This column marks the retirement of Hiram Fitzgerald from his many editorial roles of this WAIMH publication. He was the inaugural WAIMH Executive Director in 1993 when The Signal was first published with Charles Zeanah as Editor-in Chief and since that time has been actively engaged with the publication including the roles of copy editor and associate editor of Perspectives in Infant Mental Health. Of special note and acknowledgement is Dee Končar, Hi’s wife who has also contributed as a production editor of The Signal in the 1990’s. In honour of Hi’s longstanding contribution to this publication since 1993, we invited Hi to write a paper as he reflected back over the past years. The title of his paper is: Forty Years with Infant Mental Health: Some Reflections for the Future. Hi’s paper is followed by some brief commentaries and in turn these commentaries are followed by a selection of tributes to Hi. These tributes are from a selection of colleagues and friends within WAIMH that offer a glimpse into Hi’s immense outreach and support to many people in our field.
Forty Years with Infant Mental Health: Some Reflections for the Future
By Hiram E. Fitzgerald, Ph.D. Department of Psychology and University Outreach and Engagement, Michigan State University, Michigan, USA.
Forty-one years ago, Thomas Taflan-Barrett, a clinical psychology graduate student at Michigan State University, asked me to seek a position on the Michigan Association for Infant Mental Health (MI-AIMH) Board of Directors. I followed his advice and much to my surprise, I was elected. During my first year on the MI-AIMH Board (1979) two decisions launched my connection with infant mental health; a connection that has lasted 42 years (and still counting!).
The first Board decision was to establish the International Association for Infant Mental Health (IAIMH) (see Fitzgerald, 1985; Fitzgerald & Barton, 2000), and the second was to establish the Infant Mental Health Journal as its official publication. Eventually IAIMH merged with the World Association for Infant Psychiatry and Allied Disciplines (WAIPAD), creating in 1992, the World Association for Infant Mental Health (WAIMH) (Fitzgerald & Barton, 2000). Affiliate Associations linked to IAIMH transferred to WAIMH and the new organization was off and running. Sixteen years later, WAIMH’s central office moved from Michigan State University to the University of Tampere, Finland where it has continued to flourish.
The second decision created the Infant Mental Health Journal, with Jack Stack as its founding editor. Problems with the initial publishing house led to the Michigan Association for Infant Mental Health acquiring copyright of the journal (see Fitzgerald & Barton, 2000). Over the years, special issues of the Infant Mental Health Journal have drawn attention to substantive issues affecting the development of infants and very young children, including fathers and infants (Fitzgerald & McGreal, 1981; Fitzgerald, Mann & Barrett, 1999; Bocknek, Hosssain & Roggman, 2014), infant and parent depression (Fitzgerald & Field, 1998), early exposure to alcohol and other drugs (Fitzgerald & Olson, 2001), culture and infancy (Tomlinson, Swartz & Fitzgerald, 2006; Fitzgerald, Mann, Cabrera, Sarche & Qin, 2009), the impact of Early Head Start, a USA national intervention targeting families with infants and toddlers (Fitzgerald, Love, Raikes & Robinson, 2005), and infants in foster and kinship care (Clyman & Harden, 2002).
The special issue that especially influenced me was the one honoring the career of Louis Sander (Hoffmann, 2000), in which he made reference to ‘the diversity of disciplines that are emerging as the crossroads of infant mental health including biology, neuroscience, physics, genetics, obstetrics, neonatology, pediatrics, psychology, psychiatry, sociology, anthropology, linguistics, et cetera” (Sandor, 2000, p. 5). This multidisciplinary view of infant development was buttressed by Sander’s call to view early development from a nonlinear dynamical system framework and understand “change in the individual as part of a larger systems process of change” (p. 5). He also challenged infant mental health researchers and practitioners to seek longitudinal evidence for the dynamic processes of early development, attending to the transitional phases of development and life-course experiences. In effect, Sander was advocating assessing the relative impact of proximal processes relative to distal processes over the life course. In this regard, he was calling for more person-oriented analyses of development rather than variable-oriented analyses, to gain greater insight into how individuals change (or not) over time, and how such change becomes embedded or nested within increasingly complex systems over time, including the range of neurobiological networks and epigenetic changes organized by experience and synergistically organizing experience (Sameroff, 1983: Emde & Sameroff, 1989).
As infant mental health celebrates its 43rd birthday, the question Sander raised seems as relevant today as it was then: “Where are we going in the field of infant mental health” (p. 5). I believe a good starting point for a broad answer to Sander’s question is to expand on his call for more systemic views of early development, and link it to three component areas where I believe infant mental health research and practice can uniquely contribute to a deeper understanding of developmental processes during the early years of life, particularly with respect to the interplay among genetics, epigenetics and lived experiences (Champagne, 2014).
Infants and Families as Dynamic Systems
Loukas and colleagues (1998) described the family “as a unity of interacting personalities,” all of which are influenced by the codes, rituals, stories, roles (Sameroff, 1995) brought to the family by parents, grandparents, kinfolk, friends and neighbors and others. Individuals and families develop, organize, and change over the life course. Some experience positive and productive family relationships, some experience difficulties and fail, others find ways to overcome difficulties, build resilience and succeed over time. In every instance, family relationships develop and change over time due to a wide range of endogenous and exogenous influences. New members come into the family system in the form of grandparents, step-parents, foster-parents, uncles, in-laws, non-biologically related kinfolk (e.g., godparents, deep-relationship friends), teachers, peers, religious leaders, neighbors, barbers and hairdresser, and coaches, and all contribute to the individual’s relationship experiences and are evaluated and internalized in relation to the individual’s emerging sense of self.
For the past two decades I have become increasingly concerned about infant mental health’s emphasis on the importance of dyadic and at the most, triadic interactions in early development. Although there are 3 sets of dyadic relationships in a family with two parents and one child, Emde (1991) pointed out that there are 45 dyadic relationships in a two-parent family with 3 children. Imagine a study of social-emotional relationships with 45 dyads per family with a study sample of 100 such families; complex systems indeed! Although many researchers give lip service to systems theory, it is not reflected well in the majority of research published, for example, in the Infant Mental Health Journal. A notable exception is Beebe et al’s (2016) use of dynamic systems organizing concepts to examine, microanalytically, the organizational processes regulating the emergence of self and interactive-contingencies during dyadic face-to-face mother-infant interactions.
