7 Infant mental health

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Contents

Objectives

When you have completed this chapter you should be able to:

Introduction to infant mental health

7-1 What is an infant?

In this chapter, we refer to an “infant” as a child under 1 year of age.

7-2 What is infant mental health?

Infant mental health refers to a positive state of well-being that allows an infant to succesfully:

Infant mental health is a state of well-being from birth to age one year that prepares an infant to have healthy cognitive, social and emotional development.

7-3 Why does infant mental health have an impact on cognitive, social and emotional development?

Infants’ brains develop more in the first 1000 days of life, from conception to age 2, than at any other time. The brain doubles in size by the end of the first year, and by age 3, the brain has reached 80% of its adult volume.

Assessing infant mental health allows us to see how an infant is learning to understand the world. How the brain develops during this time is shaped by the infant’s experiences and perceptions of the world.

Note
Infant brains develop in stages, starting from conception with simple circuits forming first (such as the visual and auditory circuits) and more complex circuits (such as language) developing later. The timing of this may be genetic, but our earliest experiences determine if these circuits work well or not.

The first 2 years of life is an important time for brain growth and development.

7-4 What factors influence an infant’s mental health?

An infant’s mental well-being is shaped by:

The amount of environmental stress affects infant mental health.

7-5 How do you promote infant mental well-being?

The following factors promote mental well-being for the infant during the first 1000 days:

Good nutrition, loving care, stimulation and freedom from stress help to promote infant well-being.

The mental health of a mother has an impact on the physical and emotional development of the fetus during pregnancy and of the infant after the birth. Also, mental ill-health in other adults caring for the infant, can negatively affect development.

Note
The term ‘mother’ in most instances in this chapter should be taken to read ‘mother or caregiver’. A caregiver can include fathers, grandmothers, other relatives, older siblings, paid child minders and others. Many infants may be cared for by those other than their biological mothers, either permanently, or for most of the time. It has been shown that regular caregivers who are not the biological mothers, may effectively ensure the mental well-being, attachment and development of infants. However, as it is for biological mothers, this care can be negatively affected if these caregivers suffer from extreme stress or mental illness. Emotional stress in the home may lead to growth stunting in the child as occurs in some orphanages.

Caregivers who struggle with mental health problems may face challenges in looking after and bonding with their infants. This then influences the survival and development of the infant. Early treatment of parental mental health problems benefits a parent and positively affects her infant’s health and development.

Note
Research shows that infants of mothers who are depressed during pregnancy may be born with certain biological differences that put them at higher risk for mental illness like depression. For example, they may be born with an imbalance of certain hormones that regulate mood. They may be born with a higher level of “cortisol,” the hormone that makes us feel stressed and a lower level of “dopamine,” a hormone that is associated with feelings of pleasure. These newborns may appear more irritable from birth.

The mental health of the mother during and after pregnancy has an effect on the physical and emotional development of the child.

Negative effects of stress on infant mental health

7-7 What does an infant with poor mental health experience?

An infant exposed to severe stress may experience prolonged mental distress or “psychological distress”. This may impair an infant’s normal functioning and responses.

When mental distress goes on for a long time, it can impair an infant’s normal functioning and responses.

7-8 What is a “stress response”?

A stress response is the internal, mental distress experienced by an infant as a result of exposure to an environmental stressor. The stress response may include an increase in some hormone levels.

7-9 When is it normal for an infant to experience mental distress?

Experiencing mental distress is not a problem when it is a part of a temporary stress response. In fact, learning how to cope with environmental stressors is a part of healthy development so long as:

Experiencing mental distress is not a problem when it is a part of a temporary stress response and there is good adult support at the time.

7-10 What stress responses are normal for an infant to experience?

There are 2 types of normal stress responses for an infant:

7-11 What is a positive stress response?

This is temporary stress response that an infant experiences when exposed to small and new challenges. These can include:

This is a healthy stress response for an infant to experience because it is a temporary experience. It only briefly increases an infant’s heart rate and stress level. It is important for infants to experience this kind of stress and have a supportive and kind caregiver there to help them deal with their emotions. It prepares them for larger challenges later in life.

Temporary stress experiences are healthy for development because they prepare an infant for dealing with larger challenges later on.

7-12 What is a tolerable stress response?

This is the stress experienced by an infant from a more serious event, such as:

This type of stress response is more severe. However, a soothing and supportive adult can help to limit the time and effects of the stress response. In this case, the response is “tolerable” and will not have damaging effects on the brain.

Infant stress can be tolerable if a caring and supportive caregiver is present.

7-13 What can cause a problematic stress response?

A stress response is problematic when it is severe and continuous. This is called a ‘toxic stress response.’

