Supporting “The First Relationship” in Northern India I

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After our time at Deenabandhu, Ginger and I flew to Delhi from Bangalore. We were headed for the hospital we had visited briefly last year. This year we hoped to give a workshop to the nursing students but because of poor email connection, we were not sure that this would be possible. During our stay at Deenabandhu we received a welcome email from Dr. Lyall, inviting us to give the workshop and assuring us that they would take care of our accommodations and also provide for our driver. We were relieved and excited, but we still did not know what to expect.

Our trip to the Christian Hospital of Kasganj surpassed my expectations. The hospitality of Drs. Hamilton J and Nina Lyall, and the reception of the nursing school, was heart warming. Yet it started out on a less than fortuitous note. Our friend and driver, Harvinder, programmed his gps to guide our way, and the British accented female voice on the gps directed us on the shorter route from Delhi to Kasganj. Yet, the road seemed to be almost unnavigable. In fact, I was reminded of a sailing trip my husband and I took a couple of years ago on the Pas de Calais in stormy weather. The road was an old fashioned washboard of bumps and ruts, and the small towns on either side were teeming with people on foot, on bicycles, trucks, and motor scooters who had to be avoided by swerving movements. Whenever I was able manage my motion sickness well enough to open my eyes, I looked out at the fascinating view of busy humanity tucked into tiny workshops open to the street – tailor shops with sewing machines, welders, clothing shops, produce shops with red carrots and yellow and green peppers and cucumbers stacked in artistic designs. Most of the time, however, I sat quietly with my eyes shut and waited for the trip to be over. Finally, as if by a miracle, the British “woman” announced that we were at the hospital.

NinameoldmanKCH

The Christian Mission Hospital is a cluster of attractive old brick buildings. The dim corridors reminded me of the buildings of the old Peter Bent Brigham Hospital during my med school training. Our van was directed into a courtyard, where we were welcomed by the old man who had looked after my aunt many decades ago, when she worked at this hospital as a nurse. Julia, who had suggested to me that I become a doctor and come to India to work with her, died in my first year of medical school. I will tell more of her story in a future blog post. The next person to meet us was the charming Dr. Nina Lyall. A small attractive woman in a sari, Dr. Lyall was so warm in her greeting that we felt immediately at home. Dr. Lyall, who also has a master’s degree in public health from Johns Hopkins, was accompanied by one of her lovely daughters in law, a pathologist. Dr. Lyall had prepared a room for us in her home and had also found a room for our driver.

The workshop idea was inspired by the U Mass Boston parent mental health course, of whose core faculty I am fortunate to be a member. My friend and teammate, Ginger Gregory, is a graduate of the first program in Napa, where I have also taught. This  wonderful program in Napa is celebrating the tenth year since its first graduation was held next month. What Ginger and I have learned from the infant-parent course is that one of the “best bang for your buck” interventions for helping an underprivileged population is to support the mother-infant relationship. This intervention is designed to add protective factors to the mix of risk and protective factors influencing the infant’s developmental trajectory. It is based on the principle that increasing protective factors and decreasing risk factors in an infant’s life will positively affect the infant’s immediate wellbeing and future development (Shonkoff and Phillips, 2010). In the late 1990’s doctors at Kaiser Permanente conducted the famous ACE study demonstrating that adverse life events in childhood account for risk factors for illness and death in humans of all ages. Research in neurodevelopment has also documented the effect on the developing nervous system of adverse life events in early childhood (Hunter & McEwen, 2013; Perry & Hambrick, 2008). For example, traumatic events or periods affect the developing stress regulatory system with some specificity according to which part of the brain is developing at the time of the trauma (Perry, 2006).

There are many ports of entry into the mix of risk and resiliency factors in a child’s life, and one important one is the quality of the mother-infant relationship. Many studies emphasize the negative effect of maternal depression on a mother’s ability to be a responsive caregiver to her infant; the following are just a few (Apter-Danon & Candilis, 2005; Feldman, 2007; Field et al, 1998; Field et al, 2006; Murray et al, 1993; Murray et al, 2011).

Fewer, but important studies have demonstrated the positive effect of therapeutic intervention in the mother-infant relationship on the healthy development of the child. Of particular interest for this initiative are the interventions of nurse home visitors and the practice of the Touchpoints approach by pediatric clinicians (Brandt and Murphy, 2010). Nurse home visits to high-risk pregnant mothers and their infants have been shown to reduce maltreatment and abuse (Eckenrode et al, 2000), and criminal and antisocial behavior in children after 15 year follow up (Olds et al, 1998). At 6 months follow up Brandt and Murphy demonstrated improved health and developmental outcomes in children and improved maternal mental health indicators in families with home nurse visitors compared with a comparison group, and also the dyads receiving home nurse visitors with Touchpoints training did better on 10 additional measures (Brandt & Murphy, 2010, p. 185). I will consider the Touchpoints method at greater length in subsequent postings; it is an especially powerful technique for introducing developmental support into routine pediatric care.

One brief but effective intervention for supporting the infant caregiver relationship in the newborn period is the NBO, the Newborn Behavioral Observation system . This method includes a structured set of observations that the clinician uses to guide the caregiver in an introduction to the unique capacities and needs of her (or his) infant. In a recent Japanese study, the NBO was used to facilitate breastfeeding, according to the study considered an “integral part of good mothering” in Japan. The results of this study confirmed the NBO’s effectiveness in helping parents understand their newborn’s behavioral communications. Clearly, this intervention has potential for the brief educational opportunities Ginger and I would have at the nursing school. We brought copies of Kevin Nugent’s book describing the NBO, my favorite book to give as a gift to new mothers (Nugent, 2011).

