953717
APY
Australasian PsychiatryNewman AM
Australasian
Psychiatry
Editorial
Thinking about parents and infants – finding a home for perinatal and infant psychiatry Louise Newman AM
Australasian Psychiatry 2020, Vol 28(5) 489–491 © The Royal Australian and New Zealand College of Psychiatrists 2020 Article reuse guidelines: sagepub.com/journals-permissions https://doi.org/10.1177/1039856220953717 DOI: 10.1177/1039856220953717 journals.sagepub.com/home/apy
Building Early Attachment and Resilience Research Group, Department of Psychiatry, University of
Melbourne, Australia
Abstract Objectives: To describe current issues facing the field of perinatal and infant psychiatry, the issues involved in developing service models and greater awareness of the area in mental health service strategic development. To describe contemporary approaches working to integrate perinatal and infant models with a focus on early-in-life intervention and prevention. Conclusions: Perinatal and infant psychiatry has ongoing issues in clarifying the location of services and their models of care with a lack of clear higher level governance. It remains a vital area for improving the mental health of both carers and infants and child development. Keywords: perinatal, infant mental health, parenting
T
he mental health of parents and infants seems, at first glance, to be an obvious priority for psychiatry and to be of benefit to parents, infants and the mental health of the population. The impacts of untreated common perinatal disorders such as depression and anxiety are concerning, and infants experiencing poor quality interaction with carers are vulnerable to mental disorders in later life.1 This suggests that identification of parents with mental health issues and factors contributing to attachment difficulties is important, and that mental health services should be able to respond in a timely fashion.2 However, even clear arguments are not easily translated into clinical services and practice – perinatal and infant mental health remains relatively under-supported across mental health, maternity and community services. Perinatal and infant psychiatry sits in an unusual position within mental health services, both in terms of clinical services and within the overall discipline of psychiatry. This has, in some cases, contributed to an identity issue and some differing views about the types of services that should be offered in the perinatal and infant period, the location of services across maternity and mental health services and, importantly, the skills and training needed to be a specialist in this area. There are currently several differing pathways for psychiatrists wanting to work in this area. General adult psychiatrists may specialise in the perinatal period and provide high-level treatment of women with significant
mental illness, which can have a significant impact on the mother, family and relationship with the infant. Consultation–liaison psychiatry services in maternity settings respond to a range of mental disorders in mothers during pregnancy and the post-partum period, with variation across services in terms of follow-up and work with parents and infants where there is infant vulnerability. In many ways, maternity setting is an ideal place to better identify mothers with risk factors for perinatal disorders and risks for attachment and developmental problems in infants.3 Early intervention, a term with multiple uses, in this sense refers to early-in-life intervention with the aim of preventing longitudinal developmental problems and reducing the risk of mental disorders. Recent developments in early screening for depression, substance issues and family violence are welcome parts of early identification, but still require adequate referral pathways and better resourcing of mental health responses with the capacity to monitor women through pregnancy and during the critical early parenting period. Early development and transition to parenthood are also of interest to child and adolescent psychiatrists who
Corresponding author: Louise Newman AM, Building Early Attachment and Resilience Research Group, Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Floor 1, Grattan Street, Parkville, VIC 3052, Australia. Email: [email protected]
489
Australasian Psychiatry 28(5)
bring a focus on understanding the complex interplay of factors impacting developmental processes. The first 3 years of life, as is frequently noted, are seen as a critical period in both neurological and psychosocial development, with major implications for adult mental health.4 In perinatal work, child psychiatrists are able to focus on the psychological transition to becoming an attachment figure and how this relates to the parents’ own early experiences. In some ways, this has not been a traditional focus for perinatal psychiatry and raises some issues around integration of approaches and differing views about the balance of approaches a service should offer. Like many debates in psychiatry, defining territory and areas of expertise can be intense, confusing both service mangers and policy makers. These debates can be longlasting and seemingly unresolvable, but useful in a move to more contemporary practice focus. The papers in this Edition reflect the diversity of issues in perinatal psychiatry, looking at biological treatment of maternal disorder, infant development and a broader approach to looking at the family system and the