The role of the Child Health Services in promoting mental health: anintroduction

B Wickberg

Department of Psychology, Go¨teborg University, Go¨teborg, Sweden

Wickberg B. The role of the Child Health Services in promoting mental health: an introduction.Acta Pædiatr 2000; 89 Suppl 434: 33–36. Stockholm. ISSN 0803–5326

This paper gives an introduction to the psychosocial work in the Swedish Child Health Services(CHS). There are substantial problems in defining and evaluating the preventive mental healthwork of the CHS. The issues raised include: why early preventive intervention is important; thepromotion of parental mental health as an aim of the CHS; how the CHS can increase parentingknowledge and skills; what evidence there is about intervention among target groups; and finally,how recent research knowledge can be applied in the CHS.

Key words: Child Health Services, early preventive intervention, mental health promotion,psychosocial work

B Wickberg, Department of Psychology, Go¨teborg University, P.O. Box 500, SE-405 30 Go¨teborg,Sweden (Tel.�46 31 773 1646, fax.�46 31 773 46 28, e-mail. birgitta.wickberg@psy.gu.se)

The Child Health Services (CHS) in Sweden have along tradition of what is often called “psychosocialwork”. Parent education in groups and access to childpsychologists within the services are just two examplesof this work. Comprising almost 100% of parents andinfants and focusing mainly on the infant’s first year oflife, these services offer an internationally uniqueopportunity for early mental health promotion. Thereare, however, substantial problems in defining andevaluating the preventive mental health work of theCHS. The issues raised include: which theoreticalmodels of child development are important for mentalhealth promotion; whether or not the aims of the CHSneed to be specified in order to increase systematicpreventive mental health work; what target populationsneed to be defined; and what evidence there is of theeffectiveness of early identification and intervention inthese target groups.

A transactional model of child developmentIn recent decades, there has been increasing researchinterest in child development and mental health indifferent disciplines such as developmental psychology,developmental psychopathology, neurobiology andanthropology. Developmental psychology, particularlylongitudinal studies in the field of attachment, has shednew light on how early experiences influence memory,emotion and the regulation of behaviour. Developmen-tal psychopathology has provided new knowledgerelating to developmental pathways to mental disordersand has thus provided insight into prevention and early

intervention. One area of particular research interestwhen it comes to developmental psychopathology isdepression, because of the complex interplay betweenthe psychological (e.g. affective, cognitive, interperso-nal) and biological (e.g. genetic, neurophysiological,neurobiological) components that are involved. Thereflection of both maternal depressive symptoms andattachment security in infant frontal lobe function andemotional behaviour is one example of this interplay.The findings of Dawson and colleagues (1) support theview that genetic vulnerability to depression and thequality of the caregiving experience both have animpact on neurobiological development.

In “The developing mind, toward a neurobiology ofinterpersonal experience”, Daniel Siegel has pointed outthat the field of mental health is in a tremendouslyexciting period. “The early years of life is a period oftime of especial importance for the influence ofinterpersonal relationships on how the structure andfunction of the brain will develop and give rise to theorganisation of mind” (p.1) (2). The advances ininterdisciplinary research on child development havecontributed to a transactional development model. Thismeans that the interaction between the child and itsenvironment (i.e. mother–infant interaction) and theinteractive processes within the individual (biologicaland psychological) mutually influence one another (3).In developing a secure attachment relationship, forinstance, social support appears to be more importantfor mothers with temperamentally “difficult” infantsthan for mothers whose babies have temperaments thatare more easy to handle (4). The different social systemsdescribed by Bronfenbrenner, i.e. family, friends,

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Acta Pñdiatr Suppl 434: 33±36. 2000

cultural and political systems(5), also interact withprocessesandindividual traits which areimportantforchild development.It has,for example,beensuggestedfrom aculturalperspectivethattheabsenceof postnatalrituals and taboos,which are lesscommonin westernthan in non-industrialized societies,and the lack ofsocial supportmay predisposeto parentingstressandpostpartumdepression,whichmaynegativelyinfluencethe mother–child interaction and in turn the child’scognitiveandemotionaldevelopment(6).

To summarize,by integratinginsightsfrom severaldisciplines, the ability to understandhow childrendevelopwithin a matrix of interpersonalexperienceshas greatly advanced.The challengefor future pre-ventivework is to determinehowthesenewinsightsaregoing to influencepreventiveprogrammesandclinicalpractices.

