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In Canada and abroad, the prevention and perinatal intervention in early childhood have made significant headway in the last twenty years. Those advances have occurred in three main clinical fields: early childhood prevention, perinatal psychiatry and psychiatric intervention with children aged 0 to 5. This article is meant for colleagues, as an overview of these three clinical sectors; it will describe some networking and knowledge transfer initiatives organized by the different Canadian groups that work with early childhood.
It is well established that prevention efforts for the most common pathologies in child and adult psychiatry –including personality disorders – require an early screening and intervention for children from families that are most at risk of abuse and neglect. Developmental psychopathology, which will be a key conceptual aspect in the DSM-V, has shown the strong influence of early determinants on vulnerable children’s trajectories. Moreover, the most recent neurobiological data on brain development –including epigenetic factors – clearly demonstrate the importance of early intervention in children at risk (Cozolino, 2006).
This essential prevention work is mainly done by first-line professionals, Youth Centers and community organizations. Studies have shown that the trajectory of children at risk can be influenced by focused intervention programs, especially if they are intensive and multimodal (Olds, Sadler & Kitzman, 2007). Reducing symptoms of externalization in children has often been used as a benchmark for measuring the programs’ efficiency, but other “intermediate” variables, e.g. attachment, have also been used. Early intervention on the parent-child attachment bond can protect the children at risk, and help them better cope with adversity in life. In general, it can be said that though these intervention programs have not had the dramatic effect expected, they are an essential component of the identification effort and the longitudinal studies that society has to offer, in a clinical and ethical manner, to children who are most at risk of developing mental health problems (Petitclerc & Tremblay, 2009).
A significant challenge to our prevention efforts is that ‘early childhood’ is defined differently by policy makers, early educationists, early childhood mental health professionals, infant psychiatrists, neonatologists and developmental paediatricians. This often implies that the availability and duration of services tend to vary greatly, which places many preschoolers and kindergartners at risk. Even if they are inseparable, infant physical health and mental health are not always considered on the same footing. A vision shared by many Canadian clinicians is for every infant to have access to mental health services without barriers of regional politics, transportation and fragmented services. Our dream is to ensure high grade preventive intervention to infants and also to fetuses.
Two significant initiatives based in Ontario address separate aspects of preventive work with vulnerable populations. Both are based in empirical findings and are using careful evaluation to assess their impact. Supporting Security is a group intervention developed by the Infant Psychiatry Program at the Hospital for Sick Children in Toronto, for groups of mothers and/or fathers and young babies (Wittenberg, in press). It focuses on fostering more adaptive attachment relationships. It integrates multiple theoretical approaches to help parents recognize the significance of infant observation, the development of the infant’s mind and the influence of the parent’s state of mind and behaviours on the baby’s sense of security. At the present time it is being evaluated in five First Nation communities in northern Ontario where risks for attachment difficulties are seen as high.
The second initiative addresses the needs of one of our most vulnerable populations, infants and toddlers who come to the attention of the child protection system and the courts. These children may have particular challenges based on the potential for hereditary disorders, intrauterine experiences characterized by poor prenatal care and highly stressed mothers, and finally by adverse experiences and inadequate supports, abuse and neglect, after they are born. Infant Mental Health Promotion (IMP) at Sickkids in Toronto is developing plans to establish a specialty family court in the Peel Region near Toronto. This court will work by integrating the efforts of child protection and the legal system with infant mental health and social service systems. The goal is to improve support for infant mental health and development by using the power of the courts to make the more rapid and effective decisions based on what we know about developmental trajectories at this age.
The perinatal period is a developmental crisis and a very delicate transitional period during which the bases for parental functioning are established. A great number of clinical and epidemiological studies have stressed the high prevalence of psychiatric disorders during pregnancy and post-partum (Pearlstein, 2008). It is established that various parental psychopathologies very frequently appear or are exacerbated at that time, giving rise to significant morbidities in parents and harming the parent-child relationship in a sometimes significant manner. Moreover, some 15 studies have shown the correlation between maternal stress during pregnancy and the risk of perturbations in the child development, even if this link is not linear and if symptoms are present at a sub-clinical level (Talge et al., 2007). Hence infant psychiatrists need to be leaders in disseminating information regarding infant mental health to all perinatal clinicians.
