Infancy Not Too Early For MH Interventions

Absorbed in his own world, 10-month-old “Tommy” stares into space and rubs the same spot on the family-room rug over and over. He can barely sit up and shows no emotional reaction when his parents talk to him, touch him, or try to interest him in games and toys.

Concerned, his parents seek professional help and are told that Tommy may have the early warning signs of autism or mental retardation. He is referred for evaluation to child psychiatrist Stanley Greenspan, M.D., in Bethesda, Md.

“Tommy had a nervous system that underreacted to environmental stimulation,” Greenspan told Psychiatric News. “I have also seen some infants with overreactive nervous systems in my practice. If the reactivity is extremely low or high, the infant can have social, emotional, cognitive, and language difficulties. This may also put them at increased risk of having attentional, learning, autistic-spectrum, and mood disorders.”

Greenspan, who specializes in infant and early childhood mental health, has written several books on children with special needs, including one on children with bipolar patterns. He cofounded the national organization Zero to Three in 1977 and the international Interdisciplinary Council of Developmental and Learning Disorders (ICDL) in 1995. He serves on the board of directors of Zero to Three and chairs ICDL in Washington, D.C.

Greenspan has observed three patterns of behavior in infants with overreactive nervous systems. “There is the infant who is easily distracted, irritable, and moody, and the infant who is inhibited, anxious, and tense. A third type of behavior emerges when the infant who is anxious and very cautious attends preschool, for example, and encounters a lot of noise and commotion. It’s as if a switch is flipped in the child’s nervous system, and the child becomes hyperactive, aggressive, and agitated,” he said.

“This switch in the child’s moods and behaviors, depending on circumstances, may be a risk factor for developing bipolar patterns, but we need to do more research to confirm our hypothesis.”

Infant mental health specialists work in a variety of settings including neonatal units, homes, and outpatient clinics. Zero to Three defines the infant mental health field as encompassing the first three years of life, while many infant mental health specialists define the field more broadly to include parenthood and infants until the age of 5.

“We know that the child’s nervous system is still developing in the first five years of life, which makes infant mental health [care] the ultimate in prevention,” said Greenspan. “The earlier we can intervene, the greater the likelihood of decreasing the risk of early warning signs becoming significant problems.”

The approach used with Tommy typifies how specialists in this field work with young at-risk children. Greenspan evaluated Tommy’s neurological, cognitive, and psychosocial functioning and his interaction with his caregivers and family. He developed a profile on Tommy using his Developmental, Individual Difference, Relationship-Based (DIR) model and tailored a treatment plan to fit the profile.

“Tommy had not mastered the first two stages of our DIR model, which are the ability to relate to his caregivers with some warmth and trust and engage in purposeful activity, so that was our first goal,” said Greenspan.

An important part of Greenspan’s approach is to work on the child’s level. For example, Greenspan got on the floor of his office with Tommy and his parents and experimented with how to engage Tommy by interrupting his compulsion. He started by putting his hand on the spot Tommy was rubbing to see whether he would respond. When Tommy moved Greenspan’s hand, Greenspan asked the parents to do the same thing.

“We progressed from there to the mother laying her head on the same spot, and Tommy touched her face. She then made cooing sounds and gestures, which Tommy responded to and imitated, initiating reciprocal communication. In a few months, Tommy mastered the first two developmental stages and lost interest in his compulsive rubbing,” said Greenspan.

He continued to meet with Tommy’s parents to guide them in helping Tommy master each subsequent stage of development in the DIR model. “I followed Tommy for many years because his problems were severe, while other children I see only require a brief follow-up,” said Greenspan.

Infants who are traumatized by being exposed to domestic or community violence or war for example, may show a wide range of symptoms including disrupted sleep and eating patterns, difficulty learning and exploring their environment, and trouble regulating their feelings, said Alicia Lieberman, Ph.D., last month at the Association of Health Care Journalists meeting in San Francisco. Lieberman directs the Child Trauma Research Project at the University of California at San Francisco (UCSF) General Hospital and is a professor of medical psychology at UCSF.

Traumatized infants can also experience emotional distress, immature and regressive behaviors, physical complaints, and loss of certain skills especially language, said Lieberman.

Signs of distress can be seen in babies as young as four months, said Lieberman. They appear sad, withdrawn, afraid, disorganized, and cry easily, said Lieberman.

Posttraumatic stress disorder can be seen in infants aged 2 and older, particularly in extreme cases of trauma, said child psychiatrist Charles Zeanah, M.D., in an interview with Psychiatric News. He is a professor of psychiatry and pediatrics and director of child and adolescent psychiatry at Tulane University Health Sciences Center in New Orleans.

Zeanah and Michael Scheeringa, M.D., developed the PTSD Semi-Structured Interview and Observational Record for Infants and Young Children.

Young children may re-experience symptoms of the trauma through rigid, repetitive play, for example, and have increased fears and aggression in addition to PTSD symptoms similar to those seen in adults, according to Zeanah.

“The infant who is exposed to domestic violence may have trouble with attachment because it affects the quality of the primary caregiver relationship. The child may realize that the mother is in trouble and, as a result, may also feel endangered. The infant may also sense that its mother is more preoccupied and less available than before and feel neglected,” said Zeanah.

Lieberman said the caregivers may have been traumatized also, but they experienced the trauma differently from the child. “Psychotherapy should include both the child and the parent so they understand each other’s experiences and concerns, and so the parents don’t retraumatize the child,” said Lieberman.

Some of the techniques Lieberman uses in child-parent psychotherapy are play therapy, narrative therapy, modeling protective behaviors, and interpretation of events to link the past with the present.

Information about Zero to Three is posted on the Web at www.zerotothree.org, and information about the Interdisciplinary Council of Developmental and Learning Disorders (ICDL) is posted at www.icdl.com. ▪