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Salud Mental 2002; 25 (6)
Language: Spanish
References: 69
Page: 59-67
PDF size: 375.70 Kb.
ABSTRACT
This article describes infant mental health from two perspectives: why it is relevant and how to implement interventions, including preventive ones. Topics covered are based on evidence available in scientific literature. The first section addresses areas that justify the importance assigned to infants and their emotional well-being. One of them deals with new information about brain development. Recent available information emphasizes the crucial role of sensory/experiential input for the development of the brain in terms of determining the formation of new synapses, influencing cell migration and the “pruning” of refined and dedicated neuronal pathways. Experiences (exposure to language, contingent responses by the caregiver, motion in space) influence the development of the brain. Also, negative and anxiety provoking events as well as psychological trauma cause a negative outcome through this effect. Prolonged and/or severe trauma has been shown to influence negatively the functioning of the limbic system and the capacity of the child to feel empathy and/or compassion, to regulate emotions and to learn new information.
New evidence is reviewed from longitudinal research. Several studies have demonstrated that it is possible to “trace back” which elements are necessary during early childhood, to put a child at a high risk of becoming a criminal or severe offender. These include attributes in the child him or herself (restlessness, impulsiveness, lack of fear) together with a history of maltreatment and chronically adverse experiences. Excessive shyness is another fairly persistent trait from early infancy to adulthood. Since these “risk factors” are known, particular children could be targeted for early intervention programs.
A follow up study conducted by some of the authors with infants seen in a mental health clinic and followed up to age four, indicates that the strongest predictor of the outcome and functioning of the child at age four is not the severity or type of problems for which the child was originally evaluated. The strongest predictor was the quality of parenting and parenting behaviors of the caregivers as assessed during infancy. This finding suggests the importance of helping parents as early as possible to cope with infant problems in a benign and sensitive way, before negative circles of interaction are entrenched and spiral into an ongoing negative relationship.
Together with the studies of risk, those focusing on resilience are summarized. Knowing which traits or experiences are protective against psychopathology is crucial, in order to promote their flourishing in early childhood. Studies with children at high psychosocial risk from Kauai, Hawaii as well as with children from other groups in the world converge in describing resilient traits in early childhood: an easy temperament, a “social orientation”, sense of humor, attractiveness and the ability to communicate with others, as well as intelligence. Several experiences are protective, such as having few separations from the mother and having had a sibling when the index child was at least three years old. This knowledge can be used to promote resilient features in children and to develop interventions for those at most risk.
Epidemiological evidence suggests that infancy disturbances are not rare, but frequent (15 to 20% of the population). Studies of the prevalence of problems like feeding and sleeping disturbances, excessive crying and disruptive behavior in infancy point in this direction. This justifies the need for early recognition and identification, particularly when they are severe. Excessive crying increases the risk of the child being abused or shaken; likewise sleep disturbance is associated with irritability and hyperactive behavior in the infant. Parents who are deprived of sleep are prone to be more negative and to feel exhausted. Eating disturbances can be associated with failure to thrive. Early malnutrition has been associated with hypertension in middle age, as well as with a higher risk of coronary disease. Maternal depression and domestic violence are rampant in the perinatal period. Maternal depression is associated with more crying and sleeping problems in infancy, and hyperactivity and negative behavior in the school age child. The findings of a survey in a “well-baby clinic” (health surveillance clinic) conducted by some of the authors concur in the finding that parents are worried about their baby’s behavior in all these areas and that they readily identify the problems, when asked. Furthermore, their worries are justified. This is in sharp contrast with the tendency in most pediatric settings to “wait and see” hoping that problems in the baby will be solved by themselves.
The second part of the review focuses on two issues: techniques of clinical intervention and preventive strategies and their results. There is scant scientific evidence on the efficacy of parent infant psychotherapies. Techniques vary widely in their content and their focus or target population. Strategies like brief parent-infant psychotherapy and the therapeutic consultation are framed psychodynamically and focus on the transgenerational transmission of “fantasmatic” interactions and projections placed on the infant. These appear more suitable for families that are relatively healthier and lacking massive stressors. On the other side of the spectrum, techniques such as interactive guidance and infant-parent psychotherapy are designed for families under more stress, and when the parent child relationship is very negative.
