COMPREHENSIVE
INTERVENTIONS FOR TRAUMATIZED YOUNG CHILDREN I: UTILIZING
TOUCH AND SMELL TO CREATE SOMATOSENSORY RICH EXPERIENCES,
WHICH ENHANCE INFANT DEVELOPMENT
A doctoral project submitted to the faculty of the California School Of
Professional Psychology in partial fulfillment of the requirements for the degree of
Doctor of Psychology at
Alliant International University, Los Angeles, California
By
Sara C. Abbot
June 2, 2004
i
Copyright by
Sara C. Abbot
2004
ALLIANT INTERNATIONAL UNIVERSITY Los Angeles
The doctoral project of Sara C. Abbot, directed and approved by the candidate’s
Committee, has been accepted by the Faculty of the California School of
Professional Psychology in partial fulfillment of the requirements for the Degree
of
DOCTOR OF PSYCHOLOGY
_____________
Date
Doctoral Project Committee:
_____________________________________
Leena Banerjee, Ph.D., Project Supervisor
______________________________________
Karen Finello, Ph.D., Project Consultant
ii
Dedication
To my grandparents, who always supported me and encouraged me to follow my
dreams. To my parents, for their on-going words of encouragement. To all of my
brothers and sisters, for their never ending support. To my friends, for their
patience and thoughtfulness over the years.
iii
TABLE OF CONTENTS
Dedication……………………………………………………………………………….iii
List of Appendices……………………………………………………………………….v
Acknowledgements……………………………………………………………………..vi
Vitae……………………………………………………………………………………..vii
CHAPTER I INTRODUCTION………………………………………………………..1
CHAPTER II LITERATURE REVIEW………………………………………………...3
Child Development……………………………………………………...3
Introduction to Developmental Milestones. …..……………...3
Socio-emotional Developmental Milestones………………....4
Cognitive Developmental Milestones………………….....…...6
Language Developmental Milestones ……..………………....7
Physical Developmental Milestones…………………………..9
Neurodevelopment and Maltreatment ……………………….……..10
Introduction ……………….….………………………………..10
Findings on Neurodevelopment …………………….….……10
Findings on Maltreatment and Neurodevelopment………...13
Research and Findings on Somatosensory Touch and Smell……17
Introduction …………….………………………………………17
History of the Research of Touch with Infants ……………..18
Cross Cultural Observations on Touch and Children……...20
Recent Findings on Touch……………………………………21
Findings on Use of Oils and Scent Involved with the Healing
Process…………………………………………………28
Use of Massage Across a Variety of Settings………………30
Fathers, “Grandparents,” and Massage……………………..31
Potential Mechanisms by which Touch Facilitates Positive
Outcomes………………………………………………32
Summary of Findings on Touch……………………………...37
CHAPTER III METHODS……………………………………………………………..39
Questions Asked of Field Consultants………………………………40
CHAPTER IV SUMMARY AND RECOMMENDATIONS….………………………44
Summary of Key Findings with Information from Field
Consultants…………………………………………………….44
Clinical Recommendations………..………………………………….51
Personal Process……………………………………………………...55
REFERENCES…………………………………………………………………………57
APPENDICES………………………………………………………………………….60
iv
LIST OF APPENDICES
Appendix A: Email / Phone Correspondence……………………………………...60
Appendix B: PowerPoint Presentation Slides……………………………………..68
v
Acknowledgements
First and foremost, I would like to acknowledge Dr. Leena Banerjee. She had a
vision and transformed it into a powerful program, which will positively influence
the lives of many children and offer hope where it is needed. Her constant
support and insight were an inspiration and I feel fortunate to have assisted her
in this endeavour. I would also like to acknowledge my fellow classmates,
Mackenzie Barickman, Lizeth Porras, and Brenda Van Wyck for their dedication
and hard work. Without their support and own collaborative efforts, this project
would not be complete. I would also like to thank Dr. Karen Finello for her expert
feedback and readiness to assist. Finally, I would like to acknowledge my field
consultants, Dr. Tiffany Field, Dr. Jeffery Gold, Rauni King, and Dr. Connie Lillas,
for their enthusiasm and insight, which added to the depth and potential of this
project.
vi
VITAE
October 1977
Born, Attleboro, Massachusetts
May 1999
Bachelor of Arts, Psychology
Elementary Education Certification
Gettysburg College
Gettysburg, Pennsylvania
August 2002-August 2003
Practicum Student
1736 Family Crisis Center
Redondo Beach, California
August 2003-August 2004
Predoctoral Psychology Internship
1736 Family Crisis Center
Redondo Beach, California
May 2004 – Present
Psychological Assistantship
Advantage Psychological Services
Los Angeles, California
September 2004-August 2005
Predoctoral Psychology Internship
Los Angeles Child Guidance Clinic
Los Angeles, California
vii
Chapter I
Introduction
This project focuses on the development of comprehensive interventions
for maltreated and traumatized children, birth to age three. The following section
depicts the motivation behind this project as well as essential background
information pertinent to understanding the current research.
As this is a
collaborative piece, additional work utilizing the same model will be referenced.
This collaborative effort is aimed at gathering research for the
establishment of a comprehensive program for abused and neglected infants and
toddlers as conceptualized in Comprehensive Interventions for Traumatized
Young Children (Banerjee, 2004). The focus is on building resiliency in this
population. This means accounting for the effects of abuse on attachment and
development in comparison to normative development. Components include, but
are not limited to, somatosensory touch, smell and sound, attachment in terms of
psychological and interactional rupture and repair, and good transitions. The
latter includes education and facilitation of an optimal fit between child and
caregiver on a physical, social, emotional, and cognitive level.
The main components addressed in this project are somatosensory touch
and smell, with the intention of clarifying how and why these pieces fit into the
overall project. In essence, this piece will validate how touch and smell facilitate
brain stem regulation and limbic modulation in abused and neglected children,
enhancing social, physical, and emotional development.
1
Creating a sensory
enriching experience is conducive to soothing brain stem dysregulation in the
abused and neglected population of birth to three year olds (Banerjee, 2004).
This somatosensory touch review primarily focuses on massage with the children
but also incorporates a general interaction component with positive, consistent
experiences, including holding, rocking, eye gazing, smiling, talking, and playing
within a safe and contained environment.
The other components making up this model include somatosensory
sound (Barickman, 2004), as well as findings on attachment, effects of
maltreatment, and neurodevelopment (Van Wyck, 2004). The ultimate goal is to
establish constructive internal representations and memories that counteract
prior internal defenses created from experiences of abuse and neglect. Also
there is the intention to promote the adoption of positive future socio-emotional
development. Finally, the good transitional component (Porras, 2004) is included
with the intention of allowing for a consultation with the caregivers, whether it be
biological parents, adoptive parents, foster parents, and any other adult present
and active in this child’s life. This provides an opportunity to educate and divulge
some of the interactional approaches used to create positive experiences for the
children. This would also present an opportunity to ascertain a goodness of fit
between caregiver and child. A follow-up component would be optimal in highrisk families and would include a three to five year follow-up to ensure the fit is
appropriate and provide any referrals the family requires (Banerjee, 2004).
2
Chapter II
Literature Review
Child Development
Briefly identified are the applicable developmental milestones for newborn
to
three
year
olds.
Also
included
is
information
covering
general
neurodevelopment and the impact maltreatment can have on the normative
sequences of this process. This data is pertinent to the application of the next
piece, a literature review of somatosensory touch and sound. A comprehensive
overview of current research is provided as well as components related to cross
cultural observations and the history of touch. The potential mechanisms by
which touch is believed to facilitate positive outcomes are also referred to in this
chapter.
Introduction to Developmental Milestones
There are many different aspects of child development. By exploring and
observing individual children, researchers have established general milestones
for each domain as well as how adverse external events affect these standards.
The domains included in child development are socio-emotional development,
cognitive development, language acquisition, and physical development. This
paper briefly addresses the main framework of each domain for newborns to
three year olds; however, for a more thorough report see Porras (2004).
3
Overall, it is important to note the significant role touch plays in each area
of development. Touch is how children learn about their environment. It is how
they communicate with others as well as develop a bond with their caregivers
(Caplan, 2002).
The main theorist addressed here is Erik Erikson in regard to his stages of
psychosocial development; however, each domain of development also
incorporates the works of several theorists taken from Bukatko & Daehler (1995).
It is important to bear in mind, that although categorized here, one domain can
have a direct influence on attainments in other domains. This reiterates that
each child is a whole individual with interacting components of development.
Socio-emotional Developmental Milestones
Erikson classifies the first stage, birth to two years old, as being the basic
trust versus mistrust stage. Infants are adapting through incorporation or taking
things in from their world and on some level giving back. A caregiver’s behavior
must be perceived as consistent, predictable, and reliable. When this occurs,
infants secure a sense of hope and realize that there is trust in the world. The
next stage is referred to as autonomy versus shame and doubt, this stage
includes two to four year olds. The adaptive mode for this stage entails control,
in terms of seizing things and releasing. The child is given choices and then
engages in exploration.
As each child discovers his/her environment and
interacts in the environment, he/she learns what is appropriate and acceptable
4
and what will not be tolerated. However, they do not lose their sense of will or
feeling that they can cope in the world (Bukatko & Daehler, 1995).
For infants, socio-emotional development is illustrated from their early
preference for their mother based on sensory discrimination. Throughout their
first year, they begin to smile at their caregiver, who can soon distinguish
between their infant’s expression of anger, surprise, and sadness. Reciprocal
interactions also occur between adult and child where there are clear emotional
responses from the infant. Early on, the adult usually leads these exchanges.
However, towards the end of the first year, the infant will take more initiative and
the sensitivity of the caregiver in leading and following the infant’s cues are vital
to building a solid foundation of social mirroring of feeling accepted, understood,
and responded to in a primary socio-emotional sense (Banerjee, personal
communication, 1 June, 2004). At about seven months, the child experiences
his/her first attachment episode with the caregiver (Van Wyck, 2004). These
exchanges and the attachment episode are essential determinants for the child’s
later social and emotional behavior.
At one year of age, an infant will use social references and seek out
information from the environment to determine how to respond in a given
situation. This may entail looking to their mother’s face, reading her expression,
and then acting depending upon her cues.
Towards the end of an infant’s
second year, he/she will exhibit emotions such as shame, guilt, and envy, which
reflect an understanding of complex situations and awareness of alternative
perspectives. Along with this insight comes the association between emotional
5
states and words. Toddlers will start to identify how they are feeling and at three
years old, can determine the cause of the feeling state (Bukatko & Daehler,
1995).
Cognitive Developmental Milestones
Between birth and one year of age, infants develop object permanence,
which means an understanding that when an object is hidden, it still exists. This
is usually achieved through repetitious experiences.
They also grasp an
understanding of the properties of objects such as height. They show recognition
memory, and can distinguish whether a simple stimuli has been formerly
encountered. Infants also show habituation to physical causality, meaning they
are aware of something causing something else to occur. Infants also organize
their environment based on their sensorimotor activities and positioning within
their own space as well as simple landmarks. In other words, they primarily rely
upon their own egocentric frames of reference in order to understand the layout
of their environment. From about one to one and a half years of age, children
can classify objects using common perceptual characteristics, such as things that
look alike.
For example, they can group different types of dogs together by
pointing at them (Bukatko & Daehler, 1995).
Once children reach the ages of one and a half to two and a half years,
they begin to classify objects according to thematic relations, meaning objects
that coincide with or compliment each other. They can also categorize according
to taxonomic groupings, concurring with higher-order groups.
6
At this age,
children understand simple number terms and can discriminate between
inanimate and animate objects. This leads to understanding what pretend play
entails. In regards to memory, they can recall about two stimuli after a brief
period of time. Memory strategies include naming and looking. Children at this
level also realize in a very preliminary way some general differences in visual
perspectives, meaning someone else may not visually perceive something quite
the same way (Bukatko & Daehler, 1995).
Once children are three years old, however, their understanding of visual
perspective becomes more advanced. Their understanding of their environment
is now based on cues in their surroundings. They can use landmarks, opposed
to just their own bodies, to understand spatial relationships, reaching out for cues
around them. At this point there is some beginning comprehension of counting
principals. Their recognition memory now can account for over fifty items while
their memory span can accommodate recall for three items. Three-year-olds
also begin to differentiate between mental and physical entities, that is, what
actually exists opposed to what only exists in the mind.
They can also
understand concepts of desire and pretend (Bukatko & Daehler, 1995).
Language Developmental Milestones
Newborns have been shown to prefer and be more sensitive towards
human voices, particularly their mother’s voice. They can discriminate between
the fundamental sounds, or phonemes, that make up words.
