Author: DrKT

Most people, on the street, when asked ‘Do you know about infant mental health?’ say, 'What? A baby could have a mental health problem?'  Then they look at you like you have a ridiculous 'first world problem' such as 'What kind of fleece coat shall my labradoodle wear in winter?' Or 'Why doesn't Mulberry's stock quinoa?' This is not a very validating response for infant mental health professionals....!

I am so thankful that now the 1001 Critical Days APPG have tasked PIP UK with helping create a shared narrative about Infant Mental Health.  This is essential https://fnp.nhs.uk/blogs/uniting-behind-the-first-1001-days/

It’s been #children’smentalhealthweek this week (4-10th February 2019) and we have a whopping child mental health epidemic in the UK with at least 1 in 10 children having a diagnosed mental health condition https://youngminds.org.uk/about-us/media-centre/mental-health-stats/ and 56% of children saying they worry about something all the time. https://www.childrensmentalhealthweek.org.uk/research

This week I found myself questioning:
Where and when do people think child mental health starts?  Do they think it’s like an physical illness that comes on all of a sudden in year 6?  Why do many people (including informed and engaged commissioners) think child mental health only begins at age 5?

Some statements:       1. Babies as young as 2 months old can be observed as depressed, anxious and developing attachment disorders.
2. A child’s brain undergoes an amazing period of development in the first few years of life producing more than 1 million connections per second. http://www.zerotothree.org
3. Infant mental health is PREVENTION of ongoing and further trauma to a tiny little person who cannot tell us what s/he is feeling or thinking and is born without defenses.

The smaller and less formed we are the more malleable (and therefore vulnerable) we are.  We are born into thousands of different possible cultures, traditions, and languages.  The only way we could survive as a species is to have offspring who can adapt to this.  A human infant is born ‘prematurely’ and unable to walk or survive at all compared to any other mammal. 

This enables us to download our entire cultural (and social and emotional repertoire).  It is known by neuroscientists that the brain is literally shaped by each environmental influence…. moment by precious.. moment. 

 

So What is Infant Mental Health?

Infant mental health is not maternal or paternal mental health.
Recently, there has been a big increase in understanding the impact of maternal mental health.  In 2014 Bauer et al highlighted the cost and implications of perinatal mental health at £8.1 billion per year with 72% of this relating to impact on the baby. https://www.nationalelfservice.net/populations-and-settings/perinatal-mental-health/  We are just catching up with this in the UK.  NHS England is working to ensure maternal mental health is addressed and support accessible.  But what about infant mental health in babies who do not have a parent with a mental health diagnosis?  Just because a parent has a diagnosis of, for example, depression, anxiety or bi-polar disorder does not automatically mean that the baby is in danger of a later mental health problem.  It is a risk factor but not essentially a cause.

 Infant mental health is not the same as infant development.  Some babies develop quickly, some are premature, some have a syndrome or a delay.  This may or may not impact on that baby's mental health.

Infant mental health is not parenting support.   While infant mental health can be played out in how a baby weans, sleeps or communicates, this is not in itself mental health, just a symptom  This is not necessarily the only thing we need to target (via parenting or behavioural strategies) to address this little person's mental health.

Infant mental health is not just about parent infant attachment but this is getting closer to the core of the issue.  In pregnancy we cannot separate a mum-to-be from the infant's state.

We also cannot separate the type of attachment patterns that develop from conception to aged 2 from a baby’s (and later that child and adult’s) mental health.  It may be helpful to think of attachment as the mechanism that surrounds and protects each person. 

In 1975, a ground breaking paper written by Selma Fraiberg et al, told the story of how a parent’s own history links with attachment and so shapes infant mental health.  This speaks of 'ghosts in the nursery'. https://www.ncbi.nlm.nih.gov/pubmed/1141566  

In considering infant mental health and working alongside parents we can ask: When you hear your baby cry what are you hearing? Pain? Sadness? Anger? Grumbling? Tiredness? Is it your baby’s real communication or is it your own 'stuff'? Did you experience being heard? Loved? Understood? 

Our 'stuff' is the mist and fog that would prevent us seeing our baby for who they are and therefore can seriously get in the way of us acting in a sensitive, loving, protective way to ensure our parent infant relationship is healthy and secure and our baby stays mentally healthy.  It was the analysts (Freud, Winnicot, Bion and more) who discovered infant mental health and they are the port from which we always set sail in addressing infant mental health in 2019 and beyond.

Infant mental health is impacted by a myriad of factors... too many to cover here but including a parent's own history of being cared for as well as social support and poverty, physical health, the parents relationship or witnessing domestic abuse, drug or alcohol misuse or the impact of birth trauma.

