-worth that
can be drawn upon when the child becomes a parent to interrupt the cycle of maltreatment” (p. 504). Thus,
even in the context of—or perhaps especially in the context of—efforts to interrupt maladaptive relationship
repetitions, clinicians may search for islands of nurturance and trust in parents’ experiences from which to
draw strength on which to build.
Much as young infants engender hope for a better future in general, the field of infant mental health strives
to delineate, establish, and sustain positive developmental trajectories for young children. Therefore,
intervention efforts always involve prevention because the infant is constantly developing and changing, and
the infant’s developmental trajectory must be attended to, in addition to here-and-now adaptation. This
means there is a simultaneous focus on relieving here-and-now suffering, as well as attending to future
development, all through attention to primary caregiving relationships (Zeanah, Nagle, Stafford, Rice, &
Farrer, 2004; Zeanah, Stafford, & Zeanah, 2005).
As we highlight throughout this chapter, interventions with young children are an effort to change their
experiences. In all of these efforts, the empirical foundations of infant mental health have broadened and
deepened in ways that have important implications for practice and policies.

EMPIRICAL FOUNDATIONS OF INFANT MENTAL HEALTH

Basic knowledge underpinning infant mental health, including child development, developmental
psychopathology, and studies of clinical disorders and their treatment, has been bolstered by research in
genetics, neuroscience, and cellular and molecular biology. Compelling findings from seemingly disparate
lines of research reinforce and clarify clinical observations, deepen theoretical understanding, and stimulate
new efforts in clinical work, as well as policy and systems development. We highlight findings from across
lines of inquiry that provide the substantive and empirical foundations of infant mental health.

Early Experiences Matter

Considerable research has documented the importance of early experiences for the developing person. Brain
development involves a basic plan programmed by genes, but many details of brain development are
responsive to experiences. Circuits are established at an extremely rapid rate in the early years of life, and
various experiences influence not only how brains function but also the neural architecture of how they
develop. This not only confers capabilities to adapt to varied environmental circumstances, but it also means
that in adverse environments, brain development can go awry. We are only beginning to understand the
details about how experiences influence brain development, but evidence in humans on this point is growing
(see Berens & Nelson, Chapter 3, this volume).
Although mild to moderate stress can be growth promoting, serious and cumulative adversity can impair
the proper development of brain structure and functioning, which may be especially vulnerable as it develops
during early childhood (Koss & Gunnar, 2017; Sheridan & McLaughlin, 2014). If individuals develop a lower
threshold for stress, thereby becoming overly reactive to adverse experiences throughout life, both physical
and mental health can be compromised (see also Thompson, Kiff, & McLaughlin, Chapter 5, this volume).
A related question concerns the ways in which the timing of experiences matter, usually framed as a
sensitive period or critical period hypotheses. Knudsen (2004) noted that the period during which the effects
of experience on the brain are particularly strong is referred to as a “sensitive period,” and when experiences

18
provide information that is crucial for normal development and alter performance permanently, these periods
are known as “critical periods.” It is quite clear from animal literature that sensitive and critical periods in
brain development are evident (Knudsen, 2004). For example, C. Nelson and colleagues (2007) found that
children removed from institutional care in the first 3 years of life and placed in foster families, showed
increases in IQ. For children removed prior to age 24 months, the gains were substantial, but for those
removed after age 24 months, the gains were few. For a construct as complex as IQ, we would expect to find an
enormous number of circuits with different sensitive or critical periods involved. A review of many studies
indicated that there is no critical age after which recovery is no longer possible, but the sooner a child gets into
a more favorable caregiving environment, the better chance for recovery (Zeanah, Gunnar, McCall, Kreppner,
& Fox, 2011).
As noted, and in keeping with these findings, infant mental health emphasizes the importance of infant
experience. Indeed, developmental psychopathology has demonstrated that more stable individual differences
lie initially in the infant–caregiver relationship, and only later become a characteristic of the individual child.
Furthermore, how an individual thinks about relationship experiences, the internal representation or working
model, is crucial because the meanings an individual attributes to experiences may alter their consequences
(Sroufe, 1989; Sroufe & Rutter, 2000).
For infant mental health practitioners, the task is nothing less than attempting to understand what an
individual child’s experience is and helping that child’s caregivers empathically to appreciate that experience.
From a policy perspective, even more daunting is the challenge of attempting to extend this appreciation of an
infant’s experience to the level of systems, such as the child protection system or the legal system. How
different the lives of infants in dire circumstances might be if these large and complex systems better
appreciated and valued their experiences (Knitzer, 2000).

Essential Experiences Involve Caregiving Relationships

The importance of the contexts, or environments, in which infants grow and develop is well established.
Appreciating the complexities and importance of context has enhanced our understanding of infant
development and our ability to predict developmental trajectories (Sameroff & Fiese, 2000). Contexts exert
their effects from within and from without, determining which experiences an infant has, and how that infant
perceives those experiences. One of the most distinctive features of the early years is the clear importance of
multiple interrelated contexts (e.g., caregiver–infant relationship, family, cultural, social, historical) within
which infants develop. For young children, relationships with caregivers are the most important experience-
near context for infant development and are the major, distinctive focus of infant mental health.
A considerable body of research has documented the importance of the quality of the infant–caregiver
relationship and its impact on infant development (Humphreys, Zeanah, & Scheeringa, 2016; National
Research Council & Institute of Medicine, 2000). In fact, although individual differences in infant
characteristics are readily identifiable, they are not particularly predictive of characteristics later in
development. Positive qualities in infant–parent relationships, such as warmth, attentive involvement, and
sensitive resolution of distress, have been linked to more optimal social, emotional, and cognitive development
(see Rosenblum, Dayton & Muzik, Chapter 6, and McDermott & Fox, Chapter 7, this volume). In addition,
parents who promote the development of self-regulation and minimize problematic behavioral tendencies
have children who avoid maladaptive trajectories (Degnan, Henderson, Fox, & Rubin, 2008; Gardner, Sonuga-
Barke, & Sayal, 1999). Conversely, parents who have problematic relationships with their young children may
increase the likelihood of maladaptive outcomes in them (McGoron et al., 2012; Scheeringa & Zeanah, 2001).
Infant–parent relationships moderate intrinsic biological risk factors in infants (Martin, Brooks-Gunn,
Klebanov, Buka, & McCormick, 2008); that is, infants with biological difficulties such as the complications of
prematurity or difficult temperamental dispositions have better outcomes when their caregiving environments
are supportive and more problematic outcomes when their caregiving environments are less supportive. For
example, in one study, attachment relationships moderated the effects of prenatal stress on child fearfulness at
17 months, even after researchers controlled for the effects of postnatal stress, as well as obstetric, social, and

