The urgent need to support and invest in the mental wellbeing of parents
I have spent nearly 40 years working as a doctor in the NHS, with early training in medicine, surgery and obstetrics in what was then the deprived East End of London followed by over 30 years practicing psychiatry. Throughout that time, most of my work and that of many others working in healthcare as well as social services and criminal justice, was patching up the effects of damage done to people in their earliest years. Although it has always been a commonly held understanding that childhood experiences shape our adult lives, the enormous depth and breadth of this effect on our physical and mental wellbeing has only been demonstrated clearly by science in the last two or three decades.
We now know that various forms of emotional adversity or ‘trauma’ - abuse, neglect and other sources of severe persistent stress in childhood - lead to people developing patterns of emotions, thinking and behaviour which can make their lives very difficult and unhappy. These psychological responses are accompanied by changes in structure and function in the body and the brain, for example in the hormones and systems that govern our responses to stress and danger, to our immune system, and even to chemicals that alter the expression of our genes. These in turn regulate multiple brain and body functions such as attention, memory, breathing and heart rate, sensitivity to pain, bowel function and protection from illness and disease. The greater the adversity, threat or environmental stress and the earlier our exposure, the greater the adverse effects.
A landmark investigation in this ongoing scientific exploration was the ACES study. This resulted from the observation that amongst the clients of the worlds largest health insurer, Kaiser Permanente, most of the healthcare utilisation was by a small proportion of the insured population. It turned out that the factor they had in common was exposure to a range of adverse childhood experiences – ACEs. The scale of the effect was staggering: for example compared to people with no ACEs, those with 7 or more ACEs have 10 times the rate of alcoholism, 20 times the rate of suicide attempts, double the risk of heart disease and they die 20 years younger (Felitti et al, 1998) . These increases in risk were seen across health and social outcomes, including but restricted to, drug misuse, smoking, obesity, cancer, diabetes, stroke and depression. Not surprisingly therefore, the cost of ACEs in England and Wales exceeds £40billion every year (Hughes et all, 2020)
Further understanding of the range and scale of these effects, and of what constitutes early adversity, has come from prospective studies. These follow groups of children and their parents over years from pregnancy through to adulthood. As well as confirming that earlier exposure to such stresses leads to greater effects, it is now clear that babies in the womb are sensitive to adversity and stress experienced by their mothers, increasing the risk of emotional and behavioural problems throughout childhood and into adulthood. We can also extend the list of what we understand as adverse childhood experiences: a particularly strong predictor of poor outcomes appears to be primary caregiver unresponsiveness to babies’ cues and interactions. From birth, babies initiate interactions with others by making sounds, facial expressions and body movements that are far from random. Attentive, responsive caregivers promptly make predictable responses to these. This process nurtures the learning needed for mind and brain development, and assures security and safety for the baby who is completely dependent on the caregiving adult’s responsivity to its needs for its survival. Not having an attentive and responsive caregiver is literally life threatening and we know that the resultant patterns of attachment between baby and primary caregiver predict poor outcomes for the development, health and well-being of that baby into adulthood.
There is growing evidence that this risk can be transmitted to the next generation: adversity suffered by mothers in their own childhood increases the risk of difficulties in their children and possibly even grandchildren.
It is important to emphasise that these findings all relate to substantial increases in risk, but effects in individuals are not inevitable – indeed most are not measurably affected - and are potentially reversible. Nevertheless, it is abundantly clear that we must act on this knowledge by supporting and nurturing parents who are experiencing the effects of adverse experiences, both as our responsibility to alleviate their suffering, as well as in acknowledgement of the importance of the role they are undertaking at this critical time for them and their families. This represents an extraordinary opportunity to improve the future health, wellbeing and functioning of countless numbers of people for generations to come. If we grasp this opportunity it could be the greatest revolution in public health and social improvement we have ever seen.
To break this intergenerational cycle we must reduce adverse experiences and improve mental wellbeing amongst parents and young children, particularly at that crucial time of pregnancy and the first couple of years.
