Sociology of Health & Illness Vol. 36 No. 3 2014 ISSN 0141-9889, pp. 416–431 doi: 10.1111/1467-9566.12074

Infant mental health promotion and the discourse of risk Angela Lawless1, John Coveney2 and Colin MacDougall3 1

South Australian Community Health Research Unit and Southgate Institute for Health, Society and Equity, Flinders University, Australia 2 Public Health, Flinders University, Australia 3 Public Health and Southgate Institute for Health, Society and Equity, Flinders University, Australia

Abstract

The field of infant mental health promotion has rapidly developed in academia, health policy and practice. Although there are roots in earlier childhood health and welfare movements, recent developments in infant mental health promotion are distinct and different. This article examines the development and practice of infant mental health promotion in South Australia. A regional, intersectoral forum with a focus on families and young children was used as a case study. In-depth interviews with forum members were analysed using a governmentality lens. Participants identified a range of risks to the healthy development of the infant. The study suggests that the construction of risk acts as a technique of governing, providing the rationale for intervention for the child, the mother and the public’s good. It places responsibility on parents to self-govern. Although the influence of broader social contexts is acknowledged, the problematisation of mothering as risk shifts the focus to individual capacity, rather than encompassing the systems and social conditions that support healthy relationships. This research suggests that the representations of risk are a pervasive and potent influence that can act to undermine health promotion efforts that seek to empower and enable people to have more control over their own health.

Keywords: Infant mental health, discourse, governmentality, risk, attachment

Introduction Infant mental health promotion is described as a multidisciplinary, intersectoral collaboration, as espoused by the Ottawa Charter for Health Promotion (World Health Organization [WHO], 1986) Although it has clear roots in the early childhood health and welfare movements of the 1950s (Bowlby, 1952, 1953) the recent developments in infant mental health promotion are distinct and different. This article examines the increasing interest in infant mental health promotion by exploring its manifestation in a range of services in South Australia. While this case study is a South Australian example, interest in infant mental health is evident nationally and internationally. © 2013 The Authors. Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd. Published by John Wiley & Sons., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Maiden, MA 02148, USA

