INFANT MENTAL HEALTH AND CHILD ABUSE PREVENTION Martín Maldonado MD

Why infant mental health?

Some risk factors…. Genes temperament In utero CHILD Family relations Fit between Parents and children Biological Features, e.g. Sensory integration CHILD Social group And cultural factors Early experiences Or lack of them Family relations And functioning Parental psychopathology Child rearing style

Parental or caregiver factors temperament Psychopathology Stressors History of relation Ships child Cultural factors Parenting beliefs

What cannot be easily changed Genes Birth order Temperament of infant Socioeconomical status Parental early caregiving experiences History of trauma in caregivers

What can be changed In utero environmental experiences Preparation for arrival of the baby Parental beliefs (authoritarian beliefs) Diminish number and type of stressors Alleviate emotional disturbance in caregivers

What can changed How parents “read” their child or how they interpret the behavior Attributions toward the baby Family functioning, parenting roles, support for new mother

Having a baby Altricial species vs precocial species Primates highly altricial “cooperative breeding” New mother needs support from others in pregnancy and post-delivery

Having a baby Highly costly from the evolutionary point of view Enormous needs and sacrifices from the future mother Baby vs. mother in utero (competition for nutrients)

Having a baby Mother has to supress immunological resopnse vis a vis the baby Baby in utero has its own objectives, nutrition, growth, survival Mother has to survive too!

If no support…. From mother From “aunts” From “others”,e.g. other women, or partner Mother will be isolated

If no support … Maternal behaviors may be supressed Exhausting needs of the baby Baby is highly dependent Baby is highly ‘invalid’ For an extended period of time (1-2 yrs)

Transition to parenthood Calipedia (wish for a beautiful child) Conscious wish for a baby Imaginary baby ( preconscious desire, fantasy) Phantasmatic baby (unconscious representation, meaning of baby) “Real baby” “Cultural baby” (MR Moro)

Transition to parenthood First encounter with baby Encounter between desired baby and real baby Surprise, “shock” and ambivalence Reconciliation between imagined and real infant Process of acceptance, celebration, “mourning” of ideal features

FAMILY AND CULTURE PARENT INFANT

CULTURAL EXPECTATIONS PARENT FEATURES TEMPERAMENT REACTIVITY ATTENTION SPAN INTEREST IN NOVELTY TALENTS INTERESTS + HOPES EXPECTATIONS RULES DESTINY OBLIGATIONS CHILD FEATURES TEMPERAMENT REACTIVITY ATTENTION SPAN INTEREST IN NOVELTY TALENTS + DUTIES BIRTH ORDER RESEMBLANCE CULTURAL EXPECTATIONS GENDER APPEARANCE

Example of Goodness of Fit: “ideal” PARENT Expectation Active, energetic Likes music Wanted a boy INFANT Child has easy temperament Child is athletic and interested Likes music Child is a boy

Example of Poor fit PARENT Parent is exhausted and stressed Low level of energy Active, likes sports Conflict with own father CHILD Child is irritable and “high demand” Sleeping difficulties Is floppy and low muscular tone Child resembles the grandfather

Goodness of fit DEGREE OF FLEXIBILITY ACCEPTING THE REALITY PARENT CHILD DEGREE OF FLEXIBILITY ACCEPTING THE REALITY CAPACITY TO “READ” THE CHILD EMPATHY/MENTALIZATION MATERNAL OR PATERNAL INSTINCT ADAPTABILITY CAPACITY TO READ PARENT “BABYNESS” “SOCIAL ORIENTATION” DEVELOPMENTAL PUSH

Goodness of fit Parent adapts caregiving to child’s unique characteristics Parent modifies expectation Parent alters discipline strategies Child creates own environment Child “disarms” parent Child reinforces parent

Positive mutual feedback INFANT IS IRRITABLE AND CRIES FREQUENTLY, HIGH DEMANDS CHILD REMAINS CALM LONGER PERIODS OF TIME CAREGIVER EXPERIENCES EMPATHY AND COMPASSION TOWARD INFANT CAREGIVER TRIES TECHNIQUES TO CALM INFANT, CARRYING, BUFFERING, DISTRACTING

