evaluation of the quality of parent-child relationships: a longitudinal case study

The Arts in Psychotherapy, Vol. 20, pp. 387-395, 1993 Printed in the USA. All rights reserved.

0197-4556193 $6.00 + .OO Copyright 0 1993 Pergamon Press Ltd.

EVALUATION OF THE QUALITY OF PARENT-CHILD RELATIONSHIPS:

A LONGITUDINAL CASE STUDY

STEVE HARVEY, PhD., ADTR, RDT, RPT and E. CONNOR KELLY, MA, ADTR, LPC*

This article presents a strategy to evaluate the quality of parent-child relationships using structured observations developed from dance/movement and drama therapy in a case study. The material was gath- ered by the first author (S.H.) at the request of a Department of Social Services agency and presented in court testimony to help determine the permanent placement of a young boy who had been in foster care for several years due to allegations of physical abuse and neglect. An assessment procedure that included categories of parent-child interactive movement, quality of developmental play and dramatic enactment provided information on attachment and affective attunement. Because this boy was seen at 18, 36 and 40 months of age, his general interactive strategies used both in his movement and dramatic play were identified. This procedure may provide a model for future research in how the expressive arts therapies can be used to investigate family relationships as well as provide clinical assessment.

Several authors (Ainsworth, Elehar, Waters, & Wall, 1978; Bowlby, 1982; Sroufe & Waters, 1978, Stem, 1985) suggested that the relationships between infants and their adult caretakers develop patterns of expectancies, social understandings and strategies that can be seen in nonverbal behavior. These patterns are organized around strong affective themes and provide direct influences on how young children develop understanding of intimacy, emotion, attachment and

their expression of these core-related issues. These authors suggested that the patterns become intemal- ized through various mechanisms (i.e., the internal working model-Bowlby, 1982-or representations of interactions that have become generalized (RIG)- Stem, 1985).

Bowlby suggested that one very important orga- nizing factor of parent-child relationships is attachment, which refers to the emotional tie between family members and develops as parents respond to their children’s nonverbal communication concerning distress and needs for comfort and protection from their earliest days of life onward. Ainsworth et al. (1978) have identified different styles of attachment that have developed from varying parent-child interactive histories during the first year. Children whose parents have been consistently available and show nonverbal sensitivity develop expectations that their needs can be met and show secure attachment. These children demonstrate clear approach, contact-seeking and contact-maintaining behavior to their caretakers’ bodies when they are distressed. Further, such physical contact is successful in producing anxiety reduction. Other children demonstrate insecure attachment, showing avoidance of and/or resistance to their parents bodies when they are distressed. Such nonverbal behavior has been associated with histories in which parents have not been as available. Avoidance in par- ticular has been interpreted by Ainsworth et al. as

*Steve Harvey is a licensed psychologist and registered member of the Dance, Drama and Play Therapy Associations. He maintains a private practice working with families and young children throughout Southern Colorado.

E. Connor Kelly is a licensed professional counselor and registered dance therapist living and working in Colorado Springs, CO. She maintains a practice working with young children and their families.

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388 HARVEY AND KELLY

reflecting a defensive posture by the child related to his or her anger at the caretakers.

Crittenden (1988) observed an attachment interactional style that appeared commonly among mother- child dyads in which severe physical abuse occurred. In this situation, mothers were identified as being controlling and their young children were obsessively compliant. These children were notable in their over- use of rigid, masked, happy facial expressions, highly restricted and unspontaneous vocal and emotional expression, awkward body position, resistance to touch, strong tendencies to accept leadership of their parents’ interests, immediate compliance with adult changes in activity and strong persistence in the adult’s choice of activity, even in the face of clearly impossible demands. Crittendon’s observations showed that such abused infants began to develop a restriction of their more natural expressions of negative feeling (vocal protest, negativism, etc.) as early as the second part of the first year in an adaptation to the abuse situation. The resulting quality of these patterns of physical interaction was one of pseudo-sensitive, pseudo- cooperation between parent and child. The development of these false selves has a clear defensive function.