They are also
extremely sensitive to the phonemes of different languages, more so than adults,
7
and come to prefer their native language. At birth, infants are limited to crying as
a primary means of communication.
At around two months, infants can
distinguish among vowels, and begin cooing, which entails making their own
vowel-like sounds. Infants also become receptive to prosody, or the rhythms in
communication and acoustic variations. Specifically, infants prefer high-pitched,
musical speech called motherese, usually used by mothers across many diverse
cultures.
At about six months of age, this cooing becomes babbling, as the
utterances from the child incorporates both vowels and consonants together.
They also continue to prefer their own language, even unfamiliar words, as they
are familiar with patterns of sounds. Infants start to employ gestures as a means
to communicate, pointing and giving something to someone. These gestures are
also conveyed with eye contact, and may be repeated to ensure comprehension
of the listener.
From nine to twelve months of age, children say their first word, typically a
nominal. It usually refers to somebody or something important in his or her life.
On the other hand, the child’s receptive language, comprehension of words, far
exceeds the one word they can produce. At this point children can comprehend
at least fifty words. Once they are one and a half to two years old, children’s
vocabulary increases dramatically and they have a “vocabulary spurt,” learning
twenty new words a week (Bukatko & Daehler, 1995, p. 252).
In addition,
receptive language is also increasing. Toddlers soon begin to produce two-word
utterances. From two and a half to three years, children’s language acquisition
8
flourishes, as two-word utterances become several words, reflecting syntax, an
understanding of how words can be combined. Children begin to ask questions
with rising intonation, and are very inquisitive, asking many questions. They will
repeat questions, in order to confirm an answer or for memory. They will use
inflections, creating plurals and changing verb tense. They also increasingly use
negatives to convey non-existence of an object, then to reject an event, and
finally to communicate denial (Bukatko & Daehler, 1995).
Physical Developmental Milestones
During the first year of life, infants will triple in weight and double in height.
There is rapid motor skill development during this time, beginning with holding
the head upright and soon lifting up his/her head. At around four months, the
infant will be able to grasp objects in his/her hand. At six months, the infant will
sit on his/her own. Rolling, crawling, and the use of the thumb to grasp objects,
follow these actions. Around nine months, with support, the infant will stand and
demonstrates more coordination in other areas, like banging blocks together.
Around eleven months, the child will stand unassisted and in a month or so, walk
independent of assistance (Bukatko & Daehler, 1995).
During the second year of life, an infant’s fine motor skills will continue to
develop, as he/she will turn pages in a book. Infants at this age will want to drink
from a cup, scribble, and start using blocks. As the year progresses, the infant
will attempt to eat with a spoon and fork, and later in the year, ascend stairs and
throw a ball. At the age of two, a child will be able to jump, run, balance on one
9
foot, catch a ball, and eat with a spoon.
At three years old, a toddler will
alternate feet while walking up the stairs, hop, use scissors to cut paper, brush
his/her own teeth, and begin to dress him/herself without assistance from the
caregiver (Bukatko & Daehler, 1995).
Neurodevelopment and Maltreatment
Introduction
The brain is what leads us through life, creating sensory experiences and
connecting external events with internal representations. In essence, our brain
defines who we are in all respects. General brain growth, according to Perry
(2000), is outlined as a means of comparison in determining the effects of
maltreatment on a child. The abuse endured by a child is essentially captured in
the brain, which serves as a record for what occurred during each stage of
development, otherwise referred to as “neuroarcheology” (Perry, 2000, p. 2).
The understanding of neurodevelopment is essential when determining empirical
data in support of the use of touch as a healing intervention. Refer to Van Wyck
(2004) for a more comprehensive coverage of neurodevelopment and the effects
of maltreatment.
Findings on Neurodevelopment
Neurodevelopment is an intricate process as several different brain
regions organize in a hierarchical, yet interconnected fashion. The primary, yet
simplest and oldest region is the brainstem, followed by the diencephalon, the
10
limbic, and finally, the neocortex areas. At each level, an organizational process
of the neurons occurs. The specific patterns that develop reflect the experiences
that the child endured during the critical organization period of that structure.
This process begins upon conception with the fundamental portion of the brain,
the brainstem (Perry, 2000).
During a process called neurogenesis, billions of neurons are created and
upon birth, are still unorganized. During the intrauterine and perinatal periods, a
majority of the neurons migrate within the brain to their final location.
The
neurons then use microenviromental cues to determine which genes are going to
be expressed in each specific neuron. This differentiation process refers to the
maturation of the neurons as they become specialized to respond to various
neurotransmitters. These neurons are very sensitive to their environment and
the chemical signals. There are many neurons that never create connections
and essentially kill themselves in a process called apoptosis. The survival of the
neurons depends upon the environmental influences and requirements, and this
flexibility allows the brain to use what is required. This process impacts how one
experiences learning, memory, and development (Perry, 2000).
In order to send and receive signals from one another, neurons create
branches or dendrites in a process called arborization. These branches are a
direct reflection of the neural activity taking place, thus, the denser the dendrites,
the more intense and complex the incoming neural activity and neurochemical
signals. The dendrites serve as communication devices between neurons. Each
neuron has one axon, or information sender, which may have several branches,
11
and leads to the dendrites or the information-receiving portion of the neuron. The
neurons connect through synaptogenesis, or synapses. These are the spaces
between the neurons. When messages need to be sent between neurons, a
biochemical substance called a neurotransmitter is released by the presynaptic
neuron and then binds to the postsynaptic neuron.
This split second action
allows the nerve impulse to travel from one neuron to the next neuron. The
neurotransmitter directly impacts how the neuron functions and the chemical
responses that transpire, which are then passed through a chain of neurons.
These chains of neurons are created through specific growth factors, meaning
this process is regulated and connected based on genetic and environmental
cues.
The basic connection between neurons occurs during the first eight
months of life. However, based on future environmental patterns and
experiences, these connections of neurons are refined (Perry, 2000).
Each neuron has been found to release several different types of
transmitters and all axons from that neuron will release the same pattern of
transmitters. However, neurons can respond to transmitters that differ from ones
they release.
Neurotransmission is strengthened by repeated release of
neurotransmitters into the synapse.
essentially dissolves.
Without constant activity, the synapse
On the other hand, with constant active release, the
synapse is strengthened. The synapse will constantly change based on the level
of neurotransmission, a process referred to as synaptic sculpting (Perry, 2000).
During the first eight months of life there is a higher concentration of
synaptic creation.
However, as with the other processes, this one is also
12
dependent on environmental demands, meaning synapses are continuously
being created or broken. By age one and throughout childhood, the number of
synapses being unused and therefore absorbed outnumber the ones created.
There is a state of equilibrium that transpires however, whereas the synapses
reabsorbed equal that of ones being created; this state tends to dominate
throughout the lifetime.
Around the age of one, the next stage, myelination,
occurs where glial cells form a myelin sheath around the axon.
This helps
synchronize the activity of the axon and the competency of the electrochemical
transduction (Perry, 2000).
Findings on Maltreatment and Neurodevelopment
It is estimated that each year around 140,000 children are maltreated,
specifically physically abused, by caregivers. The majority of these children are
under the age of four and as a result, thousands of these children experience
multiple placements within the foster care system (Poulsen, 2002). As Perry
(2000) has found, any sort of disruption during early childhood can lead to
abnormal neurodevelopment. A neuroarcheological record of any maltreatment
the infant was experiencing at the specific time of neurodevelopment is
essentially created. The severity can be accounted for by determining when
during development the event occurred, how chronic the disruptions were, and
specifically what occurred and transpired during the adverse event. This means
that the determinants for the impact of the trauma on the developing mind are
generally the extent of the trauma and what, within the brain, was developing and
13
organizing at that time. The earlier the trauma occurred, the more severe the
impact.
A child may have the genetic potential to perform a certain action,
however, without the correct timing and environmental cues, this potential may
never be developed or expressed (Perry, 2000).
As addressed earlier, the brain develops in a hierarchal fashion, beginning
with the brain stem and then moving higher up in complexity. Within each level,
as the brain develops, it can be determined whether or not a traumatic event
occurred and the impact. For example, early on in the migration process, many
intrauterine and perinatal insults can impact the development of the brain
functioning. This could include psychotropic drug or alcohol use by the mother,
infection, and several other occurrences. As the neurons differentiate, they are
very sensitive to these environmental signals, which then impact how the
neurons function and mature. The “use it or lose it” phenomenon is when the
neurons not activated die from apoptosis (Perry, 2000, p. 6). Any sort of trauma
or maladaptive event that occurs during this time can weigh heavily on apoptosis,
as the neurons essentially kill themselves because of the lack of necessity based
on the current environmental experience.
During this period, the dendrites are
also creating a network dependent upon the activity level, determined by the
complexity of the environment or activity within the environment. These neural
connections, created in order for neurons to communicate and essentially
function in a variety of ways, respond to repeated experiences of a child.
Essentially they are refined to meet the repeated needs of that individual. The
myelination process, which transpires from age one into adolescence, is the
14
essential portion of development for more complex functioning such as walking.
Researchers can use cues, for example when a child walks, to determine the
neurological development of this child.
Any delays in walking may then be
accounted for by some interruption in the myelination process.
For infants at birth, the first level, the brainstem, must be developed, as it
is responsible for critical survival functions such as cardiovascular, thermal, and
respiratory regulation.
The neurons for the brainstem must go through this
process prior to the neurons for the cortex. If any disruptions occur, for example
neglect, which would lead to an absence of critical sensory experiences or
reoccurring abuse that would create abnormal patterns of environmental cues,
the neurodevelopmental process will be profoundly altered. The system most
directly affected will depend upon biological relativity, which refers to the area of
the brain most actively developing and organizing. Adverse events literally play a
role in how this system organizes itself due to the vulnerability of a developing
system, particularly an infant or child, opposed to an already developed system
of an adult.
The sensitive period for the brainstem is the prenatal period.
However, for the other brain area and neural system, it extends much longer
(Perry, 2000).
For children who experience severe neglect and lack important organizing
experiences, the physical, emotional, and cognitive outcomes are significant. For
example, in Spitz’s landmark studies, infants who lacked touch, died (as cited in
Perry, 2000, p. 14). In animal studies, rats raised in enriching environments, had
reportedly larger brains and more dendritic branching and synaptic density
15
opposed to rats deprived of any stimulation (as cited in Perry, 2000, p. 15). It
can be assumed that humans have a longer sensitive period than the animals
tested; however, the results are comparable as found in specific human case
examples. However, a child removed from the neglectful environment, as early
as possible, and placed in a nurturing, enriching environment, has shown
significant overall improvement opposed to the pervasive deficits found in
children who remain in the adverse environment (Perry, 2000).
It is important to note that as the brain is developing in a sequential
fashion, disruptions that occur during one stage, the brainstem or diencephalons,
may impact the organization later on of the higher areas, limbic and cortical.
These areas of the brain are taking some of their cues and receiving input from
the
brainstem
and
diencephalon.
For
these
neglected
children,
their
environmental cues are chaotic, and without predictable sensory patterns, the
neural development models this disorganization, which lacks any consistent
internal representation of the environment (Perry, 2000).
For children who experience traumatic stressors or an over-stimulation
and activation of neurochemical stimuli, neurophysiological systems counter with
a stress response. The neural systems are altered and, depending on the extent
and duration of the event, may not return to the homeostatic state prior to the
extreme external threat. However, once the threat is absent, the changes in
neural development are maladaptive (for example, Post Traumatic Stress
Disorder (PTSD) or Post Traumatic Stress Symptoms (PTSS)) (Perry, 2000). As
the neural system organization has now been impacted by the stress response,
16
as well as the functions this system influences, a child may appear hypervigilant
with poor sleep patterns in relation to a general persistent stress-response state.
These children typically concentrate on non-verbal, opposed to verbal cues in the
environment and may appear learning disabled; however, they may also
experience physiological hyperarousal and activity. This correlates to increased
muscle tone, abnormal cardiovascular regulation, and higher levels of anxiety,
which leads to a host of other effects. Again, the younger a child is, the more
likely he/she is to develop a disorder such as PTSD or PTSS than an adult who
experienced an equally traumatic event (Perry, 2000).
However, there are
factors that minimize the likelihood a child will suffer impairments in neurological
development.
These mediating factors include the nature of the event,
perception of threat, and the characteristics of the support system. On the other
hand, the longer the PTSD or PTSS goes untreated, the more adverse the long
term residual effects will be in terms of emotional, cognitive, behavioral, and
social functioning and overall physical health (Perry, 2000).