A particular aspect of perinatal psychiatry regards the use of psychotropic drugs during pregnancy, which has significantly increased over the past years. We do have to treat mothers presenting mood and anxiety disorders but we have to be aware of the risk of overly focusing on medical modes of interventions at the expense of other types of treatments (St-André and Martin, in press). Moreover, we need to make sure that we encourage perinatal clinicians to include families and infants in treatment.
General practitioners, pediatricians and first-line professionals detect the classical child psychiatry disorders listed in the DSM-IV (anxieties, ADHD and externalization symptoms) very early on. Early childhood psychiatry is still developing thanks to the creation of various specialized clinics and the systematic use of early childhood diagnosis with the DC:0-3R classification, a classification that notably includes early parent-child relationship difficulties on axis 2 (DC: 0-3R, 2005). The clinical work is growing with the observation of the young child (Lebel, 2009), the developmental research on attachment (Zeanah, 2009) and the work on the comorbid neurosensory disorders commonly found in young children (Reebye and Stalker, 2008; St-André et al., 2009). In Quebec, the collaboration with youth protection teams (specialized in maltreatment or adoption) and the means these teams have currently at their disposal for detecting early trauma or attachment disorders facilitate more productive interfaces that respect every one’s mandate.
In their efforts to intervene with high-risk parents, particularly perinatally, the British Columbia group has been able to develop a parenting capacity tool that is applicable to mentally ill mothers and their infant, thus attempting to prevent developmental trajectories to pre-school aggression.
Moreover, psychopharmacology takes increasingly more space in the early childhood clinical practice, which opens new therapeutic ways but raises questions about the risk of overprescribing medication for young children (Tellier & Boivin, 2009; Gauthier, 2009).
In early childhood psychiatry, psychotherapeutic and systemic tools are diversified, but the resources available to first line professionals for applying these advanced methods often prove insufficient. Moreover, practices depend on the staff’s expertise and on where the care is provided: university hospital, general hospital, mother-child unit in a university hospital, psychiatric institute. Practice conditions and care philosophy tend to vary from one location to another; emphasis on individual, parent-child or systemic aspects of treatment also will tend to vary. As a result these factors can isolate various approaches and slow down the dissemination of knowledge in universities and continuous medical education programs.
Several other issues stand out with regard to training, such as finding enough child psychiatrists who are committed to specializing in work with infants and toddlers. Another issue has to do with creating integrated multidisciplinary teams that can provide comprehensive assessment and treatment. Finally, more needs to be done to develop trained researchers who work within the field.
In Quebec, the different players are currently making efforts to collaborate and coordinate the continuing education programs in perinatality and early childhood. This complex initiative involves the departments of the four universities, the university institutes, the professional organisms and field organizations that organize workshops, courses, educational programs and congresses on perinatality and early childhood. In November 2010, the Birthing the World Conference (www.birthingtheworld.com) proposes an interdisciplinary formula of unprecedented scope, bringing together various disciplines and organizations – public health, obstetrics, family practice, pediatrics, midwifery, nursing, infant mental health disciplines, community organizations –around a broad range of topics directly impacting perinatal and early childhood health.
The Infant Psychiatry Clinic at British Columbia’s children’s hospital is involved with training of infant mental health fellows on a regular basis for the past five years. In BC, we have emphasized the interdisciplinary aspect of infant mental health that is reflected in selection of our fellows that were chosen from varied disciplines of child psychiatry, infant development, anthropology and psychology/criminology. The training period is usually eighteen months and the candidate is expected to carry out clinical research of their interest. We have also trained many elective postgraduate trainees from overseas and nationally. These trainees typically spend a minimum of three months. In 2007, we developed a web based course and an experiential course designed for newly hired early mental health professionals in BC. This activity occurred in conjunction with the Ministry of Children and Families.
