The TEACUP Preemie Program® has been offering FirstPlay® Infant Story- Massage to preemie families since 2017 through home visitation, and we have witnessed the efficacy of this model in action. FirstPlay Therapy® is a developmental play therapy model that incorporates interactive storytelling with playful infant massage. Developed by Janet A. Courtney, FirstPlay® is an attachment-based approach that promotes joyful interaction between parent and child (Courtney, Velasquez, & Bakai Toth, 2017). This highly effective approach has the ability to transform an insecure parental bond deficit into a secure one, potentially changing the course of health and wellness for preemies. FirstPlay® is rooted in Developmental Play Therapy, Attachment Theory, Filial Play Therapy, and therapeutic storytelling, as well as research pertaining to the neurobiology of touch, infant massage, and infant mental health (Courtney, Velasquez & Bakai Toth, 2017). It is a preventative, strengths-based model that teaches parents effective ways to connect with their babies through gentle touch with respect, love, and playful interactions.
The FirstPlay® model tells a story, The Baby Tree Hug®, while giving the baby a gentle massage (Courtney, 2015). The story keeps the baby engaged with the parent and brings a sense of joy and playfulness to the bonding experience. The Certified FirstPlay® Practitioner shows the parent how to perform the story-massage using a baby doll, while parents follow along with their baby. The practitioner exhibits engagement, gentle touch, and playful interaction with the baby-doll, while highlighting attunement and key moments when “the magic” is happening between the parent and child so that the parent begins to attune to those moments naturally.
Synthesis: FirstPlay® and TEACUP Preemie Program®
What began as a trial intervention for our program has become an anchor to TEACUP®’s scope of services, as the immediate and lasting effects of FirstPlay® have strong protective factors for infants. As FirstPlay® helps to establish healthy and loving attachment and bonding, it mitigates factors that can contribute to abuse and neglect. We now know that children exposed to adverse childhood experiences (ACEs) are at a higher risk for learning difficulties, emotional problems, developmental problems, and longterm health problems (Felitti et al., 1998). FirstPlay® Infant Story-Massage focuses on the relationship between parent and child, and teaches parents how to calm and center themselves when interacting with their child. The Certified FirstPlay® Practitioner offers gentle guidance and models positive interactions between parent and infant. The training also teaches parents how to connect to their infant through attunement, which involves listening and responding to their baby’s cues. This attunement between parent and child poises them for open, positive communication as the child grows.
When practiced regularly, FirstPlay® also creates deeper sleep, increases oxygen and nutrient flow to the cells, and helps with digestion and elimination. Parents and babies engaged in the story-massage simultaneously experience the release of oxytocin, often called the “love hormone,” along with a decrease in cortisol, a stress hormone (Feldman & Bakermans-Kranenburg, 2017). These calming and relaxing physiological changes help to create a fun, special time of intimacy each day between parents and their babies.
When we promote a healthy attachment in babies, the benefits are expansive. The same area of the brain associated with attachment also regulates empathy, fear, intuition, behavioral and emotional responses, flexibility, and morality (Meyer, 2011). We know that preemies often leave the hospital with a heightened sensitivity to touch, which is due to the lengthy NICU stay, isolation, and the unpleasant pokes, prods, and procedures that they face on a daily basis in NICU (Mantis and Stack, 2018). By offering FirstPlay®, we give parents and babies the opportunity to reframe their touch relationship in a joyful way that sets them up for secure bonding and attachment for life.
Following are case examples from The Children’s Healing Institute’s TEACUP Preemie Program®, in which FirstPlay® Infant Story-Massage served as a key intervention after the preterm infants’ discharge from NICU to home.
Case of Penelope and Elena
Penelope was 34 years old and a first-time mom. I first met her when she gave birth to Elena, 26 weeks into her pregnancy. Baby Elena weighed less than 2 pounds at birth. Penelope sought emotional support from the TEACUP* Program when her baby was just a few days old, and received individual and group support through Elena’s 90-day hospital NICU stay and after she went home.