Stem (1985) discussed patterns between infants and their caretakers that are organized on a smaller scale of observation. Rather than discussing an internal working model concerning an infant’s feelings of security, Stem described representations of nonverbal parent-child interactions that have been generalized across several interactive episodes related to the expression of single emotions. According to Stem, these RIGS are organized around specific affective themes early in infancy. Stem suggested that, especially in the second year, such behavior can be observed in episodes of affective sharing in expressive interactive play. This sharing is called affective attunement and consists particularly of the matching of expressive rhythms between parents and child in emotional situations. An example of attunement for the young child may be expressing an emotion through the rhythms of his or her gestures and body postures while the parent matches these rhythms in his or her body or vocal pattern. A child can attune to the parents’ expressions as well. The development of attunement patterns is very important in the emerging social understanding of the young child. Without the development of a series of “dances” of attunement of emotional expression, children’s ability to form empathy for self and others is significantly compromised.

Such nonverbal patterns and strategies of attunement and attachment become internalized as the infant

matures into toddlerhood and the preschool years. Bertherton (1985; Bertherton, Ridgway, & Cassady, 1991) designed a structured storytelling technique in which preschool children described separations, re- unions and security-seeking behavior in a story context. Bertherton found that such stories did reliably relate to earlier attachment status. Solomon and George (1991) described a similar set of stories told by 6-year-olds in which the content of secure children suggested strategies of security-seeking behavior. However, children with insecure attachment produced stories organized by avoidance of parental security or showing aggressive, bizarre and violent themes. The strategies employed by nonsecure children’s stories did not include parental figures in any helpful way. Stem (1985, 1990) suggested a developmental sequence whereby a narrative sense of self is developed by preschool children as they tell stories in play. Ac- cording to Stem, such stories incorporate use of affect and other intimacy-related issues and are connected to the quality of early patterns of nonverbal behavior between parents and children.

This literature suggests continuities between the development of early nonverbal interactive patterns around emotional themes between children and their parents and these children’s later imaginative play and dramatic interactions around themes involving intimacy, emotional expression and family relationships. This literature suggests that as parents and children begin expressing and resolving core emotional needs, interactive patterns and strategies develop. Although such patterns may exist primarily on a nonverbal level in early relationships, basic strategies influence the storytelling and imagination of children as they ma- ture. These nonverbal patterns greatly affect the expressions concerning intimacy, social relationships and family themes. Such research is of relevance to creative arts therapists who come to understand their clients primarily through the use of the nonverbal and imaginative expressions. This article shows how observations of attachment style and attunement helped determine the quality of relationships between a young boy and his caretakers. Over time, the boy’s expressive strategies were identified in his dramatic storytelling as well.

History

Case Study

Aaron was born to two young parents, both of whom were actively alcoholic at his birth. No other siblings were present in the home at that time. During

QUALITY OF PARENT-CHILD RELATIONSHIPS

the first month of Aaron’s life, he came to the attention of the local Department of Social Services following an episode in which his mother brought him to the emergency room of a local hospital stating that she wanted to kill him. The woman was clearly inebriated at the time and stated that she could no longer stand his screaming. By the time Aaron was 7 months old, Protective Services removed him from his parents’ care and placed him in a long-term foster home.

A brief, family-oriented treatment was attempted for approximately 1 month. The family then dropped out of treatment and Aaron’s father left the state. Aaron’s mother, however, stayed actively involved with ongoing visits and attempted to regain custody. Visitation between mother and son continued irregu- larly for several years. According to Department of Social Services notes, Aaron developed a constricted and avoidant expressive style when visiting his birth mother. However, he developed a decidedly different expressive and interactive approach with the foster parents, with all developmental milestones occurring in a normal fashion. Aaron was also reported to be highly expressive, verbal and spontaneous in his adoptive home. No difficulties were noted with walk- ing, language development, toilet training, sleeping or eating. However, some intense nightmares and oppositionalism followed Aaron’s visits with his birth mother.

Parental rights were terminated when Aaron was approximately 3 years old. The birth mother could not complete her court-ordered treatment plan, which included active participation in therapy for her alcohol- related problems. Aaron was then adopted by his long-term foster parents.

Reason for Evaluation

The first author was contacted by the ongoing social service caseworker when Aaron was 18 months old to evaluate the quality of the relationship between the boy and his mother. A second evaluation was requested when Aaron was 36 months old just prior to the court ruling on termination of mother’s parental rights. The purpose of these assessments was to determine if the emotional relationship between Aaron and his mother was in his best interest, given the past history of abuse, neglect, inconsistent visitation and long placement in a foster home where Aaron was provided positive parenting. The opinion generated by this evaluation was presented in court as part of the social service case for termination, along with the

mother’s refusal to participate in treatment. The judge ultimately ruled in favor of termination of rights. Both caseworker and the foster parents requested that Aaron be seen in therapy to address nightmares and oppositionalism he developed after a series of final visits with his birth mother following the court action.

