My best wishes to all WAIMH members and those working to support infants and young children and their families in all nations. The current and ongoing COVID-19 pandemic has presented immense problems for families, communities, governments, and health services all around the world. Our Board of Directors of WAIMH, and our membership in general, have come together to see what we can do collectively to understand the urgent needs of infants and families and importantly for to support the rights of infants for an optimal life. We are aware that an inordinate preponderance of infant mental health research, and clinical resources are directed to families who are relatively better off than those in many communities facing the additional stresses poverty, isolation, and language and cultural diversity.
As in previous years, there have been a number of our professional meetings where we have joined with other organisations to share our concerns, ideas, and culturally appropriate interventions. There were shared symposia at the World Congress of Psychiatry congresses in Lisbon and planned for Bangkok but delivered virtually in March this year. Our World Congress in Brisbane in June delivered several important symposia addressing the issue of cultural diversity addressing inequalities within Australia, Asia and other countries and aimed at overcoming racism and stigma through collaboration between nations and cultures. Members of the WAIMH Board also contributed to the IACAPAP Congress, which was originally to be in Singapore, but was transferred to the online format. We also joined our colleagues for the 2021 Zero to Three Annual Conference for an inter-organisational symposium called “Holding the World’s Youngest Children in Mind: New Models of Support and Reflection for Those on the Humanitarian Frontlines Providing Early Childhood Psychosocial Services”.
The editor of the Infant Mental Health Journal, Holly Brophy-Herb, has taken a strong lead in supporting the development and publication of research across cultures, language groups, and world regions in our Journal, and introducing measures to tackle the serious impact of racism in academia.
The 20th WPA World Congress of Psychiatry 10th to 13 March 2021 was held online with participants for an international audience, and appropriately the theme of the Congress was Psychiatry in a Troubled World. (March 2021. https://2020.wcp-congress.com/scientific-program/) I was privileged on behalf of WAIMH to join the WPA Congress inter-organisational symposium, the Human Rights of Infants, Children and Adolescents, chaired by Sam Tyano, Israel & WPA, with presentations from Daniel Fung, Singapore, President of IACAPAP and Myron Belfer, IACAPAP USA. Myron Belfer’s presentation was titled ‘’Child and adolescent human rights: A global absence” and that of Daniel Fung was titled “Child and adolescent rights and responsibilities: An international mental health perspective.”
My presentation was titled: The rights of infants: Do infants have human rights in addition to those afforded to children and adolescents?
I would like to acknowledge the Traditional Owners of the land from which I’m talking to you today. The First Nations people of Australia have cared for this land with a continuous culture over 60,000 years caring for land, seas, and waterways, flora and fauna and continue to do so. I am talking to you from my home in Melbourne, which is the land of the Wurundjeri people of the Kulin Nation, and I pay my respects to First Nations elders past, present and emerging.
I acknowledge that the Aboriginal peoples of Australia have suffered much in the process of colonisation over the last 259 years. Infants and young children suffered much through various policies of “assimilation” which saw Aboriginal children forcibly removed from their families at the tender age and beyond. There is an awesome legacy of extensive intergenerational trauma, and I acknowledge the amazing strength, resilience and creativity of our First Nations peoples.
This inhumane and tragic process of infant and child removal has occurred in many countries, where there has been invasion and colonisation, including in Europe, Africa, the Americas, and beyond.
I think this symposium is particularly pertinent given the theme of the Congress, Psychiatry in a Troubled World. Indeed, the world is beset with troubles now with huge chaos, illness and death from the COVID-19 pandemic with its associated economic and social catastrophes.
There is much civil strife with the health and welfare and basic rights of whole communities and cultural groups being threatened and disrupted. Communities in many countries across all continents are subject to civil strife and war, and the persecution of minorities and cultural groups.
According to UNICEF, the war in Syria has been one of the most brutal in recent history with more than 8 ½ million Syrian children displaced from their homes becoming dependent upon assistance inside Syria and in neighbouring countries.
Natural disasters such as floods, fires and famines which still beset us, have been intensified by the impact of global warming which is an imminent, and dangerous threat to worldwide safety, stability, and indeed human survival.
Despite the efforts of many governments, international organisations, such as the United Nations, and other relief organisations, it is often children who are the ones who suffer most.
Young children certainly deserve a voice in response to these crises.