The fact is that we know little about the actual daily lived-experiences of infants and there is either little interest in naturalistic studies of infants and their families, or investigators of such work do not view the IMHJ as an appropriate outlet for such research. For example, during my first tenure as editor of the IMHJ, a paper was submitted dealing with the natural mother-infant separation experiences that occurred during early infancy, using a short-term longitudinal design. Reviewers did not respond positively, with most raising issues linked to extant attachment theory and coding of relationship dynamics within the traditional strange situation attachment methodology. At the time, I could not recall any published study that actually examined how often mothers and infants experienced separations during daily occurrences in lived experience, but I did remember Rheingold and Eckerman’s (1970) paper that drew attention to the infants separating from mothers, and the work of Shaffran and DeCarie, (1973) and Soloman-Shaffran and Decarie (1976) that illustrated continuities and discontinuities in infants’ responses to strangers during home visits over time, as well as gender differences in infants’ responses to strangers during home visits. So, I accepted the paper and to this day, I think it continues to be the only published longitudinal study of naturally occurring daily separations of mothers and infants. Check it out! (Suwalsky, Klein, Zaslow, Rabinovich, & Gist, 1987). The point is, that we tend to exclude the natural world of the infant when we conduct highly constrained cross-sectional studies of what Overton (2015) might refer to as “moments”, rather than processes that change (or not) over time. Or, to the dynamic daily events that bring the infant and young child into interactions with others in countless “strange situations” or result in naturally occurring separations from their mothers. Rheingold (1969) not only reminded developmental researchers that the infant is a social being, but also that infants do separate from their mothers (Rheingold & Eckermen, 1970). Why do developmental scientists need such reminders? We need ethological studies to understand infant development as it occurs in more normative or everyday contexts, and, perhaps to ask different questions about adaptations that occur over the life course and the lived experiences that play an explanatory role in shifting individuals to different pathways of development over time.
A different issue that needs to be addressed concerns the researcher’s view of what is normative family development. A great many babies are not reared by their parents or are only partially reared by their parents. I think most researchers in the Western world are biased by views that normative development requires parenting practices that stress individualism and the emergence of autonomy as the dominant goals of parenting. Little attention is given to cultures where communal values are the norm and the individual represents a socially constructed being who is always embedded within community (Shwalb, Shwalb & Lamb, 2013). How many assessment tools do we have that are based on such cultural values, in contrast to values that place individualism and autonomy as the gold standards for guiding human relationships and “normative” development (Dauphinais & King, 1992).
So we need to understand parenting better as well and understand within a systems framework, because parents change, so parenting a sixth child is different than parenting a first one, not just because there are six children, but because the dynamics of the family system have changed substantively (Emde, 1991). Marc Bornstein (2010) has made significant contributions to issues related to understanding parenting, especially cross-culturally, and about early child development, and Michael Lamb has led the way on identifying fatherhood in many cultures of the world (Lamb, 1987; Shwalb et al., 2013), and Harkness and Super (1996) exposed similarities and differences in parents cultural beliefs. We need longitudinal studies of families in order to understand life course-pathways other than those characteristic of children raised in families selected because of existing psychopathology (Zucker, Fitzgerald & Moses, 1995; Eiden & Leonard, 2000), low-income and family resources (Shaw, Keenan & Vondra, 1994), at high risk for the development of violence (Nagin & Tremblay, 1999), or linked to a particular relationship issue in infancy (Sroufe, 2005).
Fathers and Family Systems
Fathers are part of the infant’s everyday life experience through direct and indirect effects on family functioning, spousal relationships (including co-parenting), and child relationships (including similarities and differences between relationships with sons and daughters). The IMHJ drew attention to fathers and infancy during its second year of publication (Fitzgerald & McGreal, 1981) and subsequently (Fitzgerald, Mann & Barrett, 1999; Bocknek, Hossain & Roggman, 2014). During the 1970s and 1980s researchers focused on studies related to paternal performance. Are fathers capable of providing primary care to infants, such as changing diapers, feeding and bathing them? Relatively few early studies were focused on identifying what unique contributions fathers make to infant and child development. There now is considerable evidence that fathers contribute to early childhood development in ways other than supplying sperm, although contemporary research suggests that pre-conception paternal sperm may in fact cause epigenetic effects affecting the fetus in ways previously attributed to the mother (Day, Savani, Krempley, Nguyen, & Kitlinska, 2016; Finegersh & Homanics, 2014). Infants do develop attachment relationships with their fathers, but evidence suggests that infant-father attachment may be qualitatively different than infant-mother attachment, especially with respect to child gender differences. Lamb (1977) was among the first to note that the quality of attachment may be different for fathers and sons compared to fathers and daughters, and for mothers and daughters compared mothers and sons. Paquette’s (2004) activation relationship, which draws on Bowlby’s exploration facet of attachment (1973) captures these differences with respect to fathers and sons. The activation relationship encourages exploration and risk taking and often is expressed through father’s rough and tumble play (Flanders et al., 2010) and stronger involvement with his children to assist development of skills needed to be effective in dealing with the physical and social world, rather than the inner world of emotion regulation (Yogman, 2000).
Investigators such as Lamb (1976), Park and Sawin (1976) and Pederson and Robson (1969) among others, pushed a research agenda that has resulted in a substantial literature related to fathers’ influence on child development, including ghosts from their past that may affect their parenting behavior (Barrows, 2004), just as ghosts affect maternal parent-child relationships (Fraiberg, Adelson & Shapiro, 1975). In addition, attention has been given to the early formation of ghosts, at least within the context of very young boys reared in families with high paternal psychopathology and family conflict (Fitzgerald, Wong & Zucker, 2013).
