Mental health is important in young kids too. And it's all about relationships.

Older children and teens are typically at the center of the myriad studies and news articles spotlighting the youth mental health crisis. But not even the youngest Wisconsinites are immune to such struggles.

That's because their parents and caregivers aren't immune.

Experts say that from birth to early childhood, children's mental heath is particularly linked to that of their caregivers.

"Sometimes parents are overwhelmed, but they feel like they shouldn't need help," pediatric psychologist Stephanie Kohlbeck said. She said pediatricians at the Marshfield Clinic Health System screen parents for mental health issues when they bring their children in for well visits, and talk to parents about managing stress.

"But kids do well when parents are doing well."

Mental health looks different in early childhood than later in life, but that doesn’t make concerns during this time any less serious. Lana Shklyar Nenide, executive director for the Wisconsin Alliance for Infant Mental Health, defines “infant mental health” as the ability of children from birth to age 5 to experience and express emotions, form strong relationships and explore their environment. She added that this is influenced by the child's family relationships and culture.

When infants and young children experience mental health concerns, including stress, anxiety and PTSD, it can negatively affect every aspect of their lives. This includes their physical, emotional, social and cognitive development, as well as their ability to succeed in life, a briefing paper from Zero to Three says.

“We have the most potential, but also the most vulnerability, during these first years of life,” Shklyar Nenide said.

Infant mental health is a thing. And it's strengthened by caregivers' mental health.

The key to building strong mental health in infants and young children is fostering quality relationships with caregivers. The importance of these relationships also explains the link between caregivers’ mental health and that of their infants.

“A baby’s mental health, a child’s well-being, is very connected to adults’ well-being, adults’ state of being,” Shklyar Nenide said. “If they are stressed and not well, the kid will be stressed and not well.”

Infants rely on caregivers to meet their every need. Caregivers who are experiencing mental health concerns may not be able to meet those needs in the way they need to or want to, said Joanne Klysen, director of community-based counseling at Foundations Health and Wholeness.

If a baby’s needs are not consistently met, they won’t feel safe and valued, which results in their stress hormones increasing. This can not only damage their physical system, but also hinder secure attachment between the baby and their caregiver. As the child ages, they are more likely to struggle with forming friendships, Klysen said.

Babies learn by watching their caregivers move through the world, Shklyar Nenide said; therefore it’s essential for their development that their caregivers engage with them.

Little things can make a big difference, Klysen added. For example, playing with babies sets them up for success with future relationships and better emotional regulation.

“The simple act of frequently smiling at a baby is our easiest way to connect with our babies, and that decreases their stress hormones and increases attachment between mother and infant,” Klysen said.

But when you're confronting mental health concerns, smiling — or otherwise engaging with your baby — can be difficult.

Shannon Jefferson, a Green Bay mom of five, knows this struggle all too well. After each of her pregnancies, she battled postpartum depression — a condition experts say affects at least one in eight women — as well as postpartum anxiety.

Jefferson recalled a moment when her firstborn was just a few weeks old. The thought of even holding her young son sparked massive anxiety, coupled with numbness and confusion.

“It felt like my skin was crawling, and I was very fearful of hurting my baby,” Jefferson said.

But knowing that this skin-to-skin contact helps form that crucial connection, Jefferson knew she had to find a solution. With her husband’s help, she did.

The family formed a train of sorts: Jefferson sat on her husband’s lap. He wrapped his arms around her as she cradled their infant. With this simple action, Jefferson’s husband supported both her and their son.

“When the mother is having a hard time, we may just need another energy, another person, to come in to help push us through that, because those feelings can be really scary,” she said.

Each of Jefferson’s experiences with postpartum depression were different, but she noticed a commonality: Symptoms hit harder when she didn’t have support.

Roughly five years later, when her fourth child was about 8 months old, Jefferson joined a mother-infant therapy group at Family and Child Care Resources of Northeast Wisconsin. Klysen and Franchesca Vasquez, a mental health clinician and infant mental health consultant for Counseling and Consulting Professionals LLC, facilitated the groups.

In the first half of each session, mothers met together, while their infants were in child care in a separate space. Here, moms could dive deep into their experiences with postpartum depression and anxiety, traumas and other mental health concerns. They discussed how that might influence the mental health of their infants — without their infants there to pick up on the stress of this emotional work.

