Recently a parent came into the pharmacy, asking about the mental health of her daughter, who was 18 months old, stating she was worried about the state of her baby’s mental health. She had heard a report on the radio about the state of mental health in children and wondered if she could be doing more, as a parent, to help.
If I am completely honest, I wasn’t entirely sure what to say. I don’t exactly see myself as extensively knowledgeable in the area of infant mental health. Is it the place of pharmacist to be giving advice on children’s mental health?
Perhaps not, but surely a basic understanding of the concept would help. It struck me that this person had come into the pharmacy and asked a question to which not only did I not have an answer, I wasn’t entirely sure to whom would be the most appropriate referral.
Ultimately, I was able to put her in touch with her local health visitor who was more than happy to help. In this case provision of information was lacking, and although eventually assisted by another healthcare worker, surely not good enough. This suggested that perhaps infant mental health was something worth looking into. I have since then spent some time looking into recent trends in the analysis of children’s mental health and have tried to detail within this article some of the salient points required to have a basic understanding of infant mental health and the current thinking within the healthcare professions in Northern Ireland.
Mental health is one aspect of a persons wellbeing that has been heavily targeted in the media, with significant funding directed towards public health promotion of mental wellbeing. It is well known that depression and other mental health issues are a real cause of concern in the adult population, with one in five adults in Northern Ireland showing signs of a mental illness. The impact of this is possibly most easily quantified by looking at the statistics surrounding work attendance.
Almost 50% of long-term absences from work in the UK are due to a mental health issue, which impacts drastically on work and finances, being able to achieve personal goals, and with the maintenance of stable healthy relationships . The UK Faculty of Public Health estimates the cost of mental illness for Northern Ireland at approximately £3 billion annually . Moving into the adolescent population it is also known that teenage boys and girls are also at an increased risk of developing some form of mental health illness, in the coming years or later in life. Thinking younger again, do we know about the mental health status of children? From as young as 0-3 years old?
Initially a community pharmacy may seem as an odd place for a parent to seek advice about infant mental health, but when you think about it. Where else do parents go?
GP’s and health visitors are a prime source of information and are most often able to provide information on such topics. However, with community pharmacy positioned as such a convenient point of contact for parents and guardians, surely as part of a pharmacists health promotion responsibilities, it is important that pharmacists are aware of the current health promotion strategies such as infant mental health, so that we can continue to provide the highest standard of care as part of the wider health and social care team.
So what has been learned about infant mental health?
The Public Health Agency has outlined the need to consider infant mental health, as a growing body of evidence from the clinical and social science fields show that the areas of the brain that control social and emotional development are most active during the first three months of a child’s life, particularly so in the very first months of life. Behaviour can be altered later in life; however, it becomes significantly more difficult to do so as a child moves out of the 0-3 years age bracket. The quality of relationships between a child and their primary caregiver, for example parent or guardian, is central to the process of nurturing a child’s social and emotional health during their early years. These relationships are an important aspect in providing a child with the necessary skills to be able to form and maintain healthy relationships later in life.
There are three main aspects which currently form the foundation for discussion around infant mental health. These include:
Attachment – describes the bond between an infant and their primary guardian. A strong attachment can be developed by responsive and positive behaviours from the parent or guardian. Mirrored behaviours, physical contact and proximity are examples of positive behaviours. A child with strong attachments can have the social and emotional confidence to build relationships and explore the world around them [3,4].
Self-regulation – denotes an infant’s ability to regulate their own internal emotional states, having the ability to sooth themselves rather than relying on parental input. This in time forms the building blocks of healthy external relationships [4,5].
Building resilience – refers to an infant’s ability to bounce-back from difficult or traumatic experiences, and have the ability to learn from these experiences. Developing resilience within the first three years of life is important in being able to deal with difficulties later in life [4,6].
It has been widely stated that healthy attachment develops between 0 and 3 years This is when brain development of the infant is in its optimal phase and when healthy social and emotional development begins. Key factors such as breastfeeding, skin to skin contact, mirroring behaviours, responsive parenting, and stimulating a play environment can contribute in a positive manner to the overall health and development of the child.
It has become clear that relationship building with the guardian or parent from birth has a significant impact on the ability of the child to navigate relationships later in life. Understandably the vast majority of parents and guardians aim to ensure good mental health development and play a critical role in preventing poor developmental outcomes. This is the aim of many parents and guardians across the country. In many cases the development of attachment, self-regulation and building resilience happens without much thought, however it can be helpful for parents and guardians to think specifically about their actions and the impact such actions will have on their baby’s development from birth.
As a parent it can be difficult to recognise the signs and symptoms of issues arising from poor infant mental health, this is in part due to the vast range of symptoms that can develop. It has been suggested that problems can manifest in a number of ways:
- Issues with feeding
- Poor sleep
- Developmental delay
- Regression in emotional development
- Insecure attachment behaviours (of which there are many types; for example, anxious-avoidant attachment, where a child will avoid or ignore their primary caregiver, showing little emotion when that person departs or returns).
With children older than 3 years, these signs can present in many ways, for example, as aggressive or attention seeking behaviour.
It is worth noting that this area of study within health and social care is extremely complex, and generalisations should be avoided. As a pharmacist, it is important to be aware of many aspects of health and wellbeing, not just the medicines. In practice it can be easy to focus solely on medications and the treatments available, blaming interactions or side effects as the cause of patient behaviour – often medication can be a starting point in narrowing the search for the causative issue, however the impact of healthy relationships between infants and caregivers cannot be overestimated.
Currently infant mental health services are in place across Northern Ireland and the UK. These services were set-up to try and promote the prevention and early intervention of infant and early childhood mental health conditions by reducing risk and supporting the parent/guardian/child relationship. These services aim to optimise the social, emotional, and cognitive development of infants and toddlers with their primary caregiver by connecting people with resources, providing supportive counselling, and if necessary crisis intervention .
Public health promotion and an awareness of current health and social care thinking is important within community pharmacy, so that the people accessing information from their pharmacy team can feel confident and well supported. As pharmacists, a focus on medicines and a holistic awareness of the patient including infants from 0-3 years, it is paramount that accurate and appropriate advice can be presented.
Pharmacists should feel confident in their abilities to answer questions regarding topics such as infant mental health, because although less frequently asked these issues are of concern to a large proportion of society. Community pharmacy continues to be an ideal place for the dissemination of information to patients, and a place where patients can be signposted to accessing the health and social care services most appropriate to them.
- Action Mental Health Website. Accessed 8th April 2016. Available at: http://www.amh.org.uk/about/.
- UK Faculty of Public Health – The Cost of poor mental health website. Accessed 8th April 2016. Available at: http://www.fph.org.uk/the_cost_of_poor_mental_health.
- Barlow, J. & Svanberg, P.O. (2009) Keeping the baby in mind. Infant Mental Health in Practice. London: Routledge.
- Public Health Agency –Supporting the best start in life, Infant mental health framework. Accessed 8th April 2016. Available at: http://www.publichealth.hscni.net/sites/default/files/IMH%20Framework%20consultation%20document_0.pdf
- Schore A.N. (2004) Affect regulation and the origin of the self: The neurobiology of emotional development. Hillsdale NJ: Lawrence Erlbaum Associates.
- Newman, T. With Yates, T. & Masten, A. (2004) What works in building resilience? Barnardo’s, Barkingside
- Child and Adolescent Mental Health Services website. Accessed 8th April 2016. Available at: http://www.younghealthymindsni.co.uk/infants/