Transcript for
What is infant and child mental health?

Narrator [00:00:02] Welcome to the Emerging Minds podcast.

Sophie Guy [00:00:08] You’re with Sophie Guy and today, we’re joined by Nick Kowalenko, a child and adolescent psychiatrist based in Sydney. Nick has been practicing as a psychiatrist for more than 25 years and is president of the Trillian Family Care Services Council, as well as deputy chair of Emerging Minds. Today, we are going to discuss infant and child mental health, what it is, and how we can best support it.

Sophie Guy [00:00:31] Nick, welcome and thank you very much for joining me for a podcast episode.

Nick Kowalenko [00:00:36] Thanks, Sophie. It’s good to be here.

Sophie Guy [00:00:37] Could you start by telling us a little bit about your background and how you came to work in infant and child mental health?

Nick Kowalenko [00:00:43] Ah, yes. Look, I started training in medicine many years ago and really wanted to be a general practitioner. So then trained to general practice, family medicine it was called the time. And I guess there are a few key experiences that I had there that made me at least think about mental health issues. One was that I was working in a fairly innovative setting where there was a significant amount of videotaping of doctor-patient interactions, and I could see that I was sort of scouting around emotional issues of some of the patients I was seeing without really knowing how to address them in a straightforward manner or let alone what to do with them.

Nick Kowalenko [00:01:24] So that got me more interested in looking at interactions and how you interact with people to encourage and sustain the kind of concerns they might have in their own lives. And I guess one of the very young children who I saw at that time, about a 6 year old girl, was brought in by her dad with abdominal pain, a very common presentation at general practice. And she sort of got sat up on the chair there and looked at me and I could see her big, full eyes sort of brimming with tears. And they were the tears not of pain or discomfort, but she looked genuinely, deeply, deeply sad. So I kind of felt myself hold my breath, not quite know what to say, because I guess the response is, we don’t need to say anything, should hold the girl or something, you know, it’s like Dad, hold her. And she began then to sort of say that her grandmother had died. And so that was kind of a almost a very direct expression and made me start thinking about psychosomatic medicine and the body and how it contained emotional distress and was a bit of an interest really from then on about how that occurred. So that made me think I should in part of my family medicine training, do some training in psychiatry, which I then did so that I’d know what to do really in general practice. But once I got into psychiatry, I got much more interested and again, had some experiences with families.

Sophie Guy [00:02:50] And if I could ask you, I understand you’ve worked for a long time at a parenting centre. Could you talk about this experience and what you’ve learnt about infant mental health from your work in this space?

Nick Kowalenko [00:03:00] So working in a parenting centre, we also worked in partnership to develop home visiting programs for mothers that had suffered distress and depression. And that gave us a really excellent opportunity to look at what happened to mums when they went home. Once they sort of scored up on standardized measures for depressive symptoms and they’d been interviewed and they did have depression, and examined much more closely their relationships with their infants and their partners to some extent. So we’re able to concentrate on a couple of aspects with a home visiting program. One was to foster normal development and encourage parents in celebrating the developmental milestones of their infants, and teach them a bit about that and what to notice, what to look for, as a kind of foundation for that program. But also we tended to do brief video snippets of parent-child interaction and then use them to replay to parents because, you know, everyone’s got their screen and they can do a hand-held, and nurses will often do a hand-held video snippet, and then plug it in the big screen and have a look and then ask parents what they notice, what they saw, what they witnessed, and use that as a springboard to look at what they might identify as their strengths in their interactions with their infants, what they might notice, how their infants’ responded, and what they might want to do differently in how they could either foster responsiveness from their infants or look at other aspects of how much their infants tended to enjoy them.

Nick Kowalenko [00:04:28] And I think that was the the key feature was that people were often depressed, lose that sense of enjoyment in things that normally cheer them up. And one of those things, I think that affects parents most, and that they notice most strongly is when they’ve lost the sense of enjoyment of their kids. People are utterly aware how intense it is to look after infants and are swept up often in the sort of minute by minute intensity. Sometimes distress, sometimes contentment of it all, but to sit back and look at it, people don’t often immediately recognise the bids that infants make to interact, the bids that infants make to imitate what their parents do in terms of facial movements or language or noise or tunes. And so that became of an interest again with a number of others who we’d managed to work with over the years in psychology and developmental psychology and nursing, and of course, psychiatry and mental health, to tease out some of those aspects and look more formally at the impact on infants of parents with post-natal depression, particularly. One of the things we looked at, with one of my partners in psychology, was the quality of relationships and how they developed over time. And my psychology colleagues were able to demonstrate that resilience was maximised really in those infants where mums had shorter duration of depression, less severity of depression, but also where they had a kind of style of relating to their infants that was more adaptable, more flexible. And so that we’re able to do a little bit of work that informs some of the issues that now relate to the development of resilience in infants.