I am here with you today as the representative and President of the World Association for Infant Mental Health. WAIMH is an organisation with members across the world, and some 63 affiliates organisations across all continents were.
Why infant mental health?
For many people, the initial response to this question is: “how can babies have mental health problems? How can they have mental health disorders? That’s crazy.”
The next response is likely to be: “well, it must be just the parents. Parents could certainly have mental health problems but not the baby’s, not the toddlers. If you have not got words, how can you have mental health … What sort of mental processes can babies have?”
The ground-breaking research of pioneers such as Ed Tronick, Colwyn Trevarthen, Daniel Stern and Berry Brazelton has demonstrated the capacity of even the newborn baby to initiate conversation and interaction using gaze, voice, and body movements. Trevarthen clearly described the baby’s capacity for proto-conversational movements using hands and feet as the beginnings of communication; the roots of speech. Babies and toddlers reach out too, with their gaze, which is a powerful way of communicating with us; drawing us into creative and respectful interaction.
As Trevarthen says: infants “engage in intimate and seductive precision with other persons movements, sensing their purposes and feelings and this gives evidence that the baby arrives in the world with powerful intersubjective mental capacities” (Trevarthen, 2011).
What is the practical significance of this frame of mind, the baby’s capacity to engage with others from the outset?
The baby’s capacity for intersubjectivity, for seeing that there is another person seeing them, is frequently not acknowledged, or understood. Consequently, infants and very young children are overlooked when we are considering the impact of trauma, violence, community crises, and even family crises. A deeper understanding of the infant and very young child and their psychological, emotional and social development is crucial.
We have a mental health diagnostic and classification system for mental health disorders for infants and young children aged 0 to 5, thanks to the work of many with the Zero-to-Three, which developed the Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood, DC:0–5™.
The process of assessing, diagnosing, and classifying infant mental health difficulties is of course culturally dependent and influenced, although the pain and disruption to development, experienced by babies and toddlers, manifests across all cultures and communities (see Kai von Klitzing, 7.11.2017 in Perspectives in Infant Mental Health, 2017_3-4_29thDecember_Perspectives_IMH.pdf (waimh.org). However, it remains difficult for people to understand that the preverbal child may experience mental health disorder.
Vignette:
Jay was born on a Pacific Island in an inhumane place of detention. Jay’s parents fled their home country in the Middle East where they were subject to discrimination and threat to life. His father was about to be arrested or executed before they managed to flee, in absolute desperation, across countries through Southeast Asia and crossed treacherous seas in a crowded small boat before approaching Australian territory when they were then taken to indefinite offshore detention.
Jay’s mother was profoundly depressed, feeling permanently dislocated from her family. Her mother died while the family were in island detention. N the postnatal period she attempted suicide on several occasions, and was eventually, along with Jay and her husband, medically evacuated to Australia.
Jay was 6 months old when he reached Australia and he too was profoundly depressed. It was difficult to engage him, his eyes were empty and his gaze avoidant, he would not drink and was wasting away. He presented the picture of an infant with severe kwashiorkor (protein-calorie malnutrition). But this was in a situation in detention where he should have been receiving plenty of food and adequate nutrition. Both of his parents were perpetually despairing, feeling that they would never leave the island where they were placed.
Jay’s evacuation with his family to mainland Australia for medical investigation of his severe failure to thrive was meant to be temporary and that he would return to detention. However, it was clear that his severe mental health disorder, profound infant depression and state of severe psych- soma collapse, would persist if he and his family were returned to their indefinite island perceived imprisonment.
The hospital maintained that Jay was suffering a serious medical and psychological disorder from which he would not recover if returned to detention and that his parents persistent, profound depression and despair would lead to the continuation of his pervasive depressive disorder. Jay, as a 7-month-old infant met the criteria for a formal diagnosis of a depressive disorder of early childhood and severe disruption of attachment. He and his parents were able to stay in Australia, although they still live somewhat in a state of limbo without having received authority to stay long-term in the country.
In this case, I believe the formal infant mental health assessment of Jay, acknowledging the psychological and psychiatric impact of his detention and the impact of his parents’ despair upon his development was crucial in professionals strongly and publicly advocating on his behalf such that the family was not returned to island detention.
This raises an important question, perhaps a paradoxical one:
Do infants have the right to be acknowledged to have disorders of mental health?
I think this is a crucial question.
