Background: The Face-to-Face Still-Face (FFSF) paradigm is a well-acknowledged procedure to assess socio-emotional regulation in healthy and at-risk infants. Although it was developed mainly for research purposes, the FFSF paradigm has potential clinical implications for the assessment of socio-emotional regulation of infants with neurodevelopmental disabilities (ND) and to supporting parenting.

Aim: The present paper describes the application of the FFSF paradigm as an evaluation and intervention tool in clinical practice with infants with ND and their parents.

Methods: Theoretical and methodological insights for the use of the FFSF paradigm in the clinical setting are provided. Single-case vignettes from clinical practice further illustrate and provide exemplifications for the use of the FFSF with infants with ND and their parents.

Results: From a clinical point of view, the use of the FFSF paradigm (1) offers a unique observational perspective on socio-emotional regulation in infants with ND and (2) enhances parents’ sensitivity to their infants’ behavior.

Discussion: The FFSF paradigm appears to be a useful tool for clinical assessment of socio-emotional regulation in infants with ND and promote the quality of parenting and early parent-infant interaction.

The Face-to-Face Still-Face (FFSF) paradigm (Tronick et al., 1978) is a well-known and validated procedure to assess socio-emotional regulation in infants facing a social stressor. The FFSF paradigm has been widely used with healthy and at-risk infants at different ages and it has contributed to improve our knowledge and conceptualization of early socio-emotional regulation development (Mesman et al., 2009). The suitability of this observational procedure to clinical settings has already been suggested (Miron et al., 2009). However, to the best of our knowledge, the FFSF has not been previously used to assess infants (and children) with a neurodevelopmental disability (ND; e.g., autism spectrum disorders, cerebral palsy, genetic syndromes) in a neurorehabilitation clinical context.

Our perspective is framed by the mutual regulation model (MRM; Gianino and Tronick, 1988). The MRM argues that the parent-infant interaction is organized by a bidirectional exchange of communicative signals that are used by the infant and the caregiver to coordinate the interaction and to cope with the stress of normally occurring interactive ruptures. From this perspective, the quality of the interaction is determined by the ability of each participant to cope with external stressors, regulate his/her emotional states, express communicative messages, and respond to his/her partner’s affective communications and regulatory needs. Caregivers’ behavior is guided by infants’ expressive displays (e.g., gaze, facial expressions, gestures, and vocalizations). In turn, infant behavioral and affective states are affected by the expressive displays of the caregiver. Importantly, the MRM – rather than emphasizing just synchrony – highlights that mother–infant interaction is a process characterized by matching and mismatching and that reparation of mismatches is a key developmental mechanism (Tronick and Beeghly, 2011).

Early caregiver–infant relationship may be strongly affected by the presence of a ND and many challenges arise for parenting in the contexts of infants’ disability. On the one hand, the parents face an augmented emotional burden (Dykens, 2015). On the other hand, infants with ND are less responsive and attentive, make fewer vocal and affective signals, are fussier, and produce less clear social cues (Okimoto et al., 2000). Moreover, infants (and children) with a ND have limited regulatory abilities and, therefore, they need their caregivers’ regulatory scaffolding to maintain emotional regulation and cope with interactive stress (Hauser-Cram and Woodman, 2016). Overall, these factors can disrupt the development of the functional dyadic co-regulatory system – including the reparation of mismatched process – and might further impact on infants’ socio-emotional regulation and parenting behavior. Additionally, it should be highlighted that infants with ND need to be hospitalized with their parents to take part in early rehabilitation programs (i.e., speech therapy, physical therapy, and so on). These programs recognize the importance of supporting parent-infant interaction as part of their daily work, but this focus is not widely implemented in practice (Innocenti et al., 2013). Moreover, having a broad picture of the infant functioning and parent–infant interactive patterns can be useful in the promotion of parenting skills.

From this perspective, we propose that the FFSF paradigm may be effectively used in clinical neurorehabilitation settings. Specifically, the FFSF provides a unique observational procedure for the assessment of infants’ socio-emotional regulation and the quality of early interaction in infants with ND and their parents. Importantly, according to a collaborative consultation approach (Boukydis, 2012), we used the FFSF videotapes to offer caregivers a brief parenting intervention aimed at enhancing parents’ sensitivity and responsiveness to their infant by helping them to observe and reflect upon the infant’s behavior.