Then the infants rejoined their parents as experts observed their interactions, reinforcing actions that build secure attachments — like smiling, cooing, playing and being attuned to the infants’ needs and emotions.

The group also fostered connections between parents. This proved to be especially important for Green Bay's Nou Xiong; in the group, she met a mom whose son was battling the same kidney complications as her son.

“Before this group, I felt very lost,” Xiong said, describing the mutual support as “a relief.” Xiong’s son is now 2, and she is still in contact with the mom she met in the group.

Ashly Harrison, a De Pere mom who also participated in the mother-infant mental health group, said she benefited from Family and Child Care Resources of Northeast Wisconsin's home visiting program as she navigated postpartum anxiety. She said she was able to discuss any concerns about her child’s development, and always had someone checking in to ensure milestones were met and to connect her with experts.

“It gave me peace of mind to know that I had that person,” Harrison said.

Families need support in relationship-building — even before the baby is born

Support systems can be built even before the baby is born. This is critical, as stressors that affect a person's mental health are common in pregnancy and childbirth.

Whitney Bingham is the director of Milwaukee’s African American Breastfeeding Network's WeRISE doula program. She explained that a doula’s role is to educate people about childbirth and prepare them for what will happen in labor, delivery and postpartum. That knowledge allows pregnant people to feel empowered to create a birth plan for how the birth should go, the type of support they want during the birth and how different contingencies should be handled.

A 2019 study in the "BMC Pregnancy and Childbirth" journal notes that this support can protect against postpartum depression and anxiety as well as improve new parents' self-esteem and confidence as they start their parenting journey.

Toni Whitaker, a doula who was certified through the WeRISE program, said about a client's relationship with her doula: “We do not replace their voice, we just elevate it.”

“We never overstep the voice of the patient. We may not always agree with her decision, but it’s not about us. It’s the mom’s experience, and she has to create the way she wants it," Whitaker said. “I truly believe that when the medical people see the patient has support, they’re more inclined to listen and to not provoke fear.”

Bingham said doulas in the WeRISE program visit clients in their homes a few times after they have given birth; they use that time to talk about healing both physically and emotionally, ensuring the new parent and baby feel supported and have whatever resources they need. They also emphasize the importance of relationship building in those first few weeks and months.

“We ask things like how much skin-to-skin time they’re doing because that helps the baby to feel relaxed and grounded and safe. We also look at what their support looks like, at who’s home with them,” Bingham said. “I’m very honest with clients’ extended family. I tell them it’s not helpful to just come and want to hold the baby. They’re here to help around the house with cooking and cleaning. Baby time in those early weeks should be for Mom and Dad.”

Whitaker also uses her training in mental health first aid to provide her clients and their families with skills to recognize mental health problems and resources to address them. People who are trained in mental health first aid learn how to understand the early signs and symptoms of a mental health challenge to provide preventive support, recognize when those symptoms get worse and how to provide resources.

“As doulas, we only see our clients for a little while, and we assess and provide care to them for a period of time,” Whitaker said. “But we need to get those mental health first aid skill sets and resources to the people who are there with that person every day.

“If we can integrate that into our communities, that would be a powerful thing.”

What do mental health concerns in infants look like?

Between 10% and 16% of infants and toddlers experience anxiety, PTSD or some other mental health concern. For babies living in poverty, this figure charts even higher, at 22%, according to the Zero to Three website, www.zerotothree.org. The following are signs something may be going on, according to Joann Klysen, director of community-based counseling at Foundations Health and Wholeness, and Franchesca Vasquez, a mental health clinician and infant mental health consultant for Counseling and Consulting Professionals LLC.

• Baby doesn't coo, engage or make eye contact, has flat affect

• On the flip side, baby has difficulty calming, even with support from an adult

• Baby's body is tense

• Abnormal sleep patterns

• Digestive system difficulties

• Mood instability

More signs can be found online at bit.ly/CPPsymptoms. Centers for Disease Control and Prevention also has a list of milestones at bit.ly/milestonesCDC. These can help keep tabs on your child's development.

