About the concept of early relational withdrawal of the baby

Pr. Antoine Guedeney

The first clinical description of sustained withdrawal behaviour in young children outside autism belongs to Engel and Reischman, in 1956, with the famous case of 18-month-old Monica. With an esophageal fistula and fed by tube until digestive continuity is restored, Monica suffers from very disturbed relationships with her mother.her mother is very embarrassed by the tube, and she is also very depressed, isolated and abused by her husband.
Monica is hospitalized in a severe state of withdrawal and anorexia with severe developmental and weight loss.

The first clinical description of sustained withdrawal behaviour in young children

However she developed an increasingly clear attachment towards her doctor and her subsequent development favoured by that of her mother and their relationship was rather positive and was followed by Engel for 25 years. Engel and Schmale propose that energy conservation/depression withdrawal reaction is a basic defensive process for conserving energy in critical situations. Fraiberg had described a similar defence mechanism, freezing, observed from the age of three months in children subjected to very pathological relational situations. Menahem describes two cases of severe withdrawal in children with severe failure to thrive.

Withdrawal is a major component of the two- to three-month-old baby’s response to the altered relationship that occurs during the still-face experience or in the clinic during maternal depression.
The withdrawal behaviour is also one of the most stable during development, despite the major changes that occur in the first three years of life.

The withdrawal response is therefore an essential warning element

The baby’s defensive repertoire is initially quite limited, and focuses mainly on protest and withdrawal. Withdrawal is more difficult to detect than protest, yet it occurs in many early psychopathological situations, either manifestly or incidentally, whether they are disorders caused first by a relational disorder, or by an organic disorder, such as intense and lasting pain. The child’s prolonged withdrawal response is an essential component of most major early childhood diagnostic : depression, pervasive developmental disorders, attachment disorders, anxiety disorders, post-traumatic stress disorder, sensory disorders…

The withdrawal response is therefore an essential warning element to which the paediatrician or pediatric nurse must pay particular attention during the baby’s routine examination.

On the right and in brown the situations where withdrawal is a constant element of the clinical picture, on the left and in pink those where it appears without being constant.

The withdrawal response is therefore an essential warning element to which the paediatrician or pediatric nurse must pay particular attention during the baby’s routine examination.

Thus, withdrawal behaviour appears as an important part of the young child’s behavioural repertoire, and as an alarm signal that it is critical to perceive early, and not normalize.
We did not find in the literature an instrument for measuring relational withdrawal in young children before the age of 2, and we therefore built one: the Alarm Distress Baby Scale.

La construction de l’échelle .


Antoine Guedeney, a young paediatrician, is doing his military service in Chad as a National Service Volunteer.

It is during this experience that he observed many babies suffering from malnutrition of the Kwashiorkor type which gives a psychologically impressive picture of intense withdrawal (Guedeney, Lan and, 1995).

Antoine Guedeney works at the Institut de Puériculture de Paris, he has taken over from Michel Soulé as Director of the Guidance Department at IPP. He then contacted the PMI (maternal and child protection) to develop a collaboration. Collaboration between services was rare.

The project is launched to develop a scale to evaluate the baby’s relational withdrawal in order to have a collaboration and communication tool between the different professionals and the different care services to answer the following questions:

  • which babies PMI professionals are worried about and need to worry about
  • How to evaluate them?
  • how to communicate our concerns to parents?
  • quels sont les bébés qui inquiètes les professionnels de PMI et dont il faut se soucier
  • Comment les évaluer ?
  • comment transmettre nos préoccupations aux parents ?

Mrs Martine Vermillard-Gateau – nursery nurse, Mrs Edith Thoueille – director and the doctor of PMI, Mrs Benjellal-Zamoun educator, – Mrs Charon, Dr Charon played an essential role in the development and first validation of the ADBB, which was recognized in the award of a SFPEADA research prize in 1989 “to Dr Antoine Guedeney and his team”.

1989 – 2000


Award of the Institut de France’s Grand Prix of research.

The generous fund of this prize has enabled the financing of the website www.adbb.net, the financing of ADBB studies in particular in Argentina and Uruguay and continues to allow the financing of specific training and research and the equipment of the child psychiatry service at the Ney Jenny Aubry Clinic.[/vc_column_text][/vc_column_inner][/vc_row_inner][vc_row_inner][vc_column_inner width=”1/2″][vc_column_text]The first ADBB validation study was published in 2001, after more than 3 years of joint development (Guedeney and Fermanian, 2001).

The evolution of the scale since…

This was followed by several international validations, which confirmed the threshold score of 5 and above, and supported the transcultural validity of the scale and universality of the concept (see Guedeney Purra & Matthey, 2013 for a review in the ADBB section of Infant Mental Health Journal, in Appendix).

Studies in France have shown the predictive validity of ADBB measures, on the risk of occurrence of interactive mother-baby disorders, especially when these measures are repeated (Rochette and Mellier, 2007).

The cross-sectional study of 650 children from the DEPSE in Paris confirmed clinical validity and showed an incidence of 13% in a medium-risk population (Guedeney, Foucault, Bougen, Larroque, Mentre A, 2008).

The Norwegian and Finnish studies found a lower incidence of 3-6%, but on low-risk and less vulnerable samples. (Puura, Guedeney, Mantymaa & Tamminnen, 2007; Puura, Mantymaa, Luoma, Kaukonen, Guedeney, Salmelin, Tamminen, 2010). This made it possible to establish the links between withdrawal and psychosocial risk factors, particularly with postnatal depression.

Another series of studies has shown the evolutionary risk of long-term withdrawal behaviour: Milne & al in Australia show the effect on language and communication development of early withdrawal at 6 months when the child is assessed at 2 years (Milne, Greenway, Guedeney, Larroque, 2009).

These results were confirmed by the EDEN 2-year study in France (Guedeney, Pingault, Thorr & Larroque, and The EDEN Mother-Child Cohort Study Group ,2014). In South Africa, Chris Molteno showed that withdrawal at 6 months was the first sign of fetal alcohol exposure, and withdrawal at 6 months was predictive of IQ at 5 years, associated with iron deficiency (Molteno, Jacobson, Colin Carter, Dodge and Jacobson, 2014).

An analysis currently being written for the EDEN study shows that withdrawal (adbb >5) is associated independently of the other factors with a decrease in the IQ at 5 years (Peyre, Guedeney &al, submitted).

Several important studies have followed children longitudinally from birth to 18 months or older: EDEN, OLIMPE EPIPAGE 2 and the Norwegian study by Braarud, Moe, Smith &al (Braarud, Slinning, Moe, Smith, Trannas Vannebo, Guedeney, Heimann, 2013; Smith, Guedeney &al, 2016, Inf Behav Dev 2016, annex) such as the Portuguese study by Costa &al (Costa & Figueiredo, 2013).

These studies with varying levels of parental risk describe the normative development of the relational withdrawal response, which develops from the temperamental characteristics of the baby; they show that this response is much clearer in cases of prematurity, and even if prematurity is moderate. Finally, recent studies with family films allow us to discuss the interest of ADBB in early detection of developmental disorders, and in particular early signs of autism (Wendland, Gautier, Wolff, Brisson, Adrien 2010).