Infant mental health needs a model of service delivery
To the Editor: The United Nations Convention on the Rights of the Child holds governments responsible for ensuring children’s right to the highest attainable standard of health by providing breastfeeding support, access to nutritious food, appropriate health care and clean drinking water.1 If universally implemented, these would lower infant morbidity and mortality substantially. However, this guideline is directed only towards the physical needs of children and neglects their psychosocial and mental health.
The association between malnutrition, infant growth failure and significant long-term adverse psychosocial outcomes in children is well established.2 Health policies should be comprehensive, include the psychological wellbeing of the child, and improve the social status of women.
Years ago the Western Cape Department of Health established primary health facilities to identify, assess and render basic services. Significant progress has been made. However, while the importance of early mental health intervention for children suffering from malnutrition may be acknowledged, there is little awareness of the importance of the attachment relationship between the young child and the caregiver.
Pathology in the attachment relationship can manifest in various ways, and health care personnel must identify these to enable appropriate and early interventions. The best outcome is ensured when the physical wellbeing of the child is coupled with the psychosocial needs. To succeed in this huge and essential task, a model for service delivery must be developed that incorporates awareness and knowledge of the importance of the caregiving environment. This should be structured, goal-directed, and integrated within the existing infant and young child community health services.3
The concept of infant mental health is generally not well known, particularly in communities. In the Western Cape there is one designated infant mental health service at primary level, which has a child psychiatrist and a community counsellor.
At an academic and educational level there are also considerable gaps. The University of Cape Town and the Department of Health of the Western Cape offer 1-hour training and supervision in infant and child mental health in the primary nurse education programmes. Medical students from both medical faculties in the Western Cape receive 2 hours in lectures and clinical tuition in this regard. Registrars in general psychiatry receive one seminar on infant mental health during their 4-year training period. Paediatric registrars are not formally taught or rotate through child psychiatry, despite the fact that paediatricians provide health care for young children.
Can this situation be improved with the available resources and training facilities? How can improved infant mental health be achieved? Primary health must be infused with infant mental health practices.4 All stakeholders, provincial health departments, nurse education and pre- and post-grade medical and psychology students’ programmes should be engaged.
The primary objective of the model should be adequate delivery of infant mental health services at community level, and if needed select interventions to address concomitant major risk factors. It should train health care workers in assessing and treating at-risk infants and toddlers 0 - 3 years of age. Primary health care nurses are trained mainly in the clinical assessment of physical health, development, and management of childhood illnesses. However, they also must recognise early signs of psychosocial pathology of infants and the developmental wellbeing which is integral to health care. The same programmes can be used for doctors, especially for trainee paediatricians, as both serve the needs of children. Standard tuition models are available to achieve this, but are not taught in any medical or provincial course. The programme should also be available for other professionals in infant mental health and infant-parent psychotherapy.
National and international basic training curricula and protocols have been developed. The provincial and university health departments must be helped to develop and implement policies. If successful, this holds great promise for service and education and will have a lasting effect on the mental health of infants and children.
UCT Parent-Infant Mental Health Service
Red Cross War Memorial Children’s Hospital
2. Walker SP, Wachs TD, Gardner JM, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet 2007;369:145-157.
3. Liebermann AF. Infant mental health: A model for service delivery. J Clin Child Psychol 1985;14:196-201.
4. Graham MA, White BA, Clarke CC, Adams S. Infusing Infant mental health practices into front-line caregiving. Inf Young Children 2001;14:14-23.
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