Infant Mental Health Provision in Gloucestershire'

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Infant Mental Health Provision in Gloucestershire.
Still gestating!
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As defined by the Mental Health Task Force of
Zero to Three.

• Infant mental health is the developing capacity
  of the child from birth to three to experience,
  regulate, and express emotions form close
  interpersonal relationships and explore the
  environment and learn all in the context of
  family, community and mental health expectations
  for young children. Infant mental health is
  synonymous with healthy social and emotional
  development.

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• Human relationships, and the effect of
  relationships on relationships, are the building
  blocks of healthy development. From the moment of
  our conception to the finality of death, intimate
  and caring relationships are the fundamental
  mediators of successful human adaptation. (p.
  27)
• National Research Council and Institute of
  Medicine (2000) From Neurons to Neighbourhoods
  The Science of Early Childhood Development.
  Committee on Integrating the Science of Early
  Childhood Development. Jack P. Shonkoff and
  Deborah A. Phillips, eds. Board on Children,
  Youth and Families, Commission on Behavioral and
  Social Sciences and Education. Washington D. C.
  National Academy Press.

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Importance of early relationships.

• The interactive process most protective
  against later violent behaviour begins in the
  first year after birth the formation of a secure
  attachment relationship with a primary caregiver.
  Here in one relationship lies the foundation of
  three key protective factors that mitigate
  against later aggression the learning of empathy
  or emotional attachment to others the
  opportunity to learn to control and balance
  feelings, especially those that can be
  destructive and the opportunity to develop
  capacities for higher levels of cognitive
  processing.
• (p. 184) Robin Karr-Morse Meredith
  Wiley. (1997)
• Ghosts From the Nursery.
• New York Atlantic Monthly Press.
• (Very recommended!)

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The early attachment relationship influences
later development in a combination of ways.

• Experiences with the primary caregiver affect the
  neurobiology of the infants developing brain.
• It is the foundation for learning
  affect-regulation and impulse-control. The baby
  is soothed by the parents responses, which then
  become internalised.
• Here the infant learns relationship skills,
  especially empathy, behavioural regulation and
  synchrony.
• Internal working models are derived from this
  time, as the infant begins to anticipate the
  responses to his actions and signals. These are
  the unconscious expectations of relationships
  that may last a lifetime.

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• Genetic susceptibilities are activated and
  displayed in the context of environmental
  influences. Brain development is exquisitely
  attuned to environmental inputs that, in turn,
  shape its emerging architecture. The environment
  provided by the childs first caregivers has
  profound effects on virtually every facet of
  early development, ranging from the health and
  integrity of the baby at birth to
• the childs readiness to start
• school at age 5.
• Neurons to Neighborhoods.

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Basic beliefs that support and sustain Infant
Mental Health interventions.

• Optimal growth and development occur within
  nurturing relationships.
• The birth and care of a baby offer a family the
  possibility of new relationships, growth and
  change.
• What happens in the
• early years affects the
• course of development
• across the lifespan.

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• Early developing attachment relationships may be
  distorted or disturbed by parental histories of
  unresolved losses and traumatic life events (the
  ghosts in the nursery).
• The therapeutic presence of an Infant Mental
  Health Specialist may reduce the risk of
  relationship failure and offer the hopefulness of
  warm and nurturing parental responses.
• Guidelines for Infant Mental Health Practice.
• (2000) The Michigan Association for
• Infant Mental Health.

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Cost benefit analyses have shown

• For every 1 spent 7 saved (Perry School/High
  Scope Project)
• Elmira Home Visiting Project paid back its costs
  by 4 years. At a 15 follow up the savings
  exceeded the costs of the program by a factor of
  4. (Olds et al (1999) Prenatal and Infancy Home
  Visitation by Nurses Recent Findings. The Future
  of Children. 9 (1)
• For every 1 spent preventatively, 19 will be
  saved further down the line (P. O. Svanberg
  (1998) Attachment, resilience and prevention.
  Journal of Mental Health (1998) 7 (6) 543-578.