Why is early preventiveinterventionimportant?The preservationof the mental health of infants hasbeenidentifiedas“the key to the preventionof mentaldisordersthroughoutthe life span” (p.2) (7). The casefor thepreventionof mentaldisordersin youngchildrenrestson somewell-establishedfacts, summarizedbyPeterFonagy(7) in the following way. Thereis a highprevalence(20%)of significantpsychologicalproblemsin childrenandadolescents(8). Only asmallproportionof thesechildren(10–15%),however,find their way topsychiatric services. The remaining children haveemotional, behavioural or psychological problemswhich are clinically significant, but not regardedaspsychiatric disorders.Child health services are es-pecially important for the early identification of andinterventioninto problemswhich, in termsof severity,frequencyandinappropriatenessfor thechild’s age,areregardedasabnormal(9).

Anotherfindingthatis gainingincreasingrecognitionis thepooroutcomeof untreatedimpairment,especiallywhenit comesto disruptivebehaviouralproblems(10).In addition, emotionaldisordersof childhood, whichwere traditionally consideredto remit spontaneously,havebeenfound to havepoor recoveryrates(mostlyaround50%) (11). Early psychiatricdisorderspersistinto later childhood. A review by Campbell (12)revealed that about 60% of 3-y-olds who displaysignificant disturbancesstill have difficulties at 8 or12y of age.

In recent decades,researchon risk and protectivefactors for almost all child psychiatric disordershasgreatlyadvanced(13) andthereis now a largeamountof epidemiologicaldataon developmentalpathwaystopsychiatricproblems.Another recentfinding that hasinfluencedourview of preventivework is thediscoveryof “sensitiveperiods”in thedevelopmentof thecentralnervoussystem.Sensitiveperiodshave beendemon-

stratedin areassuchas emotionalreactivity (1), self-organization(14) and relationships(15), as has thedestructiveeffect of early emotional stress(16). Inaddition, the consequencesof maltreatmentearly ininfancy areneuropsychologicalaswell asbehavioural(17). The importance of early interaction for laterdevelopmenthasbeenshownin controlled,longitudinalstudies.One exampleof this is the disturbedmother–infant interaction (18) in the context of postpartumdepression,which may negatively affect the child’scognitiveandemotionaldevelopment(19).

Is the promotionof parentalmental healthanaim of the CHS?The generalaims of the CHS include “decreasingthehazardousstrain on parents and their children andsupportingandactivatingparentsin their parenthoodinorder to create optimal conditions for the generaldevelopment of children” (p.7) (20). In addition,psychosocialwork hasbeendescribedashaving threedifferent tasks(21): to supportthe normaltransitiontoparenthood, to support the vulnerable family andchildren with special needs and to take part inidentifying child abuseand neglect.Theseaims andtasks are, however,not specifiedwith regard to thementalhealthof the parent,despiteits importanceforinfantcognitiveandemotionaldevelopment.If theaimsof the CHS are not clear, the parent’sopportunity toinitiate contact,co-operateor choosenot to takepart intheservicesmaybenegativelyinfluenced.Oneexampleof this is postnataldepression,which is often regardedasa “hiddendisorder”(22).By comparison,theBritishCHS include reducing the incidence of parentaldepressionanddistressasa task(9).

Unclear aims, unspecified tasks and unresolvedquestionsof confidentialitymay haveimplicationsnotonly for the way preventive work is presentedtofamilies, but also for how it is recorded.Psychosocialinterventionsaimedat parentsor family are often notnotedin thechild’s record.As aresult,outcomescannotbe measuredand valuable information about familyproblemsis lost if thecontinuityof caregiversis broken(23). In addition, there is a risk that unrecorded,“invisible” work will disappear,if economy forcesprogrammesto becut.

How canthe CHSbring parentingknowledgeandskills to newparentson a generallevel?The cultural changeswithin “modern” societiesasso-ciated with childbirth include delayed childbearing,smallerfamiliesandthechangingroleof women(24).Ithasbeenarguedthat,becauseof thesechangesin familylife, the knowledge of parenting that is usuallytransmittedbetweengenerationshasbeeninterrupted.

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This discontinuity in knowledgeof parenting,and theabsenceof or uncertaintyabout postpartumsupport,may causeambivalencetowardsparenting,which mayin turn lower self-esteemandincreasetherisk of stressand depression.A rapidly changingfamily structurewithin society, evidencedby sharp increasesin thedivorce rate and high ratesof single-parentand step-families,alsocreatesnewrolesandresponsibilitiesforparents(6, 25).

