Many of my colleagues in the field of early childhood mental health work with what are termed "high risk"
populations. Children of drug addicted parents, victims of child abuse, and
families in abject poverty. While the challenges these families face are
daunting, I find myself feeling some envy for my colleagues whose clients are
in such obvious distress that the need for intensive treatment of parent and infant is not in question.
In my rural, small-town population things are not so
clear. Many families struggle under the radar for years. Recently in my
behavioral pediatrics practice (details are changed to protect privacy) I saw a
3-year-old boy, who, in taking a detailed history, I could see barreling 100
miles an hour towards trouble from the moment he was born, or even before.
But the story unfolded before our eyes without intervention. Did the
parents resist help? Did the many professionals in with contact with the family
not recognize the problems? Probably some combination of both.
We know from the CDC sponsored Adverse Childhood Experiences (ACEs) study that neglect and abuse, as well as more ubiquitous experiences of such things
as marital conflict, parental mental illness, domestic violence, and substance abuse lead to a
wide range of negative health outcomes both physical and mental. Yet babies
come and go to pediatric practices and we don't discover or address until years later that
in the early weeks and months, when their brains were most rapidly growing, parents-many themselves with a history of ACEs-struggled significantly.
We need to find a way to engage these families
with intensive support from the very beginning without making parents feel
that they are somehow not "good-enough." Engagement means not only behavior management for children and/or medication for parents. It
means listening to parents and infants together from
the start. We need to listen to the vulnerabilities the child brings into the
world as well as the often-complex relational issues between partners, among
siblings, and with extended family.
The mother of my 3-year-old patient struggled
with severe postpartum anxiety and profound social isolation. She described her son as
"inconsolable" from birth. The marriage faltered. He developed severe separation anxiety,
frequent explosive tantrums, and sleep disturbance among a range of other
behavioral and developmental disturbances.
We know from infant research
that a core sense of self develops in the moment-to-moment interactions between
infants and their caregivers. Babies arrive in state of complete helplessness,
relying 100% on their caregivers to make sense of the world and of themselves.
This does not mean parents need to be perfect. In fact, perfection as well as
absence can inhibit self-development and lead to fearful and rigid states. It
is the very imperfections in relationships that help infants to develop resilience
and a positive sense of themselves in the world.
But when parents are fighting constantly, when a
mother or father is preoccupied with anxiety and/or depression, when a parent
is in an altered mental state intermittently from substance abuse, this core
sense of self may be distorted as infants struggles to make meaning of their
experience. The "symptoms" of my 3-year-old patient can be understood
as difficulties managing both his body and developing mind in a complex social
world.
The transition to parenthood is challenging
under the best of circumstances. Alicia Lieberman, one
of the giants of the field of infant mental health, speaks in a kind of
paradoxical way of how "trauma" is "normal." ACEs are
extremely common. I recently heard a leader in the trauma field say in a
presentation, "ACEs are normal."
If we engage families at or even before birth, presenting the
challenges of the transition to parenthood as normal, when a parent struggles
we will be right there to work more intensively to support these early
relationships when bigger disruptions arise, rather than waiting until families are in crisis. Universal home visiting, relationship-based Early Intervention
services and community support groups for parents and infants offer
opportunities for a population based, non-stigmatizing approach to supporting
new families.
Pediatricians present an ideal opportunity to
engage families in this way. Currently Jack Shonkoff at the Center on theDeveloping Child is partnering with pediatric practices to develop a preventive
model on the front lines where parents and babies regularly go. My colleague Ed
Tronick has said on multiple occasions that parent-infant mental health should
be the core of pediatrics, not a subspecialty. The abundant evidence from the
ACE study certainly supports this claim.
