Detroit -- Seven-month-old Ka'Liyah Wright might be unable to talk beyond babbling, but she is far from inarticulate.
In one hour during a recent visit with her mom and an infant mental health specialist working with the little girl and her family, the infant communicated several needs and emotions to her mother, 22-year-old De'Janaye Thompson, including hunger, sleepiness and a desire for attention.
With big, brown, inquisitive eyes, Ka'Liyah took in the room around her and the people, both new and familiar, sitting in it. She sat in her mother's arms in the Detroit living room of her cousin and caretaker, Lichele Sow.
"She's the little boss of the house," Sow said.
The family had gathered for a home visit with Glendoria Colson-Head, an infant mental health specialist with CNS Healthcare, a Detroit nonprofit behavioral health clinic. Sow, 61, is Ka'Liyah's primary caregiver for now, while Thompson participates in the program.
"It's just helping me become a better mother. I'm already a mother, but it will make (me) ... stronger," said Thompson, whose two other children, boys ages 23 months and 3 years, are currently in foster care, though she hopes to care for all three children full-time in the future. "This is very important for me to visit her because she is a small baby, and babies can forget who their mother is and I don't want that."
How babies form relationships and making sure their early mental health needs are met is getting increased attention across southeast Michigan. Experts said ensuring those needs are fulfilled is critical and could lead to healthier, more stable children down the road, rather than waiting until they have issues as they develop.
Wayne State University's new Early Childhood Support Clinic -- a partnership between the School of Social Work, Wayne Pediatrics and the Merrill Palmer Skillman Institute -- debuted last year to help families facing mental health challenges and connect them to vital resources. The program combines baby well visits with assessing how an infant is doing in forming relationships with his or her caregivers.
"When we think of mental health, we don't often think of babies," said Carolyn Dayton, the associate director of Wayne State University's infant mental health program. "But in fact, we can understand the social and emotional development, or problems and development of infants, toddlers, and young children as their mental health."
The program just received funding to develop a billing and reimbursement model that will sustain the clinic in the long term, Dayton said.
An infant's early relationships with his or her primary caregivers are the foundation for the rest of their lives, experts said. Sometimes thought of as early relational health, it affects everything from children's capacity for trust and empathy to their ability to bounce back from hard times, said Kate Rosenblum, a professor of psychiatry, OBGYN, and pediatrics, and co-director of the University of Michigan Women and Infants Mental Health Program.
"All of early development happens in the context of relationships, and young babies and their caregivers are really forming these bonds that support kids' exploration and connection, and this is how they learn about themselves and the world," Rosenblum said.
The emphasis on infant mental health comes as recent studies have shown surging rates of anxiety and depression in young people. Even before COVID-19, anxiety and depression were becoming more common among children and adolescents, increasing 27% and 24%, respectively, from 2016 to 2019, according to the National Survey of Children's Health.
U.S. Surgeon General Dr. Vivek Murthy also issued a mental health and well-being advisory in August, warning that parents were more likely to report high levels of stress compared with other adults and that children of parents with mental health conditions may be more at risk for mental health conditions themselves and functional impairments.
Experts said that's why addressing a baby's mental health needs and potentially those of a primary caregiver, especially those who may also be facing economic issues and other challenges, is so critical.
"It's in the interest of everybody in our country to intervene early ... to do the best we can to make sure that these early relationship problems don't become intractable later on, to intervene when there's a shot at really changing the developmental pathway of the infant, toddler or young child," Dayton said.
Thompson and her daughter are working with Colson-Head to develop Thompson's parenting skills and help her recognize her baby's early needs and cues. Colson-Head works for CNS Healthcare, a Detroit-based nonprofit behavioral health clinic. She manages a caseload of up to 14 families at a time with children ages 0 to 6 and checks in on them through home visits.
During a visit earlier this month, Colson-Head did an assessment, but also taught Thompson about different ways Ka'Liyah may be vocalizing her needs and other useful practices. She cautioned Thompson against using the word "no" too often as babies are very attuned to tone and inflection and suggested saying "no thank you" instead.
Getting connected with children when they're very young, like Ka'Liyah, helps Colson-Head teach parents and help their children, she said.
"When you're dealing with being a parent, it's not easy, and so understanding yourself, and then when you're going through some things, having somebody to talk to, having somebody to bounce these things off of is very important," Colson-Head said.
What is infant mental health?
Infant mental health focuses on the early social and emotional relationships that young children form with their parents and caretakers, said Dayton, the associate director of Wayne State's infant mental health program. Babies are hardwired to connect with others, and these early bonds, which can begin during pregnancy, are key for the child's healthy social and emotional development, she said.
Infants, toddlers, and young children form attachment relationships with their caregivers and look to these people to keep them safe, soothe them when they're upset, and take care of them, Dayton said.
"When people respond in ways that create safe, responsive and nurturing, relational experiences, I develop an internal template of myself as valuable and as efficacious and as being able to trust," Rosenblum said. "But if I have experiences that undermine, sort of, my sense of safety or my sense of value, that becomes kind of internalized, also as a part of the self."