In addition to their overall influence on child development (Cabrera & Tamis-LeMonda, 2014), why fathers matter has been brought to light especially with respect to the development of boys. Boys have disproportionately higher rates of mortality and morbidity throughout the life span (Bale & Epperson, 2015). If one considers the full range of behavior regulation, cognitive performance and social-emotional behavior, boys have higher risk for behavioral dysregulation (Eme, 2007; Golding & Fitzgerald, 2017) and psychopathology (Hartung & Lefler, 2019) than do girls. While research has rightly drawn attention to the negative correlates of father absence, the effects of father presence also need to be examined particularly with respect to their influence on the balance of children’s exposure to risk and resilience factors during early development. In particular, the father-son relationship needs be examined more deeply with respect to the males’ disproportionate risk for aggression, antisocial behavior, and violence at all age levels (Golding & Fitzgerald, 2019; Schore, 2017).
Equally important, considerable attention needs to be directed to the positive ways that fathers contribute to children’s development. Research in infant mental health tends to focus on the outcomes of negative lived experiences, rather than on resilience building positive parenting practices. Every person’s life-course consists of maintaining a space and time on the risk-resilience continuum (Fitzgerald, 2010; Fitzgerald & Puttler, 2018). Research during infancy and early childhood disproportionately focuses on risk rather than resilience, especially with respect to fathers’ contributions to resilience (Tyano, Keren, Herrman & Cox, 2010; Hays-Grudo & Morris, 2020). Masten & Barnes (2018) define resilience as “the capacity of a system to adapt successfully to challenges that threaten the function, survival, or future development of the system (p. 99). Their short list of resilience factors include, but are not limited to: caring family, close relationships, skilled parenting, agency, problems solving and self-regulatory skills, self-efficacy, optimism, meaning-making, routines, and well-functioning schools and communities. Too often fathers are not included in such studies of resilience, especially with respect development of infants and very young children, or their inclusion is described indirectly through maternal report.
We also need to understand and respect indigenous knowledge and indigenous cultures to assess how such knowledge and practices provide resilience in ways not well understood by investigators trained and committed to WEIRD (Western, Educated, Industrialized, Rich and Democratic) science (Henrich, Heine & Norenzayan, 2010) and its underlying world views. The United Nations estimates that there are 370 million Indigenous Peoples in over 90 countries. What do we know about the early life experiences of their very young children? We need to examine our theoretical assumptions, our measurement tools, and our implicit biases and we need to practice more participatory action research when engaging in studies of Indigenous Peoples (Sarche & Whitesell, 2012; Lewis, 2019; Wilson, 2008). Culture matters! (Atran, Medin & Ross, 2005; Fitzgerald, Mann, Cabrera, Sarche & Qin, 2010; Tomlinson et al., 2006). Racism and income disparities matter! (Ciciolla, Armans, Addante & Huffer, 2019). For example, after a home visit is completed and the visitor leaves, the family still lives in poverty, the same caregiver is still in the same neighborhood and still attends the same preschool or family home care, and still deals with racist policies and practices. So one either has to have the most powerful intervention ever devised to transform everything–we know that doesn’t happen– or one needs to understand the dynamics of family or environmental/cultural resilience that enable families to adapt in order to endure and succeed in everyday life and focus on building resilience while dramatically reducing risk.
Policy and Advocacy
Dye (1987) defined policy within the context of government actions or inactions, rarely implemented or negated by an individual. Rather, policy making requires many actors to collaborate to propose legislative policy and to enact it, nearly always with some degree of opposition. John (1998) described policy making “as a dynamic, complex, and interactive system through which public problems are identified, legislated and countered by creating new public policy or by reforming existing public policy” (p.2). Transitions in human development occur inter-generationally as well as ontogenetically over the life course. In their advocacy for a dynamic systems approach to policy, Yoshikawa and Hsuch (2001) suggest that, “research that tracks across multiple sectors may begin to suggest productively directions for the integration of public policies aimed directly at enhancing children’s development” (p. 1899).
What does that mean for WAIMH regarding policy positions with respect to infants, very young children and their parents and other caregivers? WAIMH has always been policy shy, reluctant to express its position in relation to world events that endanger families with very young children. However, in 2008 the WAIMH Board of Directors proposed the development of a Declaration of Rights for Infants and Young Children to be ready in time for the 30th anniversary of the United Nations’ Convention on the Rights of the Child in 2019. The WAIMH Position Paper on the Rights of Infants was published (WAIMH, 2016), followed one year later by the seminal paper in the Infant Mental Health Journal on the worldwide burden of infant mental and emotional disorders (Lyons-Ruth et al., 2017). Each of these documents were intended to provide coherence for the extraordinary variations among countries with respect to issues promoting healthy social-emotional development during the earliest years of development. WAIMH’s Rights of Infants contained 7 Basic Principles, and 10 Social and Health Policy Areas as well as endorsement of the UN Convention. Two of the Social and Health Policy Areas specifically reference mothers, fathers, and caregivers within the contexts of facilitating emotional support and parental leave for caregivers (Policy Areas 4 and 7). Lyons-Ruth and colleagues advanced four imperative priorities in relation to enhancing the mental health for infants and very young children (p. 5):
- Priority on global education regarding the signs of disorder in infancy and toddlerhood.
- Priority on enhancing the availability of treatment for infants and their caregivers.
- Priority on developing reliable information regarding infant and toddler mental health in developing and war-torn countries.
- Priority on enhancing family systems approaches to the study of infancy and early childhood, including studies of the resilience generating influence of fathers.
For me, these documents imply that WAIMH has a clinical, scientific, and moral responsibility for promoting the optimal development of the worlds’ very young children and the adults who care for them. To my knowledge, however, WAIMH has not disseminated the Perspectives Rights of Infants to government officials in any country.
Moreover, WAIMH has recently begun to engage in a communication plan. To date, two papers have been published. The first, WAIMH position paper on Infant’s rights in wartime (Keren, Abdallah & Tyano, 2019). This paper was published in the Infant Mental Health Journal. Second, is a paper published in Perspectives, Diversity and the positive impact of culture and supporting families in context – A view from Africa (Berg, 2020). While these papers are a start, many areas remain to be addressed. For example, why has WAIMH not commissioned an article on infant and toddler mental health in developing and war-torn countries? What is the status of global education about signs of disorder in infancy and toddlerhood? Where is WAIMH’s position paper with respect to parental leave? The questions are nearly inexhaustible. Where are policy briefs that draw attention to resilience building interventions available to policy makers? As Cabrera noted (2013, p. 14), “intervention science based only on findings of adversity and maladjustment can perpetuate a deficit perspective and promote harmful stereotypes that associate deficits of a select group with an entire group of people.”
