1 Sound mental health provides an essential foundation of DEFINING - - PDF document

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Centre for Community Child Health Early Years Seminar Infant and child mental health: Ensuring optimal wellbeing for all children Parkville, 18th March 2016

WHAT DO ALL INFANTS AND CHILDREN NEED FOR OPTIMAL WELL-BEING?

Tim Moore

Centre for Community Child Health Murdoch Childrens Research Institute The Royal Children’s Hospital

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INTRODUCTION AND OUTLINE

• This seminar is devoted to infant and child mental health – but

mental health is a problematic term when applied to this age group - no one wants to think of infants and young children having mental health problems, and there is a strong public backlash when anyone tries to do so

• This appears to be partly because of the stigma attached to

mental health in general – we are afraid of it, and don’t talk about it easily – this is changing because of public campaigns such as Beyond Blue, but the atavistic fear still lurks in the background

• The reaction against applying mental health concepts to

young children also reflects a concern that this is pathologising children far too early – this is particularly the case when we try to apply adult mental health terminology such as depression or even mental health itself

• So we need to get a better understanding of what mental

health looks like in young children and how we should talk about it

• The scientific evidence is clear: Significant mental health

problems can and do occur in young children.

• Early mental health problems merit attention because they

disrupt the typical patterns of developing brain architecture and impair emerging capacities for learning and relating to

• thers.
• And regardless of the origin of mental health concerns, new

research clearly indicates that early intervention can have a positive impact on the trajectory of common emotional or behavioral problems as well as outcomes for children with serious disorders.

National Scientific Council on the Developing Child (2008/2012). Establishing a Level Foundation for Life: Mental Health Begins in Early Childhood. NSCDC Working Paper No. 6. Cambridge, Massachusetts: Centre on the Developing Child at Harvard University.

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FOCUS OF PRESENTATION

• The focus of presentation is on normal development and the

conditions that promote it rather than on mental health problems or issues

• This is to counterbalance the usual approach of focusing on

and classifying the various forms of behavioural and developmental aberrations

• We are all on some spectrum or other at some stage of our

lives – if our classification systems continues to try and describe these variations, we will all find ourselves in the DSM eventually – the map will have become the territory

• We need to understand how mental health problems develop

from the inside out, rather than treating them from the

• utside in

The more we learn about the architecture of the mind, the more we see that conditions we recognise as disorders are variations of the same biological and psychological systems that operate in all of us. Normal and abnormal are like night and day: we recognise them as different, but there is no sharp line between them.

Jordan Smoller (2012). The Other Side of Normal: How Biology Is Providing the Clues to Unlock the Secrets of Normal and Abnormal Behaviour. New York: William Morrow / HarperCollins Publishers.

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OUTLINE

• Defining our terms
• Understanding the relationships between mind and body
• What do we know about child development?
• What are the conditions that infants and children need for

their optimal wellbeing?

• What are the conditions that families need to promote the
• ptimal well-being of their infants and children?
• Implications
• Readings and resources
• Conclusions

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DEFINING OUR TERMS

• What do we mean by the terms health, mental health and

well-being, and what is the relationship between them? Does health underpin mental health and well-being? Or does mental health underpin the others?

• Each of the concepts can be defined as being broad enough

to include the other: ─ On the one hand, health can be seen as the bedrock of mental health and well-being; without a basic level of physical health, development is compromised, and their ability to develop the functional capabilities to participate reduced. ─ On the other hand, mental health and well-being can be seen as synonymous with health in its broadest sense.

• Sound mental health provides an essential foundation of

stability that supports all other aspects of human development—from the formation of friendships and the ability to cope with adversity to the achievement of success in school, work, and community life.

• Understanding how emotional well-being can be strengthened
• r disrupted in early childhood can help policymakers promote

the kinds of environments and experiences that prevent problems and remediate early difficulties so they do not destabilize the developmental process.

National Scientific Council on the Developing Child (2008/2012). Establishing a Level Foundation for Life: Mental Health Begins in Early Childhood. NSCDC Working Paper No. 6. Cambridge, Massachusetts: Centre on the Developing Child at Harvard University.