Sophie Guy [00:06:10] Could I ask you then and I would like to focus a little bit on infant mental health and we’ll probably get to child mental health later. But we don’t talk about children that perhaps we don’t focus on them to the same degree in mental health and we certainly don’t focus on infants that much in the conversation about mental health. And first of all I’ll just ask you, how would you describe infant mental health? What is infant mental health?

Nick Kowalenko [00:06:38] Infant mental health is really all about the infant’s capacity or the developing the capacity of the infant to form close, close relationships and maintain them, and manage and express their emotions, to be comfortable about exploring the environment and communicate directly, really in the context of their family, their community, their culture, and the spiritual beliefs of their culture. So it’s a pretty broad kind of picture. But the essence of it really is also one of the more important features is that the close relationships that are sustained and reliable are foundational for brain development.

Sophie Guy [00:07:20] What does a secure, trusting relationship look like from the point of view of an infant?

Nick Kowalenko [00:07:25] Infants, in fact, are inside the psychological and the mental space of their mother for the first, you know, several weeks of their life. They are in no way individuals. And yet they have some individual characteristics. They have some individual intentions. They can do some things, but psychologically, they’re not separate. So then there’s this the rest of life, which is how do you become more separate and become an individual? And in a sense, you know, we’re all familiar with that for adolescents. But a lot of that, of course, in fact, it’s even going a lot faster between those early weeks of life and up to the time a kids three. So probably what’s critical about your question, what’s it look like for an infant, is some continuity of care, particularly after the first few months of life. Up until that age of three. And children experience a sense of felt security, you know, by some routine, some regularity, by being safe, by being held not just physically and safely and protected adequately, but also kind of held psychologically. So they’re as safe as they can be in terms of the circumstances that they face. You know, we’re all familiar how kids have to manage their fears of, you know, when they’re exploring the world, there’s lots of things that they’re driven to explore, but they’re also, you know, often very cautious about how they explore. Although many kids aren’t very cautious as well. So it’s kind of about the right balance between seeking security and comfort with the need and the desire and the learning that comes from exploration, discovery, heading out on your own. That’s the other aspect, I guess, of your notion of what’s the infant exprience. The infant experiences a lot of parental delight. So the other thing that really encourages this notion of infant mental health or infant well-being is an infant who knows their parents, or someone who loves them doesn’t have to be their parents, absolutely delights in them.

Nick Kowalenko [00:09:22] And that kind of core task, I think, for parents about being secure figure for their infants in a sense that parents have to only do four things. They have to be stronger, bigger, kinder and wiser and stay in that position in terms of what they, you know, how they think about. And keep in mind their infants and their infant’s development. Strong, caring, and loving relationships can shield children, or at least partially shield children from the impact of negative experiences and can be mutually healing.

Sophie Guy [00:09:54] And how does this context of the infant and their early relationships with caregivers fit into the bigger picture of child development?

Nick Kowalenko [00:10:01] So there are two main planks and they are really for psychological development and for neurological development. And they really concentrate on those aspects about social-emotional competence, but also the same neurologically and for language and speech. And to that extent, social emotional development also depends on a normal physical development as a kind of bedrock for normal social and emotional development. So they’re the key things that we see in infant mental health and usually we talk about it covering those ages from zero to three years. So up to just before the fourth birthday, sometimes it’s talked about as being zero to five years. Zero to nearly four years is an enormous span, in terms of development. And infants are very different at a month old to, you know, three, three and a half years old. So there’s amazingly wide variation in what is normal, particularly in the first year, but then infants patterns of development get a little bit more set. And I think your question about why is it we perhaps don’t consider infant mental health much is probably a key one. And I think sometimes the argument can be summarized like this. One kind of perspective is, why call a puppy a sick puppy, which is I think the notion of mental health is too much of a burden, too much stigma is associated with the notion of mental illness. And even when we talk about mental health, many of us hear mental illness. And I think particularly if you’re talking in the context of psychiatry, people are immediately concerned that’s really a discussion about mental illness and how can an infant have a mental illness? And I guess the corollary argument is, well, you’d never want to miss a sick puppy if one was sick and actually could be improved or better made healthy again with your help. So I guess that’s the angle that those of us who are interested in mental health problems come from.

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Narrator [00:11:52] You’re listening to an Emerging Minds podcast.

Sophie Guy [00:11:58] And how do you recognise infants whose mental health may be at risk? Are some infants more at risk than others? Could you talk a bit about this?

Nick Kowalenko [00:12:08] Risk factors cover a pretty broad set of domains. And of course, there are other risk factors, cultural risk factors, et cetera, in terms of migration and things like that. Many of those risk factors increase the experience of stress on families and on infants. And sometimes that stress, especially if there’s several of those risk factors, or adverse childhood experiences including abuse,and there’s a number of those risk factors they sometimes overwhelm infants’ capacity to cope. And we call that context, kind of, toxic stress. And what happens in context stress, if it’s persistent, is that the kind of thermostat for stress responses get set too high and kids are often on, infants are, often on sort of high alert and they’re kind of almost hypervigilant and too ready to respond to things. And they are often the ones that in infancy sometimes have quite severe sleep problems or settling problems or feeding problems. And if they’re more three and four year olds, sometimes you do see hypervigilance and you see them having recurrent bad nightmares, those sorts of things. And the issue with that is that it disrupts or changes those foundations to psychology and neurology in the developing brain.

Nick Kowalenko [00:13:21] So they’ve come to be understood, I think, to be much more serious consequences of toxic stress because of the impact really on brain development and adverse childhood experiences increase the risk, not only in childhood, but also in adulthood for all sorts of adverse outcomes that include physical outcomes like coronary heart disease and diabetes, but also a wide range of adverse mental health outcomes like suicide risk, experience of mental illness, et cetera. So some of this though can be ameliorated and some of this can be ameliorated by the protective factors that kids may have. And that always the context to stress as the stress happens in contexts where there’s both stressful experiences, but also positive experiences. And it’s the balance between them. So we don’t really see toxic stress usually unless there’s several stressors occurring at the same time. So I guess that’s the other reason why people have become much more interested in the early years, and particularly infant mental health, because of the importance and the potential really, of early intervention, being effective early in life. So that’s probably the other reason why there’s an increased focus on infant mental health, Often referred to as child social, social and emotional well-being.

Sophie Guy [00:14:39] So we’ve mentioned that infant and child mental health is not widely understood and recognized, and that perhaps it’s left out of the conversation about how do we address rising rates of mental illness. Do you think this is changing at all?

Nick Kowalenko [00:14:54] Probably in the last few years, like it’s more like the last three, four or five, there is a much better understanding potentially and refining of the kind of diagnostic pictures of kids in the early years of life. And so there is potential for a bit more finer detailing of the difficulties that kids face. Probably that’s happened most in the area related to family violence, and preschoolers’ and infants’ experience of post-traumatic symptoms and post-traumatic phenomena, which I think is probably becoming increasingly and more clearly understood over the last many years. Probably a good example, too, of how important social and cultural factors are in diminishing risks for infants exposed to family violence and then where the interplay kicks in about therapeutic interventions, psychosocial support, and more intensive interventions. A sort of cascade of what’s an appropriate point to intervene, for what purpose, when. And just like often with mental illness, one of the big issues of family violence, of course, is its intergenerational component. So I guess that’s the other very serious hope of infant mental health, is whether it can be a wedge in the transmission of inter-generational issues, particularly intergenerational disadvantage and illness. And I think that’s what’s made part of our work quite interesting, and the work we do at Emerging Minds as well, in that we’ve been able to promote programs, for example, for parents with depression, where it’s always, I think, been understood that the children of parents with depression might have higher risks for developing mental health problems, particularly anxiety and depression. And was kind of always thought to be well that was predominately genetic and there might be some social factors that, or additional risk factors for that, but there hasn’t been much understanding about how to intervene effectively. And I think what’s been a real pleasure for us about working with Emerging Minds has been to develop and promote and dissem-, begin to disseminate some of those programs where relatively brief interventions, what I mean by that is two or three or sometimes up to six sessions, working with the parents who are suffering with depressive disorders can diminish the risk of their kids suffering with depression and anxiety by between 40 and 50 percent. Even though there’s a genetic influence, we can do an enormous amount in the environment to modify genetic expression or to modify the impact of genes and their expression, even in terms of their risk of causing illness and problems. So that’s very dramatic, at a public health level, at optimising opportunities for kids, is really a major impact because the problem with kids who suffer with anxiety and depression is they often don’t go to school for a while. It affects education opportunities, affects their social opportunities. So they’re kind of dents in their development you’d rather avoid if you can. And I think that’s the kind of work that we’re really pursuing within the field of Emerging Minds to make prevention present, you know, in the health, welfare, community, and social landscape.

Sophie Guy [00:18:08] So I’m now thinking about practitioners and practitioners listening to this and wondering how can they start to have a conversation with parents who may be struggling with adversities in their life and come to see them with an infant or toddler, how can they start conversations about infant and child social and emotional wellbeing in a way that’s still respectful of parents?

Nick Kowalenko [00:18:39] I think the first step is really to show some empathy for their circumstances. All parents are struggling to be the very best parents they can be for their children. But sometimes it’s good to say those kind of things because a lot of parents feel very poorly about their parenting or they feel unconfident. And often a good starting point is to ask them about what they’re doing well for their kids, what their strengths, and then sort of come back to what their concerns and worries are. And so that’s one way, I think, of encouraging people to speak. I mean, on the whole, parents are quite stoic, really, about their adverse experiences because they want to shield their kids often from them, and they want to shield themselves sometimes from knowing about how dire their consequences are. So I think the other part of that is that the practitioner kinds a has to stay within the window of tolerance about what the people they’re seeing can tolerate because you can’t admit everything up front. It always takes time. Trust has to be developed. Other things have to happen. And they have to get some evidence that you’re not going to cut them off or dismiss them and things like that. So that’s probably a way to open a conversation.

Nick Kowalenko [00:19:51] And I think by being curious you can then open up different elements about, you know, where they’re having difficulties, how they’re having difficulties, what the extent of those difficulties are. And then I think begin to ask them in the areas where they have strengths, can they use those strengths to drag them to the areas where they’re having problems? Or ask them about what are the realistic options, about how can they plan to start to address some of those difficulties? And again, I think we have some resources in Let’s talk with children, for example, that could help practitioners with, you know, some of those questions in a framework for asking about, asking parents about the developmental needs of their children at different ages. And parents are often very intuitively aware about, have they, how they have to adjust. you know, they often have that sense. They’re running a month or two behind their kids development before they’ve realized how much they’ve changed in some particular aspect.

Nick Kowalenko [00:20:43] And so they’re good points, I think, to also talk about. Development. What might come next? How do you consolidate that development? How do you keep it on track? What barriers could get in the way? So and they’re the kind of issues about if there are risks or difficulties that parents with experiences. you know, how might that, could that possibly get in the way of your kids’ development? Oh, what can we do about it? What do you think would work? So all those kind of, they’re all approaches to having a conversation to allow it to be collaborative. And then to work out together what might be a way to address it. And that might include support. That might include educational components, that might include referral to others who could help in particular ways.

Sophie Guy [00:21:25] And now I’m thinking about perhaps cases where, you know, we talked about adversity and some of the adversities are more obvious when there’s a lot of sort of entrenched economic disadvantage or domestic violence and things like that going on. But there’s also a lot of child emotional behavioural problems that emerge for families where these things aren’t so obvious. And I’m just wondering, you know, how can practitioners determine whether an infant or a child’s distress is normal or whether there’s indications that maybe there’s something more going on?

Nick Kowalenko [00:22:00] Yeah, I think that’s a really tough issue. So step one is kind of, take it seriously. [Right.] And then I think, you know, we are dealing with people that are really on a continuum from health and adjusting to changes and respond to them. And a response might be, oh, this is quite different. Oh, I’m not sure about this. I should check this out with a health practitioner. Through to, you know, what might be a concern that is overcome over time to what’s an actual problem and then kind of what’s a bit more serious about, you know, a disorder or something that needs more professional help. And it’s a tough continuum to know what the boundaries are between each of those. Time is, you know, quite critical because really looking at if there is an issue, we’re hoping it can be overcome sooner rather than later or quickly. If it’s not, then obviously the longer it drags on, the more concerned practitioners need to be about it. Then look at what other factors might be contributing to it. And I think the big issues there are, kind of, challenging behaviours and development.

