Case, Part 1
You are seeing 2-yo David, who has been brought in by his mother for immunizations. You notice that mother appears exhausted and tired. During the immunization, while David is crying, you notice that he doesn’t really turn to mother to meet his needs. Mother appears to ignore David’s cries, in order to answer a text on her cellphone...
What are you going to do?
What is Infant and Early Childhood Mental Health?
Infant and Early Childhood Mental Health is crucial for child development and is the developing capacity of the child from birth to age 5 to:
- Form close and secure adult and peer relationships,
- Experience, manage and express a full range of emotions,
- Explore the environment and learn,
- All in the context of family, community and culture.”
Elements for infant and early childhood mental health include:
- Perinatal and Prenatal health: Mental health of the mother during the pregnancy as well as after the delivery;
- Brain development: Healthy development of the child’s brain
- Attachment: The close connection between the child and caring adults
- Temperament: How the child is ‘hard wired’, which affects what type of needs the child may have;
- Self-regulation: The child’s ability to regulate their emotions and feelings;
- Resiliency: The child’s ability to withstand stress and adversity;
- Sense of Agency: The child’s ability to take initiative and take charge
Epidemiology
Children <6 years of age have a similar rate of mental illness as older children and youth (14% to 20%). Youth and their families often report that their challenges began in the preschool years (Ontario Centre of Excellence for Child and Youth Mental Health, 2014).
Normal Infant Development
In the first few months of life, just as parents are busy learning to read their baby’s cues, the baby also learns to read a parent’s emotional cues – the reciprocal serve-and-return experience. Infants sense and respond to their parent’s moods and emotions.
Although an infant’s language lacks words, it is rich with facial expressions, crying, cooing, gurgling or withdrawal. Young infants experience sadness, fear and a whole range of human emotions (Gopnik, 2000).
Attachment relationships are key to infant mental health
The attachment relationship between infant and caregiver(s) is crucial to healthy development.
A secure, warm, responsive and predictable relationship with at least one caregiver is important in the formation of neural structures in the brain that lead to positive infant well-being, including developing a healthy hypothalamic pituitary axis which regulates stress (National Scientific Council on the Developing Child, 2008/2012).
When under stressful situations, secure attachment relationships can help protect the brain from significant harm.
On the other hand, if there are early stresses (such as adverse childhood experiences, including relationship stresses) then neuronal pathways will be more vulnerable to stress. Contributors to stress may include:
- Parental mental illness
- Parental absence
- Poverty
- Unpredictability
- Violence
- Maltreatment
Significant stresses will place children at greater risk for later challenges in life, including depression, alcohol and drug use, school failure, social difficulties and physical health problems such as cardiovascular disease, cancer, not to mention encounters with the justice/legal system (Felitti, 1998).
Of all the possible investments that can be made in health and mental health, investing in infant mental health is arguably the best possible health return on investment (ROI) (Heckman, 2012), with the ability to prevent future problems in older children, youth and adults.
Screening for Infant and Early Childhood Mental Health Problems in Primary Care
Health professionals (such as nurse practitioners, family physicians and paediatricians) see infant and young children and their caregivers regularly over the first few years of life. As a result, health professionals (even if they are not mental health specialists per se), can still make a significant impact to ensure infant mental health and well-being.
Screen patients with these risk factors / red flags (Weatherston, 2000)
- Difficult/unwanted pregnancy
- Difficult delivery / trauma
- Maternal perinatal / post-partum depression
- Breastfeeding struggles
- Attachment concerns:
- Anger directed toward the infant, such as when the baby is expressing its needs
- Unhealthy beliefs about baby’s crying, e.g. “my baby is so inconsiderate; can’t she see that I’m exhausted”
- Parent ignores the child’s needs
- E.g. Parent ignoring a crying baby such as during vaccinations
- Parent has unhealthy beliefs about attachment, such as “My baby has to learn, so I’m letting her cry it out”
- Parent ignoring a crying baby such as during vaccinations
- Infant with feeding, sleeping, regulation problems with parents who are unable to set firm, loving routines related to feeding or sleep
- Special needs siblings
Assessment in the Office Setting
Observe for attachment behaviours:
- Does the infant / child have troubles turning to the parent for comfort when distressed, e.g. while getting immunization? While crying?
- Does the parent have troubles recognizing the infant / child’s cues?
- Is the parent able to attempt to soothe (i.e. co-regulate) the infant / child (eg. by gently holding and/or rocking the child, speaking in a gentle voice)? Or does the parent struggle with co-regulation?
Ask:
Coping | “How are things at home?” “How are you coping with your new role as a parent?” “Having a baby can be quite overwhelming… Does it ever get overwhelming for you? How bad does it get?” |
Attachment | “What is it like looking after your baby / child?” “Does your baby / child give you pleasure, or are you still in the ‘hard work’ stage?” “Is your baby / child comforted when you try to soothe him/her?” |
Resources and social support | “Do you feel that you have enough people to support you?” “Who do you have that can support you?” “What is your source of income?” “Any struggles getting by?” “Any troubles with rent/mortgage? Food? Necessities for the baby such as diapers?” |
Screening Tools for the Assessment of Infant and Early Childhood Health
Early Childhood Screening Assessment (ECSA)
The ECSA is a primary care screening measure developed to identify young children (aged ½ to 5-years old (i.e. 18-60 mos.)) who need further emotional or behavioural assessment (Gleason et al., 2010). It consists of 40 items. It is estimated to take 5-10 minutes to complete, and less than a minute to score.
Cost: Free.
https://medicine.tulane.edu/infant-institute/measures-manuals
Ages & Stages Questionnaire ®: Social-Emotional, Second Edition (ASQ®:SE2)
Reliable, parent-completed tool with focus on children’s social and emotional development. Can screen infants from age 1-mos., up to age 6.
Cost: Yes. Paper version is $295 for Starter Kit including paper masters that can be photocopied for future use, with no need to re-order the questionnaire. Also available as online version.
Rourke Baby Record
Recommended by the Canadian Paediatric Society (CPS), College of Family Physicians of Canada (CFPC), though not specific for mental health concerns.
Cost: Free
http://www.rourkebabyrecord.ca/pdf/RBR%202017%20National%20English%20-%20Black%20170926.pdf
Looksee Checklist®
Formerly known as the Nipissing District Developmental Screen®-NDDS, this is a short and simple checklist. It reviews a child's growth and development at a specific age (up to 6 years old).
https://lookseechecklist.com/Default
Promising tools
Copenhagen Infant Mental Health Screening (CIMHS)
New tool that appears promising, though not yet endorsed by Canadian organizations yet. Can screen up to age 12-months.
https://link.springer.com/article/10.1186/s12887-016-0744-1#Tab1
Other Screening Tools
First Words Communication Checkup
An online screening tool available to families of children aged 6 months to 5 years living in the city of Ottawa. Use it to check a child’s speech, language, social communication, fine and gross motor skills.
https://firstwords.ca/communication-checkup/
NutriSTEP®
Simple checklist to see if a child is a healthy eater, i.e. nutritional risk screening. Looks at a child's eating, physical activity, screen time habits and more.
Edinburgh Postnatal Depression Scale (EPDS)
A set of 10 screening questions that can indicate whether a parent has symptoms that are common in women with depression and anxiety during pregnancy and in the year following the birth of a child.
Management
Educating Parents about Infant and Early Childhood Mental Health
Connection
- Build your connection with parents/caregivers. Just like we recommend that parents follow the infant’s lead, professionals must also use “connection before direction” with parents. For example, connect with parents/caregivers first (e.g. providing empathy, validation, support for their goals) before proceeding to give them advice about what the professional thinks is more important.
- Encourage both parents (or caregivers) to attend office visits;
- Identify and enhance the strengths that each parent brings to the care of the infant. Fathers may need more encouragement to help keep them involved. E.g. To father: “Thank you so much for coming today. Your son is so lucky to have a father so loving and involved.”
- Identify and enhance the strengths that each parent brings to the care of the infant. Fathers may need more encouragement to help keep them involved. E.g. To father: “Thank you so much for coming today. Your son is so lucky to have a father so loving and involved.”
- Be an advocate for the infant. When parents are exhausted and tired, it may be hard sometimes for them to see their child’s needs, or infant’s accomplishments.
- Let parents know about needs that they may have overlooked;
- Let parents know about the infant’s accomplishments, e.g. growth and development.
- Offer anticipatory guidance to parents specific to their infant;
- Foster attachment between child and parent (as opposed to child and professional). Allow or encourage the parent to take the lead in interacting with their infant or determining the ‘agenda’ or ‘topic for discussion’.
- Role model healthy attachment for parents
- Model empathy, validation and curiosity for parents
E.g. Clinician: “Your baby is crying… How hard it must be, having to wait so long for our appointment!” - Remaining open, curious and reflective
E.g. Clinician: “I wonder if she’s hungry? Tired and needing a nap? Or just wanting a hug? Luckily you have a loving mommy to think about what you need…” - Validating baby’s existence as an independent being
E.g. Clinician (to the baby): “You’ve been so patient today… I’m almost done with your mommy and you’ll be on your way soon!”
- Model empathy, validation and curiosity for parents
- Encourage parents on the four Ts (Suskind, 2015):
| When possible, try to follow your child’s cues and interests |
| Describe the world to your child, e.g. “Look, there’s a tree. And look at that bird singing in the tree.” Name your child’s feelings and emotional states, e.g. “Oh, it looks like you’re hungry. Time for milk!” Read to your child. Regular reading to your child will help your child develop language skills, as well as helping you read your child’s needs better.” |
| Be a conversational partner |
| Babies have a hard time tuning out background sounds, and studies show that background TV and radio can make it harder for babies to learn language. |
- Use checklists in the office visit (e.g. Rourke Baby Record);
When to Refer?
- Identify, treat and collaborate with others if needed, in the treatment of:
- Child disorders, delays and disabilities,
- Parental mental illness and family dysfunction.
- Identify social determinants of health (e.g. poverty; social isolation) and help connect parents to relevant supports.
Resources for Parents
- Local public health units
- Provide accessible, reliable parenting resources
- Province-wide and Canada-wide examples include Best Start (http://beststart.org), Caring for Kids (www.caringforkids.cps.ca)
- There may also be specific regional resources
- Parenting in Ottawa for those in Ottawa area, http://www.parentinginottawa.ca)
- Infant/Early Childhood Mental Health Initiative (www.iecmh.ca)
Where to Refer for Infant Mental Health Issues in Ontario, Canada?
Are you a primary care provider? Consider the following resources:
- Paediatrician
- EarlyON Child and Family Centres
- Local children’s hospital or community health centre
- Local Public Health Unit with early years services
- e.g. Parenting in Ottawa, ...(add examples from other regions)
- Local childhood mental health service providers
- For a list of service providers in your area: (http://www.children.gov.on.ca/htdocs/English/professionals/specialneeds/momh/moving-on-mental-health.aspx)
Where to Refer for Infant/Early Childhood Mental Health in Ottawa, Ontario?
- The Parent Resource Centre has their Go Family! Map which includes mental health and well-being supports
https://parentresource.ca/go-family-interactive-map/ - Ottawa Public Health “Parenting in Ottawa” has resources listed on their website:
http://www.parentinginottawa.ca/en/babies-and-toddlers/baby-and-toddler-resources-in-ottawa.aspx - Mental health referrals can be made to Crossroads for English speaking families https://www.crossroadschildren.ca/
- Mental health referrals can be made to Centre Psychosocial for French speaking families https://www.centrepsychosocial.ca/
Any Concerns about Parental Mental Health, e.g. Postpartum Depression?
Refer the mother / father to appropriate mental health services such as perinatal or postpartum mental health services, or services specifically for the mother, father or primary caregiver.
For more information, view Postpartum Depression: Information for Primary Care http://primarycare.ementalhealth.ca/index.php?m=fpArticle&ID=26929
Not In Ontario? Where to Refer in Other Provinces...
Resources vary by the province:
British Columbia | Sure Start centres |
Alberta | Parent Link centres |
Saskatchewan | ‘Kids First’ programs |
Manitoba | Healthy Child Manitoba |
Ontario | EarlyON Child and Family Centres: High-quality early years programs, including free drop-in playgroups for caregivers and children from birth to 6-years old Life with a Baby: is a peer support system, a project of Healthy Start, Healthy Future, a not-for-profit organization whose goal is to provide ongoing practical and emotional peer-based support for new and expecting parents, and parents of children up to the age of six. This program offers informational seminars and programs geared towards families of young children, open forums discussing everyday parenting and child rearing issues, and fun social events for the entire family. https://www.lifewithababy.com/ Moving on Mental Health: Collective of child and youth mental health centres across the province of Ontario. http://www.children.gov.on.ca/htdocs/English/professionals/specialneeds/momh/moving-on-mental-health.aspx
|
Quebec | Famille Québec https://www.mfa.gouv.qc.ca/fr/Famille/developpement_des_enfants/Pages/index.aspx |
New Brunswick | Healthy Families, Healthy Babies initiative https://www.vitalitenb.ca/en/healthy-families-healthy-babies |
Nova Scotia | Parenting resource centres |
Newfoundland and Labrador | Brighter Futures is a not-for-profit serving families aged 0-6 years |
Prince Edward Island | Early Childhood Development Association of PEI has information about early years resources |
Resources for Parents
Looksee Checklist
Free tool available in multiple languages that has versions targetted for parents. Parents can use it as a ‘check in’ or baseline for healthy development.
18-Month Well-Baby Visit online program: Provides parents and service providers with resources on early child development, including a resource pathway for parents across Ontario.
Life with a Baby: A peer support system that offers informational seminars and programs geared towards families of young children, open forums discussing everyday parenting and child rearing issues, and fun social events for the entire family.
https://www.lifewithababy.com/
Finding Quality Childcare: Provides region-specific information and general information about what to look for in quality child care.
www.findingquality-childcare.ca
Information Resources
The following resources do not provide any direct services per se, but still provide information that may be helpful:
Reaching IN… Reaching OUT: Website that helps promote resilience in adults and young children with an evidence program, and it has free downloadable resources for families and professionals.
http://www.reachinginreachingout.com/resources-parents.htm
Information for Professionals
Infant Mental Health Promotion (IMHP): Information for professionals about mental health from the Hospital for Sick Children (HSC).
Infant/Early Childhood Mental Health Campaign (IECMH): Free information for professionals, policy makers and parents.
http://santeottawahealth.pagecloud.com/iecmh
Case, Part 2
You are seeing 2-yo David, brought in by his mother, for immunizations.
You refer them to the local ‘Early Years’ agency for support for infants/early childhood where mother receives parenting support and resources/referrals related to her sons developmental needs. At the next appointment, you notice the mother is feeling more supported, less overwhelmed, and her interactions with her son David have improved.
References
Clinton J et al.: The importance of infant mental health, Paediatr Child Health 2016 Jun-Jul; 21(5): 239-241.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4933050/
Felitti VJ, Anda RF, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. Am J Prevent Med 1998;14:245-58.
Gleason M et al.: Recognizing young children in need of mental health assessment: Development and preliminary validity of the early childhood screening assessment.. Infant Ment Health J. 2010 May;31(3):335-357. doi: 10.1002/imhj.20259.
https://www.ncbi.nlm.nih.gov/pubmed/28543224
Gopnik A, Meltzoff AN, Kuhl PK. In: The Scientist in the Crib: What Early Learning Tells Us About the Mind. New York: William Morrow–Harper Collins, 2000.
Heckman et al. (2012). Hard evidence on soft skills. Labour economics, 19(4), 451-464.
National Scientific Council on the Developing Child. (2008/2012). Establishing a Level Foundation for Life: Mental Health Begins in Early Childhood: Working Paper 6. Updated Edition. Web: www.developingchild.harvard.edu. (Accessed April 20, 2016).
Ontario Centre of Excellence for Child and Youth Mental Health. Supporting Ontario’s youngest minds: Investing in the mental health of children under 6. www.excellenceforchildandyouth.ca/sites/default/files/policy_early_years.pdf Accessed April 22, 2016).
Suskind D. In: Thirty Million Words: Building a Child’s Brain. Boston: Dutton; 2015.
Weatherston DJ. The Infant Mental Health Specialist. Zero to Three.
www.zerotothree.org/child-development/early-childhood-mental-health/vol21-2s.pdf
Detroit: Wayne State, 2000:3–10 (Accessed April 20, 2016).
Zero to Three: Making it Happen, 2012. www.zerotothree.org/public-policy/
early-child-mental-health-final- singles.pdf (Accessed April 22, 2016).
About this Document
Written by members of the eMentalHealth.ca team, adapted from an article by Dr. Jean Clinton, Child Psychiatrist, McMaster University. Special thanks to Katherine Matheson, Child Psychiatrist, CHEO; Marisa Moher, CHEO, and members of Ottawa’s Infant and Early Childhood Mental Health Initiative (IECMHI) (including Joanne Boyd, Parent Support; Catherine Millar, Parent Resource Centre; Michelle Crogie, Pinecrest Queensway Community Health Centre; Clarissa Arthur, Youville Centre).
Disclaimer
Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.
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