19
demographic factors (Bergman, Sarkar, Glover, & O’Connor, 2008).
Infant–parent relationships also are the conduit through which infants experience environmental risk
factors; that is, infants experience risk factors such as poverty, maternal mental illness, and partner violence
primarily through their effects on infant–parent relationships. Through their specific relationship experiences,
infants are impacted by the risk factors that characterize their caregiving environments, and relationships may
buffer or exacerbate risk. Secure attachment relationships between infants and parents significantly moderated
the relationship between parental stress and child aggressive behavior, for example (Tharner et al., 2012).
Furthermore, although infants who experienced severe deprivation were at increased risk for psychopathology
at age 4 years, this relationship was mediated by secure attachments at 3 years. The more securely attached the
child was at 42 months, the less likely that child had a diagnosable disorder at 54 months of age (McGoron et
al., 2012).
Finally, increasingly, we are learning that the way psychopathology is expressed in young children depends
on the types of relationships they have with their caregivers (Sroufe, 1989; Zeanah & Lieberman, 2016).
Research has shown that infants in fact construct different types of relationships with different caregivers (van
IJzendoorn & Wolff, 1997), they also may express symptoms in the presence of one caregiver but not with
another (Zeanah & Lieberman, 2016, and Chapter 28, this volume). And, there is evidence that how an
individual processes relationship experiences, through an internal working model, is importantly related to
outcomes (Benoit, Parker, & Zeanah, 1997; Sroufe, 1997).
For all of these reasons, the focus of infant mental health has been dominated by a relational approach. This
means that infants are best understood, assessed, and treated in the context of their primary caregiving
relationships. Or, as Sroufe (1989) put it, “most problems in the early years, while often manifest poignantly in
child behavior, are best conceptualized as relationship problems” (p. 70).
Beyond the caregiver–infant dyad, we must consider infant development in the context of the entire family.
Coparenting has emerged as an important area of investigation (see McHale & Lindhal, 2011; see also Larrieu,
Middleton, Kelley, & Zeanah, Chapter 16, this volume). Not only is infant development related to
characteristics of the family considered as a whole, but there are important effects on development as a result
of the infant’s individualized relationships with various family members (Favez, Frascarolo, Keren, & Fivaz-
Depeursinge, 2009). For example, considerable evidence indicates that the parents’ marital relationship is one
of the most important influences on child development (Cummings & Davies, 2002). Sibling influences on
infant development are less well studied, but evidence of their importance is widely recognized (Dunn, 1988).
Understanding family processes is a complex undertaking. Emde (1991) pointed out, for example, that the
number of dyadic relationships within families increases dramatically with increasing numbers of children.
Whereas two parents and one child have only three dyadic relationships to consider, two parents and three
children have 10 dyadic relationships, and two parents and five children have 21 dyadic relationships, and so
forth. Furthermore, an infant’s relationships with various family members are influenced by various other
relationships within the family. The numbers of dyadic relationships influencing relationships increase from
three for two parents and one child, to 45 for two parents and three children, to 210 for two parents and five
children (Emde, 1991). Obviously, one could also consider other levels of complexity, such as how an infant
and his or her relationships might be affected by the triadic relationship of his or her parents and another
sibling. Nevertheless, these levels of complexity are challenging to consider in research or in our clinical
conceptualizations.

Cultural Values

Beyond the immediate family of the infant, other family influences are important. Chief among these are
cultural contexts within which infants develop. Cultural beliefs and value systems define the assumptions of
the group about what is important and the rules about raising children to be a certain way (Ghosh Ippen,
2009) and carry with them influences of historical trauma, especially in non-dominant groups (see Ghosh
Ippen, Chapter 8, this volume). Parenting beliefs, explanations, and interpretations of infant behavior are
among the most important aspects of the cultural context of infant development. These beliefs include

20
sometimes subtle cultural assumptions about what facilitates infant development, the causes and amelioration
of psychopathology, the roles and relevance of parenting, and many other concerns central to infant mental
health. Cultures typically develop adaptively in response to larger environmental characteristics such as the
physical resources of the area in which the culture develops. Oftentimes, differences among cultural belief
systems may be understood within those larger contexts. In recent decades, however, increasing technological
advances have thrust different cultures together with increasing rapidity and have led to intense cultural
clashes, efforts at cultural coexistence, and pressures for cultural integration in the global village. All of these
factors have significant implications for infant development and mental health.

Supporting Developmental Trajectories

Other than prenatal development, the rapidity and profundity of development in the first 3 years of life is
unprecedented in the human life cycle. In a mere 36 months, infants change from totally dependent newborns
to complex creatures who can come and go as they please; understand that they can share thoughts, feelings
and intentions with others; express themselves abstractly using symbols; and empathize with others (Zeanah &
Zeanah, 2001). From an infant mental health perspective, this means not only thinking about where the infant
is now, but also where the infant has been and where the infant is going. It also requires understanding not
only what capacities are emerging in the developing child but also the processes involved in establishing and
changing trajectories of development.