mental health of fathers. This reflects an expansion of interests and approaches, a need for better integration and a clearer understanding of focus and identity as a speciality area. Perinatal and infant practice also sits awkwardly in mental health services. Currently, there are limited mother– infant psychiatric units and some separations of infants if a mother is unable to safely interact with the baby. Few settings have an ideal colocation of a mother–baby unit with a secure adult facility and baby nursery, but all these may be needed for the treatment of complex disorders. Services are limited in regional areas.5 Concerningly, babies have been ambivalently regarded in some units, described as ‘boarders’, not seen as an integral part of treatment for the mother or as an opportunity for active preventive intervention. This narrow focus may reflect a limited understanding of the place of the significant psychological changes of pregnancy and the transition to parenthood as aetiological factors for maternal mental disorder. Underlying ambivalence, conflicts and unresolved attachment-related traumas may have a direct impact on the mother’s representation of the infant and the quality of emotional interaction and regulation – all are central to early psychosocial development. The infant and a focus on early development should be integral parts of service models, which incorporate evidence-based approaches in infant mental health interventions and prevention. Regardless of the logic of supporting early development, it remains unclear where this system sits – maternity services, adult mental health, child and adolescent mental health, community early childhood services – all of which contribute to fragmented service systems, lack of clarity around funding streams, and in many areas a lack of governance at a state level to allow better planning of an integrated approach to a crucial area. Over the years, there have been many submissions and contributions on these issues to government and policy
490
makers. The evidence about early brain development and its relational context, the impact of early trauma and the association with later mental disorder is strong but this has not necessary translated into a coherent approach to service organisation and preventive programmes. There is considerable interest amongst trainees in gaining clinical experience yet few opportunities, and those wanting a career in the area have limited places on completion of training. Australia and New Zealand have active infant mental health associations that provide considerable advocacy in the area. Research in infant mental health is also difficult to fund in the current climate, and there is a major challenge dilemma of how best to demonstrate the developmental benefits of early intervention in longitudinal studies with complex outcomes. The debate around the place of early-in-life interventions as reducing the burden of mental disorder is ongoing – and at times divisive – as differing models compete for limited resources. Services struggle with the perennial question of who is the ‘patient’ or the focus of attention? For perinatal and infant psychiatry, the ‘patient’ is simultaneously the parent/family and the infant, and the relationship between them. The idea of relational interventions has emerged from the increasing recognition of the importance of the parent’s capacity to understand and reflect on the inner work of the infant and to respond to infant emotional communication. This is a significant issue for parents with complex trauma disorders and backgrounds of attachment disruption. This vulnerable group are best identified in pregnancy and worked with to support the relationship with the infant. A major service challenge is how better to meet the needs of parents with intersecting and multiple social risk factors, both past and present, who do not fit easily within current services. It is time to redefine priority areas for perinatal and infant work, recognising the needs of the most vulnerable who move too readily between services.6 It is also key to advocate for inclusion of early-in-life intervention and prevention within the mental health strategy. Psychiatry should be informed by a developmental framework and understanding of the significance of early development in shaping risk and resilience. Recently, the Victorian Royal Commission into Mental Health took evidence on these issues, as have the previous Commissions into family violence and institutional reponses to child sexual abuse. If this is a positive response it is hoped that concerns of perinatal and infant mental health are documented and we move towards service reform.7
Conclusion Perinatal and infant psychiatry is a speciality in search of a home. It would benefit from a focus and philosophical approach with shared values to overcome division,
Newman AM
promote development of the field, and bring together a diversity of interests and approaches. The challenges for proponents are clear as are the benefits for the mental health and well-being of the community. ORCID iD Louise Newman AM
https://orcid.org/0000-0002-4630-6908
References 1. Newman L, Judd F, Olsson C, et al. Early origins of mental disorder- risk factors in the perinatal and infant period. BMC Psychiatry 2016; 16: 270. 2. Perry N, Newman L, Hunter M, et al. Improving antenatal risk assessment in women exposed to high risks. Clin Child Psychol Psychiatry 2015; 20: 84–105.
