1. ©Children's Research Triangle, 2007 “It’s OK, I’m Fine” : Lessons Learned by Young Children who Experience Infant Mental Health Interventions Cheryl Pratt, PhD Linda Schwartz, PhD

2. ©Children's Research Triangle, 2007 Infant Mental Health Infants and toddlers develop emotionally and socially within the context of their primary relationship Infants and toddlers develop emotionally and socially within the context of their primary relationship

3. ©Children's Research Triangle, 2007 Definition of Infant Mental Health Infant Mental Health is the Appropriate Unfolding of: Emotional Regulation Interpersonal Relationships Exploration of the Environment within the context of the Family

4. ©Children's Research Triangle, 2007 Infant Mental Health  Is based on the understanding that infants and young children do not exist in isolation, but rather develop and experience the world within the context of relationships and environments.

5. ©Children's Research Triangle, 2007 Infant Mental Health  Each infant and young child has unique social and emotional needs. An appropriate response to these needs provides the opportunity for healthy development

6. ©Children's Research Triangle, 2007 The Parent/Infant/Child Relationship should be the central focus in helping to foster the healthy development of the PSE child The Parent/Infant/Child Relationship should be the central focus in helping to foster the healthy development of the PSE child Infant Mental Health

7. ©Children's Research Triangle, 2007 Model

8. Secure Attachment  This is of crucial importance to the child’s psychological development— and that a warm, sensitive, responsive, dependable interaction is the key ingredient in developing secure attachments

9. ©Children's Research Triangle, 2007  The parent’s internal working model of attachment is based on his/her early experiences along with particular infant development characteristics.

10. ©Children's Research Triangle, 2007 Functions of Attachment  Allows child to develop a sense of trust, safety and security  A secure base can mitigate future challenges, stressors  Provides a foundation for subsequent intimate relationships

11. ©Children's Research Triangle, 2007 Barriers to Healthy Attachment Separation from caregiver Separation from caregiver Prenatal substance exposure Prenatal substance exposure Intense pain that cannot be removed by the parent Intense pain that cannot be removed by the parent Neglectful or abusive parenting Neglectful or abusive parenting Temperament Temperament

12. ©Children's Research Triangle, 2007 Attuned Parent-Child Interaction Builds the Right Hemisphere Research has shown that the right hemisphere is dominant for:  Attachment functions  Self-regulation and survival

13. ©Children's Research Triangle, 2007  Non-conscious processing and communication of social and emotional information  The organization of the most comprehensive and integrated map of the body state available to the brain

14. ©Children's Research Triangle, 2007  Just as the left brain communicates its states to other left brains via conscious linguistic behaviors, so the right brain nonverbally communicates its unconscious states to other right brains that are tuned to receive these communications

15. ©Children's Research Triangle, 2007 Adult Attachment as it Affects the Attachment of the Child A parent’s coherent autobiographical narrative is the best predictor of secure attachment with their child A parent’s coherent autobiographical narrative is the best predictor of secure attachment with their child Interpersonal neurobiology-the non- verbal aspects of the way a parent relates to her child Interpersonal neurobiology-the non- verbal aspects of the way a parent relates to her child

16. ©Children's Research Triangle, 2007 Therapeutic Interventions  Experiential Therapies  Family System Therapy  Parent Psycho-education  Insight Oriented Therapy  Behavior Management

17. ©Children's Research Triangle, 2007 Experiential Therapies Self-regulation www.alertprogram.com Self-regulation www.alertprogram.com www.alertprogram.com Narrative therapy www.familyattachment.com Narrative therapy www.familyattachment.com www.familyattachment.com

18. ©Children's Research Triangle, 2007 Family Systems Treatment Focus on parent’s own attachment history Focus on parent’s own attachment history Model healthy limits, boundaries and structure Model healthy limits, boundaries and structure Parents are encouraged to join support groups Parents are encouraged to join support groups

