attachment and infant feeding methods

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596 LEITERS TO THE EDITOR Rothenberger, A. (1986), Kindheit im Mittelalter-aus der Sicht eines heutigen Kinderpsychiaters. Kinderarztl. Prax.. 17:589-598. Zielinski, H. (1983), Elisabeth von Thiiringen und die Kinder. In: U. Arnold & H. Liebig (Hrsg.), Elisabeth, der Deutsche Orden lind ihre Kirche. Marburg: Elwert, pp. 27-42 . Authors' Response To the Editor: We appreciate Professor Rothenberger's brief survey of recent German scholarship dealing with the history of children in the high and later Middle Ages. It is clear from his observations that both he and his colleagues are pursuing a sound quantitative approach to the materials to ours and to that followed by Professor Michel Rouche in France (1981) . There are, however, some interesting divergences between Dr. Rothenberger's results and ours. Professor Rothenberger found a much greater proportion of childhood cases in his source material than we found. This in itself is noteworthy, although it bears directly neither on the class status of the cases nor upon the effort and resources expended to obtain help for children. The variable most likely to account for these differences in class status is that of source genre. All three sources used by Professor Rothenberger arc Miracle books, whereas we used several different genre (chronicles, secular biographies, and hagiography). We have discussed the problems of bias and representativeness of single types of genre in a pre vious article (Kroll and Bachrach, 1986). Concerning the other points raised by Professor Rothenberger. we do include cases of epilepsy. These are subsumed under the heading of "Mad/Possesed," because the discrimination between a seizure disorder and "psychotic-like" behavior is often an impossible one given the descriptions in medieval sources. The point is more fully discussed in our earlier publication (Kroll and Bachrach, 1984) and is exemplified in our later child care report (Kroll and Bachrach, 1986, p. 567) by the case history describing Fridiburga, Duke Gunzo's daughter. Finally, virtually all genres of source material from the Middle Ages are skewed in favor of the upper classes and thus we arc unlikely to obtain as clear a picture of peasants as of nobles and burgers. We look forward to a better understanding of the place of children in the Middle Ages, which is sure to follow upon the increased communication between European and North American scholars. Perhaps an international conference sometime in the next 5 years would be in order. Jerome Kroll, M.D. Bernard Bachrach, Ph.D. University of Minnesota Hospitals Minneapolis, Minnesota References Kroll, J. & Bachrach, B. (1984), Sin and mental illness in medieval Europe. Psychol. Med., 14:507-514. --, -- (1986), Sin and the etiology of disease in pre-Crusade Europe. J. /list. Med ., 4:395-414. Rouche, M. (1981), Miracles, maladies et psychologic de la foi a l'epoque carolingienne en Francie. In: Hagiographie, Cultures et Societies: l Ve-Xl Ie steeles. Paris: Etudes Augustiniennes, pp. 319- 337. Attachment and Infant Feeding Methods To the Editor : In "Contributors to Attachment in Normal and Physically Hand- icapped Infants," Wasserman et al. (1987) studied many variables and had a well-thought-out experimental design . However, the method by which the study's infants were fed-bottle versus restricted versus unrestricted breast feeding-was not even mentioned by the authors, although this information was probably readily available. Infants in their experimental group were probably less likely to have been started on the breast, and less likely to have continued on it, because hospital practices associated with the birth of defective infants arc less conducive to breast feeding-i.e., there is more separation of mother and infant (Carlsson et al., 1978; Taylor et al., 1985; Taylor et al., 1986). Further, many of the infants in the experimental group had oral clefts-not usually a contraindication to breast feeding, although maternal fears and pediatric practice may belie this (Goldfarb and Tibbetts, 1980). Consideration of infant feeding methods is important in attach- ment theorizing because numerous articles have indicated clear psy- chological differences between the types of feeding for both the infant and the mother (Newton, 1971; Newton and Newton, 1967). Was- serman et al. did not find a difference in the infant's attachments but found that maternal responsiveness was less in mothers of handi- capped infants. Could it be that this was related to breast feeding? A breast feeding mother 's response to her hungry infant is hormonally influenced; the sensation oflet down and a positive affective state both being triggered by oxytocin (Newton, 1978). Thus, there is reason to believe that there may be a biological difference in the motivation to respond between breast and bottle feeding mothers. However, if methods of feeding arc ignored, or both arc subsumed under the rubric of "sucking," an important area of mother-infant interaction will not be easily elucidated. Melan ie Thombre, M.D. Assistant Professor of Child Psychiatry Medical College of Ohio at Toledo References Carlsson, S. G., Fagerberg, H., Horneman, G. et al. (1978), Effects of amount of contact between mother and child on the mother's nursing behavior. Develpm. Psychobiol.. II: 143-50. Goldfarb, J. & Tibbetts, E. (1980), Breast Feeding Handbook. Hill- side, N.J.: Enslow Publishers. Newton, N. (1971), Psychologic differences between breast and bottle feeding . A mer. J. CIi". Nutr., 24 :993-1004. -- (1978), The role of oxytocin reflexes in three interpersonal reproductive acts: coitus, birth and breast feeding . In: Clinical Psychoneuroendocrinology In Reproduct ion , cd. L. Carenza, P. Pansheri, L. & Zichella. New York : Academic Press, pp. 41 1-418. -- Newton. M. (1967 , Psychologic aspects of lactation. New Eng J. Med., 277:1179-1188. Taylor, P. M., Maloni, J. A. & Borwn, D. (1986), Early suckling and prolonged breast feeding. AJDC, 140:151-154. ---- Taylor, F. H. & Campbell, S. B. (1985) , Earl y mother infant contact and durat ion of breast feeding. Acta . Paediat , Scand. (SIIPP/.), 316:15-22. Wasserman, G. A.. Lennon, M. S., Allen, R. & Shilansky, M. (1987), Contributors to attachment in normal and physically handicapped infants. This Journal, 26:9-15 . Heterogeneous Diagnoses in Attempted Suicide To the Editor: Dr. Khan's interesting article "Heterogeneity of Suicidal Adoles- cents," adds additional data to our knowledge of adolescent suicide attempts. It is important to compare hospitalized suicidal adolescents with other groups. Most of the conclusions of his report are similar to those of my 1979 report (Crumley, 1979). Dr. Khan compares the adolescent attempters with other psychiatrically disturbed teenagers without a suicide attempt and found few differences. This supports the main conclusion of my study; all the attempters were psychiatri- cally ill before the attempt. At the time of my study, even this basic fact was being questioned. Differences do appear when looking at specific diagnoses; however, comparisons with the diagnoses in my

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Page 1: Attachment and Infant Feeding Methods

596 LEITERS TO THE EDITOR

Rothenberger, A. (1986), Kindheit im Mittelalter-aus der Sicht einesheutigen Kinderpsychiaters. Kinderarztl. Prax .. 17:589-598.

Zielinski, H. (1983), Elisabeth von Thiiringen und die Kinder. In: U.Arnold & H. Liebig (Hrsg.), Elisabeth, der Deutsche Orden lindihre Kirche. Marburg: Elwert, pp . 27-42.

Authors' Response

To the Editor:

We appreciate Professor Rothenberger's brief survey of recentGerman scholarship dealing with the history of children in the highand later Middle Ages. It is clear from his observations that both heand his colleagues are pursuing a sound quantitative approach to thematerials to ours and to that followed by Professor Michel Rouchein France (1981) .

There are, however, some interesting divergences between Dr .Rothenberger's results and ours. Professor Rothenberger found amuch greater proportion of childhood cases in his source materialthan we found. This in itself is noteworthy, although it bears directlyneither on the class status of the cases nor upon the effort andresources expended to obtain help for children. The variable mostlikely to account for these differences in class status is that of sourcegenre . All three sources used by Professor Rothenberger arc Miraclebooks, whereas we used several different genre (chronicles, secularbiographies, and hagiography). We have discussed the problems ofbias and representativeness of single types of genre in a pre viousarticle (Kroll and Bachrach, 1986).

Concerning the other points raised by Professor Rothenberger. wedo include cases of epilepsy. These are subsumed under the headingof "Mad/Possesed," because the discrimination between a seizuredisorder and "psychotic-like" behavior is often an impossible onegiven the descriptions in medieval sources. The point is more fullydiscussed in our earlier publication (Kroll and Bachrach, 1984) andis exemplified in our later child care report (Kroll and Bachrach,1986, p. 567) by the case history describing Fridiburga, Duke Gunzo'sdaughter. Finally, virtually all genres of source material from theMiddle Ages are skewed in favor of the upper classes and thus we arcunlikely to obtain as clear a picture of peasants as of nobles andburgers.

We look forward to a better understanding of the place of childrenin the Middle Ages, which is sure to follow upon the increasedcommunication between European and North American scholars.Perhaps an international conference sometime in the next 5 yearswould be in order.

Jerome Kroll, M.D.Bernard Bachrach, Ph.D.