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MIND, BRAIN AND BODY

• Thus, health and mental health / well-being can be

understood as complementary concepts

• This complementarity of the twin notions of health and

wellbeing is consistent with what we are learning about the neurobiology of mind, brain and body: ─ brain functioning is not purely cognitive, ─ ‘learning’ is not purely conscious, ─ learning is not exclusively neural, ─ the brain is not purely skull-based, and ─ the brain is closely linked with other key bodily systems THE NERVOUS SYSTEM The nervous system controls and coordinates all bodily systems. It has two main parts:

• The central nervous system,

which consists of the brain and the spinal cord

• The peripheral nervous

system, which forms a network through the body Properly understood, the brain is not just skull-based but ‘embodied’, being shaped by messages from all over the body.

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MIND, BRAIN AND BODY (cont)

• Psychological states (including mental health and

happiness), neurological functioning, and biological functioning (including health) are dynamic systems that interact with and affect each other continuously (Siegel, 2012; Davidson & Begley, 2012)

• This relationship between mind and body is bidirectional:

what is in the brain necessarily influences what is in the body, but what is in the body also influences what is in the brain (Davidson & Begley, 2012)

• The human brain and the rest of the body constitute an

indissociable organism, integrated by means of mutually interactive biochemical and neural regulatory circuits (including endocrine, immune, and autonomic neural components); the organism interacts with the environment as an ensemble: the interaction is neither of the body alone nor of the brain alone (Damasio, 1994)

THE MIND~BRAIN~BODY SYSTEM

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MIND~BRAIN~BODY SYSTEMS AND THE ENVIRONMENT

• However this mind~brain~body system is also designed to

respond to our social environments

• The mind is relational, not a product created in isolation:

interpersonal relationships shape how the mind emerges in

• ur human lives.
• Thus, brain, mind and relationships form an interlocking

system: brain influences mind and relationships; relationships influence mind and brain; mind influences brain and relationships (Siegel, 2012)

• Thus, we are simultaneously embodied (mind and body are
• ne) and embedded (in our immediate social and physical

environments)

• The implication is that preventing or promoting mental

health cannot be separated from all other aspects of development and functioning

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WHAT DO WE KNOW ABOUT CHILD DEVELOPMENT?

• The importance of the first 1000 days – the period from

conception to end of second year – and the time of maximum adaptation / developmental plasticity

• Developmental plasticity is a general biological mechanism

by which organisms, in response to cues such as nutrition

• r hormones, adapt their phenotype – the phenotype is the
• bservable outcome of the interaction between the

genotype and the environment – to their particular environment (Gluckman et al. 2010, 2011; Bateson & Gluckman, 2012; Low et al, 2012).

• Plasticity is very demanding of energy, and hence in general

is limited to an early phase of development because re- engineering the body after the phenotype has been fully developed is costly.

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PRENATAL AND POSTNATAL DEVELOPMENT

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PRENATAL DEVELOPMENT

• Until recently, there had been a scientific misconception that

the placenta provides a barrier for the growing foetus that protects it from the mother's physical and emotional environment

• We now know this is not the case – the placenta does not

protect the child against drugs, alcohol, smoking, environmental toxins or maternal stress

• Moreover, instead of being a passive bystander in the womb

during the pregnancy journey, the foetus actively responds to changes within the intrauterine environment and uses the nutritional and hormonal information that crosses the placenta to predict the kind of world it will be born into, and alters its phenotype accordingly

• While these changes might be adaptive in the immediate

environment, they can come with long-term costs, both psychologically and physically. NEUROBIOLOGY OF INTERPERSONAL RELATIONSHIPS

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NEUROBIOLOGY OF INTERPERSONAL RELATIONSHIPS

• Healthy development depends on the quality and reliability of

a young child’s relationships with the important people in his

• r her life, both within and outside the family
• Relationships are the medium through which young children

learn the skills that enable them to become fully participating members of society – in effect, children use the brains of adults to develop their own

• Sensitive and responsive care giving is a requirement for the

healthy neurophysiological, physical and psychological development of a child

• The key qualities of effective relationships are attunement,

responsiveness and respect

• Brains are changed by relationships – they can do this because
• ur brains constantly communicate with each other through

unconscious or subconscious neurobiological pathways of which we are unaware.

