BACKGROUND OF THE SERVICE
The Warm line was established in the Family and Child Section of the Thalians Community Mental Health Center (CedarsSinai Medical Center) in 1971 as a telephone consultation service for parents of infants and toddlers. Worried parents call in and receive a return call within 24 hours from one of our child-development specialists. The aim is to help parents with ordinary worries that inevitably arise in the everyday experience of parenting babies, toddlers, and children through the first five years. We talk to parents about their concerns regarding their child's development and behavior. We never talk to them about medical matters. Parents who call us are given something very specific: suggestions, alternatives, and information about child development, as well as reassurance and warm, sensitive interest.
Since 1971 we have responded to approximately 3,000 initial calls from parents. Contact with 3,000 families in this way has provided us with a large amount of data about the concerns that parents experience in the early phases of child rearing. Coincidentally, we have learned a great deal about the kinds of advice given to young parents by their own parents, by friends and neighbors, by nurses, and by pediatricians and other physicians. We have come to realize that, unfortunately, much of the advice given by health professionals does not reach parents and often misses the mark. We have concluded that this results from at least the following factors:
1. The time needed to respond fully to parental concerns is often far more than most practicing pediatricians and other physicians can provide. The result may be a verbal exchange that is hurried and leaves the parents' worries unresolved.
2. Health professionals whose training focuses primarily on the sick child are not comfortable counseling parents about the minutiae of parent-infant - especially motherinfant - behavior and emotional interactions. By contrast, child-development specialists who are knowledgeable about the first years of life and who have received specific training in family dynamics and the techniques of family counseling can respond to parental concerns in an appropriate manner. (In our program the child-development specialists may be persons with master's degrees in clinical social work or child development, with additional training in telephone consultation.)
3. Many people, including some pediatricians and other physicians, offer suggestions based on their own family experiences or belief system rather than on a knowledge of developmental process. Therefore, the advice they give is often inappropriate for parents with differing backgrounds.
PEDIATRICIANS' USE OF THE WARM UNE
It is our intention to work alongside pediatricians1 and to supplement what they themselves may be unable to provide to parents. We assume that many - perhaps most -parents are satisfied with much of the guidance they receive from their pediatricians. When they call us, it is either because they are reluctant to ask for more time from their pediatricians or because the specific problem about which they are concerned has not reduced itself following the pediatrician's advice. Also, in some instances parents are in conflict with their pediatrician's suggestions.
Because we are able to provide a full 45 minutes or more on the phone for each call, 'the parent has time to spell out his or her concerns in detail. This in itself is anxietyreducing. While there is some repetition of effort because we have to gather data from the parent that the pediatrician may already have, the parents usually seem glad to go through that process with us. On the other hand, we believe that we are of the greatest help to parents who have been referred to us by their pediatrician, with whom we can work as a team.
In many instances, however, parents are reluctant to tell their pediatrician they have called us. We regret this when it occurs, since we do not wish to be in a position of competing with pediatricians or physicians. We are developing a series of presentations for pediatric residents and established pediatricians to inform them of our work.
PROBLEM SOLVING WITH PARENTS
Entering into a problem-solving process with a worried parent requires a carefully timed sequence of comments and questions.2 First, it is essential to provide the parent time to ventilate feelings of frustration, anxiety, or guilt. This is followed by a review of the history pertinent to the specific problem about which the parent has called. Following this, an effort is made to focus on the presenting problem with the parent, leading to an offer of specific advice. Even though the advice is specific and educational, it is extremely important that it be offered in an understanding and nonjudgmental fashion, timed to reach the parent's underlying anxiety or guilt.
The Warm Line is advertised as a free community service for normal parents with normal worries about their normal children. By far the majority of the 3,000 families who have called us have seemed to be relatively normal. Therefore we conclude that our observations noted earlier about the inadequacies of the standard advice that is given to parents apply to both normal and problem children.
SOME TYPICAL PARENTAL CONCERNS
Following is a brief review of typical behaviors exhibited by infants and toddlers that may produce difficulty in the life of a young family. These are well known to pediatricians. Sleep problems. Many calls from parents are about the wakefulness of their infant or toddler. Often the problem is the toddler's resistance to staying in bed, his persistence in crying out or in wanting milk or food, or even his determination to get into the parents* bed. Sleep problems usually begin in the middle of the first year and may persist into the third or fourth year.
Head banging and temper tantrums. Many calls are from parents who feel helpless about these kinds of behavior. These usually begin in the middle of the second year, if not before. Eating problems. A large number of parents have called about a full range of eating problems with infants and toddlers. This includes those who resist food and those who eat voraciously, those who are finicky and those who are phobic. These problems frequently persist and may become symptoms that last for a lifetime.