Marshfield Clinic Health System pediatrict psychologist Stephanie Kohlbeck said that as a young child moves out of infancy, changes in sleep patterns and difficulty calming even with adult support continue to be signs of mental health concerns. Young children struggling with mental health may also:

• Show changes in appetite

• Have a reduced frustration tolerance

• Show increased attempts to seek attention

"Young kids may not know why they're upset, but they know that if they do something like punch their brother, their mom will pay attention to them and be there," Kohlbeck said. "What they do know is that they need adult support and nurturance and reassurance."

As children grow older, there's still time to strengthen relationships

Support communities remain important as babies grow into the toddler and preschool stage, and parents — especially first-time parents — benefit from reassurances that they aren't the only ones dealing with challenges.

Last August, when Sarait Reyes dropped off her then-3-year-old son Dean for his first day of preschool, she felt anxious.

"I thought he would cry on the first day, and then I would be super embarrassed because he was crying," Reyes said. "But our family advocate gave me tips on what to do when I dropped him off, to let him get settled doing his thing and then walk away and he would be fine.

"And he did. He said, 'Bye, Mom.' He was fine."

The family advocate Reyes referred to is part of a model at the United Community Center Ricardo Diaz Early Learning Center in Milwaukee, where Dean attends preschool. Each family in the center — which serves children from 6 weeks to 4 years old — is assigned a family advocate. Leticia Espinoza, who supervises the advocates in her role as the center's family and community partnership manager, compared them to social workers in that they support families in obtaining whatever resources they need.

Cyndi Hemmer, the center's manager for disabilities and mental health, said relationships between those advocates and the center's families are instrumental in their efforts to support the well-being of the children and their caregivers.

"We want parents feeling comfortable to talk to us. Maybe they're not having issues with the child, but parents might have mental health issues that maybe aren't affecting the child yet, but we know long term, it does," Hemmer said. "With these strong relationships, someone will feel comfortable telling us, 'you know, this isn't great.'"

Hemmer and Espinoza said that many times those conversations are about relieving some of the stressors parents feel by reassuring them that their child's behavior is developmentally appropriate, expected and totally normal. Even when a child does need extra help for something, it's important for families to know there are people available to support them, and there are clear next steps.

That was also the case for Reyes, since part of her anxiety on that first day of school was due to Dean's language delay.

"I was worried, like, 'why are you not talking?'" Reyes remembered. "I was so stressed out, but our advocate said, 'he's going to be fine.'"

Since starting preschool, Dean has received on-site speech therapy. Reyes also started taking parenting classes through the center to learn positive strategies to meet Dean where he is in his development.

Hemmer said it's important for parents to understand that they can provide their children what they need, even when they're dealing with their own stressors.

She said parents have told her they're working multiple jobs, that they sometimes have to pick their kids up from the UCC and then drop them off at a second child care while they go to their next job, that they're struggling to balance quality time with their children while also keeping a roof over their heads.

"We help them create these toolboxes of easy strategies so when their brains are thinking about the worst, they have those easy strategies to implement without having to think," Hemmer said. "We're not telling parents, 'you have to spend all your time fully engaged.' It's about making the most of the time you have with them."

That message of hope resonates with Reyes, who feels she missed out on forming that all-important attachment with Dean when he was a baby because health problems had her in and out of the hospital during the first few years of his life. During that time, Dean spent more time with his grandmother than he did with his mom.

"We can normalize postpartum experiences. Maybe you didn't get those magical moments; that's a reality for a lot of moms," Hemmer said. "But even if things didn't go according to plan, you can still get there. Even if your child is having a challenge right now, or you're having a challenge right now, this isn't the end of the road for you."

Now Reyes said she picks up Dean from school every day and he gets in the car, excited to sing one of his favorite songs, then asks his mom to sing her favorite to him. Mother and son take turns, enjoying their daily routine, cementing their relationship.

"We're getting attached," Reyes said. "Now I'm getting my bond back."

Madison Lammert covers child care and early education across Wisconsin as a Report for America corps member based at The Appleton Post-Crescent. To contact her, email [email protected] or call 920-993-7108. Please consider supporting journalism that informs our democracy with a tax-deductible gift to Report for America by visiting postcrescent.com/RFA.

Contact Amy Schwabe at (262) 875-9488 or [email protected]. Follow her on Twitter at @WisFamilyJS, Instagram at @wisfamilyjs or Facebook at WisconsinFamily.

This article originally appeared on Milwaukee Journal Sentinel: Mental health in young children is affected by parents' mental health