We need to be careful about how we arrive at a formal diagnosis and make sure that we consider the infant as a person within their family, relationships, and culture, reaching out to understand their inner world and acknowledge their voice.
But if we do this, the process of diagnosing, of understanding the problem facing the baby, and or the toddler is crucial. We do this by entering the inner psychic world of the infant and how it affects their mood, their cognitive development, and their relationships. This is our task.
Diagnosis is of course not just “labelling”, but if we take Hippocrates meaning of the word diagnosis: a way through of knowing, of understanding.
Classification of mental health problems allows us to communicate about how we understand the problems that a very young child might be having, the problems they are having in relationships and development, and communicating this to colleagues, parents, and sometimes government agencies who need to act to protect the welfare of young children.
Many people over time have been strong advocates for protecting the welfare, emotional, and social development of infants and very young children.
René Spitz working in Vienna between the First and Second World Wars saw the horrendous impact of war upon infants, young children, and adolescents following the death of parents and the disruption of families and the intense poverty, conflict, and hatred, which are intrinsic components of war.
We know that in modern technological warfare, the victims of war who suffer the most, both directly and indirectly, are women and children. Mass displacement of whole communities occurs, and people spend many years in temporary, and too often, dehumanising refugee camps.
John Bowlby was asked by the World Health Organisation to investigate the impact of the Second World War, specifically, the death and displacement of parents and family attachment relationships, upon children. Bowlby recognised the impact of war on family disruption and its impact on the essential process of infant-caregiver attachment. It is crucial that we follow his investigation into the impact of disrupted attachment on the emotional development of the individual. Serious disruption of attachment affects infants who are refugees, infants and toddlers facing homelessness, and those exposed to family violence as well as those infants traumatized by significant serious medical illness, or disability.
A Human Rights approach informs how we support the welfare and development of infants.
We have for all children the landmark achievement: the United Nations Convention on the Rights of the Child (1989), (UNCRC) (United Nations General Assembly, 1989), the UN convention to which almost all nations are signatories. For further information: https://ohchr.org/Documents/ProfessionalInterest/crc.pdf) See also the UN Convention on the Rights of People with Disabilities (CRDP) Convention on the Rights of Persons with Disabilities (CRPD) | United Nations Enable
In the light of this, a group of senior clinicians from the World Association for Infant Mental Health (WAIMH), aware of the particular difficulties facing infants and very young children, felt there was a need to produce a document to complement the Convention on the Rights of the Child to highlight the particular human rights and essential needs of infants.
- Prof Miri Keren (Tel Aviv, Israel), the late Emeritus Professor Bob Emde (Denver, USA), Prof Astrid Berg, (Cape Town, South Africa), and many others from the WAIMH Board worked on the development of the Position Paper on the Rights of Infants, this was formally adopted at the Edinburgh Congress, 2014, and revised by WAIMH in 2016 (WAIMH, 2016) WAIMH Position Paper on the Rights of Infants – Perspectives
- The WAIMH Board with then WAIMH President, Prof Kai von Klitzing, (Leipzig, Germany) met with one of the 18 committee members on the UN Committee on The Rights of The Child at a Board meeting in Berlin in a very fruitful discussion: we learnt about the way that the Convention on the Rights of the Child can be used to influence government policy and service delivery (OHCHR | Committee on the Rights of the Child).
The essential process requires someone from the member states/nations of the UN, a member of the government, or an individual to present to the committee itself and report on how the convention which most nations around the world have signed, is being implemented or adhered to.
Interestingly, last year, postponed by the COVID-19 pandemic, the UN Committee on the Rights of the Child (CRC) had prepared a detailed discussion on the impact of alternative care upon children. They had invited several presenters, including some children and young people who had left care to present to the committee. They seemed genuinely interested in hearing the voice of children and adolescents in understanding the impact on children of various forms of alternative care. The committee will investigate how the various practices of placing infants and children in alternative care impacts their overall emotional and social development and their relationship with their family.
The WAIMH position paper highlights 7 basic principles of infants’ rights, and importantly that these rights complement and go along with the rights of children enumerators under the Convention on the Rights of the Child (1989).
- The infant needs special safeguards and care by reason of their absolute dependence, physical and mental immaturity.
- The right to have primary caregiver relations recognised and understood and supported.
- The infant is a vital member of the family and should be registered as a citizen with equal value for life regardless of gender or characteristics such as disability.
