Infant Mental Health and Child Protection: an Essential Partnership

Michael Bush, a bright, open-minded third-year student at West Virginia University College of Law, contacted me this past summer when, in his role as an editor of the Law Review, he was organizing a symposium on Child Protection in the 21st Century. In our subsequent email conversation he wisely observed that those in the legal profession are often in a position to decide what is "in the best interest of the child" with little substantive understanding of what exactly is in the best interest of the child.  He invited me to share my knowledge as an expert in infant mental health.

This week, his efforts and those of his fellow law review editors-a remarkable group of intelligent and thoughtful young people-came to fruition. It was an extraordinary experience that opened up many opportunities for meaningful collaboration.

 In my presentation I contrasted the historical view of Child Protection as a child-saving service designed to prosecute parents with the model of relationship-focused preventive intervention promoted by the field of infant mental health (those who are interested may see the talk in its entirety on the webcast.)


Rather than giving specific ideas about what to do, I offered a different way to think about work with very troubled families.  While many in the legal profession view their task as "proving what the parent has done wrong," (this is a direct quote from a CPS social worker) I encouraged them to think about creating a "holding environment" where there is room for non-judgmental curiosity about the meaning of behavior. I presented an overview of the research that supports this paradigm.

Many very important things came out of this trip. A number of people from CASA, a non-profit organization in Virginia that supports volunteer advocacy for abused and neglected children, attended my talk. Amber Moore, the editor-in-chief of the Law Review, told me that they had requested my PowerPoint because "they couldn't write fast enough." They want to use what I was teaching to train their volunteer workers. I discovered that people were starved for knowledge about contemporary research in child development in a form that they could understand.

I quoted from my book Keeping Your Child in Mind, explaining that while it was being marketed as a parenting book, it is actually a book about infant mental health written for a general audience. I wrote it with my pediatric and mental health colleagues in mind, but now I see how useful it could be to the legal profession, specifically those working in the area of child protection.

One of my co-presenters was a delightful judge from central West Virginia who has been doing child protection work for over 20 years. He openly admitted to his lack of knowledge on the subject of contemporary child development research and bought 5 copies of my book.

I met a remarkable young woman who, in addition to attending law school, works at the Industrial Home for Youth in Salem, where prior to a recent lawsuit, children as young as 13 were routinely placed in solitary confinement. As part of a law school class, she is drafting a bill to require multidisciplinary meetings every three months for these young offenders, who currently may not meet with anyone who is advocating for them for their entire stay. Because WVU is the only law school in West Virginia, the students' bills are presented to the state legislature, and a percentage of them actually become law. I am hopeful that she and I will keep in touch and that I can support her in her efforts.

As Keynote speaker of the symposium, I have been invited to write a paper for the West Virginia Law Review that will then be available for citation in legal work.  Another of my co-presenters, who spoke about the legal challenges of adolescent parents, already told me that she intends to cite my work.

This trip was well outside my comfort zone. I had never been to West Virginia (or even Pittsburgh-where I had to fly to get there) and certainly had never spoken with an audience of lawyers. My infant mental health colleagues are "my peeps." In a few weeks they will gather in Los Angeles at the wonderful Zero to Three National Training Institute. Sadly, I will miss it, in part because of this trip.

I have often said to my infant mental health colleagues that we need to work on communicating the wealth of ideas that will be presented at that conference widely beyond our borders.  It was like a dream come true to have the opportunity to speak to a group of bright young law students- the future lawmakers and policy makers of our country. The experience left me hungry for more.

Pediatrics and Psychoanalysis: An Essential Partnership

D.W Winnicott, pediatrician turned psychoanalyst, has been among the most important influences on my work. Unlike him, however, I have been determined, in my professional life, not to "defect" from pediatrics to become a psychoanalyst. I have always felt it was important to bring the wealth of deeply meaningful ideas coming from the discipline of psychoanalysis to the practice of pediatrics.

For example, in my current position as a behavioral pediatrician at Newton-Wellesley Hospital I teach the pediatric residents and  medical students about colic by starting with Winnnicott's notion of "primary maternal preoccupation." I read to them from my book: Keeping Your Child in Mind, itself an effort to bring psychoanalytic ideas to a general audience:

Winnicott described the first weeks to months of motherhood as a period deserving of a name, a psychological state, which for both a newborn and mother is not only healthy but highly adaptive. The name Winnicott gave this state was “primary maternal preoccupation.” He referred to a mother who is preoccupied in this way with her baby as an “ordinary devoted mother.” This way of being in tune with the baby happens naturally and does not look like anything particularly dramatic. A mother knows what her baby feels through her intense identification with him. He is a part of her. Though her role is in this sense “ordinary,” it is in fact hugely important. Winnicott writes: “It will be observed that though at first we were talking about very simple things, we were also talking about matters that have vital importance, matters that concern the laying down of the foundations for mental health.”

Rather than asking "what to do" to "manage" colic, I encourage them to think about the meaning of the behavior within the context of this intense infant-parent relationship. Similarly, when parents come to see me about how to "manage" their child's "behavior problem," I help them to recognize that they are engaged in a kind of "dance of dysregulation" with their child, and that they both need to learn a new way to dance that is calm and coordinated.

This weekend, however, I get to do exactly the opposite, namely bring my knowledge as a pediatrician to a group of psychoanalysts.  Just as psychoanalysts are experts in relationships, so pediatricians (and all professionals who provide primary care to children) are experts in babies.  We are immersed in child development in a way that is unlike any other profession.

I am speaking at a conference at the Austen Riggs Center, co-sponsored by the Yale Child Study Center: Development of the Parent as a Person: Psychological, Biological and Genetic Contributions. Within minutes of looking at the proposed lineup of presentations, I knew exactly what I had to add. My talk is titled: "The Development of the Parent: the Child's Contribution."

 After more than 20 years of listening to countless parents and seeing thousands of babies, I have no doubt that babies come in to the world with their own unique set of qualities and characteristics, that from the first moment have a significant impact on the development of the parent. Almost every parent who is struggling with their child's challenging behavior has shared some variation of, "we saw this from the moment he was born."

I will use the photographs from Kevin Nugent's book: Your Baby is Speaking to You, that so beautifully captures the way babies are engaged in complex communication from the start. I have a video clip of a baby at three days of age having a conversation with me. I will introduce the Newborn Behavioral Observation system, a clinical tool designed to bring out these qualities in the baby, and promote healthy relationships from the start.

A number of years ago I attended a conference entitled "Pediatrics and Child Psychiatry: an Essential Partnership." I was hopeful, but sadly it ended up being primarily about prescribing medication, with a little bit about "parent training" thrown in. The word "relationship" was not mentioned once.

Here we have two parallel relationships: the parent-child relationship, and the pediatrics-psychoanalysis relationship. In each pair, one has the opportunity to have a profound and positive effect on the development of the other.