Toileting problems. These are a typical source of parental concern. There are frequent questions about when to begin toilet training. Additionally, there is the range of concerns about young children who defecate secretly or in odd places, are phobic about using the toilet, or retain their feces. These children are usually two years or older.
Biting or attacking other children. Some parents are concerned about how to stop their toddlers from biting them or other children (and themselves) and are often in a quandary about how to handle this behavior.
The preceding are only some of the categories of concern about which parents call. Such behaviors as masturbation, thumb sucking, weaning, jealousy, death fears, not listening, timidity, nail biting, and aggressiveness are others. Still another major area of concern for parents has to do with separation fears in toddlers and preschoolers.
In the course of weekly reviews of calls that are handled on the Warm Line, we have come to recognize a series of typical or "conventional" responses that parents hear from their relatives or neighbors or their physicians about the above-mentioned problems. We have discovered that physicians' responses are often not very different from nonprofessional responses. We have informally classified the responses as follows:
"Don't spoil him." This is the response in which the parent is advised to act so as not to be "manipulated," "controlled," or "exploited" by an infant or toddler. Consequently, parents are advised to spank the child who resists food, will not stay in bed, or cries out repeatedly. The parent may be advised to do the same with the head banger or the child who has tantrums. Even when advice to spank is not given, other "discipline" may be urged, such as isolating the child in his room with the door closed or locked or threatening to withdraw a favorite object. The underlying theme, which may or may not be stated openly, is that there is a battle of wills going on in which child and parent are adversaries. The implication is that the parent must win before the child becomes a "little monster."
"He'll grow out of it." In this kind of advice, the parent is urged to try to forget about the behavior or not take it too seriously and wait for it to go away. The implication is that there is not much one can do anyway or that it is normal development and the parent is only being overanxious. Unfortunately, this passive attitude may be combined with a prescription of medication for the child that is intended to tide the parents over until the problem disappears. Even in communities where there are child psychiatrists or mental health specialists who might be consulted, the advice is all too often, "Wait, he'll grow out of it."
"Do it back to him." This response or advice is related to the biblical injunction "An eye for an eye." It is often given to parents or toddlers who bite or attack. Parents are told to bite or hit back.
"Give him enough room." In these situations parents are encouraged to let the child fall prey to his own folly. In effect, the parents are advised to turn their backs on the toddler whose behavior is troublesome, leaving the child to exhaust himself - as in the case of head banging, temper tantrums, or crying in the night.
DEVELOPMENTAL AND PSYCHODYNAMIC WISDOM
Parents should be able to carry out firm parental authority and limit-setting. In order to do this, however, they must have clear models to help them determine what to do and how to carry it out. When they receive advice of the kinds illustrated above, they tend to get into adversary positions with their children and soon feel helpless and defeated. The alternative to this is to provide parents with the opportunity to review their child's behavior and their own reactions to that behavior. In this way it becomes possible for the parent, with the help of the professional, to devise a plan of action that feels right for the parent and is appropriate for the child's developmental level.
PROBLEM SOLVING WITH PARENTS
Following are some examples of problems, together with specific professional advice that is offered by our Warm Line professionals. Sleep problems. It is important to understand the psychologic factors that contribute to sleep disruptions in young children. These usually have to do with anxiety about separation from the parent. Knowledge of infant development tells us that infants can distinguish their mother from others by the age of five to eight months. This leads into a phase in which they are vulnerable to the disappearance of the mother. For some infants separation becomes very distressing. By the second year this vulnerability may even increase. It is in this period that the child normally turns to "transitional objects" for comfort. For certain infants or toddlers, letting go into sleep is felt to be a traumatic separation, and transitional objects do not suffice for comforting. In these cases, parents must be helped to understand what is distressing the child; then they must be guided into reworking the separation anxieties that are interfering with their child's sleep.
There are also instances when a child who has regularly slept through the night becomes wakeful and troubled. This may occur during and following an illness or hospitalization of the child3 or its parent, the birth of a sib, or a change in residence, with resulting loss of familiar surroundings. Even a family trip can precipitate such a reaction.
Generally, what has become aroused in the child is anxiety about separation and the associated loss. Consequently, our "routine" advice in cases of children over six months of age who have sleep disruptions addresses itself specifically to separation anxiety. We suggest that the parent put a cot or temporary bed in the child's room for use when a disturbance occurs. When the child awakens, the parent goes into the child's room and says, "Go to sleep, I'll be here," and pats the child but does not take him out of the crib.
