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chapter 3 early years, children and young people:mental health

Introduction

In Scotland at any one time about 10% of children and adolescents will have a mental health problem of sufficient severity to affect them on a daily basis - the rate rises with age ¹⁹.

Influences in very early life for future mental health

Babies are born helpless. Their overriding biological drive, however, is to establish and adapt to the relationship with their parents. That early parent-infant relationship (or good infant mental health) is critical to child development both within the family and in society. Increasing evidence highlights the importance of antenatal maternal health and wellbeing to the later social, emotional and cognitive development of the child ²⁰.

The structure of the human brain is highly malleable at birth. Development in key areas of the brain continues from early in the womb until adolescence, but the antenatal period and first years of life mark the period of most rapid change ²¹. Infant brains develop most rapidly in the first year of life, but development is selective and purposeful. The infant's instinct is to seek out relationships and the parent's role is in responding and enhancing the relationship. "The instruction to attend to the primary caregiver is genetic, the outcome depends on what happens." ²² The process is often referred to as "attachment". The infant has no choice in the attachment relationship formed. He or she must adapt best to what is (or is not) provided by the parent. Good attachment helps the infant to develop the capacity to balance and control feelings, deal with stress, be adaptable and to form future relationships.

Infants who develop a secure attachment can be distinguished from others at 1 year by their ability to show greater positive interactions during play ²³. Insecurely attached infants are at greater risk of problems in emotional development, and children with very poor attachment experiences are at greatest risk of failure to thrive in early years and behaviour problems, lowered self-esteem and schooling difficulties in childhood and adolescence. Children who have had poor attachment experiences are overrepresented in social services referrals and youth justice systems. They are also more likely to suffer anxiety and depression in adult life. In one long-term follow-up of children suffering abuse in the first years of life, 90% had at least one psychiatric diagnosis by age 17 ²⁴.

Factors influencing attachment include features in the parent, infant and the environment. Poverty is the most important broad risk factor predicting later life maladjustment. For the parent, her ability to provide secure attachment is influenced by her own experiences of being parented, mental health or addiction problems, and domestic violence. Infant factors include prematurity, disability and illness.

Biological mechanisms linking early life to future adult mental health problems

In the past few years, attempts have been made to explain the biological links between adverse and chaotic early life and subsequent high risk of poor physical and mental health. A number of scientists have pointed out the strong relationship between deprivation, the body's hormonal response to stress and subsequent risk of ill health. An intriguing hypothesis has emerged which owes much to the work of individuals such as Sir Michael Marmot in London, Professor Bruce McEwen in New York and several other groups around the world whose studies have produced supporting evidence for a biological link.

As a baby develops in its mother's uterus, its development is influenced by the biochemical signals it receives from its mother's blood. The suggestion is that an expectant mother living in adverse circumstances will produce high levels of stress hormones which will influence the baby in a number of ways. McEwen has carried out a number of complex and elegant studies ²⁵ which show that exposure to high levels of mother's stress hormones antenatally, together with over production of its own stress hormones after birth, can influence a baby's brain development in ways which predispose the infant to increased risk of physical and psychological illness.

The centres of the brain which are most closely involved in our daily task of responding to the challenges of life may be influenced by those early experiences in ways which result in over activity of stress response. This over activity influences systems in the body involved in physiological and behavioural coping mechanisms. These abnormal functions can lead to a chronic elevation of stress hormones and an inability for the child and young adult to discriminate between situations that are fear producing and those that are not. The end result for an adult who has lived with an over responsive physiology may be an increased propensity to develop heart disease, stroke and a variety of other common illnesses. The young adult who has not learned appropriate psychological responses to stress may have had schooling disrupted and be more likely to have acquired criminal convictions.

This hypothesis is complex and must be viewed as a work in progress. The available evidence, however, does highlight the importance of early development to adult health and it reinforces the need to support parents and children in difficulty.

Development of disordered mental health

When a child exhibits a mental health disorder, abnormalities in areas of behaviour, development, relationships and emotions may be communicated in subtle ways. Assessment needs to ascertain the impact of these factors on the child and family's well-being, any risk to the child or others, the strengths that the child and family have to deal with the difficulties and the explanatory model that the family uses to understand the difficulties. The presence of predisposing, precipitating and perpetuating factors are important in assessing why there is a disorder presenting in any child at a particular time. Also of great importance is the presence or absence of any protective factors that may reduce the likelihood of a disorder developing or improve outcomes for the child. For example, a young person with a genetic predisposition towards psychotic illness may have an adolescent first episode precipitated by stressful life events ²⁶ and substance misuse. High expressed emotion within the family may perpetuate the symptoms while high verbal IQ and hence good insight ²⁷ may be a protective factor.

