Policy & Intervention: Promoting infant Mental Well-Being

Policy & Intervention: Promoting infant Mental Well-Being

by Barbara Chandler

Sue Gerhardt writes in her 2010 book, The Selfish Society:

“When I wrote ‘Why Love Matters: how affection shapes a baby’s brain’ (2004), my purpose was to explain what I had learned about the importance of babyhood as the foundation of individual emotional well-being, mental health and good character. I demonstrated the links between the quality of early care and the later incidence of depression, personality disorders and anti-social behaviour – issues that specifically concerned me as a psychotherapist working with individuals who were struggling with their relationships, their unfulfilled potentials, or their destructive and self-destructive behaviours … My goal was to encourage parents and policy makers to become more aware of the importance and significance of early child-rearing, in order to prevent further individual suffering and poor emotional development”.

And, importantly, she adds, the impact is not only for the individual but also a matter for society.

And that is why I would like to talk about how we get both our policy makers and parents to understand the importance of this vital and sensitive developmental stage of infancy. How do we disseminate this knowledge to parents from every walk of life and every social stratum? And how can we start to advocate for meaningful policy and intervention?

The field of infant mental health is founded on attachment theory, underscored by amazing developments in understanding the neurobiology of the brain. Also of importance is our knowledge of how relational trauma may be carried from one generation to the next and that this repetition continues through the generations until it is brought to awareness.

In this presentation I will briefly look at existing policy, some of the many gaps and start to think about how we might start to advocate for change. I will look at what is required in early intervention, how early is early and what we need to do to get it right.

Existing services, legislation and policy, Non-profit organisations (NPOs) and non-governmental organisations (NGOs) in South Africa very often play a major role in identifying, developing and implementing programmes and projects that promote social development. However, there are still too few organisations involved in or even aware of the field of infant mental health.

Gauteng Association for Infant Mental Health (GAIMH) chairperson Nicola Dugmore published her research on parent-infant services in South Africa in 2012. She found the NGO sector in this field restricted to a few services in and around Cape Town and Johannesburg and the following public sector sites: the Red Cross War Memorial Children’s Hospital in Cape Town; a limited Parent-Infant Psychotherapy Clinic at Johannesburg’s Rahima Moosa Mother and Child Hospital; and, a similar project at Dr George Mukhari Hospital, linked to Medunsa University, in the City of Tshwane District. Nicola found the private sector has a handful of parent-infant/child practitioners (psychoanalytic and/or other professionals). Referrals to parent-child intervention professionals are by word-of-mouth.

There is little doubt that partnerships between government and civil society – public/private partnerships – are essential for any meaningful work and change to happen in this field. The challenges are huge, and, as Nicola says, “initiatives must be developed across all health sectors … However the relevance of parent-infant/child psychotherapy is intricately linked to the potential for reaching vulnerable and at-risk parents and infants/children”.

How good is our legislation and where are the problems? Here I quote the oft repeated statement around policy. We have good, sound laws which are, mostly, well thought-through and solid, but it is in the implementation that things fall apart.

We have an outstanding Bill of Rights. Our Constitution is amongst the best in the world. The Children’s Act, the Child Justice Act and the Criminal Law (Sexual Offences and Related Matters) Amendment Act are not perfect, and some amendments may yet be tested in court, but careful thought has laid a reasonably good foundation.
And the National Development Plan (NDP)? It is scandalous that so much thought and hard work is put into formulating plans that may never come into being. Having said that, the closest we get to something akin to infant mental health falls under the broad heading early childhood development, widely known as ECD, which, while essential, is simply not early enough. In actual fact, if infant mental health is to be taken seriously enough it needs representation and inclusion in almost every governmental department – Social Development, Justice and Constitutional Development, Basic and Higher Education, Health, Women, Human Settlements, Home Affairs, Traditional Affairs, Economic Development and Correctional Services, International Relations and Cooperation, among others.

And, alas, plans for the National Health Insurance (NHI) does not name or seem to include a space for infant mental health. At this moment, there seems little hope that foundational developmental projects will find a place in the current, overwhelmed system. This while there are countries where the infant mental health committees are represented in the Minister of Health’s Advisory Board. And taken seriously.