3. Milgrom J, Ericksen J and Sved-Williams A. Impact of parental psychiatric illness on infant development. In: Sutter-Dallay A-L, Glangeaud-Freudenthal NMC, Guedeney A, et al. (eds) Joint care of parents and infants in perinatal psychiatry. Switzerland: Springer, 2012, pp. 47–79. 4. Emde RN. The prevention sciences of early development and challenging opportunities for psychoanalysis. In: Emde RN and Leuzinger-Bohleber M (eds) Early parenting and prevention of disorder. London: Karnac Books, 2014, pp. 3–20. 5. Lee WW and Newman L. A model for the provision of integrated perinatal and infant mental health services in regional settings. Australas Psychiatry 2018; 26: 531–533. 6. Judd F, Newman L and Komiti A. Time for a new zeitgeist in perinatal mental health. Aust NZ J Psychiatry 2018; 52: 112–116. 7. Parliament of Victoria Family and Community Development Committee. Inquiry into perinatal services. Final Report 2018, www.parliament.vic.gov.au/images/stories/committees/fcdc/inquiries/58th/Perinatal/inquiry into perinatal services.pdf
Podcast Dr Andrew Amos Deputy Editor, Australasian Psychiatry Director of Training - North Queensland [email protected]
Very early intervention...effective prevention starts with perinatal mental health and wellbeing Australia and New Zealand are world leaders in developing the broader health, welfare, and cultural support systems needed for broad-based mental health and wellbeing. While early intervention in adolescent and young adult groups has been the most visible area of development and debate for the last two or three decades, there is growing recognition of the importance of early experiences for development and health throughout the life span. There
Cover art The cover art by Leslie Holding called an equation for a child (or a happy girl) comes from the Cunningham Dax Collection. The artwork has been chosen to represent themes associated with child psychiatry, gender dysphoria and the coronavirus pandemic. The artist makes the following statement about their artwork: “I do my art to seek enjoyment on how others find my works pleasing. To satisfy the beholders of my works is the motivation I have while I do art. Most of the time when creating works I ask others of what they think of my works. After some time I also ask how does my artwork make them feel, I hope good.”
About the Cunningham Dax Collection The Cunningham Dax Collection consists of over 15,000 artworks created by people with an experience of mental illness and/or psychological trauma. The art includes works on paper, paintings, photographs, poems, textiles, sculpture, journals and digital media.
has been controversy on how best and how early to start looking for risk factors for later development of mental illness, but there is little resistance to the idea that reducing the stressors and improving the welfare of infants and their families is likely to improve outcomes across all areas of health and wellbeing. The October 2020 issue of Australasian Psychiatry features a number of articles on perinatal mental health. The October podcast interviews Professor Louise Newman of the University of Melbourne who describes the special challenges of the Covid-19 pandemic facing families with or expecting new babies, and the importance of robust health and welfare systems for dealing with acute perinatal issues as well as the great promise of very early intervention for the reduction or prevention of mental illness at the population level.