Vicious cycle feedback CHILD IS FUSSY AND IRRITABLE INFANT BECOMES INCREASINGLY DYSREGULATED, UNABLE TO CALM, DISORGANIZED CAREGIVER IS MOSTLY ANGRY AND READS AS MANIPULATION , SPOILED CAREGIVER IGNORES YELLS, SHAKES SPANKS THE INFANT

Effects of child on parent TODDLER DISOBEYS TRANSGRESSION THROWS A TEMPER TANTRUM CHILD SHOWS SENSE OF HUMOR MAKES PARENT LAUGH CHANGES TONE OF INTERACTION CHILD LEARNS FROM EXPERIENCE PARENT CALMS DOWN SEES THE “BIG PICTURE” LETS TH INGS GO PARENT BECOMES EXASPERATED, LOSES TEMPER

Mutual coercive training (GR Patterson) CAREGIVER USES MOSTLY COERCIVE STRATEGIES (THREATS, PHYSICAL, PUNISHMENTS) CHID LEARNS TO COMPLY MOSTLY IF UNDER DURESS OR THREAT CHILD COMPLIES CHILD DOES NOT COMPLY CHILD, IF STRONG RESISTANCE, NO COMPLIANCE AND NOT FOLLOW RULES

How to intervene? Home visitor, nurse, clinician “mental health appraisals and interventions are unavoidable” Given the nature of the early intervention

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How to intervene? First step is to assess the situation in a comprehensive way: Child as individual Parent as individual Parent child interaction or “fit” Stressors for parents Family relationships, marital relationship Cultural factors and parental beliefs

How to intervene? Who is this child? Sensory integration, motor functioning, ability to communicate, to relate Mood, self-regulation Functioning in sleep, eating, maintaining state of contentment, etc.

How to intervene? Who is this caregiver? Psychosocial functioning, emotional or behavioral problems Level of stress History of being cared for and of relationships Working model of relationships, ability to empathize and to “mentalize”

How to intervene? What is the nature of the relationship? degree of psychological involvement Mutual sharing of feelings, warmth Observe actual behaviors and interactions first hand

How to intervene? Stressors in the family The higher the number, the worse the psychological functioning of the person Removing one or two stressors may make a difference

Intervention Multimodal Recognition of number of problems Priorization of problems Contact with family Focus of intervention Outcome Psychosocial problems Family problems Problem in relationship Problem in parent Problem in infant Intervention Multimodal

Zone of mutual co-existence tolerance Multimodal…. Relationship changes Good enough Compromise Zone of mutual co-existence tolerance Mutual satisfaction Enjoyment Ideal Parent changes infant changes

Continuum of Interventions Multimodal…. Continuum of Interventions Emotional support Cognitive-behavioral intervention Advice Psychodynamic interpretation Information Long-term corrective attachment experience Practical help *Use of multiple techniques at different times *For same problem or several problems

Continuum of psychosocial functioning of caregivers Less difficulties, less psychopathological issues More difficulties, personality disturbance, much Emotional trauma, severe deprivation

Continuum of infant’s functioning Difficulty is recent and not severe More flexibility in the intervention More space to explore options More need of an expert And for the intervention Severe difficulty or in multiple areas, chronic

Continuum of interventions Provide information about child’s development Concrete help, diminish stress, relief Give emotional support, containment Give suggestions to remedy Cognitive behavioral interventions Psychodynamic interventions Psychiatric intervention

LIST OF USEFUL BOOKS Suggested by Dr. Martin Maldonado, following his presentation on March 5, 2009. DeGangi, Georgia. Pediatric disorders of self-regulation. Lieberman, Alicia. The emotional life of the Toddler. Maldonado-Duran JM. Ed. Infant and Toddler Mental Health. Models of clinical intervention American Psychiatric Press. 2003. Sameroff, Arnold and McDonough, Susan. Treating Relationship Disturbances in Infancy. Stock-Kranowitz, J. The Out of Synch Child. Stock-Kranowitz J. The Out of Sync Child has Fun