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Perinatal health issues
Child adolescent functioning school
failure, looked after, conduct
disorder, antisocial behaviour, substance
abuse, teenage pregnancy.
Effects on child e.g. neurological impairment, in
secure attachment, poor emotional
or behavioural regulation, cognitive impairment.
I.M.H. team
Stressed dysfunctional caregiving
Parental life course e.g. unplanned
pregnancies, benefit dependence, substance
abuse, domestic violence.
Negative peer group
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So what do we actually have in place to help
emotionally vulnerable families and babies?

• Health Visitors the early warning system
  for babies and the most important resource for
  the adult mental health service!
• A 2 day / week dedicated team in Cheltenham Sure
  Start time limited.
• Under-fives clinics within CAMHS, only at
  Delancey and Acorn House.
• Social Services, over-stretched and
  under-resourced.

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• And being delivered
• We will soon be in a position
• to start rolling out training in
• the Solihull Approach.
• This has been a joint venture between Health
  Visitors and the CAMHS under-fives clinic at
  Delancey.
• Infant Mental Health services have been
  specified in both the CAMHS development plan and
  the Maternal Mental Health Strategy for the
  County.
• But can the latter influence the former?

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Where does early intervention designed to support
a positive relationship between parent and small
child belong?
Prevention
Treatment
Who is the patient?
Families can be identified before there is a
difficulty, i.e, previous history or diagnosis.
The relationship between parent and small child.
CAMHS. May say they cannot offer to work with
adult, especially if under another service.
Adult Mental Health. Not tasked to work with
babies and toddlers may see them as just a
source of stress!
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Antenatal postnatal mental health risks.

• 10 16 of pregnant women experience
  depression.
• 2 - 4 of pregnant women experience anxiety or
  have a Panic Disorder.
• Approximately 30 of women with a history of
  depression prior to conceiving will develop
  postnatal depression.
• 12 - 16 of women experience postnatal
  depression.
• Up to 26 of adolescent mothers experience
  postnatal depression.
  (www.bcrmh.com)

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• Out of every 1000 live births 2 mothers will
  need admission to a psychiatric hospital,20 40
  will have moderate to severe enduring mental
  health problems and 100 will develop depression.
• (Holden, et al (1989) A controlled study of
  health visitor interventions in the treatment of
  postnatal depression. British Medical Journal.
  298 223-226)
• (The W.H.O. predicts that
• depression is going to be
• the number one illness in
• the world by 2020)

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Children of parents with mental health
difficultieshave

• 70 chance of developing at least minor
  adjustment problems by adolescence
• 10 - 15 chance of becoming seriously mentally
  ill if one parent has a mental health problem
• 30 chance if
• health problems both
• parents have mental.

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Effects of maternal mental illness on attachment
patterns in their children.

• 1) When young children of mentally ill mothers
  are compared to index groups of children of non
  mentally ill mothers they have been found to have
  high rates of disorganised / controlling
  attachment.
• (DeMulder, E. K., Radke-Yarrow, M. (1991)
  Attachment with affectively ill and well-mothers
  Concurrent behavioral correlates. Development and
  Psychopathology. 3, 227-249.)

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• 2) In high-risk, low socio-economic status
  families, the rate of disorganised attachment in
  young children with depressed mothers has been
  estimated to be as high as 60.
• (Lyons-Ruth, K., et al. (1990) Infants at
  social risk Maternal depression and family
  support services as mediators of infant
  development and security of attachment. Infant
  Mental Health Journal. 17, 257-275.)
• 3) Rates of insecure-disorganised attachment are
  higher in chronically depressed mothers than in
  those who are not chronically depressed.
• (Teti,D., et al. (1995) Maternal depression
  and the quality of early attachment An
  examination of infants, pre-schoolers and their
  mothers. Developmental Psychology. 31, 364-376.)