In the context of working with families in extreme situations and to state this strongly and clearly to get a point across: Traumatic events in a baby's life can cause him or her harm.  If something happens to an adult they can talk about it, call Samaritans, talk to a friend. 

 If something happens to a child, they can play it out, adapt in some way, tell a teacher or their mum.

 

 

 

 

 

There is hope that the event can be processed. 

If something is experienced by a baby who does not know where they end and the world begins - then they don't know where the event ended and they began. Without intention- this is not about blame- the event becomes part of them and who they are.  It’s important to remember that babies are amazing at adapting and most babies, even when there is a fair amount of chaos around them, will actually be okay.  However, the quality of the parent infant connection and later the parent child connection will dictate how well they recover.  In this way, infant mental health is entirely formative in terms of mental health prognosis over the lifespan.

 Developmental trauma and the way this shapes a vulnerable infant can be thought of as infant mental health. Our work is in PREVENTION of ongoing and further trauma to a tiny little person by developing security of their attachment to their carer.

Infant Mental Health is important and it’s not a luxury.  Unlike how we dress our pet or what superfood is in fashion, it applies to everyone.  It is I believe, a key to reversing our child mental health epidemic. 

Does this make sense? Do you agree or disagree?  Please post below, I would love to hear your ideas!

It's the final blog for Winston Churchill! Here he is waving me off.

By some strange co-incidence he was right outside the Hilton Riverside, exactly where the Zero to Three conference (https://www.zerotothree.org/events/2-annual-conference-2016-building-powerful-connections#overview) was held which was the grand finale of my Fellowship trip.  My benefactor looks more jaunty in New Orleans as you can see.  It was good to see him and silently say a very big warm THANK YOU to him for all of the learning and opportunity to develop that the WCMT (http://www.wcmt.org.uk/categories/early-years-prevention-intervention) has enabled for myself and for many many other Fellows.

I am briefly in JFK airport, NY on the way back from the New Orleans conference.  On the television monitor, New York is still reeling from the election.  The headline at CNN is 'Trump challenges CIA over Russia hack swaying vote'.  Unlike the east and west coast areas, New Orleans was not mourning the election result.  Louisiana is indeed a red state.  Apart from this, my experience in New Orleans was progressive, uplifting and incredibly inspiring.  Zero to Three is a statewide organisation representing all that is needed for this precious age group.  They are an informed and strong voice for babies.  Thankfully we now do have such representation in the UK e.g. The WAVE Trust http://www.wavetrust.org/and 1001 critical days http://www.1001criticaldays.co.uk/).  However this is just beginning.  Zero to Three has been running for nearly 40 years and so has an established middle-aged presence in government lobbying and co-ordination of knowledge and all professionals in the field.

The conference was accessible in that it didn't take itself so seriously. It was alternately passionate, emotionally moving and playful with a lot of jazz music thrown in around the edges with requirements for participants to have fun and dance along.

Highlights of the conference can be seen on Twitter @ZEROTOTHREE or #ZEROTOTHREE2016, my highlights included under #ZEROTOTHREE2016 @BrightPIP.  For me, this Fellowship came together at the conference.  It was as if the pieces of the puzzle about what I had learned in NYC and why I had come on this Fellowship fell into place. Why? How?  Well there were some moments of clarity. They were:
1. #ThinkBabies
The Zero to Three network launched the #ThinkBabies http://www.thinkbabies.org/campaign at this conference.  This is a catchy soundbite and way of lobbying congress. This, together with a film from No Small Matter http://www.nosmallmatter.com/about-the-film/ illustrated the power of raising national and local awareness.  The campaigns argue so clearly, 'when babies thrive we all benefit'. The scene of parent infant in NYC and across the US where there are many people campaigning and creating maximum impact led me to understand how far practitioners here have come in creating national awareness and how we can do the same in the UK.
2. Prevention of toxic stress
Dr Sarah Watamura gave a capturing Science Plenary about toxic stress and mitigating the impact of this on the developing infant.  This re-emphasised for me the use of ACE as this was predictive of everything they measure in her research department.  Some interesting data was presented on pre-natal stress and the impact of this on the foetal brain (Dr Sherri Alderman).  We also heard that this can be greatly reduced with the right support.  The impact we can have as professionals working with parents and babies to buffer this stress and enable parents to recover enough to protect their babies was emphasised.  This is heart warming indeed in terms of all of the hard work parent-infant practitioners do with families and the long-term impact of this.
3. Leadership
In the last five years, the biggest learning curve (and still being at the very beginning of this curve), has been leading in an area where I passionately feel we need change.  It was not intentional to be the person to co-ordinate and facilitate a very small parent infant psychology organisation - but it turns out if you feel the most strongly about something then you end up being the person who steers the ship.  Paul Schmitz in his inspiring lecture last Friday at Zero to Three placed this into context and gave a containing framework.  He talked about needing a whole system to change a system - not an individual.  The type of leadership we now need for infant mental health is powerful leadership to change the way everyone thinks about and values babies.  This is collective and collaborative and about working together.  He gave some prerequisites for this (see #4 below).  The reason this held personal meaning for me is that I have felt frequently like a failure or lost (as well as occasionally energised and happy!) in setting up BrightPIP.  Most of all it has been a lonely journey not knowing many peers who are in the same position.  There are many people in the field in the US who have struggled with the same dilemmas, questions and feelings.  Meeting these people has been hugely reassuring.  This confirmed the need for collaboration and working together - driven by the cause of the families.