Research and Findings on Somatosensory Touch and Smell
Introduction
This section begins with the some global history that has elicited an
awareness of how fundamental touch is for all aspects of infant development. It
refers to various theories on the importance of physical interaction between
caregivers and infants. Next, there is a detailed literature review, which covers
past and current findings, relevant to the implementation of touch and smell into
17
the course of treatment and daily interactions between caregivers and children.
More specifically, the studies address infants and children who have undergone
a variety of traumas or illnesses. The research alludes to the significance of
massage in the daily routines of these infants and children in order to promote
healthy development and resiliency as well as improve socio-emotional
responses from both infant and caregiver. The final section refers to researched
biological and chemical mechanisms behind the positive findings for tactile
stimulation. This provides empirical data to support the establishment of this
program.
History of the Research of Touch with Infants
Massage has been recognized as a healing technique amongst a variety
of cultures. In India, one medical text, the Ayurveda, which dates back to the
1800 BC, referred to massage as a plausible healing method (Field, 2001). In
2000, the Journal of Neuroscience reported that when the physical attention from
a parent to infant is blocked, the architecture of the baby’s brain, specifically
memory capabilities, is negatively affected (as cited in Caplan, 2002).
Furthermore, babies who are raised in institutions that are overcrowded and
understaffed often do not develop the same intellectual capacities as other
children do because of deficient caretaker touch and personal and emotional
investment, which affects neurodevelopment. In some cases, however, lack of
physical attention results in more serious consequences. Marasmus, stemming
from the Greek root meaning ‘to waste away,’ is a condition that results in
18
physical death of infants when they are not given sufficient amounts of touch. Dr.
Rene Spitz witnessed this condition during his research on orphanages.
He
found that more then 30% of children, raised in orphanages that deprived the
children of contact and affection from a primary caretaker, didn’t survive their first
year despite food, materially hygienic surroundings, and advanced medical care
(Caplan, 2002).
James Prescott (as cited in Caplan, 2002) went on to develop the concept
of Somatosensory Affectional Deprivation (S-SAD), which refers specifically to
infants who are raised without sufficient body contact stimulation from their
mothers. S-SAD results in abnormal development and functioning of the brain.
During formative periods of brain growth certain kinds of sensory deprivation
such as a lack of touching and rocking by the mother results in incomplete or
damaged development of the neuronal system that mediates sensory
information, for instance there could be a loss of the nerve cell branches or
dendrites.
The child would then appear developmentally delayed due to the
disruption in the brain’s ability to process the sensory information, organize
muscular responses, and interact with the environment.
Infants who are not
rocked and cuddled are also at risk for incomplete development of the brain
pathways and systems that mediate pleasure, the limbic-frontal corticalcerebellar complex. The cerebellum is also part of this system and it regulates
both pain and pleasure sensations and states (Caplan, 2002).
Touch promotes the individualization process of infants and has also been
found in many cases to contribute to the physical and mental recovery of
19
children. From an object relational perspective, infants have an unintegrated
personality (Bick, 1968).
What serves to contain this is the skin, more
specifically, an external object helping the infants form a container of the
undifferentiated personality and body. Unfortunately, in many cases, a “secondskin” formation takes place, which is a disturbance in the skin container. This
later entails a confusion of identity and concepts of internal and external
boundaries, separation of self and object. For example, this may be manifested
in an infant who experiences little consistency in interrelations with her mother,
forming a “muscular type of self container” which may translate to an aggressive
infant.
The states of the child are unintegrated, a sort of disorganization in
response to helplessness.
Touch can serve as a means to reestablish and
reaffirm boundaries, specifically through establishing the identification of the selfcontainer skin (Bick, 1968).
Cross Cultural Observations on Touch and Children
Although touch is universal, various cultures differ in how it is valued and
integrated in daily life. At one time, most monarchies in France and England
practiced a “laying on of hands.” This comprised of a healing touch from royalty.
Although this practice is no longer in use, several cultures still utilize massage as
a daily routine and a beneficial, healing practice (Field, 2001). In India, New
Zealand (the Maori), Nigeria, Uganda, Bali, New Guinea, Venezuela, and Russia,
infant massage is part of the infants’ daily routine (Field, 2001). Although the
techniques may vary, there are similar intentions. In the United States, however,
20
massage has not been considered a valid source of healing by the general
medical field. Insurance companies who refuse to cover massage under basic
medical coverage reflect this stance (Field, 2001).
The way touch is integrated and accepted in communication also varies
between cultures. For example, the French frequently incorporate touch into
daily interactions amongst peers, even between young children, and family.
However, among the American majority culture, touch is discouraged. There is
not only limited touch between adults and children, but contact among peers is
not permitted and may lead to reprimand. This has manifested into self-touch,
whereas American children can be observed playing with their hair or hugging
themselves more often then French children.
The touch that does transpire
between American children is much more aggressive than other cultures (for
example, poking each other, or grabbing things away).
This aggression is
reflected in adulthood whereas in “touching” cultures, aggression levels are much
lower across the population (Field, 2001, p. 13).
Recent Findings on Touch
Utilizing somatosensory touch as a means to heal and stabilize
physiological and psychological health has been supported in the work of Tiffany
Field and colleagues (1986, 2001). Field (1986) has recognized and promoted
massage as a beneficial treatment modality particularly when working with
preterm infants. Field et al. (1986) found a 47% greater weight gain per day in
infants who were massaged for three, fifteen-minute intervals per day over the
21
course of ten days. Researchers also found that these infants showed more
mature habituation, orientation, motor, and range of state of behavior. This was
based on scores from the Brazelton Neonatal Behavior Assessment, which
consists of twenty-eight behavioral items scored on a nine-point scale, and looks
at eighteen elicited reflexes scored on a three-point scale. Also, non-biased
observers, blind to appointed group, partook in the study by observing and
documenting massaged verse control infant’s sleep/wake behaviors. Findings
showed the treatment group spent more time in active alertness during the wake
states.
The preterm massaged infants also performed better on the Bayley
Scales of Infant Development, which incorporates mental and motor scales. It is
believed that the higher scores on the Brazelton may have enhanced parental
motivation to interact with their infant, therefore accounting for increased scores
on the Bayley Scales of Infant Development (Field, 1998). At one year of age,
the treated infants were again assessed and still weighed more then the control
group. These results were also replicated overseas in studies performed in the
Philippines, where there was also a 47% increase in birth weight, Taiwan, where
both birth weight and length increased, and Israel, where the procedure utilized
the infants’ mothers as the massagers (Field, 2001).
A follow-up study by Dieter, Field, Hernandez-Reif, Emory, and Redzepi,
(2003) followed similar methods but shortened the course of the treatment. The
findings from this study reflect a five-day treatment program versus the ten-day
period previously assessed. This modification was in response to policy changes
regarding earlier discharge of pre-term infants from intermediate care nurseries.
22
The goal was to verify the beneficial results of massage after just five days,
inspiring continued use with these infants being discharged at lower birth
weights. Similar to the first study, the hypothesis that massage directly affects
weight gain was supported; in this case there was a 53% greater weight gain in
the experimental group receiving the massage treatment opposed to the control
group. It is important to note that caloric intake was controlled across groups and
therefore was not a factor in the weight gain results. Also, for each individual
infant’s calculated gestational age, birth weight was appropriate which accounts
for possible extraneous factors in terms of physiological influences. The changes
in the sleep/wake patterns were also supported in this study with the massaged
infants showing a decrease in the amount of time in sleep states but an increase
in the amount of drowsiness, developmentally more equipped to receive
supplemental stimulation to facilitate interactions with their environment. This is
most likely a direct reflection of developmental maturation in sleep/wake patterns.
Both studies have also shown how using massage as a treatment not only
promotes weight gain, but also is a cost effective method that potentially saves
thousands of dollars as infants are discharged days earlier after overall
significant improvement.
In 2001, this translated to an average savings of
$10,000 per infant if the infant was discharged approximately six days earlier, the
average modification (Field, 2001).
The Massage Therapy Protocol by Tiffany Field et al. (1986) was used in
both of these studies and is currently still considered the most appropriate
method.
This includes three, fifteen minute massages, alternating between
23
tactile stimulation, kinesthetic stimulation, then tactile stimulation (Field, 2001).
Applying moderate pressure is emphasized; otherwise light stroking may be
experienced as an uncomfortable tickling sensation (Kato & Mann, 1996).
Results are not replicated when light stroking is applied (Field, 1999; Kato &
Mann, 1996).
Another study by Field et al. (1996) researched the effects of massage
compared with rocking, in terms of social and physical development with full-term
infants of depressed mothers.
In most cases, the infants of chronically
depressed mothers will show signs of stunted growth over the first year of life.
However, the findings of this study showed the massaged infants gained weight,
suggesting that massage may be an effective technique for sustaining weight
gain. Other findings in this study pointed to temperamental and social ability
improvements, specifically a heightened response to social stimulations. Lower
stress hormones or salivary cortisol levels and urinary catecholamine levels were
found which implies lower stress levels and an enhanced ability to sooth the
infants; caregivers reported less crying. A reported increase in vagal activity and
beta waves and decrease in alpha waves occurred during the massage
treatment. This was reflected in lower stress levels and heightened alertness
and responsiveness during the massage period and later wake states. However,
following the massage treatment sleep was enhanced, something that did not
occur in the rocked infants. The infants then spent less time in active awake
states implying massage actually induces a deeper sleep opposed to rocking an
infant prior to bedtime (Field et al., 1996).
24
This method can also apply in the case of infants experiencing sleep
difficulties, primarily with sleep onset. Parents massaged their infants for 15
minutes prior to bedtime. Findings showed these children’s behavioral problems
as well as sleep onset time decreased significantly. Findings also revealed a
decrease in parental anxiety concerning the bedtime process and less difficulty
getting their infant to sleep (Field, 2001).
Not only has massage proven to be significantly helpful in weight gain and
sleep but other areas as well. One study by Schachner, Field, Hernandez-Reif,
Duarte, and Krasnegor (1998) looked at the effects of massage on atopic
dermatitis symptoms with children two to eight years old. Stress is known to
manifest in various skin ailments such as infections and allergic reactions
(Schachner et al., 1998). This is in response to peripheral vasoconstriction and
increases in cortisol levels or stress hormones in the body, which most likely
have a negative effect on the immune system. These rashes and other skin
diseases are not only uncomfortable for the children in terms of itchiness and
irritation but can also be embarrassing. This just reiterates the cycle because the
children feel insecure and have raised stress and anxiety levels, increasing
cortisol levels and therefore further increasing skin irritations. A logical response
would be to use a relaxation technique such as massage to decrease stress
hormone levels and in turn, reduce the desire to itch.
In fact, this is what
transpired; the children in the massage group of this study showed significant
clinical improvement in the severity of the atopic dermatitis based on several
25
measures. The children’s self esteem levels improved as well as overall comfort
with touch (Schachner et al., 1998).
Following an initial, relatively inexpensive, training session, parents could
perform the massage. Parental involvement also became a positive aspect of
this study. Prior to the introduction of massage, parents reported feelings of
hopelessness because of their inability to directly facilitate any progress.
However, this method provided an appropriate role in assisting their children’s
improvement, which decreased their own anxiety levels and promoted healthy
touching between parents and their children.
Parental attitude towards their
children was also impacted; post-treatment, parents reported better feelings
about their children.
Parents also perceived that their children’s stress and
anxiety levels decreased while coping levels increased throughout the treatment
period.
Finally, this was also a cost effective method.
The parents were
mandated to massage using the prescribed emollients and with the improvement
of the atopic dermatitis, fewer prescriptions were required. Also, the parents
could provide the intervention in their own home as opposed to frequent doctor
visits (Schachner et al., 1998).
Several studies have paired the massage treatment with children ages two
to twelve years old experiencing other physiological and psychological
conditions. For children with psychiatric problems, findings revealed a decrease
in levels of depression and anxiety and lower saliva cortisol levels. Nurses also
reported less anxious and more cooperative behavior, quiet sleep throughout the
night, and a decrease in urinary cortisol and norepinephrine levels (Field, 1995).
26
For children with Post Traumatic Stress Disorder (PTSD), symptoms decreased
as well as levels of anxiety and depression and reported levels of cortisol. The
children’s drawings also reflected fewer depressive and disorganized features
(Field, 1999). For children who had been abused sexually and physically, a
fifteen minute massage on a daily basis for one month led to an increase in
sleep, alertness, a decrease in touch aversion and, per the caregivers report, the
children became more active and sociable (Field, 1995).
For children with
autism, massage could be less aversive then other kinds of touch because it is
predictable. A study conducted by Field, Lasko, Mundy, & Henteleff (1994) found
that pre-school children with autism, following a massage treatment, were less
sensitive to touch, less distracted by sounds, more attentive in class, related on a
more appropriate level with their teachers, and received better scores on the
Autism Behavior Checklist.