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Infant mental health promotion: definitions and development Interest in the early years of life encompasses not only the physical wellbeing of infants and young children, but also mental health and the impact of the early years’ experiences over the life-course. The field of infant mental health promotion has rapidly developed in academia, health policy and practice. The World Association for Infant Mental Health (WAIMH) defines infant mental health as: the ability to develop physically, cognitively, and socially in a manner which allows them to master the primary emotional tasks of early childhood without serious disruption caused by harmful life events. Because infants grow in a context of nurturing environments, infant mental health involves the psychological balance of the infant-family system. (WAIMH 2009) Infant mental health is seen as a still emerging field consisting of ‘an inter-disciplinary field of research, clinical practice and public policy-making concerned with the emotional development of infants’ (Australian Association for Infant Mental Health 2008). The journal Infant Mental Health was established in 1980. The lead article of the first issue identified a contemporary explosion in research about infants and families (Trout 1980). Tracking the emergence of the field identifies strong roots in what Rose (1999) calls the ‘psy’ disciplines. Selma Fraiberg, a clinical social worker, is credited with coining the term infant mental health (Weatherstone et al. 2002) and her contribution to the field is acknowledged by other authors (e.g. Zeanah and Zeanah 2009). Infant mental health, as conceptualised by Fraiberg, consists of working with mothers and infants to strengthen the infant wellbeing through promotion of secure attachment relationships (Weatherstone et al. 2002). Barrett (1980) discusses the contribution of Caplan who introduced notions of preventive mental health in his 1964 text Principles of Preventive Psychiatry. Caplan’s (1964) model suggested that people have common needs, which include physical supplies (e.g. food and shelter), psychosocial supplies (personal interaction) and sociocultural supplies (cultural and social norms and values). Barrett (1980) suggested that infant mental health programmes were being formed by a blending of Caplan’s community-based approach with Fraiberg’s individual psychotherapeutic approach. Here we can see some resonance with the broader health promotion movement with the sometimes competing, sometimes complementary, foci on individuals and the community. Infant mental health promotion: actors and actions The WAIMH suggested that the field of infant mental health combines three assumptions: infant behaviour cannot be viewed separately from relationships; the most important relationships are with the primary caregivers and infant caregivers, operate in a social context (McDonough and Fitzgerald 2003). Particularly significant in the emphasis on the infant-caregiver (mother) relationships has been attachment theory, first developed by Bowlby in the 1940s and 1950s. Published as one of the WHO’s first major reports, Bowlby (1952) reported his findings on early caregiving experiences and later emotional health. He wrote: ‘mother-love in infancy and childhood is as important for mental health as are vitamins and proteins for physical health’ (p. 158). In 1953 Bowlby wrote that there is ‘a high level of agreement among child-guidance workers regarding approaches, aims and theories of mental health: an infant and young child should experience a warm, intimate, and continuous relationship with his mother’ (p. 13). The term attachment came into common usage as a description of the affective bond between infant and caregiver that provides the basis for emotional, social and cognitive development. © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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Infancy is seen as offering unique opportunities for promoting mental health. Infant mental health interventions comprise a range of strategies focusing on relationships: emotional support, resource assistance, developmental guidance, advocacy and infant-parent psychotherapy (Weatherstone 1998). Attachment-based interventions were seen to have the potential for supporting healthy development, improving long-term outcomes and ameliorating the damaging effects of factors such as maternal mental illness (Paris et al. 2009). As the infant’s mental health cannot be considered independent of the caregiver, usually the mother. Her performance of health-promoting behaviour becomes an important measurement in assessing infant health (Gaffney et al. 2001). While infant mental health has strong roots in the psy disciplines, interdisciplinarity is emphasised. In 2000 an editorial entitled ‘Where are we going in the field of infant mental health?’ provided a list of disciplines making a contribution to the field: ‘biology, neuroscience, physics, genetics, obstetrics, neonatology, pediatrics, psychology, psychiatry, sociology, anthropology, linguistics’ (Sander 2000: 5). The contribution of neurosciences was especially significant in that brain development is now seen to be directly influenced by experiences in infancy and even prenatally. Sander (2000) describes this as ‘a dramatic new grasp of the way the brain works, especially the way infant experiencing and changes in brain morphology are related’ (p. 17). Evidence from neuroscience is widely cited in discussions of infant mental health and in advice to policymakers, practitioners and parents. For example, Mustard (2008) recommended neuroscientific research and teaching, neurobiological education for child development workers, including the teaching of brain development in the secondary school curriculum and the integration of neuroscientific knowledge into parenting programmes. The field has gained momentum in the last few decades. At the beginning of the 1980s, programmes aiming to improve mental health in infancy were still rare and mostly the province of ‘creative and outstanding psychologists’ (Murphy and Frank 1979: 174). The 1990s saw attachment theory gain new impetus through neuroscience research linking early life experience with brain development (Wall 2004) and thus providing a scientific rationale for the emerging field of infant mental health. By 1991 Jennings et al. were able to write that the need for infant mental health programmes had received wide acceptance (Jennings et al. 1991). In 2000 Sander was speaking of a societal awakening to the critical place of infant mental health for the future of social organisation. Infant mental health interventions are now seen to include: the promotion of well-being, the prevention of risk in infancy and early childhood, intervention specific to relationship disturbances, and treatment of identified disorders of infancy within the context of relationship care. (Fitzgerald et al. 2011: 181)

Infant mental health promotion: a project of government As Dean (1999) puts it, government shapes ‘the field of action’ (p. 13), giving shape to the way in which people act and think. Practices of government are complex apparatuses that act to govern in the sense that they are productive of meanings, consequences and outcomes. Dean (1999: 21) described them as institutional practices: the routinized and ritualised way we do these things in certain places and at certain times. These regimes also include moreover, the different ways in which these institutional © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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practices can be thought, made into objects of knowledge, and made subject to problematizations.z Recognising infant mental health promotion as a form of government in this sense allows us to draw upon methods of analysing government as a means of examining not only formal programmatic interventions but also all the means by which we govern others and govern ourselves. The present study was framed by the following questions: how and why has infant mental health become a source of concern requiring a public health response? How has infant mental health developed into a problem for which a range of solutions, including infant mental health promotion, can be developed?

