Readers might not expect to find the words “infant” and “mental health” in the same sentence, but babies can show signs of depression within weeks of being born if they are not getting the attention and responses they crave.
They may not be able to speak when they come out of the womb but they are ready to communicate. Their language ranges from a turn of the head and a splaying of fingers, to widening eyes and a change of colour – all of which are much more subtle than the full-on cry we most readily associate with babies expressing their feelings.
Just as parents strive for an immediate rapport with their newborn, "the baby is desperate to make this relationship work for him too", says Dr Kevin Nugent, director of the Brazelton Institute at Children's Hospital Boston in the US. He and colleagues devised the Newborn Behavioural Observations (NBO) system for health professionals to help parents try to understand what their babies are saying – long before the much-anticipated first "ma" or "da" comes out of their mouths.
Spotting a baby’s cues and responding to the needs being signalled are the building blocks for the parent-infant bond, which in turn is the foundation for the rest of that child’s life.
Nugent was in Ireland recently to address a symposium, hosted by the Tipperary Infant Mental Health project in Clonmel. He also led the first NBO training workshop to be held in this country, for 25 health professionals linked to the Tipperary project.
The moment parents start to see their baby “as a person and not just as a reflex organism” is key, he explains in a follow-up interview from Boston. As soon as they begin to recognise how their newborn has his or her individual “needs, talents, capacities, fears, and realise how emotionally available the baby is, yet how emotionally vulnerable, they’re drawn into that relationship – irrevocably hopefully”, he says.
A first principle of NBO is the health professional partnering with parents, rather than teaching them. This is what Nugent, an Irish-born psychologist from Mullingar, Co Westmeath, describes as “a big paradigm shift”. It also acknowledges that parents are the “experts” when it comes to their own babies.
‘Voyage of discovery’
“I may have worked with thousands of babies but I have never worked with this particular baby and family. It’s a voyage of discovery – who is this child? What does he want us to know? Although it is parent-focused, the baby is probably the only teacher in the room.”
Parents will often have lots of questions for professionals and “there is a seduction there in giving answers”, he acknowledges. However, “I feel the minute you give the answer, you have closed off a whole avenue of inquiry for parents who need to work on their own skills as parents”.
His advice to new parents on getting to know their baby is: “Just listen and look at your baby – and take your baby seriously.” Right from the beginning, babies can sense love, respect and that feeling of being valued for who they are, which is so crucial to self-esteem and confidence in later life.
"Parents, especially first-time parents, often think they don't know anything and of course they do, they know their baby the best," says Naomi Burke, manager of Clonmel Community Resource Centre and a founding member of the Tipperary Infant Mental Health project. "It is much easier for a parent to accept support if you are putting them in the central role, rather than telling them what to do."
She sees how young, first-time mothers can feel so vulnerable in the early days. If a health professional observes how “you’re so good at soothing your baby”, she says, “it elevates them so much and they just build on that and get better and better”.
A Community Mother in Clonmel for the past 20 years, Margaret Waters was in the first group for NBO training, which was funded by the Quality Capacity Building Initiative (using money from dormant accounts) and the Tony Ryan Fund through the Community Foundation for Ireland. There's a waiting list for the next 35 training places.
“We can use it across the board with our babies and toddlers – and with mums in ante-natal,” says Waters. She sees some women towards end of pregnancy think that once they get rid of the bump, everything will be fine. They imagine going back home with their baby to a beautiful nursery and an idyllic start to family life.
‘Sleep deprivation and hormones’
“They don’t pencil in sleep deprivation and hormones.” There is a period during those difficult first weeks when any little thing you can give new mothers to cling on to, she says, such as pointing out the little smile, or what the baby can do, or their need to be cuddled, will get them through the day.
“Babies are so well designed – that’s all it takes, a little smile, and you can go again,” adds Waters, who runs two parent and baby groups and also does home visits.
When three HSE psychologists approached the Clonmel Resource Centre in 2012 to discuss how they could get the community involved in a local infant mental health project, Burke admits her first reaction was “what is infant mental health?” However, “once you’re aware of it, you can’t go back”, she says. It changes not only the way you work but your attitude in all relationships.
You have to think about who people are and why they are, especially when you work with families, she explains. “Not to judge but to understand where they are coming from. They are not an extension of yourself; you have to understand the context.”
Burke likes that the NBO “has a very scientific root – it’s not just namby-pamby stuff. The neurons in the brain are developing and have to wire. When the child is not getting these positive interactions, this doesn’t happen.”
By age three, the brain is at between 80 and 90 per cent of its adult volume. “Even more importantly, the synapses – the connections between neurons and brain cells – are formed at a faster rate during these years than at any other time in life,” Nugent told the Oireachtas Joint Committee on Health back in 2015, when stressing how the early years have lifelong implications for future mental health. “In the first years of life, between 700 and 1,000 new neural connections are formed every second, as the brain builds synapses.”
Audrey Lonergan is one of the psychologists who contacted Burke about setting up the project. She was on the founding committee in 2009 of the Irish Association for Infant Mental Health, of which she is now president-elect, and was committed to highlighting the importance of early intervention.
“Working in psychology in primary care, we would often get referrals of children when they are six, eight, 10 and in their teenage years, but we could really see, when we looked back on the histories, often right from the get-go there were difficulties – sometimes in the attachment and in the relationship.” There was a feeling of “if only we could have got in there earlier and provided support”.