Therefore, the general goal of the present paper is to provide a theoretical framework and methodological insights to use the FFSF in clinical settings specialized in the assessment of infants with ND and early parenting intervention. First, we provide a theoretical rationale integrating evidence from the FFSF paradigm research field and literature on socio-emotional regulation and parenting associated with ND. Second, we provide methodological insights for the application of the FFSF paradigm as a valid tool in the clinical setting dealing with ND, both for assessment purposes and parents’ support. Finally, we present clinical examples from our clinical practice highlighting the unique contributions of the FFSF procedure in this context.

The ‘70s have been a period of wide-spread growth for the infant research field (e.g., Stern and Stern, 2012; Sander et al., 2014). Within this field of research, the FFSF paradigm was developed by Tronick et al. (1978) to test the hypothesis that infants are active contributors in social interactions and to evaluate how they respond to the violation of interactive and social contingencies in the relationship with their main caregiver. In the FFSF paradigm, caregiver and infant engage in a 2-min-long face-to-face interaction (i.e., Play episode). Subsequently, the caregiver is instructed to stop any communication directed to the infant and to maintain a still face while keeping eye contact with the infant for 2 min (i.e., Still-Face episode). The lack of a contingent caregiver response is stressful for the infant who exhibits the typical still-face effect, which includes heightened negative emotionality as well as a reduction of social engagement and display of avoiding behaviors (Weinberg and Tronick, 1996; Weinberg et al., 1999; Montirosso et al., 2015a; Provenzi et al., 2015a). After the still-face exposure, the caregiver and the infant resume normal face-to-face interaction for another 2 min (i.e., Reunion episode). During the Reunion episode, a carry-over effect is usually observed, which consists in the persistent exhibition of negative emotionality and distress signals (e.g., avoiding behaviors) during the very first moments of the interaction (Weinberg and Tronick, 1996). Usually, during the Reunion, the mother–infant dyad gradually reaches a new homeostatic equilibrium and regains reciprocal positive interaction and playful exchanges (Montirosso et al., 2015a).

The FFSF paradigm has been used to assess developmental trajectories of infants’ emotional regulation (Hsu and Jeng, 2008; Yato et al., 2008), individual differences in behavioral stress response (Weinberg et al., 1999; Montirosso et al., 2015b), socio-cognitive domains such as episodic memory (Montirosso et al., 2013, 2014) as well as physiological reactivity (Muller et al., 2015; Provenzi et al., 2015b; Montirosso et al., 2016a,b; Provenzi et al., 2017). Moreover, the FFSF paradigm has also been used to investigate socio-emotional regulation in developmental risk conditions, such as preterm infants (Segal et al., 1995; Montirosso et al., 2010, 2016b), infants of depressed or anxious mothers (Weinberg et al., 2006; Kaitz et al., 2010; Reck et al., 2013).

Moreover, the interactive nature of the FFSF also allows researchers to assess parenting contribution to infants’ socio-emotional regulation. Different characteristics of parental interactive behavior have been found to be supportive of better socio-emotional regulation in infants: maternal sensitivity associates with more positive emotionality during the Still-Face episode (Braungart-Rieker et al., 2001; Chow et al., 2010); maternal social engagement associates with better regulation and less distress signals in the infant (Lowe et al., 2006; Montirosso et al., 2015b). Recently, one study has documented that infant and maternal behavior during normal face-to-face interactions (e.g., the Play episode) are both significant predictors of the infant’s ability to deal with socio-emotional stress (e.g., the Still-Face episode) at 6 months (Provenzi et al., 2016c).

Although they may present very different etiological, genetic and phenotypic characteristics, infants with ND often share a common pattern of difficulties in socio-emotional and behavioral regulation (Hauser-Cram and Woodman, 2016). Socio-emotional dysregulation has been reported in infants and children with cerebral palsy (Odding et al., 2006; Sigurdardottir et al., 2010), children diagnosed with an autism spectrum disorder (Mazefsky and White, 2014; Berkovits et al., 2017) as well as infants with genetic syndromes (e.g., Williams syndrome, Einfeld et al., 2001; Down syndrome, Jahromi et al., 2012). Previous FFSF research further highlighted difficulties in socio-emotional regulation in infants with ND. For example, the response of 3–13-month-old infants with Down syndrome lacked the typical reduction of positive emotionality to the Still-Face episode (Carvajal and Iglesias, 1997). Moreover, preschool children with a diagnosis of autism spectrum disorder reported the typical still-face effect but exhibited immature regulatory behaviors compared to age-matched typically developing children (Ostfeld-Etzion et al., 2015). Importantly, FFSF research also showed that parental behavior contributes to socio-emotional regulation even in infants with ND: in children with an autism spectrum disorder, maternal regulatory support was found to have a buffering effect on infants’ stress reactivity (Ostfeld-Etzion et al., 2015).

