Resumen de La salud mental del bebé. Nuevas evidencias

Teresa Lartigue, J. Martín Maldonado-Durán, Juan Manuel Sauceda García

• español

  En este artículo se resume la evidencia más significativa sobre la importancia de la salud mental del lactante. Aborda asimismo la implementación de intervenciones clínicas y preventivas. Se revisan la importancia del desarrollo temprano del cerebro, su necesidad de estímulo para establecer sinapsis y vías refinadas, así como el impacto negativo de experiencias adversas.

  Esto significa que la infancia temprana es un periodo de gran vulnerabilidad pues estos procesos de reconfiguración pueden ser alterados con consecuencias negativas a largo plazo para el funcionamiento psicomotriz del niño o niña. Se describen algunos estudios longitudinales que conectan factores de la etapa preescolar con la criminalidad y la timidez excesiva en la edad adulta.

  Se cubren los estudios epidemiológicos sobre la prevalencia de llanto excesivo, problemas relacionados con el sueño y la alimentación, así como con la ansiedad, el trastorno traumático en el bebé y finalmente los efectos de la depresión materna. Se abordan técnicas de intervención clínica y la escasa evidencia sobre su eficacia, subrayando las indicaciones y las diferencias entre los diversos enfoques terapéuticos. Finalmente, se aborda el efecto de la intervención temprana (durante el embarazo, periodo neonatal y visitas domiciliarias) como factor de prevención a largo plazo.

• English

  This article describes infant mental health from two perspectives: why it is relevant and how to implement interventions, including preventive ones. Topics covered are based on evidence available in scientific literature. The first section addresses areas that justify the importance assigned to infants and their emotional well-being. One of them deals with new information about brain development. Recent available information emphasizes the crucial role of sensory/experiential input for the development of the brain in terms of determining the formation of new synapses, influencing cell migration and the “pruning” of refined and dedicated neuronal pathways. Experiences (exposure to language, contingent responses by the caregiver, motion in space) influence the development of the brain. Also, negative and anxiety provoking events as well as psychological trauma cause a negative outcome through this effect. Prolonged and/or severe trauma has been shown to influence negatively the functioning of the limbic system and the capacity of the child to feel empathy and/or compassion, to regulate emotions and to learn new information. New evidence is reviewed from longitudinal research. Several studies have demonstrated that it is possible to “trace back” which elements are necessary during early childhood, to put a child at a high risk of becoming a criminal or severe offender. These include attributes in the child him or herself (restlessness, impulsiveness, lack of fear) together with a history of maltreatment and chronically adverse experiences. Excessive shyness is another fairly persistent trait from early infancy to adulthood. Since these “risk factors” are known, particular children could be targeted for early intervention programs. A follow up study conducted by some of the authors with infants seen in a mental health clinic and followed up to age four, indicates that the strongest predictor of the outcome and functioning of the child at age four is not the severity or type of problems for which the child was originally evaluated. The strongest predictor was the quality of parenting and parenting behaviors of the caregivers as assessed during infancy. This finding suggests the importance of helping parents as early as possible to cope with infant problems in a benign and sensitive way, before negative circles of interaction are entrenched and spiral into an ongoing negative relationship. Together with the studies of risk, those focusing on resilience are summarized. Knowing which traits or experiences are protective against psychopathology is crucial, in order to promote their flourishing in early childhood. Studies with children at high psychosocial risk from Kauai, Hawaii as well as with children from other groups in the world converge in describing resilient traits in early childhood: an easy temperament, a “social orientation”, sense of humor, attractiveness and the ability to communicate with others, as well as intelligence. Several experiences are protective, such as having few separations from the mother and having had a sibling when the index child was at least three years old. This knowledge can be used to promote resilient features in children and to develop interventions for those at most risk. Epidemiological evidence suggests that infancy disturbances are not rare, but frequent (15 to 20% of the population). Studies of the prevalence of problems like feeding and sleeping disturbances, excessive crying and disruptive behavior in infancy point in this direction. This justifies the need for early recognition and identification, particularly when they are severe. Excessive crying increases the risk of the child being abused or shaken; likewise sleep disturbance is associated with irritability and hyperactive behavior in the infant. Parents who are deprived of sleep are prone to be more negative and to feel exhausted. Eating disturbances can be associated with failure to thrive. Early malnutrition has been associated with hypertension in middle age, as well as with a higher risk of coronary disease. Maternal depression and domestic violence are rampant in the perinatal period. Maternal depression is associated with more crying and sleeping problems in infancy, and hyperactivity and negative behavior in the school age child. The findings of a survey in a “well-baby clinic” (health surveillance clinic) conducted by some of the authors concur in the finding that parents are worried about their baby’s behavior in all these areas and that they readily identify the problems, when asked. Furthermore, their worries are justified. This is in sharp contrast with the tendency in most pediatric settings to “wait and see” hoping that problems in the baby will be solved by themselves. The second part of the review focuses on two issues: techniques of clinical intervention and preventive strategies and their results. There is scant scientific evidence on the efficacy of parent infant psychotherapies. Techniques vary widely in their content and their focus or target population. Strategies like brief parent-infant psychotherapy and the therapeutic consultation are framed psychodynamically and focus on the transgenerational transmission of “fantasmatic” interactions and projections placed on the infant.

  These appear more suitable for families that are relatively healthier and lacking massive stressors. On the other side of the spectrum, techniques such as interactive guidance and infant-parent psychotherapy are designed for families under more stress, and when the parent child relationship is very negative. These strategies are used with “unreachable families”. Interactive guidance attempts to focus on what the parents are doing well through a videotaped feedback given to them, and gradually expanding their repertoire of sensitive and empathic behaviors towards the baby. Infant-parent psychotherapy is long term and involves interventions that are non traditional, like psychotherapy at home, practical help to the parents, and the promotion of a long term relationship of trust between the caregivers and the therapist. The focus is to achieve a “corrective attachment experience” in the parents, which will in turn render them more sensitive and responsive towards their baby. Multimodal and flexible techniques are advocated in order to tailor the intervention to the particular needs and style of each family. Finally, evidence on the effectiveness of various prevention programs is reviewed. These are grouped according to the timing of the intervention, from pregnancy to toddlerhood. Evidence suggests that improving marital communication and promoting conflict resolution before the baby is born may enhance maternal sensitivity and lead to a more secure attachment in the infant. There is research on interventions in the perinatal period. These include having psychosocial support during the delivery process. In addition, “bonding” between newborn and mother (without undue intrusion by health care personnel) has positive effects. This involves skin to skin contact and early breast-feeding. These simple interventions have been shown to promote maternal sensitivity, more patience and less behavioral difficulties several months later. The mere demonstration of the abilities of the newborn, his or her uniqueness and preferences as well as an observation of the baby’s perceptual abilities, is associated with long term positive behavioral effects. All this points to the importance of conducting an intervention during a “sensitive period”. Several meta-analytic studies on home visitation conclude that these programs are most effective if the intervention has a clear focus, is brief and practical help and advice are given to the parents on site. By contrast, with families having a high risk of abusing their child, home visitations are the only hopeful strategy so far. In this case, home visitation should be long-term and also focused on specific problem solving with parents and suggestion of alternative strategies of behavior management with the child. In families under considerable stress home visitation, together with the opportunity to have positive experiences for the infant, in the form of a good day care setting, also have a lasting and beneficial effect several years later, in terms of better academic performance, reduced psychopathology and better parent child relationships.