In this case, an infant is frequently exposed to serious environmental stressors without adquate support from an adult, e.g. their caregiver does not provide adequate comfort and security in response to the stressor. These environmental stressors can include persistent:

A stress response is a problem when it is severe and continuous

7-14 Why is this stress “toxic”?

This type of stress is “toxic” because it can result in prolonged mental distress that can eventually develop into a mental illness like depression and anxiety. Toxic stress is abnormal and can also result in later stress-related health problems such as:

Note
An infant can be in mental distress and have depressive symptoms without having a diagnosis of depression. It is not clear at what exact age a clinical diagnosis of depression can be made, but some clinicians believe that depressive symptoms can be diagnosed after 18 months of age. In this case, early signs that an infant is unhappy may mean they are at risk of developing depression later in childhood.

7-15 What can be done to change the effects of environmental stress?

Care givers may not be able to change the stressors in the environment, but the effects that they have on the child can be influenced as some of the negative effects of toxic stress are preventable and reversible if an infant is under the care of a loving and responsive adult.

Some of the negative effects of toxic stress are preventable and reversible if an infant is under the care of a loving and responsive adult.

7-16 How can maternal depression or anxiety affect an infant’s stress response?

Maternal depression or anxiety may affect a mother’s ability to parent effectively. She may find it very difficult to soothe her infant, which may prolong her infant’s experiences with stress.

Depression and anxiety are very hard to cope with in addition to facing the challenges of being a new mother! It is important to be empathic to these new mothers. The presence of another caregiver for the infant or a supportive partner can assist mothers with depression and anxiety to nurture their infants well.

Maternal depression or anxiety may affect a mother’s ability to parent effectively

Identifying poor mental well-being in infants

7-17 What are some concerning signs of poor mental well-being in infants?

You should be concerned about an infant’s well-being and investigate further if:

  1. You notice signs of social withdrawal in the infant. Infants who are experiencing prolonged mental distress may show signs of “social withdrawal.”
  2. You notice signs of attachment problems.

It is important to look out for these signs in an infant as they could indicate various emotional problems. It is also important to look for signs of depression or anxiety in the mother and other caregivers, as their mental illness could affect the infant’s mental health.

Infant social withdrawal

7-18 What does social withdrawal mean?

Social withdrawal is the apparent emotional detachment of an individual from their surroundings. Social withdrawal can have various causes, one of which is depression. An infant who is at risk of developing depression may show signs of social withdrawal at around 3 months of age.

Social withdrawal is the emotional detachment of an individual from their surroundings

7-19 What are some signs of social withdrawal in an infant?

At around 3 months, infants should begin to engage in face-to-face interactions in response to social signs (‘cues’) like an excited adult trying to play with them.  An infant displaying withdrawal behaviours will not respond appropriately to social cues. For example, during 10 minutes of active, playful interaction with an adult, an infant with social withdrawal may:

An unhappy and withdrawn infant may cry more frequently or less frequently. An infant who does not cry frequently is not necessarily happy, they may be simply less active or engaged with their environment. This could be a problem.

Note
It is important to note that during a single interaction, an infant may appear withdrawn. This may be appropriate. It could show their wariness to interact with a stranger for the first time. They may be tired or physically unwell. If an infant initially appears withdrawn, it is important to interact with the infant more than once to assess if they have more problematic and ongoing withdrawal behaviour.

7-20 Why might a mother not notice or report signs of withdrawal behaviour?

Possible reasons are:

This is why it is important that health and social workers stay alert for signs of behavioural or developmental problems in infants.

Note
The infant’s withdrawal behaviour may be the result of a mirroring or mimicking of their mother’s behaviour. If they have a mother who is depressed, she may be demonstrating the withdrawal behavior that is also seen in the infant.

7-21 What are some long term impacts of infant social withdrawal?

Infant social withdrawal is associated with:

Infant social withdrawal may lead to atypical social behavior in adulthood.

Attachment problems

7-22 What is attachment?

Attachment is the non-verbal emotional bond or connection between an infant and their primary caregiver. Attachment develops from how the caregiver responds to the infant’s cues. Attachment is important for the infant’s sense of security.

7-23 What is secure attachment?

A secure attachment is a stable emotional bond between an infant and their caregiver. It is established when the infant has been made to feel they can freely express their negative emotions and needs. Their caregiver consistently understands and responds in an appropriate and sensitive manner.

7-24 How can you tell an infant feels securely attached?

Infants with secure attachment will appear:

Note
Attachment develops over time as the infant senses a pattern.  Developing a secure attachment requires that the adult consistently respond sensitively. Responding sensitively only sometimes can shatter the infant’s sense of a secure attachment.  This is why it is not advisable to ignore an infant’s cries during the first 6 months of life.

7-25 What are the long term benefits of early secure attachment?

Secure attachment:

7-26 How do you promote secure attachment?

Development of secure attachment is dependent on the caregiver’s ability to understand and meet their infant’s needs in times of distress. The caregiver should nurture and calm the developing infant when they are hurt, frightened or emotionally distressed. To do this, they can:

7-27 What is insecure attachment?

Insecure attachment is an unstable emotional bond between an infant and their caregiver.  The infant does not feel that they can rely on their caregiver.

7-28 What information can help you identify attachment problems?

You can identify attachment problems by:

7-29 How may an infant’s physical health and behavior suggest attachment problems?

Infants with attachment insecurity may:

When interacting with their caregiver, they may:

Some of these behaviours may show that the infant has learned that the caregiver is insensitive to their needs or not available consistently. If an infant is showing these signs, it may mean the caregiver is having trouble understanding the infant’s needs or is unable to respond appropriately because they are depressed or anxious.

7-30 How may a mother or caregiver’s mental health suggest attachment problems?

Assessing the mental health of the mother or caregiver can provide very important information.  If a mother or caregiver is depressed or anxious, insecure attachment is more likely to develop. Depressed or anxious mothers or caregivers can sometimes feel so bad it is as though they are in a fog. It may become difficult for them to focus on their infants cues and respond appropriately. This affects the quality of attachment and can lead to infant social withdrawal.

It is important to be able to identify if a caregiver may be suffering from mental distress or a mental illness like depression or anxiety. If she is showing signs of these mental illnesses, she may need to be referred for help.

Note
Ideally all new mothers would be screened for depression. But, if there are not enough resources to screen every new mother, those who are at higher risk for depression and anxiety should be screened.

7-31 How may the mother-infant interactions suggest attachment problems?

Assessing how a mother or caregiver interacts with the infant can provide clues about the quality of attachment that has formed. Some examples of interactions to notice are:

Without these interactions, the caregiver may need help in understanding the infant’s cues or help in improving their mood.

Interventions for improving mother-infant interactions

7-32 Why is it important to intervene as early as possible?

If a mother is having trouble with attachment because of depression or anxiety, even after these signs have improved, the insecure attachment bond may remain and there may be negative consequences for the infant’s development.

7-33 How can you help improve interactions between a depressed mother and her infant?

There are some behaviours that can help a caregiver establish a more secure attachment and promote mental wellbeing in the infant. These include:

  1. Focus on keeping the infant’s attention:  For a caregiver who is feeling down or worried, positive emotions and expressions, like smiling, may not come naturally. Therefore, providing them with another goal, like keeping the infant’s attention, may come more easily. Caregivers who focus on keeping their infants attention during an interaction:
    • Are more likely to appear energetic and positive.
    • The infant is more likely to show positive expressions. Watch to see what the infant is doing. What does the infant respond to? Movement and sound will focus their attention to you. Be gentle. Talk to the infant, tell them about your surroundings and what you are doing. This will help them to develop language skills.
  2. Gentle rocking or gentle singing and humming: This can lower an infant’s stress levels.  During rocking, an infant is also likely to fall asleep.

  3. Massage: Massaging an infant several times per week can:
    • Lower stress levels and improve an infant’s mood
    • Help soothe an infant
    • Cause the infant to sleep after the massage
  4. Learn about infant behaviours:  It can be overwhelming to look after a new infant. The caregiver may struggle to understand the infant’s behaviours and how to respond. It may be helpful to learn about common infant behaviours and what to do with each. This could come from a new mothers’ support group or simply from learning from other experienced mothers or caregivers.

Because infants are unable to tell you how they are feeling, crying may be trying to tell you that they need something or that something is wrong. Infants may cry if they are hungry, tired, too hot or too cold, need to have their nappy changed, are uncomfortable due to wind, are over-stimulated or are sick. It takes time to work out what the infant is trying to tell you.

Chapter Summary

Case study 1

A local maternity clinic has decided to start providing education to new mothers about infant mental health. There are 5 important topics that they want new mothers to understand about infant mental well-being so that they can help their babies to get a good start in life.

1. What is infant mental health?

Infant mental health is a positive state of well-being from birth to age 1 that prepares an infant to have healthy cognitive, social and emotional development

2. Why does infant mental health have such a big impact on development?

Because infants’ brains develop more in the first 1000 days of life than any other time.

3. What factors affect an infant’s mental health?

The following factors can influence an infant’s mental well-being:

4. How can caregivers promote infant mental health?

Caregivers can promote infant mental health by:

The mental health of a mother has an impact on the physical and psychological development of the infant, from birth onwards. Also, mental ill-health in other adults caring for the infant can negatively affect development.

Case study 2

A new mother comes into the postnatal clinic and reports that her husband is drinking a lot of alcohol recently. She says he often comes home drunk and she is worried his drinking might be stressful for her infant.

1. What types of stress responses do infants experience?

There are 3 types of stress:

2. Which type of stress response is problematic?

A “toxic stress response” is problematic because it is severe and continuous.

3. Does this mother have reason to be concerned about her infant?

Yes, exposure to substance abuse in the family can be a cause of toxic stress.

4. The mother asks, what kind of negative effects can toxic stress have on her infant? What can you explain to her about toxic stress?

Toxic stress can cause:

5. She then asks what she can do to protect her infant from the negative effects of toxic stress?

Yes, she can provide her infant with loving and responsive care. The negative effects of toxic stress are preventable and reversible if an infant has a loving adult to soothe them and reduce the level of stress they experience. It is also important for her to be supported and look after her own mental well-being.

Case study 3

A new mother comes in with her 5 month old baby. The pregnancy was unintended (unplanned) and she reports the father of the infant recently revealed he has a new girlfriend. She says she feels very sad. You actively play with the infant for 10 minutes and discover the infant does not smile often, show much eye contact or make any sounds.

1. What does social withdrawal mean?

Social withdrawal is the apparent emotional detachment of an individual with their surroundings. Social withdrawal can have various causes, one of which is depression.

2. At what age might an infant who is at risk of depression show signs of social withdrawal?

At around 3 months of age, when the infant begins to engage in face-to-face interactions in response to social cues.

3. What signs of social withdrawal is this 5 month old infant showing?

The infant does not smile much, has less eye contact and is very quiet, even while an adult is trying to engage.

4. After playing with the infant, should you tell the mother her infant is socially withdrawn?

Not quite yet. This is a single interaction and it is possible the infant is withdrawn due to tiredness or feeling unwell.

5. The mother reports that her infant seems happy because she does not cry often. Do you think that the infant rarely crying is a sign of infant mental health?

Not necessarily. An infant who does not cry frequently may actually be less engaged with their environment. This could present a problem.

6. You meet the infant and her mother several more times at the clinic. Each time, you notice the same signs of social withdrawal in the infant. Why might the mother not have noticed that there was withdrawn behavior?

Case study 4

A teenage mother comes into the postnatal clinic. She says the pregnancy was unplanned and she had to leave school to support her new baby. Her family has not been very supportive and her parents say they are disappointed in her. She seems down, irritable and overwhelmed. She does not seem to be engaging with her infant.

1. What is attachment?

Attachment is the non-verbal emotional bond between an infant and their primary caregiver.

2. You ask this mother how she responds when her infant cries. She says she feels annoyed and often finds herself yelling at her infant to stop. What kind of attachment do you think might have formed between this mother and her infant?

Given her responses, the infant may have learned that crying annoys their mother and as a result, an insecure negative attachment bond may have formed. This infant may actually avoid their mother in times of distress.

3. You ask this mother to bring her infant for another appointment. What are some signs of attachment insecurity you may notice when the infant comes in?

When interacting with their caregiver, infants with insecure attachment may:

4. You show the mother how her infant responds when you smile at the infant. The mother says, “Smiling a lot doesn’t feel natural to me right now.” You suggest she focus on keeping her infant’s attention during an interaction, rather than focus directly on smiling. Why might this come more easily to her?

For mothers who are feeling down, positive emotions and expressions may not come naturally. Providing her with an alternative purpose like keeping her infant’s attention may come more easily. Mothers who focus on this during an interaction:

5. The mother tells you “I feel like I don’t know what my baby is trying to tell me when he cries.” What else do you think you should recommend to this mother?

She may need support from a new mothers group or a more experienced mother to learn about common infant behaviours and how to respond to each. It sounds like she is not receiving much support at home and this is her first child. It could be very overwhelming for her.

It also sounds like she could be feeling depressed. It may be a good idea to screen her for depression.

Case study 5

A grandmother comes into Social Development Grant office with her 14 month old granddaughter. The infant begins roaming around the office, picking up pencils and touching the seat cushions. She suddenly bangs her elbow against the chair and begins crying. Almost immediately, her grandmother picks her up and begins to rock her.

1. What type of stress did this infant experience?

This is an example of positive stress. She experienced a temporarily stressful experience and she was immediately soothed by a caring adult. No damage has been done.

2. What did this grandmother do well?

She immediately responded to her granddaughter’s call of distress.

3. What type of attachment bond is this grandmother promoting?

She is promoting secure attachment, or a stable emotional bond in which an infant feels they can rely on their caregivers to respond to their cues of distress. It is the foundation for the infant’s sense of security and trust.

4. Why is it important to promote early attachment security?

Early attachment security is important for:

5. The grandmother mentions that her granddaughter was very close to an aunt who passed away 2 months ago. She is concerned this may have been upsetting for her granddaughter. What should you tell her?

Her granddaughter should be fine. This is an example of tolerable stress because it is in response to a time-limited event. It should not be damaging, especially if she and the mother of the infant continue to provide love, support and comfort.