Child in Mind

Promoting children's healthy development.

Infant Mental Health: A Case of a Hitting Toddler

Supporting first relationships to promote healthy emotional development

This month I launched a new program at Newton Wellesley Hospital, an affiliate of Massachusetts General Hospital in Boston. I will see children under the age of six with a range of behavior issues, including, but not limited to, colic, sleep problems, explosive behavior and separation anxiety. I will work with parent and infant together in the setting of perinatal emotional complications such as depression and anxiety. The name of the program name is the  "Early Childhood Social-Emotional Health" program (ECSH.) It is an infant mental health program, drawing on the explosion of knowledge coming out of this growing discipline. I had the privilege of learning about the most current research first-hand from leaders in the field in an excellent a yearlong program at UMass Boston: The Infant-Parent Mental Health Post-Graduate Certificate Program.

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There are two major problems with the term "infant mental health." First of all, it implies that there is such a thing as infant mental illness, which is, in my opinion, not the case. Second, when say that I am a pediatrician who treats behavior problems in children under age six, most people are puzzled. I tell them that I give parents space and time to reflect, and to be curious about the meaning of behavior, with the aim of getting development back on a healthy path. Still the blank look. I have found that the best way to explain it is through stories, as I do in my book Keeping Your Child in Mind. As always, I protect privacy by changing identifying details.

"She always hits! I don't know what's wrong with her!" Jane despaired at the start of her visit with me. She came with her three-month-old son, who slept in his carrier. She was horrified that her 18-month-old daughter Callie (who did not come to this visit, so Jane and I could talk freely) was behaving this way. She and her husband never hit. She couldn't understand where this behavior came from. The worst time, she said, was when she was trying to nurse the baby. Callie would try to climb up on her, and when told to get down she would hit her mother, the baby or both. Jane felt tense and angry. Her husband worked long hours and she was alone with the two kids most of the day. "What can I do to make her stop?" she asked.

This is not an uncommon occurrence. I frequently hear parents describe "visions of Columbine" when they see aggressive behavior in their toddlers. Rather than jumping right in with what to do, I took some time to listen to Jane's story. She told me of a difficult pregnancy and how hard it had been when she was alone much of the time when Callie was an infant.

Then she began to talk about her own family. Her father was an alcoholic who was verbally and sometimes physically abusive to her mother. There was constant yelling. She told me that she "hated aggression." When she saw Callie hitting she had an immediate physical sensation of stress. Jane just wanted her to stop.

We began to wonder together about why Callie might be hitting. Jane described how close she and Callie had been before the baby was born. With her husband gone much of the time she rarely had time alone with Callie anymore. "Perhaps she misses me," Jane said. She was surprised when I suggested that while clearly hitting was not acceptable, aggression in a toddler could be seen as a healthy thing. It was not the same as adult aggression, which carried a whole host of complex meanings. We might reframe Callie's behavior as claiming what she felt was her rightful place. We talked about how toddlers are asserting their emerging sense of self . Yet they recognize that they are in fact powerless in many situations. "Wow!" Jane exclaimed. "I feel that way sometimes, but I have words to express my feelings!"

We talked very little about what to do. I was careful to frame the issue of her childhood trauma and its relation to the current situation. This history did not mean that Callie's hitting was her "fault." Rather Jane needed to move her issues out of the way so she could see the situation from Callie's perspective. I was confident that she would then know what to do.

Sure enough, when she returned two weeks later, this time with Callie, the hitting had almost completely resolved. "I give her a bottle," Jane said. She had thought that she was "supposed to" get rid of the bottle by a year. But when the baby was born, Callie had become interested in the bottle again. So the three of them now sat quietly while Jane nursed the baby. Callie would drink an ounce or two and then lose interest in the bottle. She would play at her mother's feet until Jane was finished nursing.

Callie was a delightful little girl who played quietly while Jane and I spoke. Then we got to see the essence of toddlerhood in action. Callie went to her mother's purse and said "passie." Jane explained to me that as with the bottle, Callie had a renewed interest in the pacifier. "I decided to just let her have it." Jane rummaged in her bag and pulled it out, handing it to Callie, who took it, looked it over and gave it back. She returned to her play. A few minutes later she again said, "passie. " Again her mother gave it to her, and again she gave it back. This, I said, is the ambivalence of toddlerhood. Part of her wants to be a baby, but she also wants to grow up and be a big girl. Jane, by being respectful of Callie's perspective, was enabling her to sort this through naturally, Had Jane refused to let her have the pacifier, it is likely that, as an assertion of her wish to control the situation, Callie would have insisted on having it, and a battle would have ensued. She might have started using the pacifier again.

Jane, through her natural intuition about her daughter, figured out what to do. I simply offered her the space and time to think and to be heard. I hope that this small intervention has set the whole family on a different path. The baby now can nurse in peace. Jane is less worried that there is something wrong with Callie, who is in turn free to express her emerging self. For a young family, a little reflection goes a long way.

 

Claudia M. Gold, M.D., is a pediatrician and fellow in the University of Massachusetts Boston Infant Parent Mental Health Post Graduate Certificate Program.

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