- The right to be given nurturance love, physical and emotional safety, nutrition, and sleep.
- The right to be protected from neglect, physical, sexual, and emotional abuse.
- The right to access informed professional help when exposed to traumatic events directly or indirectly.
- Infants with life-limiting conditions need access to good medical care and palliative services, to the same standard as older children.
The WAIMH document goes on to list specific recommendations as to how social and health policy must be informed by these principles.
The preamble of the Convention on the Rights of the Child, and throughout the document, emphasises “the family, as the fundamental group of society, and the natural environment for the growth and well-being of all its members particularly children.”
Clearly, there are many children in out-of-home care around the world, and still, there are some very large institutions where infants and young children are placed. The convention recommends phasing out large institutional care for infants.
The Committee on the Rights of the Child endeavours to ensure that the Convention is a living document and that there is an ongoing process of collaboration and recommendations as to how the principles can be applied in practice. For example, “General Comment Number 7” (GC:7), “Implementing Rights in Early Childhood” (Committee on the Rights of the Child, 2006), emphasises how the rights enshrined in the convention apply equally to early childhood and emphasise the importance of very-young children needing special protection.
Conventions and statements about the Rights of Infants, or Children are well and good, but how can we make sure that they are helpful in the real world?
The Convention on the Rights of the Child has influenced the development of the important WHO Nurturing Care Framework, “a framework for helping children survive and thrive and transform health and human potential” (Nurturing Care Framework for Early Childhood Development – HOME (nurturing-care.org). This framework is a partnership with many agencies and has the potential to influence the emotional development of infants and very young children in extreme situations.
WAIMH has also developed a Position Paper on Infants’ Rights in Wartime. It was written by Miri Keren, Ghasson Abdullah, and Sam Tyano, and published in the Infant Mental Health Journal in 2019. Given the lack of attention to the impact of traumatic consequences upon the individual child and family of modern warfare, the authors cogently recommend greater attention to the psychological needs of infants in war zones, and those who are refugees as a result of war. The voice of infants is often not heard as services struggle to respond to all children and adolescents trapped in invidious and horrific circumstances.
I think it is incumbent upon all of us as mental health professionals to take note of the important rights of infants and young children as well as those of adolescents and their parents, in our day-to-day clinical work, and our ordinary lives, as citizens in the world.
Infants and their parents have a right to a thorough assessment, a thorough understanding from as mental health professionals so that we can advocate for them, we can provide appropriate therapeutic interventions and support those working in other agencies, professional and voluntary, to provide day-to-day care to promote the infant and young child mental health.
As Donald Winnicott, paediatrician and psychoanalyst notably said, “there is no such thing as a baby, only a baby caregiver set up.” So, we must also be ensuring the mental health of parents, there is no infant mental health without parent mental health. And I think this is where the World Psychiatric Association has been able to play such a powerful role. Bringing together adult mental health clinicians and policymakers, child, adolescent and youth clinicians and policymakers and those of us from the field of infant mental health.
References
Committee on the Rights of the Child, United Nations. (2005). General Comment No. 7 Implementing child rights in early childhood (CRC/C/GC/7/Rev.1). Retrieved March 21, 2012, from http://www2.ohchr.org/english/bodies/crc/docs/AdvanceVersions/GeneralComment7Rev1.pdf
Keren, M., Abdallah, G., & Tyano, S. (2019). WAIMH position paper: Infants’ rights in wartime. Infant mental health journal, 40(6), 763–767. https://doi.org/10.1002/imhj.21813
Trevarthen, C. (2011). What is it like to be a person who knows nothing? Defining the active intersubjective mind of a newborn human being. Infant and Child Development, 20(1), 119-135.
United Nations General Assembly (1989). Convention on the Rights of the Child https://www.ohchr.org/Documents/ProfessionalInterest/crc.pdf
WAIMH (2016). WAIMH Position Paper on the Rights of Infants. WAIMH Perspectives in Infant Mental health, (Winter-Spring), 24 (1-2), 3-5.
World Health Organization, United Nations Children’s Fund, & World Bank Group. (2018). Nurturing care for early childhood development: A framework for helping children survive and thrive to transform health and human potential. Geneva, Switzerland: World Health Organization.
Authors
Paul, Campbell,
Associate Professor, President of WAIMH,
Melbourne, Australia