Evaluation Procedures

Aaron was seen in interactive evaluation with his birth mother when he was 18 months old. The same interactive evaluation was conducted with his foster parents. This evaluation consisted of a 40-minute observation of interactive play with foster parents on one occasion. Two sessions between Aaron and his birth mother were conducted to insure reliability. This interactive play consisted of approximately 15 minutes of initial free play followed by approximately 5 minutes of Aaron’s solo play. A reunion between Aaron and the respective caretakers was then observed, followed by an additional 15-20 minutes of interactive play. The same format of observation was conducted at 36 months between Aaron and his birth mother. No formal observation between Aaron and his foster parents was conducted at 36 months. In the sessions, Aaron and his respective caregivers were led into a large playroom filled with attractive props that en- couraged physical play interaction. These props included large stuffed pillows, stretch ropes, large stuffed animals, parachutes, gymnastic balls and art material, which consisted of paper and markers and was easily accessible.

Observational Techniques

Affect Attunement

To gain some understanding of the quality of interaction at these two different points in Aaron’s life, observations included quantitative counts of affective attunement or affective sharing (Stem, 1985). For these observations, affective attunement was defined as clear, shared nonverbal rhythms, postures, gestures and facial expressions, and/or verbal or vocal gestures that were initiated and matched by Aaron and his respective caretakers. An example of this process was an occasion when Aaron became excited during play with a ball. He showed this nonverbally through facial expression and hand gesture while his foster parent exclaimed, “You are a happy boy!,” using a rhythm of verbal expression similar to Aaron’s nonverbal ges- tural movement. Affective attunements were noted by

390 HARVEY AND KELLY

both authors of this article independently. An initial training period was established where disagreements in obse~ations of affective attunements were dealt with via conference. Throughout almost 21% hours of videotaped review, agreement of affective attunement was highly similar. Both observers in this case had had extensive experience and training in movement observation and training and practical experience as members of the Academy of Dance Therapists Registered.

Breaks in I~teruct~on

Observations of Aaron’s interactions with his birth mother suggested that he would repeatedly stop mutual activity by distancing himself, turning his back and/or developing a different activity (such as playing with a separate prop). These breaks served the function of halting the progress of emotional development in play interactions when physical closeness or attunement might occur. A numerical count of breaks in all interactions was done. Occasionally, Aaron would

shift his attention with genuine curiosity and distance himself to explore other play props when with his foster parents. Aaron would then use this prop to re-include the caretakers. Therefore, his breaks needed to be observed and counted within the context of each interaction. The interactive function and in- tent of Aaron’s distancing and piay shifts needed to be considered. In these observations, a short time factor was able to be used to differentiate the interactive breaks from the attentional shifts due to curiosity. For this article, breaks were identified as the nonverbal behavior that removed Aaron from interaction with the respective adults for longer than 5 seconds. Both authors were able to reach agreement as to the iden- tification of breaks after watching approximately 5 minutes of video together. Breaks were then independently rated. After their observations both authors agreed as to the total number of breaks. The number of Aaron’s interactive breaks was used to describe comparison of relationship differences.

Use of Intimate Space

The amount of time Aaron spent in intimate reach space with each parent was timed. Reach space re- ferred to the distance Aaron or the adults had between their bodies, their arms or legs when these limbs were extended comfortably in all directions. When Aaron and an adult were inside their reach space, they were

involved in an activity where they could touch each other comfortably. In this measure, if Aaron passed into the common reach space with a parent, a stopwatch was started; if he passed out of this reach space, this time was stopped. Time spent a distance of more than 5 feet from each other was taken in a similar fashion. In this way, the amount of time Aaron and his parents spent in a sharing of intimate space and that spent at a further distance from each other was compared.

frost-to~Front Interaction

The amount of time Aaron spent with each respective caretaker in a front-to-front communicative position was also taken. When Aaron entered a face- to-face position with a caretaker, timing with the stopwatch was initiated. As Aaron passed out of this face-to-face position, this time was stopped. Compar- isons of cumulative time spent in face-to-face posi- tions were then compared across caretakers.