Some other areas where massage has proven effective have been with
cocaine exposed preterm infants as well as HIV exposed infants (Scafidi & Field,
1996).
The infants showed similar improvement to the preterm neonates in
terms of increases in weight, scores on the motor and orientation portions of the
Brazelton, as well as the scores on the stress behavior scale (Field, 1995). More
specifically,
cocaine-exposed
preterm
infants
exhibited
fewer
postnatal
complications and exhibited fewer stress behaviors during the ten-day period
used in the study. Also, there was a reported 28% greater daily weight gain and
more mature motor behavior on the Brazelton exam.
HIV-exposed neonates
also exhibited greater weight gain, better performance on the orientation and
27
motor clusters of the Brazelton scale, and better performance on the stress
behavior scale (Field, 1995).
Massage studies done with healthy infants also noted significant
improvement in comparison to a control group. Even long-term effects have
been noted. The full-term infants spent more time in active alert and awake
states, demonstrated better habituation ability on the Brazelton, cried less, had
lower salivary cortisol levels, gained more weight, sustained face-to-face
interactions for longer periods, had lower levels of urinary stress hormones and
catecholamines, and had higher levels of serotonin (Field, 1995). With healthy
infants, findings also showed that massage facilitates parent-infant bonding,
reduces stress response to painful procedures, reduces pain associated with
teething and constipation, and reduces colic (Field, 1995). Other areas where
massage has proven to be an effective technique for children include burns,
cancer, blindness or deafness, developmental delays, asthma, juvenile diabetes
(Type I), eating disorders, fibromyalgia, juvenile rheumatoid arthritis, and
attention-deficit hyperactivity disorder (Field, 2001).
Findings on Use of Oils and Scent Involved with the Healing Process
There have been many positive trends in terms of the effectiveness of
massage therapy in reducing stress hormone levels, elevating moods, and
improving the overall clinical course. Field, Schanberg, Davalos, & Malphurs
(1996) incorporated the use of oil into the massage procedure. A massage with
28
oil enhanced the results, implying lower cortisol levels and increased vagal
activity when compared to a no oil massage.
Expanding on this find, there has been work done which has looked at
using scented oils in psychotherapy. These results are significant for work with
massage and infants because incorporating soothing smells into the sensory
experience could enhance the healing process.
Research recognizes the
significant relationship between olfaction and the limbic system, the portion of the
brain responsible for emotion (Olko & Turkewitz, 2001). This finding implies
significant possibilities in providing olfactory information to infants. At just a few
days old, infants respond to smells and can differentiate between certain smells,
turning towards positive odors when given a choice (Olko & Turkewitz, 2001). In
fact, infants’ threshold for olfactory information and responsiveness to chemical
stimuli increases significantly over the first few days after birth (Lipsitt, Engen, &
Kaye, 1963). Infants have even been shown to respond to very specific smells,
for example their mother’s nipples (The Smell Report, 2004).
By three years old, children are comparable to adults in terms of olfactory
preferences (The Smell Report, 2004).
This is essential when determining
whether to incorporate aromatherapy into the massage technique. Studies have
found that smells are powerful tools to activate memories and feelings associated
with that memory. It is an alternative way to link the past and the present on a
nonverbal level, which is an essential factor when working with infants. One
main question for practitioners is how to introduce specific aromas into the
therapeutic setting? One way is to utilize scented oils in massage, especially
29
since oil is proven safe for massage with infants. Specifically the lavender scent
has been shown to reduce nervous tension.
With the link between smell,
memory, and emotion, this is an essential factor when working with infants
whose olfactory systems are functioning shortly after birth.
This soothing
somatosensory experience could help create positive memories, counteracting
the trauma, which has manifested into nervous tension (La Torre, 2003). Several
studies have used anecdotal examples with adults, which is important when
considering the beneficial results aromatherapy could also have on caretakers
providing the massage.
Use of Massage Across a Variety of Settings
Although several of these findings utilize the massage technique, findings
also show that increasing the amount of initial contact a mother has with her
infant, particularly in terms of maternal touching, can be beneficial (Prodromidis
et al., 1995). The two methods compared rooming-in mothers whose infants
stayed in the hospital room with their mother vs. those who just had contact
during feeding. Results showed that the rooming-in mothers illustrated more
intimate touching behaviors with their infants and were more attuned with their
child’s particular needs for stimulation. Also, these mothers were more apt to
touch the child in intimate places on the body, like the head and face, overall
exhibiting more maternal affection.
This finding reiterates that touch allows
parents to know their child’s body better and to impart to the child that touch is
good, and that there is safety in receptivity (Caplan, 2002).
30
Positive touch (for example, handholding, smiling, hugging) is not only
important in the home but also the classroom. One study focused on touch in the
classroom between teachers and infants, toddlers, and preschoolers (Field et al.,
1994). It was observed that very little positive touch transpired between teachers
and the children, particularly as the children grew older. Findings showed that by
informing preschool nursery teachers of this finding and requesting that they
increase positive touch, it was effective in terms of increasing the amount of
positive touch between teacher and child. Observations displayed, however, that
the boys were touched more frequently than the girls in these classrooms. There
was also a correlation between parent-child touch and the amount of positive
touch between the teacher and that child. This finding is not based on these
children’s extraverted tendencies or seeking out touch, but rather the teacher
observing the appropriate contact with each student.
Fathers, “Grandparents,” and Massage
Most of the research has focused on mothers or trained professionals
as implementing the massage technique.
However, one study focused on
father’s involvement in the caregiving role by having fathers massage their
infants, who ranged from three to fourteen months old, for fifteen minutes prior to
bedtime (Cullen, Field, Esclona, & Hartshorn, 2000).
Findings showed the
interactions between father and infant in the massage group were more positive
than the control group, showing more enjoyment, responsivity, warmth, and
acceptance (Cullen et al., 2000). Caregiving responsibilities did not change for
31
this group of fathers, although fathers in the control group showed less
involvement by the completion of the study.
Another study utilized volunteer “grandparents” to implement the massage
procedure to the infants (Field et al., 1994).
This study simultaneously
addressed touch deprivation with the elderly “grandparents” as well as with the
infants, striving to decrease any touch aversions the infants may have had from
enduring sexual or physical abuse. According to Field et al, the results for the
infants showed that after one month of massage, they were more alert and
showed increased activity.
Findings also revealed that the “grandparents,”
following their participation in the massage procedure, demonstrated less
symptoms of anxiety and depression, improved mood, lower stress levels, more
social contacts, fewer trips to the doctor, fewer cups of coffee, and improved self
esteem (Field et al., 1994).
Potential Mechanisms by which Touch Facilitates Positive Outcomes
Many rationales have been offered to explain the positive effects of
massage treatment. Some of the underlying explanations indicate an interaction
between biochemical and physiological mechanisms, some occurring in
conjunction with one another. Provided here is empirical data that supports the
use of massage through explanations of the physiological/neurological changes.
An increase in protein synthesis has been shown to occur in response to
touch. Researchers have studied this phenomenon by investigating what occurs
when a mother rat licks her pups. Field cites studies done by Schanberg in
32
1994, investigating the effect of touch deprivation of rat pups (Field, 2001, p. 33).
It was found that removing the pups from their mother instigated a decrease in
the growth hormone ornithine decarboxylase. Furthermore, there was also a
decrease in the function of all bodily organs such as the heart, liver, and brain.
However, by simulating the mother’s touch (for example, using paintbrushes to
“lick” the rat pups) the physiology and biochemistry of the pups was restored.
According to Field, Schanberg and his colleagues (1994) discovered a “near
immediate gene underlying protein synthesis that responds to tactile stimulation,
suggesting genetic origins of this touch-growth relationship” (Field, 1998, p. 3).
Another explanation is based on increased motor activity.
This idea
stemmed from the observation that infants, following massage, are more active.
This phenomenon has also been found to occur in rats following exercise,
although there had been no caloric increases (Field, 2001).
Researchers have also noticed a significant increase in parasympathetic
activity, which means non-emergency functions that usually conserve energy
(Kalat, 2001). Interestingly, an important factor throughout the massage
procedure is vagal activity. This is notable because the increase in vagal nerve
activity directly affects the release and circulation of food absorption hormones,
specifically insulin, in the blood (Field, 2001). As the massage or stimulation
increases, there is a direct increase of hormones that absorb food, therefore
facilitating weight gain (Dieter, 2003).
This hypothesis was supported in the
Dieter study, which found that vagal tone increased following the massage
therapy and was linked to a 62% upsurge in the release of insulin. This could be
33
a direct proponent of weight gain in the massaged infants because the vagal
nerve is linked to the gastrointestinal tract, which could enhance gastric activity
(Field, 2001). Vagal activity also slows down the nervous system, enhancing
relaxation, reducing stress hormones, and increasing alertness, all of which
promote sleep, performance, and immune function (Field, 2001). All of these
factors are particularly pertinent to the population under age three in terms of
promoting normal development and bonding with caregivers.
Parasympathetic activity also correlates to increased ability on cognitive
tasks and alertness. This may be associated with the finding that during the
massage experience, there is a decrease in alpha waves, which also is
associated with alertness (Field, 1999).
Increase in vagal activity following
massage therapy lowers physiological arousal and stress hormones. Part of the
vagal nerve also stimulates facial expression and vocalizations, which enhances
communication and attentiveness.
Underlying mechanism for the effects of
massage may be increased parasympathetic activity; this increase may lead to
increased alertness and better performance on cognitive tasks (Field, 1999).
Several potential mechanisms currently being explored entail changes in a
variety of hormones. There has been an increase in the release and circulation
of the hormone oxytocin. In the study by Dieter, Field, Hernandez-Reif, Emory,
and Redzepi, (2003) there was a significant increase in the oxytocin hormone
levels following the tactile stimulation. Crenshaw (as cited in Caplan, 2002) also
discussed how touch alters the chemical composition of the body. She described
how peptide oxytocin increases when an individual receives nurturing physical
34
touch. Yet another biochemical mechanism influenced by massage is a hormone
directly associated with growth called Insulin-Like Growth Factor 1, or IGF-1.
IGF-1 is believed to boost metabolism and there have been correlations found
between birth weight and this hormone (Field, 2001).
Finally, the impact of
another hormone, cortisol, is also being assessed. Cortisol is a stress hormone
that decreases with tactile stimulation. Interestingly, decreases in cortisol have
been correlated with increases in oxytocin and IGF-1 (Field, 2001). Also, lower
levels of catecholamines have been reported following massage, which
correlates to decreased stress levels. Lower cortisol and norepinephrine, anxiety
and stress hormones, result not only in prevention of illness and improved health
but also in an overall sense of aliveness and well being (Caplan, 2002).
However, during the stimulation period, there have been reported increases in
these specific catecholamines, norepinephrine and epinephrine. Although these
are shown to also increase in adults under stressful situations, in neonates it is
considered healthy because a normal increase marks positive development in
infants (Field, 1998).
Reports recounted less pain for children with juvenile rheumatoid arthritis
(JRA) and severe burns who had received the massage treatment. A potential
model explaining this finding is the “gate theory.” This theory states that the
pressure receptors actually inhibit the pain messages from being received in the
spinal chord due to the pressure stimuli being processed first (Field, 1999).
Another potential theory entails increases in serotonin, which is known to relieve
pain. In conjunction with this notion, following the massages, elevated levels of
35
serotonin were found. Finally, there is the hypothesis which incorporates the
findings of improvement in restorative deep sleep in massaged children. This is
notable because a lack of deep sleep promotes the release of Substance P, a
neurotransmitter, and somatostatin, which together enhance pain (Field, 1998).
Chemical and electrophysiological changes have also appeared while
measuring frontal EEG activation. There was a transfer of activation from the
right frontal region, which is associated with “sad affect,” to the left frontal region,
associated with “happy affect.” This shift to a positive balance was reflected in
reported elevated moods post massage. EEG’s have also illustrated a decrease
in the amount of alpha wave activity during the massage, which correlates to an
increase in alertness during the treatment (Field, 1999).
Another important finding is in conjunction with the research done with
HIV-positive children (Field, 1999). Lower levels of cortisol have been found in
the massaged children. This is significant because cortisol is known to abolish
natural killer cells, which are essential components of maintaining immunity
against viral cells.
Therefore, by decreasing cortisol levels, this may also
decrease the risk of infection. This theory may also apply to cancer patients
because the natural killer cells fight cancerous cells as well.
Another interesting area being researched is brain development and how
tactile stimulation may impact this process. MRIs are being conducted on infants
following massage treatments and hypotheses predict an increase in dendritic
bifurcation in the hippocampal region. This could be important because of the
36
positive impact on the development of memory as pleasant associations form
through tactile stimulation.
Summary of Findings on Touch
With all of this research, which shows a positive trend towards utilizing
massage therapy, some ask why workers in NICUs are reluctant to adopt the
massage techniques. In fact, only 38% of NICUs have any sort of massage
therapy program in place (Dieter, Field, Hernandez-Reif, Emory, & Redzepi,
2003). A “minimal touch policy” is still a common theme on NICUs, due in some
part to previous research illustrating raised tcPO2 levels, or transcutaneous
oxygen saturation levels, following the interaction between nurses and infants.
Despite close monitoring of all of the infants in these studies, raised tcPO2 levels
were not found. However, regardless of research that disputes the raised tcPO2
levels, this policy is still maintained in several hospitals. This may also be the
case because massage is a not a technique regularly referred to in medical
textbooks and handbooks and therefore is considered taboo (Field, 2001).
Minimal touch policies extend beyond the medical community, however,
particularly in schools and daycare centers. Despite these policies, which have
been implemented to deter abuse, percentages of children abused have not
decreased (Field, 2001). Children are just being touched less, despite the many
positive implications from the use of massage with infants. There are many
physiological and psychological improvements and possible financial savings that
could be achieved from implementation of this technique into hospital settings.
37
Infant massage is invigorating to the child’s skin and thereby stimulating to
the organs and provides the child with comfort and pleasure. Massage has many
benefits including decreases in stress hormone production, decreases in pain,
increases in sleep, improved functioning of the nervous and digestive system,
and promotion of weight gain in premature infants, only to name a few. There is
however, limited current research and application of data for the birth to three
year old, maltreated population.
On the other hand, based on the negative
impact maltreatment can have on infant development (Perry, 2000), these factors
are believed to be the most important ways to promote and correct the previously
damaging experiences (Field, 2001).
Findings do show that loving and
compassionate touch can provide the unparalleled experience of soothing,
nurturing, safety and pleasure, which is essential for a maltreated population.
Because the infant has not yet entered the world of concepts and ideas,
nurturance can best be communicated through the means of touch. Massage
also allows caregivers to know their child’s body better, and to impart a message
that touch is good and that there is safety in receptivity. Another function of the
parent’s touch is to help the child to process emotions and energy. When the
child’s dependency as well as physical needs are adequately attended to, these
needs diminish as the child matures and becomes self sufficient. As Joseph
Chilton Pearce noted (cited in Caplan, 2002), the bonding that occurs between
caretaker and infant becomes the most profound measure of touch.
38
Chapter III
Methods
This project is a comprehensive literature review with clinical program
recommendations.
These recommendations are part of an overall model for
developing an intervention program for abused and neglected infants and
toddlers. In working towards completion of the project, the first step entailed a
comprehensive literature review, focusing on touch, particularly massage, and
the effects on young children.
The critical summary of the literature serves as the main focus of this
paper and provides comprehensive coverage of the research on somatosensory
touch and smell with maltreated children, primarily birth to three years old. Some
findings with older aged children are included as a means of comparison or to
provide possible trends when limited research was available for the birth to three
years old population. The goal was to critique this literature and tease out the
most promising intervention methods.
Throughout this process there was on-going interaction with Leena
Banerjee, Ph.D., who provided overall direction and feedback.
consultants were also contacted.
Four field
Tiffany Field, Ph.D., who established the
University of Miami School of Medicine, Touch Research Institute (TRI) in 1992,
is one of the leading psychologists working in the field of infant massage. The
TRI is the first institute in the world devoted solely to the study of touch and its
39
application to science and medicine. She is currently the director of the TRI and
has authored several books on massage and touch as a healing force.
In
addition, she runs various workshops on massage. Jeffrey Gold, Ph.D., is the
Clinical Assistant Professor of Pediatrics USC Keck School of Medicine,
USC/UCE Mental Health Services, and Children’s Hospital Los Angeles. He is
currently working on Magik (making aches go away in kids) Comfort and Pain
Program in the Department of Anesthesiology Critical Care Medicine.
Rauni
King, R.N., B.S.N., H.N.C., C.H.T.P/I, is the founder and planning manager at the
Scripps Center for Integrative Medicine.
She is a certified Healing Touch
practitioner and instructor, coordinating many workshops and lectures around the
United States and Europe. Connie Lillas, Ph.D. is the director at the
Interdisciplinary Training Institute Los Angeles, California as well as the Training
and Supervising Analyst at the Newport Psychoanalytic Institute and the Institute
of Contemporary Psychoanalysis. She coordinates several trainings that focus
on collaborative programs that service high-risk birth to five year olds, and their
families using assessment, diagnosis, and intervention. Each field consultant’s
feedback to my questions provided an additional perspective as well as personal
observations from their applied work in the field.
Questions Asked of Field Consultants
1. Do you work solely with hospital staff in the NICU when providing infant
massage, or do caregivers ever participate in the procedure?
40
2. I know in the past there have been limited touch policies, especially in
NICUs, how does this impact your work? Have you found there is
an acceptance of massage as a beneficial, healing intervention or
prevention measure? If so, by whom?
3. What
kinds
of
changes
have
you
witnessed
between
caregivers/massagers and infants/toddlers following the use of massage?
Have you observed differences in response from an infant when different
adults massage him/her?
4. Do you adapt your massage technique when working with infants opposed
to older children? In what ways?
5. Have you found any programs that incorporate massage in the NICU, and
then encourage the continued use of massage once the infant exits the
hospital? If so, have you found any differences in the long-term healing
process?
6. In working with this population, what do you believe are some of the most
influential underlying biochemical and physiological explanations for the
benefits of massage? For my own understanding of the biochemical
procedure: During the massage session, infants spend more time in active
alert states and parasympathetic activity has been known to increase.
Also, alpha levels decrease. However, directly following the massage the
infants are more likely (than infants who were rocked) to fall into a deeper
sleep. Can this be explained by: during the massage the infants are being
stimulated which leads to decreases in alpha levels and therefore
41
increased alertness. However, once that stimulation stops, the cortisol
levels are still lower and there is increased parasympathetic activity,
leading
the
alpha
levels
to increase
and
therefore
promoting a
deep sleep?
7. What types of psychological changes are most prevalent?
8. How do you translate these findings to parents/caregivers?
9. Some researchers have found in massaged infants an increase in
dendritic arborization in hippocampal regions. This is then hypothesized
to have a positive influence on memory performance. Has there been any
further research, perhaps long-term studies, in this domain? Have any of
the programs with adults found similar results?
10. Have you ever paired massage with other somatosensory experiences,
such as sound? Our intention is to create a somatosensory rich
experience. With the findings on neurodevelopment and memory, what
kinds of long-term effects could this type of experience have on an infant?
11. Researchers have found there are also positive effects in terms of
decreasing stress and depression levels in those providing the massage.
Has there been any research that has looked at any neurological effects
on caregivers or those providing the massage? What would you predict
findings would show?
12. In what direction do you believe future research with massage and/or this
population should go?
13. What first inspired you to incorporate touch into the healing process?
42
14. What advice would you offer to the caregivers implementing the massage
into their daily routines with their children?
A prelim oral was connected to gather feedback on the project at the mid-way
point.
Both Leena Banerjee, Ph.D. and academic consultant Karen Finello,
Ph.D. were in attendance along with each student, who provided the various
components. This provisional meeting allowed for a professional review and
critique of the material as well as additional resources.
The project was
concluded with final reviews from Dr. Banerjee and Dr. Finello. The findings were
summarized in a Power Point presentation (see Appendix B) that will be available
for professionals at local and/or national seminars as well as clinical settings.
43
Chapter IV
Summary and Recommendations
Summary of Key Findings with Information from Field Consultants
For infants, touch serves as a primary factor in developing self-awareness
and exploring and making sense of the environment. A fundamental experience
for building security and bonding with a caregiver is through multiple forms of
healthy touch and communication. For a child who has been abused or
neglected, his/her early sense of security may be diminished due to either the
absence of sensory input or the repeated patterns of unpredictable, intrusive,
invasive, or otherwise unhealthy interactions. Development during these early
years of life is very susceptible and sensitive to these positive or negative
experiences (Perry, 2000).
Therefore, any maltreatment can have grave
implications on an infant’s biological and psychological growth. Without early
interventions, this population is at a high risk for severe neurological and
psychological impairments. For example, PTSD is prevalent in this population
and becomes more severe the longer it is untreated (Perry, 2000). Also, these
children lack a healthy attachment to a caregiver, in most cases, which affects all
future relationships (Van Wyck, 2004).
Touch can become associated with
negative experiences and as a result, the child may have a negative or avoidant
reaction to human contact.
Without correcting this experience, life may be
devoid of a primitive sense of security. Considering the pertinent role touch plays
in this process, there is a diminished potential for normal development. Many
44
presume little can be done to amend the damage.
However, there is hope.
Creating experiences that provide enriching sensory experiences can directly
affect the development of mind and body.
These children can thrive with
nurturing interventions, designed to stimulate regulation and healing.
We do not experience the world in isolation, but rather we are inundated
with information, thus creating a more comprehensive image. Infants rely on
sensory experiences and repetition to learn, and soon start accumulating
memories (Bukatko & Daehler, 1995). However, without well-developed motor or
verbal skills, they must depend upon and endure what a caregiver provides. If a
caregiver creates a sensory rich experience by pairing positive touch, pleasant
smells, and soothing sounds, this does, in essence, create the most stimulating
and pleasing environment an infant could ever experience and tolerate.
It
provides an environment conducive to normal development in terms of neuronal
growth, biological stability, and psychological soothing.
On the other hand,
damage may have been done if a child has endured abuse at an early stage in
life, impairing development. However, neural pathways are still developing and
day-to-day experiences still have significant impact, as neural pathways are
being fine-tuned for current and future use (Perry, 2000). This creates a window
of opportunity for corrective experiences and early interventions.
Many maltreated children will frequently change caregivers who may
hesitate to interact on an intimate basis with a previously abused child. In the
American culture, touch is especially discouraged, particularly with non-parental
figures. This is evident by the limited-touch policies across several domains like
45
NICUs, schools, and daycare centers. Changes are being made in some NICUs,
but they are slow because it is like “introducing a new culture” into already wellestablished, long-standing medical programs (J. Gold, personal communication,
1 June, 2004). The child then remains unaccustomed to the healing benefits of
touch.
With the maltreated young population, massage serves an essential
purpose.
The child can learn how to tolerate being touched and how to
communicate and bond with someone through his/her body. A caregiver learns
about healthy touch and can learn about the child and become attuned to the
child through this non-verbal modality.
applied.
This is exemplified in the techniques
For example, if the strokes used are too light, it is experienced as
tickling, and the infant responds negatively.
However, with slightly harder
strokes, the infant is able to relax (Field, 1998). The caregiver must remain
cognizant and attuned to these cues and adapt their touch based on how the
infant guides the massage.
As is true of anyone maltreated, these children have high stress hormone
levels, which increases muscle tenseness. A caregiver who is familiar with the
child and familiar with his/her body can use touch to relax the muscles, which
decreases cortisol levels. Touch can also serve as an indicator or cue to the
child, who can become cognizant of when their body is tense opposed to relaxed.
Touch serves as a tool as well as an intervention. The children can begin to
identify their physical boundaries through touch against their skin and learn to
trust and relax their bodies. Caregivers discover a way to actively care for their
child through non-verbal intimacy. Once a child is aware and more attuned with
46
his/her own body, it will be easier in the future for the same child to self-regulate
and self-sooth and be calmed by external touch from a caregiver. With this
sense of security and attunement, children will be better able to regulate
interactions with others.
Paired with other sensory rich memories and
experiences such as smell and sound (Barickman, 2004), this intervention has
the potential to heal the child and nurture resiliency as he/she enters the world
with more self-awareness and coping skills (Field, 2001).
Research has focused on isolated programs that incorporate tactile
stimulation into a short period of time. For maltreated children, programs that
could encourage stable, long-term implementation of massage across caregivers
would be most beneficial, especially with a population constantly relocating. For
a portion of maltreated children, the abuse or neglect may have begun as early
as the womb. As a result, a percentage of the children spend time in the NICU.
Therefore, a potential place to develop this type of program would be in NICUs
where caregivers could then be encouraged to maintain the massage regimen at
home. As Tiffany Field reported, these programs are in place in England where
massage is more accepted as a viable source of healing (T. Field, personal
communication, 19 April, 2004).
On the other hand, it is important to look at programs already in place in
the NICUs. When a human being, either adult or child, is under strain related to
environmental factors, similar underling mechanisms exist.