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WHAT WE KNOW ABOUT CHILD DEVELOPMENT (cont)

• Children learn through the immediate environments in

which they spend their time – there is no such thing as a non-learning environment

• Neurological development – building connections between

neural networks – between limbic and cortical systems, between left and right hemispheres

• An added complication is that children are differentially

susceptible to environmental experiences: while most children are ‘dandelion’ children who do well in most environments, a minority are ‘orchid’ children who flourish in positive environments but react particularly badly to negative environments

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WHAT WE KNOW ABOUT CHILD DEVELOPMENT (cont) What are the risk factors for mental health problems?

• absence of positive relationships – insecure attachments
• adverse experiences
• neglect / abuse
• verprotection
• environmental toxins
• impoverished opportunities to participate
• inadequate nutrition

How do these experiences get ‘under the skin’?

• Hertzman and Keating (1999) called this process ‘biological

embedding’, while Shonkoff (2010) talks of biological ‘memories’

• Trauma therapists talk of the way ‘the body remembers’

(Rothschild, 2000) and ‘the body keeps score’ (van der Kolk, 2014) even when conscious memory systems are blocked.

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BIOLOGICAL EMBEDDING

• Biological embedding refers to a developmental process

whereby prenatal and early childhood experiences influence physiological and neurological development in ways that have long-term consequences

• Early life social and environmental stressors, such as

childhood abuse, neglect, poverty, and poor nutrition, become deeply embedded in the child’s neurobiology

• These changes have been associated with an increased risk
• f common metabolic and cardiovascular diseases later in

life, the emergence of mental and physical illness (such as anxiety, mood disorders, poor impulse control, psychosis, and drug abuse) and increased risk for psychopathology (from depression and conduct disorders to autism and schizophrenia)

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WHAT ARE THE CONDITIONS THAT INFANTS AND CHILDREN NEED FOR THEIR OPTIMAL WELLBEING?

• Responsive caregiving – attunement, responsiveness
• Attachment – developing secure attachments to a small

number of caregivers

• Emotional functioning – experiencing range of emotions /

acknowledging emotions / listening to the body

• Self-regulation and executive functioning – importance of

co-regulation

• Meaningful participation – experiencing agency
• Social relationships – experience with a range of adults and
• ther children
• Safety - protection from social, physical, environmental

harms

• Security - providing a safe place for exploration

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CONDITIONS THAT INFANTS AND CHILDREN NEED FOR THEIR OPTIMAL WELLBEING (cont)

• Resilience – learning that relationship ruptures / failures /

accidents can be overcome and how they can do this

• Children do not need cotton wool environments where they

are never stressed and are totally protected from failure

• Instead, they need moderate stress in the form of freedom

to explore and sometimes fail, as well as in the form of high expectations

• However, children also need some caregiver with whom

they have a secure relationship who provides them with support whenever they face challenges or experience failures or temporary breakdowns in relationships

• ‘Good-enough’ parenting – children don’t need perfect

parenting, but they do need a threshold-level of responsive caregiving

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WHAT ARE THE CONDITIONS THAT FAMILIES NEED TO PROMOTE THE OPTIMAL WELL-BEING OF THEIR INFANTS AND CHILDREN?

• Family functioning is significantly influenced by their

proximal environments

• Environmental features that shape family functioning

include positive support networks, supportive communities, healthy physical environments, access to green spaces, employment opportunities, financial security, and housing security

• Family stressors – various sources of stress can

compromise responsive caregiving, and it is important that these be reduced or eliminated

• Families also need access to services - parents need a

service system that responds promptly to their emerging concerns about their children and their family

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IMPLICATIONS

• We need to ensure that the conditions under which families

are raising young children are optimal – especially ensuring they have positive social networks

• We need to minimise sources of extraneous stress on

families

• We need to support parents in providing positive and safe

home environments

• We need to help parents and caregivers to use specific

strategies to promote key aspects of development and functioning WORKING WITH VULNERABLE FAMILIES

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IMPLICATIONS (cont)

• We need to ensure that children’s immediate social and

learning environments are optimal

• We need to help parents and caregivers to use specific

strategies to promote key aspects of development and functioning: strategies to promote ‒ secure attachments, ‒ emotional development, ‒ positive behaviours, ‒ self-regulation and brain integration, ‒ a sense of safety, and ‒ a sense of agency

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ESTABLISHING SAFETY

Key features for ensuring children’s felt sense of safety:

• Ensure the habitual presence of an attachment

figure

• Maintain predictability
• Enhance safety when disciplining
• Plan in advance for changes and separations
• Avoid isolation
• Be deliberate with surprises
• Repair the sense of safety whenever it gets broken

Hughes (2009)

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READINGS

• Dan Siegel and Tina Payne Bryson (2011). The Whole-Brain

Child: 12 Revolutionary Strategies to Nurture Your Child's Developing Mind. New York: Delacorte Press.

• Dan Siegel and Tina Payne Bryson (2014). No-Drama Discipline:

The Whole-Brain Way to Calm the Chaos and Nurture Your Child's Developing Mind. Brunswick, Victoria: Scribe.

• Sue Gerhardt (2014). Why Love Matters: How Affection Shapes a

Baby's Brain. London, UK: Routledge.

• Vicky Flory (2005). Your Child’s Emotional Needs: What they are

and how to meet them

• John Gottman (1998). Raising an Emotionally Intelligent Child.

New York: Simon & Schuster.

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READINGS (cont)

• Daniel A. Hughes (2009). Attachment-Focused Parenting. New

York: W.W. Norton.

• Daniel Hughes and Jonathan Baylin (2012). Brain-Based

Parenting: The Neuroscience of Caregiving for Healthy

• Attachment. New York: W.W. Norton
• Sue Roffey (2006). Circle Time for Emotional Literacy. London,

UK: Paul Chapman.

• Robyn Dolby (2007). The Circle of Security: Roadmap to building

supportive relationships. Canberra, ACT: Early Childhood Australia.

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RESOURCES

• Raising Children Network

www.raisingchildren.net.au The Australian parenting website: comprehensive, practical, expert child health and parenting information and activities covering children aged 0-15 years.

• Encylopedia on Early Childhood Development

http://csefel.uiuc.edu/ Canadian website offering up-to-date scientific knowledge on early childhood development, from conception to age five.

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RESOURCES

• KidsMatter Early Childhood

http://www.kidsmatter.edu.au/ec/ KidsMatter Early Childhood is an Australian national mental health promotion, prevention and early intervention initiative specifically developed for early childhood services.

• Centre on the Social and Emotional Foundations

for Early Learning

http://csefel.uiuc.edu/ The Centre on the Social and Emotional Foundations for Early Learning is a national US centre focused on strengthening the capacity of child care and Head Start programs to improve the social and emotional outcomes of young children. The Centre publishes a series of short What Works Briefs on various aspects of how to promote children’s social and emotional development

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CONCLUSIONS

• To prevent / promote mental health, we need to attend to all

factors that impact on child development and functioning – social, physical, environmental

• To support families, we need to attend to the conditions

under which they are raising young children

• Importance of ‘pre-prevention’ - prevention is usually thought
• f as primary prevention (promoting positive health etc.),

secondary and tertiary – but there is a level before these that addresses the conditions that families live in

• Promoting children’s mental health is everyone’s business.

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• Dr. Tim Moore

Senior Research Fellow

Centre for Community Child Health, Murdoch Childrens Research Institute, The Royal Children’s Hospital, Flemington Road, Parkville, Victoria, Australia 3052 Phone: +61·3·9345 5040 Fax: +61·3·9345 5900 Email: tim.moore@mcri.edu.au Website: www.rch.org.au/ccch