These strategies are used with “unreachable families”. Interactive guidance attempts to focus on what the parents are doing well through a videotaped feedback given to them, and gradually expanding their repertoire of sensitive and empathic behaviors towards the baby. Infant-parent psychotherapy is long term and involves interventions that are non traditional, like psychotherapy at home, practical help to the parents, and the promotion of a long term relationship of trust between the caregivers and the therapist. The focus is to achieve a “corrective attachment experience” in the parents, which will in turn render them more sensitive and responsive towards their baby. Multimodal and flexible techniques are advocated in order to tailor the intervention to the particular needs and style of each family.
Finally, evidence on the effectiveness of various prevention programs is reviewed. These are grouped according to the timing of the intervention, from pregnancy to toddlerhood. Evidence suggests that improving marital communication and promoting conflict resolution before the baby is born may enhance maternal sensitivity and lead to a more secure attachment in the infant. There is research on interventions in the perinatal period. These include having psychosocial support during the delivery process. In addition, “bonding” between newborn and mother (without undue intrusion by health care personnel) has positive effects. This involves skin to skin contact and early breast-feeding. These simple interventions have been shown to promote maternal sensitivity, more patience and less behavioral difficulties several months later. The mere demonstration of the abilities of the newborn, his or her uniqueness and preferences as well as an observation of the baby’s perceptual abilities, is associated with long term positive behavioral effects. All this points to the importance of conducting an intervention during a “sensitive period”. Several meta-analytic studies on home visitation conclude that these programs are most effective if the intervention has a clear focus, is brief and practical help and advice are given to the parents on site. By contrast, with families having a high risk of abusing their child, home visitations are the only hopeful strategy so far. In this case, home visitation should be long-term and also focused on specific problem solving with parents and suggestion of alternative strategies of behavior management with the child. In families under considerable stress home visitation, together with the opportunity to have positive experiences for the infant, in the form of a good day care setting, also have a lasting and beneficial effect several years later, in terms of better academic performance, reduced psychopathology and better parent child relationships.
REFERENCES
BARKER DJP, OSMOND C, RODIN I, FULL CHD, WINTER PH: Low weight gain in infancy and suicide in adult life. Brit Medical J, 311:1203, 1995.
BECKER C, LIEBRSCH R, TAUTZ C: Shaken Baby Syndrome: report on four pairs of twins. Child Abuse Negl, 22:931-937, 1998.
BECKWITH L, SIGMAN MD: Preventive interventions in infancy. Child Adol Psychiatr Clin North Am, 4:683-700, 1995.
BOWER CM, GUNGOR A: Pediatric obstructive sleep apnea syndrome. Otolaryngologic Clin North Am, 32:49-75, 2000.
BRADLEY SJ: Affect Regulation and the Development of Psychopathology. Guilford Press, Nueva York, 2000.
BROWN J K, OMAR T, O’REGAN M: Brain development and the development of tone and movement. En: Connoly KJ, Forssberg H (eds.) Neurophysiology and Neuropsychology of Motor Development. Clin Dev Med No. 143-144, Mc Keith Press : 1-41. Londres. 1997.
CASPI A: The child is father of the man: personality continuities from childhood to adulthood. J Pers Soc Psycho, 78:158-172, 2000.
CASPI A, SILVA K: Temperamental qualities at age three predict personality traits in young adulthood: longitudinal evidence from a birth cohort. Child Dev, 66:486-498, 1995.
CEDERBLAD M: The children of the Lundby study as adults: a salutogenic perspective. Eur Child Adolesc Psychiatry; 5:38- 43, 1996.