Total Time Spent in Interaction

The amount of total time spent in and out of interaction was estimated. Time in interaction was calcu- lated by starting a stopwatch when Aaron and respective caretakers were involved in a mutual expressive activity. Time out of interaction was estimated by starting a stopwatch when Aaron was involved in his own separate activity without including the respective adult. Each of these times did not add up to the total time because the amount of transition of mutual to individual activity was not included in these estimates.

~~a~itat~~~e assessments of ~tt~c~~lent Category

Observations of interaction during initial episodes, in solo play and at reunion, were conducted to determine attachment classification status. Observations, particularly at reunion, were helpful in this regard both at 18 and 36 months. The two authors conducted judgments of proximity-seeking and contact- maintaining, avoidance and/or resistance to contact with Aaron’s approach toward his caretaker. Clear patterns emerged at both observation times, which led to the assignment of a distinct avoidant or secure attachment style. These observations were conducted using video review of child behavior at reunion with the current authors matching Aaron’s behavior with


the published attachment criteria cited by Ainsworth et al. (1978).

Other Qualitative Evaluations

Other qualitative observations conducted throughout these evaluations helped describe the quality of relationship between Aaron and his caretakers. These observations included presence or absence of repetitive sensory-motor activity, quality of dramatic role activity, presence or absence of the use of a transitional object and use of other dramatic play props provided, quality of language used and other general interactive movement themes that Aaron used from his emergent patterns of relationship.

Stories

The stories reported in this article were generated when Aaron was approximately 3% years old in therapy sessions with the first author. Aaron completed interactive dramatic play with his foster mother present as well as by himself. This play was primarily nondirective. However, the therapist did introduce a large stuffed animal as the “other mama” (Aaron’s words) briefly at the beginning of one session. During later sessions, a small stuffed animal was placed on a pillow with the action of “going to bed by himself.” These images introduced emotional and family themes relevant to the treatment issues. Aaron’s play related to these themes was spontaneous without other influence by the therapist or foster parent.

Observational Results

Attunement Interactive Breaks in Time Spent in Interaction

As can be seen clearly from Table 1, the interactions between Aaron and his birth mother contained relatively many breaks in continuous interaction (Ep- isode A = 40, B = 27, C = 50) and relatively few episodes of attunement (Episode A = 6, B = 5, C = 6), whereas interactions between Aaron and his foster parents were characterized in the opposite fashion, with many attunements (D = 115) and virtually no breaks (C = 2). These contrasting styles led to Aaron spending almost as much time involved with his birth mother in interaction (A = 12:17, B = 23:10, C = 17:12) as in his own activities out of interaction (A = 11:20, B = 23:10, C = 18:15). However, virtually

all Aaron’s time was spent involved with his foster parents (28:20 minutes).

Aaron also tended to spend more time at a distance of more than 5 feet from his birth mother (A = 19:48, C = 25:02) and a relatively small amount of time in a face or frontal interaction with her (A = 3:20, B = 1:51, C = 7:50). Again, this style was in contrast to the amount of time spent in close physical contact space (D = 9:54) and/or frontal contact (D = 11:lO) with his foster parents. It is interesting to note that Aaron and his birth mother shared relatively few attunements, time in close physical touch space, had more time further away from each other, less time facing each other and used a higher amount of breaks consistently in interaction at 18 months as well as at 36 months.

Aaron’s birth mother began the second observation when her son was 18 months old by initiating a relatively long hug (2:30). Aaron responded to this intimate approach by becoming very passive, showing restricted range of nonverbal expression and by re- maining just outside his birth mother’s reach space, turned slightly away from her, taking himself from face-to-face position. Though he did not spend as much time distancing himself (B = 2:32) or creating breaks by turning his back (B = 3:12), Aaron did occupy himself with the meaningless, repetitive sensory-motor activities. This interactional style is similar to interactions of severely abused toddlers and their abusive parents, characterized by obsessive compliance (Crittenden, 1988). This compliant man- ner appears to have been cued by the birth mother’s initial demand for physical closeness (the hug) as the session began. The demand seemed to influence Aaron’s more usual style of avoidance of physical/ emotional closeness by taking distance. However, though Aaron did not remove himself from his birth mother as often or as spontaneously as he might have, neither did he actively seek out closeness (time in reach space B = 2:09). Rather, his sensory-motor activity just outside his birth mother’s face and touch appeared to function as a less obvious expression of avoidance.

Interactive Play Quality

The quality of interactive play between Aaron and his birth mother, and Aaron and his current foster caretakers was very different. Throughout all interactive play scenarios with Aaron and his birth parent, the boy, both at 18 months and at 36 months, showed

392

Table 1

HARVEY AND KELLY

Quantitative Longitudinal Observations of Interactive Behavior Between Aaron and His Birth Mother, and Aaron and His Foster Parents (18 months-36 months) (time in minutes:seconds)

Episode A Episode B Episode C Episode D

Number of affective attunementa

(expressive rhythm sharing)

Number of breaks in mutual

play activity

Time spent in mutual activity Time spent in solo activity

Time in front-to-front activity

Time spent with child’s back

to adult

Time spent with parent/child

within their reach/touch space

Time spent with parenuchild

beyond 5 ft. of each other

Behavior at reunion

Play quality

*Time of episode 35 minutes 42 minutes 34 minutes

6 5 6 115

40 27 50 L

12:17 17:20 17:12 28:20 I I:20 23:lO 18:15 00:24 3:20 I:51 7:50 11:lO

12:22 3:12 17:32 0O:lO

2:30 2:09 255 9:54

00:04

Immediate approach/

comfort seeking.

Distress relieved.

19:48 2132 25:02 Avoidance through Avoidance through Avoidance through

distance taking. No distance taking. No distance taking. Turn approach seeking. approach seeking. back. No approach.

No distress. No distress. No distress.

Repetitive Repetitive Repetitive

sensory-motor sensory-motor sensory-motor activity. activity. activity.

Metaphorical play with

props, use of

transition object

during solo play.

36 minutes

Episode A: boy at 18 months with his birth mother. Episode B: boy at 18 months with his birth mother 1 week later. (Mother began by demanding a hug; boy responded with weight contact for 1% minutes.) Episode C: boy at 36 months with birth mother. Episode D: boy at 18 months with foster parents. *Times of categories do not add up to total time due to unmeasured transition time.

very little verbalization as well as very little symbolic or metaphorical content in his shared activities. In fact, little developmental progress as reflected in play was noted at the two observations, despite a year-and- a-half of physical and psychological growth. Aaron’s play during both observations, at 18 and 36 months, was characterized by repetitive sensory-motor activities. During approximately 2% to 3 hours of videotaped play, Aaron used the magic markers in a repetitive way by taking the caps off the markers and re- placing them. This activity especially dominated interactive sessions when Aaron was within 2 to 3 feet of his birth mother. The interactions between them consisted of handing markers back and forth to each other.

When Aaron’s birth mother did attempt other interactive activities, Aaron responded by changing the games to again establish more physical distance be-

tween them as well as significantly restricting other avenues for emotional communication. At 18 and 36 months, Aaron’s birth mother initiated a game of rolling a ball toward him. On both occasions, Aaron responded by rolling the ball away from her. This same strategy was repeated when Aaron’s mother introduced a balloon in a similar fashion. Aaron again hit the balloon away from his mother and continued to look away. On another occasion, at 36 months, when Aaron and his mother started to play on the large pillows, his play had the effect of placing pillows between them.

Aaron’s interactions in play with his foster adoptive parents were different. During the formally observed interactions at 18 months and more informal observations at 36 months, Aaron’s play was far more age specific. At 18 months, both Aaron and his foster parents were able to use stuffed animals to express

QUALITY OF PARENT-CHILD RELATIONSHIPS 393

positive affect. This game had the foster parents and Aaron hugging a stuffed monkey together. During solo play, Aaron hugged the monkey on several occasions, suggesting that he was using the activity as a transitional object to metaphorically represent his parents during their absence. Additionally, all other interactions between Aaron and his foster parents contained the use of reciprocal turn-taking and other social roles that suggest caretaking and affect, such as caring for stuffed animals.

Observations of Reunion Behavior

Using Aaron’s observable behavior at reunion, judgments of attachment styles were used during the interactive interviews at 18 and 36 months with Aaron and his respective caretakers. Such reunion sequences followed episodes in which Aaron was observed in solo play for approximately 5 minutes. The patterns of Aaron’s interactive behavior at reunion were similar during all such reunion episodes, which were observed once with Aaron and his foster parents at 18 months, on two different occasions with Aaron and his mother at 18 months and once between Aaron and his mother at 36 months.

In all three reunion sequences observed between Aaron and his mother, Aaron showed a high degree of avoidant behavior coupled with little proximity- seeking and no contact-maintaining behavior. Fur- ther, Aaron showed no active resistance. During both reunion sequences at 18 months and at 36 months, Aaron turned his back on his mother and increased his distance further. At 18 months on both occasions, Aaron continued to be involved in the play activity he had developed during his solo play and showed no attempt to accommodate to his mother’s entrance. Aaron continued this activity until his mother inter- vened through questioning or attempting to initiate an alternative activity. At 18 months, Aaron was con- spicuous in introducing the marker activity described above. At 36 months, Aaron introduced impersonal verbal themes in response to his mother’s questioning. In addition, Aaron offered these verbalizations with his back to his mother. The strategy of such play behavior with the markers at 18 months and the verbalizations at 36 months functioned in a way to offer clear avoidance of his mother.

The reunion sequence between Aaron and his foster parents was different. During this period, Aaron was observed following solo play, both with his foster mother and his foster father. On these occasions,

Aaron warmly approached his caretakers and showed a decrease in the mild distress he evidenced during his episodes of solo play. Interactive activities between Aaron and his foster caretakers were easily established within 30 seconds. By all indications, these suggest that Aaron had developed a secure attachment to his foster parents.

Individual and Conjoint Family Therapy Play Themes

Aaron was seen in individual and in family- oriented play therapy to address nightmares, tan- trums, mood changes, difficulty sleeping alone, and oppositionalism following the final visits with his mother when he was 40 months old. The play samples were generated in the same therapy room as other assessment sessions described above. Aaron was seen primarily with his foster mother. Both the therapist and foster mother took the roles of observing Aaron’s play. As the sessions progressed, Aaron was assisted in asking his foster mother to assume a protective and caretaking role when repeated distressful themes were identified.

During the initial sessions, Aaron introduced the theme of the “other mama. ” The therapist identified a large stuffed bear as this “other mama. ” Aaron then produced spontaneous dramatic play using this figure, showing a lack of interest in and avoidance of this character. Aaron’s interactive style with the large animal was strikingly similar to the avoidant interactive style between him and his birth mother described above. During later sessions, Aaron elaborated on the “other mama” by enacting the “other mama” attempting to steal the younger, smaller bear cubs.

In the next session, a small bear was placed in bed by Aaron to represent his difficulty sleeping alone. To this story beginning Aaron added a snake who was a friend of the “other mama,” and several other large bears who were mean to the younger “children bears. ’ ’ The threatening figures also were described as wanting to steal the children from their bed and the house of their mother. The large figures were described as having spiders and bugs inside them and on their stomachs and wanting to eat the younger children. In one very moving scene, Aaron demonstrated how the large “other mama” would steal his heart and put the bugs and spiders all over it. In contrast to these frightening images, Aaron consistently cast his foster mother in a warm and protective role when he and the young play protagonists would come close in order to chase the mean figures away.

HARVEY AND KELLY

Discussion

Observations of Aaron’s nonverbal and dramatic play behavior suggest he had developed an interactive style that was characterized primarily through a strategy of avoidance. Some obsessive compliance during one of the evaluation sessions was also suggested. This strategy consisted of showing little significant affect or expressive matching of affect (attunement), little or no sharing of face-to-face and front-to-front nonverbal communication, little or no eye contact and little or no sharing of intimate space. Rather, Aaron used his nonverbal behavior to break episodes of mutual activity with his birth mother to regulate and control the amount of emotion and physical closeness he shared with her. Further, Aaron had developed a style in which he would not include his birth mother in any significant core-related emotional experiences normally associated with parenting or secure attachment such as seeking reassurance and physical closeness when distressed. Aaron also was restricted in the use of his imaginative and verbal abilities throughout his play with his birth mother and tended to use repetitive activity in her presence. In later dramatic play, Aaron represented his mother with frightening and intrusive imagery. In general, this theme of avoidance and lack of comfort formed an interactive strategy that was resistant to change.

However, Aaron’s nonverbal behavior with his foster parents showed he had developed a very secure relationship with them. This security was demonstrated by secure attachment behavior and free and easy use of affective attunement or affective sharing. Additionally, Aaron showed virtually no interactive breaks with his caretakers. This combination of few breaks in mutual play coupled with ongoing attunement suggested that Aaron was willing and able to share expressive rhythm with his foster caretakers. Also, Aaron was able to augment this interactive style with interactive play that included development of metaphors to express intimacy, caring, safety and positive affect. At 18 months, Aaron initially showed similar kinds of behavior with a small stuffed animal that he had shown with his foster parents. During solo play, he was able to use this animal as a clear transitional figure, hugging it and showing the same nonverbal affective expressions to the animal he had developed and shown with his primary caretakers. In this later dramatic play, he cast his foster mother in roles that clearly protected him from the “other mama” character. These nonverbal behaviors and

play suggested that Aaron’s history with his foster mother was quite positive and that he was able to use this relationship to calm the distress generated by the final visitation with his birth mother.

Summary and Conclusions

In reviewing these observations, it is clear that Aaron had developed very different interactive styles with his caretaking adults. Although this difference is not surprising given the varying histories between the boy and his birth and foster parents, it is worth no- ticing how Aaron showed these differences in his movement and dramatic play. These expressions were organized around consistent themes and strategies over 2 years, and these themes were apparent in the nonverbal patterns as well as in the dramatic stories.

The use of multiple observations suggests that Aaron’s more general quality of avoidant or secure emotional attachment was reflected in the moment- to-moment use of active engagement in expressive rhythm sharing or breaks of such sharing. Also, Aaron’s attunement style appeared to function together with his use of close space, front-to-front po- sitioning and ability to maintain mutual play.

The use of a common evaluation procedure and structured interactive observations helped highlight important child expressions that could reflect emotional relatedness. The movement structure included interaction with the child and his caretaker in episodes of: (a) free play with parents, (b) the child’s solo play and (c) a reunion episode between child and parents. Specific observations of movement behavior at reunion and through the interactions were included. Dramatic play in which the child developed elaborat- ing images, from story beginnings provided by the therapist related to symptomatic behavior and family situation, produced additional information. The strategies and imagery involving relationships to parent figures were identified. Clinical impressions concem- ing relationship quality were generated from both movement and dramatic representation. Because of the similarity of observations between the adults involved in this case, some conclusions about differences of relationship quality may be made.

The structure and observation included in this evaluation can provide a general outline for further research by creative arts therapists into the nature of parent-child relationships. One important study may be to use this procedure with parents and children with varying interactive histories, including children


whose parents are depressed or children who are adopted at birth and who have no history of trauma, children with parents separated by divorce and children who have no history of trauma and have positive relationships with their parents, as well as children such as Aaron who have experienced abuse. It can be that children who have experienced different kinds of separation, abusive trauma and sensitive parenting or- ganize their interactive strategies concerning attachment and emotional communication differently.

All of the observations in this case study proved to associate with each other in rather clear patterns of avoidance or security. However, this may not occur in situations including other kinds of relationships. Therefore, the use of multiple movement observation categories and dramatic enactment may prove useful. For example, it may be that some children who show resistance or disorganization in their approach behavior also show different patterns of attunemen~breaks/ space use or body orientation.

As in this case, the ratio of attunements and breaks may prove to be a useful indication of a child’s emotional restriction in situations that have different social demands even with a single family member. Ob- servations of the variation of young children’s nonverbal attunement/brcaks over a single session may provide indications of specific emotional themes that have positive or fearful meaning within the family. By following parent-child subjects over time, con- tinuing investigations can be made as to how rela- tional meaning develops from nonverbal to ~amatic/ verbal imagery. As was the case with Aaron, the patterns of core emotional experience likely provide connections between physical and verbal/play expression. Additional direct observations of parental nonverbal sensitivity and response to attunement and breaks can better describe adult contributions to the relationship through their ongoing movement behavior.

The evaluation used here can also be useful in clinical situations. In this case, these observations provided the social service and legal system with very

clear and concrete information as to how Aaron tended to express his needs while in two homes being considered as his long-term placement. Although the judge’s decision to terminate the birth mother’s parental rights ultimateiy was made on her inability to seek treatment for herself, the evaluation of Aaron’s quality of relationship was also important. If more positive indications were present in Aaron’s interactive behavior, such as more direct approach or more use of attunement, the court may have been more favorable toward her request to resume as parent to her son. Similar evaluations can also be used to iden- tify areas of weakness with interaction to more spe- cifically address treatment.

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