We tell the parent that food or milk should not be given during the night. According to our pediatric consultant, it seems clear that, from a nutritional point of view, a child no longer needs middle-of-the-night feedings after six months. We also advise not to give juice or even water.
In other words, following the premise that sleep disruptions are based on separation anxiety, we deal with those disruptions accordingly. The parent stays in the room when the child awakens, remaining there the rest of the night or returning to his or her own bed after the child falls alseep. We suggest that if the mother is nursing - especially if she has been doing so during the night - the father should go into the child's room when the child awakens. We have found that the sleep disruption usually stops or is appreciably relieved in about three nights if the parent can be calm, consistent, and reassuring.
The question (or fear) often heard from a parent is that the child will never again let the parent go. From our experience with almost 1,000 calls about sleep disruption, it is apparent that most follow a pattern: the child will awaken as usual and may have a period of crying if he has been accustomed to being taken out of bed. Once it becomes clear that the parent is firm (not angry) and stays in the child's room, the child may awaken several more times that night in order to be reassured. On the second night, the child may awaken somewhat later. The parents should hold to the same routine as before. During the third night the child usually sleeps until about 5:00 a.m., and on the fourth night a new sleep pattern becomes established.
Temper tantrums and head banging. The single most common reason for calls is sleep disturbance. The second most common kind of problem has to do with temper tantrums, head banging, and other expressions of anger. Again, it is essential to understand the psychologic and developmental factors behind this behavior. Usually such behavior occurs in the second year and is related to the child's experiences as he begins to separate from the mother.4 Following is an illustration of this theme.
A one-year-old has learned to walk and can move away from the mother. He is now busy exploring his surroundings. Because of his inexperience, he encounters many barriers and frustrations. This results in tension and often anger. The anger may be outwardly expressed in the form of temper tantrums or may be expressed against himself in the form of head banging. There are, of course, other possible sources for tantrums or head banging that become apparent. Our "routine" advice to the mother is that she ally herself with the child and lend her mature understanding to the difficult situation the child is experiencing. We suggest that the parent say, in words and with actions, "Pm not going to let you hurt yourself - I'm going to keep you safe." She must then do so in specific ways. That is, she must stay with the angry or head-banging child and hold him in a specific manner that we carefully describe to the parent. The goal is to keep the child safe from his own anger. In effect, the mother communicates to the child the following message: "I understand you are filled with overwhelming and unmanageable feelings right now, and you hurt. I, your parent, am mature and will lend you my strength, maturity, and protection and help you manage those distressful feelings. I'll keep you safe."
The above "routine" has been so successful that we have been astonished with the uniformity of the positive results. An essential element in the success is the parents' ability to contain their own anger and to remain calm and reassuring while they restrain the child. It confirms our belief that a supportive approach to a distressed child may include firm parental authority. This is not the same as punitive parental control. Rather, it is a way of giving to a child.
Symptoms as expressions of anger. Besides head banging or overt tantrums, small children may develop behaviors representing anger that they feel unable to express more directly. These include breaking of objects, provoking siblings and adults, messing, selfhurting actions, resisting food, encopresis or feces retention, nail biting, and some speech disturbances, such as stuttering or elective mutism.5
Behaviors that are indirect or "symbolic" - such as messing, feces withholding, or stuttering - usually occur in families in which the parents are very uneasy about allowing their child (or themselves) fairly direct avenues for expressing or verbalizing anger. Thus we have observed that stuttering often appears at the time of the birth of a sibling in families in which parents are uneasy about allowing the child to verbalize negative feelings over being displaced by the new baby.
It is important to understand that unexpressed anger tends to go underground and becomes a source of inner conflict for children, while the symptomatic behaviors that occur confuse parents and may unfortunately lead them to use punitive measures. Parents who are themselves in conflict about showing anger must be helped to recognize how these attitudes may be contributing to their child's symptoms.
After hearing a description of the situation in the family, our "routine" advice is to explain to the parent the "normality" of ambivalent feelings. Then we try to help parents formulate an approach for helping their child tap and express angry feelings. We proceed step by step. We call the parent back after two or three days to see what has evolved from our suggestion, and then we go to the next step. When parents demonstrate an ability to work with us, we may work with them on the telephone for several weeks or months in tackling some of these problems. If nothing changes, we suggest a family consultation at our center.
We perceive the Warm Line as a form of case finding. When the telephone consultations fail to resolve the problem or the parents show no ability to change, it becomes evident that more serious psychologic problems are present and we then suggest direct family evaluation.