University of Minnesota HospitalsMinneapolis, Minnesota

ReferencesKroll, J . & Bachrach, B. (1984), Sin and mental illness in medieval

Europe. Psychol. Med., 14:507-514.--, -- (1986), Sin and the etiology of disease in pre-Crusade

Europe. J. /list . Med ., 4:395-414.Rouche, M. (1981), Miracles, maladies et psychologic de la foi a

l'epoque carolingienne en Francie. In: Hagiographie, Cultures etSocieties: l Ve-XlIe steeles. Paris: Etudes Augustiniennes, pp . 319­337.

Attachment and Infant Feeding Methods

To the Editor :

In "Contributors to Attachment in Normal and Physically Hand­icapped Infants," Wasserman et al. (1987) studied many variablesand had a well-thought-out experimental design . However, themethod by which the study's infants were fed-bottle versus restricted

versus unrestricted breast feeding-was not even mentioned by theauthors, although this information was probably readily available.

Infants in their experimental group were probably less likely tohave been started on the breast, and less likely to have continued onit, because hospital practices associated with the birth of defectiveinfants arc less conducive to breast feeding-i.e., there is moreseparation of mother and infant (Carlsson et al., 1978; Taylor et al.,1985; Taylor et al., 1986). Further, many of the infants in theexperimental group had oral clefts-not usually a contraindicationto breast feeding, although maternal fears and pediatric practice maybelie this (Goldfarb and Tibbetts, 1980).

Consideration of infant feeding methods is important in attach­ment theorizing because numerous articles have indicated clear psy­chological differences between the types of feeding for both the infantand the mother (Newton, 1971; Newton and Newton, 1967). Was­serman et al. did not find a difference in the infant's attachments butfound that maternal responsiveness was less in mothers of handi­capped infants.

Could it be that this was related to breast feeding? A breast feedingmother's response to her hungry infant is hormonally influenced; thesensation oflet down and a positive affective state both being triggeredby oxytocin (Newton, 1978). Thus, there is reason to believe thatthere may be a biological difference in the motivation to respondbetween breast and bottle feeding mothers. However, if methods offeeding arc ignored, or both arc subsumed under the rubric of"sucking," an important area of mother-infant interaction will not beeasily elucidated.

Melan ie Thombre, M.D .Assistant Professor of Child PsychiatryMedical College of Ohio at Toledo

ReferencesCarlsson, S. G., Fagerberg, H., Horneman, G. et al. (1978), Effects of

amount of contact between mother and child on the mother'snursing behavior. Develpm. Psychobiol.. II: 143-50.

Goldfarb, J. & Tibbetts, E. (1980), Breast Feeding Handbook. Hill­side, N.J.: Enslow Publishers.

Newton, N. (1971), Psychologic differences between breast and bottlefeeding. A mer. J . CIi". Nutr., 24 :993-1004.

-- (1978), The role of oxytocin reflexes in three interpersonalreproductive acts : coitus, birth and breast feeding . In: ClinicalPsychoneuroendocrinology In Reproduct ion, cd. L. Carenza, P.Pansheri, L. & Zichella. New York : Academic Press, pp . 41 1-418.

-- Newton. M. (1967 , Psychologic aspects of lactation. New EngJ. Med., 277:1179-1188.

Taylor, P. M., Maloni , J . A. & Borwn, D. (1986), Early suckling andprolonged breast feeding . AJDC, 140:151-154.

-- -- Taylor, F. H. & Campbell , S. B. (1985) , Early motherinfant contact and duration of breast feeding . Acta. Paediat , Scand.(SIIPP/.), 316:15-22.

Wasserman, G. A.. Lennon, M. S., Allen, R. & Shilansky, M. (1987),Contributors to attachment in normal and physically handicappedinfants. This Journal, 26:9-15 .

Heterogeneous Diagnoses in Attempted SuicideTo the Editor:

Dr. Khan's interesting article "Heterogeneity of Suicidal Adoles­cents," adds additional data to our knowledge of adolescent suicideattempts. It is important to compare hospitalized suicidal adolescentswith other groups. Most of the conclusions of his report are similarto those of my 1979 report (Crumley, 1979). Dr. Khan compares theadolescent attempters with other psych iatrically disturbed teenagerswithout a suicide attempt and found few differences. This supportsthe ma in conclusion of my study; all the attempters were psychiatri­cally ill before the attempt. At the time of my study, even this basicfact was being questioned. Differences do appear when looking atspecific diagnoses; however, comparisons with the diagnoses in my