Samantha Wilson, PhD, will never forget working the overnight shift at the St. Louis Crisis Nursery, a short-term shelter for children at risk of abuse, neglect or homelessness. One night she cared for a 4-year-old who had accidentally set a fire that burned down his house and killed his infant sibling.
“He woke up in the middle of night, screaming. He was as terrified as if the fire was happening again,” said Dr. Wilson, who is now a psychologist with Children’s Hospital of Wisconsin. “I remember feeling so helpless that I didn’t know how to help him. I still think about that boy. How does a 4-year-old recover from that? How can we help him heal?”
Those questions inspired Dr. Wilson to focus her graduate studies on early childhood mental health. Today, she is one of just a handful of clinicians statewide who is credentialed by the Wisconsin Alliance for Infant Mental Health as an infant mental health mentor, the highest level possible.
The emerging field of early childhood mental health focuses on a child’s first five years, a critical period for social-emotional development, which makes it highly responsive to early intervention. Children’s Hospital of Wisconsin recently launched an Early Childhood Mental Health Program, reflecting its growing commitment to mental and behavioral health and focus on the full spectrum of child development.
As any parent can attest, life with a young child can be trying at times. But for some children, especially those who have experienced trauma, everyday challenges can trigger tantrums that last for hours, night terrors, severe separation anxiety and other social-emotional issues.
Dr. Wilson brings her expertise into Children's Hospital of Wisconsin's International Adoption Clinic because children who spent time in orphanages can struggle with social-emotional development. Children within the foster care system are also vulnerable to what clinicians call “dysregulated behavior,” which can include taking hours to fall asleep or waking up multiple times at night, overeating or eating very little, severe tantrums that can’t be soothed, frequent biting or hitting, head-banging or excessive rocking.
“A major misconception is that babies are too young to remember early traumatic experiences,” said Gretchen Huletz, PhD, manager of Children’s Hospital of Wisconsin’s Early Childhood Mental Health Program. “They may not remember cognitively, but their little bodies can remember, so if they hear yelling and witness domestic violence as an infant, when they’re 3 years old and get triggered, they can have a physical reaction and have a tantrum or anxiety. Our bodies carry a lot of trauma.”
Mental health problems can be difficult to diagnose at an early age. “Parents can’t get help they need, so they feel isolated, and that can impact relationships within the family,” Dr. Wilson said.
But with the right support, families can reduce social-emotional problems early, before they escalate. And that has implications for a child’s lifelong well-being.
“You’re laying the architecture of the brain,” Dr. Wilson said. “Brains grow through experience. When we’re born, our brains are only 25 percent developed, and those early experiences get etched into our brain. If we think about it as building a house, you’re laying a foundation. So if the foundation is rocky because of chronic stress or trauma, the brain starts to wire to those experiences.”
Many factors can contribute to a rockier start to life, whether it’s a long stay in a neonatal intensive care unit or chronic poverty.
“We consider the potential impact of generational trauma, where parents and grandparents have grown up in a culture of poverty and food insecurity,” Dr. Huletz said. “Trauma physically changes the brain. These changed brains can even change DNA that can be passed down to children.”
Part of Dr. Wilson’s work is also consulting with community agencies that serve young children, including the Waukesha County Head Start and Early Head Start program. Brittany Sabel, a home visitor coach for the program, has witnessed generational trauma firsthand. Her team works with families in Waukesha and Washington counties who are at or below the federal poverty line or who are vulnerable for other reasons. Early Head Start’s staff visit families at home weekly to support them from pregnancy until age 3.
“We definitely see our little ones affected by their parents’ mental health and so it’s so important for us to support the whole family,” Sabel said. “Many of our families are dealing with a lot of trauma and heightened anxiety related to chronic homelessness, chronic poverty, the immigration crisis, substance abuse and domestic violence. That in turn affects their ability to be present with their child. If you have a parent who is so depressed they’re having a hard time getting out of bed in the morning, then the children don’t get the interaction they need.”
The program’s staff, including child and family specialist Bonnie Friese (pictured above), meet with Dr. Wilson regularly to talk through cases. “We’re seeing a rise in anxiety and depression in children. That can manifest itself in a lot of different ways, from not sleeping consistently to night terrors to tantrums to being withdrawn from peers,” Sabel said. “We brainstorm ways to help these families, different ways and techniques that may engage the parent and child. Dr. Wilson is so rich in resources, and she provides us with ideas that we may not have come up with.”