Furthermore, it should be noted that parenting assumes a different significance when an infant and child is diagnosed with a ND. Different dimensions of parenting are affected by the presence of a ND in infants, for example the ability to read the infant’s signals, to respond contingently and to provide adequate stimulations and sustain infants’ attention (Landry et al., 2008; Innocenti et al., 2013). Parents may face critical emotional burden (Dykens, 2015) and the acceptance of their own infant’s diagnosis may end up in emotional disturbances, such as high and chronic levels of distress, depression and anxiety (Baird et al., 2000; Papaeliou et al., 2012; Bemister et al., 2015; Cianfaglione et al., 2015; Cohrs and Leslie, 2017). Parents who have unresolved feelings about their infants’ ND also appear to be less able to provide regulatory support (Marvin and Pianta, 1996) and the reduction in maternal sensitivity has been found to be a key predictor of later socio-emotional development of their infants and children (Azad et al., 2013). At the same time, infants with ND may only partially give intelligible signals of their emotional states and needs (Okimoto et al., 2000). The difficulty in parental interpretation and appropriate responsiveness to infants’ cues and communications may further lead to the emergence of directive (Guralnick et al., 2008) or intrusive parenting style (Venuti et al., 2009; Bornstein et al., 2012; Blacher et al., 2013). Globally, these findings show that parent–infant relationship in the context of ND has a heightened risk of incurring in dysfunctional interactive transactions.

In light of this evidence, parenting behavior appears to play a key role in supporting infants’ socio-emotional development, even in the presence of ND. Early interventions that engage parents in assessment and rehabilitation phases have better long-lasting effects on developmental trajectories of infants and children with ND (Spittle et al., 2015). Additionally, investing in early interventions is also beneficial from a socio-economic point of view, as it guarantees a major economic return for healthcare systems (Doyle et al., 2009). Previous research that aimed to support parenting in families of infants with ND by using collaborative consultation on videotaped parent–infant interactions (Kim and Mahoney, 2005; Phaneuf and McIntyre, 2007; Lam-Cassettari et al., 2015) reported better outcomes for parental sensitivity and attunement as well as for infants’ behavioral stability and development. In recent years, an increasing number of intervention studies have used the video-feedback method in which infant behavior observation is performed with parents by a trained consultant (Juffer et al., 2012). Different approaches to the video-feedback are described in literature with the common goal of enhancing parental sensitivity and better behavioral strategies (for a review, Fukkink, 2008). The joint observation focuses on the observable interaction between parent and infant and has found to be effective in helping parents to recognize signs of infant’s stress, socio-emotional regulation strategies and parenting behavior also in dyads of infants with ND (Phaneuf and McIntyre, 2007; Poslawsky et al., 2015). The appropriateness of using FFSF paradigm within video-supported collaborative consultation with parents has been already suggested. For example, Papousek (2007) reported that using FFSF with parents can be effective in “recruiting the parent’s intuitive competence and restoring intersubjective emotional relatedness as a basis for the infant’s recovery of communicative growth” (p. 265). However, no previous study has specifically addressed the use of FFSF as an observational procedure for clinical assessment of infant socio-emotional regulation and the quality of early interaction in infants with ND and their parents.

We use the FFSF paradigm with 4–36-month-old infants diagnosed with a range of ND including cerebral palsy, autism spectrum disorders, genetic syndromes, and other mental retardation conditions. This age range is consistent with previous FFSF applications in research (Mesman et al., 2009; Provenzi et al., 2016) and the manipulation of maternal responsiveness is a reasonable age-appropriate stressor. Importantly, despite the fact that FFSF procedure has been mainly used with infants less than 10 months of age (Mesman et al., 2009), limited exceptions apply to the application of this paradigm to older infants with ND (Ostfeld-Etzion et al., 2015). Moreover, it should be noted that Montirosso and Tronick (2008) and Weinberg et al. (2008) have proposed a slightly modified version of the FFSF paradigm to be used with older infants up to 30 months of age.

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Keywords: early intervention, mother–infant interaction, neurodevelopmental disabilities, parents, still-face, rehabilitation

Citation: Giusti L, Provenzi L and Montirosso R (2018) The Face-to-Face Still-Face (FFSF) Paradigm in Clinical Settings: Socio-Emotional Regulation Assessment and Parental Support With Infants With Neurodevelopmental Disabilities. Front. Psychol. 9:789. doi: 10.3389/fpsyg.2018.00789

Received: 09 February 2018; Accepted: 03 May 2018;Published: 22 May 2018.

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Copyright © 2018 Giusti, Provenzi and Montirosso. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Livio Provenzi, [email protected]