19. ©Children's Research Triangle, 2007 Family Systems Treatment (con’t) Treatment team and parents create a strong and unified collaborative alliance Treatment team and parents create a strong and unified collaborative alliance Help parents develop positive working relationships with resources in the community Help parents develop positive working relationships with resources in the community

20. ©Children's Research Triangle, 2007 Parent Psycho-education Effects of problematic attachment histories on development Effects of problematic attachment histories on development Developmental expectations Developmental expectations Parenting skills for the attachment-resistant child Parenting skills for the attachment-resistant child Advocating for services Advocating for services

21. ©Children's Research Triangle, 2007 Insight Oriented Therapy Treatment individually for the foster parent, adoptive parent, or biological parent Treatment individually for the foster parent, adoptive parent, or biological parent Decision based on cognitive and mental health abilities of the adult Decision based on cognitive and mental health abilities of the adult Assess adults internal working model of attachment Assess adults internal working model of attachment

22. ©Children's Research Triangle, 2007 Behavior Management Parenting classes/curricula Parenting classes/curricula Issues-quality and appropriateness of the curriculum for special needs children Issues-quality and appropriateness of the curriculum for special needs children Use of behavioral logs, role modeling, 1:1 Use of behavioral logs, role modeling, 1:1 therapy, videotaping, etc. therapy, videotaping, etc.

23. ©Children's Research Triangle, 2007 Infant Mental Health Interventions  Concrete Support Services  Brief Crisis Intervention/Problem Solving  Developmental Guidance  Parent-Child Interaction Guidance  Infant-Parent Psychotherapy

24. ©Children's Research Triangle, 2007 Parent Child Interaction Guidance Developed by Dr. Susan McDonough Developed by Dr. Susan McDonough School of Social Work and Center for School of Social Work and Center for Human Development at University of Human Development at University of Michigan Michigan Goal is to promote and nurture the Goal is to promote and nurture the care-giving relationship care-giving relationship

25. ©Children's Research Triangle, 2007 Defining Treatment Family Defines the Problem Family Defines the Problem Family Defines Intervention Success Family Defines Intervention Success

26. ©Children's Research Triangle, 2007 Interventionist’s Role Offer Assistance in Helping the Family Define the Problem Offer Assistance in Helping the Family Define the Problem Enhance Parent-Infant Interaction through modeling, coaching, and video feedback Enhance Parent-Infant Interaction through modeling, coaching, and video feedback Monitors Treatment Progress Monitors Treatment Progress

27. ©Children's Research Triangle, 2007 Treatment Process Assessment of the infant, family, home environment and cultural context Assessment of the infant, family, home environment and cultural context Family engagement process Family engagement process Treatment implementation Treatment implementation Monitoring treatment progress Monitoring treatment progress Evaluation of treatment efficacy Evaluation of treatment efficacy

28. ©Children's Research Triangle, 2007 Using Videotape Feedback Provides salient feedback Provides salient feedback Increases awareness of family interactions Increases awareness of family interactions Emphasizing instances of positive parenting, acceptance of negative family feelings, and providing new perspectives through discussion of concrete behaviors Emphasizing instances of positive parenting, acceptance of negative family feelings, and providing new perspectives through discussion of concrete behaviors

29. ©Children's Research Triangle, 2007 Concern Parents over-reliance on modeling behaviors

30. ©Children's Research Triangle, 2007 Infant-Parent Psychotherapy Developed by Selma Fraiberg to address mental health problems in infants from birth to three years of age Developed by Selma Fraiberg to address mental health problems in infants from birth to three years of age The theoretical target (Stern) is the web of mutually constructed meanings in the infant-parent relationship The theoretical target (Stern) is the web of mutually constructed meanings in the infant-parent relationship

31. ©Children's Research Triangle, 2007  The primary therapeutic focus involves the uncovering of unconscious links between the parent’s psychological conflicts and parenting practices that are gravely mis- attuned to the baby’s needs and derail the infant’s normative development.