Writing in the context of policy changes needed to counter racism and discrimination, McKinney et al. (2017) suggest that there is a need for “studies at the exo- and macrosystem levels (Bronfenbrenner, where structural policies embedded in economic and racial inequities contribute to risk.” I suggest that similar studies are needed to impress policy makers about broader issues concerning early development than are provided by studies of parent-infant dyads. Perspectives in Infant Mental Health would be an appropriate publication for articles related to policy implications of the scientific and clinical studies published in the Infant Mental Health Journal and other scientific journals that rarely, if ever, cross the desk of policy makers. The special issue on infants in foster and kinship care (Clyman & Harden, 2002) provides an excellent case in point about translating science to practice/policy. Eight articles address critical issues related to infants being reared in non-parental settings. A concise summary article drawing attention to policy issues in relation to the wealth of information contained in the special issue about non-parental care settings could have ended the special issue, and also disseminated as a policy brief by WAIMH as one of the official sponsors of the Journal. More recently, the Infant Mental Health Journal’s “Special notice on the COVID-19 crisis” is a step in the right direction because it references a number of publications where readers can find detailed information about the impacts of COVID-19 other than prevalence and death rates.
Despite the publication of the Rights of Infants and 50 years of intensive research focused on infancy and early childhood, Weatherston and Fitzgerald (2018, p. 17) note four key public policy area that continue to challenge optimal development for infants and very young children:
- Chronic underinvestment in infancy and early childhood.
- Fragmented efforts to implement or sustain services for children 0-3 especially services supporting social and emotional health and infant mental health.
- Persistent child and family poverty, increasing the burden of vulnerability infancy and early childhood and stress in early parenthood.
- The resurgence of racism and discrimination linked to increased migration of human populations throughout the world.
Summary and Key Points
The origins of the interdisciplinary field of infant mental health can be traced to numerous strands of inquiry that emerged during the early part of the 20th century. Its emergence as an organized professional field of clinical science, however, is more recent. I have been studying infants for 54 years, and for 39 of those years was either a member of the board of directors, president, or executive director of professional societies (Michigan Association for Infant Mental Health, International Association for Infant Mental Health, World Association for Infant Mental Health) working collaboratively with clinicians, scientists, and practitioners with extraordinary commitment to understanding the world of infants, very young children and their parents in efforts to truly optimize the quality of relationships that we know lead to productive life-course pathways. The breadth and depth of knowledge that now exists related to the early years of human development arguably is more extensive than any other age period.
Yet, because nature, built environments, human social and political institutions and the environment itself are dynamic, open systems, clinical science and public policy must also be dynamic continually studying the factors that impact infants and young children and the individuals who provide for their care and development throughout and across the life cycle.
In this essay I drew attention to systems theory, fathers, and social policy, three areas of research and practice that, if intensified, will move infant mental health specialists ever closer to the desired common goal of truly enhancing the optimal development of infants and families throughout our species. Specifically, I believe that the interdisciplinary field of infant mental health must attend to at least the six needs noted below:
- We need more research about infants within the family and larger systems within which they live from an inter-dependent experience perspective.
- We need more person-oriented longitudinal studies/analyses to understand individual differences and the continuities and discontinuities that occur over the life course.
- We need more research about the impact of men/fathers on child development, especially within the first five years of life.
- We need more research focused on the balance between adversity and resilience that reflects the lived experiences that most humans have over the life course.
- We need to examine the impact of cultural context in all studies of human development, particularly with respect to indigenous peoples.
- We need to find ways to translate our science and convey its practical meaning to policy makers, program developments and the legal community.
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Brief Commentary Forty Years with Infant Mental Health: Some Reflections for the Future. A lens from USA.
By: Julie Ribaudo, Clinical Professor of Social Work, University of Michigan, Ann Arbor, Michigan, USA.
Yes, yes, yes and yes. Reading Fitzgerald’s (2020) paper left me nodding throughout. Yes, of course humans grow and change throughout their lifetime. Yes, indeed, my own father mattered tremendously. He metaphorically sat with me through many a session as I engaged with fathers interacting with their babies and young children, alert to the ways I might unwittingly impose my gendered expectation of parenting, all the while recalling the thrill of the games (e.g., “hide and go seek” in the dark) my father played with us that heightened our tolerance for anticipation and excitement.
Yes, culture matters tremendously. We don’t know what we don’t know until we know it. Culture shapes what we “know” and don’t know. And yes, indeed, resilience is fostered through proximal and distal relationships. As Bretherton reminded us (1992), Bowlby once wrote, “Just as children are absolutely dependent on their parents for sustenance, so in all but the most primitive communities, are parents, especially their mothers, dependent on a greater society for economic provision. If a community values its children it must cherish their parents” (Bowlby, 1951, p. 84).
Early in my training I was taught to ask, “what would the baby say?” As I finished Fitzgerald’s cogent analysis of what remains to be attended to in protecting infant mental health, I wondered what the baby would say. One plea might be: “teach the teachers.” The comprehensive approach Fitzgerald outlines will require novel and creative ways of teaching, training and supervising practitioners, researchers, and policy makers. Many institutions of higher education have yet to develop true interdisciplinary education. Continuing to train in our siloed fashions will only further contribute to an emphasis on the very modalities of intervention and research that are limiting our capacity to move the field further. Research funding models that favor lab-based randomized controlled trials vs. community-based, “person-oriented longitudinal studies/analyses” inhibit creative, cross-cultural, intensive understanding of the lived experience of babies and the families and communities that care for them. Only with paradigm shifts encouraged at the university level will we train the next generation of practitioners, researchers, and policymakers to think with the wisdom Fitzgerald so generously offers.
Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28, 759-775.
Brief Commentary Forty Years with Infant Mental Health: Some Reflections for the Future. A lens from Australia.
By: Professor Leonie Segal, Foundation Chair Health Economics and Social Policy, University of South Australia, Australia
In reading Hiram’s paper there are many issues that I would like to comment on, and I hope to do so more comprehensively, at a later time. However, for now, I will comment on two issues that relate to areas in which I have a particular research interest: first nations peoples parenting style and the associated individualism vs communitarianism; and social determinants.
Considering the issue of first nations peoples parenting style and individualism vs communitarianism. It is of course true that there can be cultural differences in parenting practices. However, we now know much about what is harmful to children, based on decades of empirical and theoretical research. With a growing evidence-base in the last 15 years in particular around the toxic impact of child abuse and neglect for the developing brain [1,2] as well as relational patterning . To argue that what we see in many first nations peoples is a matter of parenting style, and not concerning levels of neglect and abuse, would only make sense if the outcomes for these children were fine. But, if children are not safe  – and while accepting that dispossession, racism, intergenerational abuse and neglect, substance abuse are part of the story, this just defines the complexity. Children still require a nurturing environment to thrive and this has to drive policy. Excess hospitalisations, a dead child, a child with feotal alcohol spectrum disorder; these are real outcomes, they are not cultural constructs. And yes, a sense of community and a close identity with the group offers a valuable sense of belonging; but this does not preclude development of an individuated sense of self with agency as a legitimate goal of parenting. In the absence of a strong sense of self with a recognition of agency over one’s own life, the role left is that of victim. A well-developed sense of self does not preclude a concern for the wider humanity and a strong group identity can protect the weak but can also create an ‘us’ and ‘them’ reinforced by conformity and censure. Let’s ensure we are alert to the actual circumstances of the child, and not be prejudiced by the cultural context.
Second, the issue of social determinants. Certainly, working with families in the context of extreme poverty, homelessness, low education, high welfare dependency and similar attributes characterised as social determinants is challenging. But it is useful to think about the dynamic interaction between:
- A history of child maltreatment and the associated profound distress (also coined toxic stress)  and associated disturbed brain development  and relational patterning  and
- Consequences – such as, poor educational engagement and success, mental illness , addictions, criminal involvement, failed relationships, welfare dependency and poverty.
That is, social determinants are inextricably tied up with child maltreatment, in a bi-directional relationship . But, repair of parent child relationships can occur, even in the context of deep poverty and this can be instrumental in helping the child create an alternate future – that is healing of the parent child relationship. Addressing child maltreatment can be a pathway out of poverty and homelessness and intergenerational cycles of child abuse  and disadvantage.
- Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., Garner A. S., et al. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1):e232-e46.
- Child Welfare Information Gateway. Issue Brief: Understanding the effects of maltreatment on brain development. (2015). Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau [Available at: https://purl.fdlp.gov/GPO/gpo87623.
- Amos, J., Furber, G. & Segal, L. (2011). ‘Understanding maltreating mothers: a syntheses of relational trauma, attachment disorganization, structural dissociation of the personality and experiential avoidance’, Journal of Trauma and Dissociation, 12(5):495-509, doi: 10.1080/15299732.2011.593259.
- Productivity Commission. Report on Government Services 2020. Canberra: Productivity Commission; [Available at: https://www.pc.gov.au/research/ongoing/report-on-government-services/2020.
- Fryers, T. & Brugha, T. (2013). Childhood determinants of adult psychiatric disorder. Clinical Practice and Epidemiology in Mental Health, 9:1.
- Segal, L., Doidge, J. & Amos, J. (2011). ‘Determining the determinants: Is child abuse and neglect the underlying cause of the socio-economic gradient in health?’, Chapter 13 in Determining the Future: A Fair Go and Health for All, eds Laverty and Callaghan, Connor Court Publishing, Ballan, Victoria.
- Amos, J. & Segal, L. (2018). ‘Disrupting intergenerational maternal maltreatment in middle childhood: Therapeutic objectives and clinical translation’, Frontiers in Psychiatry, 9:623, doi: 10.3389/fpsyt.2018.00623.
Brief Commentary. Forty Years with Infant Mental Health: Some Reflections for the Future. The need for longitudinal intervention cohorts. A lens from South Africa.
By: Professor Mark Tomlinson, Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Cape Town, South Africa; and School of Nursing and Midwifery, Queens University, Belfast, UK.
Hiram Fitzgerald has produced a lucid and broad ranging history of the research and clinical application of the research on infant mental health across four decades. There is much that is thought provoking in his sweep of infant mental health and I could comment on each and every point he makes. But I have restrained myself and chosen to focus on point 2 – the need for more person-oriented longitudinal studies in order for us to better understand individual differences and the continuities and discontinuities across the life course.
While I completely agree with each point that is made, I would like to suggest an added dimension to this. Because there is much still to be known about the continuities and discontinuities of development we also need to shift more of our time and resources to trying to fix what we know is going wrong and not only to describe it. I am therefore making a plea for more longitudinal intervention cohort studies . Observational longitudinal studies, while key to better understanding dose, mechanism and as Fitzgerald states, continuities and discontinuities, they are limited in their ability to identify true causal effects and of course are limited in what they can tell us about changes based on a new intervention.
Another important reason for the need for longitudinal intervention cohort studies is to better understand how to prevent ‘fade-out’ of the impacts of early interventions . Most of the evidence we have of the impact of early intervention only tells us that the intervention had an impact immediately post intervention or 12 months later. In terms of mechanisms we desperately need to know more about what we can do to sustain intervention effects across the life course.
- Tomlinson, M., Fearon, P., Christodoulou, J. & Rotheram-Borus, M. J. (2020). Editorial Perspective: Stop describing and start fixing – the promise of longitudinal intervention cohorts. J Child Psychol Psychiatry. Epub 2020/02/23. doi: 10.1111/jcpp.13213. PubMed PMID: 32077089.
- Bailey, D., Duncan, G. J., Odgers, C. L. & Yu, W. (2017). Persistence and fadeout in the impacts of child and adolescent interventions. Journal of Research on Educational Effectiveness;10(1):7-39.
Brief Commentary Forty Years with Infant Mental Health: Some Reflections for the Future. A lens from USA.
By: Tova Walsh, Ph.D., M.S.W., Assistant Professor, School of Social Work, University of Wisconsin-Madison, Wisconsin, USA
Hi Fitzgerald has identified six critical directions for the infant mental health field to continue building on the advances of the past 40 years. One of these directions is to expand research on the impact of men/fathers on early child development. As Hi articulates so well, recent decades have seen an increase in attention to the ways that fathers contribute to children’s lives, health, and development. Men’s own physical and emotional health and wellbeing, as well as the nature of their involvement with their children and their children’s other caregivers, are influential.
As someone who studies men’s experiences across the transition to fatherhood, and interventions to support and strengthen early father-child relationships, I share Hi’s recognition that the impact of fathers on early development is an important area for continued investigation and understanding. In particular, this research should include and address diverse family constellations, and we must prioritize the incorporation of our findings into practice.
It is a tenet of our field that the parental capacity to nurture an infant or young child is dependent on the extent to which the parent is supported and nurtured, and this is true regardless of the parent’s gender or marital status. As we seek to learn more about the role and contribution of fathers, we must attend to the wide range of cultural and social norms for fathers and fathering, and structural barriers to involvement faced by vulnerable and marginalized fathers. And as our understanding of these realities grows, we must reflect and act to expand inclusion of fathers in our work with infants, young children and families in ways that respond to the needs and circumstances of diverse fathers and families.
Brief Commentary Forty Years with Infant Mental Health: Some Reflections for the Future. A lens from Sweden.
By: Catarina Furmark, clinical psychologist, PhD student Karolinska Institute Stockholm and former chair of the Nordic Association for Infant Mental Health.
- How to find ways to translate our science and convey its practical meaning to policy makers, program developments and the legal community.
Hiram Fitzgerald provides an excellent summary of the interdisciplinary field of infant mental health whilst challenging us to reflect on the future. The article offers many “ports of entry” and I have chosen to comment on its very last point – the need to translate existing science and convey its practical meaning to politicians and policymakers.
Even though existing science on the rapid, sensitive, and relationship-dependent brain- and behavioral development of infants indeed is no longer new, there is still a lack of recognition of its significance. The actual concept of mental disorders in infancy is widely unrecognized, as Lyons-Ruth and colleagues point out (2017). Increased knowledge on the impact of mental ill health in infancy and how to promote infant mental wellbeing has still not been matched by increased funding, prioritizing or impact on social policy despite the importance of this knowledge, and “the costs, financial and social, of its failure to do so” (Leach, 2017).
One can easily feel defeated by efforts to change policy, only to experience policy makers reluctance or inability to change – despite their often good intentions. However, we now more than ever need policies that reflect the knowledge we have about how to promote parental and infant mental well-being, support sensitive parenting, increase resilience in families, reduce societal costs and reap the benefits to society when it acts accordingly. What we can do, is with ever renewed efforts, carry on. And, defeat does not automatically mean we have been unsuccessful (Jansson, 2007). When we make the effort to try and change policy, we can sensitize and educate people who may not have been aware of the issue of infant mental health. While this result may not be what we had initially hoped for, it may pave the way for later successes.
We must find the particular times, when the political and/or psychological climate is right for policy change. To be successful, we can adopt the strategy of the “eight P’s” (Meredith & Dunham, 1999). We need to plan well, using a strategic planning process. We must prepare, including doing all the necessary research and becoming experts on existing policies. We need to cultivate personal contacts with policy makers, other change agents, and anyone else necessary. Not easy, as the turnover of staff means that the personal contact you had last year, is no longer working in that particular office. We need to take the pulse of the community, that is to find out what our families need, to know where to start in order to be successful. We do need a certain amount of positivism, framing policy changes and outcomes in a positive way. We need each other, we need participation of everyone affected by or concerned with the issue in planning and implementing policy change. We may use publicity for our effort in general and for our suggested policy changes in particular. We need to stay persistent, not to give up but to monitor and evaluate our actions and keep at it for as long as necessary.
Finding ways for changing policies are not always easy. They are time-consuming, they rarely seem to yield any tangible results, and any efforts need to be repeated over and over again. They can be draining. That is why we need our community. WAIMH as an organization, with its international scientific and clinical community, and its affiliates, has high credibility. There are efforts already as Hiram Fitzgerald mentions in his article; WAIMH’s position paper on the rights of infants being one (WAIMH, 2016). This paper has been presented to the Swedish Board of Welfare and to the Department of Welfare in 2017 by members of the Nordic Affiliation. These efforts should continue and be ongoing. The members of WAIMH and affiliates are the appropriate leaders in campaigns for changes in policy. Keep calm and carry on!
Jansson, B. (2007). Becoming an Effective Policy Advocate: From Policy Practice to Social Justice. Thomson Higher Education. Belmont, CA.
Lyons-Ruth, K., Todd Manly, J., Von Klitzing, K., Tamminen, T., Emde, R., Fitzgerald, H. E. Paul, C., Keren, M., Berg, A., Foley, M., & Watanabe, H. (2017). The world-wide burden of infant mental health and emotional disorder report of the World Association for Infant Mental Health. Infant Mental Health Journal, 38, 695-7805.
Leach, P. (2017). Transforming Infant Wellbeing: Research, Policy and Practice for the First 1001 Critical Days. Routledge. London.
Meredith, C. J., & Dunham, M.C. (1999). Real Clout. Boston: The Access Project.
World Association for Infant Mental Health (2016). WAIMH position paper on the rights of infants. Perspectives in Infant Mental Health, 24 (1-2), 3-5.
Tribute Celebrating Hiram Fitzgerald: Forty years with Infant Mental: A lens from USA
By Joy Osofsky, Past President of WAIMH, Professor of Pediatrics, Psychiatry, and Public Health Head, Division of Pediatric Mental Health, Barbara Lemann Professorship of Child Welfare, New Orleans, USA.
It is both an honor and a pleasure to share my thoughts about Hiram (Hi) Fitzgerald. Hi is not only a pioneer and major leader in the infant mental health field, but also, he is also a very special person. While we had known each other for many years, those who read this tribute may not know that my first major endeavor with Hi Fitzgerald was to collaborate to create the World Association for Infant Mental Health (WAIMH) which resulted from a merger of the World Association for Infant Psychiatry and Allied Disciplines with the International Association for Infant Mental Health. It was a wonderful collaboration where we both assumed leadership for the newly established organization with me as President and Hi as Executive Director. I very much enjoyed this period of time working and collaborating with Hi helping to build the field that is now widely recognized as Infant Mental Health because of his skill, finesse, great problem-solving ability and clear direction, all of which were important to move forward. While the work was hard with frequent challenges, it was an exciting joint adventure together with the international Board of Directors in broadening the perspective of WAIMH into a truly multidisciplinary international organization.