The unique Cunningham Dax Collection is now one of the largest of its kind, with only two other similar collections of comparable size and stature: the MusŽe Art Brut in Lausanne, Switzerland, and the Prinzhorn Collection in Heidelberg, Germany. The Dax Centre is a not-for-profit organisation that relies on the generosity of the community to carry out its mission of promoting mental health through art. We aim to change community attitudes to mental illness by increasing empathy and understanding of mental illness, psychological trauma and the mind through art, thereby reducing stigma against mentally ill people. The Dax Centre holds an important history and clinical focus, but it is today visited by many people such as students from a diverse range of learning purposes, artists and those interested in art, community and special interest groups; all who seek to demystify mental illness and address the associated stigma that has historically underpinned individual and community perceptions of mentally ill and traumatised persons. For more information on the Cunningham Dax Collection and The Dax Centre, visit: www.daxcentre.org 491
APY
Australasian PsychiatryNewman AM
Australasian
Psychiatry
Editorial
Thinking about parents and infants – finding a home for perinatal and infant psychiatry Louise Newman AM
Australasian Psychiatry 2020, Vol 28(5) 489–491 © The Royal Australian and New Zealand College of Psychiatrists 2020 Article reuse guidelines: sagepub.com/journals-permissions https://doi.org/10.1177/1039856220953717 DOI: 10.1177/1039856220953717 journals.sagepub.com/home/apy
Building Early Attachment and Resilience Research Group, Department of Psychiatry, University of
Melbourne, Australia
Abstract Objectives: To describe current issues facing the field of perinatal and infant psychiatry, the issues involved in developing service models and greater awareness of the area in mental health service strategic development. To describe contemporary approaches working to integrate perinatal and infant models with a focus on early-in-life intervention and prevention. Conclusions: Perinatal and infant psychiatry has ongoing issues in clarifying the location of services and their models of care with a lack of clear higher level governance. It remains a vital area for improving the mental health of both carers and infants and child development. Keywords: perinatal, infant mental health, parenting
T
he mental health of parents and infants seems, at first glance, to be an obvious priority for psychiatry and to be of benefit to parents, infants and the mental health of the population. The impacts of untreated common perinatal disorders such as depression and anxiety are concerning, and infants experiencing poor quality interaction with carers are vulnerable to mental disorders in later life.1 This suggests that identification of parents with mental health issues and factors contributing to attachment difficulties is important, and that mental health services should be able to respond in a timely fashion.2 However, even clear arguments are not easily translated into clinical services and practice – perinatal and infant mental health remains relatively under-supported across mental health, maternity and community services. Perinatal and infant psychiatry sits in an unusual position within mental health services, both in terms of clinical services and within the overall discipline of psychiatry. This has, in some cases, contributed to an identity issue and some differing views about the types of services that should be offered in the perinatal and infant period, the location of services across maternity and mental health services and, importantly, the skills and training needed to be a specialist in this area. There are currently several differing pathways for psychiatrists wanting to work in this area. General adult psychiatrists may specialise in the perinatal period and provide high-level treatment of women with significant
mental illness, which can have a significant impact on the mother, family and relationship with the infant. Consultation–liaison psychiatry services in maternity settings respond to a range of mental disorders in mothers during pregnancy and the post-partum period, with variation across services in terms of follow-up and work with parents and infants where there is infant vulnerability. In many ways, maternity setting is an ideal place to better identify mothers with risk factors for perinatal disorders and risks for attachment and developmental problems in infants.3 Early intervention, a term with multiple uses, in this sense refers to early-in-life intervention with the aim of preventing longitudinal developmental problems and reducing the risk of mental disorders. Recent developments in early screening for depression, substance issues and family violence are welcome parts of early identification, but still require adequate referral pathways and better resourcing of mental health responses with the capacity to monitor women through pregnancy and during the critical early parenting period. Early development and transition to parenthood are also of interest to child and adolescent psychiatrists who
Corresponding author: Louise Newman AM, Building Early Attachment and Resilience Research Group, Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Floor 1, Grattan Street, Parkville, VIC 3052, Australia. Email: [email protected]
489
Australasian Psychiatry 28(5)