A traumatic event ( e.g. abuse experiences) can influence the developing brain and damage the developing pathways in such areas as emotion and memory so that memories become intrusive and disturbing and cause severe emotional reactions ²⁸. Physical and mental health disorders in parents can cause disruption in child development mediated through the development of insecure attachments ²⁹. The lifelong ability to relate properly to others can then be impaired and this will disrupt the later ability to form relationships, to work, deal with adversity and also predisposes to mental disorders ³⁰. An insecurely attached child is more vulnerable than others to be the victim of traumatic experiences ²⁸. The development of disorders such as depression and psychosis can be associated with earlier trauma ³¹.

Children who require to be looked after and accommodated are among the most developmentally vulnerable and have a very high rate of mental health disorders ³². These children are less likely to develop protective factors such as good peer relationships because they may have particular difficulty forming new attachments ³³, attachment figures may be unavailable, particularly in residential care, placements are often changing and there can be repeated rehabilitations into chaotic homes with variable competencies in parental care. Disruption in attachment relationships can result in poor regulation of emotions in later life ³⁴. Young people who have problems with regulation of their emotions may turn to drugs and alcohol to provide the soothing that has not been available through attachment relationships.

Meeting the mental health care needs of infants, children and young people

There is a continuum from mental health to mental ill health in childhood and adolescence and there is a complex interaction between a child (temperament, nature, genetics, intelligence, experience, etc.) and his or her circumstances. Finding out why a child or adolescent is suffering from mental health difficulties and influencing change is an important role of Child and Adolescent Mental Health services ( CAMHS). Promoting good maternal mental health and early parent-infant attachment, to ensure optimal early infant development, is an important role of Perinatal Mental Health Services ( PMHS).

The work of perinatal mental health teams

The Mental Health (Care & Treatment) Act, Scotland (2003) recommended the establishment of suitable facilities to admit mentally ill mothers with babies, and the development of linked specialist community and maternity liaison services. In Scotland, tiered services now exist in a number of health board areas. They assess and treat women with, or at high risk of developing, significant mental illness in pregnancy or the postnatal period, to facilitate and enhance mother-infant relationships where the mother suffers from mental illness, and to support partners and other family members. Postnatal depression and puerperal psychosis are thought of as typical, but women may suffer any form of mental disorder during pregnancy or postnatally, and increasing numbers of women with severe enduring mental illness are now becoming parents. Early effective treatment of the mother is essential to improve child development, but evidence suggests that there is a need to specifically address the parent-child relationship, in addition to treating the mother, to maximise child outcomes and good infant mental health. Disciplines in perinatal mental health teams include:

• psychiatrists
• mental health nurses
• clinical psychologists
• social workers
• nursery nurses
• health visitors and
• occupational therapists

There are close links to primary care and maternity services. Interventions for the mother are biopsychosocial in approach, and a range of techniques, including infant massage, video interaction feedback, play therapy and education on child development are used to enhance parent-child attachment. Regional specialist inpatient mother and baby mental health units bring these interventions together for the most severely ill women, allowing them to continue to interact with their babies while recovering from illness.

The work of child and adolescent mental health teams

Many children who attend a child and adolescent mental health team will have more than one area of difficulty. Mental health problems and other developmental problems such as speech and language or motor difficulties are often inextricably linked ^35,36. Understanding child or adolescent disorder requires a comprehensive consideration of all contexts. Children with complex developmental problems, such as Autistic Spectrum Disorders, Attention and Hyperkinetic Disorders and Tic Disorders are also more at risk of developing problems recognised in adolescence such as Eating Disorders ³⁷. For example, eating disorders can be formulated in social and developmental terms but they have a very high medical morbidity and huge impact on body development, linear growth, bone density and secondary sexual characteristics. These children also have an increased risk of other psychiatric disorders such as depression, obsessive compulsive disorder with subsequent impact on social, emotional and academic development and achievement.

"Children who require to be looked after and accommodated are among the most developmentally vulnerable and have a very high rate of mental health disorders."

What constitutes a child and adolescent mental health team?

CAMHS services take account of the developmental stage of the child. Professionals often develop expertise in working with a particular age group with particular developmental needs. Examples include infant mental health clinics focusing on parent-infant interaction, and adolescent psychiatry that takes a particular account of the maturational tasks of adolescence such as development of independence and establishment of gender role. CAMHS services aim to assess, treat and prevent disorder. An integrated approach to services from Health, Social Work and Education is essential to meet the child's needs.