Risk and Protective Factors

Experiences that alter developmental trajectories are created by risk and protective factors or processes. Certain
conditions or characteristics increase or decrease the risks of developmental disruptions and psychopathology.
These risk factors are used to define high-risk groups, such as infants born preterm, infants of depressed
mothers, and infants raised in institutions. On the other hand, risk factors are neither randomly distributed
nor unrelated to one another. Complex interacting risk factors within groups are the rule rather than the
exception. In other words, although intervention programs may target single risk factors, such as substance
abuse, maternal depression, or early parenthood, most of the time, infants face multiple risk factors.
Studies of many types of risk factors, from mild to severe, consistently have been shown to lead to quite
variable outcomes. In fact, it appears that the number of risk factors rather than the nature of any one is the
best predictor of outcomes (Sameroff & Fiese, 2000). For example, prenatal substance exposure is widely
accepted to be a risk factor for infant development (Boris, Renk, Lowell, & Kolomeyer, Chapter 11, this
volume). Nevertheless, Carta and colleagues (2001) studied the effects of prenatal exposure and environmental
cumulative risks. They found that although both prenatal drug exposure and cumulative environmental risk
predicted children’s developmental level and rate of growth, environmental risk accounted for more variance
in developmental trajectories than did prenatal drug exposure. In fact, over time, the effects of environmental
risk outweighed the adverse consequences of prenatal substance exposure.
Drawing on the tradition of cumulative risk studies, the Adverse Childhood Experiences (ACE) Study
examined the relation between the number of childhood risk factors and a large number of health and mental
health outcomes in adulthood. The more adverse experiences the individuals reported having before age 18
years, the more likely they were to engage in risky health behaviors and to be diagnosed with disorders such as
depression, alcoholism, substance abuse, heart disease, cancer, chronic pulmonary disease, obesity, and
diabetes, among others (Dube, Felitti, Dong, Giles, & Anda, 2003; Felitti et al., 1998). These findings remind us
that infant mental health has important implications for both physical health and mental health outcomes. In
fact, ACEs occurring in the earliest years also have been shown to have harmful near-term effects (Bright &
Thompson, 2018; Jimenez, Wade, Lin, Morrow, & Reichman, 2016; Kerker et al., 2015).
Protective factors may directly reduce the effects of risk, enhance competence, or protect the individual
against adversity (Garmezy, Masten, & Tellegen, 1984). Protective processes may operate simultaneously or
successively even within the same individual in the face of different challenges and at different points in

21
development.
As noted, infant mental health has a long tradition of focusing on strengths, and using strengths to
minimize risks. A central concern, then, for infant mental health is how to balance the influence of risk and
protective factors and their mutual effects on a child’s particular situation. In addition, in the first few years of
life, it appears that environmental risk and protective factors matter more than within-the-infant risk and
protective factors. In the Rochester Longitudinal Study, for example, highly competent infants in high-risk
environments fared worse in terms of competence at age 4 years than did less competent infants in low-risk
environments (Sameroff, Bartko, Baldwin, Baldwin, & Seifer, 1998). Thus, identifying, supporting, and
strengthening caregiver and family strengths is a fundamental principle underlying the work of infant mental
health and provides direction for policymakers interested in supporting young children.

Psychopathology May Be Evident Early

Despite increasing recognition of psychopathology in early childhood (Lyons-Ruth et al., 2017), some still ask
whether infants and toddlers can experience or express psychopathology. Psychopathology in infancy has
been the source of controversy (see von Klitzing, 2017; Zeanah et al., 2017) in part because we are reluctant to
believe that infants can experience or suffer from psychiatric disorders. Behavioral indicators of infant mental
health include emotion regulation, the ability to communicate feelings to caregivers, and active exploration of
the environment. These behaviors lay the groundwork for later social and emotional competence, readiness to
enter school, and better academic and social performance.
Psychopathology often is characterized by the inability to change and adapt, but infants constantly change
by developing. This means that infant problems must be distinguished from the large range of normal
variations in behavior and from transient perturbations in development. Obviously, one way to address this
challenge is to follow children over time and determine whether problems persist. On the other hand, it is
important to recognize that psychopathology and maladaptation may not produce static symptomatology;
rather, the manifestations of problems may be different at different times in development. For example,
indiscriminate behavior toward unfamiliar adults in early childhood has been shown to predict peer relational
disturbances in adolescence (Hodges & Tizard, 1989)—the continuity is in interpersonal disturbances, but
they manifest differently at different ages. Lawful developmental transformation of symptomatology, known
as “heterotypic continuity,” adds to the complexity of assessing psychopathology in infancy and early
childhood.
For an individual child, however, risk factors are less important than the actual development and
functioning of that child at a given time. Professionals must determine whether a given child, at a given
moment, has sufficient distress or maladaptive behavior to constitute a disorder that requires intervention.
This introduces the other approach to psychopathology in infancy, which is to consider that at least some
infant problem behaviors are signs and symptoms of psychiatric disorders. Clinicians have found categorical
diagnostic approaches to be valuable in treating young children, as they allow for conceptualizing how clusters
of symptoms hang together and provide clearer indicators of “caseness” than do dimensional scores of various
constructs.
Though some still hesitate to describe early deviant behavior as psychopathology, rather than risk for
psychopathology, there are increasingly compelling reasons to think that this is a useful approach. For
example, most would agree that autism represents a disorder, and there are compelling indicators that autism
as a disorder is evident at least as early as the second year of life (see Barton & Chen, Chapter 18, this volume).
There are almost certainly neurobiological abnormalities and behavioral differences that are evident even
before the second year, but the reliability of a categorical diagnosis of autism from about 2 years of age is
reasonable at our present state of knowledge.
New studies are beginning to show that many types of psychiatric disorders are prevalent in young
children. In the United States, a study of more than 300 2- to 5-year-old children attending pediatric clinics
found that 16% had diagnosable psychiatric disorders associated with impairment in functioning (Egger et al.,
2006). In Bucharest, Romania, a similar study of 18- to 60-month-old children determined that 8.8% had

