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For GPs…Antenatal,Baby &Child healthChild healthservices in Brisbane’s NorthSaturday July 11, 2009Royal Children’s Hospital, Herston

Proudly brought to you in collaboration by:

GPpartners | Royal Brisbane and Women’s HospitalRoyal Children’s Hospital | Community Child Health ServicesChild and Youth Mental Health Services

With Thanks to our Sponsors:

Dr Elisabeth HoehnChild Psychiatrist – Program DirectorFuture Families, RCH CYMHSFuture Families, RCH CYMHS

Acting State-wide Director for Perinatal and Infant Mental Health

Saturday July 11, 2009Royal Children’s Hospital, Herston

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Infant Mental Health refers to a baby’s ability to: experience emotionsdevelop relationshipslearn through nurturing relationships

Infant mental health is about supporting theInfant mental health is about supporting thedevelopment of an infant’s emotional wellbeing

Infants learn about themselves and the world around them through the relationships they have with the people in their liveswith the people in their lives.

Through relationships, infants learn what people expect of them and what they can expect of others.

Adults’ emotional health, level of stress and lifeAdults emotional health, level of stress and life circumstances can affect their relationship with their infants.

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‘There is no such thing as a baby; there is a baby and someone’ y

Donald Winnicott

Infants are social beings that need to live in constant connection with other people in

their world, especially their primary i ( t )caregivers (parents)

‘Human connections create the neural connections from which

the mind emerges’

‘Relationships and the brain interact to create who we are’

D i l Si lDaniel Siegel

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Interpersonal relationships affect the structure and functioning of the brain, and in turn help shape a person's emotional, social, and mental functioning. Human development comes out of a fluid pinterchange between neurophysiological development and the interpersonal experiences or interactions we have with other people – a convergence of neurophysiology and attachment theoryThis provides an integrative framework for understanding human developmentunderstanding human development

"The Developing Mind - Toward a Neurobiology of Interpersonal Experience“ - Daniel Siegel

When an adult provides a secure attachment to a child, involving a sense of safety and protection, the child's mind is allowed to do what its genes intended it to do which is to develop a rich and intricatedo, which is to develop a rich and intricate, complex set of interconnections among different aspects of the brain.

How the structure and functioning of the brain develops is determined by how experiences, that are primarily social in nature, shape genetically programmed maturational information.

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Infant brain is undeveloped at birthRapid growth occurs in the first three p gyears of life (connections and networks)Neural differentiation is stimulation dependent Neurones change in response to patterned repetitive stimulationp p

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Connections develop between neurones in response to activation by experiences‘Neurones that fire together, wire together’

Daniel Siegel

Synapses and connections develop into neural pathways that reflect the degree and type of input.and type of input.

Activity-dependent fine-tuning of connections and pruning of surplus i it i d lcircuitry occurs in adolescence

‘Use it, or lose it’ Daniel Siegel

Experience makes the decision about which neurones survive and how theywhich neurones survive and how they connect with each other

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Are the context within which the child learns to regulate emotion

Have the capacity to influence every aspect of a person - mind, body, emotions, relationships and values

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John Bowlby - first emphasised importance of early relationships (1969/1972/1980/1982)(1969/1972/1980/1982)Attachment is the deep and enduring connection established between a child and a parent/caregiver in the first several years of life (primarily first 3 years)Attachment is something that children and gparents/caregivers create together in an ongoing reciprocal relationship

Attachment is “an affectionate bond between two individuals that endures through time and space and serves to jointhrough time and space and serves to join them emotionally”

Klaus and Kennell, 1976

This ‘bond’ that ‘joins them emotionally’ is at a primal level ie long before verbalat a primal level ie., long before verbal and reasoning capacities mature

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Attachment to protective and loving parents/caregivers who provide guidance and support is a basic human need, rooted in evolution and essential for the survival of the speciesThere is a biological predisposition in infancy to maintain proximity to

t / i hi h i tparents/caregivers which exists across many species (Hofer,1994)

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As humans we have an instinct to form “secure” attachmentsInfants instinctively reach out for the safety of the “secure base” with parents/caregivers, who in turn instinctively protect and nurture their offspring providing a “safe haven” from which the infants’ curiosity and desire towhich the infants curiosity and desire to master their world (exploration) can be satisfied

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Infants are ‘hardwired’ to engage in social relationshipsInfant cries and behaviours are designed to engage the attention, care and concern of those close around them (infant cues)Their primary caregivers, if emotionally sensitive, are attuned to these cues and will respond and relieve the infant’s distress and will enhance communication by touch, eye gaze, talking and mirroring of the infant’s expressions

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Patterns of child-rearing may be more or less conducive to the development ofless conducive to the development of secure attachments

Fonagy, 1996

Secure attachment requires sensitive and consistent parenting

Essential task of infant’s first year is the creation of a secure bond of emotional communication (attachment) between themselves & a primary caregiver (mother)

To create this communication, mother must be psychobiologically attuned to the changes of the infant’s bodily-based states of arousal

During play episodes, mother & infant show increased heart rate (sympathetic nervous system) and then decreased heart rate (parasympathetic nervous system) in response to the smile of the other →language of the mother & infant consists of signals produced by the Autonomic Nervous System (ANS) in both parties & the goal is for interactive synchrony of these signals

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If interactive synchrony is achieved, the mother is regulating the infant’s postnatally developing ANS – in this way the attachment relationship mediates dyadic regulation of infant’s emotionsInfant has genetically coded internal rhythmsInfant has genetically coded internal rhythmsMother provides attuned external sensory stimulation to the infantIf mother can synchronise her external stimuli to the infant’s internal rhythms she can regulate the infant’s developing ANSIf the mother is misattuned, she induces a stress response in the infantStress = asynchrony in the interactional sequence

A ‘good-enough mother’ will adjust her response and reattune in a timely manner, regulate the infant’s negative state, reduce the stress response & shift the infant into a positive state

Therefore maternal sensitivity acts as an external organiser of the infant’s emotional state

Re-established synchrony allows for stress recovery & coping

In this way, the internalised regulatory capacities of the infant develop in relation to the mother & the motherinfant develop in relation to the mother & the mother shapes the infant’s stress coping systems

Therefore, the maturation of the infant’s ‘emotional brain’ (Limbic system & ANS), continues postnatally & is directly influenced by the attachment relationship

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Emotion is initially regulated by others, but becomes increasingly self-regulated withbecomes increasingly self-regulated with emotional developmentInfants are not born able to self-regulateInfants rely on their caregivers to interactively regulate their internal states

SelfSelf--Regulation and CoRegulation and Co--RegulationRegulation

Feelingsorganized*

by the parent

Feelings organized

with the help of the parent

Feelingsorganized

by the child

* Feelings that the parent can recognize and “be with”

Adapted from Kent Hoffmann

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This interactive regulation is essential to learning self-regulation, both in social and autonomous contextsThe ability to flexibly regulate emotional states interactively in interactions with other h & t t l t i t

yhumans & to autoregulate in autonomous contexts, is the adaptive capacity central to emotional self-regulationIt is the foundation of social and emotional developmentIt is the basis for development and learningIt is the core of the development of identity, value and safetyThis interactive regulation underpins the development of attachment relationships

Babies raised in their first year by a Babies raised in their first year by a y yy yparent who offers emotional support and parent who offers emotional support and

connection for key feelings (sadness, connection for key feelings (sadness, anger, joy, fear, etc.) are, at the age of anger, joy, fear, etc.) are, at the age of two, better able to agree with parental two, better able to agree with parental directions and have fewer tantrums.directions and have fewer tantrums.

ieie: They are better able to self: They are better able to self--regulateregulate

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Sharing positive emotional states with a caretaker promotes brain growth and the development of regulatory capacities

Over time child acquires the capacity for self-regulation of brain stem and mid-brain-limbic arousal

Secure attachment is internalised at a mid-brain-limbic level as an enduringmid brain limbic level as an enduring capacity to regulate, generate and maintain states of emotional security

An efficient internal system that can adaptively regulate various forms of arousal & psychobiological states, & therefore emotion,

iti & b h i l d l icognition & behaviour, only develops in a growth-facilitating emotional environment with a good-enough motherGood-enough mother:− ‘Welcomes’ infant after separation

D li h i h i f− Delights in the infant− Responds appropriately & promptly to the infant’s

emotional expressions− Allows for interactive generation of high levels of

positive emotion in co-shared play states

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‘Bottom-up’ Developmental Hierarchy of the Brain(Burnell and Archer, 2003)

Cognitive/ behaviouralCortex

(Human)

Developm

ent

Midbrain/Limbic

(Mammalian)

Dev

elop

men

t

Dance of

Playfulness

OFC OFC

Containment

Security

Brainstem

(Reptilian)Affective/

somato-sensory

Nurturing

AttunementCo-regulation

Containment

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In contrast, if there is a growth-inhibiting early environment, with an abusive or neglectful caregiver, there is not only less play with the infant, but the infant is also in a traumatic state of enduring negative emotion

This caregiver:− Has a weak attachment relationship

− Provides litle protection from other potential abusers

− Is emotionally inaccessible

− Reacts to the infant’s expressions of emotion & stress either inappropriately and/or rejectingly

− Shows minimal or unpredictable participation in various types of arousal regulating processes

Instead of modulating induces extreme levels of− Instead of modulating, induces extreme levels of stimulation & arousal, very high in abuse and/or very low in neglect

− Provides no interactive repair, leaving the infant in intense negative states for long periods of time

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When infants are not in homeostatic balance or are emotionally dysregulated they are at the mercy of these states.

U til th d l t d t t b ht dUntil these dysregulated states are brought under control, infants must devote all their regulatory resources to reorganising them

While infants are doing this, they can do nothing else

‘Nothing else’ means a failure to continue to develop

These infants forfeit potential opportunities for socioemotional learning during critical periods of right brain development

Trauma is being overwhelmed and unable to cope p

Fonagy, 2001

Stress becomes trauma when the intensity of the frightening events becomes unmanageable to the point of threatening

h i l d h l i l i t itphysical and psychological integrity

Lieberman et al, 2008

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Trauma causes biochemical alterations in the developing brainTrauma, maltreatment and associated chronic stress damage brain structuresEarly and prolonged trauma and stress damages all stages of developmentEarly maltreatment and chronic stress

Decreased overall brain sizeDamages corpus callosum disrupting right/left brain g p p g gconnections and integration of brain function

Evident in developmentally compromised brains of maltreated Romanian orphans, and traumatised and neglected children generally

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Traumatic stressors experienced by infants can include:

Neglect – animal studies have shown that early t l d i ti i t t Thmaternal deprivation is an extreme stressor. The

stressor may be the dysfunctional parent child relationship in neglected children

De Bellis, 2005

Sexual or physical abuse

Severe accidental injury

Prematurity and prolonged early hospitalization

Traumatic Stressors experienced by infants can include:

Institutional care

Maternal depression / mental illness

Long term hospitalisation with multiple carers

Child protection systems where multiple placements and carersp

Refugee Detention Centres

High conflict divorce

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Children’s early experiences with their primary caregivers create generic mentalprimary caregivers create generic mental models of social relationships. These models, though constantly evolving, govern an individual’s behaviour and functioning

Peter Fonagy, 1996gy,

From an early age a child lays down representations of self and primary attachment figures as ‘internal working models’ Children can have a hierarchy of internal working models of attachment, relating to different time periods and attachment figuresThese models are ‘roadmaps’, providing the child with an internal framework of his world

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These models are experience driven and organise the child’s thoughts, memories and feelings regarding attachment figuresfeelings regarding attachment figuresInternal working models are ‘burned’ into the nervous system at the neurobiological levelThe models are unconscious and once established very resistant to changeOur earliest and most longstandingOur earliest and most-longstanding relationships are the most influential

During normal childhood development internal working models of primary attachment figures are updated and modified as the child grows and develops and changes are integrated intoand develops and changes are integrated into existing mental schemata resulting in a continuous and coherent narrative of primary relationships that adapts to changes over time.

This continuous and coherent narrative provides ‘felt security’ and functions as aprovides felt security and functions as a psychological immune system against future stresses

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If children experience traumatic separations, loss, neglect or maltreatment, internal working models of relationships can become fixed and often remain fragmented andfixed and often remain fragmented and unintegrated

These children often have a primary representation of themselves as unwanted and unloved and of attachment figures as rejecting uncaring or frighteningrejecting, uncaring or frightening

These representations are often too painful to hold in the conscious mind

Resilience in children can be fostered by at least one stable person in the child’s life building on positives, enhancing skills and aptitudes shown by children and providingaptitudes shown by children, and providing some structure, limit-setting and sense of responsibility.By helping parents to enhance resilience in their infant, the goal is to prevent future mental health problems in their infantmental health problems in their infant.

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Dr Elisabeth Hoehn

CChild Psychiatrist – Program DirectorFuture Families, RCH CYMHSActing State-wide Director Perinatal and Infant Mental Health

31-33 Robinson RoadN d h QLD 4012Nundah QLD 4012Ph: (07) 3266 3100Email: Elisabeth_Hoehn@health.qld.gov.au