Another important model that involves a more focused and extensive therapeutic approach to the infant-caregiver relationship is the Child Parent Psychotherapy (CPP) developed by Alicia Lieberman (Lieberman et al, 2005; Lieberman et al, 2006; Ghosh Ippen et al, 22011). The CPP intervention model integrates a number of conceptual models such as psychodynamic theory and attachment theory, and works with the child and primary caregiver to support and strengthen the caregiving relationship. In a randomized control study, children exposed to domestic violence receiving CPP were shown to have a reduction in total behavior problems at 6 mos. (Lieberman et al, 2006), and maintained these gains at 4 years (Ghosh Ippen et al, 2011).
It is with these studies in mind that Ginger and I approached the workshop at the Kasganj Mission Hospital. In the next postings I will describe the workshop.

References:

Apter-Danon G., Candilis D. (2005). A challenge for perinatal psychiatry: Therapeutic management of maternal borderline personality disorder and their very young infants. Clinical Neuropsychiatry, 2 (5), 302-314.

Brandt K, Murphy JM (2010), Touchpoints in a nurse home visiting program, in B Lester J Sparrow (eds), Nurturing Children and Families: Building on the Legacy of
T. Berry Brazelton, Wiley-Blackwell, pp 177-190.

Eckenrode J, Ganzel B, Henderson C, Smith E, Olds D, Powers J, … Sidora K (2000). Preventing child abuse and neglect with a program of nurse home visiting: the limiting effect of domestic violence, 284(11): 1384-1391.

Feldman R (2007) Parent–infant synchrony and the construction of shared timing: Physiological precursors, developmental outcomes, and risk conditions. Journal of Child Psychology and Psychiatry, 48, 329–354.

Field, T., Healy, B., Goldstein, S., Perry, D., Bendell, D., Schanberg, S., Simmerman, E., & Kuhn, O. (1988). Infants of depressed mothers show “depressed” behavior even with non-depressed adults. Child Development, 59, 1569-1579.

Field, T., Hernandez-Reif, M., & Diego, M. (2006). Intrusive and withdrawn depressed mothers and their infants. Developmental Review, 26 (1), 15–30.

Ghosh Ippen C, Harris WW, Van Horn P, Lieberman AF (2011). Traumatic and stressful events in early childhood: Can treatment help those at highest risk? Child Abuse and Neglect, 35:504-513.

Hunter R, McEwen B (2013). Stress and anxiety across the lifespan: structural plasticity and epigenetic regulation, Epigenomics 5(2): 177-104.

Lieberman AF, Van Horn P, Ghosh Ippen C (2005). Toward evidence-based treatment: Child-Parent Psychotherapy with preschoolers exposed to marital violence. J Amer Acad Child and Adolescent Psychiat, 44, 1241-1248.

Lieberman AF, Ghosh Ippen C, Van Horn PJ (2006). Child-Parent Psychotherapy: Six month follow up of a randomized control trial. JAACAP, 45(8):913-918.

Murray L, Kempton, C, Woolgar, M, Hooper, R. (1993). Depressed mothers’ speech to their infants and its relation to infant gender and cognitive development. Journal of Child Psychology and Psychiatry, 34 (7), 1083–1101.

Murray et al (2011). Maternal postnatal depression and the development of depression in offspring up to 16 years of age, JAACAP, 50(5): 460-470.

Nugent K (2011). Your Baby is Speaking to You, Houghton Mifflin.

Olds D, Henderson C, Cole R, Eckenrode I, Kitzman H, Lucky D (1998). Long term effects of nurse home visitation on children’s criminal and antisocial behavior : 15 year follow up of a randomized trial, J Amer Med Assoc 280(14): 1238-1244.

Brandt K, Murphy JM (2010), Touchpoints in a nurse home visiting program, in Lester B, Sparrow J (eds), Nurturing Children and Families: Building on the Legacy of
T. Berry Brazelton, Wiley-Blackwell, pp 177-190.

Perry B (2006). Application of principles of neurodevelopment to clinical work with maltreated and traumatized children, In Working with Traumatized Youth in Child Welfare, Nancy Boyd Webb, Ed., Guilford Press.

Perry B, Hambrick E (2008). The neurosequential model of therapeutics, reclaiming children and youth at www.reclaiming.com

Shonkoff J, Phillips A, From neurons to neighborhoods, Minnesota Association for Children’s Mental Health, http://www.macmh.org/2010/05/from-neurons-to-neighborhoods/

photographs by Ginger Gregory

2 thoughts on “Supporting “The First Relationship” in Northern India I

  1. Emily Walker

    HI Dr. Harrison!! I am a graduate of the IPMHP from 2011-2012. I love reading your blog and would love to be able to follow the blog. Please let me know if there is a way to get automatic updates on your blog.
    Thanks,
    Emily Walker

  2. Heidi Pace

    Dear Dr. Harrison,

    I am currently enrolled in the IPMHP at Napa. I live and work on the West Coast of the South Island of New Zealand. I agree with your comment, ” ‘the best bang for your buck’ interventions for helping an underprivileged population is to support the mother-infant relationship”. The population we serve is rural and often underprivileged. The manager of ICAMHS, who has her Masters in Infant Mental Health, and I have had our paper accepted to the WAIMH congress in Scotland. We have worked hard to develop an Infant Mental Health Program as part of the Child and Adolescent Mental Health Service offered by the District Hospital. The hospital has not agreed to fund our trip to Scotland.

    We are looking into local sponsorships, but if you have any ideas could you let me know. I am self -funding my trips to California to attend the IPMHP and I cannot afford to self- fund for the presentation in Scotland. I believe what we have to share will be of value to anyone working in a remote, rural area with an underprivileged population.

    Thank you for the work you are doing and for any ideas you may have to help us share what we have learned developing this program over the last 11 years.

    Warm regards

    Heidi Pace

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