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Effects of maternal depression.

• Infants with a depressed mother during the
  first year of life show more neurophysiological
  and behavioural signs of stress and depression
  including greater activation in their right
  frontal lobes, lower vagal tone, and higher heart
  rates and cortisol levels. They engage less in
  interactive behaviours with all adults.
• (Field, T. M., Healy, B., Goldstein, S.,
  Perry, S., Bendell, D. (1988) Infants of
  depressed mothers show depressed behavior even
  with nondepressed adults. Child Development. 59,
  1569-79.)

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The context of parental depressioneffect on
infant security.
Economic hardship.
Less sensitive interactions
Infant attachment security.
Increase in frequency of spanking.
Relationship stress.
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• Post-natal depression is linked to an
  increase in insecure attachment in toddlers,
  behavioural disturbance at home, less creative
  play and greater levels of disturbed or
  disruptive behaviour at primary school, poor peer
  relationships, and a decrease in self-control
  with an
• increase in aggression. It impacts
• cognitive, emotional,
• behavioural attachment
• domains of development.
• (Cummings Davies, 1994
• Murray, 1997 Sinclair Murray, 1998
• Murray et al., 1999 Zeanah et al., 1997)

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• Depression in pregnancy is associated with
• Diagnosis of depressive disorder in both boys and
  girls. Every 16 year old in this group had a
  mother who had been depressed in pregnancy.
• Overall lower scores on a global developmental
  assessment measure.
• Outcome of post-natal depression when child is
  16 years old.
• Lower I.Q. in boys (10 points on average)
• Fewer core GCSEs at A to C passes in boys.
• Increase in diagnosis of conduct disorder.
• Greatly increased hyperactive behaviour in boys.
• 
  (South London Child Development Study)

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Babies of depressed mothers may withdraw from
their mothers.

• Babies of depressed mothers take twice the
  usual amount of time to habituate to (recognise
  as familiar and take for granted) the pairing of
  their mothers face and voice. Longer habituation
  correlates with later cognitive deficits,
  including lower IQ.
• They also failed to show any visual
  preference for either the mothers or a
  strangers face.
• (Hernandez-Rief, M., Field, T., Diego, M.
  Largie, S. (2002) Depressed mother newborns show
  longer habituation and fail to show face/voice
  preference. Infant Mental Health Journal. Vol.
  23(6), 643-653)

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Do not forget teenage mothers.Who are

• Less successful in educational, occupational
  economic attainment.
• More likely to be single parents, and to engage
  in risk behaviours.
• More likely to experience moderate to severe
  depressive symptoms. These are more than a
  transient adjustment to motherhood and studies
  have shown significant stability and elevation in
  depressive symptoms across the first 2 to 3 years
  of childrearing.

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Mothers with post-partum psychosis

• Tend to be unresponsive to babys emotional
  needs.
• Are more preoccupied with hallucinations and
  psychotic ideation.
• Have infants who tend to be passive and
  uncooperative,
• and in middle childhood they frequently develop
  anxiety disorders.

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Mothers with schizophrenia

• Tend to be remote, insensitive self-absorbed.
• Touch and play less with their babies.
• They perceive their infants as passive
• And often interpret their smiles as
• accidental grimaces.
• Their infants are more difficult,
• insecure, inhibited, and less spontaneous and
  responsive.

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Mothers behaviour and infant development.

• At 6 months infants of high-risk teenage
  mothers and moderate risk adult mothers had lower
  mental scores on the Bayley Scales than at 1
  month. They were also significantly lower than
  scores of infants in a low-risk group. The
  mothers in both at risk groups were found to
  vocalise less with their babies and to be less
  contingent on their infants behavioural signals.
  There was no difference on motor development.
• (Pomeleau, A., Succimarri, C. Malcut, G.
  (2003) Mother-infant behavioral interactions in
  teenage and adult mothers during the first six
  months postpartum relations with infant
  development. Infant Mental Health Journal, Vol.
  24 (5), 495-509.)

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Partner relationship during pregnancy
childrens pre-school functioning.

• The capacity of pre-birth parents to anticipate
  the oncoming triadic relationships in their new
  family arrangement is predictive of their
  childs lack of externalising problems and
  ability to represent affection coherently four
  years later.
• Von Klitzing, K. Burgin, D. (2005) Parental
  capacities for triadic relationships during
  pregnancy Early predictors of childrens
  behavioral and representational functioning at
  preschool age. Infant Mental Health Journal. Vol.
  26 (1), 19-39.

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Effects of maternal stress during pregnancy.

• Maternal stress is associated with lower birth
  weight, irritability, hyperactivity and learning
  disabilities.
• Prenatal stress may result in permanent
  alterations in dopamine activity and cerebral
  lateralization, making offspring more susceptible
  to anxiety and limiting their functioning into
  adulthood.

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Stress in pregnancy leads to childrens
psychological problems.

• Analysis of stress hormone levels in
  10-year-old children whose mothers suffered
  stress during pregnancy has provided the
  strongest evidence yet that prenatal anxiety may
  affect the baby in the womb in a way that carries
  long-term implications for well-being. The study
  suggests that foetal exposure to prenatal
  maternal stress or anxiety affects a key part of
  their babies' developing nervous system leaving
  them more vulnerable to psychological and perhaps
  medical illness in later life.
• (O'Connor, T. G., Ben-Shlomo, Y., Heron,J.,
  Golding, J., Adams, D., Glover, V. (2005)
  Prenatal Anxiety Predicts Individual Differences
  in Cortisol in Pre-Adolescent Children.
  Biological Psychiatry 58211-217)

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Effects of maternal anxiety during pregnancy.

• This doubles the risk of behavioural problems in
  both boys girls at 4 7 years of age.
• The chemical changes associated with even mild
  anxiety (maternal cortisol ? placental CRH ?
  raised cortisol in foetus) are more harmful than
  those associated with depression.
• Cortisol in babys bloodstream is a trigger for
  premature delivery, causes intrauterine growth
  retardation.
• Ante natal events appear to have a bigger
  negative effect on the Bayley Mental Development
  score then post natal events.

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Levels of infant mental health provision.
Local Level e.g. Service provision Care
pathways Planning Funding
Governmental Level e.g. NICE Guidelines, Children
s NSF, Funding.
Universal/preventative services.
Screening assessment
Parenting education Access to
services Referral
Focussed services for at-risk children families.
Assessment Intervention Referral
Consultation Referral
Tertiary Intervention Services. Direct infant
mental health service. Diagnostic
assessment. Treatment for parent child.
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Standard 9 of the NSF. The mental health and
psychological well-being of children and young
people.

• PCTs and LAs ensure that CAMH Tier 2 3 services
  with specialist expertise, are available to
  promote assessment and therapeutic support for
  infants/young children and their families to
  promote parent child relationships and address
  attachment difficulties.
• CAMH Tier 2 3 services with specialist
  expertise work together with those local
  community services, especially early years
  services, which work with infants/young children
  and their families, to promote parent child
  relationships and address attachment difficulties
  and early problems.

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Improving relationships interactions. Different
systems need to be targeted.
The relationship
Infant
Social conditions
Wider Family
Caregiver(s)
Multi-disciplinary infant mental health team.
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Model of a comprehensive Infant Mental Health
service with a central specialised team.
Court welfare
Child Protection.
Family Centres.
Fostering and adoption Services.
Drugs Project
G.Ps.
Health Visitors.
Daycare and nursery provision.
Adult Mental Health Services.
C.A.M.H.S.
Domestic Violence Services.
Looked After Children teams
B.I.G.
Sure Start.
Midwives.
Perinatal Psychiatry.
Teenage Pregnancy Project.
Voluntary Agencies.
Obstetrics