Coming into Nugent’s NBO training, Lonergan says “I thought I knew about babies”. But it was a revelation to her the way “babies are born being able to communicate with us, if we can just understand what their cues are”.
What she learnt “is a language to bring the baby into the equation. When a mother is sitting there with a six-week-old baby, it is giving me a way of focusing the mum on what the baby is trying to tell us. I could have been doing that verbally before but it has given me a way to totally focus on the baby – but not to the exclusion of the mother and the father.”
She also gained knowledge on reading colour changes that indicate a baby is feeling under pressure, or a little tremor in arms or legs signalling he or she is starting to be stressed, and how to explore responses to soothe them.
Huge potential
Lonergan sees huge potential for linking this in with the maternity services and public health nurses, initially through the few staff who have trained in NBO and encouraging others to train too.
“Once you are trained in it, you can layer it in to whatever you would be doing with the family anyway.” She saw at the training, where NBO was being demonstrated with a six-week-old baby, how to use the method to help parents notice their infant’s responses.
“The trainer was holding the baby and the mother was sitting beside her; the mother spoke and the baby turned his head to the mother. It was just a beautiful example.”
The NBO system helps to show parents how special they are to their baby, who will respond to their voice and touch. Parents can lack confidence, especially if it’s their first baby, she points out, so it’s great for them to learn that the infant is ready to form a bond with them.
Life can be so busy when a newborn is brought home from hospital, says Lonergan. “The only advice I have is to try and slow down and to enjoy the time with the baby; to spend time watching the baby and noticing.”
Parents won’t always get it right but if they take the time to try to figure out what their baby is trying to say and seeing how they respond to voice and touch, “you’re helping to get things off to the best start possible”.
While parents may put a lot of pressure on themselves to have the latest toy or gadget, “in those early days, what’s most important for the baby, even from the play of point of view, is the parent – the parent’s face and the parent’s voice.” She wants parents to realise “they are enough”.
At a policy level, the crucial importance of the first three years of a child’s life is being more widely recognised. But NBO puts the spotlight on the first three months.
The results of a randomised-controlled trial in Massachusetts suggest it is effective in strengthening the relationships between parents and infants. There is also evidence it can help to reduce the incidence of post-natal depression in mothers.
A baby is, says Nugent, “a beacon of hope and has the capacity to draw the best out of us”. For parents who may have struggled with relationships in their family of origin, “there is a chance for psychological rebirth”. But they do need support.
If you want to make a difference to families, he continues, the immediate peri-natal period is perhaps the most critical time, “that is when so many families fall through the gaps”. Whereas with the right help it is, he believes, “a pivotal moment in family getting together and the relationship beginning for everybody”.
A child’s expectations about life are shaped certainly well before the third birthday, explains Nugent, author of Your Baby is Speaking to You, a gorgeous visual guide, with photographs by Abelardo Morell, first published in 2011. “That is not to say things can’t be recovered but it is a greater struggle to recover the sense of self and needs a lot of support in a health setting after that. I am hoping the NBO will become part of the delivery of care in the country,” adds Nugent.
Health and social services here are under pressure and need more support for early intervention, says Lonergan, who is interim principal psychologist with the HSE South Tipperary Therapy Services. While her local management has been very supportive, she knows colleagues can find it difficult to give time to prevention.
She too sees how that, no matter what circumstances parents are in, the sense of hope a newborn brings. “They hope they can give this baby a better beginning than maybe they had themselves. So, it’s a unique opportunity to get in and offer that support because parents are so receptive to it.”
Operating an infant mental health network is very low cost, she points out, with any professionals working with families coming together once a month for reflective practice about using the approach to pick up difficulties at an early point and to offer support.
“The vast majority of people don’t need to come to specialist services,” she adds, “if we can build that community of people who can offer support. From the HSE point of view, it’s a very cost-effective way of building services.”
Having come straight from Norway for his latest visit, Nugent says he sees the same kind of Scandinavian idealism here in Ireland, in principle at least, with “a real shift at Government level” towards the importance of early years. “I may be very romantic about this,” he concedes, “but there is a sense of fairness in Ireland and that everybody deserves the best start in life. Given the size of the country that is much more feasible than, in say North America, where it is much more challenging.”
But as the ongoing No Child 2020 campaign, by both this newspaper and the Children’s Rights Alliance is highlighting, there is still a huge chasm between knowing the right thing to do – and achieving it. Every baby needs the country’s full attention.
The HSE is launching new online resources about pregnancy and child health, mychild.ie, on July 4th. There is also a series of three books, starting with a pregnancy guide to be given to all parents at their first ante-natal visit, who will later receive handbooks to ages 0-2 and 2-5 from their public health nurse.
The NBO system explained
The Newborn Behavioural Observations (NBO) system is designed to show how infants have a wide range of visual, auditory and perceptual abilities, which they use to explore the world.
The 18 items taken into consideration when looking at behaviour patterns for what is a relationship-building tool are:
1. Habituation to light (sleep state)
2. Habituation to sleep (sleep state)
3. Muscle tone in legs and arms
4. Rooting
5. Sucking
6. Hand grasp
7. Shoulder and neck tone
8. Crawling response
9. Visual tracking (red ball)
10. Visual response to face
11. Visual response to face and voice
12. Orientation to sound (rattle)
13. Orientation to sound (voice)
14. Crying
15. Soothability
16. State regulation
17. Response to stress – colour change, startles, tremors
18. Activity level
