Children in care Looking after infant mental health
Babies and young children thrive in relationships which offer them warm, nurturing and responsive care.
They are entirely dependent on carers for their physical and emotional wellbeing. When they experience emotional abuse, neglect or physical harm the impact on their mental health is especially damaging.
Unstable care placements after abuse and neglect can make their mental health worse.
We need to give infants in care a better chance at a stable, nurturing home by intervening early.
Mental health of babies
Babies don't exhibit the classic symptoms of mental illness or disorder, but research has shown infants can experience depression as early as 4 months old. They can also experience serious psychiatric disorders related to attachment and traumatic stress (Luby, 2000).
Most infant mental health problems can be characterised as relationship disturbances, so intervention and prevention efforts in infant mental health need to focus on the infant-carer relationship (Zeanah et al, 2000).
Attachment and the infant-carer relationship to the developing brain
The first months and years are critical to a child's development and provide the essential foundations for future behaviour and health. During this time the building blocks of a baby's mind are being put in place. New neural connections forming the permanent architecture of the brain are being created at the rate of 700 per second (Center on the Developing Child, 2009).
Babies' babbling is an instinctive effort to interact with the world around them in order to learn. When a carer responds in a meaningful way through talking, facial expressions and gestures, connections form in the baby's brain which lay the foundation for development in language, behavioural control, motor skill, memory and emotion (Knudsen, 2004).
Stimulation from a nurturing carer is the crucial bedrock for a child's future development. Experiencing stable and supportive relationships, alongside challenges such as meeting new people, forge good brain development. When an infant lacks healthy stimulation their ability to learn language, social interaction and other complex behaviour is compromised (Knudsen, 2004).
The relationship, or bond, between a child and their primary caregiver is described by attachment behaviour. Good attachment gives the infant the 'secure base' needed to explore, learn about and relate to the world (Rees, 2007). Positive attachment experiences are essential to emotional, social, physical and cognitive development (Morewood, 2015).
Abuse, neglect and the developing brain
‘Toxic stress’ caused by trauma, abuse and neglect disrupts the architecture and chemistry of an infant’s brain (Scannapiecco and Connell-Carrick, 2005). It does this by provoking a number of reactions in the body including:
- an increased heart rate and higher blood pressure
- elevated blood levels of stress hormones (cortisol) and proteins associated with inflammation (cykotines).
In the short term these responses are a natural reaction to potential threats and essential to survival. However, if the body’s stress management systems remain activated at high levels over a long period of time they can cause serious damage to the developing brain with potential lifelong consequences for the child’s learning, behaviour and mental and physical health (Shonkoff, 2007).
Effects of negative attachment experiences
Poor attachment experiences can have a negative effect on a child's levels of trust and resilience (Morewood, 2015). When young children are abused or neglected they are at increased risk of developing reactive attachment disorder (RAD) which follows two patterns:
- inhibited - children are emotionally withdrawn, show limited or no response to social interactions with caregivers, fail to form bonds, and are hypervigilant.
- disinhibited - children are indiscriminately social, seeking nurturing and bonding indiscriminately, and are willing to 'go off' with strangers.
Children in care are at high risk of exhibiting RAD after traumatic experiences at home. It is crucial to address these difficult behaviours early on with nurturing care, especially as RAD can develop into behavioural problems, such as aggression, later in childhood (Zeanah et al, 2005; Perry et al, 1995).
Recovery from the effects of early abuse and neglect
Babies and young children can recover from the effects of maltreatment but intervention needs to happen early – ideally in the first year of life (Dozier et al, 2008; Lieberman et al, 2005; Zeanah et al, 2001).
When infants who have been abused or neglected are placed with loving carers they demonstrate rapid, healthy brain development comparable to infants who are not in care (Rubin et al, 2004; James et al, 2004). However it is during this period, when neural connections are being made at a rapid rate, that the effects of traumatic stress can be undone.
Our case for change: looking after infant mental health
Looking after the mental health of every infant in care means:
- comprehensively understanding their individual needs
- ensuring they experience sensitive and nurturing care as quickly as possible
- supporting them to recover from trauma through effective, evidence-based treatments.
Our case for change emphasises the fundamental importance of looking after infant mental health.
There is evidence that clinical treatment and service intervention approaches which support parents and carers to develop trusting, nurturing relationships with their infants are the most effective means to help infants recover from the trauma of abuse and neglect (Chu and Lieberman, 2010).
We have been exploring an approach (PDF) to supporting young children in care which has been developed in the United States:
The New Orleans Intervention Model is an evidence-based multi-disciplinary programme which uses an infant mental health approach to improve the quality of permanent placement decisions so that children can receive appropriate nurturing care as early as possible (Minnis et al, 2010).
We're working to bring the model to the UK and are currently testing the approach in Glasgow and South London.
We are also developing a better understanding of practical, evidence based solutions from the UK and abroad. Written for professionals across health, social care and the judicial system, these case studies (PDF) are examples of approaches which focus on:
- looking after the emotional well-being of children and their parents by intervening early
- working together
- focussing on children’s relationships
- building parental capacity
- providing personalised and intensive support
- making evidence based decisions.
An intensive, therapeutic and practical support programme for women who have had, or are at risk of having, multiple children taken into care.
An interdisciplinary, multiagency child protection service run in a child-friendly physical setting.
An intensive home-based intervention for parents with complex situations, focused on building the quality of care-giving relationships.
A problem-solving family court working with parents of children who are put at risk of significant harm through parental substance misuse and other difficulties.
More about children in care
Safeguarding looked after children
Most children living in care are kept safe from harm. But we must all do more to ensure that all children in care are protected and given the support they need.
Returning home from care
The most common outcome for a child who has left the care system is to return back home to a parent or relative.
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Center on the Developing Child (2009) Five numbers to remember about the developing child. Harvard: Center on the Developing Child.
Chu, A. T. and Lieberman, A. F. (2010). Clinical Implications of Traumatic Stress from Birth to Age Five (PDF). Annual Review of Clinical Psychology Annu. Rev. Clin. Psychol., 6(1), 469-494.
Dozier, M et al. (2008), Effects of an attachment-based intervention on the cortisol production of infants and toddlers in foster care. Developmental Psychopathology 20:845-59.
James, S., Landsverk, J., Slymen, D. J., Leslie, L. K. (2004) Predictors of outpatient mental health service use: the role of foster care placement change. Mental Health Services Research, 6(3):127-4.
Knudsen, E.I. (2004) Sensitive periods in the development of the brain and behaviour. Journal of Cognitive Neuroscience, 16(8), pp. 1412-1425.
Lieberman, A.F. et al. (2005), Towards evidence-based treatment: child-parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child & Adolescent Psychiatry, 44:1241-8.
Luby, J. (2000) Depression. In C. Zeanah (ed.) Handbook of Infant Mental Health (pp. 296- 382).
Moorewood, G.D. (2015) Understanding attachment disorders: training session.. (Optimus Education insight: secondary edition, No.3) pp 54-55.
Perry, D.B., Pollard, R.A. Blakley, T.L. Maker, W.L. & Vigilante, D. (1995) Childhood trauma, the neurobiology of adaptation and 'use-dependent' development of the brain: How states become traits. Infant Mental Health Journal, 16(4). 271-291.
Rees, C (2007) Childhood attachment. The British Journal of General Practice, 57 (544): 920-922.
Rubin, D. M., Alessandrini, E. A., Feudtner, C., Mandell, D. S., Localio, A. R., Hadley, T. (2004) Placement stability and mental health costs for children in foster care. Pediatrics, vol. 113 no. 5 1336-1341.
Scannapieco, M. and Connell-Carrick, K. (2005) Understanding child maltreatment: an ecological and developmental perspective. Oxford: Oxford University Press.
Shonkoff, J.P. (2007) A science based framework for early childhood policy (PDF). Harvard: Center on the Developing Child.
Zeanah et al (2000) Infant-parent relationship assessment. New York, NY, US: Guilford Press.
Zeanah, C. H., Smyke, A. T., Koga, S. F., Carlson, E. and The Bucharest Early Intervention Project Core Group (2005) Attachment in Institutionalized and Community Children in Romania. Child Development, 76: 1015–1028.
Zeanah, C.H. et al. (2001), Evaluation of a preventative intervention for maltreated infants and toddlers in foster care. Journal of the American Academy of Child & Adolescent Psychiatry, 40: 21:4-21.