In the NICUs, a
majority of children may also have high cortisol levels and present with similar
conditions to the abused and neglected population, for example poor sleep, low
47
birth weight, and lower levels of alertness. Therefore, it is important to look to
programs that have been successful in places like NICUs to identify what works
as some of the underlying mechanisms experienced by this population and
maltreated infants and toddlers are the same.
This is pertinent data when
considering future research and development, as the intentions are similar in
regards to design and philosophy. The intended intervention program should
embody
long-term
stable
massage
paired
with
other
somatosensory
experiences, immersing the child in corrective experiences. This may become
the one consistent experience in a foster child’s life, because it can be taught to
the various caregivers with simple education (Porras, 2004). This routine will
create a sense of security and familiarity usually absent in a foster child’s life, not
to mention all of the positive attributes of massage in terms of growth and
development.
Touch is the most primitive sense, yet many cultures deny children the
pleasure of receiving touch on a regular basis (Field, 2001). Touch between
humans become rare, something to be wary of, yet all of the findings show we
need human touch in order to thrive. Limited touch policies were designed in
some cultures with good intention yet instead, sterile environments free from
physical contact have been created, denying children of any healthy touch. In
the United States, some aggressive tendencies have been observed, which can
be explained by their seeking out any contact, even negative, in order to fulfill a
primitive need. However, societies where touch is more acceptable, children are
observed to be less aggressive (Field, 2001). The no-touch policies, however,
48
do not appear to protect children from predators, and are instead creating an
overall deprivation of touch. Despite repeated findings as well as cross-cultural
observations, a negative stigma remains attached to touch (Field, 2001).
Some findings, however, have initiated interest and produced substantial
data to support the use of massage. One such area is the increase in dendritic
arborization in the hippocampal regions (Field, 2001).
These findings may
account for the improved performance on infant memory scales. In fact, it has
been proposed that enhanced numerical memory capabilities of Indian children
could be due in part to the daily massages (Field, 2001). The potential for longterm positive effects is imminent, especially for the proposed model. Through
pairing massage with other pleasant sensory experiences, the positive effects
are vast and have significant long-term effects in terms of memory and
neurological growth for traumatized infants and children. The findings presume
increased memory and associations of the sensory rich experiences. This is an
area for further research.
Another area where promising yet limited results have surfaced is in
regards to effects on caregivers who provide the massage treatment. Tiffany
Field also noted this as a pertinent area for future research (T. Field, personal
communication, 19 April, 2004).
The majority of research documents self-
reported improvement, however, there is little empirical data to support the
findings. If, in fact, there are decreases in levels of depression or anxiety as selfreported (Field, 1999), data should also ascertain any neurological changes, for
example in catecholamine or cortisol levels. Jeffery Gold noted the importance
49
of allowing the caregivers to also experience the benefits of massage. For the
maltreated, young population, he said that it would allow the parents to be more
relaxed
and
therefore
more
efficient
caregivers
(J.
Gold,
personal
communication, 1 June, 2004). Further research would only enhance the already
promising findings that support massage as beneficial for both child and
caregiver.
The development of this proposed interventions program has
empirical data to support the establishment, and has future potential for
supplementing areas of limited research.
Rauni King also noted the importance of the intent to heal, specifically
the energy involved in the healing process (R. King, personal communication, 28
April, 2004). She has observed the changes that can occur in relaxation when
she incorporates an energy-based healing approach. Other changes included
overall personal well-being, decreases in anxiety levels, pain, blood pressure,
increases in wound healing, as well as the bonding that occurs with the patient.
This type of healing is an area to address in future research, particularly
addressing the intent to heal and the energy involved, in combination with the
positive massage procedure.
50
Clinical Recommendations
The
intervention
program
has
been
designed
to
offer
specific
recommendations for professionals looking to use massage in the healing
process to promote healthy development with traumatized infants.
The
information is recommended for caregivers, researchers, social workers, and any
person with daily interaction with infants. This program can be easily adapted by
those trained in infant massage and has been found to conserve money and time
in the long run (Field, 2001). The following are specific recommendations that
should be considered:

Early intervention programs are most beneficial for young children.
Research shows that with children who have experienced trauma or
maltreatment, the earlier the intervention is introduced the better in terms
of positive bearing on the child. This is because children who remain
longer in adverse situations, experience more “hard wired” neurological
impairments (Poulsen, 2002, p. 5). Therefore, once the child is outside of
the situation, the once adaptive growth patterns (for example, with high
arousal or vigilance or dissociations) becomes maladaptive (Perry, 2000).
The child becomes vulnerable across many situations, even when stress
responses, like hypervigilance, are not required. Stress hormones are
constantly being reactivated, leaving the child unable to self-regulate
(Poulsen, 2004). However, research has shown that for young children
whose critical neurological development is still occurring, the neural
systems can be altered depending on the extent and duration of the event.
51
Experiences and memories can be created that counteract damage done
from the abuse and ultimately sooth brain stem dysregulation (Perry,
2000).

The caregivers, and those performing the massage need to become
comfortable and familiar with the specific massage techniques in order to
understand the most beneficial procedures.
This includes becoming
familiar with the infant’s body and areas that are more sensitive to touch.
Especially when working with young children who have been maltreated,
and have limited verbal skills, it is important that the massager become
attuned to the child and his/her verbal and non-verbal cues of comfort and
discomfort. This way the massager can adjust the massage accordingly,
allowing for a pleasant, beneficial experience. The massage technique is
most effective when minimal stroking and moderate pressure is applied,
for example Swedish massage. Light stroking can be experienced as a
tickling sensation and is unpleasant to the infant (Field, 2001). The best
way for caregivers to comprehend the massage technique is through
experiencing the massage directly (T. Field, personal communication, 19
April, 2004). For a variety of infant massage protocols, refer to:
Touch… A Parent’s guide to Infant Massage (brochure by J&J
Pediatric Institute)
http://www.hearttouch.org
http://www.healingtouch.net
52
Baby Massage; Parent – Child Bonding Through Touch (book by
Amelia Auckett, 2004)
Touch (book by Tiffany Field, 2003)

When massaging the infants, use oil, particularly lavender scented oil. Oil
is beneficial for lowering cortisol levels and increasing vagal activity
following the massage (Field et al., 1996). Also, using lavender has been
shown to reduce nervous tension. For infants, whose olfactory systems
are functioning shortly after birth, these are essential components in
developing a soothing experience because trauma becomes manifested
into nervous tension. This implies that for the intended population, using
the lavender oil may enhance the results. Also, factoring into this is the
recognized link between smell, memory, and emotion (La Torre, 2003).

Pair the touch experience with other sensory rich experiences such as
sound.
The vibration of the music in conjunction with the massage
essentially creates a rhythmic experience, which can help regulate the
infant physically, psychologically, and spiritually (R. King, personal
communication, 27 April, 2004). Infants need rhythmic patterns to assist in
organizing themselves and for those who have limited abilities to selfregulate, providing rhythmic stimulation may help sooth and regulate the
body (Field, 2001).
For more on the soothing effects of music on
stabilizing the infant, see Barickman (2004).
53
As Tiffany Field also
suggests, when combining soothing music and aroma with massage, keep
it simple (T. Field, personal communication, 19 April, 2004).

Links to good transitions.
Teach the parents/caregivers the massage
technique as well as allow the caregivers to experience the benefits of
massage.
Several programs, such as Care for Caregivers, have
recognized the importance of allowing caregivers to also receive the
benefits of massage which will enhance their ability to be a good caregiver
because their stress levels will be lower and they can be more alert and
attuned to the child (J. Gold, personal communication, 1 June, 2004).

The education of caregivers, social workers, and anyone in contact with
the children on the significant findings related to massage and infants.
This educational piece can also incorporate a videotaping of the
interactions (J. Gold, personal communication, 1 June, 2004) to assist in
building a strong support system as well as promoting a stable, on-going
intervention program. This educational piece can clarify the distinction
between healthy and unhealthy touch, in order to determine that certain
touch promotes healthy development (Field, 2001).
This can then be
translated to the children by the caregivers, on a daily basis.
54
Personal Process
I began this project with the intention of working independently on a topic
of interest. However, once the collaborative work was introduced to me, I quickly
saw the merits in the research. By dividing up the various pieces, it allowed us to
create a much more comprehensive foundation for our topic. It also allowed us
to work cooperatively on sharing information or educating each other on our
specific findings in order to merge the work together and build off of each other.
Connecting with each consultant provided me with practical input and
clarifications into how this research is currently being put to use. It also enhanced
my enthusiasm, making the work more applicable and pertinent for a collective,
global purpose.
As I researched touch, I became fascinated with my topic,
wanting to share my findings with others, and I did. My thinking changed from
strictly research focused to envisioning the true impact a project like this could
have on the intended population. I could feel it opposed to just think it and it
made sense to me! As I researched all of the significant effects massage and
touch have on the body, I reflected upon the role touch has played in my life, and
the ways I continue to communicate through touch. This helped me apply the
research on a deeper, more meaningful level. I became attuned with touch on an
everyday basis and how it determines trust, security, and companionship.
For the intended population, it is essential to remember these infants are
young living human beings who should be offered life experiences that foster
their potential to thrive in their environment.
We can create this through
correcting opportunities that entail sensory rich experiences. These experiences
55
can become standard as caregivers become familiar with the procedure and
observe the benefits. I found that this work is more than just a doctorate project;
it is creating the opportunity for children to be given life. I am proud of this work
but even more so, I am proud of the caregivers who will seek out this information
and adopt it into their routines with their children or the hospitals that will open up
their doors to the possibilities for giving newborns alternative survival tools.
Children will find they have resiliency to live in a world that at times is
unsympathetic; however, through familiarity and comfort with their bodies as well
as the neurological capacity and support network, they will still have the potential
to thrive.
56
References
Banerjee, L. (2004). Comprehensive Interventions for Traumatized Young
Children. Unpublished manuscript.
Barickman, M. (2004). Comprehensive Interventions for Traumatized Young
Children II. Unpublished doctoral project, California School of Professional
Psychology at Alliant International University, Los Angeles, California.
Bick, E. (1968). Surviving Space: Papers on Infant Observations. In A. Briggs
(Ed), Essays on the Centenary of Esther Bick, (pp.55-59). New York: Karnac
Books.
Bukatko, B. & Daehler M. W. (1995). Child Development: A Thematic Approach
(2nd ed.). Boston, Massachusetts: Houghton Mifflin Company.
Caplan, M. (2002). To Touch is to Live: The need for genuine affection in an
impersonal world. Prescott, Arizona: Holm Press.
Cullen, C., Field, T., Esclona, A. & Hartshorn, K. (2000). Father-infant
interactions are enhanced by massage therapy. Early Child Development and
Care, 164, 41-47.
Dieter, J. N. I., Field, T., Hernandez-Reif, M., Emory, E. K., & Redzepi, M. (2003).
Stable preterm infants gain more weight and sleep less after five days of
massage therapy. Journal of Pediatric Psychology, 28, 403-411.
Field, T. (2001). Touch. Cambridge, Massachusetts: The MIT Press.
Field, T. (2001). Massage therapy facilitates weight gain in preterm infants.
Current Directions in Psychological Science, 10, 51-54.
Field, T. & Hernandez-Reif (2001). Sleep problems in infants decrease following
massage therapy. Early Child Development and Care, 168, 95-104.
Field, T. (1999). Massage therapy: More than a laying on of hands.
Contemporary Pediatrics, 16(5), 77-94.
Field, T. (1998). Massage therapy effects. American Psychologist, 53(12), 12701281.
Field, T., Grizzle, N., Scafidi, F., Abrams, S., Richardson, S., Kuhn, C., &
Schanberg, S. (1996). Massage therapy for infants of depressed mothers. Infant
Behavior and Development, 19, 107-112.
57
Field, T., Schanberg, S. Davalos, M., & Malphurs, J. (1996). Massage with oil
has more positive effects on normal infants. Pre- and Perinatal Psychology
Journal, 11(2), 75-80.
Field, T. (1995). Massage therapy for infants and children. Developmental and
Behavioral Pediatrics, 16(2), 105-111.
Field, T., Harding, J., Soliday, B., Lasko, D., Gonzalez, N., & Valdeon, C. (1994).
Touching in infant, toddler, and preschool nurseries.
Earl Childhood
Development and Care, 98, 113-120.
Field, T., Schanberg, S., Scafidi, F., Bauer, C., Vega-Lahr, N., Garcia, R.,
Nystrom, J., & Kuhn, C. (1986). Tactile/kinesthetic simulation effects on preterm
infants. Pediatric, 77, 654-658.
