Early, Early Child Psychiatry: Infant Mental Health Therapy
Honey, I Shrunk The Kids; Parents Are Sharing Therapy With Their Babies As Field of Infant Mental Health Gains Popularity, an article in the October 24th Wall Street Journal describes the growing “field of infant mental health” (the article is only available online by subscription):
By starting treatment as soon as possible — even before their patients are out of diapers — doctors feel they are helping kids become better adjusted. But the field is also getting a push from anxious parents, who are increasingly eager to catch serious problems, such as autism or anxiety disorders, in their children as early as possible. Indeed, doctors are finding that they can recognize the signs of some of these problems earlier — sometimes in infants as young as one.
Parents of autistic children know too well that early intervention—as a result of getting an autism diagnosis when a child is still a toddler (my son Charlie was 18 months old when my husband thought he might be autistic)—-can make a huge difference in a child’s life. Charlie, for instance, received intensive ABA and speech therapy from the time he was just over two years old on; as a result of these, he is able to talk.
The “mental health” problems that the Wall Street Journal refers to are not so much about a neurological disability like an autism spectrum disorder, but “focus on the relationship between the baby and the primary caregiver — usually the mother, but sometimes also the father and even the nanny.” More and more parents are seeking out therapies “initially designed to help kids with early signs of emotional problems” to address “common parent-infant issues”: toilet-training, crying, and sleep and eating problems. Infant mental-health professionals who practice “early childhood family-based therapy” look especially at the relationship between infant and caregiver:
In the late 1960s, Selma Fraiberg, a researcher at the University of Michigan, began examining the infant- caregiver relationship. She coined the phrase “ghosts in the nursery” to denote emotional patterns that parents bring with them from their own childhood, and created services for vulnerable babies and their families as well as one of the first training programs for professionals in the field.
Since then, research has shown that a baby’s environment affects both its psychology and its neurobiology. If a mother is depressed, for example, her baby may become listless and nonresponsive. Additionally, studies show that negative experiences during infancy can alter brain chemistry. Experts understand that many adult disorders — such as depression, anxiety or attention-deficit hyperactivity disorder — start in childhood, and increasingly can recognize them as early as late infanthood or early toddlerhood.
What stands out to me here is emphasis on the parents’, and especially the mothers’, emotional health, and the impact of this on their infants, and all the more because one of the child psychiatrists cited is Dr. Stanley Greenspan of George Washington University Medical School whose DIR Floortime is (as his website describes) an “innovative” approach with “very promising results that could one day stem the tide against this dread disorder,” the “dread disorde” being autism.
Back in July, I wrote a number of reviews of Greenspan’s new book, Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate and Think in which I pointed out that:
- Greenspan suggests that parents “contribute” to a child’s developing an autism spectrum disorder by not promoting proper emotional development in their children—that is, children are “at risk” for autism because of their parents. (See Engaging Floortime (3): Floortime for Parents)
- Greenspan’s book Engaging Autism is not as “engaged” with treating children with ASD as its cover suggests, but rather suggests that children with ASD are just like any other children. (Engaging Floortime (6): Don’t judge this book by its cover)
And indeed, the emphasis on the mental state of parents who anxiously seek out infant mental-health therapy for their babies as described in the Wall Street Journal article sounds very similar to Greenspan’s description of the parents of autistic children in Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate and Think. These parents are said to “contribute” to a child being “at risk” for an autism spectrum disorder due to the child not having had the proper “formative” experiences from the environment provided by their parents—and this explanation for autism contains more than a few echoes of Bruno Bettelheim’s refrigerator mother theory of autism.
Is this what the infant mental health practitioners are concerned about?
