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.
At the tender of of 3 there is plenty of opportunity to help my patient and his family, who are invested in doing the work to set relationships and development on a better path. But I hope for shifts in culture, health care, and public health that will allow all families to set out on a healthy path from the start.