Penelope’s relationship with Elena’s father Diego was contentious, at best, and emotionally abusive. He withheld everything from money to personal grooming items to nourishing food from Penelope. When she brought Elena home, Diego was not interested in a relationship with either of them, spending nearly all of his time out of the house, either at work or out with friends. 1 introduced the idea of FirstPlay® to her to give her and baby Elena a positive way to interact and temper the stressful environment of their home.
As FirstPlay® is a “manualized program,” parents receive the FirstPlay Parent Manual at the first session, and the training closely follows the contents of the book (Courtney, 2015). In our first session, Penelope learned about the supporting literature and scientific backbone of FirstPlay® along with the benefits to both herself and her baby. Penelope remarked rather earnestly that it had never occurred to her to respect her baby. She loved her baby fiercely, but had not given thought to Elena’s personhood. This moment was one of her first awakenings and an entry-point to a new level of relationship with her daughter.
Over the course of two in-home sessions, Penelope learned the story of the Baby Tree PIugu and the corresponding story-massage techniques. I sat with my baby-doll, in a dyad alongside hers with Elena. In the moments that she and Elena were engaged in FirstPlay®, it was as if the rest of the world fell away. The story and corresponding touch techniques came quite naturally to her. My role as instructor became a role as witness — she needed very little redirection, prompting, or guidance, although she was open to learning and making sure she was “doing it right.” 1 amplified moments of attunement and connection between Penelope and Elena by simply stating my observations (“She’s smiling and looking right into your eyes! Look Elena! Mommy is smiling right back at you!”).
After learning the story-massage in the first session, the following visit is often a review of the whole process, with the mom and baby - instead of the practitioner — leading the story. Penelope was eager to show me how she and Elena had progressed, and their shared joy through the experience was palpable. Penelope remarked that when she and Elena were engaged in FirstPlay®, which she was using one to two times daily, the rest of life’s stresses fell away and she saw herself as a confident and capable mother. This boost in self-confidence was no small feat, and ultimately helped her find the courage to leave her abusive partner and toxic home environment to start a healthy, loving life with her daughter.
Case of Ana, Dean, and Leo
Baby Leo was born 11 weeks early due to intrauterine growth restriction, a condition of pregnancy caused by placental insufficiency that results in a significant reduction in fetal growth for gestational age (Levine et ah, 2014). Leo’s growth had stopped 26 weeks into Ana’s pregnancy and he only weighed 1 pound and 11 ounces at birth. Ana was distraught and inconsolable throughout Leo’s 8-week NICU hospitalization, and she was worried about her tiny fragile Leo and hoped he could come home soon.
When Leo was finally discharged from NICU, I visited Ana and her husband Dean in their home. Baby Leo was resting in a “bouncer seat” close to his parents. I asked how he was adjusting to life at home, and Ana’s tears began to flow. “I don’t hold him often. He doesn’t seem to like my touch.” I paused for a moment and responded, “Let’s reframe that. He is learning your touch. Up until now, he has had a very specific and limited relationship to touch from the NICU. We are going to change that.” I told her about FirstPlay® and explained how it could help her and Leo redefine their touch relationship. She was open to trying it, so we scheduled a time the following week to get started.
After reviewing the preliminary didactic material, we began the FirstPlay® demonstration and instruction. Dean was reluctant to participate at first, saying that he was “leaving the nurturing stuff to mom,” so we carried on without him, but left the invitation open for him to come join us. As I demonstrated the story and corresponding massage steps, Ana mirrored me with Leo. Her first touch brought a smile to his face and he locked eyes with her. In that moment, their beautiful dance began. Ana became more confident with every stroke, and every lyrical line of the story. There were many opportunities for me to bring to her awareness little Leo’s fixed attunement with her, and her sheer delight in the exchange happening between the two of them.