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POSTED IN: Diagnosis, Environment, Family, Health, History, Neuroscience, Parenting, Psychiatry, Psychology, Stereotypes, Treatment
2 opinions for Early, Early Child Psychiatry: Infant Mental Health Therapy
Jaylark
Aug 8, 2007 at 2:32 am
I work in the field of infant mental health, and thought that I would try to answer your question. The term “infant” may be confusing here, because infant mental health is generally defined as therapy for children under 3 and their parents, “infant and young child” might be a better description. For children who *need* help, and this is a very important caveat, there is now very compelling evidence that for each $1 invested in infant mental health, societal cost savings in subsequent physical and mental health expenditure can be as high as $17 per dollar invested. The free resources at the following links provide more information about this research:
http://mi-aimh.msu.edu/Policy/InvestmentintheEarlyYears.pdf
http://www.rand.org/pubs/monographs/2005/RAND_MG341.pdf
The WSJ did not go a very good job of explaining that infant mental health is mostly for children who have experienced trauma. It usually consists of play therapy with caregiver, child and therapist all in the session together. The goals of play therapy are either child-centered or “parent-child relationship”-centered: the parent’s own parenting experiences receive attention to the extent that they appear within, help with or disrupt the parent-child relationship in the room. Classic articles about this include Fraiberg, Adelson & Shapiro’s (1975) Ghosts in the Nursery and Lieberman, Padrón, VanHorn and Harris’ (2005) Angels in the Nursery.
At the hospital where I work, we see many children 0-6 who have been abused, molested or have witnessed horrendous acts of inhumanity. Some children have seen their parents die due to a murder, suicide or overdose, or have watched one parent batter the other. Sometimes the family lives in an area in which community violence has reached epidemic levels: murders seen on the news in familiar streets and parks, siblings or parents murdered just outside, hearing regular gunshots, bullets passing through the walls of the house, and so on. Other children have parents who went to jail or were deported, at an age when the child can’t understand where they went. Sometimes the children were themselves molested, abused or neglected. None of these are within the normal range of a child’s ability to understand… but all them are becoming distressingly common urban childhood experiences in this 21st century.
These are issues that can drive adults to therapy: children, while arguably more resilient than adults, nevertheless remain much more primitive in their coping skills and defenses. While I might wish that these were isolated cases, unfortunately there are often many more children on our waiting list than our staff of 15 or so is able to see. There are many more whose parents never follow up on referrals to us after incidents of domestic, community or personal violence.
When a little child is mourning a parent and is talking daily about wanting to die in order to see them again, and maybe fascinated with window ledges or found playing with knives near a younger sibling, therapy can be very valuable, very quickly. Even at 18 or 24 months, a child can grieve through their play, if not in words. They can fail to understand that the parent did not want to go, did not mean to leave without saying goodbye, still loves them from up in Heaven, and so forth. That’s where infant mental health can come in, hopefully with the input and active involvement of the caregiver. The idea is to address psychopathology when the resulting patterns of behavior are still least fixed and most flexible, and often among society’s poorest and least-connected children. When they display problematic behaviors, we endeavor to help them back onto a healthy developmental track before they begin having behavioral, attentional, social or learning problems in school that can contribute to lifelong social or emotional problems, as well as lifelong struggles with feelings of shame, alienation, rejection or failure.
Parents can find their children’s trauma symptoms baffling. As you likely know, in traumatized children we sometimes see overwhelming exaggerations of common problem behaviors like tantrums, nightmares, clinginess, being controlling, or attempts to harm self, siblings or other children. These symptoms are pleas for help every bit as much as they are misbehavior. While love and discipline are both important, if trauma symptoms are not understood in the context of the child’s emotional life and experiences, there is a risk that discipline will actually compound the trauma and its symptoms, rather than alleviate them. For examples of this, I would refer you to Bowlby’s On Knowing What You are Not Supposed to Know, and Feeling What You are not Supposed to Feel, and Slade’s Making Meaning and Making Believe: Their Role in the Clinical Process.
Some kids (and parents) don’t really know how to play, and infant mental health can help to teach this critical relational skill, as well.
Many parents are, of course, doing a wonderful job and are very responsive already. However, in many instances we provide services to families in which the parents’ own parents were either neglectful, abusive, substance addicted or absent. For a parent who never experienced “good enough” parenting themselves, some time to reflect with a professional upon what they’d like to do, or not to do as parents in sessions with their children and the dilemmas of parenting present in the room can already be an invaluable gift for parent and for child, no matter what the therapy is called. Therapists can help parents to understand the meaning inherent in their children’s play, what it might imply about the child’s inner life as they try to make sense of their world… but highlighting, emphasizing and enhancing the relationship between parent and child is paramount.
We believe that this is most easily and most usefully accomplished with the child in the room. This is all a very long-winded way of saying that what we do depends upon the children and the parents, which, of course, you know already. But I thought it might be helpful to clear up who receives infant mental health services, the sorts of experiences they’ve had, and how it might help.
Sandra-qb
Oct 8, 2007 at 10:00 am
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