The disciplines required within CAMHS teams include:

• Psychiatry medical staff
• Mental Health Nursing
• Clinical Psychology
• Psychotherapy
• Occupational Therapy
• Dietetics
• Speech and Language therapy
• Family Therapy
• Other health staff such as Paediatric Neurology, Physiotherapy and Creative Therapies
• Social Work
• Teachers
• Other Non-health Staff

Highly specialised services

These provide services for children and young people with a greatly increased vulnerability for mental health disorders. These may include:

• Learning Disability CAMHS
• Forensic CAMHS
• Looked after and accommodated Services
• Inpatient Units
• Academic CAMHS

What interventions work to improve child and family outcomes?

Interventions aimed at promoting good parent-infant relationships may be universal (population-based) or targeted at high risk families and can be home or centre-based. Child-focused, goal-directed, well-structured interventions have the best outcomes. Such interventions are cost-effective ³⁸. However, no one approach suits all infants or families and several interventions targeted at high risk families are often necessary.

Measures that improve preparation for parenthood:

These include parenthood programmes in schools and using computerised dolls. For new parents, the Solihull Approach trains health visitors to detect and improve parent-infant relationship difficulties, and improves health visitor confidence in resolving behavioural problems. The Positive Parenting Programme ("Triple P") is a further evidence-based intervention that enhances parents confidence and skills in managing child behaviour.

Examples of successful intensive interventions with high-risk families:

• Abcderian Project ( USA): high-risk families were offered intensive support in the first 5 years. At age 3 the intervention group had average IQ, outstripping the non-intervention group. They had significantly greater eucational achievement at age 12 and their use of special educational services was halved.
• Sunderland Infant Project ( UK): health visitors used video feedback to help improve parents' sensitivity in parent-infant interactions, with different levels of intervention dependent on need. There was a reduction in insecure attachment.
• Nurse Home Visiting Programme ( USA): a series of studies using nurse home visiting in pregnancy and early years with vulnerable young mothers resulted in greater stability for the mother and less antisocial behaviour in offspring.

Progress in Scotland

Over the last four years, child and adolescent mental health services have developed in the context of the Needs Assessment Report on Child and Adolescent Mental Health ³⁹. This major needs assessment used data from all frontline services in contact with children and adolescents including CAMHS, police, social work, education and primary care. Innovations in practice, such as the "New to CAMHS" training programme run by National Health Service Education for Scotland, and the development of Community Health and Social Care Partnerships aim to bring key agencies together to benefit children and their families. Other new developments include the building of a new 24-bed adolescent unit in the West of Scotland due to open in Autumn 2008, and planning of the expansion of inpatient services nationally from 44 to 56 inpatient beds by 2010 ⁴⁰ (Child Health Support Group Inpatient Working Group 2004).

Over the last three years, specialist perinatal mental health services have been developed in the west, east and north of Scotland. Dedicated inpatient mother and baby mental health units, in Greater Glasgow & Clyde (opened in 2004) and Lothian (opened in 2007), provide regional services to almost all of Scotland. Primary care and the voluntary sector have also been active in recognising and providing for the particular needs of this group.

Further examples of Scottish programmes

• Mellow Parenting and Mellow Babies: group approaches for vulnerable families where parent-infant interaction problems have been identified. Behavioural interventions and video feedback are used. Early results suggest improved mother-infant relationship and improved maternal depression in the Mellow Babies intervention.
• Infant Mental Health Short Life Working Group (HeadsUp Scotland, 1996): summarised existing evidence for improving infant mental health at population level and for high-risk families and made recommendations for the Scottish context.
• Sure Start Scotland: promotes a range of local interventions across Scotland.
• LAAC training: Basic mental health training for those working with looked after and accommodated children.

What further research is needed?

• Exploration of biological mechanisms that link early life adversity to adult disease.
• Assessing the impact of maternal mental disorder and treatment on the developing fetus.
• Good psychopharmacological research is vital.
• Sound epidemiological research to understand the interplay between mental health disorders and their genetic and environmental aetiologies.
• A model of evaluation of complex intervention in CAMHS from qualitative investigations to randomised controlled trials to ensure that new innovations for children and their families are useful and cost-effectiveness in a Scottish setting.

Summary

Pregnancy and the first years of life have a huge influence on the future mental health of the child and future adult. Adverse events during this time can lead to irreversible problems for future ability to cope with everyday life and increase the probability of future poor mental and physical health. Such problems can then run on across generations. It is essential that we recognise the need to invest in the health of infants, young people and children as action by effective Child and Mental Health Services and other agencies can reap substantial long-term rewards for our future child and adult populations.

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