Parenteducation,individually or in groups,is oneuniversalmeasuretakenby theCHSin order“to supportthe normal transition to parenthood”and to reducestressin the parentingrole. By offering social supportandincreasingparentingknowledge,parenteducationisintended to be a moderating factor for postpartumdistressanddepression.Therearetwo obviousaimsforparenteducationin groups.First, basicknowledge(i.e.about infant regulation and states, temperamentaldifferencesin infants, infant communicationand rela-tional capacities) can be presentedand discussed.Secondly, parents have the opportunity to shareexperiencesof transitionto parenthoodandchildrearingwith otherparents.Commonbeliefsanddisbeliefscanbediscussedandanxietiesandworriesshared.Theroleof parentaleducationin transmittingparentingknowl-edgeor increasingsocialsupportis, however,unclear.Theeffectsaredifficult to measurein a systematicwayandmostSwedishevaluationshavefocusedon processvariablesratherthaneffectvariables.Oneobviousissueof concernis whetherthe contentof parenteducationhasbeenupdatedto includeinsightsinto newandbasicresearch.

What evidenceis thereaboutinterventionamongtargetgroups?From a recentreview of psychosocialtreatmentinter-vention, the following conclusionswere drawn: Pre-vention as well as treatmentneed to be disorder orproblemspecific.“Preventionneedsto be focusedonspecific risk or protective factors, firmly rooted inempirically basedformulationsof the developmentofthe disorder” (p.7) (7). Several studies indicate thepotential benefit of intensive early intervention pro-grammesto promoteparents’mental health and self-esteemand reduce the risk of child abuse(for anoverview, see 9). These interventionsare, however,characterizedby the fact that theyaremainly basedonresearchprogrammes.Theultimatetestof thevalueofinterventionresearchmay,however,be its compatibil-ity with existing essentialservices.Defining selectedpopulationsandproviding an intensivesupportserviceor interventionfor thesegroupsis a challengefor thefuture work of the CHS. The flexibility of the CHSnurse to determineand plan the needsof each newfamily and infant togetherwith the parents,aswell asthe flexibility to adaptthe coreprogramme,is of great

importance.If the guidelinesare too vague,however,thereis a risk thattheseneedswill bedefinedin widelyvaryingways,accordingto theinterest,competenceandwork loadof the individual nurse.

Oneway of improving the serviceswould be to usestructuredmethods,such as screeningscales,for theearlyidentificationof differentmentalhealthproblems.In Sweden,self-rating scaleshave not been system-atically usedin the CHS.An instrumentfor measuringparentingstresshas recently beenadaptedfor use inSweden(26).Anotherwidely usedself-ratingscale,theEdinburghPostnatalDepressionScale(27), has beenvalidatedonaSwedishpopulation-basedsample(28).Aself-rating scale can be used as a base for carefulinterviewing,i.e. aboutissuesrelatingto stress,vulner-ability, social adversity, as well as support andresourcesaround the family. Only after a carefulclinical interview can tailored and early interventionbe planned. Before being recommendedas formalscreeningprogrammes,screening instrumentsmust,however, be evaluated against certain criteria forscreeningprogrammes(29).An opportunisticscreeningprocedure,not aimedat theentirepopulation,couldbehelpful for health professionals.Evidencerelating toearly interventionin improving attachmentbehaviourand insensitiveparentingand of intervention in thecontextof socially deprivedparentsandtheir children,depressedmothers,parentswith prematureinfantsandparentsat risk of child abusewill be reviewedin thefollowing two papers.

How canrecentresearchknowledgebeappliedin the CHS?Finally, thereis anincreasinggapbetweennewresearchknowledge,especiallyin attachmenttheory and earlychild development,and the “real world” of the childhealthcareworker.Oneway of reducingthis gapmightbe to organize an interdisciplinary perinatal/infantmentalhealthunit linked to universitydepartments.Aunit of this kind could co-ordinate and evaluateprogrammes,initiate researchand serve as a linkbetween the researchand clinical worlds. Anotherimportant task for an infant mentalhealthunit wouldbe to organizejoint training for professionalsworkingin maternal and child healthcare,adult and childpsychiatry and neonatal and obstetric wards. Theongoing ReadingHealth Visitor Programme,run bytheDepartmentof PsychologyatReadingUniversity,isoneexampleof theway recentresearchknowledgecanbeappliedin theCHSin orderto facilitate goodinfantcareandparent–infantrelationships(personalcommu-nication). This programme includes training healthvisitors in four componentsof preventiveintervention:counselling,assessmentof the interactivecapacitiesofthe newborn infant, managementof certain areasofdifficult infantbehaviour(i.e.sleep,cryingandfeeding)

ACTA PÆDIATRSUPPL434(2000) Child HealthServicesandmentalhealth 35

andfacilitation of mother–infantinterpersonalinvolve-ment.

In conclusion,training programmesfor child healthprofessionalsandstructuredmethodsfor the identifica-tion of and intervention within well-defined targetgroupsneedto be developed,or adapted,for Swedishusein order to improvethe quality andcost-effective-nessof psychosocialwork in theCHS.

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