CEDERBLAD M, DAHLIN L, HAGNELL O, HANSSON K: Salutogenic childhood factors reported by middle-aged individuals. Follow-up of the children from the Lundby study grown up in families experiencing three or more childhood psychiatric risk factors. Eur Arch Psychiatry Clin Neurosci, 244:1-11, 1994.
CEDERBLAD M, DAHLIN L, HAGNELL O, HANSSON K: Intelligence and temperament as protective factors for mental health. A cross-sectional and prospective epidemiological study. Eur Arch Psychiatry Clin Neurosci, 245:11-19, 1995.
COOPER PJ, TOMLINSON M, SWARTZ L, WOOLGAR M, MURRAY L, MOLTENO C: Post-partum depression and the mother-infant relationship in a South African periurban settlement. Br J Psychiatry, 175:554-558, 1999.
CRAMER B, ROBERT-TISSOT C, STERN DN, SERPARUSCONI S, DE MURALT U, BESSON G, PALACIOESPASA F, BACHMANN JP, KNAUER D, BERNER CD, ARCIS U: Outcome evaluation in brief mother-infant psychotherapy: A preliminary report. Infant Mental Health J, 17:97-114, 1996.
CROWE HP, ZESKIND PS: Psychophysiological and perceptual responses to infant cries varying in pitch: comparison of adults with low and high scores on the Child Abuse Potential Inventory. Child Abuse Negl, 15:19-29, 1992.
EINSPIELER C, PRECHTL HF, FERRARI F, CIONI G, BOS AF: The qualitative assessment of general movements in preterm, term and young infants—review of the methodology. Early Hum Dev, 50:47-60, 1997.
FARRINGTON DP: Psychosocial predictors of adult antisocial personality and adult convictions. Behav Sci Law, 18:605- 622, 2000.
FIELD TM: Massage therapy effects. Am Psychol, 53:1270- 1281, 1998.
FONAGY P: Prevention, the appropriate target of infant psychotherapy. Infant Mental Health J, 19:124-150, 1998.
GUEDENEY A : La dépression du nourrison: nécessité d’une définition et d´une évaluation précises. J Pédiatrie Puériculture, 7:436-440, 1990.
HEINICKE HC, BECKWITH L, THOMPSON A: Early intervention in the family system: A framework and review. Infant Mental Health J, 9:111-141, 1988.
HERNANDEZ RM, FIELD T, DIEGO M, BEUTLER J: Evidence-based medicine and massage. Pediatrics, 108:1053, 2001.
HERSCHKOWITZ N: Neurological bases of behavioral development in infancy. Brain Dev, 22:411-416, 2000.
KAUFMAN J, CHARNEY D: Effects of early stress on brain structure and function: Implications for understanding the relationship between child maltreatment and depression. Dev Psychopathol, 13:451-471, 2001.
KENNELL JH, KLAUS MH: Bonding: recent observations that alter perinatal care. Pediatr Rev, 19:4-12, 1998.
KENNELL JH, MCGRATH S: What babies teach us: the essential link between baby’s behavior and mother’s biology. Birth, 28:20-21, 2001.
KLAUS, MH, KENNELL JH: The doula: an essential ingredient of childbirth rediscovered. Acta Paediatr, 86:1034- 1036, 1997.
LARTIGUE T, MALDONADO-DURAN JM: Psicoterapias padres-bebé. En: Salles M (ed.) Manual de Psicoterapia Infantil. Plaza y Valdez, 339-388, México, 2001.
LEBOVICI S: Le pratique des psychotherapies mères-bebés par Bertrand Cramer et Francisco Palacio-Espasa. Psychiatrie Enf, 37:415-427, 1994.
LEECKMAN JF, HERMAN AE: Maternal behavior and developmental psychopathology. Soc Biol Psychiatr, 51:27-43, 2002.
LIEBERMAN AF, WESTON DR, PAWL JH: Preventive intervention and outcome with anxiously attached dyads. Child Dev, 62:199-209, 1991.
LOEBER R, FARRINGTON DP: Young children who commit crime: epidemiology, developmental origins, risk factors, early interventions, and policy implications. Dev Psychopathol, 12:737-762, 2000.
LUCAS A: Role of nutritional programming in determining adult morbidity. Arch Disease Childhood, 71:88-90, 1994.
MACMILLAN HL: Preventive health care, 2000 update: prevention of child maltreatment. Am J Orthopsychiatry, 71:171- 181, 2001.
MACMILLAN HL, MACMILLAN JH, OFFORD DR, GRIFFITH L, MACMILLAN A: Primary prevention of child physical abuse and neglect. A critical review. Part 1. J Child Psychol Psychiatry, 35:835-874, 1994.
MALDONADO-DURAN JM: La conducta del recién nacido normal. En: Jasso-Gutiérrez L (ed.) Neonatología. Temas de Pediatría. Asociación Mexicana de Pediatría AC. Ed. Interamericana-McGraw Hill, 49-59, México, 1996.
MALDONADO-DURAN JM: A new perspective on Failure to Thrive. Bulletin Zero Three. National Center for Infants, Toddlers Families, 21:1, 2000.
MALDONADO-DURAN JM, GLINKA J: Motor Skills Disorders. Textbook of Pediatrics. Washington, eMedicine
MALDONADO-DURAN JM, MILLHUFF C: Posttraumatic stress disorders. En. Textbook of Pediatrics. Washington, wwweMedicine.com
MALDONADO-DURAN JM, SAUCEDA J: Excessive and persistent crying: Characteristics, differential diagnosis and management. En: Maldonado-Duran JM (ed.). Infant and Toddler Mental Health. Models of Clinical Intervention with Infants and Families. American Psychiatric Press, 239-268, Washington, 2002.
MALDONADO-DURAN JM, SAUCEDA JM: Epidemiología de los trastornos psiquiátricos del niño y el adolescente. En: Sauceda-Garcia JM, Maldonado-Durán JM (eds.). Psiquiatría. Temas de Pediatría. Academia Mexicana de Pediatría. Editorial Interamericana-McGraw-Hill, 31-48. México, 1998.
MALDONADO-DURAN JM, SAUCEDA JM: Los problemas de alimentación en la primera infancia. En: Lartigue T, Maldonado-Durán JM, Avila H (eds.). La Alimentación en la Primera Infancia y sus Efectos en el Desarrollo. Asociación Psicoanalitica Mexicana y Plaza y Valdez, 133-162. México, 1998.
MALDONADO-DURAN JM, HELMIG L, MOODY C: Signos de alarma en la detección temprana de problemas emocionales y conductuales en el bebé. Perinatologia Reproducción Humana, 15:21-30, 2001.
MALDONADO-DURAN JM, BARRIGUETE JA: Evaluation and treatment of eating and feeding disturbances in infancy. En: Maldonado-Durán JM (ed.). Infant and Toddler Mental Health. Models of Clinical Intervention with Infants and their Families. American Psychiatric Press, 309-344, Washington, 2002.
MASTEN AS, HUBBARD JJ, GEST SD, TELLEGE A, GARMEZY N, RAMIREZ ML: Competence in the context of adversity. Pathways to resilience and maladaptation from childhood to late adolescence. Dev Psychopathol, 11:143-169, 1999.
MOFFIT TE, CASPI A: Childhood predictors differentiate life-course persistent and adolescence-limited antisocial pathways among males and females. Dev Psychopathol, 13:355-375, 2001.
MURATORI F, MAESTRO S, TANCREDI R, PFANNER P: Interventi terapeutici flessibili. En: Muratori F (ed.). La Nascita della Vita Mentale e i Suoi Disturbi. Argomenti di Psicopatologia della Prima Infanzia. Edizioni del Cerro. v166-184. Pisa, 1999.
MURRAY L, COOPER P: Effects of postnatal depression on infant development. Arch Dis Child, 77:99-101, 1997.
MURRAY L, WOOLGAR M, COOPER P, HIPWELL A: Cognitive vulnerability to depression in 5-year-old children of depressed mothers. J Child Psychol Psychiatry, 42:891-899, 2001.