Infant mental health promotion: an analytics of government This research drew on the work of Carol Bacchi (1999, 2009) in the exploration of problematisations as a conceptual tool for governmentality research. Governmentality research derives from the work of Foucault (1978), which examined the development of mechanisms to govern the conduct of conduct. Bacchi’s approach is captured in the question ‘what is the problem represented to be?’ (WPR), which understands problems as particular representations that have particular consequences. This also allows us to imagine different representations with different consequences. Bacchi’s approach has been used in a number of analyses that have examined discourses as particular forms of power in health and social policy and practice (see, for example, Begley and Coveney 2010, Dwyer et al. 2011, Widding 2011). The exploration of power relations embedded in such an approach is particularly relevant to a consideration of health promotion initiatives. Petersen and Lupton (1996) suggested that there has been little analysis of power relations in such work, given the importance ascribed to notions of empowerment in health promotion work. In a similar vein Potvin et al. (2005) noted that the social and relational dimensions of public health practice post-Ottawa Charter (WHO 1986) remain largely undertheorised and unexamined.

Methodology A case study approach The research used a case study approach examining the emergence in South Australia of infant mental health promotion as a field of thought and action using govermentality analysis. A regional, intersectoral forum with a focus on families and young children was the basis of fieldwork exploring the structures, practices and events of infant mental health promotion. The forum was selected as an instance of a multidisciplinary, intersectoral group reflecting the whole government approach promoted in the health promotion literature and policy. It provided a setting where and individuals for whom the processes being studied were most likely to occur (Denzin and Lincoln 2000: 378). In terms of this study, sampling sought ‘access to enough data, and with the right focus, to enable [the researcher] to address the research questions’ (Mason 2002: 134). Participants The first author (AL) attended a meeting of the forum to introduce the study. The forum members identified themselves or their agency as having a specific interest in early childhood. E-mails were then sent to these members inviting them to participate in the study. Two © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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members who were approached suggested that another person in their agency would be more appropriate and both the suggested participants agreed to be interviewed. The sample consisted of 11 informants. Ten interviews were conducted, one including two participants. The participants came from local government, primary health care, Aboriginal health, family support, child protection and supported accommodation and comprised a range of disciplinary backgrounds. Although small, this sample provided access to rich data gathered from a heterogenous group of informants. A preliminary analysis of the data revealed both emerging common themes as well as some divergent views and appeared to constitute a ‘meaningful range’ (Mason 2002: 124) in terms of sampling. These preliminary findings were presented at a forum meeting and an invitation made to members who had not yet been interviewed to participate, with particular encouragement given to people who felt they had differing perspectives or new insights. No further informants volunteered. Ethics approval for this research was granted by the Flinders University Social and Behavioural Ethics Committee. Analysis of data All interviews were recorded, transcribed and analysed using NVivo software. The analysis was iterative and incremental. The first stage of analysis was undertaken based on listening, reading and re-reading the interviews. A descriptive thematic analysis of interviews was then undertaken. The second stage of the analysis involved coding the data using the questions posed by Bacchi to interrogate them. In this study Bacchi’s (2009) WPR approach has been used to work backwards, so to speak, from what agencies do in relation to infant mental health and infant mental health promotion. In other words, the forms of practice described by interviewees were used as a point of entry to examine the problem representations implied by these practices. Here the task was not to categorise but to contextualise the data by seeking relationships between the data that act to form a coherent whole (Maxwell 1996). Guided by the conceptual tools of governmentality analysis and in particular the application of a ‘WPR?’ approach, the data were analysed to identify the emergence of infant mental health promotion discourse(s). Bacchi’s WPR approach interrogates the data through a series of questions that critically examine how problems are thought about and acted upon rather that accepting the problem presentation as a given – how is infant mental health problematised? Thus, the discourses were examined in terms of how they act to direct or constrain thinking and action, create those who are able to speak authoritatively on the subject and explore power relations and the technologies of governing and self-governing. Finally, the discourses were examined in terms of how they act to shape practice in ways that are either congruent with or undermine health promotion objectives.