22
psychiatric disorders (Gleason et al., 2011). In fact, 10–15% prevalence is roughly what is found with older
children and adolescents (Angold & Egger, 2007; Costello, Mustillo, Erklani, Keeler, & Angold, 2003).
There also has been progress in distinguishing transient individual differences from true psychopathology.
For example, although tantrums in young children are typical, daily tantrums are not, and prolonged and
violent tantrums are definitely non-normative (Belden, Thomson, & Luby, 2008; Wakschlag et al., 2012; see
also Biedzio & Wakschlag, Chapter 24, this volume). Also, separation anxiety as a disorder can be
differentiated from more transient separation anxiety in 2-year-old children by the degree of impairment
(Egger, 2009).
There have been a number of alternative nosologies for early childhood disorders because of developmental
insensitivity of many disorders, as defined in DSM-IV (American Psychiatric Association, 1994) and
International Classification of Diseases (ICD-10; World Health Organization, 1992). DSM-5 (American
Psychiatric Association, 2013) has made explicit efforts to be more developmentally sensitive and includes a
subtype of posttraumatic stress disorder defined for preschool children, but overall the changes are relatively
minor. Zero to Three’s (2016) alternative nosology has been recently substantially revised as DC:0–5 and is
already in use in many parts of the world. This level of activity underscores considerable interest in psychiatric
disorders in young children.
We believe that both the risk and protective factor approach of developmental psychopathology and the
categorical disorder approach of many clinical studies have merit, and both advance our understanding of
infants’ and young children’s experiences. In addition, we must concern ourselves with not only adverse
outcomes but also desired outcomes and how to achieve them.

Social Competence and Resilience

Health is sometimes defined as the absence of disease, although increasingly researchers and clinicians are
concerned with health promotion, that is, with enhancing individuals’ quality of experience. One desired
outcome for young children is social competence, the ability to adapt successfully to differing social and
environmental demands. Social competence is an ongoing adaptive capacity that itself may change over time
in relation to different stressors and situations. A focus on competence also reminds us that symptoms alone
do not make a disorder; their functional significance for the individual also must be considered. Social
competence has emerged as an increasingly important outcome in infant mental health, as well as in studies of
developmental psychopathology.
A special form of social competence receiving increasing attention is resilience, which is concerned with
infants and young children who achieve positive outcomes despite high-risk status, who maintain competent
functioning despite stressful life circumstances, and who recover from frankly traumatic events and
experiences (Masten, 2014). Increasingly, it has become clear that resilience, like competence, is a
multidimensional construct, and one that changes over time and context. In addition, it may be that rather
than being resilient to many problems, individuals may be resilient to some stressors but not be resilient to
others (Rutter, 2000).
For children in the early years, having a relationship with a caregiver who is available and responsive to
help them navigate the demands of development over time is likely to be the most important factor in helping
them achieve positive outcomes, maintain competent functioning under stress, and recover from traumatic
experiences (National Research Council & Institute of Medicine, 2000; Zeanah & Lieberman, 2016). Young
children who have the capacity to elicit support and positive responses from others may be advantaged in this
regard (Werner & Smith, 2001). Policies that support families, especially those who have limited resources,
from the time they are expecting through their child’s early years are the best ways to enhance young
children’s competent functioning (Nelson & Mann, 2011).

Some Early Problems Are Enduring

One question about problem behaviors seen in the early years is whether they are transient perturbations

23
rather than lasting disturbances. We noted recently that prospective, longitudinal studies of early childhood
psychopathology have documented links to family history, risk factors, and biological differences, and these
characteristics show patterns of continuity and discontinuity that are remarkably similar to those found in
older children and adults (Zeanah et al., 2017). In young children, social–emotional symptoms and patterns of
symptoms show persistence (i.e., homotypic and heterotypic continuities) similar to those found with older
children (Briggs-Gowan, Carter, Bosson-Heenan, Guyer, & Horwitz, 2006; Bufferd, Dougherty, Carlson, Rose,
& Klein, 2012). In fact, continuity of symptoms from early to middle childhood appear to be roughly
comparable to stability within middle childhood (Briggs-Gowan et al., 2003). As one example, a number of
studies have documented that children with concerning and impairing levels of aggression show persistence of
aggression from early to middle childhood and early adolescence (Hudziak et al., 2003; National Institute of
Child Health and Human Development Early Child Care Research Network, 2004).
These findings emphasize that it is no longer acceptable to assume that early appearing symptomatology is
always or even usually transient. Furthermore, there are reasons to believe that intervening earlier is more
effective—at least for some domains of development.
Dishion and colleagues (2008) suggested three reasons why earlier intervention may be more beneficial.
First, earlier interventions may target child behaviors before they take on a more serious form. In their focus
on externalizing problems, they argued that noncompliant and oppositional behaviors are easier to remediate
than are lying, stealing, and proactive aggression. Second, if children are younger, then parents are also
younger and may have had fewer stressful experiences and more capacity to change. Third, the sense of
optimism caregivers have regarding the possibility of parent–child relationship change is much higher during
their offspring’s early childhood.
Knudsen, Heckman, Cameron, and Shonkoff (2006) pointed out that a convergence of findings from child
development, neuroscience, and economic research indicates that greater return on investments are to be
expected when intervening earlier. Citing studies from all three areas of research, they present compelling
evidence that early intervention is more likely to be effective, providing a basis for policies that support a
broad array of early childhood initiatives. This leads us to consider various levels of early intervention
encompassed by infant mental health.

COMPREHENSIVE INTERVENTIONS ARE NEEDED

The goals of infant mental health treatment are to reduce or eliminate suffering, to prevent adverse outcomes
(school failure, delinquency, psychiatric morbidity, interpersonal isolation or conflicts, developmental delays
and deviance), and to promote healthy outcomes by enhancing social competence and resilience. In order to
accomplish these overarching goals, interventions must (1) enhance the ability of caregivers to nurture young
children effectively, (2) ensure that families in need of additional services can obtain them, and (3) increase the
ability of nonfamilial caregivers to identify, address, and prevent social–emotional problems in early
childhood. The target of intervention can be the child’s behavior, the parent’s behavior, or even the social
context in which the child is developing, but the main focus of infant mental health is on strengthening or
improving relationships as they impact the young child’s development and behavior.
Young children and their parents with relationship challenges can be identified across a number of settings,
and the level(s) of care needed can vary widely as well. Therefore, cross-disciplinary and often cross-system
collaboration is essential. In fact, in the United States, major policy initiatives in infant mental health are
evident in most states, supported by federal and/or state governments (Rosenthal & Kaye, 2005).
Figure 1.1 represents the scope of infant mental health services based on the mental health intervention
spectrum put forth by the National Research Council and Institute of Medicine (2009), and is an update of our
previous conceptualization (Zeanah et al., 2004). The National Research Council and Institute of Medicine
(2009) model extends the distinction between prevention and treatment services to include promotion as well
as maintenance services. It is important to recognize that infants and families may seek or enter services at any
point along the continuum, may need services from more than one point simultaneously, or they may move
between service levels over time. For example, when treating a young child for trauma symptoms related to a

24
life-threatening experience (treatment), additional interventions may include general education to support
normal social–emotional development (universal prevention) and interventions for the caregiver to address
emerging symptoms of anxiety or depression (indicated prevention). Provision of services at the different
levels described below vary in intensity, provider type, skill and experience required, and availability, and
examples include evidence-based approaches currently available in the field.

FIGURE 1.1. Mental health intervention spectrum. From Zeanah et al. (2004). Adapted with permission.

Promotion

Promotion is conceptualized as approaches that “enhance the individual’s ability to achieve developmentally
appropriate tasks (competence) and a positive sense of self-esteem, mastery, well-being, and social inclusion,
and strengthen their ability to cope with adversity” (National Research Council & Institute of Medicine, 2009,
p. 66). Promotion activities are aimed at the general population, do not require professional guidance or
involvement, and are useful adjuncts to all levels of prevention and intervention (see Figure 1.1). In infant
mental health, promotion includes general parenting education about early social and emotional development,
early relationship building, language and literacy development, family relationships and so forth. The
parenting education resources provided by Zero to Three (www.zerotothree.org/parenting), and the Daily
Vroom smartphone app (www.joinvroom.org/tools-and-activities) are good examples of infant mental health
approaches that draw on current science and are useful to all parents. Promotion also may include advocacy;
raising awareness; and collaborations with parents, professionals, and communities to develop networks and
resources to support optimal development (e.g., Infant Mental Health Promotion, 2016).

Preventive Interventions

Preventive interventions aim to prevent or decrease risk or causal factors before problems become apparent, to
increase protective factors, and/or to decrease the severity or duration of a disorder. In infant mental health,
the emphasis is on enhancing or altering infant and parent behaviors and family functioning in order to
preserve or restore infants to more normative developmental trajectories and to support healthy parent–infant
relationships. A report from the National Research Council and Institute of Medicine (2009; adapted from
Mrazek & Haggerty, 1994) describes three distinct levels of preventive interventions.

Universal Preventive Interventions

These interventions are considered applicable to everyone in a population and can be provided in a variety of
settings. Universal preventions are generally acceptable to members of the population, and are low cost and

25
low risk (National Research Council & Institute of Medicine, 2009, p. 66). Early child care provides one
example of a universal setting for enhancing cognitive and social–emotional development. Scarr (1998) noted
that there is an international consensus about what constitutes quality child care—warm, supportive
interactions with adults in a safe, healthy, and stimulating environment. Considerable evidence supports her
assertion. For example, the National Institute of Child Health and Human Development study of Early Child
Care is a prospective, longitudinal study designed to examine concurrent, long-term, and cumulative
influences of variations in early child care experiences of young children. In this study, 1,364 healthy full-term
newborns were recruited from 10 sites around the United States. Investigators examined what aspects of child
care are important for promoting child development across a number of domains by assessing the child, the
family, and the child care setting longitudinally. Investigators found that among child care variables, quality of
care was most important predictor of child outcomes. Quality of care is related to cognitive and language
outcomes, as well as social and behavioral outcomes in young children (National Institute of Child Health and
Human Development Early Child Care Research Network, 2005). Access to quality child care is a vitally
important universal intervention for young children and should be the focus of sustained advocacy and policy
efforts to help achieve that goal.
An important caveat was that characteristics of the parent–child relationship were better predictor of child
outcomes than any combination of child care variables (National Institute of Child Health and Human
Development Early Child Care Research Network, 2006). This does not mean that child care experiences are
unimportant. Rather, it emphasizes the importance of all caregiving relationships for young children, with
special primacy for parent–child relationships for all young children.

Selective Preventive Interventions

Interventions at this level target members of a group who have high lifetime risk or high imminent risk for
subsequent problems. Some within the group may be functioning well; others may more obviously be
struggling. Interventions focus on risks related to specific outcomes inherent in the population. Selective
interventions are delivered in a variety of settings (e.g., health, mental health, educational, or social services),
and there is a great range in the structure of such services, such as frequency or intensity, type of intervention
provided, skills or behaviors targeted, and amount of monitoring or follow-up.
A notable example of selective preventions directed at improving maternal and infant outcomes, including
the reduction of abuse and neglect, are the home visiting programs supported by the Health Services and
Research Administration’s Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. In
order to secure federal funding, MIECHV programs must meet standards of evidence and demonstrate
effectiveness in achieving benchmarked outcomes addressing maternal and child health, child development
and/or school readiness, positive parenting practices, family economic self-sufficiency, reductions in juvenile
or family violence, reductions in child abuse and neglect, and linkages to community services (Sama-Miller et
al., 2017). Not all programs target all of these outcomes, and programs vary in effectiveness in addressing the
outcomes. At present, 18 different programs meet evidentiary standards and serve approximately 160,000
parents and children in all 50 states, the District of Columbia, and five territories (Health Resources Services
Administration, n.d.-a). It is important to note that there are also a number of home visiting programs
implemented in communities that are not part of the MIECHV programs.
The MIECHV programs vary in terms of intensity, type of provider, and length of service, but all are
characterized by provider training, emphasis on fidelity of service to the model, and monitoring outcomes
(Sama-Miller et al., 2017). An exemplar of maternal-child home visiting is the Nurse–Family Partnership©
(NFP), which serves impoverished first-time mothers by providing home visits by highly trained registered
nurses in an intensive visiting schedule that begins prior to the 29th week of pregnancy and continues until the
infant turns 24 months of age. Emphasizing a relationship-based approach, nurse home visitors use
manualized guidelines to provide education, support, and referrals for these vulnerable mothers. A series of
randomized controlled trials has demonstrated NFP’s significant impact across a variety of outcomes,
including reduction in child maltreatment, reductions in serious accidental injuries in children, delays in

26
subsequent pregnancies and increased maternal employment, as well as reductions in child and maternal
criminal and antisocial behaviors as long as 15 years after program completion (Olds, Sadler, & Kitzman,
2007; Olds et al., 1998). At least two independent groups have demonstrated that NFP yields significant cost–
benefit advantages (Aos, Lieb, Mayfield, Miller, & Pennucci, 2004; Karoly, Kilburn, & Cannon, 2005).
Increasingly, programs are specifically screening for maternal depression, interpersonal violence, and
developmental delay, and research is ongoing to determine overall implementation and cost–benefit effects of
the MIECHV program (Health Resources and Services Administration, n.d.-b). The mental health challenges
in home visiting are discussed more fully by P. Zeanah and Korfmacher (Chapter 38, this volume).

Indicated Preventive Interventions

Interventions at this level are appropriate for those who manifest minimal but detectable behavioral symptoms
that may later become a full-blown disorder. For example, intrinsic infant risk factors, such as difficult
temperament, cannot be prevented, but the adverse consequences of difficult temperament, such as the
emergence of behavior problems, may be the focus of prevention efforts. Similarly, insecure, and especially
disorganized, attachments between young children and their caregivers are known to be a risk factor for
subsequent psychosocial adaptation.
Noting multiple risks associated with preschool children in foster care, especially those demonstrating
disruptive behaviors, Fisher and colleagues (Fisher, Kim, & Pears, 2009) developed an intervention based on
principles of parent management training (Forgatch & Martinez, 1999). The Early Intervention Foster Care
Program (EIFC) involved a comprehensive approach. First, foster parents received intense training followed
by support from a consultant and support and supervision through daily telephone contacts, weekly foster
parent support group meetings, and 24-hour on-call crisis intervention. The children received behavioral
interventions from trained clinicians working in preschool or day care and home-based settings. Also,
children attended weekly therapeutic playgroup sessions. A consulting psychiatrist provided necessary
medication management to address symptoms of attention-deficit/hyperactivity disorder (ADHD), anxiety,
and other disorders.
A randomized controlled trial demonstrated that children in the intervention group had significantly fewer
failed permanent placements than children in the regular foster care comparison condition. Especially
noteworthy was that the number of prior placements was positively associated with the risk of failed
permanent placements for children in the comparison condition but not for children who received the EIFC
intervention.

Treatment of Established Disorders

Treatment of existing disorders is the highest level of intervention in this conceptualization. For young
children who already have identifiable disorders, psychotherapy aimed at alleviating suffering or repairing or
remediating functioning is necessary. Most often these services are provided by mental health professionals
trained in specific infant mental health assessment and intervention techniques. Treatment of already
identified problems may be focused primarily on changing the infant (Benoit, Wang, & Zlotki, 2000), the
parent and his or her behavior (McDonough, 2000), or the infant–parent relationship (Lieberman, Van Horn,
& Ippen, 2005). Stern (1995) has argued that these different forms of intervention may use different ports of
entry into the parent–infant relationship, but all are concerned with changing the relationship as a way of
changing infant behavior and experience. Treatment of established problems is concerned with current
resolution of symptoms and distress, but there is also concern about infants’ developmental trajectories. For
these reasons, infant mental health treatments are concerned simultaneously with present and future
adaptation of the child.
An increasing number of treatments in infant mental health are supported empirically (Table 1.1), many by
randomized controlled trials. Some of these treatments derive from psychodynamic traditions (e.g., child–
parent psychotherapy and Watch, Wait and Wonder) and use parents’ representations as a primary port of

27
entry, and some derive from behavioral traditions (e.g., parent–child interaction therapy and trauma-focused
cognitive behavioral therapy) and use parent or child behavior as the primary port of entry. Some are explicitly
dyadic in format (child–parent psychotherapy and Attachment and Biobehavioral Catch-Up), whereas others
are more parent directed (e.g., Triple-P and Circle of Security).

TABLE 1.1. Some Evidenced-Based Interventions in Infant Mental Health for Children Younger Than 5 Years Old

Age range (birth to 60

Intervention Developer Primary port of entry Format months)a

Child–parent Alicia Lieberman and Parent’s representation Dyadic sessions Pregnancy through 60
psychotherapy colleagues (derived from of child supplemented by months
Selma Fraiberg and individual sessions with
colleagues) parent

Parent–child interaction Sheila Eyberg and Parent’s behavior Dyadic sessions with 24–60 months
therapy colleagues parent and child
observed by therapist
who coaches via bug in
the ear

Trauma-focused Judith Cohen and Child’s behavior Individual sessions with 36–60 months
cognitive-behavioral Anthony Mannarino; child and therapist
therapy Michael Scheeringa observed by parent and
another therapist.

