Infant Mental Health:
A National Policy Issue
George Hosking, WAVE Trust
Infant Mental Health Policy & Practice Forum
Dublin, 7th October 2011
When is the key period in a child’s life?
Pathways to crime often laid down
by age 3
Dunedin study of all children born in 1972, to age 21

At age 3, an ‘at risk’ group identified by nurses

At age 21, ‘at risk’ males, compared with others:
– 2.5 times as many with 2+ criminal convictions
– 55% of their offences violent (18% others)
– 47% abused their partners (9.5%)
Pathways to crime often laid down
by age 3
Dunedin study:

‘At risk’ group offences much more serious
– (e.g. robbery, rape, homicide)

Fewer females conduct disordered, but for those who were:
– 30% of ‘at risk’ group had teenage births (vs. 0%)
– 43% were in violent, abusive relationships
Pathways to violence by age 3
Trends in aggression, ages 1.5 to 15
high 1-5
moderate 1-5
low 1-5
chronic 6-15
high desisters 6-15
moderate desisters 6-15
low 6-15
1½
2½
3½
4½
5
6
10
11
12
13
14
15
We need to start in the womb
Professor Michael Meaney, McGill University

Epigenetics - very early life environment - changes function &
structure of genes
 twins with identical DNA could end up with very
different effective DNA

Disadvantage begins very early, and persists throughout life
 e.g. through messenger RNA
 methylation, hypermethylation (caused by early abuse)
and acetylation
We need to start in the womb
Professor Vivette Glover, Imperial College

Post-natal depression correlated with poor mental health
outcomes for children, later violence and antisocial behaviour

Pre-natal depression as damaging as post-natal depression

Anxiety during pregnancy even more damaging than
depression

Pregnancy peak period for domestic violence
We need to start in the womb
Professor Vivette Glover, Imperial College

Cortisol, created by stress, crosses placenta to child

Mothers with high stress at 32wks pregnancy produce children
with significantly higher social & emotional problems

Babies with higher amniotic fluid cortisol did worse on
subsequent IQ tests

Prenatal plus postnatal anxiety produces worst outcomes
Understanding the infant brain

Works via neurons (brain cells) & synapses (connections)

At birth: 10 trillion synapses - 200 trillion (or more) by age 3

Emotional brain largely created by experience in first 18 months;
acutely vulnerable to trauma

Brains of abused children significantly smaller, less developed
Understanding the infant brain
Critical Windows

Critical windows of time during which brain hones particular
skills or functions

Size of window different for different skills

If the chance to practise a skill is missed during the window, a
child may never learn it (or be impaired)
Understanding the infant brain
Critical Windows

Synapse formation in visual cortex
– peaks at 3 months, finished by age 2

Auditory map formed by 12 months
– after this Japanese infant struggles to distinguish “L” and “R”

Deaf children need language exposure before age 5

Emotional brain largely created in the first 18 months
Understanding the infant brain

Infant brain acutely vulnerable to trauma

If early experience fear: stress hormones wash over brain

Children’s brains reflect world in which they are raised

If characterized by threat, chaos, unpredictability, fear, trauma
– development of neural systems for stress and fear responses altered
Understanding the infant brain
Brains of abused children significantly smaller
– many areas dark on CAT scans (“black hole”)
– limbic system (emotions) 20-30% smaller, fewer synapses
– hippocampus (memory) smaller
Understanding the infant brain

Alan Schore - 10-year immersion in thousands of scientific
papers in neurobiology, psychology, infant development
“The child’s first relationship, the one with the mother,
acts as a template … permanently moulds the individual’s capacity
to enter into all later emotional relationships”
Keys: Attunement and Empathy

Attunement: parent and child emotionally in tune with each other

Not mimicking: a correspondence of behaviour to their feeling state

Responding to emotional needs leaving it feeling understood, cared
for, valued

Empathy begins with sense of “oneness” with the other – coming
from attunement
Keys: Attunement and Empathy
Lack of attunement means empathy does not develop
Low maternal responsiveness at 10-12 months predicted:
–
–
–
–
–
at 1.5 years: aggression, non-compliance, temper tantrums
at 2 years : lower compliance, attention getting, hitting
at 3 years : problems with other children
at 3.5 years: higher coercive behaviour
at 6 years : fighting, stealing
Keys: Attunement and Empathy

Empathy the single greatest inhibitor of propensity to violence

Established early by observation of parental reaction to suffering

Babies show empathy by one year old. Not all develop this

Abused toddlers react negatively or aggressively to signs of
distress

Absence of empathy characteristic of violent criminals
– worst psychopaths no emotion at all
Skill deficiencies of concern to employers
Research 2002-2006: survey of 19,000 employers
Lifelong skills created very early
Research of James Heckman

Skills needed for success in life multiple in nature

Soft skills very important
–
–
–
–
–

conscientiousness
- perseverance
self-esteem
- motivation
ability to pay attention
- self-regulation
self-esteem
- ability to defer gratification
sociability (the ability to work with and cooperate with others)
These crucial skills mostly created in early years
Lifelong skills created very early
Research of James Heckman

Families play essential role in shaping skills of their children

Early years before school lay foundations for all that follows

Large gaps in abilities between advantaged and disadvantaged
open up early before children enter school, and persist
Lifelong skills created very early
Oxbridge study of children aged 1 to 12, Andhra Pradesh

Investigated what determined children's cognitive and noncognitive skills

Parental investment positive effect on skill levels for all ages

Pathway: parental care from pregnancy onwards through
child health at age 1 through cognitive abilities at age 5
Lifelong skills created very early
Mannheim Study of Children at Risk (MARS)

‘Differences in cognitive and non-cognitive capabilities
consistently associated with socio-emotional home resources’

Adverse consequences of initial risks cumulate and persist until
adolescence
 Individual
differences in basic abilities amplify
between 3 months and 11 years
ACE Studies
Adverse Childhood Experiences (ACE) Study







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Emotional abuse
Physical abuse
Sexual abuse
Physical neglect
Emotional neglect
Alcoholic in household
Drug user in household
Witnessed domestic violence
Californian ACE Study

Center for Disease Control and Prevention & Kaiser Permanente

One of largest investigations ever on links between childhood
maltreatment and later-life health and well-being

17,000 members at comprehensive physical examinations
provided detailed information on childhood abuse, neglect and
family dysfunction
Californian ACE Study
Likelihood of Heart Disease with single ACEs:
1.3 x by Emotional Neglect
1.3 x by Substance Abuse
1.4 x by Physical Neglect
1.4 x by Domestic Violence
1.4 x by Sexual Abuse
1.5 x by Physical Abuse
1.7 x by Emotional Abuse
Californian ACE Study
Health risks which increase with ACEs (17% of popn):







liver disease (x 2)
lung disease (x 3)
adult smoking, depression, serious job problems (x 3)
intercourse by 15, absenteeism from work (x 4)
alcoholism and alcohol abuse (x 6)
intravenous drug use (x 11)
suicide attempts (x 14)
Early prevention makes economic sense
Source: J Heckman & D Masterov (2005) Ch 6, New Wealth for Old Nations: Scotland’s Economic Prospects
Implication for optimum investment
Source: J Heckman & D Masterov (2005) Ch 6, New Wealth for Old Nations: Scotland’s Economic Prospects
Pattern of public spending on education in England & Wales
over the life cycle, 2002/2003
6000
5000
£s per student
4000
3000
2000
1000
0
Under 5s
Primary
Secondary
FE
HE
Source: Speech by Charles Clarke, Labour Party Conference, Bournemouth, 30 September 2003
Is early prevention spending wisely?
Expert opinion USA:

Dr Bruce Perry; James Heckman (Nobel Prize winning
economist); RAND Research Institute; Karoly, Kilburn, and
Cannon (2005); Felitti and Californian ACE studies;
Washington State Institute for Public Policy (WSIPP)
Expert opinion UK:

WAVE Trust; Croydon Total Place; Government Office for
Science; London School of Economics; Action for Children /
New Economics Foundation
Cutting waste – spending wisely
Where is the waste created by the wrong type of early years?









£150 billion p.a. Welfare benefits
£78 billion p.a. Costs of crime
£77 billion p.a. Mental health problems
£55 billion p.a. Alcohol abuse
£20 billion p.a. Violence
£20 billion p.a. Family breakdown
£15 billion p.a. Drug abuse
£6 billion p.a. Domestic violence (plus human cost £10 bn?)
£8 billion p.a. NEETS, Prison Service, Young Offenders Institutes,
Pupil Referral Units, Special Education
Cutting waste – spending wisely
What would it cost to transform the situation totally?


WAVE’s 70/30 strategy: (economic model work-in-progress):
 £100 billion over 16 years
Action for Children/NEF:
 £620 billion over 20 years
What cost if we don’t switch to prevention?


Assuming 12% of the waste figures, more than £1 trillion
Action for Children estimate £4 trillion
What would it take to succeed?

National and local strategies of prevention rather than reaction

Transformation of attitudes to, and preparation for, parenting

Acceptance of children’s rights

Understanding and adopting interventions that work
Strategies of prevention

National strategies
 Sweden
 Scotland

Local strategies
 Croydon
 Derry, Fermanagh and Tyrone
 Young Ballymun
A National Strategy of Prevention
Approach to Infancy and Early Childhood in Sweden

99% of pregnant women access maternity healthcare services
– typically 11 individual contacts, mostly with midwives

98% of maternity healthcare clinics offer group parenting
education to first-time parents

Additional specialist support for young mothers, single
mothers, those expecting twins
A National Strategy of Prevention
Approach to Infancy and Early Childhood in Sweden

100% of hospitals have BFHI (baby-friendly) status (UK <10%)

Long periods of maternity and parental leave support attention to
needs of the child in its earlier months

Breast-feeding
 98% of Swedish mothers begin breast-feeding (79% UK)
 72% breastfeeding at 6 months (22% UK)
 15% exclusive breastfeeding at 6 months (<1% UK)
A National Strategy of Prevention
Approach to Infancy and Early Childhood in Sweden

99% of all families make use of child healthcare services
– an average of 20 individual contacts, primarily with nurses

Parents invited to join parent groups when child 1-2 months
– in Stockholm County 61% of first-time parents in at least five sessions
(Bremberg 2006)

Parent education around 8-10% of midwives’ working time

65% of midwives received regular professional training on the
subject, and 72% instructed by a psychologist
A National Strategy of Prevention
SWEDEN
% Live Births to teen mothers
UK
1.6
7.1
2.5
5.1
Smoking (% per day aged 15+)
16
25
Alcohol (litres per person p.a.)
7
11
11
23
196
245
4
9
Cancer Deaths, < 65 yrs (per 100,000)
56
67
Circulatory Disease Deaths, Under 65
32
43
Infant Mortality
(per 1,000 live)
Adult Obesity (% of population)
Smoking Related Deaths (per 100,000 popn)
Chronic Liver Disease Deaths, < 65 yrs (per
100,000)
A National Strategy of Prevention
Scottish Parliament Finance Committee

The Committee agrees with many of the witnesses that the focus
for all decision makers, including the Scottish Parliament and the
Scottish Government, should be on the more effective
implementation of early years policy.

The Committee recommends that both the Scottish Government
and the Scottish Parliament take the lead in delivering a radical
step change in the existing approach to early years intervention.
A National Strategy of Prevention
Scottish Parliament Finance Committee

The Committee makes clear its strong support for the concept of
preventative spending, particularly on the early years … more
effective use of preventative spending has the potential to deliver
great social and financial benefits to Scotland. The Committee
welcomes the Scottish Government’s shared commitment to this.

The Committee considers that the most compelling evidence to
have emerged from this inquiry relates to the benefits that could be
derived from more effective spending on early intervention
support for children … at as early a stage in their lives as possible,
including pre-birth.
Local Strategy of Prevention: Croydon

Children and parents experience system from conception onwards
which supports and develops their parenting capabilities

Pre-natal care holistic preparation for parenthood; emotional needs
of parents strongly supported

All early years practitioners equipped to spot early signs of needs,
know how to engage parents quickly in high quality services

Geographically based Family Partnership Teams leading





Preparation for parenthood
Early identification
Family advocates
Early years academy to train staff
Peer2peer support
Local Strategy of Prevention: Croydon
Preparation for parenthood

Maternity services within hospitals transformed
–
–

characterised by holistic preparation for parenthood
wider needs and vulnerability identified
Parents directed to social networks for support
–
networks supported and developed

Early warning signs such as missed appointments followed up

Particular care with most vulnerable parents, e.g. teenagers
Local Strategy of Prevention: Croydon
Early identification

System with capacity to spot and respond to need early and quickly
–
–
–

Rapid identification of needs:
–
–

appropriate services available for referral
identification and response long before CAF necessary
assessment tools available for staff
attachment, motor skills, emotional or behavioural issues
speech and language, maternal mental ill-health and domestic conflict
Gap in provision before child starts school addressed
Local Strategy of Prevention: Croydon
Projected costs and savings (preliminary)

Upfront investment £2.5 million over 2 years

Projected savings £8m in 3yrs, £25m in 6yrs, £63m in 13yrs

Areas of saving
–
–
–
–
–
Looked after children
Teenage pregnancy
NEET
Offending
Anti-social behaviour
Pupil Referral Units
Child and adolescent mental health
Emotional and Behavioural Difficulties units
Infant Mental Health Strategy: Derry,
Fermanagh and Tyrone
Vision for the Infant Mental Health Strategy:

WHSCT is committed to supporting families to provide the secure
attachments children need to make the best possible start in life

Every child living in the WHSCT area has a right to a supportive
environment in order to create and support positive mental health
and emotional wellbeing throughout their lives

We recognise the importance of investment in early years’ child
development and positive infant mental health, contributing to
lifelong health, social and economic outcomes for the individual
Infant Mental Health Strategy: Derry,
Fermanagh and Tyrone
Guiding Principles:
Whole Child Approach: a holistic systems-based model of Early Intervention
Collective Responsibility:



1) Women and Children’s Services plays a primary role in delivering strategy
2) Ante-natal and perinatal services a core universal service access point
3) Every Directorate within WHSCT to actively support delivery of the strategy
Quality Service Standards:


All service delivery based on timely access to services based on need,
transparent outcomes, and informed by service user involvement at all levels
Evidence-based best practice and innovation at the core of all services and
initiatives with a view to embedding this in future mainstream provision
Infant Mental Health Strategy: Derry,
Fermanagh and Tyrone
Key Beneficiaries:
Strategy
aims to support every child living within WHSCT area
Key principle: to build protective and resilience factors within
population to create gradual reduction in number of children and
families in crisis

Extra support for key vulnerable groups e.g. antenatal and
postnatal, ethnic minorities, mental health clients, looked after
children, families with domestic abuse, substance or alcohol misuse

Infant Mental Health Strategy: Derry,
Fermanagh and Tyrone
Specific Initiatives:

Hidden Harm Action Plan for Northern Ireland and Think
Child/Think Parent/Think Family project

A universal perinatal mental health pathway
– An example in action is the Early Intervention Service for Alcohol, delivering midwife-led
client supports in co-operation with Early Intervention Workers

Leading on Roots of Empathy and Nurse Family Partnership

NI Regional Healthy Futures strategy principles
– endorsed by all Health Visitors in WHSCT represent a crucial investment in the support of
children and their families during the formative early years
Young Ballymun: Ready, Steady, Grow
Service aims:

Improve positive pregnancy and birth experiences

Strengthen adaptive protective systems in infancy and toddlerhood

Increase confidence and competence of parents

Promote healthy infant and child development

Reduce childrearing problems
Young Ballymun: Ready, Steady, Grow
 The
service has three strands:
– Amplify range and increase uptake of ante natal support in
collaboration with HSE primary care team, maternity services,
local community partners
– Deliver enhanced baby development clinic in partnership with
HSE Public Health Nurse team with increased emphasis on
infant social and emotional development.

provide direct support to families and onward referral as appropriate
– Build capacity of statutory/community services to understand
and respond to infant mental health need.

through training in competencies and endorsement
Young Ballymun: Ready, Steady, Grow
Strand I - Preparing for Parenthood

Focuses on pregnancy and Infant Mental Health incl. systematic
strategy for engaging expectant mothers and partners

Supports adaptation to pregnancy & relationship with unborn child

Better meets ante natal needs of women and their families

Increases capacity of ante natal care
Young Ballymun: Ready, Steady, Grow
Strand II - Parent-child Psychological Support Programme

Promotes strong parent-child relationships, parental wellbeing and
adaptive systems in children

Provides parents with information on child development

Checks baby’s progress and changing needs

Empowers parents to solve conflict
Young Ballymun: Ready, Steady, Grow
Strand III - Infant Mental Health Promotion

Focuses on promoting social & emotional development in children

Builds capacity of services to respond to infant social and
emotional need
–
–
–
–
capacity building for staff, families, programmes, systems
identifies, treats and reduces mental health problems, birth – 3 years
direct observation of children and care-giving environment
design of interventions to change behaviour
Early intervention programmes
Parenting programmes

Nurse Family Partnership

Roots of Empathy

First Steps in Parenting

Leksand Model, Sweden

SKIP (Strategies for Kids, Information for Parents)
Early intervention programmes
Fostering attunement, breast-feeding, secure attachment
Attunement
 Video-feedback Intervention to Promote Positive Parenting
 Video Interactive Guidance
Breast-feeding
 Effect of early postnatal breast-feeding support, Denmark
 Breastfeeding Initiative, Blackpool
Secure Attachment
 Circle of Security
Early intervention programmes
Remedial
Parent Child Interaction Therapy (PCIT)
Family Checkup
Dorset Healthy Alliance Project
---------------------------------------------------------------------------------Further information on WAVE website: www.wavetrust.org