Findings The problem represented as risk Primary analysis of the interviews identified threads of meaning in the discourse of infant mental health: the messages of brain science regarding the importance of the early years for lifelong health and development; the notion of critical periods as never-to-be repeated windows of opportunity; the primacy of attachment relationships as a foundation for development and the role of the mother as primary caregiver. Each of these concepts was imbued with meaning drawn from the notion of risk: messages of risk become reinforced and increasingly highlighted in the discourse as concepts interact and act in concert with each other. © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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The participants identified a range of risks to the healthy development of the infant. Risks were often linked, producing cumulative effects. For example, maternal mental illness was a risk for establishing healthy attachment and poor attachment constituted a risk for child and adult mental health. Risk was identified as residing in individuals ‒ the mother and child ‒ and in their environment. Just as the presence of some factors constituted risk, so did the absence of others ‒ a lack of support, a lack of knowledge about child development and a lack of parenting skills were noted. Risk has become a motif of modern society. It is a key word that signifies danger and threat (Lupton 1999). It figures in the way we think about and act upon a range of issues from child development to chronic disease. It is perhaps not surprising then, that risk emerged as a

Figure 1 Intertwining messages of risk © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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dominant thread in most interviews undertaken for this study. The following sections: risk and child development, at risk, mothers and children and discourse shaping practice examine the ways in which infant mental health is problematised and acted upon. Risk and child development Armstrong (1995) described the development of the ‘novel and pivotal medical concept of risk’ (p. 400, original italics) as part of new 20th century surveillance medicine. Surveillance medicine is concerned not only with illness, but the apparently precarious nature of health. The child, the first target of surveillance medicine, also became the object of the new concern with the non-physical as attention turned to ‘the unformed mind of the child’ (Armstrong 1995: 396). Psychological growth was rendered problematic – a subject to be monitored and a site of intervention. An increasingly complex web of informal and formal institutions beyond the medical operated to provide means of surveillance (Heaton, 1999). The work of John Bowlby (1952, 1953), fundamental to the notion of infant mental health, sought to establish just such complex circuits. Rose (1999) suggested that Bowlby’s work built solid connections between governing, mental health, childhood and the role of expertise. May (2006) noted that the state employed a concern with the psychological to promote full-time mothering and other social interventions in the mid-20th century. Since Bowlby (1952, 1953) argued that children’s wellbeing was dependent on early and healthy attachment to their mother there has been an accepted imperative for mothers to be a constant presence in their young children’s lives (Smart, 1996). The focus on mother–child relationships and attachment borrows support from discourse regarding maternalism (Ailwood, 2007). Discourses of maternalism (constructing ‘the good mother’) are strongly interrelated with discourses of risk in discussions of early childhood and infant mental health. The newer discourse of brain science has acted to revitalise the focus on attachment and mothering. As Parker (1992) noted, discourses interact, drawing institutional support from each other. Attachment and appropriate nurture and stimulation are now understood to be the foundation for brain development. Scientists tells us that there are physical consequences of early years’ relationships and environment in terms of neural sculpting. Not only does the early years’ experience shape the brain but scientists also suggests that an opportunity missed is an opportunity lost; that is, critical windows for brain development, once passed, are closed forever. This is reflected in these responses: the whole early brain research has been a major impetus. (Sally, primary health care [PHC] allied health professional) it’s the understanding of neural development and, and social development and the physical development, there are things if they don’t happen in those first few years people spend a lifetime trying to compensate for what didn’t happen. So it’s actually … the physical wiring of the brain. (Gerry, non-government organisation [NGO] manager) This scientific discourse of risk presupposes that risk is identifiable, objective and based on science (Lupton 1999) and can ‘provide a basis for making ethical decisions about personal conduct’ (Petersen 1996: 54). Using the notion of risk to make decisions about which individuals should be the target of intervention assumes certainty about the predictive nature of risk, which was evident in a number of the interviews and was captured here by Gerry, NGO manager: ‘these kids are going to grow up to be dysfunctional people’. Their future is determined in these early years. © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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At risk: mothers and children The interviewees shared a vocabulary of risk despite different sectors and professional backgrounds being represented. Descriptors of families, mothers and children included: ‘marginalised, dysfunctional, at risk, high risk, deprived, high need, disadvantaged, deprived and vulnerable’. This shared language points to a ‘family resemblance’ (Rose et al. 2006: 97) between the various programmes and practices of forum members. So, for example, practice focusing on developing attachment was described in supported accommodation, health and state-funded and NGO community service settings. Despite the family resemblance presented by the notion of risk, two threads of meaning in relation to risk in the language of interviewees were discerned. A family support worker spoke of risks that essentially reside in the individual, in this case the parents: We have a number of risk factors that we can identify, six or seven of them … Drug abuse, age of parents, attachment issues, intellectual disability, abuse, previous abuse for other kid. Yeah, stuff like that and often it is not just one, it’s a whole bunch. (Michelle, family support social worker) A community development worker spoke of family dysfunction but also of social conditions: poverty, homelessness and unemployment: A lot of council’s services are universal. We also work with agencies who are working at the sharp end. Intervention with groups who would be identified as at risk groups on a whole range of issues: poverty, homelessness, family dysfunction, breakdown, intergenerational unemployment; all of those things we’re pretty conversant with. We tend to target those communities. (Jean, local government community development worker) These two representations resonate with two streams of health promotion: one individualistic, concerned with individual choices and behaviour; the other recognising the impact of more distal influences on the lives of individuals; the social determinants of health. Often, however, what may be termed proximal risk factors and more distal risk conditions are not differentiated. In Bacchi’s (2009) examination of health policy, she observes that it is possible to examine and acknowledge the social determinants of health and still attribute responsibility to individuals by focusing on risk factors. The language and ideas within discourses shape the way issues are problematised and the action that flows from this. They are productive: ‘Discourses accomplish things. They make things happen’ (Bacchi 2009: 35). They contribute to the construction of social identities, social relationships between people and construction of systems of knowledge and belief (Fairclough 1992). In governmentality terms, the identification of defining properties and categories of people operate as techniques of governing. The use of terms such as dysfunctional (functional) or disadvantaged (advantaged) act as binary representations that can simplify complex issues and shape our understandings of problems (Bacchi, 2009). Jones (2003) argued that those able to draw on social, cultural and economic capital to assert authority reproduce binaries, or what he terms paired categories, which reproduce patterns of inequality. These categorical distinctions are pervasive and act to distribute inequality and legitimate it (Tomaskovic-Devey et al. 2009). One of the effects of descriptors such as functional or dysfunctional is an assignment of responsibility to individuals; in this case, usually mothers. Risk vocabulary acts to position mothers as either positive factors in fulfilling their children’s potential or as risks to that potential. It is about their individual behaviour and individual choices. It is a construction that suggests it is all about agency rather than structure. On show here is not only the relationship © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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between the parent (mother) and child, but the development of, and risk to, the infant’s mind qua brain.