Not long after we began, Dean came into the room to observe. I encouraged him to come closer and see how Leo was responding. He was immediately drawn into the beautiful moment with Ana and Leo. Ana showed him how she was handling one arm, and invited him to try it with the other. As the session progressed, Dean and Ana began naturally taking turns telling the story to Leo and using the massage techniques. Dean seemed to enjoy being part of this joyful and nurturing moment with his son and wife.
The following week, 1 returned for a follow-up visit. Ana met me at the door, wearing a baby sling with Leo snuggled close to her chest. When I mentioned her “babywearing,” she smiled and remarked that she had kept him close to her all week. She shared that they were practicing FirstPlay® every day and having so much tender fun with it. In our review, she led the entire story with very few questions or prompts from me. Leo was relaxed to the point of dozing off by the end of the story, and Ana shared that they had been doing FirstPlay® right after his bath before bedtime. As this has become their routine, it was obvious that Leo was beginning to make the connection between FirstPlay* and readying for sleep.
When 1 brought up other FirstPlay® activities such as “This Little Piggy” and “Patty Cake,” that she could build upon with what she has learned, she looked puzzled. Brazil is Ana’s homeland, and English her second language. She stated, “These are not my songs.” 1 encouraged her to use songs and games that she had learned as a child, in her native Portuguese. It was an important reminder to me that culture plays an important role in childhood songs, games, and FirstPlay® activities.
FirstPlay® helped Ana redefine her touch relationship with Leo. She was frightened of hurting him, and he was accustomed to not only the confines of the NICU isolette, but the daily needle sticks, painful and uncomfortable procedures, and minimal physical contact compared to what a healthy fullterm newborn would receive. FirstPlay® gave Ana permission to have fun with Leo and enjoy loving and playful moments with him. The gentle massage helped Leo form new neurological connections in relation to touch, and Dean learned that dads can be part of the nurturing relationship just as much as moms can. Dean and Ana credit FirstPlay® with helping them reach a new level of confidence as new parents, and for establishing a foundation for a beautiful touch relationship as a family.
The TEACUP Preemie Program® offers FirstPlay® to every family enrolled in the program, which has led to an increase in families’ sustained engagement with the program. In 2018, 31% of families remained enrolled in our program after their babies’ discharge from NICU compared to only 18% before we began to offer FirstPlay . It offers gentle guidance and models positive interactions between parent and infant, teaching them how to connect through attunement and poising them for open, positive communication for years to come. Fostering preemies’ secure attachment to their parents creates a foundation for positive developmental outcomes from birth through adolescence. By fostering a healthy and loving attachment and bonding through FirstPlay®, the TEACUP Preemie Program® continually champions our ultimate mission of eradicating child abuse and neglect.
- 1 Discuss with a colleague the various factors that can complicate the development of a healthy, secure attachment in preterm infants.
- 2 In the case of Penelope, why do you imagine it had never occurred to her to respect her baby? Discuss how Penelope’s insight may influence her parenting style and her relationship with Elena.
- 3 Discuss your thoughts on FirstPlay® as it relates to maternal mental health. How might this modality affect a preemie-mother’s mental wellness, particularly after a traumatic birth and the NICU experience?
American Music Therapy Association (AMTA). (2019). Retrieved July 17, 2019, from http://www.musictherapy.orgCheng, C. D., Volk, A. A., & Marini, Z. A. (2011). Supporting fathering through infant massage. The Journal of Perinatal Education, 20(4), 200-209. doi:10.1891/1058-243.doi:20.4.200
Courtney, J. A. (2015). FirstPlay parent manual. Boynton Beach, FL: Developmental Play & Attachment Therapies.
Courtney, J. A., Velasquez, M., & Bakai Toth, V. (2017). FirstPlay® infant massage storytelling: Facilitating corrective touch experiences with a teenage mother and her abused infant. In J. A. Courtney & R. D. Nolan (Eds.), Touch in child counseling and play therapy: An ethical and clinical guide (pp. 48-62). New York, NY: Routledge.