Kaitz, M., & Eidelman, A. I. (1992). Smell-recognition of newborns by women
who are not mothers. Chemical Senses, 17(2), 225-229.
Kalat, J. W. (2001). Biological Psychology (7th ed.). United States: Wadsworth
Thomson Learning.
Kato, P., & Mann, T., Handbook of Diversity Issues In Health Psychology, New
York, 1996.
La Torre, M. A. (2003). Aromatherapy and the Use of Scents in Psychotherapy.
Perspectives in Psychiatric Care, 39(1), 35-37.
Lipsitt, L. P., Engen, T., & Kaye, H. (1963). Developmental changes in the
olfactory threshold of the neonate. Child Development, 34(2), 371-376.
Mackereth, P. (2001). Touch research institutes: An interview with Dr. Tiffany
Field. Complementary Therapies in Nursing & Midwifery, 84-89.
O’Connor, K. J., The Play Therapy Primer, New York, 2000.
Olko, C.& Turkewitz, G. (2001). Cerebral asymmetry of emotion and its
relationship to olfaction in infancy. Laterality, 6(1), 29-37.
Perry, B. D. (2000). The neuroarcheology of childhood maltreatment: The
neurodevelopmental costs of adverse childhood events.
Porras, L. (2004). Comprehensive Interventions for Traumatized Young Children
IV. Unpublished doctoral project, California School of Professional Psychology at
Alliant International University, Los Angeles, California.
58
Poulsen, M. K. (2002). Series on Infant and Early Childhood/Family Mental
Heath. CWTAC Updates, 5(3), 1-10.
Prodromidis, M., Field, T., Arendt, R., Singer, L., Yando, R., & Bendell, D. (1995).
Mothers touching newborns: A comparison of Rooming-in versus minimal
contact. Birth, 22(4), 196-200.
Russell, M. J., Mendelson, T., & Peeke, H. V. (1983). Mothers’ identification of
their infant’s odors. Ethology & Sociobiology, 4(1), 29-31.
Scafidi, F. A., & Field, T. (1996). Cocaine – exposed preterm neonates show
behavioral and hormonal differences. Pediatrics, 97, 851-856.
Schachner, L., Field, T., Hernandez-Reif, M., Duarte, A. M., & Krasnegor, J.
(1998). Atopic dermatitis symptoms decreased in children following massage
therapy. Pediatric Dermatology, 15, 390-395.
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Children III. Unpublished doctoral project, California School of Professional
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59
Appendix A
Email / Phone Correspondence
60
Tiffany Field, Ph.D.
1. Have you found an increase in the acceptance of massage as a
beneficial, healing intervention or prevention measure? If so, by whom and
where is the technique being implemented? By the medical community &
about 30% Am. Population.
2. What kinds of changes have you witnessed between caregivers
and infants/toddlers following the use of massage? Have you observed
differences in response from an infant when he/she is massaged by different
adults? (for ex. the mother one night and father the next) Infant is less irritable,
more attentive and socially interactive following massage
3. Do you adapt your massage technique when working with infants
opposed to older children? In what ways? Massage with infants is slower
and simpler so as not to get them aroused or disorganized
4. Have you found any programs that incorporate massage in the NICU,
then encourage the continued use of massage once the infant exits the
hospital? Yes, London
5. In working with this population, what do you believe are some of the
most influential underlying biochemical and physiological explanations for
the benefits of massage? How do you translate these findings to
parents/caregivers? Decrease in arousal/ increase in relaxation, heart
rate slows, less stress hormone
6. Have you ever paired massage with other somatosensory experiences,
such as sound? No, not in the same research project but we have studied
music and aromas
7. Where do you believe future research with this population should go?
The benefits to the massager as well as the infant
8. Do you have any general advice or direction you believe should also be
accounted for or included? Keep it simple e.g. simple, soothing music,
and an aroma known to be effective with infants (e.g. Lavender) and the
touch should be simple stroking with moderate pressure to be effective.
Do it on the caregivers first so they know how it feels to receive it.
61
Jeffery Gold, Ph.D.
(summary of phone conversation)
Jeffery Gold, Ph.D. described his recent massage project with
hospitalized children. He said that it took three years to integrate the massage
program into the NICU. Currently a research study in the level 3 NICU, with
critically ill children, is underway. The two goals of this study include improving
the health of the children, particularly through weight gain, and caregiver
satisfaction. There was also an interest in attachment and bonding but at this
time the funds do not support this research.
He described the “rigorous hurdles” that have had to be met, from
designing an appropriate massage protocol, which has currently been translated
into English, Spanish, Korean, and Armenian based on the population
demographics, as well as finding support in a very “traditional” medical center.
Essentially he said it was like introducing a “new culture.”
The design of the research looks at the effects of massage over a
seven-day treatment program. There are ten children in the massage group and
ten children in the control group. There is also a one-month follow-up and the
caregivers keep a massage journal. A standardized technique is used with the
children, which he described as a 20-30 minute massage, from hand
containment from the head to the toes, then back to hand containment. Oil is
used, although it is non-scented from fear of allergic reactions. The massage
technique and time varies depending on how much the infant can tolerate. The
62
massager must follow the cues and body language of the child.
A trained
therapist provides the first massage while the caregiver is an observer.
However, over the course of the week, the caregiver provides up to four of the
massages, although this number is not controlled for in the research.
Throughout the massage treatment the children are being monitored to record
any physiological changes taking place.
At this point in the program, Dr. Gold noted a “phenomenal” parental
response, saying that the parents have been very appreciative. He described
two programs currently available at the hospital, Care for Caregivers and Care
for Parents, where regular massages are also provided for the caregivers. He
believes this decreases the stress of the caregivers, changing their hormone
levels, and essentially allowing them to be more efficient as parents. Another
program currently underway is massages for the hospital staff. Each month a
different unit in the hospital is provided with massage therapists.
This has
enhanced overall interest in the program and acceptance of massage as a viable
healing mechanism for children.
Massage has also been introduced in the rehabilitation unit for children.
These are children who live in the unit three months or longer, and are
recovering from accidents, burns, loss of function in a limb, etc. Although this is
not a funded research program, physicians have the option to prescribe massage
as a healing intervention. It is a complementary service and parents may request
massage for their children. Dr. Gold provided a case example, which enthused
the hospital staff. A young child suffered a motor accident, leaving one side of
63
his body tensed up. Despite much work with a physical therapist, the child was
unable to open his clenched fist. However, following two massage sessions, the
child demonstrated the first sign of relaxation, soon regaining the ability to open
and close his fist. Overall, Dr Gold feels massage has been a wonderful asset to
these children, especially since many children lack verbal skills from brain injury
or just their developmental age. Since massage is non-verbal it is very practical
and adaptable.
Dr. Gold has observed an increase in the acceptance of massage,
children becoming excited when it is massage time, or parents verbalizing their
support. Many nurses seem to be supportive of the program although waiting for
the empirical data to confirm the benefits.
Dr. Gold recommended future
researchers should videotape each massage session for education purposes as
well as for scientific presentation. He said the massages should be coded as a
means for determining the effects of massage as well as for providing feedback
on technique.
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Rauni King, R.N., B.S.N., H.N.C., C.H.T.P/I
1. What first inspired you to incorporate touch into the healing process? I
HAVE BEEN AN ICU NURSE FOR 20 YEARS. TOUCH IS VERY IMPORTANT
FOR PERSON'S HEALING, BUT TOUCH IS NOT AS POWERFUL AS THE
FOCUSED INTENT TO HEAL, IN THIS CASE HEALING TOUCH WHICH IS AN
ENERGY BASED HEALING.
2. I know in the past there have been limited touch policies, especially in
hospitals, how does this impact your work? Have you found there is an
acceptance of massage as a beneficial, healing intervention or prevention
measure? If so, by whom? IN CALIFORNIA, NURSES ARE LICENSED TO
TOUCH SO FOR THAT REASON IT HAS NOT LIMITED MY SCOPE OF
PRACTICE. THERE IS AN ACCEPTANCE OF TOUCH IN THE HEALTH CARE
SETTING BY THE TRAINED STAFF.
3. What kinds of changes have you witnessed in patients during and following
the touch intervention? HEALING TOUCH WHICH IS AN INTENDED ENERGY
APPROACH HAS SO MANY BENEFITS THAT I CAN'T WRITE THEM ALL. THE
FIRST IS VERY POWERFUL RELAXATION RESPONSE. PERSONAL WELL
BEING, DECREASE IN ANXIETY, PAIN, BLOOD PRESSURE, INCREASE IN
WOUND HEALING, DEVELOPING CLOSENESS WITH THE CLIENT.
4. Does your program encourage the continued use of massage once the patient
exits the hospital? If so, have you found any differences in the long-term
healing process? WE ENCOURAGE PATIENTS TO COME AND HAVE
HEALING TOUCH AND/OR MASSAGE AT THE INTEGRATIVE CENTER.
5. What do you believe are some of the most influential underlying
biochemical and physiological explanations for the benefits of massage?
What types of psychological changes are most prevalent? MY WORK IS IN THE
ENERGY HEALING AND IT IS OPENING UP MERIDIANS, CLEARS ENERGY
FIELDS, OPENS MAJOR ENERGY CENTERS AND BALANCES HUMAN
ENERGY SYSTEM (VIBRATIONAL FREQUENCY) WHICH PROMOTES
NATURAL HEALING TO OCCUR.
6. Some researchers have found in massaged infants an increase in dendritic
arborization in hippocampal regions. This is then hypothesized to have a
positive influence on memory performance. Have any of the programs with
adults found similar results? MY EXPERTISE IS NOT MASSAGE
7. Have you ever paired massage with other somatosensory experiences, such
as sound? Our intention is to create a somatosensory rich experience. From
your own work, what types of long-term effects would you believe this type
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of experience would have? SOUND IS VERY HEALING. IT IS VIBRATION
THAT
TRAVELS THROUGHOUT THE BODY CELLS. IT IS THE MOST HEALING
THING ACCORDING TO SOME OF MY TEACHERS. ALL THE 7 MAJOR
ENERGY CENTERS CORRESPONDS WITH THE SOUND (MUSICAL NOTE).
WE ALL VIBRATE IN THE DIFFERENT FREQUENCY.
8. In what direction do you believe future research with massage should go?
I DO NOT KNOW ABOUT MASSAGE BUT I BELIEVE THAT THE ENERGY
MEDICINE OR VIBRATIONAL MEDICINE IS THE MEDICINE OF THE FUTURE.
THERE ARE LOT OF RESEARCH DONE WITH THAT.
9. What advice would you offer to the caregivers implementing the massage
into their daily routines with their children? I OFTEN TIMES TEACH MY
PATIENTS AND/OR FAMILY MEMBERS HOW TO DO SIMPLE HEALING
TOUCH TO SELF OR OTHERS.
Finally, I would love to learn more about your project and any advice, in
terms of developing the healing environment etc., you have as we continue to
create this intervention program. I WOULD LOVE YOU TO COME AND TAKE
LEVEL ONE HEALING TOUCH, IT WILL COVER ALL THE AREAS ABOVE.
YOU DO NOT HAVE TO HAVE PRIOR TRAINING IN IT. THE PROGRAM IS
DEVELOPED FOR HEALTH CARE PROFESSIONALS AND FOLLOWS
NURSING PROCESS. YOU MAY CONTACT LIZ FRASER FOR
MORE INFORMATION ON OUR CLASSES. 858 554-3360 OR E-MAIL HER
FRASER.ELIZABETH@SCRIPPSHEALTH.ORG
<mailto:FRASER.ELIZABETH@SCRIPPSHEALTH.ORG.
Thank you very much Rauni for your interest, expertise, and time. I really
appreciate it and look forward to attending one of your programs in the near
future. Sara
YOU ARE WELCOME. I HOPE TO MEET YOU AND I HOPE THAT YOU
EXPLORE THIS TOUCH
THAT DOES NOT NECESSARILY NEED TO BE PHYSICAL. GOOD LUCK.
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Connie Lillas, Ph.D.
thanks for your email. i, myself, am not in the NICU hospital setting nor involved
in massage right now. however, i do know of some folks who are involved in this
and forward the following email addresses for you to contact.
1. Jeffery Gold, PhD i think is involved in some research study with NICU
preemies and massage. i could have him mixed up and he may not be the right
person, but i do think you should try to contact him. jgold@chla.usc.edu he is at
Children's Hospital LA.
2. Maria Augusta Torres i know personally, and she has been involved in the
cross between trauma and massage and i believe the Children's Hospital
research. her email is: mariagtorres@yahoo.com she recently has relocated in
the San Francisco area and the phone number i have for her is: 415-641-4162
this is a home phone, but she can be reached via a phone message left here if
she is not currently residing there.