Discourse shaping practice One discursive effect of situating early childhood and infant mental health within a discourse of risk is that the problem is made governable in particular ways, with particular techniques and for particular goals. Lupton (1999) suggested a Foucauldian approach to discourse sees these expert forms of knowledge as techniques of governmentality; constructing understandings of individuals and populations and regulating their conduct. Risk both determines the scope of what can be done and provides a focus for it. In order to prevent risk and subsequent adverse outcomes we look to ensuring the needs of the child are met: but exactly what are these needs? The sociology of childhood challenges us to rethink our understanding of children’s needs (Woodhead 1997). While some needs are universal, for example food and shelter, others may not be. Children’s needs, rather than being constructed as universal and monolithic, could be understood as diverse, as well as culturally and contextually dependent. Childhood experiences characterised as essential in one cultural context may be discouraged in another (Boushel 2000). Indeed Bowlby’s early writings on attachment were challenged by Margaret Mead (1962, cited in Ainsworth, 1965), who argued that an exclusive mother–child relationship was not the only appropriate way to nurture infants, pointing to examples of non-western child rearing practices. Rogers (2004) argued that children’s needs are conceptualised as those required to develop an autonomous, independent individual. She asks: ‘But what if a different sort of adulthood is aspired to – one that values connectedness, mutuality, and interdependence?’ (p. 132). Ailwood (2007) noted that dominant ideas regarding motherhood and maternalism constitute only one way of constructing the mother–child relationship. For example, Martin (2007) described the notion of relatedness for Australian Aboriginal people, in which particular family members – mothers, aunts, siblings – have nurturing roles in relation to children that extend from conception to adulthood. Child-rearing work is a shared responsibility. Given the complexity of families in contemporary society there are presumably many ways in which the mother–child relationship is constructed in ways that do not conform to the dominant script. Arendell (2000) suggested that ‘single mothers, welfare mothers, minority mothers, immigrant mothers, and lesbian mothers’ (p. 1195) become the subjects of deviancy discourses with respect to motherhood. In governmentality terms, this can be seen as a technique of government, encouraging the majority to think and behave in desirable ways, to self-govern. D’Cruz (2004) described how discourses of the normal family act to inculcate the self-regulation of families and women. Rose (1999) described the intensification of demands for citizens to assume responsibility for their own health and welfare in the last decade of the 20th century. Where governance of families fails, the ‘failed, flawed or anti-citizens’ are directed to experts for ‘treatment and reform’ (Rose 1999: 264). Thus mothers who are unwilling or unable to take up the role of the good mother come to the attention of experts and their relationships, behaviour and thoughts become subject to scrutiny and intervention. Scrutiny is primarily in terms of inherent risks as to whether and how the baby’s needs are being met: So what we can offer is based on the individual, like for example we don’t tell the client what we want them to do, we start from saying these are the risks, this is what we have to address, how do you and I go about doing it. (Michelle, family support social worker) © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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The pivotal relationship between mother and child, beginning even before birth, extends the field of intervention to the pregnant mother. As one worker pointed out: infant mental health is happening right from the point of time from conception essentially. The way the foetus and baby is growing in utero is being impacted on by the mother’s mental health and the environment that she’s living in and that the baby’s wiring neurologically is being set even at that time. (Sally, PHC allied health professional) Powell (2011) suggested that competence in the management of risk establishes and maintains the professional status of healthcare and social care professionals. Thus, risk acts to define both mother and expert. Given that brain science tells us that we have a small and critical window of opportunity to ensure healthy development, intervention in the lives of these families becomes urgent. The following argument captures this reasoning: Children cannot choose their parents. While people disagree about how social policy should treat adults who have been unlucky or unwise, there is something fundamentally unfair about making children’s life chances hostage to the circumstances of their parents. The reality, though, is that family background has a powerful influence on how children develop, beginning early in their lives. Our society’s goal should be to intervene early, often, and effectively in the lives of disadvantaged children from birth to age ten, so that by the end of this period we substantially narrow – or eliminate – disparities in cognitive and non cognitive skills across race and class lines. (Ludwig and Sawhill, 2006: 5) Intervene early, intervene often and intervene effectively: these are the key messages about how society should respond to children who are deemed to be disadvantaged. As the quote makes clear, disadvantaged children are likely to be defined by race and class. At a policy level this can result in interventions aimed at ameliorating the effects of disadvantage rather than targeting the causes of disadvantage. At the practice level it directs us to identify the targets of intervention: those described by the interviewees as marginalised, dysfunctional, at risk, high risk, deprived, high need, disadvantaged and vulnerable and ensure that such children receive appropriate nurture and stimulation. Roe and Morris (2004) suggested that such representations of the problems of mothers and mothering tend to (re)produce unequal power relations in services provided for mothers and children. Parker (1992) argues that ‘We should [italics in original] talk about discourse and power in the same breath. Institutions, for example, are structured around and reproduce power relations’ (p. 12). Problem representation that attributes primary responsibility at an individual level also leaves unproblematic a range of factors that negatively impact on children’s health. Franzblau (1999) asked whether attention to mother–child relationships acts to lessen serious and pervasive threats to their health such as violence and poverty. Yates et al. (2003) recounted a number of studies that demonstrate the negative impact of socioeconomic disadvantage in a range of domains – cognitive, academic, social and emotional – beyond the contribution of factors such as maternal education and family structure. Poverty, they suggested, reduces the capacity for positive parenting as low-income families face ‘a barrage of needs to be filled and inadequate resources with which to meet them’ (p. 245). It is likely that parents are unable to pay attention to the attachment needs of the child when they are in chaotic circumstances and experiencing urgent needs in areas such as income, employment, discrimination and housing (Cyr et al. 2010). © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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There is widespread acceptance that maternal mental illness acts as a risk to healthy child development and this was noted by respondents: So it is pretty much a given if mum’s got mental health issues, if she is not feeding the baby properly there’s every good chance she’s also got issues going around attachment because she is not cueing in. (Michelle, family support social worker) We have a mental health person coming once a month now … halfway through this year we had him come to talk to our staff about how best to work under certain situations, at what stage do we refer them on, what to look out for. (Barbara, supported accommodation worker) Seifer (2003) noted that beyond concurrence that it does constitute a risk, the degree of consensus in the field declines. Examination of attachment studies using a resilience lens suggests that the absence of other socio-contextual risks acts to protect children from the individual risk of maternal mental illness (Seifer 2003). A focus on risks, in this case maternal mental illness, can leave other social and contextual risks unexamined. Furthermore we are less likely to examine why some children of mentally ill mothers have no adverse outcomes, thus failing to explore and understand the processes of resilience. Goodman et al. (2011) noted that although evidence supports an association between maternal depression and children’s emotional and behavioural problems, the direction of the association is not established and transactional models are required to consider the child’s role in contributing to or exacerbating the mother’s depression. Descriptions of practice in the interviews make it clear that for a number of the interviewees new areas of practice had developed as a result of the emphasis on attachment and risk. Supported accommodation facilities now provide psychotherapy for young mothers and consciously model attachment behaviour. A shift from adult to child-centred practice was described by the NGO informant; early childhood workers now focus not only on children’s development but also intervene in caregiving relationships and extend their area of interest to the prenatal period. In our study two interviewees stood out from the others in that these intertwining discourses were playing out quite differently in their areas of practice. One is the Aboriginal health manager who examines these discourses through an Aboriginal health lens and whose questioning resonates with that of Bacchi (2009): ‘what’s going to be in it for Aboriginal people, what are they going to get, what are the benefits out of it?’ The other was the local government community development worker who noted that their remit is universal services rather than individual and that they engage with communities rather than individuals. The interviewee characterised her work in this way: ‘we facilitate the pathways into community life’ (Jean, local government community development worker). The interviewee presented local government’s niche role as providing supportive community environments that facilitate connection to wider community networks and provide opportunities for skill and knowledge development.

Discussion How has this risk consciousness developed as a dominant theme of discourse? How has risk become embedded in the way we think about and act on infant mental health? Most interviewees were not from medical or scientific fields where their professional training may have © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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inculcated notions of risk. Their adoption of risk discourse may be understood as the product of sociocultural processes (Lupton 1999). Social, historical and political threads have interwoven to produce an anxiety about our children and early childhood, in particular. There was a sense that we are somehow failing our children despite the affluence of modern society: ‘a growing perception of substantial threats to the health and well being of today’s children and youth in the very societies that benefit most from this abundance’ (Keating and Hertzman, 1999: 1). Keating and Hertzman (1999) have called this modernity’s paradox. Their concern with modernity’s paradox can be seen as a manifestation of the reflexive processes of modernisation as proposed by sociologists Beck (1992) and Giddens (1990). They postulated that we are living in an age of reflexive modernity; a risk society where expanding notions of risk permeate both individual and social consciousness and lead to increasing attempts to avoid, minimise and manage risk. Beck (2000) wrote that modernisation has produced a risk society, focusing attention on the negative outcomes of modernity. The notion of modernity’s paradox perfectly exemplifies this loss of trust in societal progress. Beck (2000) suggested that this point, where trust in security and progress ends, is where the discourse of risk begins. The discourse of risk occupies the space ‘between security and destruction’ (p. 213), creating a frame of reference and determining thought and action. Sachs and Mellor (2005), in their examination of child protection policies, argue that risk is highlighted when moral panic is a shaping force in the discursive processes of an issue. Risk becomes foregrounded in the research, the policies and the responses. Tulloch and Lupton (2003) suggested that statements of risks are essentially a way of framing moral principles. Scientific and technical progress has allowed us to see risk, to make it material. An examination of Keating and Hertzman’s (1999) influential volume Developmental Health and the Wealth of Nations: Social, Biological and Educational Dynamics provides us with examples of risk being made visible through scientific progress. The book included contributions from fields such as psychoneuroimmunology – a discipline that emerged only in the latter part of the 20th century ‒ and was illustrated with images and graphs made possible only by recent technical developments. Bowen et al. (2009) reported that policy actors noted the influence of visual presentations when reflecting on the evidence for early childhood interventions: ‘Many interviewees commented on powerful research about brain development and the impact of neglect and abuse, and most importantly on its visibility and starkness in messages when presented visually’ (p. 10). Technology and science continue to expand the ways in which problems and risk can be made visible: There are so many exciting problems for people to get stuck into. And what’s more exciting now than it was in my day … is the technology and the capacity that we have now to look at brain function, to look at what’s happening in various systems in the body – structural biology, in the gene. It is just so much more. (Stanley 2008: 4) Having been made visible through science and technology, new risks can be consolidated into discourses of risk and hence shape the material consequences that arise from them. Risk can act as justification for interventions that ‘at other times or in other circumstances might be considered intrusive, oppressive, discriminatory or paternalistic’ (Petersen 1996: 56). If risks are understood to reside in the individual then responses become focused on individuals and individual relationships. Approaches that identify targets of infant mental health promotion by the existence of individualised risk factors are in danger of positioning families and children as somehow lacking, lending a victim-blaming stance to a practice that intends to be empowering. © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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Finally, it is worth noting that, despite issues of power and equity being central to the work of health promoters, attention has not always been paid to power relations as a mechanism of health promotion itself. Health promotion practice is infused with power relations that flow from unstated, taken-for-granted assumptions that are embedded in practice. This research suggests that representations of risk are a pervasive and potent influence that can act to undermine health promotion efforts that seek to empower and enable people. This was evident in language and practices that acted to ‘other’ families and particularly mothers, positioning them as a risk to their child health and development. Threads from discourses of brain science, attachment theory, critical periods, children’s needs, mothering and maternalism have woven together to shape thinking and practices around infant mental health in often invisible ways. Risk discourse shapes those with whom health promotion professionals work, how they engage with them and the settings in which they work.

Conclusion The relatively recent expansion of interest in early childhood and mental health is apparent in both policy and practice. Understanding infant mental health promotion as a project of government allows the exploration of the conditions and practices of government and the way in which the field is being shaped and practised. Infant mental health is understood and positioned as always existing within social relationships and these operate within social contexts. While the mother–child relationship has become highly visible, mothers’ needs, social, cultural and contextual factors and the gendered nature of child rearing have remained largely hidden. The authority of experts, including health promoters, has promoted and promulgated particular representations of the problem. This has potentially created an inequity which health promoters themselves seek to overcome. Without critical reflection on the assumptions underpinning health promotion, practices may act to reproduce unequal power relations: an outcome far from the stated intention of health promotion. A form of reflexivity that moves beyond a consideration of activity to one that allows us to examine the assumptions that underpin our work is required. Governmentality analysis, as employed in this study, has provided a method for achieving this level of reflexivity. Address for correspondence: Angela Lawless, South Australian Community Health Research Unit and Southgate Institute for Health, Society and Equity, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia. e-mail: angela.lawless@flinders.edu.au

Acknowledgement We would like to thank the participants in this study who generously gave their time and shared their experiences. We also wish to thank the anonymous reviewers for their helpful comments and suggestions.

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