I am sure that those who know and have worked with Hi understand what a pleasure it is to be able to call him a close colleague, fine collaborator, and warm friend. I learned quickly that we share a similar style of working, that is, being available most of the time, responding quickly to correspondence, emails and phone calls, and believing that even very challenging situations coming from different cultural perspectives are solvable. In other words, Hi and I agree with the adage that if you need something to be done quickly and well, you should turn it over to a very busy and competent person. I will share a brief story related to my respect for Hi in problem solving that required an immediate and creative response. I was editor of the Infant Mental Health Journal at the time that Hurricane Katrina devastated New Orleans on August 29, 2005 with the breach of the levees. Fortunately, the IMHJ office then located with the editor just sent an issue to press in mid-August. In 2005, we still had paper files for the Journal, all of which were then sitting in our filing cabinets on the 3rd floor of my flooded and deserted office building in the flooded city. It was impossible to retrieve the files in New Orleans so Hi and I started to “problem-solve” and figure out how we could retrieve submissions, those that were under review, and start to digitize the journal. Somehow, with Hi’s ingenuity, hard work, and again awesome collaboration, we accomplished that work before the next issue was due to go to press! How we did it would not have been possible without Hi’s persistence and resourcefulness – and true collaboration!
I am confident that those of you who know Hi will agree that he is a very accomplished psychologist, academician, researcher, teacher, and administrator. While his many professional accomplishments are well respected, I have also very much admired his commitment to his family as a devoted husband, father and grandfather who has always been very involved with family life, taking much pride in his children and grandchildren, and sharing his love of family with others. I was extremely impressed and touched that as Hi decided to begin a new chapter in his life, his family established the Hiram E. Fitzgerald Engaged Scholar Endowment Fund to help students carry out work that “transforms the human experience.” I am very fortunate to have Hi Fitzgerald as a wonderful collaborator and friend, and I join my WAIMH colleagues and friends in wishing him much satisfaction and pleasure in the next important phase of his life.
Tribute Celebrating Hiram Fitzgerald: Forty years with Infant Mental: A lens from Australia
By Rochelle Matacz (Clinical Psychologist, IMH Specialist (IMH-E®) and Lynn Priddis (Clinical and Counselling Psychologist), Perth, Australia.
Leaped into our lives with his larger than life presence at a time when our university was looking for overseas professors to build research capacity.
I had of course seen Hiram from afar at WAIMH congresses on panels with people whose names were all stars to us. Rochelle had spent time with Hiram in Ireland as he helped establish the Irish Affiliation of IMH and was a keynote speaker of Ireland’s inaugural conference on IMH in 2006. When we considered who to bring out to Australia to help build a research profile in PIMH we sought advice from Debbie Weatherston who without hesitation, immediately recommended Hiram. We proceeded to set about investigating the university systems and processes required to support this if indeed it became a reality and not just a fantasy. Together Rochelle and I bravely sent an invitation to Hi to visit the university for three months and to do this for 2 consecutive years, since in Australia we have a plethora of people who fly in and fly out and leave little impact or follow up. We were not sure what changes or developments would come from our time together with Hi but in true Hiram fashion he transformed our perspectives and the way we approach the field of IMH in so many ways we never imagined possible prior to his visit.
Hiram arrived with his wife Dee and from the beginning shook us out of our comfort zones. There were a few minor cultural issues to get our heads around such as Hiram’s persistence in calling our beautiful red flowering red “Bottle Brush” bush the “Pipe Cleaner” tree. More significantly was his way of viewing the responsibilities that universities have to community and his systematic perspective to improving the lives of vulnerable infants, young children and their families. He guided and shaped our understanding of the significant role the entire system plays in supports families transitioning into parenthood.
Hiram questioned why our focus was on one small part of the system rather than a much broader, holistic perspective that would engage stakeholders across the continuum of care and hold the views and experiences of families at the centre of everything we do in the field. Initially, Rochelle and I talked with Hi about how he might support us to develop a research framework that captured the positive changes in families and the clinical significance of the PIMH intervention work carried out in the newly established university based Pregnancy to Parenthood clinic. We also considered that Hiram might help build awareness of IMH in other areas of the university such as Education and Nursing and Midwifery as well as our Psychology Department.
Well, Hi’s first questions to us were “what is the point of evaluating one clinic that has an isolated impact?” How will that change anything across the system and impact more than the 50 families you treat each year? “What is the system of care your clinic sits within and how does it currently function?” What does your clinic offer in relation to improving the system that supports families with infants and young children? We were lost for words and didn’t know how to respond to Hiram’s direct questions as our perspective up until this point had been primarily focused on building an evidence base for the service we were providing families which we valued and felt pride in delivering within the community.
After we took a few breaths and reflected deeply about Hiram’s provocative questions we began to understand the field of PIMH from a new broader perspective. The questions Hiram posed enabled us to develop clarity about what we needed to do and how to proceed which was different to what we had ever imagined. Our minds opened and our perspectives changed. We shifted our focus and commitment to developing a deep understanding of our system and all its complexities and how we might offer interventions that improve the functioning of the system and the family’s experiences across the continuum of care. It didn’t take long for us to wonder how we could have not taken this approach prior to Hiram’s visit. We both feel that this experience exemplifies the impact of Hi’s presence. He had the capacity to dramatically shift our perspective towards a direction that will provide a much larger impact on vulnerable families than our isolated service provision could ever offer.
With Hiram’s guidance we developed a proposal, and to our surprise received a large grant to conduct a system analysis of the local PIMH system of Care. He has supported us at every stage of the process and with persistence we have now produced a report that has the potential to be so impactful on the wider PIMH system of care and be used as an exemplar for system evaluation and change at a state and federal level.
At all stages of this journey Hiram has generously provided us with his wisdom, expertise and knowledge. His input has transformed how we see ourselves and our capacity to make real and impactful long-term sustainable changes to the emotional lives of infants, young children and their families. It has given us renewed strength and courage to persist with these innovative ways of working from a systems-based approach that our Western Australian system has yet to fully understand. Hiram embodies ‘relationship-based work’ and has become one of our secure bases that is always available for support, advice, or guidance when things become tricky or overwhelming. He has an amazing capacity to ground us and help keep us focused when we are confronted with barriers or unexpected challenges.
Rochelle had the opportunity to visit Hiram and Dee in East Lansing last year and witness his local work. For the first time she was able to come to terms with the enormity of what Hiram has created at Michigan State University and how his impact stretches way beyond the field of infant mental health and beyond the USA all the way to the Perth, the third most isolated city in the world! We also know that his impact stretches to many other parts of the world.
Acknowledging Hiram also comes with recognition of a very important partner and influencer behind the scenes-known fondly by everyone as ‘Dee’. During their time in Australia and Rochelle’s visit to Michigan we were able to have many moments of fun together with Hiram and Dee. We shared laughs and got to see the less serious side of Hiram with time spent away from work and with more of a focus on good food and wine, always finishing the night with a night cap of Irish whiskey!!
Tribute Celebrating Hiram Fitzgerald: Forty years with Infant Mental: A lens from Finland.
By Kaija Puura, WAIMH Executive Director, Tampere, Finland
In this issue of the Perspectives we celebrate our colleague and friend, Professor Hiram Fitzgerald. Hiram Fitzgerald – or Hi as many of us call him – has had a magnificent academic career and been a significant and central person in WAIMH over the years as one of its founders, as the WAIMH Board President, as the Executive Director, and now, as one of the Honorary Presidents.
I first met Hi in June 1995 when we were preparing for the WAIMH 1996 Tampere Congress and the Board of Directors of WAIMH came to Finland for its meeting and site visit. At that time, I was working as the secretary of the Local Organizing Committee, and in that role, I had the privilege of also meeting Hi’s wife, Dolores Fitzgerald – or Dee as she was known, another important person working for WAIMH. I could hardly guess that 10 years later I would be working with Hi, helping to organize WAIMH World Congresses as the Associate Executive Director of WAIMH. Hi was great to work with; no question I asked was too stupid; no detail too small; and, he did not hesitate to give constructive feedback. I also remember having many evenings with lots of fun with Hi and Dee, either “talking shop” or just joking about funny happenings in our lives.
Hi had a wonderful way of helping younger colleagues like me to move forward with their careers. Ever since our first meeting, he recruited me to work as a reviewer, first for the WAIMH Congresses and then, once I had gotten my PhD, for the Infant Mental Health Journal (IMHJ). In addition to that, Hi has generously offered me and many other younger colleagues opportunities to contribute to special IMHJ issues about infant mental health or chapters in books. As a result of these opportunities, my list of publications got longer and, of importance, I also found that I had developed a large network of colleagues from around the world I might not have met otherwise. I am grateful to Hi for all that he has made possible for me.
Now that I have been the Executive Director of WAIMH for two years, I am truly thankful for the years that I have known Hi and worked as “Hi’s Shadow” (as we often joked about). The basics of the work around preparations for WAIMH World Congresses and many other responsibilities became familiar to me through Hi’s guidance, as well as his understanding of the unique characteristics of WAIMH as an organization.
People working in and for WAIMH are like a family where we take care of each other, so that we all in turn can care for infants and families around the world. In many ways, Hi has been my father figure in the WAIMH family and very important, both professionally and personally. Thanks to Hi I also got to know Dee, one of the warmest and most down-to-earth teachers I know, with whom it was easy to reflect on all sorts of problems, big or small. So, if you hear me calling Hi and Dee “dad and mom,” that is my way of showing them my gratitude and affection and thanking them for all the support they have given me.
Tribute Celebrating Hiram Fitzgerald: Forty years with Infant Mental: A lens from the international Alliance for the Advancement of Infant Mental Health.
By Nichole Paradis, LMSW, IMH-E, Infant Mental Health Mentor-Clinical
Executive Director, Alliance for the Advancement of Infant Mental Health
I can say that I have known Hi now for about 10 years. But I have known OF Hi since the very beginning of my work in this field 25 years ago. Hi is a giant in infant mental health, especially in Michigan. His height and commanding voice lend to this “giantness,” but mostly it is his reputation that looms large. Many years ago, I asked Hi to send me his curriculum vitae so that I could print it out to keep on file with Endorsement records (back when paper files were still a thing). Hi said to me, “You don’t want to print it out, it’s far too long.” I asked that he send it anyway. And of course, he was right. I had to refill the printer twice because Hi’s CV is an astounding 106 pages. It is a remarkable tribute to his commitment to scientific inquiry, but also to Hi’s support and promotion of people, organizations, and most of all, infants and families. What also stands out about his CV is the number of other giants in the field that he has mentored and with whom he has collaborated. It seems Hi’s passion creates a gravitational pull that has attracted hundreds of other experts. Together, they have advanced the field and paved the way for the application of research into practice.
The Alliance for the Advancement of Infant Mental Health (Alliance) is one of the many organizations who owes much to Hi. Hi was one of the founders of the Michigan Association for Infant Mental Health, the organization that “gave birth” to the Alliance. Hi was integral in establishing the Infant Mental Health Journal and served in several editorial capacities since its beginning; he was Editor-in-Chief for at least eight years. Last year, because the Alliance has some responsibilities for managing the IMHJ, I had the privilege of chairing the committee to select the next Editor-in-Chief. Hi, of course, was crucial to this effort. Hi shared his incomparable institutional memory that helped me to more fully understand the role the IMHJ itself has played in lending legitimacy to the field of infant mental health.
Hi has been a supporter of the Alliance and our mission to build and sustain a diverse, reflective, skilled, and relationship-based workforce that supports pregnant women, infants, young children and their families with cultural humility. He lets us know when he sees us getting it right, and he lets us know if he sees us missing something important. The Alliance owes Hi a debt of gratitude for his honest feedback. It drives us to do the best possible job for the infant-family workforce. This is just a small part of what makes Hi Fitzgerald a giant force for good for the infants, caregivers, and parents around the world. On behalf of the leaders from the 32 associations for infant mental health that make up the Alliance, we say THANK YOU, and congratulations on an absolutely extraordinary career!
Hiram E. Fitzgerald, Ph.D. Department of Psychology and University Outreach and Engagement, Michigan State University, Michigan, USA.