OLDS D, HENDERSON CR, COLE R, ECKENRODE J, KITZMAN H, LUCKEY D, PETTIT L, SIDORA K, MORRIS P, POWERS J: Long term effects of nurse home visitation on children’s criminal and antisocial behavior: 15 year follow up of a randomized controlled trial. JAMA, 14:1248-1244, 1998.
OLDS D, HILL P, ROBINSON J, SONG N, LITTLE C: Update on home visiting for pregnant women and parents of young children. Curr Probl Pediatr, 30:107-141, 2000.
OSOFSKY JD: The impact of violence on children. Future Child, 9:33-40, 1999.
PAPOUSEK M, von HOFACKER N: Persistent crying in early infancy: a non-trivial condition of risk for the developing mother-infant relationship. Child Care Health Dev, 2:395- 424, 1998.
PROVENCE S, NAYLOR A: Working with Disadvantaged Parents and Children. Scientific Issues and Practice. Yale University Press, New Haven, 1983.
RAINE A, REYNOLDS C, VENABLES PH, MEDNICK SA, FARRINGTON DP: Fearlessness, stimulation-seeking, and large body size at age 3 years as early predispositions to childhood aggression at age 11 years. Arch Gen Psychiatry, 55:745-751, 1999.
RAMSAY M: Feeding disorder and failure to thrive. Child Adol Psychiatr Clin North Am, 4:605-616, 1995.
RUTTER M: Transitions and turning points in developmental psychopathology as applied to the age span between childhood and mid adulthood. Inter J Behav Develop, 19:603-626, 1996.
SKUSE D, WOLKE D, REILLY S: Failure to thrive. Clinical and developmental aspects. En: Remschmidt H, Schmidt M (eds.). Developmental Psychopathology, Child and Youth Psychiatry. European Perspectives. Vol. 2. Hogrefe & Huber, 46- 71, Götingen, 1991.
ST JAMES-ROBERTS I, HALIL T: Infant crying patterns in the first year: normal community and clinical findings. J Child Psychol Psychiatry , 32:951-958, 1991.
THELEN E: Motor development. A new synthesis. Am Psychol, 50:79-95, 1995.
UPSHUR CC: Early intervention as preventive intervention. En: Meisels SJ, Shonkoff JP (eds.). Handbook of Early Childhood Intervention. Cambridge University Press, 633-650, Cambridge, 1991.
VAN DER WAL MF, VAN DEN BOOM DC, PAUWPLOMP H, DE JONGE GA: Mothers’ reports of infant crying and soothing in a multicultural population. Arch Dis Child, 79:312-317, 1998.
VAN IJZENDOORN M, JUFFER F, DUYVESTEYN MG: Breaking the intergenerational cycle of insecure attachment. A review of the effects of attachment-based interventions on maternal sensitivity and infant security. J Child Psychol Psychiatry, 36:225-248, 1995.
VYGOTSKY L: Thought and Language. MIT Press. Cambridge, 1962.
WERNER EE: Vulnerable but invincible. High risk children from birth to adulthood. Acta Paediatrica, 86:103-105, 1997.
WERNER EE: Protective factors and resilience. En: Shonkoff JP, Meisels SJ (eds.). Handbook of Early Childhood Intervention, 115-134. Nueva York, 2000
WERNER EE, SMITH RS: Journeys from Childhood to Midlife. Risk, Resilience and Recovery. Cornell University Press, 25-37, Ithaca, 2001.
WURMSER H, LAUBEREAU B, HERMANN M, PAPOUSEK M, VON KRIES R: Excessive infant crying: often not confined to the first 3 months of age. Early Hum Dev, 64:1-6, 2001.
ZERO TO THREE, Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. National Center for Clinical Infant Programs, 49-55, Washington, 1994.
ZUCKERMAN B, STEVENSON J, VEIRA-BAILEY: Sleep problems in early childhood: Continuities, predictive factors and behavioral correlates. Pediatrics, 80:664-671, 1987.
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