Back in NYC, in a conversation with Tonia Spence about leadership, she said she has conjured a 'virtual board' of advisors around her and I love this idea.  This trip has given a newfound confidence and leadership identity simply by connecting to others with the same story who have followed their beliefs to set up a service.

4. Collective impact
The required qualities for leadership of an organisation to have collective impact were useful and reaffirming. These are a) To be doing with a community (not to or for) and based on building relationships.  b) About collaboration and building TRUST with others within and outside of the organisation.  There may be conflict but this can constructive.  c) With diversity and inclusion as essential in steering the organisation; 'when you change who is at the table you change the table itself'.  d) With continuous learning emphasised and talking about mistakes.  Paul placed a list of 'things I suck at' in front of the staff team and reminded us, that these will be no secret to everyone who works with you (!).  Others will hold strengths we do not. e) Integrity and holding oneself and organisation accountable are critical for collective impact.  This means not putting an individual organisation above a cause.
5. Being open about personal story (and not English 'stiff upper lip')
Setting up a not-for-profit is a given for many practitioners in the US and these people often come at things from a personal perspective.  This is no big deal for Americans..

Paul Schmitz described his history of drug dependency before inspiring others to become leaders.  In NYC, when meeting people in the projects, there were many conversations about who we are and why we do what we do.  It's not a coincidence, we are all working out our own stuff.  The other day Erasma Monticciolo wrote to me 'It’s so important to share, as that is part of our healing'.  We had an exchange where I thanked her for talking so openly about her own level of adverse childhood experiences and about growing up in poverty in Brooklyn and later having PND.  This gave me permission to be honest about my own similar background.  As clinicians we know why we are so driven to do this work yet it is so rarely talked about openly.                                                                                                                                       6. Humility in approach
Finally, an idea I frequently come back to was echoed in the conference.  This was about humility through self-compassion and self-care.   Berry Brazelton's quote about attunement and repair sums this up: 'when you do something that doesn't work, you have an opportunity to learn something and grow closer' .  In the Reflective Approach for Promoting Family Engagement seminar (Armstrong and colleagues), self-care was talked about as a key part of the model for working successfully with families.  Mindfulness is integrated into the approach supporting each Home Visitor and also integral to supervision.  A lovely example was given of a Home Visitor and how she used mindfulness before each meeting with a family.  The Home Visitor said that as part of this she would, on the approach to a family's house, walk mindfully to the door placing each foot carefully and consciously.  Then she would give a particular knock on the door 'knock knock...knock knock' (four altogether; two and then two).  This little sequence corresponded to the words in her head 'I'm here, to listen'.  I like this very much as it's a reminder of the frame of mind to be in to practice this work.

So this is the end of the adventure although the learning will continue forever.  I am so grateful for everyone who made this trip possible.  The Winston Churchill Memorial Trust of course and the supportive colleagues and friends who encouraged this application and held the BrightPIP baby so competently in my absence.  However, there is no way I could have done this without two people in the world; my husband and my mum.  Both of whom had to hold everything together, childcare, household and various other projects whilst I jetted around.  They have not complained about this massive imposition even once.  I will always remember being able to do this, and would like to end by dedicating this blog to both of them.  You are two amazing, kind, tolerant people...THANK YOU!

Illuminations on the way to be accessible and non-stigmatising for families began for me 12 years ago - during my doctoral thesis.  I chose to study the stories of asylum-seeking families.  They are notoriously an elusive group for services to engage due to completely understandable and obvious reasons; fear of statutory authorities, high level of trauma, stigma and often a very different cultural explanation for mental health symptoms.