In early childhood development, being "school-ready" is a common benchmark, Dayton said. This doesn't necessarily refer to a child's ability to count to 10 or name colors but rather how well their early social-emotional development supports their learning in a structured environment.
A child who didn't get their early emotional needs met may be more focused on survival than on the capacity to learn.
"So if a child is growing up in an environment where there's a lot of violence and not a lot of protection, and that child goes to kindergarten, they're not going to be well prepared for a learning environment," Dayton said.
Stress and infant mental health crisis
Other factors can affect a baby's mental health and the stability of early relationships, such as food insecurity, racism and domestic violence. Those factors can stress a parent or caretaker and compromise their ability to be a nurturing and attentive figure for their young child, Dayton said.
Perinatal mood and anxiety disorders such as anxiety or post-partum depression also can make it hard to care for a newborn, she said.
"We weren't meant to do this alone -- parenting is a team sport, and parenting is really hard, and when parents are feeling lonely and isolated, they're more likely to feel high levels of stress when you couple that with economic pressures and worries," Rosenblum said. "The time when you're most likely to feel lonely in your life is during childbearing ages, and families with young kids are most likely to be poor and experiencing economic oppression."
Early interventions for infants facing challenges can promote better outcomes, Rosenblum said, though there's not always a perfect correlation between unmet needs and potential challenges down the road.
"Just because you as a parent had a hard time growing up, or you as a parent are struggling with stressful circumstances, this does not mean you will be a bad parent, and it doesn't mean that your child will have poor outcomes," Rosenblum said. "Those interventions that matter the most are often ones that support parent mental health, help connect them to community and to nurture early relationships."
Screening
While pediatricians evaluate how a baby is developing physically, infant mental health experts assess the quality of the baby's relationship with their caregivers, Dayton said. This goes beyond screening for things such as depression in new parents or intellectual and developmental disorders in children, although those are important too, she said.
Screenings can be done at the bedside of exam rooms when infants are brought to their typical check-ups or in people's homes.
"When we see kids with really significant mental health problems, it might look like shutting down, not being responsive, being hyper-vigilant or fearful, having problems with self-regulation, so problems with sleeping, feeding, crying," Rosenblum said.
When professionals have been trained in assessing what a quality relationship looks like between an infant and a caregiver, Dayton said they get very good at noticing signs of problems. Still, talking about problems can be very difficult for young parents, who often want to convey that they're doing OK even if they're struggling, she said. Some may even have a sense of shame.
"So it takes a degree of sensitivity and care and expertise to help parents who are really struggling either with their own mental health and/or with the relationship with their child, to get them to open up," Dayton said.
Home visits like those with Ka'Liyah are a really powerful approach for addressing the mental health needs of parents and young children, Rosenblum said.
Models of care
In CNS Healthcare's home-based care model, infant mental health providers such as Colson-Head go directly to a family's home, said Carlynn Nichols, interim chief clinical officer of children, families and intellectual and developmental disability services at CNS, a Detroit nonprofit. The care model is taught by the Michigan Association of Infant Mental Health, and providers are reimbursed through Medicaid, she said.
A caseworker helps clients access and coordinate health care if they need help, such as prenatal appointments. But the key focus is on the caregiver-child relationship, whether it is a father, mother or grandparent, Nichols said.
It involves ensuring the caregiver relationship is helping the baby develop and "making sure that the supports are in place for that baby to thrive," Nichols said.
Other providers, such as Wayne State's Early Childhood Support Clinic, combine infant mental health with regular physical health check-ups for infants and post-partum people.
"The parent's mental health is critical," said Dayton, who added that mental health need is screened for and assessed.
Other supports for parents
Through the UM's Zero to Thrive Center, which Rosenblum co-directs, experts facilitate support groups such as Mom Power in Washtenaw County and the Fraternity of Fathers in Pontiac. The groups help parents of young children prevent mental health issues before their kids start school.
UM also provides individual child-parent psychotherapy sessions where a therapist helps to create a space for families to process difficult experiences together, often through playing, Rosenblum said.
Supporting an infant's mental health can even start during pregnancy, said Uriel Stephens, director of child and family services for Behavioral Health at Easterseals MORC, a statewide health and human service agency. The organization started a trauma-focused infant and early childhood program to deal with psychological trauma in early childhood in Genesee, Macomb, Oakland and Kent counties.
"Psychological trauma, even regardless of the age, can have a change in how our brain develops and our responses," Stephens said.
The needs of families have become more complex, regardless of age, and more families are reporting behavioral concerns at earlier ages, Stephens said.
"(This) either is a great thing because we're more educated, or it's ... a result of some, let's say, community trauma that we've all had to endure under like the pandemic," she said.
Training more clinicians, especially in Detroit and the surrounding area, is also needed, said Deborah Weatherston, co-founder of the Wayne State Interdisciplinary Graduate Certificate Program in Infant Mental Health and former executive director of the Michigan Association for Infant Mental Health.
"We need the policymakers to really recognize the importance of early engagement of parents and their very, very young children, and pour some money into it," Weatherston said, "because you can't do this without training competent staff and competent providers to do assessments, observations, interventions (and) carry out the services."