Development of micro-skills

Development of micro-skills in premmies                                                                                                                   March 2016

Theory of Mind   


The doorbell rings. The baby on the floor hears the bell, looks at me, at the look on my face, at how I stop what I am doing and how I turn with pleasure and expectancy towards the door, and my baby squeals with delight. Does this mean that my child loves the doorbell sound itself?  Not at all.  My baby has learned that when that bell rings, I will notice it, I will have a certain attitude, and expectancy, I will walk to the door, open it and welcome one of our many fun visitors.


This learning is not quite the same as classical conditioning, where Pavlov’s dogs learned to dribble when a bell sounded (because the sound of the bell was always followed by food). No, my baby has learned a few intermediate steps. Bells do not always mean visitors. Bells do not always mean I will walk to the door. There are many kinds of bell sounds and not all of them mean pleasure. It is her looking at me and the look on my face, how she “reads” me, that translates into a knowledge that something different and good is about to happen.


My baby can read lots of expressions on my face. When she was only 3 months old and a stranger (or even her grandmother), came close and coo –cooed in her face, she would turn to check out what my face said. Did I convey encouragement, a smiling acceptance, a slight frown of not-knowing, concern? The baby could pick up these subtle nuances right from her early weeks. Now as a 10-month old, she can read me like a book: not just what I am feeling in the moment, but also what I am thinking. She has developed  the first steps towards “Theory of Mind” (ToM). She is attending to and interpreting my face ad actions.


Of course I, the grown-up, have developed ToM many years ago. I know what is in my baby’s mind much of the time. It is not just the emotions and behaviour that I can read. I can read her thinking as well. When she crawls towards her brother’s open bedroom door I know she is taking advantage of the possibility of getting into his precious Lego models. When she pouts and shakes her head at the table, I know she is telling us she’s had enough, or that she has spied the birthday cake on the bench and wants that and not her vegetables.


Understanding the thinking of others, the intentions and motivations of others, is such an important developmental milestone. We cluck and gurgle at our babies when they seem so clever about these things. It’s like magic that such little children can “know” things, and yet this is one of those unannounced, wonderful developmental “muscles” that we love.


Telling lies – a sign of true ToM

What would it be like if we could always read others’ minds and motivations, if other people could read our own minds? It would be terrible. They would know that you thought your best friend did not look good in those pants. They would know that sometimes you say one thing, even though you don’t really think that. It’s not that we need to be liars, but more that sometimes we need to be able to keep our thoughts to ourselves, to not say things that might hurt or expose others.

James, my son, aged 3, came to the door. I was angry, and ready for him. Did you…. (I can’t remember what the issue was). He looked me in the eye. With a straight face he said “No”. I was pretty sure he was guilty but didn’t want to accuse him of lying, to my knowledge he had never lied before, and in the moment, in my own confusion, I said nothing. Then, in the quiet space,  he said. “I don’t think so, I’m pretty sure I didn’t, well I might have…..(then) yes I did.”

We hate it when our previously beautifully honest “babies” start to lie to us. Yet lying is the sign of true ToM, when the child knows that not all their thoughts are transparent and not all our thoughts are readable by them. James must have been just at the beginning of that new knowledge, but wavered in the moment. Can Mum really read what is in my mind? Can I get away with telling her a lie and not being in trouble?

We don’t want our children to lie, but ToM is not really about lying, but the knowledge that the child can have thoughts and motivations that are not transparent to others. They can hold two kinds of knowledge in mind at once – what I know and what the other person knows.


At my water-aerobics class, our very funny teacher has asked us to do 2 identical actions, and then every third movement is different. I see her glance down at several of the older women at the front and make a little grin. I watch them and notice they are just doing the one action all the time – they can’t be bothered changing every third action. I smile to myself,  she follows my attention (as I have followed her gaze) and smiles at me. I can’t be absolutely sure, and neither can she, but it is as if we have had a conversation and know what the other is thinking. We seem to have followed each others’ thinking. I may be wrong, because I like her. She may have been thinking – those silly old fools are too lazy to concentrate.  Or, her little grin may have been transparent- she understands that it is too complicated and hard for these women. We need to be able to do both- to make assumptions and to also understand that we may be wrong.


It makes life so much easier when we can watch others and get a sense of what they are thinking. This is a most wonderful skill and we use it all the time. Yet, at the same time, we cannot really know what another person is thinking unless they tell us.


Preterm infants and children


Studies show that children who are born prematurely are more likely to have interpersonal difficulties. ToM is one of those sub-skills that eventually come together to help young children have emotionally satisfying friendships. ToM itself has not been tested in ex-premmies although one of its own subskills – shared attention – is found to be delayed or missing in these (preterm) children. Shared attention develops at the end of the baby’s first year of life. It happens when babies follow the gaze of another – what their mother or brother is looking at.  Babies demonstrate shared attention when they begin pointing. It’s like saying I’m looking at this bird and I want you to look at it too so we can share our excitement about this interesting thing.

The singing kangaroo

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Babies learn right from birth - even before that. We can see this in their behaviours but also in their brains. These days we can see the number of neurones (brain cells) increase and also how each cell increases the number of other cells it connects to.

Have a look at this Ted talk on the way experience shapes the brains of babies right from the get-go.

What are cognitive abilities?

What do parents need from hospital staff?

Variations in NICU practices can affect the well-being of premmies into later life  

 For example, family-centered care directed to parents can support the neurobehavioural development of premmies in their future life. This is why hospital nurseries go to so much trouble to engage with parents at every step of the journey through the nursery, from NICU to discharge. Parents tend to need different things at different stages. Immediately after the baby's birth they need reassurance about the baby's condition and what is being done to help him or her. Often, staff don't yet know the all the details of the baby's condition, yet parents take relief from a warm, respectful approach that gives them information, even if it's not exhaustive or definitive. This approach helps open a dialogue between staff and parents that is helpful in the coming weeks and months. The next period of time is characterized by a highly-intensive environment with much technology surrounding the baby, Parents' needs are mainly for information and their own well-being may run parallel with that of their baby. They often need to understand the technology, and how to behave in this strange environment. They may fear hurting their baby simply by touch and can be helped by learning some of the ways to touch and skin-to-skin hold their babies. As the baby's health improves, contact with the baby is much less restrained and mothers can start to develop a rich, full sense of motherhood by completing normal parenting tasks. Staff provide role models and active strategies to support and comfort the baby. Parents begin to take over cares. Once the baby is home, parents are free to develop their own interactive style. They may like to hold their baby for long periods since they have had so little privacy and intimacy in the nursery. The notion of "family-centered care" is coming of age, with hospitals finding creative ways to engage and empower parents. These practices have a beneficial effect to parents and babies alike.