8/3/2009
1
For GPs…
Antenatal,
Baby &
Child healthChild health
services in Brisbane’s North
Saturday July 11, 2009
Royal C...
8/3/2009
2
Infant Mental Health refers to a baby’s ability to:
experience emotions
develop relationships
learn through nur...
8/3/2009
3
‘There is no such thing as a baby;
there is a baby and someone’y
Donald Winnicott
Infants are social beings tha...
8/3/2009
4
Interpersonal relationships affect the
structure and functioning of the brain, and in
turn help shape a person'...
8/3/2009
5
Infant brain is undeveloped at birth
Rapid growth occurs in the first threep g
years of life (connections and n...
8/3/2009
6
Connections develop between neurones in
response to activation by experiences
‘Neurones that fire together, wir...
8/3/2009
7
8/3/2009
8
Are the context within which the child
learns to regulate emotion
Have the capacity to influence every
aspect o...
8/3/2009
9
John Bowlby - first emphasised
importance of early relationships
(1969/1972/1980/1982)(1969/1972/1980/1982)
Att...
8/3/2009
10
Attachment to protective and loving
parents/caregivers who provide guidance
and support is a basic human need,...
8/3/2009
11
As humans we have an instinct to form
“secure” attachments
Infants instinctively reach out for the
safety of t...
8/3/2009
12
Infants are ‘hardwired’ to engage in social
relationships
Infant cries and behaviours are designed
to engage t...
8/3/2009
13
Patterns of child-rearing may be more or
less conducive to the development ofless conducive to the development...
8/3/2009
14
If interactive synchrony is achieved, the mother is
regulating the infant’s postnatally developing ANS
– in th...
8/3/2009
15
Emotion is initially regulated by others, but
becomes increasingly self-regulated withbecomes increasingly sel...
8/3/2009
16
This interactive regulation is essential to
learning self-regulation, both in social and
autonomous contexts
T...
8/3/2009
17
Sharing positive emotional states with a
caretaker promotes brain growth and the
development of regulatory cap...
8/3/2009
18
‘Bottom-up’ Developmental Hierarchy of the Brain
(Burnell and Archer, 2003)
Cognitive/
behaviouralCortex
(Huma...
8/3/2009
19
In contrast, if there is a growth-inhibiting early
environment, with an abusive or neglectful
caregiver, there...
8/3/2009
20
When infants are not in homeostatic balance or are
emotionally dysregulated they are at the mercy of
these sta...
8/3/2009
21
Trauma causes biochemical alterations in the
developing brain
Trauma, maltreatment and associated chronic
stre...
8/3/2009
22
Traumatic stressors experienced by infants can
include:
Neglect – animal studies have shown that early
t l d i...
8/3/2009
23
Children’s early experiences with their
primary caregivers create generic mentalprimary caregivers create gene...
8/3/2009
24
These models are experience driven and
organise the child’s thoughts, memories and
feelings regarding attachme...
8/3/2009
25
If children experience traumatic separations,
loss, neglect or maltreatment, internal
working models of relati...
8/3/2009
26
Dr Elisabeth Hoehn
CChild Psychiatrist – Program Director
Future Families, RCH CYMHS
Acting State-wide Directo...
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  1. 1. 8/3/2009 1 For GPs… Antenatal, Baby & Child healthChild health services in Brisbane’s North Saturday July 11, 2009 Royal Children’s Hospital, Herston Proudly brought to you in collaboration by: GPpartners | Royal Brisbane and Women’s Hospital Royal Children’s Hospital | Community Child Health Services Child and Youth Mental Health Services With Thanks to our Sponsors: Dr Elisabeth Hoehn Child Psychiatrist – Program Director Future Families, RCH CYMHSFuture Families, RCH CYMHS Acting State-wide Director for Perinatal and Infant Mental Health Saturday July 11, 2009 Royal Children’s Hospital, Herston
  2. 2. 8/3/2009 2 Infant Mental Health refers to a baby’s ability to: experience emotions develop relationships learn through nurturing relationships Infant mental health is about supporting theInfant mental health is about supporting the development 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.
  3. 3. 8/3/2009 3 ‘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
  4. 4. 8/3/2009 4 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 fluidp interchange between neurophysiological development and the interpersonal experiences or interactions we have with other people – a convergence of neurophysiology and attachment theory This 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.
  5. 5. 8/3/2009 5 Infant brain is undeveloped at birth Rapid growth occurs in the first threep g years of life (connections and networks) Neural differentiation is stimulation dependent Neurones change in response to patterned repetitive stimulationp p
  6. 6. 8/3/2009 6 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
  7. 7. 8/3/2009 7
  8. 8. 8/3/2009 8 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
  9. 9. 8/3/2009 9 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 andg parents/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
  10. 10. 8/3/2009 10 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 species There is a biological predisposition in infancy to maintain proximity to t / i hi h i tparents/caregivers which exists across many species (Hofer,1994)
  11. 11. 8/3/2009 11 As humans we have an instinct to form “secure” attachments Infants 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
  12. 12. 8/3/2009 12 Infants are ‘hardwired’ to engage in social relationships Infant 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
  13. 13. 8/3/2009 13 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
  14. 14. 8/3/2009 14 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 emotions Infant has genetically coded internal rhythmsInfant has genetically coded internal rhythms Mother provides attuned external sensory stimulation to the infant If mother can synchronise her external stimuli to the infant’s internal rhythms she can regulate the infant’s developing ANS If the mother is misattuned, she induces a stress response in the infant Stress = 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
  15. 15. 8/3/2009 15 Emotion is initially regulated by others, but becomes increasingly self-regulated withbecomes increasingly self-regulated with emotional development Infants are not born able to self-regulate Infants rely on their caregivers to interactively regulate their internal states SelfSelf--Regulation and CoRegulation and Co--RegulationRegulation Feelings organized* by the parent Feelings organized with the help of the parent Feelings organized by the child * Feelings that the parent can recognize and “be with” Adapted from Kent Hoffmann
  16. 16. 8/3/2009 16 This interactive regulation is essential to learning self-regulation, both in social and autonomous contexts The ability to flexibly regulate emotional states interactively in interactions with other h & t t l t i t y humans & to autoregulate in autonomous contexts, is the adaptive capacity central to emotional self-regulation It is the foundation of social and emotional development It is the basis for development and learning It is the core of the development of identity, value and safety This interactive regulation underpins the development of attachment relationships Babies raised in their first year by aBabies raised in their first year by ay yy y parent who offers emotional support andparent who offers emotional support and connection for key feelings (sadness,connection for key feelings (sadness, anger, joy, fear, etc.) are, at the age ofanger, joy, fear, etc.) are, at the age of two, better able to agree with parentaltwo, 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
  17. 17. 8/3/2009 17 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 mother Good-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
  18. 18. 8/3/2009 18 ‘Bottom-up’ Developmental Hierarchy of the Brain (Burnell and Archer, 2003) Cognitive/ behaviouralCortex (Human) Development Midbrain/Limbic (Mammalian) Development Dance of Playfulness OFC OFC Containment Security Brainstem (Reptilian) Affective/ somato-sensory Nurturing Attunement Co-regulation Containment
  19. 19. 8/3/2009 19 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
  20. 20. 8/3/2009 20 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 copep 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
  21. 21. 8/3/2009 21 Trauma causes biochemical alterations in the developing brain Trauma, maltreatment and associated chronic stress damage brain structures Early and prolonged trauma and stress damages all stages of development Early maltreatment and chronic stress Decreased overall brain size Damages corpus callosum disrupting right/left braing p p g g connections and integration of brain function Evident in developmentally compromised brains of maltreated Romanian orphans, and traumatised and neglected children generally
  22. 22. 8/3/2009 22 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
  23. 23. 8/3/2009 23 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 figures These models are ‘roadmaps’, providing the child with an internal framework of his world
  24. 24. 8/3/2009 24 These models are experience driven and organise the child’s thoughts, memories and feelings regarding attachment figuresfeelings regarding attachment figures Internal working models are ‘burned’ into the nervous system at the neurobiological level The models are unconscious and once established very resistant to change Our 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
  25. 25. 8/3/2009 25 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.
  26. 26. 8/3/2009 26 Dr Elisabeth Hoehn CChild Psychiatrist – Program Director Future Families, RCH CYMHS Acting State-wide Director Perinatal and Infant Mental Health 31-33 Robinson Road N d h QLD 4012Nundah QLD 4012 Ph: (07) 3266 3100 Email: Elisabeth_Hoehn@health.qld.gov.au

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