So how are we doing in the UK at reducing childhood adversity? Approximately 20% of adults recall abuse or neglect in their childhoods (ONS, 2020). That would equate to nearly 2,500,000 of England’s children. Currently our child protection processes document 388,000 children in need and 50,000 subject to Child Protection processes. This is clearly a drop in the ocean of need, and even those services are so stretched that their ability to meet the needs of many of those identified children is significantly challenged.
Child mental health looks no better: our children have the lowest level of life satisfaction in Europe, and fare poorly on multiple other measures of wellbeing (Childrens Society, 2020). Growing rates of child mental health problems far exceed healthcare or education systems’ capacity to provide help and support.
Thus, as a society we are inevitably dependent on parents, and their mental functioning, to deliver the nurturing care that the next generation relies on for its future wellbeing, particularly in the very earliest months of life. Yet the evidence clearly shows that we are not doing enough to support their mental wellbeing: depression and anxiety are the most common major health complications of maternity, and suicide has long been and remains the leading direct cause of postnatal maternal death (MBRRACE, 2021). The number of teenage suicide deaths is increasing. At least 1 in 10 new fathers also experience mental health problems, and both mothers and fathers describe significant barriers to seeking help (NCT, 2017; Darwin et al, 2017) with at least half not being recognised or getting help.
There is much we should urgently be doing to support and invest in parents for what is the most important task undertaken in our society: protecting and enhancing the future wellbeing and functioning of the population. This should include ensuring they have the emotional support that comes from widespread acknowledgement of the value and the challenges of their role, coupled with practical support to ensure they live in secure environments suitable for children and are not struggling to meet their day to day needs (CDC, 2019).
I believe health and social care services should identify parents most at risk of intergenerational problems – those with past childhood adversity and mental health difficulties – and provide trauma informed support and care in a holistic way for their physical and mental wellbeing and for the happy development of their relationship with their children. Support and psychological care services should be rapidly accessible, trauma informed and focus on parents, babies and the relationships between them. Professional bodies and individual professionals must embed into their thinking and their work a better understanding of childhood adversity and how it affects parents and children.
This starts with an age-appropriate understanding of what is traumatic to humans, ie a severely stressful, potentially life threatening external environment, for example as a foetus having a constantly anxious mother subject to domestic violence, or as a baby having a primary caregiver who is chronically too depressed to respond to cues.
Secondly, the typical effects of psychological difficulties that arise from early adversity must be understood and recognised by all, particularly in the early years and amongst parents. For example, babies become withdrawn and unresponsive and toddlers anxious or overfamiliar. Amongst older children, adults and parents the effects are often very obvious, although often poorly recognised, and indeed easily understandable if one considers what living in a dangerous environment teaches us:
If we have been badly treated or not been sufficiently protected from severe persistent stresses as children, we may learn not to trust other people. We may build up barriers around ourselves and not let people get too close. This makes it difficult to have good relationships. Often the only people who break through such barriers are controlling or abusive.
If we experience persistent adversity as children, we may learn that we cannot be in control of what happens to us and we stop planning ahead, making decisions for ourselves and we do not learn to solve problems we face in life.
When trapped in stressful or traumatic situations as children, our brain learns to escape mentally by switching off or “dissociating” and this then becomes a way of dealing with stressful situations as adults.
If we repeatedly experience external stresses, it teaches us to be on the lookout for danger, always on edge or anxious and very jumpy.
This can over activate our mental and bodily reactions to minor or ‘invisible’ danger signals. These strong reactions can make our emotions, thinking and behaviour changeable and extreme.This includes reactions to bodily sensations leading to psychosomatic problems and seeking healthcare reassurance or help.
The way in which traumatic memories are stored makes them more likely to suddenly intrude into consciousness, often in a fragmented, distorted but intense and vivid form, casing extreme and sudden distress.
Extreme distress can lead people to look for anything that will make the feelings go away, for example taking drugs, drinking alcohol, engaging in intense and risky behaviours, or causing physical pain through self-harm to drown the mental pain
These effects are so pervasive that people who have these difficulties and often those around them, including professionals, may think that this is just the way they are somehow inherently destined to be, or ‘just their personality’.
In my clinical work, these are the most common problems for which women need specialist mother and baby mental health care. I also frequently see patients who have been inaccurately diagnosed with personality disorder, depression, ‘atypical’ depression, ADHD, eating disorder of various types, fibromyalgia, ‘unexplained medical symptoms’, ME and chronic fatigue, bipolar disorder, substance misuse, and a multitude of other labels in childhood and adulthood, or indeed all of these at various times, who in fact are experiencing the typical mental and physical effects of early life trauma.
For those affected and those close to them, it can be extremely helpful to establish an understanding of these medical, psychological and social difficulties that is coherent, comprehensible and remediable and to use a term that recognises the reality and source of their difficulties. The pattern of these difficulties is strikingly similar to that of Post Traumatic Stress Disorder, for example as in soldiers in war situations, and researchers have also found close similarities in physical changes, for example those seen in brain scans (Hart and Rubia, 20212). Thus the World Health Organisation has created a new, internationally accepted diagnosis of Complex-PTSD that begins to define the adult effects of childhood adversity.
The major difficulties in life and the distress that C-PTSD causes can be reduced by trauma informed approaches to support, care and treatment. These acknowledge the traumatic source of the difficulties and address the effects though respect, empowerment, choice, earning trust, and assuring safety. Trauma informed principles can be applied to individual interactions and any organisational or institutional settings such as maternity services, social services, family hubs or schools. Specific therapeutic approaches can helpfully address difficulties such as the rapid and extreme changes in thinking and behaviour, replacing these with more regular steady routines, thinking ahead and predicting difficulties and more helpful ways of dealing with thoughts and situations.
There is also growing evidence that interventions aimed at reprocessing traumatic memories, for example EMDR (Eye Movement Desensitisation and Reprocessing) can be helpful for C-PTSD. For parents of babies, early support with the parent infant relationship, for example using videos of interactions (VIG and VIPP), is both therapeutic and much valued by parents. Much more research is needed to refine our understand of what is most helpful and to whom, but it is already abundantly clear that targeted support and help to this group of mothers, parents and babies should be provided now so that we and they can begin to accrue the undoubted future benefits.
We are the first generation to have this scientific knowledge and to be privileged with such an extraordinary opportunity to improve the lives of so many for generations to come. With this privilege comes a duty to act now, at the crossroads of intergenerational disadvantage: supporting parents and babies in pregnancy and their very earliest years together.
References
Hughes K, Ford K, Kadel R, et al. Health and financial burden of adverse childhood experiences in England and Wales: a combined primary data study of five surveys. BMJ Open 2020;10:e036374. doi:10.1136/ bmjopen-2019-036374 https://bmjopen.bmj.com/content/10/6/e036374
Childrens Society, 2020: www.childrenssociety.org.uk/sites/default/files/2020-11/Good-Childhood-Report-2020.pdf
Hart H, Rubia K (2012) Neuroimaging of child abuse: a critical review. Frontiers in Human Neuroscience. Doi.org/10.3389/fnhum.2012.00052
MBRRACE, 2021 UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_FINAL_-_WEB_VERSION.pdf
Darwin Z, Galdas P, Hinchliff S, Littlewood E, McMillan D, McGowan L, Gilbody S; Born and Bred in Yorkshire (BaBY) team. Fathers' views and experiences of their own mental health during pregnancy and the first postnatal year: a qualitative interview study of men participating in the UK Born and Bred in Yorkshire (BaBY) cohort. BMC Pregnancy Childbirth. 2017 Jan 26;17(1):45. doi: 10.1186/s12884-017-1229-4. PMID: 28125983; PMCID: PMC5270346. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-017-1229-4
National Childbirth Trust (2017) The Hidden Half. Bringing postnatal mental illness out of hiding. www.nct.org.uk/sites/default/files/2019-04/NCT%20The%20Hidden%20Half_0.pdf
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May;14(4):245-58. doi: 10.1016/s0749-3797(98)00017-8. PMID: 9635069. https://pubmed.ncbi.nlm.nih.gov/9635069/
CDC (US Centre for Disease Control and Prevention), 2019. Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence. https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf