Prevention and Early Intervention in Mental Health- Prenatal Period to Early Childhood

Prenatal Period to Early Childhood

Addressing mental health begins before birth. Throughout the prenatal period and into the first years of life, a child’s brain and body develop rapidly, leaving the child particularly vulnerable to outside influences. The infant brain is developing abilities like language and motor skills with feedback from external sources, and is more vulnerable to substances than the brains of older children and adults. While the changes from conception to early childhood are obvious from the outside, research on brain development continues to show us why this period is so important for later brain architecture and future functioning.

As noted above, infancy and early childhood is an especially important time for brain development. Outside of the environmental factors that affect brain development outlined below, scientists have also long considered the importance of looking at the blooming brain of infants for indication of developmental disabilities like Autism Spectrum Disorder (ASD).[i],[ii],[iii] Specifically, these scientists have considered that ASD might be linked to processes that result in an over blooming or abnormally high levels of brain growth in the first years of life.

Health:

  •  Prenatal Substance Use: The use of alcohol, tobacco, and recreational drugs during pregnancy can have a serious, lasting impact on the child. Substances are particularly harmful at this stage, as the barrier of cells adults have to protect the brain from chemicals does not yet exist. Substance use and abuse can also lead to premature birth or very-low to low birth weight. Very-low birth weight (under 3 lbs.) is associated with an up to 4.5 times higher risk for psychiatric problems, while low birth weight (under 5 lbs.) increases risk for psychiatric problems in adulthood by 2.5 times.[iv] Alcohol has the most damaging effects of all substances during pregnancy, with strong links to delayed development, reduced emotional control, problems with attention, and hyperactivity.[v] Tobacco use has also been linked to disruptions in cognitive, emotional, and behavioral development.[vi] Other recreational drugs, like cocaine and methamphetamines, appear to have a more delayed effect with a slight impact during early life but difficulties in mood, attention, and hyperactivity during adolescence. Given the sensitivity of the prenatal and infant brain, even medications like acetaminophen (Tylenol) have been recently linked to increased rates of autism, attention deficit, problematic psychomotor, cognitive, and emotional development.[vii],[viii],[ix]  This new research is especially concerning since acetaminophen is often the recommended pain reliever for pregnant women.  Further research is certainly needed to explore these connections.[x] Until more is known, it is important that families are informed of the risks of taking substances during pregnancy and the first years of life.
  • Maternal Health: Some common health issues during pregnancy have been linked to a child’s future mental health. For example, studies suggest that the risk for developing schizophrenia is three times greater in children whose mothers’ had the flu during pregnancy.[xi] Other studies show children born to mothers with iron deficiencies are four times as likely to develop schizophrenia.[xii] In terms of maternal mental health, high levels of stress, anxiety, and depression during pregnancy have been linked to preterm birth and low birth weight.[xiii] In multiple large studies, maternal trauma has been associated with higher rates of psychiatric disorders in the child, and its effect may actually be underestimated due to reliance on hospital records of disorders.[xiv]
  • Toxic Exposure: Exposure to mercury, lead, manganese, and organophosphates, among other chemicals, are dangerous from the early stages of pregnancy into early childhood.[xv] Exposure can occur through water, food, or synthetic materials like paint or gasoline. While all toxic exposures have the potential to affect future development, mercury can be particularly dangerous, as it may leave the brain more exposed to additional toxins.[xvi] Lead exposure has also been repeatedly linked to disrupted brain formation, leading to learning, behavioral, and attentional difficulties.[xvii] In a 2006 report, the national Scientific Council on the Developing Child estimated that the cost of cognitive impairments from lead alone is close to $43 billion each year.[xviii]

Safety & Security:

  • Exposure to Intimate Partner Violence: Intimate partner violence (IPV), also referred to as domestic violence, includes physical, sexual, emotional, verbal, and psychological abuse. While it can be difficult to find reliable data on its prevalence, some research shows women are at an increased risk for intimate partner violence from a year prior to pregnancy until a year following birth.[xix] Exposure to intimate partner violence during pregnancy is associated with more than twice the risk for preterm birth and low birth weight, both of which are associated with increases in attentional, behavioral, and psychological disorders in children.[xx] For the mother, exposure to intimate partner violence has been associated with increased likelihood of abdominal trauma, health problems, mood and anxiety disorders, and symptoms of posttraumatic stress disorder (PTSD), all of which may be related to the impact of IPV on a developing child.[xxi]

Resources:

  • Health Care: While the Affordable Care Act (ACA) has increased access to health insurance and mandated coverage of maternity and newborn care, there is limited knowledge of the percent of pregnant women who experience inconsistent or inadequate care. Mothers who are uninsured and do not qualify for Medicaid cannot enroll outside of an insurance company’s open enrollment period because pregnancy is not considered a “qualifying life event.”[xxii]  This is dangerous for women and their children, particularly for women living in states that have not expanded Medicaid. Half of all pregnancies are unplanned, which means some women who become pregnant may not find out that they do not have adequate coverage until it is too late.[xxiii] Statistics show that mothers who do not receive medical care during pregnancy have three times the rate of low birth weight and five times the rate of infant mortality as mothers who received care during pregnancy.[xxiv] Maternal mortality is also five times higher among those who do not receive care.[xxv]
  • Housing: Young women experiencing homelessness are almost five times more likely than their peers to become pregnant.[xxvi]  Mothers experiencing homelessness during pregnancy at all ages are less likely to receive medical care. Additionally, we know that those experiencing homelessness have higher rates of exposure to violence and substance abuse, both of which are tied to disruptions in development.[xxvii] Children born to mothers experiencing homelessness are three times as likely to be born preterm and have a greater chance of low birth weight.[xxviii]
  • Access to Food: Access to food during pregnancy and early life is crucial for the rapidly developing child. Multiple, cross-cultural studies have shown that children born to undernourished mothers had significantly increased likelihood of developing depression, mania, and schizophrenia.[xxix] It is important to focus not only on whether food is available but also on what type of food is available, as ensuring adequate nutrition, not just caloric intake, is important in pregnancy and early life.[xxx] In some environments, such as urban “food deserts,” nutritious food is more difficult to access and consumption of higher calorie, less nutritious food is promoted, placing mothers in these environments at risk.[xxxi]

Relationships:

  • Parenting: Nurturing parenting or caregiving during infancy and early life is essential for healthy physical, psychological, and social development. This includes sensitivity to the needs of the infant, using praise or rewards for positive behavior, using appropriate and consistent negative consequences for undesired behavior, and spending positive time with children doing activities like playing or reading.[xxxii] Nurturing parenting is affected in part by the parent’s socioeconomic resources – is the new family supported by positive relationships or are they under a lot of stress?[xxxiii] Parenting related challenges during infancy and early childhood can impact the development of important neural pathways and the architecture of the brain. Mounting research shows this disruption can increase the likelihood of future mental health problems.[xxxiv]

Interventions:

Interventions that ensure that new families have access to necessary medical care, food, housing, and social supports are necessary to child health and nurturing parenting.  In addition, home intervention programs have proven helpful in addressing short-term difficulties and long-term mental health risks. While formats and content vary, these programs work with pregnant women and new mothers into early childhood to provide education about child development and positive parent-child interactions, serve as social support, and increase access to social and health services. For example, women who enrolled in Healthy Families New York prior to their 31st week of pregnancy saw a 48% reduction in low birth weight deliveries.[xxxv] Healthy Families New York provides home-based services to new and expectant parents and offers participation until the child reaches school age.[xxxvi] Another program called Nurse Family Partnerships focuses on first-time mothers and provides in-home visits by nurses. Nurse Family Partnerships was founded to improve maternal caregiving, reduce rates of antisocial behavior in children, and decrease maternal tobacco use. One study on Nurse Family Partnerships showed a drop in average nicotine levels from 250 ng/ml at the start of the study to 12.32 ng/ml after intervention.[xxxvii] The Incredible Years also offers home visitation for parents of infant, toddler, preschool, and school age children. After family participation in the Incredible Years program, two-thirds of the children diagnosed with oppositional defiant disorder and ADHD no longer met criteria for those diagnoses at 3 and 10 year follow-ups, and with a large effect size relative to the control groups.[xxxviii] One meta-analysis using 60 home visitation programs determined that, even with the difficulty of evaluating the different programs as a group, families who participated in home visitation programs generally had better outcomes than those who did not.[xxxix] Across the board, mothers were more likely to pursue additional education, and children performed better in three out of five areas of cognitive and social-emotional functioning. Another meta-analysis of 25 programs noted that average benefits outweighed the costs of the programs.[xl] Home visitation programs are a cost-effective way to promote healthy development and address many of the risk factors for mental health disorders in a comfortable setting for the whole family.

Prevention and Early Intervention in Mental Health

[i] DiCicco-Bloom, E., Lord, C., Zwaigenbaum, L., Courchesne, E., Dager, S. R., Schmitz, C., ... & Young, L. J. (2006). The developmental neurobiology of autism spectrum disorder. The Journal of neuroscience: the official journal of the Society for Neuroscience, 26(26), 6897.

[ii] Courchesne E, Karns CM, Davis HR, Ziccardi R, Carper RA, Tigue ZD, Chisum HJ, Moses P, Pierce K, Lord C, Lincoln AJ, Pizzo S, Schreibman L, Haas RH, Akshoomoff NA, Courchesne RY (2001) Unusual brain growth patterns in early life in patients with autistic disorder: an MRI study. Neurology 57:245–254.

[iii] Courchesne E, Redcay E, Kennedy DP (2004) The autistic brain: birth through adulthood. Curr Opin Neurol 56:269–278.

[iv] Boyle, M. H., Miskovic, V., Van Lieshout, R., Duncan, L., Schmidt, L. A., Hoult, L., ... & Saigal, S. (2011). Psychopathology in young adults born at extremely low birth weight. Psychological medicine, 41(08), 1763-1774.

[v] National Scientific Council on the Developing Child, Early Exposure to Toxic Substances Damages Brain Architecture, spring 2006

[vi] Allen, Jessica, et al. "Social determinants of mental health." International Review of Psychiatry 26.4 (2014): 392-407. http://www.tandfonline.com/doi/full/10.3109/09540261.2014.928270

[vii] Bauer, A. Z., & Kriebel, D. (2013). Prenatal and perinatal analgesic exposure and autism: an ecological link. Environ Health, 12(1), 41.

[viii] Brandlistuen RE, Ystrom E, Nulman I. et al. Prenatal paracetamol exposure and child neurodevelopment: a sibling-controlled cohort study. Int J Epidemiol 2013; 42:1702–13.

[ix] Shaw, W. (2013). Evidence that increased acetaminophen use in genetically vulnerable children appears to be a major cause of the epidemics of autism, attention deficit with hyperactivity, and asthma. Journal of Restorative Medicine, 2(1), 14-29.

[x] Brandlistuen, R. E., Ystrom, E., Nulman, I., Koren, G., & Nordeng, H. (2014). Authors' Response: More research on paracetamol is required. International journal of epidemiology, 43(3), 975-976.

[xi] Kirsten Weir. The beginnings of mental illness. American Psychological Association, February 2012, Vol 43, No. 2. P 36. http://www.apa.org/monitor/2012/02/mental-illness.aspx

[xii] Kirsten Weir. The beginnings of mental illness. American Psychological Association, February 2012, Vol 43, No. 2. P 36. http://www.apa.org/monitor/2012/02/mental-illness.aspx

[xiii] Talge, N. M., Neal, C., & Glover, V. (2007). Antenatal maternal stress and long?term effects on child neurodevelopment: how and why?. Journal of Child Psychology and Psychiatry, 48(3?4), 245-261.

[xiv] Ibid.

[xv] National Scientific Council on the Developing Child, Early Exposure to Toxic Substances Damages Brain Architecture, spring 2006, https://developingchild.harvard.edu/resources/early-exposure-to-toxic-substances-damages-brain-arch…

[xvi] National Scientific Council on the Developing Child, Early Exposure to Toxic Substances Damages Brain Architecture, spring 2006, http://developingchild.harvard.edu/wp-content/uploads/2015/05/Early_Exposure_Toxic_Substances_Brain….

[xvii] National Scientific Council on the Developing Child, Early Exposure to Toxic Substances Damages Brain Architecture, spring 2006, http://developingchild.harvard.edu/wp-content/uploads/2015/05/Early_Exposure_Toxic_Substances_Brain….

[xviii] National Scientific Council on the Developing Child, Early Exposure to Toxic Substances Damages Brain Architecture, spring 2006, http://developingchild.harvard.edu/wp-content/uploads/2015/05/Early_Exposure_Toxic_Substances_Brain….

