1. INFANT MENTAL HEALTH AND CHILD ABUSE PREVENTION
Martín Maldonado MD

2. Why infant mental health?

4. 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

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

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

7. 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

8. 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

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

10. 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)

11. 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!

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

13. 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)

14. 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)

15. 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

16. FAMILY AND CULTURE
PARENT
INFANT

17. 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

18. 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

19. 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

21. 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

23. 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

25. 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

26. 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

27. 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

28. 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

30. 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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32. 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

38. 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.

39. 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”

40. 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

41. 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

42. 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

43. 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

44. 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

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

46. 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

47. 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

48. 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
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