South Africa is a signatory to the United Nations Children’s Fund’s (Unicef) Reform of the Legal and Judicial System which aims to provide equal protection to women and children and ensure national legislation is consistent with the Convention on the Rights of the Child (CRC), the African Charter on the Rights and the Welfare of the Child, and the Convention on the Elimination of all Forms of Discrimination against Women (Cedaw).

In addition, the World Association for Infant Mental Health (WAIMH) – you might want to look them up on the worldwide web – is in the process of specifying infancy as a particularly sensitive developmental stage thusly:

“The infant (from birth to the age of 3 years) by reason of his physical and mental immaturity and absolute dependence needs special safeguards and care, including appropriate legal protection, before as well as after birth.

As professionals who work with infants and parents within different cultures and societies, we feel there is a need for specifying the infant’s rights, beyond what has been already included in the Declaration of Children’s Rights.”

Why Even Earlier?

Now let me have a word on ECD which spans the period after infancy (or nought to three) until Grade 1. In recent years ECD is receiving attention and our government is now invested in it. Government support mainly takes two forms: (1) the expansion of Grade R in public schools funded by the Department of Education (DOE), and; (2) subsidies by the Department of Social Development (DSD) to private community-based ECD facilities serving children too young for Grade R. As a result, enrolment in ECD programmes increasing rapidly.

While commendable, this focused support on education outside of the home is not enough. It still misses the point of the deeper understanding of the role of emotional development based on the scientific knowledge that neuroscience and psychology offers us for the even earlier stage, starting with conception. Thus, much earlier attention and intervention needs to be prioritised in the first place.

The impact on society of early child-rearing

Instead of citing statistics or listing projects I want to use news headlines and stories to support my argument. Scan through the newspapers and look at the South African stories therein. Adolescent pregnancies; baby dumping; a toddler found walking on the highway; a week later another toddler found walking on the highway; the Waterkloof Four who killed a homeless man; the 18-year-old accused of killing a fellow pupil with a Samurai sword; the rape, disembowelling and mutilation of Anene Booysen from Bredasdorp; the 14-year-old from Springs who axed his family to death; the House of Horrors in Springs; and, school initiations involving unspeakable cruelty and torture. These daily horror stories, all of them evidence of something that went horribly wrong in early childhood, ironically desensitise us, make us take less notice. After all, South Africans suffer from what Wits trauma expert Gill Eagle calls continuous stress syndrome.

I could have gone further afield to India where a young medical student’s rape on a public bus at night time started a nationwide outrage. Or to the United Kingdom where Jon Venables was released 20 years after he and Robert Thomson murdered James Bulger (Venabels and Thomson were ten years old at the time, Bulger two years old – read Sue Gerhardt intelligent discussion of this case in her book, Why Love Matters).

What Has This Got to do With Infancy?

There are many complex reasons to help explain the state of our society. But the quality of the debates in the various media invariable excludes two vital dimensions: the role of our child-rearing practices and the intergenerational repetition of trauma. If we give these aspects a space in our understanding the links will become clear and, then, we will be able to understand why intervention programmes are so absolutely essential. If we don’t there is a price to pay. The cases mentioned above are extreme, but we should never forget the very mundane difficulties that parents face every day: depression, stress, conflict and difficulties in bonding, feeding andsupporting. I say this knowing that painful stories involving babies and small children often evoke unbearable feelings within us. In these circumstances our defences come up and shut down our thinking or, for example, we become dismissive and pretend babies are too young to register these disturbances. There is often a backlash when these difficulties are mentioned and, as a result, these programmes are then considered a waste of time and money.

What are the reasons for the trickle of initiatives and services?
As mentioned above, denial and defensiveness are two of the reasons why the relational health of our very young and their caregivers are being neglected. There are also other complex reasons: difficulties in accessing resources; no resources; too few professionals with knowledge and training; a lack of co-ordination between the relevant interest groups; and, a lack of political will.

