Seeing our youngest patients through

Maria Kroupa

With Masonic support, U child psychologist helps infants and toddlers to thrive in the face of trauma

As a clinical child psychologist, Maria Kroupina, Ph.D., director of the University of Minnesota’s Birth to Three Clinic and Early Childhood Mental Health Program, has helped young people through a lot. But one patient who will always stick with her is an 18-month-old boy being treated in the Blood and Marrow Transplant unit of the U’s Masonic Children’s Hospital.

“When he experienced stress due to blood draws or other standard procedures, this little boy would clench up his body and turn onto his side away from his parents. During his prolonged hospital stay, he developed ineffective strategies to deal with his stress and pain,” Kroupina recalls.

But after working with the boy and helping his parents recognize how to read and respond to his cues, Kroupina saw noticeable changes in his behavior.

“His mother read his cues and his parents were able to help him even during the most difficult and stressful times. There was this beautiful connection they built,” she says.

“Sadly, this child passed away,” continues Kroupina. “But I hope the bond that he and his parents built made a difference and that his parents feel they did as much as they could for him.”  

Intervening early against toxic stress

With Masonic pilot support, Kroupina has built the U’s Birth to Three Clinic and Early Childhood Mental Health Program from the ground up.

The goal of her work, which draws on the latest research in early brain development, is to set young people up for success by addressing and preventing toxic stress. Toxic stress occurs when a child experiences strong, frequent, or prolonged adversity without adequate adult support. It can include anything from a parent’s stressful divorce to multiple foster care placements to health issues or prolonged hospitalizations.

While it isn’t unusual for psychologists to address toxic stress, the age of Kroupina’s patients is unusual. She focuses on infants and toddlers from birth to three years, a crucial period for the development of key social and cognitive skills.

“Young children are the most vulnerable to toxic stress because brain development is so rapid during the first years of life,” explains Kroupina.

But brain plasticity also makes infants and toddlers more open to intervention.

“It’s a huge difference to provide therapy to a patient who’s six months or one year old as opposed to 10 years old,” Kroupina says. “It’s much more effective for us to work with infants and toddlers because of where they’re at developmentally.”

Partnering with parents

Today, Kroupina provides mental health evaluations and ongoing therapy to young patients who have experienced early adversity, including medical trauma and other issues, at an outpatient clinic and in inpatient units of Masonic Children’s Hospital. Her team now gets nearly 600 visits per year, five times as many as when their practice launched three years ago.

Regardless of the situation, Kroupina says the single most effective tool for helping infants and toddlers overcome toxic stress is a parent or guardian who provides what she calls a “buffering relationship.”

That’s why her program focuses just as much on parent-child relationships as it does on the child.

“In our therapy sessions, we work with children and their parents in the same space. We reflect together with parents on the trauma and how it’s affecting the child’s ‘here and now’ behavior,” says Kroupina. “We provide a safe place for parents to truly try to understand their child’s behavior and how they respond to it.”

Extensive research, including cutting-edge studies led at the U, shows that the interventions used by Kroupina and her team make a difference long term. “There is extensive data showing that these interventions positively impact children’s stress sensitivity systems, executive functions, and much more,” Kroupina explains.  

But Kroupina also hears firsthand from many parents that her clinic is making a difference. As one mother recently reflected:

“When I first learned about psychotherapy for an infant or toddler, I was skeptical. At least two of my child’s other physicians laughed and said it couldn’t hurt, but that they didn’t see how a child that small would get anything out of talking. From the very first weeks of psychotherapy, I saw huge changes in my child. When I learned to control how I talked about his illness in front of him and to control my own responses and emotions, I was able to help him. He’s made huge strides in his emotional development that would not have happened without this intervention. I am slowly getting my child back, the person who’s hidden behind all of the medical trauma and anxiety. I can’t imagine navigating a child through chronic illness without this support.”

Making early mental health mainstream

Although Kroupina has done a lot for her patients, there is still much to be done to make early mental health care a widespread practice.

“I’m very proud when I introduce myself as an infant psychologist,” says Kroupina. “However, it’s still very unusual for us to think of mental health for such young patients.”

To counter this, Kroupina is working on a number of fronts to make early mental health more mainstream. Some of her recent successes include:   

  •  Designing and implementing clinic and hospital protocols for addressing toxic stress in infants and toddlers
  •  Launching a clinical research program that collects valuable data on patient outcomes and helps inform best practices in the field
  •  Partnering with Children’s Minnesota to introduce early mental health services in general pediatrics clinics and to pilot the HealthySteps program, which helps families understand and manage behavioral, social, and emotional aspects of healthy child development

Kroupina also believes that promoting early mental health is a team effort.

In addition to parents and close guardians, there are many players in an infant or toddler’s support system who make a difference, especially in health care. That’s why she and her team have launched a number of educational initiatives for current and future health practitioners, including:

  •  Training for nurses, social workers, and other staff at Masonic Children’s Hospital in addressing toxic stress and medical trauma
  •  Clinical training and research-clinical internships for pediatrics residents and medical students
  •  Symposia and courses for pediatric primary care providers across the state

And, Kroupina says, the work is going global. She and her team have connected with and trained health providers and students from several other countries. As a result of their work in Uganda, for example, their partners at Kampala University will soon launch the country’s first-ever infant mental health program. 

“It’s really exciting to see this work catch on,” says Kroupina.

The Masonic difference

Without support from Minnesota Masonic Charities, none of these initiatives—from Kroupina’s Birth to Three Clinic to her training programs and clinical research efforts—would have gotten off the ground.

“Masonic support enabled us to launch our entire program,” Kroupina explains.

“Before that, all we had was a one-day-per-week program for adopted children. Now, we have nearly 600 inpatient and outpatient visits per year, a robust clinical research program, and strong partnerships as we work to make early mental health care more mainstream.”

And this is just the tip of the iceberg.

“There’s so much to do, whether it’s creating a system to help parents through the struggles of having a chronically ill child or helping to start an early mental health program in a country that’s never had one,” says Kroupina.

“It’s been amazing to be able to translate cutting-edge ideas about early brain development into practice and to think big. Masonic funding has been absolutely critical. It’s really made a difference in my life and will hopefully make a difference in kids’ lives.”

Going global: launching early mental health programs abroad

Maria Kroupina

Maria Kroupina is passionate about making early mental health care the norm for infants and toddlers.

In addition to integrating it into the work of Masonic Children’s Hospital and clinics across Minnesota, she has traveled internationally to help researchers and clinicians from other countries adopt key systems and practices.

She is especially proud of recent momentum in Uganda. After working with partners at Makerere University in Kampala, Kroupina has learned that her collaborators there will soon be launching the first-ever infant mental health program in Uganda and possibly East Africa.

“Uganda has around 40 million people and the majority are children. Yet, there’s only one child psychiatrist in the whole country,” says Kroupina. “Equipping and training a range of practitioners to address early mental health care there will be a challenging and exciting journey.”


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