Nick Kowalenko [00:23:00] And probably the part of development we haven’t talked a bit about is the notion of emotional regulation or emotional control, because obviously one of the big issues in the first three years of life is about mastering controlling emotions and mastering, so by affect we mean mood, by managing moods. And that’s obviously a very much a sort of emerging competence, you know, that is in one sense mastered pretty quickly from birth to, you know, first two or three years. But all that crying and difficulty in the first early months of life can be incredibly distressing for parents. And yet a lot of crying is quite common in infants. Parents often driven quite spare, in a sense, by what they can do to manage their kid’s crying and those sorts of issues. And there’s certainly, you know, some specific support, advice, and guidance about settling that can make a difference for that and it tends to be a phase. But it’s a normal phase that’s quite distressing. It’s a normal phase which assistance can sometimes help and it tends to improve quite dramatically, you know, after several months or in that first year. But there are always exceptions to that. So that’s kind of an important issue.

Nick Kowalenko [00:24:09] I think the thing for infants and parents in the early, early months is talking about how different infants can be in terms of their temperament, their kind of style of being. Some kids have a very difficult temperament. They’re a bit more active. They are more emotionally reactive. They’re more physically active and they don’t settle so easily. And that probably applies to about 15 percent of kids and there’s another 50 percent who are very easy, calm, you know, restful, get on easily, don’t react in big ways to small changes as opposed to more difficult kids. And 70 percent of kids who lie in between that.

Sophie Guy [00:24:49] For infants and children who are experiencing significant problems, what what is out there? What is on offer in terms of specialist mental health services?

Nick Kowalenko [00:24:59] Ah I think specialist mental health services are probably a bit limited. There is some emerging perinatal and infant mental health services, which I think realistically are pretty focussed on maternal mental illness, where those mums with significant mental health problems have infants. Then I think if we look more broadly in the specialist health sector and I’m kind of leaving out all the other welfare, psychosocial, NGO kind of functions. Well, I might talk about them a bit in a minute. If we look at the mental health services include primary mental health care services like access to psychologists and that kind of range of specialist infant mental health service delivery, the work that Leonie Segal and others have done really demonstrates that that is the age group getting least access to mental health services, even in primary care settings such as psychology services that you access through GP mental health care plans. And then if you’re looking at the younger age groups, much more service goes to youth. To some extent that is justified because they are the ones that have some more emerging mental health problems that are more apparent. But the discrepancy is really very massive. So if we look at mental health problems, both in terms of our national studies, it looks like certainly for the under twelves but even for the under sixes, around about at least one in ten kids have significant mental health problems, but probably more. And yet their access to specialist mental health services really diminishes, especially for those under five. And that’s a much bigger disproportion than you’d think. And then I think there are a lot of services that contribute to promoting stronger families and healthier families in the welfare sector, in non-government agencies. And some of them do carry some more specific services that foster mental health and foster mental health development in younger children. But they’re a bit harder to get a grip on, I think formally, compared to if we can look at the services that are available in the Medicare-funded systems and those that are a bit more regulated, at least at a national level. So that’s a discrepancy, that feeds into that underplayed in the community and in the professions, but in our funding bodies, and as I mentioned, our policy settings. Infant mental health, as such, is still very much underplayed and is an emerging field that really needs to emerge a lot further to have the impact that it can.

Sophie Guy [00:27:37] And are there particular resources or sources that come to mind for you that could be helpful for practitioners wanting to perhaps be able direct parents or learn a bit more about infant and child mental health?

Nick Kowalenko [00:27:53] Yes, look, there’s a good range of resources. Certainly I tend to go to zero to three to have a look at things for practitioners. Kids, and I guess more about infant mental health, Kids Matters has some good resources more around early childhood mental health from an Australian context. Our own Australian Association of Infant Mental Health has some nice resources available. I think Early Childhood Australia has some resource and Raising CNildren network, but that’s more for parents. And I’m sure you know, here in Emerging Minds we’re going to develop an ever increasing suite of resources to look at infants and children. Oh and some states have some resource, something like Queensland has a perinatal infant mental health educational framework and some web-based resources. So some of the states also have specific resources around infant mental health. So they are all, I think, useful to practitioners and having a look at that.

Sophie Guy [00:28:50] Well, I think we’ve really had quite a good wide ranging conversation about it. Thank you very much for your time, Nick, [that’s a real pleasure] I really appreciate it.

Narrator [00:29:02] Visit our website at www.emergingminds.com.au to access a range of resources to assist your practice. Brought to you by the National Workforce Centre for Child Mental Health, led by Emerging Minds. The National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program.