bring a focus on understanding the complex interplay of factors impacting developmental processes. The first 3 years of life, as is frequently noted, are seen as a critical period in both neurological and psychosocial development, with major implications for adult mental health.4 In perinatal work, child psychiatrists are able to focus on the psychological transition to becoming an attachment figure and how this relates to the parents’ own early experiences. In some ways, this has not been a traditional focus for perinatal psychiatry and raises some issues around integration of approaches and differing views about the balance of approaches a service should offer. Like many debates in psychiatry, defining territory and areas of expertise can be intense, confusing both service mangers and policy makers. These debates can be longlasting and seemingly unresolvable, but useful in a move to more contemporary practice focus. The papers in this Edition reflect the diversity of issues in perinatal psychiatry, looking at biological treatment of maternal disorder, infant development and a broader approach to looking at the family system and the mental health of fathers. This reflects an expansion of interests and approaches, a need for better integration and a clearer understanding of focus and identity as a speciality area. Perinatal and infant practice also sits awkwardly in mental health services. Currently, there are limited mother– infant psychiatric units and some separations of infants if a mother is unable to safely interact with the baby. Few settings have an ideal colocation of a mother–baby unit with a secure adult facility and baby nursery, but all these may be needed for the treatment of complex disorders. Services are limited in regional areas.5 Concerningly, babies have been ambivalently regarded in some units, described as ‘boarders’, not seen as an integral part of treatment for the mother or as an opportunity for active preventive intervention. This narrow focus may reflect a limited understanding of the place of the significant psychological changes of pregnancy and the transition to parenthood as aetiological factors for maternal mental disorder. Underlying ambivalence, conflicts and unresolved attachment-related traumas may have a direct impact on the mother’s representation of the infant and the quality of emotional interaction and regulation – all are central to early psychosocial development. The infant and a focus on early development should be integral parts of service models, which incorporate evidence-based approaches in infant mental health interventions and prevention. Regardless of the logic of supporting early development, it remains unclear where this system sits – maternity services, adult mental health, child and adolescent mental health, community early childhood services – all of which contribute to fragmented service systems, lack of clarity around funding streams, and in many areas a lack of governance at a state level to allow better planning of an integrated approach to a crucial area. Over the years, there have been many submissions and contributions on these issues to government and policy
490
makers. The evidence about early brain development and its relational context, the impact of early trauma and the association with later mental disorder is strong but this has not necessary translated into a coherent approach to service organisation and preventive programmes. There is considerable interest amongst trainees in gaining clinical experience yet few opportunities, and those wanting a career in the area have limited places on completion of training. Australia and New Zealand have active infant mental health associations that provide considerable advocacy in the area. Research in infant mental health is also difficult to fund in the current climate, and there is a major challenge dilemma of how best to demonstrate the developmental benefits of early intervention in longitudinal studies with complex outcomes. The debate around the place of early-in-life interventions as reducing the burden of mental disorder is ongoing – and at times divisive – as differing models compete for limited resources. Services struggle with the perennial question of who is the ‘patient’ or the focus of attention? For perinatal and infant psychiatry, the ‘patient’ is simultaneously the parent/family and the infant, and the relationship between them. The idea of relational interventions has emerged from the increasing recognition of the importance of the parent’s capacity to understand and reflect on the inner work of the infant and to respond to infant emotional communication. This is a significant issue for parents with complex trauma disorders and backgrounds of attachment disruption. This vulnerable group are best identified in pregnancy and worked with to support the relationship with the infant. A major service challenge is how better to meet the needs of parents with intersecting and multiple social risk factors, both past and present, who do not fit easily within current services. It is time to redefine priority areas for perinatal and infant work, recognising the needs of the most vulnerable who move too readily between services.6 It is also key to advocate for inclusion of early-in-life intervention and prevention within the mental health strategy. Psychiatry should be informed by a developmental framework and understanding of the significance of early development in shaping risk and resilience. Recently, the Victorian Royal Commission into Mental Health took evidence on these issues, as have the previous Commissions into family violence and institutional reponses to child sexual abuse. If this is a positive response it is hoped that concerns of perinatal and infant mental health are documented and we move towards service reform.7
Conclusion Perinatal and infant psychiatry is a speciality in search of a home. It would benefit from a focus and philosophical approach with shared values to overcome division,
Newman AM
promote development of the field, and bring together a diversity of interests and approaches. The challenges for proponents are clear as are the benefits for the mental health and well-being of the community. ORCID iD Louise Newman AM
https://orcid.org/0000-0002-4630-6908
References 1. Newman L, Judd F, Olsson C, et al. Early origins of mental disorder- risk factors in the perinatal and infant period. BMC Psychiatry 2016; 16: 270. 2. Perry N, Newman L, Hunter M, et al. Improving antenatal risk assessment in women exposed to high risks. Clin Child Psychol Psychiatry 2015; 20: 84–105.