One technique that Early Head Start has adopted is having parents reflect on “angels and ghosts” in the nursery — the positive and negative experiences a parent had growing up that might influence their own parenting style. “These are really wonderful tools for parents who have pretty significant mental health issues,” Sabel said.
Mental health issues cut across socioeconomic lines. Postpartum depression, which affects up to 15 percent of moms, is a particular concern. “When women are depressed, they have a flat affect. They have no facial expressions. The babies catch on to that, and they may not reach out or coo as much. The baby learns, ‘If I cry, no one comes,’” Dr. Huletz said.
Anxiety disorders can also affect one’s parenting. “Obsessive-compulsive disorder is really common, where moms are so disturbed by thoughts of, ‘What if I drop the baby?’ that it inhibits their interactions,” Dr. Huletz said.
But parents shouldn’t blame themselves — parenting isn’t easy under the best of circumstances, and therapy can help both parents and children heal together.
Early childhood mental health specialists don’t use a traditional therapeutic model: the “client” is the relationship between the parent/caregiver and child, not the child or parent themselves.
“We’re trying to build healthy families as early as we can,” Dr. Huletz said. “The relationship is everything. If children and caregivers have a solid, loving relationship and bond, and then if something happens to that child later in life, they’re going to have more resilience.”
Early childhood mental health specialists also support families to find ways to reduce difficult behaviors. For Dr. Wilson, a child’s behavior is valuable communication if you remain curious and seek to understand it.
“Part of it is understanding the purpose of the behavior,” Dr. Wilson said. “There might be lots of reasons why a toddler hits. So I sit with the parent and talk about what hitting does for the child. Maybe it helps discharge stress, maybe it helps them get a toy, maybe it gets people to leave them alone. It’s a little more complicated then just putting them in timeout. If the child is hitting because they want to be left alone, then a timeout doesn’t help.”
Sometimes therapy doesn’t completely eliminate a behavior, but simply understanding the emotion behind it can help parents cope. “How parents perceive behavior is going affect how a child acts,” Dr. Wilson said. “If a parent perceives a response as defiant, they’re more likely to get angry, which can increase the child’s fear, maintaining the defiant behavior.”
Another tool is Parent-Child Interaction Therapy, where the therapist stays out of the room but watches through a one-sided mirror, giving feedback to the parent via an earbud as the parent and child engage in various play interactions. That playtime in the therapist’s office is more important than it might look.
“When kids feel safe enough to play, they learn to regulate excitement,” Dr. Wilson said. “A lot of times parents will tell me, ‘They love this time with you.’ And I tell them, ‘They like this special time with you. It’s actually not about me.’ There aren’t a lot of times when we’re intentional about being together, where we can cherish each other. It doesn’t happen as much because we’re busy, we’re on our phones, we’re trying to manage 5,000 things at once. My first job is to build some positive interactions between the child and caregiver.”
Dr. Wilson recalls one 3-year-old who had been removed from an abusive situation and placed in foster care. The boy regressed significantly when he had to be separated, even briefly, from his foster mom: babbling, flapping his hands, and clutching safety objects.
During initial therapy sessions, Dr. Wilson introduced hide and seek, which was at first terrifying to the boy. She and the foster mom, who eventually adopted the boy, hid around the office until the boy was able to tolerate short periods of not being able to see his caregiver. Dr. Wilson worked with the family regularly for four years and was present at his adoption day. Now 10, the boy is doing well and recently called her to chat, acting so developmentally typical that she could hardly believe it was the same kid.
“You were part of our life at such a critical time,” the boy’s mother said.
It’s moments like these that make the job worth it, and Dr. Wilson sees them again and again.
“I sit with a lot of adversity, but that’s not how it feels to me,” she said. “I feel incredibly hopeful. I get to see the resilience of children when they’re embedded in relationships that are nurturing. It’s the beauty of the human experience.”
The focus on early intervention, before mental health problems escalate, is the best way to address Wisconsin’s critical shortage of mental health professionals. Dr. Huletz and her team are developing a Milwaukee clinic focused on children ages 0-5, aim to get at least one early childhood therapist at every Children’s Hospital of Wisconsin clinic throughout the state, and are working to integrate relationship assessments into pediatricians’ checkups.
“We want early childhood mental health practices to be part of what we do every day in every area of the hospital,” Dr. Huletz said. “The first three to five years of a child’s life are so important for development, and whatever they learn is the blueprint for the rest of their lives. We’re doing this because it’s the right way to care for children’s health.”