Creating Space to Discover a Baby’s Intentions

At the outset of a Zoom visit with 7-week-old son James in my behavioral pediatrics practice, his mother Sondra explained to me that he is “stiff because of my medication.” While feeding him a bottle she told me she was unable to breastfeed due to the effects of MAT (medicated assisted treatment, now called medication for opioid use disorder, or MOUD.) It was not concern about her current use of methadone, which is widely considered to be safe for breastfeeding, but rather the in-utero exposure. Yet when I asked about the pregnancy and delivery, I learned that James had not had any withdrawal symptoms, had not required any treatment, and had gone home from the hospital in 2 days. I wondered about the certainty of her conviction that what she called “stiffness” was related to her medication. But at this point in the visit, I didn’t know. It was possible. I decided to take a bit of a risk. What might we discover if we observed his movements together?

I suggested she lay him down on a blanket where we could watch him. She unwrapped him and carefully placed him on the floor. We both immediately noticed how with his extremities free, he straightened out his arms and legs as Sondra talked to him. I wondered if his movements might reflect a communication with her. As she continued to speak in a soft, lilting voice James moved his arms as if to reach for her. In what I call a “Trevarthan moment” he offered evidence for infant researcher Colwin Trevarthan‘s discovery of purposeful movements in newborn infants. As if in response to his gesture, she spontaneously picked him up. He again extended his arms and legs as he turned to her voice before folding himself up in her arms. “Look how he likes to curl up. He knows how to comfort himself.” she remarked with delight, “He’s such a little person already!” She now saw his movements not as her failure but as his strength.

Before our session together Sondra attributed motivations and intentions to James’ behavior based on her own explanatory model. Likely her persistent guilt over exposing him to opioids during the pregnancy contributed to her difficulty giving any other meaning to his behavior. Sondra had longed to breast feed. But in those early days when she saw his movements as reflecting her “harming” James, the stress inhibited her from connecting with him while nursing. She easily gave up, preferring the more shame-free experience of bottle feeding where she did not need to grapple with his extremities so intimately. Yet now seven weeks later, she wept openly as she described the lost opportunity. “If someone had helped me to make sense of his behavior, I might have kept at it,” she said through her tears. I replied, “You made what was the right decision for you and James at the time.” I wanted to help her to discover joy in feeding her son, who was clearly thriving.

In a fascinating book Becoming Human, research psychologist Michael Tomasello describes the ability to recognize each other’s intentions as central to our humanness. He proposes that “the ontogeny of human cognitive and social uniqueness is structured by the maturation of children’s capacity for shared intentionality.” To highlight the significance of the process he writes: “Social bonding via the sharing of emotions, attention, actions and attitudes is an evolutionarily novel phenomenon: individuals feel closer to others as they share experiences with them. This is foundational to virtually all forms of uniquely human cooperation and shred intentionality.” He names the age of nine months, when this behavior first becomes easily observable, the “birth of shared intentionality.”

As a pediatrician who has worked with newborns and parents for decades, my “research” consists of intimate observation and listening to stories. I wonder if, using Tomasello’s model, the meeting of two separate selves at birth could be seen as the conception, with the first nine months of life offering a kind of “gestation” of shared intentionality as caregiver and infant get to know each. Both partners in the pair, as unique individuals, come with their own set of intentions. Through a messy process of interaction each comes to know the other’s, leading to moments of meeting such as Sondra shared with James during our visit when they discovered the shared intention of connection. I witness not only emergence of shared intentionality, but also what can inhibit the process. When caregivers substitute their own intentions for their infant’s, relationships and development can become derailed.

In in rural western Massachusetts where poverty, community violence, and substance use sit side-by-side with natural beauty and a wealth of cultural opportunity, the Hello It’s Me Project brings together practitioners from a wide variety of disciplines who work with infants and parents every other week to discuss the challenges of our work. On a recent Zoom call, we heard from Rosalie, director of Berkshire Nursing Families, and a passionate advocate for parents in the critical days of the immediate postpartum period. She spoke of parents she knows with adult children who still hold vivid memories of the sense of failure surrounding their inability to successfully breast feed their baby. While she recognized that bottle feeding can be a perfectly fine choice, the pain of parents who want to breastfeed but are not able to do so can remain alive for decades, with long-term effects on the parent-child relationship.

If shared intentionality is a critical part of our humanity, we would do well to protect time and space for new parents to listen to their baby’s earliest communications. In a society lacking in a culture of postpartum care, this critical developmental process can be easily disrupted. When caregivers themselves feel supported and understood, their natural intuition leads them to make sense of their baby’s behavior, freed from projections and misinterpretations.

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