Training for infant mental health in Ontario, as in most other locales, occurs in an uncoordinated, organic fashion rooted in many different disciplines, sometimes occurring as a result of integrated efforts but often in more isolated ways. As interest and awareness have grown, some training has occurred within disciplines as disparate as early interventionists, social workers, psychologists, psychiatrists, child protection workers, etc. In some sites, disciplines are brought together to provide and to seek training (e.g. IMP, The Hospital for Sick Children, the Hincks-Dellcrest Institute). For example at the Hospital for Sick Children, monthly Infant Mental Health Rounds bring community agencies and the Hospital together to share knowledge about research and interventions. IMP has been a long term resource for a wide range of educational programs aimed primarily at front-line workers and has developed a program of study at York University. IMP also has a project underway to educate professionals who work in the areas of child protection and the courts. Work is being done to improve consultations specialists in infant mental health can provide to the courts (Wittenberg, in press). Strong efforts are being brought to developing educational access via the Internet and distance learning. Jean Wittenberg at the Hospital for Sick Children uses telepsychiatry to provide training for leaders of Supporting Security groups in remote aboriginal communities.
The research climate in Canada has evolved positively in many areas of Canada for studying infants. A description of specific projects would be beyond the scope of this article. The Center for Excellence of Early Childhood Development, which is based at the Université de Montréal, works in partnership with Canadian and international health organizations, education and social services, non-governmental organizations, and other research organizations. It publishes regular bulletins summarizing key Canadian and international research activities dealing with infants and their families, including research done in Quebec in developmental psychopathology and perinatal mental health.
In BC, research networking has expanded thanks to the physical proximity of the Child and Family Research Institute, the Women’s Research Institute and the Children’s Hospital. The past and current research activities of this clinic have included studies collaborating with reproductive psychiatry, genetics, and criminology. Our clinic studied self-regulation capacities of young children and Regulation disorder with Sensory Processing disorder. Currently we are studying the home visitation impact on externalizing disorders, a longitudinal project studying the socio-emotional development of young children, and infant massage as a valid treatment option for depressed mother-infant dyads.
In Ontario, a great deal of research is carried out on infant development and even into specific areas of developmental disorders, the most predominant being autism and fetal alcohol syndrome. Some intervention evaluation has been carried out (e.g. Cohen et al, 1999; Cummings and Wittenberg, 2008) Much more needs to be done on clinical interventions but this type of research is notoriously difficult to carry out.
Revived by the international congress of the World Association for Infant Mental Health in Montreal in 2000 under Dr. Yvon Gauthier’s presidency, l’Association québécoise pour la santé mentale des nourrissons (WAIMH-Quebec) has some 100 members and a circulation list of some 700 people and local organizations. It regroups health care staff, professionals and physicians involved with very young children; it is a forum that integrates the diverse clinical practices and circulates recent data on perinatal research. Thanks to the partnership it has established with Autonomie Jeunes Familles, the Association has an organizational basis that enables it to offer training program, scientific nights and annual days on topics as diverse as pregnancy, new parental practices, attachment, adoption, paternity or transcultural practices.
In Ontario, IMP, which grew out of a collaboration agreement between the Infant Psychiatry Program at the Hospital for Sick Children and many community agencies, has run workshops and conferences for many years. In collaboration with York University, IMP has run a university level program in infant mental health. It produces IMPrint, a quarterly bulletin for frontline infant mental health workers across disciplines. It has produced DVD’s addressing attachment and emotional regulation. It is engaged in cross-Canada collaborations for education and as mentioned above, in an initiative to support infants and toddlers at risk for abuse and neglect.
Infant programs in BC are affiliated with the World Association of Infant Mental Health (WAIMH), and represent the Western Canadian region. This division includes our infant mental health professional colleagues from Alberta and Saskatchewan. Whenever possible, we have tried to raise its profile by having conferences on an annual basis and an ongoing informal discussion group that meets every month.
Child psychiatrist and adult psychiatrists interested in this fascinating clinical field are invited to participate more actively in their provincial network activities. Those who wish to become members of the Western Canadian Association for Infant Mental Health can visit www.vcn.bc.ca/wcaimh or ac.cb.wc@eyberp. The address of the Infant Mental Health Promotion in Ontario is firstname.lastname@example.org. Colleagues who wish to become members of the Association québécoise pour la santé mentale des nourrissons or have their names on the free circulation list can go to www.aqsmn.org.