Children's Voice Mar/Apr 2008

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Making the Case for Infant Mental Health

By Jennifer Michael

Amy Swanson is used to talking to legislators. One of her primary tasks as Executive Director of Voices for Ohio's Children is to lobby local and state legislators to advance her organization's agendas.

So when Voices took the lead on an advocacy effort launched in 2004 to raise awareness of infant mental health issues in Cuyahoga County (Cleveland), as well as statewide, she put on her lobbying hat and headed to local and state legislators' offices. And she went with evidence of a widespread problem--parents and day care providers had begun complaining in growing numbers about serious emotional and behavioral issues among children birth to age 3.

Swanson soon discovered the issue was a tough one to sell.

"When I said 'infant,' it was such a roadblock; you couldn't get to the next part of the conversation to even talk about what [infant mental health] was," she recalls. "You couldn't get it out of their head that babies couldn't have mental health issues."

Swanson isn't the only one fighting to make the case for how important early mental health intervention is for very young children. Many people outside the fields of child health and advocacy find it hard to believe that a child still learning to walk and talk would need a therapist. Funding for adult mental health treatment is hard enough to come by, let alone funding for babies' mental health, the argument often goes.

The good news is that a growing body of scientific evidence has emerged over the past decade that points to the need for more investment in healthy infant brain development--neuro-brain imaging chief among them. This new technology is revealing detailed pictures of the brain that show just how early babies' brains are wiring up to survive in the world after birth. Seventy-five percent of the brain's wiring occurs by age 1, and 90% by age 5, according to New Directions Institute for Infant Brain Development in Phoenix, Arizona.

Knowing more about how early brains wire and how malleable the brain is from birth to age 3 is not only helping researchers develop evidence-based, positive behavior support programs for very young children, it's also driving new community collaborations, like the one led by Voices for Ohio's Children, to figure out how best to strengthen infant mental health services for children who need it.

As a message to local legislators and the community at-large, Voices, along with the Ohio Department of Mental Health, issued a report last year containing evaluations of services available in the state for young children with behavioral and emotional challenges. The report found services were unequal across counties--some had a complete range of services and many different providers, while others had "at best, very new, and at worst, extremely limited" services.

In addition to the report, Voices has organized parents and caregivers to lobby before local legislators on the issue. The organization also spearheaded a series of forums across the state that provided free information about and networking around infant mental health--or "early childhood mental health," as they now term the subject. Educators, day care providers, therapists, and social workers want to know how to improve services, Swanson says, and they are hungry for any information they can find on early brain development.

The advocacy work, she notes, "strengthened existing collaboration and partnerships and has allowed us to really present a cohesive strategy and case for funding early childhood mental health services for children [in Ohio], both consultation and treatment."

Child welfare has been slow to embrace the advances in early brain development and infant mental health, but interest appears to be growing. CWLA conducted an informal survey of its membership last year that revealed infant mental health was a top concern among public and private child welfare agencies. And it's no wonder, considering moderate to severe mental health and behavioral problems affect 50%-80% of children in foster care, many of whom are younger than 5.

Understanding Infant Brain Biology

If anybody is aware of the mental health needs of children in foster care, it is Deborah Williams. For five years, she has provided therapeutic foster care to young children through For Children's Sake, a private child welfare agency in Dumfries, Virginia.

The children she has cared for have exhibited a range of behavioral problems resulting from severe abuse and neglect. Earlier this year, she took in a 1-year-old boy who experienced extreme neglect while living in a homeless shelter with his mother. Shortly after taking him into her home, Williams began noticing his odd behavior. The toddler would constantly bite and hit himself, both at home with Williams and in day care.

"I've never seen this type of behavior," Williams says. "I know how good or how frustrating his day has been by looking at his hand to see how many bite marks and how deep the bite marks are in his hand."

Williams knows his behavior is the result of the inattention he received during his first year of life. But early last summer, after having cared for the boy for three months, she began noticing he was hurting himself less and less, and she was hopeful that by working with him closely, she could turn his behavior around.

According to Jill Stamm, Executive Director of New Directions Institute for Infant Brain Development, Williams should be able to have an effect on the child's behavior, particularly considering his young age and the fact his brain is still undergoing rapid development.

Stamm cofounded New Directions Institute in 1998 to take all of the new information neuroscientists are discovering and make it understandable to parents, caregivers, educators, and therapists. The institute focuses on children birth to age 5, with an emphasis on birth to 3 because of how vulnerable and malleable the brain is during that period.

Stamm and her staff are beginning to look closer at research on the effects of abuse and neglect on the developing brain. When she gives talks about healthy infant brain development, Stamm likes to use a slide that shows the neuroimage of a normal 3-year-old child's brain versus the image of a 3-year-old child whose brain has been sensory deprived. The normal child's brain scan is swimming with yellow and orange color representing normal levels of activation and brain activity, while the sensory-deprived child's brain shows up on the image as largely black, with far fewer yellow and orange areas. In other words, neuroimaging has revealed that maltreatment actually damages the brain and results in structural differences as the brain is developing.

The brain, therefore, is not a moral organ that decides, "This is good for me," or "This is not good for me," Stamm explains. "The brain is just an adaptation organ that helps a person survive a situation the best [he or she] can, and wires up in response to what is happening. So a lot of the behaviors we see in young children that are maladaptive… may actually be very adaptive to the world they are living in."

Stamm uses the example of a very young child living in a home where domestic violence is prevalent. The child is eventually removed from the home and placed into foster care. Even though she now lives in a loving setting, she exhibits severe behavioral problems, including throwing punches at other children at school, because, as Stamm explains, "when [her] brain was learning how to survive, the environment was very different." When her parents were throwing things at each other at home, she had to react very quickly to avoid being hurt herself.

In the case of Williams's foster son, who was severely neglected and now hurts himself when he becomes frustrated and angry, Stamm explains, "When you're not getting any contact or stimulation from other people, those sort of self-stimulating things, like biting yourself, are a way to connect with the fact you are alive." Again, as the boy was developing as an infant, his brain was wiring up to think in such a manner. But the boy's behavior is not a lost cause, Stamm points out, because neural plasticity, which gives a person the ability to change, is greater in young children.

Because so many children enter the child welfare system at very young ages, Stamm sees the advantage the child welfare system can have on early brain development. "It's a system that already has money in it to be able to do these prevention strategies." As part of an effort to better integrate its work within the field, New Directions Institute recently became a member of the Arizona's Children Association. The association does more downstream, intervention work for kids and families already in crisis, Stamm explains, and New Directions focuses more on upstream, prevention work. Together, they hope to meet families somewhere in the middle.

Promoting Positive Behavior

In addition to helping make the case for infant mental health prevention and treatment, new scientific information on how babies' brains work is helping researchers develop positive behavior support programs for caregivers to use with children at very young ages, while their brains are still hard wiring.

The Center for Evidence-Based Practice: Young Children with Challenging Behavior, at the University of South Florida, has focused quite a bit of study on understanding and resolving problem behavior in children. Recently, a team took a model of individualized positive behavior support used for children and adults age 3 and older and brought it down to a younger population--ages 18 months to 3 years-- to study its effectiveness. Partnering with the toddlers' families, the researchers gave the parents strategies on responding to their children's significant challenging behavior.

"For the kids we worked with, there were wonderful outcomes," says Lise Fox, a professor at the University of South Florida who worked on the project. "We had parents all of a sudden feel like, 'Oh, I can handle this now.' Children's problem behavior was reduced, and typically then there were more positive interactions between the parent and the child as a consequence."

Fox adds, "My hope is that we can integrate this [model] into the various programs that will provide support to very young children. Right now, we're working with child care centers in our community and using that model as a piece of what we have them do."

New Directions also offers various training programs that give caregivers an introduction to infant brain development and how they can play a role in stimulating that development. In addition, it sells a series of "brain boxes" for parents and caregivers to use with children birth to age 5. Each box contains toys and other materials that encourage healthy brain development. Accompanying activity cards tell caregivers how to use the materials to stimulate brain development and school readiness.

For researchers, the need for more financial investment in these kinds of programs on the local and national levels is indisputable. "These are the years we can make a difference for these children," Fox says. "When we talk about waiting until it really becomes a problem, typically then it's intractable; typically, then all we are doing is managing the symptoms."

Although many legislators still need convincing, child advocates are beginning to see pay-offs nationwide:
  • In Washington State, a new law went into effect last July to improve delivery of children's mental health services. It's the state's first legislation to contain language pertaining to infant-toddler mental health.

  • Pennsylvania Governor Edward Rendell has created an Office of Child Development and Early Learning, bringing together in one office several programs involved with early learning and child development previously located in the departments of Education and Public Welfare.

  • The District of Columbia's Task Force on Strategic Planning for Infant and Toddler Development gave Mayor Adrian Fenty recommendations for improving supports and services for infants and toddlers.

  • Connecticut policymakers and stakeholders are building a comprehensive early childhood system under the Connecticut's Early Childhood Partners, a coalition of various state agencies, community organizations, and direct service providers.

  • California's First 5 Commissions--funded through a tobacco tax initiative--advocate for infants and toddlers by developing a more in-depth understanding of the local, state, and national framework and using that knowledge to build capacity for early childhood mental health. The California Department of Education and WestEd also recently created the Infant/Toddler Learning and Development Program Guidelines.

  • Illinois's legislature has dedicated millions of dollars in additional funding for mental health services for children birth to 18.

  • Ohio Governor Ted Strickland fulfilled a campaign promise by establishing a new Early Childhood Cabinet that will bring together key state agencies working with children, birth to age 6.
Of Ohio's efforts, Swanson says, "All of that community advocacy...has created a sense of urgency around the issue of early childhood mental health. It helped demystify it. That has been one of the greatest outcomes of all the work that we've done."

Jennifer Michael is former Editor-in-Chief of Children's Voice.


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