Barry Nurcombe, M.D.
Douglas Teti, M.D.
Virginia Rauh, Sc.D., A.C.S.W.
Thomas Achenbach, Ph.D.
Dr. Als poses a number of searching questions, quite apart from her discussion of the causes of developmental morbidity. We welcome the opportunity to discuss the key issues, which we will address according to the following criticisms: (1) the allegedly inappropriate design of the Mother Infant Transaction Program; (2) the failure of randomization to control for maternal education; (3) the exclusion of certain groups from the cohort; (4) the failure to separate intervention from outcome evaluation; (5) the apparent failure of the intervention to affect outcome.
When the MITP was designed, we drew upon the following sources: Als and Brazelton (1975), Als, Tronick, and Brazelton (1976), Beckwith and colleagues (1976), Brazelton (1973), Bromwich (1976), Parmelee (1975), Prechtl (1974), Robson (1967), Sameroff and Chandler (1975), and Thoman (1975). The rather intricate concepts Dr. Als includes in her synactive theory were not available to us in 1976, when the program was conceived. Instead, the MITP was deceptively simple. The essence of the program was conveyed in daily sessions during the week before the discharge of the baby from hospital, when it was clear that the infant's medical condition had stabilized. The first five days were spent in helping the mother to appreciate the baby's potential, to detect the autonomic and motoric signs of stimulus overload, to help the baby organize her- or himself, and to recognize the state of quiet alertness that might indicate a readiness for interaction. The sixth and seventh days were used to prepare the mother to imbed her sensitivity, responsiveness, and interactional skill in the procedures of daily care. The purpose of the four home visits during the three months following discharge was to consolidate the knowledge and skills already learnt. Ultimately, the program aimed to promote maternal responsiveness, contingent interaction, and mutual enjoyment in the context of daily care.
We did not try to teach the process of subsystem differentiation, integration, and modulation or the concept of "threshold of integration to defense and avoidance." Given the wide SES range of our cohort, it would have been difficult to do so.
Dr. Als makes the point that the different subsystems function as a whole, so that to concentrate on one at a time is not only a distortion but potentially unbalancing. Quite so. But the same problem faces all educators who wish to foster the knowledge and-skill that underlie a complex procedure: how to analyze the operation into sequential components and convey them in an integrated manner.
It should be stressed that the introduction,