3. Ayelet Talmi, PhD is a clinical psychologist involved in NICU's in Denver. she
may know of some hospital based research on massage. She is a national Zero
to Three Fellow. ayelet.talmi@uchsc.edu (303) 315-0481
4. Vonda Jump has done massage in Haiti with severely malnourished and
attachment disordered orphans. she has "live" vignettes, and some cortisol
samples pre and post but was short on money to get the research data
developed. if interested, she is at: vonda@cpd2.usu.edu (435)797-3579 She
is at the Univ of Utah and she is also a ZTT Fellow.
5. Elaine Fogel Schneider is an OT/PhD businesswoman in the field who is
promoting and teaching massage to parents to use with their infants. while not
involved in research, she is a big trainer of infant massage. she's at:
drelainefschneider@hotmail.com
6. my contribution is likely not to help you for what you need right now. i am coauthoring a book titled: Infant Mental Health and Early Intervention: A
Conceptual Framework for Interdisciplinary Practice, Norton Press. it's not
coming out til Sep 05 and it would possibly provide some theoretical grounding
for massage, etc. since i am writing and researching, please let me know about
your research project. i would love to get a copy of it and possibly could use it in
the book if the timing was right with your timeline and my deadlines coordinating.
i hope this helps. PLEASE, let these folks know you were sent to them through
your contact with me. best wishes, Connie
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Appendix B
PowerPoint Presentation Slides
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Why Somatosensory Touch?
- For infants, touch serves as a primary factor in developing self-awareness and
exploring, making sense of the environment, and bonding with caregivers.
- For a maltreated child, their early sense of security is tainted because there is
an absence of sensory input or else repeated patterns of unpredictable
interactions.
- Development during these early years of life is very susceptible and without
early interventions, this population is at a high risk for experiencing severe
neurological and psychological impairments due to maladaptive development.
The History of Touch
- In India, the medical text called Ayurveda, which dates back to the 1800 BC,
referred to massage as a plausible healing method (Field, 2001).
- Dr. Rene Spitz found that more then 30% of children, raised in orphanages that
deprived the children of contact and affection from a primary caretaker, didn’t
survive their first year despite food, materially hygienic surroundings, and
advanced medical care (Caplan, 2002)
Cross-Cultural Findings on Touch
- Touch is universal, however, various cultures differ in how it is valued and
integrated in daily life.
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- In India, New Zealand (the Maori), Nigeria, Uganda, Bali, New Guinea,
Venezuela, and Russia, infant massage is part of the infants’ daily routine (Field,
2001).
In the United States massage is not considered a valid healing method by the
general medical field. Insurance companies refuse to cover massage under
medical practice.
Cross-Cultural Findings on Touch (cont.)
- More observed self-touch by children in the US, for example playing with their
hair or hugging themselves, compared to the French.
The touch that does transpire between American children is much more
aggressive than other cultures, for example, poking each other, or grabbing
things away, etc.
Recent Findings on Touch
Tiffany Field PhD is one of leading researchers in this field.
Field et al, (1986)
Focus: Infants were massaged for three, fifteen-minute intervals per day over the
course of 10 days.
Findings: 47% greater weight gain, more mature habituation, orientation, motor,
and range of state of behavior, more time in active alertness during the wake
states, and better performance on the Bayley Scales of Infant Development.
- At one year of age similar results were found.
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- Results replicated overseas in the Philippines, Taiwan, and Israel (Field, 2001).
Follow-Up Study
- J. N. I. Dieter et al (2003).
- Focus: Verify the beneficial results of massage after just five days, inspiring
continued use with these infants who were being discharged at lower birth
weights.
- Findings: 53% greater weight gain and a decrease in the amount of time in
sleep states but an increase in the amount of drowsiness, which promoted
interactions with their environment.
- Caloric intake was controlled across groups and therefore was not a factor in
the weight gain results.
Cost Benefits
- Infants are discharged days earlier after overall significant improvement.
- In 2001, this translated to an average savings of $10,000 per infant if the infant
was discharged approximately 6 days earlier, the average modification (Field,
2001).
Tiffany Field’s Massage Technique
- Three fifteen minute massages.
- Alternation between tactile stimulation, kinesthetic stimulation, then tactile
stimulation (Field et al, 2001).
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- Apply moderate pressure; otherwise light stroking may be experienced as an
uncomfortable tickling sensation by the infant (Kato & Mann, 1996).
Rocking vs. Massage Treatments
- Field et al (1996)
- Focus: The effects of massage verse rocking in terms of social and physical
development with full-term infants of depressed mothers. - Findings: Weight
gain, temperamental and social ability improvements, lower stress hormones or
salivary cortisol levels and urinary catecholamine levels, less crying, an increase
in vagal activity and beta waves and decrease in alpha waves during the
massage treatment.
- Following the massage treatment sleep was enhanced, something that did not
occur in the rocked infants.
Massage and Atopic Dermatitis
- Schachner et al (1998)
- Focus: The effects of massage on atopic dermatitis symptoms with children 2 8-years old.
- Factors: Stress is known to manifest in various skin ailments such as infections
and allergic reactions.
- Cycle: The children have skin irritations -- feel insecure -- have raised stress
and anxiety levels – increases in cortisol levels and desire to itch– increases in
skin irritations.
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- Findings: Decrease in stress hormone levels and in turn, the desire to itch,
improved self esteem levels, improved overall comfort with touch.
Impact on Caregivers Who Provide the Massage Treatment
- Caregivers often report feelings of hopelessness because of their inability to
directly facilitate any progress in a child.
- Findings following their involvement in the massage treatment: Decreases in
their own anxiety and stress levels, promotion of healthy touching between
parents and their children, and improvement in attitude towards their children.
(Schachner et al, 1998)
The Use of Massage for Various Conditions with Children
- Sexual and physical abuse: Increase in sleep and alertness, a decrease in
touch aversion and, per the caregivers report, the children became more active
and sociable. (Field, 1995)
- Psychiatric problems: Decrease in levels of depression, and anxiety and lower
saliva cortisol levels. Less anxious and more cooperative behavior, quiet sleep
throughout the night, and a decrease in urinary cortisol and norepinephrine
levels. (Field, 1995)
- Post Traumatic Stress Disorder (PTSD): Decrease in symptoms, lower levels
of anxiety and depression as well as cortisol levels. (Field, 1999)
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The Use of Massage for Various Conditions with Children (cont.)
- Autism: Less sensitive to touch, less distracted by sounds, more attentive in
class, related on a more appropriate level with their teachers, and better scores
on the Autism Behavior Checklist. (Field, Lasko, Mundy, & Henteleff, 1994)
- Cocaine exposed preterm infants & HIV exposed infants: (showed similar
improvement) Increases in weight, increased scores on the motor and orientation
portions of the Brazelton, and improvement of scores on the stress behavior
scale. (Scafidi & Field, 1996)
The Use of Massage for Various Conditions with Children (cont.)
- Healthy infants: (long-term effects found) More time in active alert and awake
states, better habituation ability on the Brazelton, less crying, lower salivary
cortisol levels, weight gain, sustained face-to-face interactions for longer periods,
lower levels of urinary stress hormones and catecholamines, higher levels of
serotonin, improved parent-infant bonding, reductions in stress responses to
painful procedures, reductions in pain associated with teething and constipation,
and reductions in colic (Field, 1995).
The Use of Massage for Various Conditions with Children (cont.)
- Other areas where massage as proven effective: Burns, cancer, blindness,
deafness, developmental delays, asthma, juvenile diabetes (type I), eating
disorders, fibromyalgia, juvenile rheumatoid arthritis, and attention-deficit
hyperactivity disorder. (Field, 2001)
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Enhancing the Massage Through Use of Oil
- (Field et al, 1996)
- Findings: Oil enhances massage results. A massage with oil enhanced the
results, implying lower cortisol levels and increased vagal activity when
compared to a no oil massage.
Enhancing the Massage Through Use of Scents
- There is a significant relationship between olfaction and the limbic system. (as
cited in Olko et al., 2001)
- At just a few days old, infants respond to smells and can differentiate between
certain smells. (Olko, et al, 2001)
- By 3-years old, children are comparable to adults in terms of olfactory
preferences. (The Smell Report, 2004)
- Smells are powerful tools to activate memories and feelings associated with
that memory.
- Lavender scent shown to reduce nervous tension. (La Torre, 2003)
Findings in Initial Contact Between Mother and Infant
- (Prodromidis et al, 1995)
- Focus: Comparing rooming-in mothers vs. contact only during feeding for
whether increasing the amount of initial contact a mother has with her infant,
particularly in terms of maternal touching, can be beneficial.
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- Results: Rooming-in mothers illustrated more intimate touching behaviors, more
attuned with their child’s particular needs for stimulation, more apt to touch the
child in intimate places on the body, (the head and face), and overall more
maternal affection.
Touch in the Classroom
- (Field et al, 1994)
- Focus: Touch in the classroom between teachers and infants, toddlers, and
preschoolers.
- Findings: Little positive touch between teachers and the children, particularly
as the children grew older. Boys were touched more frequently than the girls in
these classrooms.
- However, there were increases in healthy touch between teachers and children
after informing preschool & nursery teachers of this finding and requesting
increases in positive touch.
Fathers’ Involvement in Massage Procedure
- (Cullen et al, 2000)
- Focus: Father’s involvement in the care giving role of their 3 - 14-month olds
through providing a 15 minutes massage prior to bedtime.
- Findings: Interactions between father and infant in the massage group were
more positive, showing more enjoyment, responsivity, warmth, and acceptance.
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- Care giving responsibilities did not change although fathers in the control group
showed less involvement by the completion of the study.
Utilizing “Grandparents” in Implementing Massage
- (Field et al, 1994)
- Focus: Volunteer “grandparents” implemented massage to abused infants for
one month. Simultaneously addressed touch deprivation with the infants as well
as the “grandparents.”
- Results with infants: More alert and showed increased activity.
- Results with “Grandparents:” Less symptoms of anxiety and depression,
improved mood, lower stress levels, more social contacts, fewer trips to the
doctor, fewer cups of coffee, and improved self esteem.
Potential Models for Mechanisms of Touch
- Indication of an interaction between biochemical and physiological
mechanisms, some occurring in conjunction with one another.
- Increase in protein synthesis. (Schanberg and colleagues, 1994)
- Increase in motor activity.
- Increase in parasympathetic activity
- Increase in vagal activity.
- Increase in the release and circulation of the hormone oxytocin.
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Potential Models for Mechanisms of Touch (continued)
- Increase in the hormone Insulin-Like Growth Factor 1, or IGF-1.
- Decrease in cortisol hormone levels.
- Lower levels of catecholamines.
- While measuring frontal EEG activation: Chemical and electrophysiological
changes include a transfer of activation from the right frontal region to the left
frontal region.
- From MRIs: Increase in dendritic bifurcation. This could be imperative to the
work done on infants because of the positive impact on the development of
memory as pleasant associations form through tactile stimulation.
Potential Models for Mechanisms of Pain Relief
- The “gate theory.”
- Increases in serotonin.
- Improvement in restorative deep sleep; a lack of deep sleep promotes the
release of Substance P and somatostatin, which together enhance pain (Field,
1998).
How These Relate to the Intended Population
- Similar underlying mechanisms for all human beings experiencing stress
- Lower cortisol levels  increase weight, increase alertness
- Increase in vagal activity Increase weight gain through improved digestion - Increase motor activity  increase strength and alertness
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- Increases time spent in restorative sleep  increase alertness
- Increase serotonin  improved mood, less “fussiness’
- Increase in dendritic bifurcation  increase pleasant associations with touch
Why Minimal Touch Policies are Maintained
- In NICUs: previous research illustrated raised tcPO2 levels, or transcutaneous
oxygen saturation levels, following the interaction between nurses and infants.
- In these studies, this finding was not supported.
- Massage is a not a technique regularly referred to in medical textbooks and
handbooks and therefore is considered taboo (Field, 2001).
- Result: These policies are also implemented to deter abuse, however,
percentages of children abused have not decreased (Field, 2001), just levels of
healthy touch, despite the many positive implications from the use of touch &
massage with infants.
Relational Benefits of Massage
- Massage also allows parents to know their child’s body better, and to impart a
message that touch is good and there is safety in receptivity. Also, helps the child
to process emotions and energy.
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Conclusions
- Without providing correcting experiences for maltreated infants, there are
diminishing potentials for normal development to occur.
- There is hope; Creating experiences that provide enriching sensory
experiences can directly affect the development of the mind and body. These
children can thrive with nurturing interventions, designed to stimulate regulation
and healing.
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