I spent 6 months (6 months!) trying in vain to recruit participants via schools and organisations. Despite a lot of effort, travel and payments to interpreters I was failing entirely to find even ONE family.  Then, having exhausted my resources and everyone else's resources so that I had no childcare options left, I came across a friend of the family who ran a drop-in group for asylum-seeking and refugee families.  She invited me to come in and help.  I had to take my son (aged 8 months) with me. With baby on hip I made a few cups of tea for families.  We chatted about them and their appreciation of the drop-in family centre.  Then...bingo! I had 8 families to participate in my study!

The lessons learned: be where people enjoy and value going, be human, approachable, make sure people know you are not judging or critical.  I have had numerous situations of engaging families in community work since then and I don't think this 'discovery' has become any more sophisticated - common sense after all.

There is some great practice in engagement that I have encountered on the Fellowship which I hope will enrich BrightPIP in reaching Brighton families.   All in all, I have visited and talked to people about nearly 20 programmes.  They all approached things in unique ways using different combinations of clinical interventions but all with the mission to reach the babies that most need preventative infant mental health.  Here are some of the best ideas:

Universal screening proposed in the Early Intervention city wide project within 'Thrive New York City' helped me learn about the power of their strategic work group (Evelyn Blanck).  This will ensure the policy is that all professionals will be involved in making sure no family goes unseen or unheard.   This includes ACE and ASD screens (see Blog 20/11/16).

Early is best and the research based program of PREPP: Practical Resources for Effective Postpartum Parenting http://pregnancy.bmedcumc.org/ (Dr Catherine Monk) gathers pregnant women in a non-stigmatising way using a screen for likelihood of PND.  The support offered is focused on bonding and caring for baby so that crying is reduced and ability to regulate and settle at night is increased (a tempting offer for all parents-to-be!) and it is called ‘coaching’ rather than therapy.

Avoiding stigma of therapy is a big challenge.  This can permeate those of all social groups and backgrounds.  The power of sharing and talking to others during normal family social events may be just as therapeutic.  This was used by a post 9/11 project specifically for families with babies (Candi Cuchero, NYS-AIMH) as families were rejecting of the stigma of therapy.  It was fascinating to learn from Bonnie Cohen (Early Childhood Division, University Settlement) about a similar approach which she coined 'stealth mental health'.  In their Early Intervention model, there is a whole range of possible services that a family can access (e.g. baby groups, play sessions, parent groups, parenting skills).  Child Parent Psychotherapy work is only offered as an additional if needed and then when the family are engaged in other support.

In stealth mental health there is what the Americans term a 'warm hand-off', an expression I have heard a lot in New York.  This means that the family are introduced to the therapist by an already trusted worker.   Meeting Tonia Spence at the Jewish Board, Harlem Child Development Centre, we discussed the success of instigating a service that is essentially 'familiar' in every way to the families.  This would mean training the key referrers already working with the families to do this warm hand-off as well as considering the importance of ensuring workers are from the same ethnic and social group as the families we are trying to reach.

Community presence can mean stepping outside what we expect to deliver and starting by designing the service requested by the parents.  This means building trust with a community (and might include less clinical work to begin with).  An agency needs to simply provide the very information that families need at any given time e.g. showing them a nearby food pantry or providing information if they become homeless.  From the 'Power of Two' programme (Erasma Monticciolo) I have learned that a person who makes those contacts locally and gets to know key leaders in the community can then build the trust and respect of that community from grass roots up (always the best way!).  The ideas from this programme link to the discussion with Tonia as they use specially selected and trained Home Visitors to deliver intervention, often with more of a history in common with the families.

When building trust with fearful or ambivalent families who are in the system and are having to participate due to mandatory court ordered treatment, it is essentially a make or break time to engage.  I spoke with Dr Susan Chinitz 'Strong Start Court Initiative' ( http://www.courtinnovation.org/project/strong-starts-court-initiative) and Hazel Gacman about the 'Babies First' programme. This works alongside the court process but making it very clear that the therapeutic work is with the family rather than against them.  This, like the 'Babies Can't Wait' programme (Dr Marcy Safyer) helped me understand further about combining early work with parents and babies and Child Protection Plans while not alienating the families due to the helping stance that we take.  It is such a fine line for clinicians to tread - but such programmes show that it can be done.

The right location is essential and from the GABI programme: Group Attachment Based Intervention  http://www.attachmentresearch.com/gabi (Dr Anne Murphy) I learned that a key way to hold families when they most need it is to provide groups regularly (they provide 6 per week!) in their community.  The groups are nurturing and containing and use key reflective clinical skills.   Also, hospital based programmes, such as the teen-parents group at Bellevue (Susan Linker), the Family PEACE Trauma Treatment Centre at New York Presbyterian (Dr Erica Wilheim) and national Healthy Steps (http://healthysteps.org/) where clinicians link with paediatric services confirm that the best way to meet these families is to be where they are at.  In the US this happens to be their regular checking appointment with their paediatrician (they don't have Midwife led-care or universal Health Visiting here so the hospital is where it's at).  These, like all good programmes, demonstrate very good relationship building with other professionals in the hospital.

