Infant Mental Health: A
clinical application of the
new biology of Mind
Sam Tyano, M.D., FRCPschy., Miri Keren, M.D.
Tel-Aviv University Sackler School of Medicine Community
Infant Mental Health Unit, Geha Mental Health Center,.
What was known until
Kandel
• The human brain growth spurt begins in
the last trimester of pregnancy, is at
least five-sixths postnatal, and continues
to about 18-24 months of age (Dobbing & Sands,
1973).
•
DNA production in the cortex increases
dramatically over the course of the first
year.
“A new intellectual
framework for psychiatry”
Kandel, 1998, Am J Psychiat, 155, 457-469
Genetically encoded information
+
Neural activation by experience
=
Activation of genes --- creation of
proteins needed for shaping brain
structure.
• Learning leads to changes in synaptic
strength at specific synapses, and
memory is associated with the
persistence of those changes (Kandel).
• Interactive experiences directly impact
genetic systems that program brain
growth (Schore, 1994, 2001)
The current Model
(Cicchetti &
Tucker, 1994)
• The traditional assumption was that the
environment determines only the
psychological components of
development, such as memory and
habits, while brain anatomy matures on
its fixed ontogenetic calendar.
• Environmental experience is now
recognized to be critical to the
differentiation of brain tissue itself.
From brain to mind
• During the early years of life, the
basic circuits of the brain are
developing which will be primarily
responsible for a number of
important mental processes,
involving emotion, memory, behavior
and interpersonal relationships.
Where, in the brain?
• Early interpersonal affective
experiences have a critical effect
on the early organization of the
limbic system (Cingulate, septum, orbito-frontal
cortex, hypothalamus, amygdala, hippocampus), an
area of emotion processing,
organization of new learning, and
capacity to adapt to a rapidly
changing environment (Mesulam, 1998).
About the limbic
system…
(Blonder et al, 1991; Wexler et al, 1992; Spence et al, 1996)
• It is expanded in the non-verbal
right hemisphere.
• It is centrally involved in the
processing of the physiological and
the cognitive components of
emotions without conscious
awareness.
• It is centrally involved with
emotional communication.
Right versus Left hemisphere
functions during Infancy
• While the left hemisphere mediates
most of the linguistic behaviors,
the right hemisphere is important
for broader aspects of
communication.
• The right hemisphere is precisely
the one that is dominant during the
first 3 years of life (Chiron et al, 1997).
The cyclic growth of the
brain hemispheres
(Thacher, 1994)
•
Hemispheric brain growth is cyclic and continues asymmetrically
throughout childhood:
– First year: Right hem. spurts
– 1.5- 2.5 yrs: Left hem. spurts
– 2.5- 4.5 yrs: Right
– 4.5- 6 years: Left
– 6.5- 10.5 yrs: Right
Still, in the first 3 yrs, the right hemisphere is dominant :
resting cerebral blood flow shows a right hemisphere
dominance, which then shifts to the left on the 4th year
(Chiron et al, 1997)
Brain MRI supports the idea
of “the crucial first 3 years”
• The volume right than left of the
brain increases rapidly during the
first 2 years, and normal adult
appearance is seen at 2 yrs.
• Infants under 2 yrs show higher
hemispheric volumes.
• All major fiber tracts can be
identified at age 3. (Matsuzawa et al, 2001)
“Left brain, Right mind”
• These findings about the right brain
links with emotional communication
and unconscious affective processing
led to the notion of “right mind”
(Ornstein, 1997) and has become the
scientific ground for the new field
”neuropsychoanalysis”
MRI and the Social Smile
• Functional brain MRI of 8 weeks-old infants
showed the biological correlate of the social
smile seen in face-to-face interactions: a rapid
metabolic change occurs in the primary visual
cortex of the infants, reflecting the onset of a
critical period in which synaptic connections in the
occipital cortex are modified by visual experience.
(Yamada et al, 2000) .
Attachment experiences and
the interactive regulation of
the right brain
• The right brain is dominant in
human infants (Chiron & al, Brain, 1997).
• Attachment experiences, also
dominant in infancy, specifically
impact the development of the
infant’s right brain limbic system
(Schore, 1994; Ryan et al, 1997, Keenan et al,
2001).
Attachment experiences:
Definition
• From 3 months on, the infant internalizes
“schemas-of-being-with- different
caregivers and around various situations (D.
Stern, 1985, The Interpersonal World of the Infant).
• The attachment experience occurs around
daily stress situations: the securely
attached infant to a specific caregiver has
developed a schema of “This-personmakes-me feel-safe-and-protected-whenI-am-in-distress”.
Secure Attachment facilitates
secure Exploratory behavior
I need
you
to…
Support my
exploration
•Watch over me
•Help me
•Enjoy with me
I need
you to…
•Comfort me
•Delight me
•Protect me
•Organize my feelings
Welcome my
coming to you
The concept of
Resonance
• The attuned dyad infant-parent constitutes
a biologically-based “conversation between
limbic systems”, where the behavioral
manifestation of each partner’s internal
state is monitored by the other.
• Therefore affect regulation is not only the
dampening of negative emotions, but also
the amplification of positive emotions.
A context of resonance
• The infant’s right
hemisphere is
involved in
attachment
behaviors.
• The mother’s right
hemisphere is
involved in
comforting
functions. (Siegel,
1999)
Resonance and
intergenerational
transmission
• Empirical finding (Hesse, 1999): 75%
concordance between the infant’s pattern
of attachment to the parent’s attachment
classification (i.e. autobiographical
narrative coherence, as measured by the
AAI).
• The concept of resonance may explain this
finding at the neural level : the parent’s
internal integration of emotional
experiences promotes the infant’s
interpersonal experience integration.
Experiences, memory, and
brain development
• Without memory, there is no
development: memory is the way in
which past experience is encoded in
the brain and shapes present and
future functioning.
• Kandel: Long-term memory differs
from short term memory in requiring
the activation of a cascade of genes,
this genetic program leads to the
growth of new synaptic connections.
Developmental path of
memory
• First year of life: Implicit memory only
(unconscious, no sensation of recall, but
influence on behaviors and emotions
directly, in the here and now).
• By 1.5 yr, explicit memory starts, and by
3yrs is established: conscious retrieval,
with the internal sensation of “I am
recalling something now”. Maturation of
the hippocampus in the medial temporal
lobe is necessary for it.
To summarize (1)
• The mental apparatus becomes a
regulatory system as a product of the
experience-dependent maturation of the
orbitofrontal system (Bechara, Damasio et al, 1997).
• Such non-conscious regulatory mechanisms
are embedded in implicit-procedural
memory of internal working models of the
attachment relationship that encode
strategies of affect regulation. The right
hemisphere is dominant for implicit
learning (also for “intuititive parenting”?).
To summarize (2)
• The expanding ability of the growing individual to
cope with interpersonal and bodily stressors is an
important achievement in continuing human
development, and reflects the growth of the right
brain, the hemisphere dominant for the human
stress response.
• In terms of interpersonal stressors, the right
hemisphere is specialized for processing facially
expressed auditory and visual emotional
information, from infancy into adulthood.
Infancy and Neural plasticity
are therefore good friends…
Experiences shape the brain by:
– Strengthening, weakening or pruning synapses formed
from primarily genetically encoded information.
– Formation of new synapses.
– Increasing linkages among neurons by repeated
experience (memory).
– Laying down myelin and thus increasing the speed of
conduction.
– Elimination of synapses by toxic substances and
stressful or absent experiences.
Major significance
Interventions targeted to
improve/change early childhood
experiences = Intervention at the
level of brain development
This is the scientific
rationale for Infant
Psychiatry…
• We detect high risk infants and/or parents for
early relationship disturbances.
• We treat the parent-infant relationship
(dyadic/triadic parent-infant psychotherapies).
• This new relational experience is believed to
impact on the infant’s brain development, and
optimize the quality of the object relationships
he/she will develop along the years, and on the
parental reflective functioning.
PREVENTION
EARLY DETECTION
EARLY TREATMENT
in creating or restoring favorable conditions for
the young child’s development and mental health.
Targets of prevention
Prevention in Infant Mental Health
focuses mainly on changing the
human and physical environment of
the infant (which he totally
depends on), in order to improve
the way the child experiences
himself in the external world.
Selective prevention
• Target Population:
Infants, asymptomatic,
exposed to biological or
environmental risk factors
that has been detected
(based on pre-existing
empirical research
studies) and/or Parents at
Selecting target of
intervention
Identification of risk factors in:
• Environment (violence, poverty,
unemployment, family structure).
• Parent (education status, mental distress,
lack of parental skills).
• Child (biological vulnerability, rough temper).
• Parent-Child (lack of kindness, lack of
pleasure, conflict).
Impact of studied selective prevention
programs (1).
• van den Boom, 1994:
Target: Difficult infant temperament +
low SES mothers
Aim: To increase maternal sensitivity
Action: attachment-focused guidance
during period of attachment (age 6-9 mos).
3 years-long effect: 68% secure
attachment vs 28% in non-intervention
matched group.
Impact of studied selective prevention
programs (2).
• Webster-Stratton (1990):
Target: Coercive-criticizing-harsh
parents
Aim: To decrease chance of later
conduct disorder.
Action: Videotapes reviewing and
reflecting with parents.
Effect: Decreased incidence of
behavioral pbs . Limitation: Short followup.
Impact of studied selective prevention
programs (3).
• McCarton (1997):
Target: 12 months-old VLBW premature
babies and parents
Aim: Decrease risk for later cognitive,
developmental and behavioral problems
Action: Special parent-child day care for
2 years.
Effect: Higher IQ and less behavior pbs
at 3 yrs of age, versus control group.
Impact of studied selective prevention
programs (4).
• Lyons-Ruth et al (1990):
Target: Depressed and low-parental skilled
mothers.
Aim: Enhance security of attachment and
functioning in infants.
Action: Home visits every week during
first 13 months.
Effect: More secure and better functioning
of the infants at 18 months versus control.
Impact of studied selective prevention
programs (5).
• Olds’s (1997) longest longitudinal study: From
pregnancy to adolescence (15yrs):
Target: 400 multi-environmental risk
pregnant mothers.
Aim: Decrease risk for delinquency &
abuse.
Action: Home-guidance by nurses.
Effect: Less delinquency, less abuse and
less subsequent births.
Conclusions
Focused interventions in high risk
populations seem efficient, at least
on a short-term basis.
A worrying stability of
developmental/ emotional/ social
symptoms, exists from infancy up
to school-age.
ARRANGEMENT - FOSTER CARE
MEDICAL AND PARAMEDICAL TREATMENTS
INTERACTION GUIDANCE
PSYCHOTHERAPIES : dyadic – triadic – family - group
Psychoanalytically oriented – Cognitive/behavioral –
SET-PC
PHARMACOTHERAPY
Intervention during
Infancy:
its levels of impact
• Behavioral level: Role modeling
• Affective level: Therapist as Secure
Base
• Psychological level:
- To identify parental projections
on infant and to connect them with
past exp.
- To enhance the “Parental
Reflective Functioning”.
“The parent-infant
relationship is
the
patient” (D. Stern)
Role of Baby’s presence in the therapy
session
-As a trigger of unconscious affects
and projections in real time in parents.
- As a listener to therapist’s comments
and perceptions of his/her behaviors
(Therapist’s Reflective functioning stance)
Role of Father’s presence:
“Schema-of-being-with-M-&-F”
How to intervene
• Interactional guidance:
“Here and Now” in the interaction.
Use of videotape reviewing.
• Psychodynamic dyadic/triadic psychotx:
Use interactional micro-events to
identify conflictual/ pathological
parental projections on infant (“Ghosts
in the nursery”).
• Psychodynamic short-term psychotx:
SET-PC