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Infant Mental Health Provision in Gloucestershire'


Infant mental health is the developing capacity of the child from birth to three ... (O'Connor, T. G., Ben-Shlomo, Y., Heron,J., Golding, J., Adams, D., & Glover, V. ... – PowerPoint PPT presentation

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Title: Infant Mental Health Provision in Gloucestershire'

Infant Mental Health Provision in Gloucestershire.
Still gestating!
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

  • 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.
  • 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.

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
  • (p. 184) Robin Karr-Morse Meredith
    Wiley. (1997)
  • Ghosts From the Nursery.
  • New York Atlantic Monthly Press.
  • (Very recommended!)

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
  • 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.

  • 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.

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
  • What happens in the
  • early years affects the
  • course of development
  • across the lifespan.

  • 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.

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.

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
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

  • 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
  • Infant Mental Health services have been
    specified in both the CAMHS development plan and
    the Maternal Mental Health Strategy for the
  • But can the latter influence the former?

Where does early intervention designed to support
a positive relationship between parent and small
child belong?
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!
Antenatal postnatal mental health risks.
  • 10 16 of pregnant women experience
  • 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
  • Up to 26 of adolescent mothers experience
    postnatal depression.

  • 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)

Children of parents with mental health
  • 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.

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
  • (DeMulder, E. K., Radke-Yarrow, M. (1991)
    Attachment with affectively ill and well-mothers
    Concurrent behavioral correlates. Development and
    Psychopathology. 3, 227-249.)

  • 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.)

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,

The context of parental depressioneffect on
infant security.
Economic hardship.
Less sensitive interactions
Infant attachment security.
Increase in frequency of spanking.
Relationship stress.
  • 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)

  • 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)

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)

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.

Mothers with post-partum psychosis
  • Tend to be unresponsive to babys emotional
  • Are more preoccupied with hallucinations and
    psychotic ideation.
  • Have infants who tend to be passive and
  • and in middle childhood they frequently develop
    anxiety disorders.

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

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.)

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.

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

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)

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
  • Ante natal events appear to have a bigger
    negative effect on the Bayley Mental Development
    score then post natal events.

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.
Standard 9 of the NSF. The mental health and
psychological well-being of children and young
  • 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.

Improving relationships interactions. Different
systems need to be targeted.
The relationship
Social conditions
Wider Family
Multi-disciplinary infant mental health team.
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
Health Visitors.
Daycare and nursery provision.
Adult Mental Health Services.
Domestic Violence Services.
Looked After Children teams
Sure Start.
Perinatal Psychiatry.
Teenage Pregnancy Project.
Voluntary Agencies.