[xix] Bailey, B. A. (2010). Partner violence during pregnancy: prevalence, effects, screening, and management. International Journal of Women’s Health, 2, 183–197.

[xx] Bailey, B. A. (2010). Partner violence during pregnancy: prevalence, effects, screening, and management. International Journal of Women’s Health, 2, 183–197.

[xxi] Van Parys, A. S., Verhamme, A., Temmerman, M., & Verstraelen, H. (2014). Intimate partner violence and pregnancy: A systematic review of interventions.

[xxii] Tag Archives: Pregnancy special enrollment. (2015, March 19). Retrieved from http://younginvincibles.org/tag/pregnancy-special-enrollment/

[xxiii] Tag Archives: Pregnancy special enrollment. (2015, March 19). Retrieved from http://younginvincibles.org/tag/pregnancy-special-enrollment/

[xxiv] Prenatal Services. (n.d.). Retrieved from https://mchb.hrsa.gov/

[xxv] Berg, C. J., Callaghan, W. M., Syverson, C., & Henderson, Z. (2010). Pregnancy-related mortality in the United States, 1998 to 2005. Obstetrics & Gynecology, 116(6), 1302-1309.

[xxvi] Smid, M., Bourgois, P., & Auerswald, C. L. (2010). The Challenge of Pregnancy among Homeless Youth: Reclaiming a Lost Opportunity. Journal of Health Care for the Poor and Underserved, 21(2 Suppl), 140–156. https://www.doi.org/

[xxvii] Cutts, D. B., Coleman, S., Black, M. M., Chilton, M. M., Cook, J. T., de Cuba, S. E., ... & Frank, D. A. (2014). Homelessness during pregnancy: A unique, time-dependent risk factor of birth outcomes. Maternal and child health journal, 19(6), 1276-1283.

[xxviii] Cutts, D. B., Coleman, S., Black, M. M., Chilton, M. M., Cook, J. T., de Cuba, S. E., ... & Frank, D. A. (2014). Homelessness during pregnancy: A unique, time-dependent risk factor of birth outcomes. Maternal and child health journal, 19(6), 1276-1283.

[xxix] Weir, K. (2013). The beginnings of mental illness. Monitor on psychology,43(2), 36.

[xxx] Women, Infants and Children (WIC). (2013, November 18). Retrieved from http://www.fns.usda.gov/wic/about-wic-how-wic-helps

[xxxi] Song, H., Gittelsohn, J., Kim, M., Suratkar, S., Sharma, S., & Anliker, J. (2009). A corner store intervention in a low-income urban community is associated with increased availability and sales of some healthy food. Public Health Nutr., (12)11, 2060.

[xxxii] O'Connell, M. E., Boat, T., & Warner, K. E. (Eds.). (2009). Preventing Mental, Emotional, and Behavioral Disorders Among Young People:: Progress and Possibilities. National Academies Press.

[xxxiii] Barrett, AE & Turner, RJ (2005). Family Structure and Mental Health: The Mediating Effects of Socioeconomic Status, Family Process, and Social Stress. Journal of Health and Social Behavior, 46(2), 156-169.

[xxxiv] Bramlett, M. D., & Blumberg, S. J. (2007). Family structure and children’s physical and mental health. Health affairs, 26(2), 549-558.

[xxxv] Healthy Families New York: A Home Visiting Program that Works. (2012, July 1). Retrieved from http://ocfs.ny.gov/main/publications/Pub5134.pdf

[xxxvi] Healthy Families NY. (n.d.). Retrieved from http://www.healthyfamiliesnewyork.org/

[xxxvii] Olds, D. L., Robinson, J., O’Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., ... & Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics, 110(3), 486-496. Chicago 

[xxxviii] https://incredibleyears.com/.  See also Webster-Stratton, Carolyn. "The incredible years: Parents, teachers, and children training series." Residential treatment for children & youth 18.3 (2001): 31-45.

[xxxix] O'Connell, M. E., Boat, T., & Warner, K. E. (Eds.). (2009). Preventing Mental, Emotional, and Behavioral Disorders Among Young People:: Progress and Possibilities. National Academies Press.

[xl] O'Connell, M. E., Boat, T., & Warner, K. E. (Eds.). (2009). Preventing Mental, Emotional, and Behavioral Disorders Among Young People:: Progress and Possibilities. National Academies Press.