Attachment and Mary Dozier and Parent’s behavior Dyadic sessions Infancy version: 6–24
Biobehavioral Catch-Up colleagues augmented by video months; toddler version:
review 25–60 months

Video Interaction Hilary Kennedy and Parent’s behavior Dyadic sessions Early infancy through 60
Guidance colleagues augmented by video months
review

Interaction Guidance Susan McDonough and Parent’s behavior Dyadic sessions Early infancy through 60
colleagues augmented by video months
review

Circle of Security Kent Hoffman, Glen Parent’s representation Group sessions or Early infancy through 60
Cooper, and Bert Powell of child individual sessions for months
parents augmented by
video review

Video-Feedback Femmie Juffer, Marian Parent’s behavior Dyadic sessions Birth through 60 months
Interaction to Promote Bakermans-Kranenberg, augmented by video
Positive Parenting and Marinus van review
IJzendoorn

Watch, Wait and Elizabeth Muir and Parent’s representation Dyadic sessions 6–30 months
Wonder colleagues of child

Triple P—Positive Matt Sanders and Parent’s behavior Individual sessions with Birth through 60 months
Parenting Program colleagues parents or group
sessions with parents
a
Many of these can be used with children older than 60 months.

One striking commonality is that eight of the listed treatments explicitly use video review with parents to
augment the treatment. Video review may be used to encourage parents’ reflective functioning about the
meaning of parent and child behavior. Parents may increase their observational skills by having an
opportunity to watch behaviors that they may have been unaware of in the moment. Given that replays may be
viewed repeatedly, they allow for review of interactions in less emotionally intense moments and also allow
exploration of the reasons for intense emotional responses by parent and/or child.

Maintenance and Relationship Reconstruction

28
Although those in the field of infant mental health typically have not used the term “maintenance,” that is,
provision of services to caregivers and infants when there has been a disruption of the relationship (e.g., when
there is separation because of parental mental health or substance abuse treatment, or loss of custody because
of abuse or neglect), the clinical challenge is different than from that when help-seeking parents attend
outpatient clinics. When a young child is separated from a primary caregiver for a prolonged period, a number
of unique challenges arise, including ensuring that the child has a safe and secure alternative caregiver,
negotiating how or wheher the child is able to maintain the relationship with the primary caregiver when the
caregiver is absent, and reestablishing the relationship upon return (e.g., Zeanah & Smyke, 2005). Instead of
treatment of relationship disturbances, these situations call for reconstruction of a relationship following a
disruption, while simultaneously attending to parent and child mental health status. Maintaining mental
health stability in caregivers may be essential to ensuring well-being of young children in their care.

Challenges of Infant Mental Health Interventions

The good news about infant mental health interventions is the growing number of evidence-based
interventions across promotion, prevention, treatment, and maintenance. It is worth noting, that most of the
treatments in Table 1.1 also have been used as preventive interventions focused on high-risk status (e.g.,
maltreatment or insecure attachments) or elevated symptomatology (e.g., aggression or
inattention/overactivity). This reminds us about the overlap in the different levels of intervention and
treatment. On the other hand, interventions also share several challenges.
First, the ideal continuum of services to address the full range of needs for young children and their
families is limited by the lack of availability of trained therapists and professionals, funding, and service
priorities. A number of states are exploring reimbursement through Medicaid for services including
developmental and mental health symptoms screening, provision of mental health services in non-mental-
health settings, dyadic treatment, parenting support, and care coordination (Smith, Granja, Ekono, Robbins &
Nagarur, 2016), developing early childhood systems (Gebhard & Oser, 2012), and other creative state-level
strategies (Cohen, Gebhard, Kirwan, & Lawrence, 2009).
A second challenge is how best to involve families of young children and to incorporate their concerns into
planning and implementing services. Most parents want information about children development and
childrearing, and they seek information from many sources, yet often feel overwhelmed with the amount of
information available, mistrust or are confused by conflicting information, or may not find the resources
particularly helpful. In addition, parents want to teach others about their experiences (Zero to Three, 2016).
While engaging parents in treatment can be difficult, evidence is available regarding strategies that work
(Stewart-Brown & Schrader-McMillan, 2011).
The third, related, challenge is the impact of personal, family, cultural, professional, and organizational
values on every aspect of infant mental health. These values create explicit and implicit lenses through which
relationships are developed and understood. Families bring past experiences into services, and expectations
and readiness for change may not match those of the professional or intervention program. Furthermore, as
noted by Ghosh Ippen (Chapter 8, this volume), historical trauma is also a central concern for many families
seeking mental health services. Professionals need to recognize and address how their personal value systems
and professional perspectives impact their understanding of the dyad and have the potential to cloud
objectivity or undermine the success of the intervention. In addition, organizational and system values and
priorities frame service delivery and limits. In all cases, provider education and appropriate supervision are
essential to competent implementation of effective interventions (see Hinshaw-Fuselier, Zeanah, & Larrieu,
Chapter 35, this volume).
A fourth challenge in this multidisciplinary field is clarifying what can be done where, and by whom. Infant
mental health principles are relevant across a number of settings, activities range from promotion through
treatment, and the field needs and benefits from the efforts of professionals across disciplines. Services are
incorporated into settings that range from traditional offices to schools, child care centers, and homes, and the
lines between screening, assessment, and diagnosis, and education, support, and treatment are often blurred.