Personally, it is reassuring to see the same dilemmas and to see ways of approaching and successfully overcoming barriers - even in another system and culture.  The value of seeing first-hand the success of innovative thinking and diverse projects gives confidence in the work in the UK and is energising and inspiring.  But what stands out?  What can we take back to the UK for those families?  I think all of this and more.

There is, as with all such dilemmas, a tidy way to think about engagement.  I am at the excellent Zero to Three national conference (http://annualconference.zerotothree.org/right now and this morning in a talk about leadership in this field, Paul Schmitz outlined collective impact and 'doing with the community (not to or for)'.  This approach requires integrity, humility and commitment to the cause of infant mental health.  In the same way, engagement with a community of families needs us to be alongside respectfully.  This takes some attunement, just as when trying to form a secure attachment.  My understanding is that often this comes back to ourselves.  We can be good (enough) attuned parents if we can attune to ourselves, think clearly and attune to our children.  We can be good engaging practitioners if we hold the same genuine qualities.   This goes back to my first steep learning 12 years ago.  If we can be real, then families will know this and work with us.

Did you find the ideas here surprising? Obvious? Different?  Please go to the comments button below and let me know!

This is a commercial break kind of blog where I promise not to talk about psychology.  The place called home this month is a little room in a shared apartment in East Harlem, also known as 'Spanish Harlem'.  This was chosen as it's not way too expensive but apparently it's not 'the ghetto'.

This is a vibrant place and to begin with it was a fair old culture shock compared to white, middle class Brighton.

Strangely, I don't notice anymore.  It's amazing how quickly it just becomes life as we know it.  But for your entertainment, here are the first nine things I noticed in my culture shock...

1.  Music is everywhere.  People hanging on the street, on stalls, on the subway (img_subway).
In the park....

Also, people are carrying their music with them and playing it nice and loud - whether walking, selling corn cobs or sweeping rubbish. It's good music, especially in Harlem; a bit of reggae, a bit of samba, a blast of Stevie Wonder.  In Brighty it is only the very eccentric gentlemen of Hove who rides his mobility scooter (laden with crazy stuffed toy decorations) who does this.  He is the only one.

2. White people do not live in East Harlem.  I am an alien.  There are only Hispanic and Black people.  Getting on the subway at 116th to go downtown, it is marked that the White people only get on at 96th.  Everyone looks green on the subway - but you know what I mean.

3.  People stand around.  People just stand and hang out. They just stand on a corner and look about enjoying the scene. Often with (see #1) their music for company.  We would be far too self-conscious to do this.  It's also November and it's cold.

4. Poverty is everywhere.  So much so in East Harlem.. but also in pockets elsewhere.  It is especially shocking so near to the wealthiest places in the world 20 blocks away. There are 3 soup kitchens near me, many pawnbrokers, people sleeping rough and oh, a methadone clinic around the corner.

5. Indomitable spirit.  There is an approach 'if we fall we will rise again stronger'.  This seems an unspoken philosophy.  Some New Yorkers have looked crestfallen at the timing of my visit, shaking their heads apologetically and saying 'We are normally so positive and smiling in this city but we are all so fearful now'.  Yet there is no sense of giving up.  NYC will always celebrate diversity and the belief in equality and justice.  Thousands of post-it notes in Union Square subway are testimony.

6. Mid-town is a different culture entirely.  Ladies dressed head to toe in Chanel...oh is that Madonna's apartment? Or Lady Gaga? And being trampled by professional dog walkers wielding 8 pampered poodles at a time.

7. You can do ANY exercise you imagine.  Being different and unique is acceptable.  A candle lit spin class whilst listening to spiritual affirmations? Yes, it's a franchise.  You want to go to a class cycling underwater (4ft of salt water) no problem.  Pregnant?  That's okay, there are special underwater cycling classes for pregnant ladies with some calming prenatal yoga thrown in.

8. Sweaters in the oven.  People generally have apartments that are 3m by 2m, that's normal.  Maybe even a luxury.  In their apartments people don't cook.  There is no room for cooking and no room for sitting.  I heard of a girl who used her oven to store clothing, this is entirely normal.

9. Sunglasses on the subway even on a cloudy November day? Yes!

 

 

It’s probably high time to talk about the parent infant experts I have been meeting here in NYC.  Here are just some of them:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

And there are some people I have yet to photograph: Beatrice Beebe, Clinical Professor of Medical Psychology; Tonia Spence, Senior Director-Early Childhood Services; Dr Susan Chinitz, Consultant, Strong Starts Court Initiative.  Apologies that not all have photos yet due to camera shyness or my forgetfulness.

In the next few blogs I hope I can share some of their incredible stories and the learning opportunities these people have given.  So far there have been fourteen (fourteen!) meetings with inspirational individuals.  It seems improbable that this could have happened, given that before this Fellowship I knew no-one and no-body.

With each conversation, pieces of the puzzle have come together.  In my first week I found that my head would hurt with the fast pace of the New Yorker dialogue (think machine gun fire compared to the UK tempo which is relatively steady and with actual pauses).  There were many acronyms and terms that were beyond me.  I had to keep stopping people and asking in my anxious English voice ‘Sorry the what? Pardon?’  Embarrassingly, some of the questions I had to ask were elementary like ‘What is Federal?’.. (it’s the central government of the US). ‘What is a Senator?’ (a bit like an MP) ‘What is CPP?’ (it’s Child Parent Psychotherapy and used by many with parents and babies).

It has been a joy to speak to people in so many places who all have a similar vision and have worked through the very issues that I have faced personally and professionally.  It is impossible to capture the depth of the conversations here but I have begun to notice themes and big questions in UK v US differences to practice.  This is fascinating and will form the basis of the Winston Churchill Fellowship report back to the UK. Here are some initial findings:

How to approach getting funding?   The projects in the US are so different in that many people set up not-for-profits or charities because of the underdevelopment of the public sector.  It is not seen as unusual or brave.  The paths for ordinary clinicians networking with commissioners are well trodden and less daunting.  There are also massive benefactors everywhere it seems.  It is possible to raise millions just by being in the right place at the right time!

There is something else, less tangible but one of the reasons that I chose NYC as a place to visit.  It is the source of the ‘can do’ attitude that is needed in these situations.  There is no fear as people describe setting up their projects, making the right connections and campaigning for a cause they believe in and this is typical New Yorker spirit.  Follow your heart and take risks.

ACE as screening?  ACE means 'Adverse Childhood Experiences' scale and comes from a highly influential long term study https://www.cdc.gov/violenceprevention/acestudy/.  This used a list of 10 items that have long been established as traumatic (e.g. abuse, neglect, having a parent with mental health problems or substance misuse).  It's quite easy to ask a parent to tick how many ACES they have had.  While ACE’s are common, it is an accumulation of them that is predictive.  Nice and simple.  The ACE study demonstrated an association of adverse childhood experiences (ACEs) with health and social problems as an adult.  Importantly, it ALSO suggested that maltreatment and household dysfunction in childhood contribute to health problems decades later. These include chronic diseases (e.g. heart disease, cancer).  Most of the projects and researchers I have spoken to assume the use of ACE questions.  When I ask about reaching the families we really need to reach, they often say that this is a clear identifier.

Early diagnosis in infants? This has been the biggest surprise and something to think about more.  The US diagnostic classification system 0-3 is all about catching babies early and the established optimum time for an autistic spectrum diagnosis is aged 12 months..12 months!  If we compare this to the UK, our National Autistic Society describes aged 2 as 'early'.  The average age of diagnosis in the UK is 4 ½.

My initial response to the early diagnosis issue was to recoil in horror. To label babies aged one?!  'What if you are seeing an attachment related issue???' (e.g. not something ‘wrong’ with the baby at all but wrong with his or her environment) I said.  However, Gil Foley, an expert in this area who I believe has contributed to the latest as yet unreleased diagnostic manual was very rational in his explanation.  He told to me that a diagnosis from every perspective, health cover included, meant that babies and families get the support they so badly need. Recently as I talked to Susan Chinitz,  she explained further that it is possible to ‘lose the diagnosis' with the right support.  I tried to explain that in the UK we are wary of labels as it can be hard to 'lose' them – but from what I gather this rigidity in thinking is a British thing.

I would like to say thank you to these people who have blessed me with their time and wisdom in the first few weeks of the Fellowship.   Also, thank you to the blog commentators so far- it is amazing to get your feedback.  So, what do others think of the themes that are emerging? Does this fit with your experience in the US or UK?  There are some contentious issues here, do tell me your opinion!

 

These are the scenes from the cafe inside and up along 5th Avenue as I write this.

 

It is hard to convey but watching everyone in peaceful protest: holding placards, shouting and chanting together is quite an emotional experience. This is not just today but all week.
So there are many ways of coping with the shock, sadness and anger. Samantha Bee helps us to laugh rather than cry (https://www.youtube.com/watch?v=s1SaD-gSZO4).  Another way is to devise theories and work out how we got here. How did this happen?!

If you will, allow me the following stream of thought.  The need to make a logical connection could lead us to say: Economic crisis = struggle = blame = ripe climate for inciting bigotry = electorate make bad choices.

Let's go back to the economic crisis.  Why did that happen? It's complicated but it started with the bankers.  People were rich and wanted to get richer.  Hence layer upon layer of hot air and exploitation of dreams leading to sub-prime lending. The story has similarities in the US and the UK.  It led to an absolute implosion in the system.  I am puzzled about what prevented us seeing this coming.  It seems we were all excited by the bubble.

Why the need to get richer and richer beyond all rationale? Wealth gives us ultimate power and independence.  It's a good feeling: 'I don't need to depend on others, on relationships, on community, I can do anything with money'. This need for supreme independence (over and above all other needs) would be an 'Avoidant' personality trait.  So you see where I am heading as a parent infant psychologist with this?
Going back to infancy.  As a tiny baby, when our attachment strategies are forming, this is when we could learn that in order to survive, we must inhibit out vulnerable emotions, look after ourselves, be as independent as possible.  Such early formation means these are our deepest instincts.  It's about staying alive.  Let's get this clear I am not saying all bankers had a traumatic babyhood.  Just trying understand why greed superseded common sense.  We are all a little bit responsible.

The next stage in our demise, is coined very well by Mike Baum (played by Steve Carell) in the movie, 'The Big Short'.  In despair he says: 'In a few years people will do what they always do and blame the economic crisis on immigrants and the poor'. Never has that line been more true than 2016's disastrous voting outcomes of Brexit and Trump.

The final step in trying to make logical sense of it is to ask: how were so many people in the red states of America putting all the blame for problems onto immigrants and others?  They were encouraged by somebody, yes - but only because they felt vulnerable, angry, not considered, not heard.  These are quite infantile states.  A psychoanalyst would explain 'splitting and projection' with more finesse, but I will try my best.  Splitting off the negative from ourselves and projecting it onto others, saying they are the ones with the problem, begins in babyhood.  The splitting of our carer figure into 'all bad' or 'all good' is an 'early primitive defence mechanism' (a way of dealing with being overwhelmed).  As we are just tiny we can't understand or cope with the idea that the carer who meets our needs (it's called the good breast to credit Klein) is the same one we are furious with (bad breast) when they don't get it right (as no parents get it right 100% of the time).  To cope, we temporarily believe as if they are two different people.  The theory is that adequate loving care allows us to integrate bad/less satisfactory bits and good bits so that we are able to tolerate that there is both 'good' and 'bad' in all of us.  If we stay with the primitive mechanism due to inappropriate caregiving and without being helped to mature, we are in danger of using splitting as a defence against our vulnerability in later life. For example idealising ourselves, and putting all the negative onto the 'other'.  Does this make sense? Please say if not and I can explain some more.

So could infant mental health have saved us?  Well, obviously this is a generalisation and I am incredibly biased but...YES.  Infant mental health with some of the 'privileged' who struggled so hard to get their needs met as babies and grew up to became hardened and money grabbing.  Infant mental health with the 'underprivileged' who struggled to get their needs met as babies and became ripe for reliance on racism, sexism or homophobia to make sense of their world.

OF COURSE, I am the first to admit this is over simplistic, and perhaps a little bit (okay maybe a tiny bit!) skewed towards my own particular area of work.  But remember that we have now established both through neuroscience and research (replicated and longitudinal) that attachment is the foundation for social and emotional mental health.  Like the foundations of a house, this needs to be solid, secure and safe.  The Center on the Developing Child at Harvard explains this well (https://www.youtube.com/watch?v=VNNsN9IJkws ).

As always I am very curious, what do you think?  Please don't hesitate or be shy to give me your opinion.  Post a response.

It is a really tense time here in NYC and all over the U.S. and worldwide.  It seems everyone is anxious and the tension is palpable. This is understandable, it is election night....

By the time you wake up and read this (as if...of course reading this blog is the first thing you do), we will know the outcome of what feels like the most alarming election in history.  I am having Brexit flashbacks which prevents any sense of being smug that nothing this disastrous a choice could happen in my OWN country.  For now, for colleagues in NYC and I, there is nothing to do but wait.

Back in the parent infant NY scene, there is so much to tell you that it is hard to know where to start.  Maybe some reflections following some excellent clinical teaching?  Apologies in advance for the jargon.  I have included some links to explain the psychotherapy speak.

Last week I attended a fascinating 2 day seminar in 'Mentalisation in Psychotherapy' (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816926/). This was at the New School http://www.newschool.edu/nssr/ and facilitated by Drs George Downing and Howard Steele. It helped me grasp far more about using the concept of Reflective Function (RF) http://www.tandfonline.com/doi/abs/10.1080/14616730500245906?journalCode=rahd20 and how to enhance this in parents. By the way, this is the RF manual I didn't realise we can get it online! http://mentalizacion.com.ar/images/notas/Reflective%20Functioning%20Manual.pdf.

The seminar used video a lot and I love this as it brought it far more to life for me. Howard Steele was joined by Miriam Steele. As they both spoke the room lit up and I felt blessed to be hearing this RF concept from 'the horses mouth' that is, from a people who coined this idea.

I wanted to hug them (I restrained myself). It was worth coming all the way to NY just to hear concepts explained so clearly, concisely and with such direct clinical applications that I could just imagine walking back in to see one of my families and supporting them with thinking about their own and their baby's mind.

Howard at one stage explained, 'RF is a synonym for resilience'.  I am still thinking about this.  If secure attachment in the parent is a function of the capacity for reflection about ones own life (as measured in the AAI http://www.psychologyconcepts.com/adult-attachment-interview-aai/) and this is predictive of secure attachment between baby and parent, then the heart of the success of our work with many families is about increasing RF.
This led me to question, taking away all the clever concepts, what do I believe are the essential ingredients for this? To make this simple and common sense let's imagine a mother with a new baby feeling very vulnerable and sitting in the the therapy room. This is what I think she would say:

1. Think about me, show me compassion, show me that you really care and that you can think about my possible mental state. Only then can I learn about doing this for my baby.

2. Help me stop feeling so fearful and to slow down. Help me know that my baby has a mind and to understand what is going on inside my baby.

3. Show me what I am doing okay with at the moment and build on my strengths. Right now, please don't make me feel worse about myself as I will not be able to reflect any more (my defences will come right up!). I want to know what I can do more of to get better and better at this parenting thing.

I wonder do other people agree with these as the key essentials? Are there more? I am really curious about what other parents and/or clinicians would say.

It is beautiful here in NYC.  Unseasonably warm and blue skies.  What better way to start the day than basking in the sun beside Harlem Meer?

Seminars and meetings of the first week have already blown me away and I can feel myself developing a sense of the NYC scene for parent infant work. On the one hand, it's not so far from our UK system in that there are key professionals moving and shaking (like psychotherapists, psychiatrists and psychologists) all with a clear dedication to infants.  And, as with the UK we are all setting up interesting pieces of work, developing research projects and training and offering support to frontline staff.  On the other hand, it is everything different from our system.  The lack of statutory provision in the US means plenty of room for individuality, innovation and movements toward social change - together with an essential requirement for the New Yorkers famed networking abilities.

For this networking, I am indebted to Dr Jeanette Sawyer Cohenhttp://www.edparenting.com/for taking me under her wing and introducing me to this scene.  She is actually an angel, disguised as a clinical psychologist and has an in depth understanding of this field on top of that.  So, here she is. (see also twitter @motherhoodbk) Turns out, even if Dr Jeanette doesn't know a famous parent infant New Yorker, she will know someone who does.  Thank you Dr J!

Earlier this year I was given the massive news that I had been awarded a Winston Churchill Memorial Trust fellowship (http://www.wcmt.org.uk/categories/early-years-prevention-intervention). This meant I could travel to learn more about the topic I feel most passionately about (parent infant projects!) to anywhere I wanted to go in the world (I chose the inspiring city of New York and around).
It was astonishing news, as over 1000 people apply for the Fellowships. In my mind, it had been only ever a long shot - to follow a dream and my passion for early intervention with babies and their parents.
Right now I am preparing to leave on the 1st November for this adventure and still cannot believe my luck (or actually that it is even quite real) and that I have been granted the honour of this trip.

The mission: to travel and and gather knowledge, understanding, and practical skills in the field of parent infant projects, specifically how to reach those families who might not necessarily come forward and speak out and demand support for their parent infant relationship - yet who possibly need it the most.

The plan: to visit, talk, listen and learn from as many knowledgeable and inspiring people - active in the field of early intervention, infant mental health, and parent infant therapy - as possible. Traveling around Manhattan, Harlem, The Bronx, Brooklyn, Long Island and visiting teaching colleges such as Columbia University, The New York Center for Child Development and the New School for Social Research in New York.

The aim: To develop insight into how to reach those families we really need to reach, and bring this back to the U.K.