But, let me mention one or two less obvious reasons. The first is that where we as a country come from has a lot to do with where we are at now. I do buy the argument that we cannot mould the future without truly understanding the impact of the past. I think we sometimes pay lip service to the effects of our past. The air-time it gets – and it gets lots – is at times superficial. It fails to unpack and unravel the depths and the divides. The let’s-move-on-brigade dismisses the past as irrelevant. The lets-blame-it-all-on-apartheid-brigade uses it to excuse dismal performance. If the adults in a society are fearful, aggressive, abused and negatively entitled they cannot hope to help regulate or meet the emotional needs of children.

I would like to bring two blocks or impediments in implementing meaningful policy around our children into our thinking.
We live in a country that negates mental health.

When I researched policy, I struggled to find programmes focusing on mental health. In an article I came across the Department of Health’s budget for mental health was put at only 4%. Physical healt, gets attention. Mental health is negated. We can talk about why this is so. There are many reasons, not least among them patriarchy, macho cultural imperatives, stigmatisation, a lack of understanding and fear. For example, against all the contextual risk factors we in South Africa face, we cannot get medical aids to pay for a reasonably meaningful time in therapy for children at risk. As a society we have chosen to believe that people do not have minds!

The False Dichotomy

And, then, there’s the false dichotomy. The broad argument bandied about goes like this: when you have extreme poverty as we do, therapy cannot be prioritised since children are starving and we are under-resourced.
Let’s debate this false dichotomy. When you think about it, this argument makes no sense. How do we get to a place where we believe that only when our children are fed and clothed, immunised and, perhaps, educated then, and only then, we can step in and take care of their minds. We deny babies have minds that need as much, if not more, care. Care linked to every aspect of their bodies, their well-being.
Children who lack a good-enough infancy will struggle at school. Physical well-being cannot be elevated above mental health. Both are inextricably linked. We have a body and a mind.
We see daily examples of mind-less-ness which we do not understand, that makes us shake our heads. We cannot believe what we see and hear. We continue to listen to court cases and condemn mothers who dump their babies, absent fathers, men who rape the young – all the while failing to look for acknowledge the root causes of these problems: the neglect in addressing and treating early emotional and mental turmoil.
Will there be a backlash if tax payers have to fork out for mental health? Perhaps. But the cost implications of no infant mental health awareness and programmes are huge. In our country we see the evidence every single day. I hope by now we have a sense that implementing meaningful, wide-reaching infant health programmes will bring society and government invaluable returns in all areas of society. Let us get South African business schools to do the research and sums other countries with infant mental health services have done.

What have we got and What do we need?

I pointed out very clearly why what we have in terms of infant mental health assistance is by far not enough. We need many more initiatives from civil society and government. They will need to work together to fill gaps and share their expertise.

Early intervention needs a deep commitment to be meaningful. It has to be widespread to be far-reaching. It cannot be limited to two years of early childhood education exposure as the NDP outlines. We have to shift our focus to include our children’s, and their parents and care-givers’, emotional development and care if we want to go anywhere as a country.

I want to write an open letter to the Minister of Health, Dr Aaron Motsoaledi, to ask him to start off NHI programmes with attention to infancy, the beginning of life. I want to impress on him that such a focus will result in reduced substance use, reduced levels of violence and relationship breakdowns in adults and fewer learning difficulties in children. The list is endless. The benefits will include gains in empathic relating in the next generation of parents, as well as real learning in children which will translate into higher creativity and productivity in society. And an empathic population!

I urge all of you to read Sue Gerhardt’s, The Selfish Society. I also urge you to heed veteran journalist and editor Allister Sparks’ words (written in praise of Johannesburg-based NGO, Ububele):

“In the endless debates about our many critical issues – poor education, youth unemployment, shortage of skills, the wealth gap, the crime rate, dysfunctional social behaviour – somehow we seldom hear a word about the single most vital factor that connects them all: the nurturing of small children during their most formative years, under the age of six” (in “The single best investment we can make in our future” in Business Day of 30 January 2013).

* This edited text is from a presentation to honours in journalism students at Wits in 2014, which formed part of a Media Monitoring Africa (MMA) programme. MMA is passionate about bringing child issues to the attention of those in the news media. Barbara Chandler, who is equally passionate about child issues, is a practising social worker in private practice and community initiatives. In a previous life she worked in paediatric and neonatal intensive care units, as well as early childhood education. Her thinking in work and life is informed by psychoanalytic psychotherapy.

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