29
However, an infant mental health approach that takes into account the experiences of the infant, the parent,
and the dyad can provide a paradigm shift, especially in those for whom infant mental health is not their
primary role, and often requires significant additional training and supervision to fully integrate perspectives
into clinical work. Currently, there are many efforts to educate professionals across disciplines in various
infant mental health practices (see Hinshaw-Fuselier et al., Chapter 35, this volume) as the field rapidly evolves
to meet the needs of families and young children.
When intervention is indicated, a fifth challenge emerges: It often is not clear what works for whom. For
example, what is the best strategy for a dyad when the mother is depressed, the child is aggressive, and the
relationship is characterized by insecure attachment? Or how long should one stick with a treatment strategy
before trying something else? If multiple interventions are needed simultaneously, how much can a dyad
endure at any given point in time? These decisions may rest on the skills or interests of the provider, the place
of service (pediatric clinic, mental health office, school, home), priorities of the parent, and practical issues
such as transportation, costs, or amount of time needed for the therapy, “fit” between family and clinician, or
availability of other services. Complex circumstances, such as history of trauma, an aversive support network,
and inability to meet basic needs, create additional dilemmas for treatment. Interestingly, though many
interventions appear to have positive effects long after the intervention is concluded (e.g., Humphreys et al.,
2015; Martin et al., 2008; Olds et al., 1998), the key to long-term outcomes is not always clear: education and
information? relationship experience? timing or intensity of services? readiness of the parent or family?
Furthermore, the burgeoning number of evidence-based therapies that require significant training and
supervision can make it difficult for providers to develop and maintain skills across many therapies. Some
propose that therapies focus on key underlying issues rather than targeting specific symptoms (Marchette &
Weisz, 2017; see also Hinshaw-Fuselier, Zeanah, & Larrieu, Chapter 35, this volume).
In any case, an ongoing need in the field is to identify the components of the intervention, such as (1) the
targeted recipient; (2) methods of intervention; (3) frequency, intensity, and length of services; (4) location of
service delivery; and (5) type of service provider, and link these with anticipated, measurable outcomes
(Karoly et al., 2005). A particular need is for research that examines the impact of sequential interventions
(Mrazek & Haggerty, 1994). In developing more refined questions in intervention research, clinicians need to
work closely with researchers. The ultimate goal is for professionals to be able to select approaches that are
best suited to address an individual child’s or dyad’s particular problems and circumstances.

TABLE 1.2. Guiding Principles of Infant Mental Health

1. Infant mental health is concerned with healthy social–emotional development.

2. Relationships form the fundamental building blocks of social and emotional development:
Early experiences matter.
3. Infant–caregiver relationships provide the framework for assessment and intervention in infant mental health.
4. Infant mental health aims to identify, establish, and sustain positive developmental capacities.
5. Assessment and intervention are strengths-based:
Strengths are used to minimize risk and support parent, infant, and family competency.
6. Intervention always includes prevention:
Intervention aims to reduce distress and maladaptive behaviors in the present, and restore positive developmental trajectories and build
competence and resilience for future functioning.
7. Cultural and ethnic beliefs define assumptions about important aspects of childrearing.
8. Families must be involved in the planning and delivery of services.
9. Personal, professional, and program values permeate all aspects of infant mental health.
10. A comprehensive continuum of services is needed, and cross-system collaboration is essential:
To be effective, policies and programs must reflect and respond to the relational needs of infants.

EMERGING AREAS

A growing focus of attention of infant mental health is the impact of social and cultural mores on infant
mental health. Recognizing how culture impacts parenting remains important, and recent attention focuses on
malleable social determinants, such as poverty, the unequal distribution of power, goods and services, and

30
even environmental or climate conditions related to significant disparities in health and health outcomes
(Braveman, 2014; Braveman & Gruskin, 2003; Commission on the Social Determinants of Health, 2008).
Social conditions may directly impact the well-being of young children. One response, the Tenets of Diversity
in Infant Mental Health, developed by the Professional Development Network of the Irving Harris
Foundation (St. John, Thomas, & Norona, 2012) has stimulated discussion and education on issues such as
racism, diversity, and class on perspectives about parenting and infant mental health.
Concerns about social justice are generating discussion about reproductive justice and infant mental health.
Reproductive justice, based on the principles of every person’s right to have a child, not to have a child, and to
parent in a healthy and safe environment (Ross & Solinger, 2017, p. 9), highlights the intersection of the issues
of race, gender, and economic inequality, stigma, and access. Because these issues directly impact the care of
infants, there is interest in better understanding and incorporating a reproductive justice perspective into
infant mental health (Lauen, Henderson, White, & Kolchi, 2017).
The challenges in the field, as well as emerging areas, lead to the need for a more explicit discussion of
ethics and infant mental health. The major professions that comprise the field have their own professional
codes (e.g., psychology, medicine, social work, counseling, education) that define the conduct of the
professional with clients (patients), with other professionals, and with the public, and there are similarities and
differences among them.
Although the field of infant mental health articulates crosscutting values such as respect for human
relationships, diversity (justice), the need for appropriate supervision and training (competence), unlike
professional organizations, infant mental health does not have a body of representatives that defines ethical
practice for the field. As services become more available to a wider range of families and young children in
more diverse settings, there is a need to better articulate the range and responsibilities of professionals,
including accountability to families and accountability of services, among other issues. We expect ethics will
be a growing area of future inquiry and discussion.
Finally, the growth of infant mental health has in part been due to the recognition, via policy, of the
importance of supporting young children and their caregiving relationships. For example, alignment of the
federal MIECHV and the Early Childhood Comprehensive Services programs is providing substantial support
to states as they develop services for families of young children (Stark, Gebhard, & DiLauro, 2014). Similarly,
the child care and early education policies administered by the Office of Administration for Children and
Families provide additional support for families (Administration for Children and Families, 2017). Advocacy
for families and policy development will be central to gaining needed support for infant development for the
forseeable future (Nelson & Mann, 2011).

CONCLUSIONS

Infant mental health focuses on early experiences of infants and young children, and emphasizes the
importance of caregiving relationships as having major effects on the young child’s social and emotional
experience. Healthy caregiving relationships, which are embedded within multiple social and cultural
contexts, promote social competence in young children, and social competence is associated with adaptive
behavioral, emotional, and cognitive outcomes. The breadth of infant mental health includes clinical, research,
and policy efforts, and encompasses the theoretical perspectives and knowledge base of multiple professional
disciplines. The complexity of the problems of infants and toddlers must be matched by the
comprehensiveness of our efforts to minimize their suffering to enhance their competence.

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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN