The Infant Mental Health Approach

From their first moments, infants are busy building an emotional and social life.
by Gambi White-Tennant and Gerard Costa
When the Infant Mental Health (IMH) Specialist walks into the playroom, she sees Karina and her mother Karen. Six-month-old Karina sits in her infant seat on the table and Karen sits in a chair. They both face the door. Karen reads a magazine as Karina gazes at the side of her face. The IMH Specialist softly says, "Karina, is Karen the prettiest mommy you've ever seen?" Karen looks up and smiles at the IMH Specialist. The IMH Specialist then says, "Did you see how lovingly Karina was looking at you?" Karen laughs and tickles Karina's belly, saying, "You're such a silly baby!" Karina and her mother exchange sounds and giggles as the IMH Specialist looks on.

The home visitors happily chat over the complimentary breakfast that the agency provides for their meeting every Friday morning. They are also getting ready for their meeting with the Mental Health Consultant (MHC). Every Friday the MHC meets with the home visitors as a group and then holds a reflective supervision session with the home visitor supervisor. The supervisor, in turn, conducts individual supervision sessions with the home visitors. Everyone looks forward to Fridays because they feel appreciated, taken care of, and important.

These scenarios are typical of any infant/toddler program that provides mental health services. Mental health services for pregnant women, infants and toddlers, and their families can take many forms, depending on the program and the families (e.g., consulting with staff, consulting with children and families, providing direct mental health services, etc.). Regardless of how mental health services are delivered, the understanding of mental health is the same: prevention first, promotion always, and intervention when necessary.

Before making recommendations and decisions to guide the mental health services in a program, the first step is to understand infant mental health. This article will illustrate the infant mental health approach by providing a historical and philosophical context, identifying infant mental health guiding principles, and outlining examples of infant mental health program features.

Infants and Mental Health
The term "infant mental health" conjures up odd images for many–even for those people who have worked for years in early childhood settings. Some have never considered the words "infant" and "mental health" together. Some think of the negative and stigmatizing meanings of "mental health" and are surprised that infants can have mental health problems. Unfortunately, some view mental health as a human quality or a field of work that is concerned with deficits in people.

Infant mental health affirms that mental health is a positive aspect of human development (although we address problems when they arise) and the field of mental health is both proactive and reactive–hence the prevention, promotion, and intervention approaches noted earlier.

From their first moments, infants are busy building an emotional and social life. Infants' emotional development forms basic notions about the self and the world. Development in all other areas–cognition, communication, and motor skills–is organized by the emotional development of the child. Most importantly, the infant's development begins and continues within the context of an emotional relationship. As Donald Winnicott (1987), famed pediatrician turned child analyst stated, there is no such thing as an infant alone. We must always consider the infant/caregiver relationship. Emotional life is fundamentally a relational life. We must always view infants in the context of their earliest attachment relationships. This relational focus is relevant throughout early childhood–and throughout life.

Infant Mental Health as a Field
The process whereby infants and parents attach or have difficulty attaching to each other, and the factors that influence this dynamic and vulnerable process constitute the field of infant mental health. It is an interdisciplinary field that studies the optimal emotional, social, physical, communicative, and motor development of infants within the context of their earliest primary relationships.

Selma Fraiberg (1987), Social Worker and Child Analyst at the University of Michigan at Ann Arbor, is credited as the founder of infant mental health as a distinct field of intervention. She founded the Child Development Project at Ann Arbor which created influential ways of understanding and treating problems in the infant/parent relationship–most notably the notion that all work must be dyadic, meaning that the dyad, or pair, to always consider is that of the infant and parent. This gave rise to unique methods of intervention, particularly infant/parent psychotherapy and home-based services (sometimes called "kitchen-based" therapy, see article on page 39). This emphasis on the relationship, rather than on the child or parent alone, forever changed the methods used in understanding and helping infants and their families.

While students and professionals who study and work with infants and their families come from many different fields, there are certain principles that guide this work for everyone.

Guiding Principles

1. The human infant comes into the world with remarkable capacities for human relatedness–with Attachment Promoting Behaviors (APBs)–that help invite, inform, and regulate relationships with the caregiver. From the earliest moments, infants require consistency, stability, predictability, availability, and attuned love.
   
   
2. The period of life from birth to three is a sensitive period of development for the formation of character or personality. The greatest period of brain development, the brain "growth spurt", occurs from the last trimester of pregnancy through the first 18 months of life. During this period, nutritional, physical, social, and emotional satisfactions and failures will be "biologized," meaning that actual changes occur in the physical and chemical structures in the brain.
   
   
3. Pregnancy and childbirth are powerful conscious and unconscious reminders in the parent of childhood issues that can help or hinder the parent in responding to, caring for, and loving the infant. In every birth, the infant can serve as a powerful transference object for the parent–meaning that thoughts, feelings, and beliefs about other figures and events in the parent's past can become associated and confused with the infant. Pregnancy, birth, and the first two years of maternal care require the availability of psychological resources, emotional support, and parent/infant psychotherapy. Parenting is a relationship, not a skill, and the belief that parenting can be "taught" as we do other skills is not clearly supported.
   
   
4. Those of us who work with infants and their parents also have our own emotional histories that influence how we work with families–especially those families where infants are not adequately cared for or are hurt. We are not immune from the same psychological forces that influence the parent/child relationship. Infant mental health requires that these feelings be addressed. Delivery systems and child protective agencies must provide protected time for intensive and rigorous staff training and ongoing regular supervision.
   
   
5. The nature of the infant/parent relationship is best understood within the setting of the family home because the context of family events (eating, sleeping, relating, nurturing) as well as the alternate ways parents communicate to us (through pictures, objects and toys, family stories and memories) are rooted in the family home.
   
   
6. The infant/parent relationship emerges within a unique set of cultural and economic factors that provides a historical and practical context to the family and to the intervention. Infant care, expression of affection, use of health care, and relationships with mental health professionals are strongly influenced by these factors.
   

As we consider ways to integrate principles of infant mental health into Early Head Start and Head Start programs, we should consider the following points–

• Understanding infant mental health and working with a relationship-based approach are skills that are not exclusive to mental health professionals. These skills belong to all of us who work with infants and their families. Teachers, pediatricians, speech therapists, occupational therapists, bus drivers, nutritional staff, and all others within the Head Start family can learn ways to implement IMH practices.
  
  
• There are many strategies of intervention, including building an alliance with families and providing services and systems advocacy; developmental/parental guidance; supportive counseling; and more specialized services of infant/parent assessment and dyadic psychotherapy.

Integrating IMH practices into Early Head Start and Head Start programs does not mean that everyone must now become a psychotherapist. Those who wish to develop these specialized mental health skills can participate in the growing number of graduate and post-graduate programs being developed throughout the United States. It does, however, mean that awareness of infant mental health and the importance of working in a relationship-based way with families must be supported through training, supervision, and consultation to ensure that the guiding principles are achievable.

To incorporate these principles, programs should consider several strategies to become more infant mental health centered.

Infant Mental Health Program Features
The following features for an infant mental health program are typically implemented by using the program's internal capacity to provide mental health consultation or through collaboration with external consultants from local agencies. Any combination of employee or consultant services can be used. The design depends on the strengths and needs of the children, families, and staff, as well as on the program's human and fiscal resources.

When staff identifies children needing mental health assessment or services, a mental health professional can provide direct consultation to the children and families. This can be accomplished through playgroups that may include parents. These groups assist children in the initial learning of social skills, such as the capacity to wait, take turns, read the cues of adults and peers, and accept support from others. Groups with parents and their young children allow time for parents to enjoy their children and learn to play with them in sensitive and attuned ways. Staff is able to observe the interaction between the caregiver and child, assess the need for intervention, and model emotional presence and ways of handling emotionally challenging behaviors. This consultant would communicate and maintain documentation with the appropriate staff and parents as well as maintain communication with teachers and parents to support the outcomes of the intervention.

Another option is to provide direct consultation services to the program staff. This can take the form of regular reflective supervision with the staff members who have direct contact with children and families, or supervision of the supervisors, strengthening their ability to provide support and technical expertise to their staff. Within this context, challenging classroom interactions or difficult family situations can be discussed in depth. In this model, the primary focus is on providing training to staff rather than clinical services to the children and families.

Staff members who are trained to conduct developmental screenings and psychological assessments and to create developmental plans also provide valuable consultative services in Early Head Start and Head Start programs. Through the use of insights gained through formal and informal assessments, staff and parents can develop a deeper understanding of their child's behavior and needs.

Collaborations with local agencies, clinics, hospitals, and universities providing services to the Early Head Start and Head Start population can be formed or expanded. Students being trained as professionals within the variety of disciplines that make up infant and preschool mental health can be a valuable source of providing counseling services and playgroups as well as formal assessments.

As you design or make improvements to your IMH program keep the following in mind–

• The design must fit the strengths and needs of the children and families.
  
• The program's resources must be able to support the design or outside resources should be cultivated.
  
• Contracted services are only as good as the contract's content.
  
• Communication is vitally important to the success of the program.

Paraprofessionals and professionals involved must have a piece of the family picture.

These are exciting times for families and those of us who work with them. Programs that invest in knowledge and skill development will yield priceless dividends for both families and staff. Our goal is to regard every infant and family with respect, consideration, and empathy to better support their loving and attuned relationships. n

References

Brazelton, T.B. 1992. Touchpoints: The essential reference. Reading, MA: Addison-Wesley/Lawrence.

Costa, G. 1996. Guiding principles in infant mental health and their implications. Keynote Address. New Jersey Association for Infant Mental Health.

Fraiberg, S. 1987. The clinical dimensions of baby games. In Selected writings of Selma Fraiberg, ed. L. Fraiberg. Columbus: Ohio State University Press.

Stern, D. & N. Bruschweiler-Stern. 1998. The birth of a mother. New York: Basic Books.

Winnicott, D. 1987. Babies and their mothers. New York: Addison-Wesley Publishing Co.

Gambi White-Tennant is an Infant Toddler Specialist at NYU Steinhardt School of Education, Head Start Quality Improvement Center. T: 212-998- 5550; E: gambi. whitetennant@nyu.edu. Gerard Costa is the Director for the Institute for Training in Infant & Preschool Mental Health, Youth Consultation Service. T: 973-483-2532; E: gcosta@ycs.org.

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