3. Milgrom J, Ericksen J and Sved-Williams A. Impact of parental psychiatric illness on infant development. In: Sutter-Dallay A-L, Glangeaud-Freudenthal NMC, Guedeney A, et al. (eds) Joint care of parents and infants in perinatal psychiatry. Switzerland: Springer, 2012, pp. 47–79. 4. Emde RN. The prevention sciences of early development and challenging opportunities for psychoanalysis. In: Emde RN and Leuzinger-Bohleber M (eds) Early parenting and prevention of disorder. London: Karnac Books, 2014, pp. 3–20. 5. Lee WW and Newman L. A model for the provision of integrated perinatal and infant mental health services in regional settings. Australas Psychiatry 2018; 26: 531–533. 6. Judd F, Newman L and Komiti A. Time for a new zeitgeist in perinatal mental health. Aust NZ J Psychiatry 2018; 52: 112–116. 7. Parliament of Victoria Family and Community Development Committee. Inquiry into perinatal services. Final Report 2018, www.parliament.vic.gov.au/images/stories/committees/fcdc/inquiries/58th/Perinatal/inquiry into perinatal services.pdf
Podcast Dr Andrew Amos Deputy Editor, Australasian Psychiatry Director of Training - North Queensland [email protected]
Very early intervention...effective prevention starts with perinatal mental health and wellbeing Australia and New Zealand are world leaders in developing the broader health, welfare, and cultural support systems needed for broad-based mental health and wellbeing. While early intervention in adolescent and young adult groups has been the most visible area of development and debate for the last two or three decades, there is growing recognition of the importance of early experiences for development and health throughout the life span. There
Cover art The cover art by Leslie Holding called an equation for a child (or a happy girl) comes from the Cunningham Dax Collection. The artwork has been chosen to represent themes associated with child psychiatry, gender dysphoria and the coronavirus pandemic. The artist makes the following statement about their artwork: “I do my art to seek enjoyment on how others find my works pleasing. To satisfy the beholders of my works is the motivation I have while I do art. Most of the time when creating works I ask others of what they think of my works. After some time I also ask how does my artwork make them feel, I hope good.”
About the Cunningham Dax Collection The Cunningham Dax Collection consists of over 15,000 artworks created by people with an experience of mental illness and/or psychological trauma. The art includes works on paper, paintings, photographs, poems, textiles, sculpture, journals and digital media.
has been controversy on how best and how early to start looking for risk factors for later development of mental illness, but there is little resistance to the idea that reducing the stressors and improving the welfare of infants and their families is likely to improve outcomes across all areas of health and wellbeing. The October 2020 issue of Australasian Psychiatry features a number of articles on perinatal mental health. The October podcast interviews Professor Louise Newman of the University of Melbourne who describes the special challenges of the Covid-19 pandemic facing families with or expecting new babies, and the importance of robust health and welfare systems for dealing with acute perinatal issues as well as the great promise of very early intervention for the reduction or prevention of mental illness at the population level.
The unique Cunningham Dax Collection is now one of the largest of its kind, with only two other similar collections of comparable size and stature: the MusŽe Art Brut in Lausanne, Switzerland, and the Prinzhorn Collection in Heidelberg, Germany. The Dax Centre is a not-for-profit organisation that relies on the generosity of the community to carry out its mission of promoting mental health through art. We aim to change community attitudes to mental illness by increasing empathy and understanding of mental illness, psychological trauma and the mind through art, thereby reducing stigma against mentally ill people. The Dax Centre holds an important history and clinical focus, but it is today visited by many people such as students from a diverse range of learning purposes, artists and those interested in art, community and special interest groups; all who seek to demystify mental illness and address the associated stigma that has historically underpinned individual and community perceptions of mentally ill and traumatised persons. For more information on the Cunningham Dax Collection and The Dax Centre, visit: www.daxcentre.org 491
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