Feldman, R., 8c Bakermans-Kranenburg, M. J. (2017). Oxytocin: a parenting hormone. Current Opinion in Psychology, 15, 13-18. https://doi.Org/10.1016/j.copsyc. 2017.02.011
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14, 245- 248. Retrieved July 18, 2019from: https://www.ncbi.nlm.nih.gov/pubmed/9635069 Forcada-Guex, M., Borghini, A., Pierrehumbert, B., Ansermet, F., & Muller-Nix, C. (2011). Prematurity, maternal posttraumatic stress and consequences on the mother—infant relationship. Early Human Development, 87(1), 21-26. doi:10.1016/ j.earlhumdev.2010. 09. 006
Hallin, A., Bengtsson, H., Frostell, A. S., & Stjernqvist, K. (2011). The effect of extremely preterm birth on attachment organization in late adolescence. Child: Care, Health and Development, 38(2), 196-203. doi:10.1111/j. 1365-2214.2011.01236.x Jefferies, A. (2012). Kangaroo care for the preterm infant and family. Paediatrics & Child Health, 17(3), 141-143. doi:10.1093/pch/17. 3. 141 Levine, T. A., Grunau, R. E., Mcauliffe, F. M., Pinnamaneni, R., Foran, A., & Alderdice, F. A. (2014). Early childhood neurodevelopment after intrauterine growth restriction: A systematic review. Pediatrics, 135(1), 126-141. doi:10.1542/peds.2014-1143 Linden, D.W., Paroli, E.T., & Doron, M.W. (2010). Preemies (2nd ed.). New York, NY: Gallery Books.
Loewy, J., Stewart, K., Dassler, A., Telsey, A., & Homel, P. (2013). The effects of music therapy on vital signs, feeding, and sleep in premature infants. Pediatrics, 131(5), 902-918. doi: 10.1542/peds.2012-1367d Mantis, I., & Stack, D. M. (2018). The functions of mutual touch in full-term and very low-birthweight/preterm infant-mother dyads: Associations with infant affect and emotional availability during face-to-face interactions. International Journal of Comparative Psychology, 31. Retrieved July 27, 2019 from: https://escholarship. Org/content/qt62x2k310/qt62x2k310.pdf?t=piy331&nosplash=33ea8d7c6a5daad3c48f61 3ed26hl4d6
March of Dimes. (2013, October). Long-term health effects of premature birth. Retrieved July 17, 2019, from http://www.marchofdimes.org/complications/long- term-health-effects-of-premature-birth.aspx Martin, J. A., Hamilton, В. E., & Osterman, M. J. (2018, August). Births in the United States, 2017 [PDF]. Hyattsville: U.S. Department of Health and Human Services.
Meyer, D. (2011). Neuroplasticity as an explanation for the attachment process in the therapeutic relationship. Retrieved from http://counselingoutfitters.com/vistas/ vistasll/Article_52.pdf
National Institute of Child Health and Human Development (NICHD). (2017, January 31). What are the risk factors for preterm labor and birth? Retrieved July 17, 2019, from http://www.nichd.nih.gov/health/topics/preterm/conditioninfo/who_risk Pagni, A. M., Kellar, S., & Rood, M. (2017). Effects of kangaroo care on procedural pain in preterm infants: A systemic review. Honors Research Projects, 441, 1-39. Retrieved from http://ideaexchange.uakron.edu/honors_research_projects/441
Purdy, I. B., Craig, J. W., & Zeanah, P. (2015). NICU discharge planning and beyond: Recommendations for parent psychosocial support. Journal of Perinatology, 35(SI), doi: 10.1038/jp.2015.146
Schore, A. N. (2012). The science of the art of psychotherapy. New York, NY: Norton.
Standley, J. (2012). Music therapy research in the NICU: An updated meta-analysis. Neonatal Network, 31(5), 311-316. doi: 10.1891/0730-0832. 31. 5. 311
The Children’s Healing Institute (2019). Retrieved July 18, 2019, from http://www. childrenshealinginstitute.org
World Health Organization (2017, November 17). What is a preterm baby? Retrieved July 17, 2019, from https://www.who.int/features/qa/preterm_babies/en/