RELFECTIONS ON MASTERY AND AUTONOMY
Our knowledge of family dynamics and child development, coupled with our experience on the Warm Line, has led us to the following notions about how certain developmental behaviors occurring in infants and toddlers become "problems" for their parents and eventually for the professionals who advise parents. We have realized that in our culture there is a strong tendency to perceive the infant or toddler as an untamed little being who needs training or taming by adults. As the toddler begins to explore his environment and to try out new levels of mastering, he tends to disrupt the status quo and may create disequilibrium in the relationships with mother or parents. As this movement toward mastery and autonomy proceeds, parents may easily slip into viewing the child's efforts as willful disruption. A conñict between child and parent begins to form. Such an attitude gains momentum if the professionals to whom the parents turn reinforce it with advice implying that the parents need to "control" the toddler or to outwit the infant so as not to spoil him or be overpowered by him.
A phrase that has become commonly used to apply to the relationship between parents and small children is the "power struggle." While professionals in the field of child development may use this phrase as a means of describing the dynamics of the relationship, it lends itself too easily to misuse and may have destructive effects. The notion of a power struggle between child and parent places them in adversary positions even as the child approaches 18 months of age. Along with this we hear of "the terrible twos" and additional references to how small children try to "manipulate" parents. Again, the words themselves lead to the notion that the young child is determined to fight against the parents.
An alternative way of viewing this phenomenon is to understand that what appears to be a struggle between toddler and parent is in fact a process occurring inside the child.
By the end of the first year, the pleasures and gratifications that have been relatively passive must be left behind. Being held, rocked, nursed, and cuddled gives way to the new experiences that accompany maturation. Standing, walking, exploring, and making brief but ever more extended movements away from the mother evoke inner conflicts. These conflicts arise over the desire to move out into the immediate world as opposed to the desire to retreat to the cozy comforts of being a baby. This back- and -forth oscillation of impulses becomes an inner struggle that needs well-timed and sympathetic support from the parent. What the child needs, if he is to become comfortable with mastering new experience, is an ally who cheers him on and not an adversary. Parents who can recognize that the unevenness of behavior in their toddlers and young children is not a way of trying to win a battle against them, but a reflection of the child's inner struggles with letting go of the old and mastering the new, are able to avoid battles with their children.
WARM UNE CONTRIBUTIONS TO THE COMMUNITY
The Warm Line provides a source for raising community consciousness about the need for early prevention of emotional disturbance in infants and toddlers. By bringing to the attention of the community the necessity for providing young parents an opportunity to talk in detail about how to manage the behavioral aspects of their children's development, a Warm Line helps deepen community wisdom about child rearing.
University programs in early child development are increasing in number, reflecting the realization that more attention can profitably be paid to the techniques of rearing infants and toddlers. Child psychiatrists have become interested in the field of infant psychiatry. Those who major in such studies need to be in touch with the practical and clinical aspects of the parenting of very young children if they are to be of real help. Field placement in a clinic where a Warm Line is functioning can be of profound value for future specialists in early child development, just as it can be of great value for pediatric residents and for child psychiatrists.
It is to be hoped that the well-staffed pediatric clinic and private office will be able to employ child specialists who have been trained to provide a Warm Line service, thereby fulfilling the notion of early and primary prevention. The Warm Line that we began in 1971 has now been replicated in six clinical centers across the country, and all are experiencing gratifying results.
1. Augenbraun, B., Reid, H. L., and Redman, D. B. Bret intervention as a preventive force in disorders of early childhood. In Barten. H. H., and Barten, S. S. (eds.). Children and Their Parents in Brief Therapy. New York: Behavioral Publications, 1973, pp. 137-145.
2. Brown, S. L. On the functions and stresses of parenting. In Arnold. L. E. (ed). Helping Parents Help Their Children: Principles of Parent Guidance for Professionals. New York: Brunner/Mazel (in press).
3. Brown, S. L. Emotional disorders. In Gellis, S- S., and Kagan, B. M. (eds.). Current Pediatric Therapy, Volumes 7 and 8. Philadelphia: W. B. Saunders Company. 1976. 1977.
4. Mahler. M. S.. Pine. F, and Bergman, A. The Psychological Birth of the Human Infant. New York: Basic Books. 1975.
5. Brown. S. L Family experience and change. In Friedman. R. (ed). Family Roots of School Learning and Behavior Disorders. Springfield. Ill: Charles C Thomas, Publisher. 1972, pp. 1-44.
6. Fraiberg. S. H. 7ne Magic Years. New York: Charles Scribner's Sons, 1959.