32. ©Children's Research Triangle, 2007 Basic Premises Because behavioral patterns are not internalized as part of the personality structure before the age of 3 years, infants and toddlers can regain their momentum toward normal development when they are no longer the recipient of maladaptive parenting practices Because behavioral patterns are not internalized as part of the personality structure before the age of 3 years, infants and toddlers can regain their momentum toward normal development when they are no longer the recipient of maladaptive parenting practices

33. ©Children's Research Triangle, 2007 Because profound personality changes occur throughout the lifespan this perspective forms the basis for relational approaches to psychotherapy for children and with adults Because profound personality changes occur throughout the lifespan this perspective forms the basis for relational approaches to psychotherapy for children and with adults

34. ©Children's Research Triangle, 2007 Mental Health problems in infancy and early childhood, regardless of their etiology, need to be addressed in the context of the child’s primary relationship, because the child’s sense of self unfolds and is sustained by these relationships Mental Health problems in infancy and early childhood, regardless of their etiology, need to be addressed in the context of the child’s primary relationship, because the child’s sense of self unfolds and is sustained by these relationships

35. ©Children's Research Triangle, 2007 Mental Health risk factor in the first 5 years of life operate in the context of transactions between the child and his/her social environment, including family, neighborhood, community, and the larger society Mental Health risk factor in the first 5 years of life operate in the context of transactions between the child and his/her social environment, including family, neighborhood, community, and the larger society

36. ©Children's Research Triangle, 2007 Childrearing mores and parenting practices are deeply held, often unconscious cultural values about who is a worthy human being and which characteristics should be encouraged and discouraged in raising a child Childrearing mores and parenting practices are deeply held, often unconscious cultural values about who is a worthy human being and which characteristics should be encouraged and discouraged in raising a child

37. ©Children's Research Triangle, 2007 Therapeutic Themes Ghosts in the Nursery Ghosts in the Nursery Supporting Affective Attunement Supporting Affective Attunement Assessing the Child’s and Parent’s Contribution to the Relationship and Dyadic Functioning Assessing the Child’s and Parent’s Contribution to the Relationship and Dyadic Functioning

38. ©Children's Research Triangle, 2007 Intergenerational Transmission of Psychopathology Intergenerational Transmission of Psychopathology Ports of Entry in Infant-Parent Psychotherapy Ports of Entry in Infant-Parent Psychotherapy The Therapeutic Relationship as the Matrix for Treatment The Therapeutic Relationship as the Matrix for Treatment

39. ©Children's Research Triangle, 2007 DIR Model Developmental Individual- Difference Relationship Based Approach Developmental Individual- Difference Relationship Based Approach Developed by Serena Weider Ph.D. and Stanley Greenspan M.D. Developed by Serena Weider Ph.D. and Stanley Greenspan M.D.

40. ©Children's Research Triangle, 2007 Developmental= Greenspan’s 6 Stages of social Emotional Development Developmental= Greenspan’s 6 Stages of social Emotional Development Individual-Difference= the unique way a child processes information Individual-Difference= the unique way a child processes information Relationship Based=learning and facilitating relationships that enable a child to progress in his/her development Relationship Based=learning and facilitating relationships that enable a child to progress in his/her development

41. ©Children's Research Triangle, 2007 Stages of Functional Emotional Developmental Capacities Stage One: Regulation and Interest in the World First few months of life Stage One: Regulation and Interest in the World First few months of life Stage Two: Engaging and Relating 2-6 months Stage Two: Engaging and Relating 2-6 months Stage Three: Intentionality and Two- Way Communication 6-9 months Stage Three: Intentionality and Two- Way Communication 6-9 months

42. ©Children's Research Triangle, 2007 Stage Four: Social Problem-solving, Mood Regulation, and Formation of a Sense of Self 9-18 months Stage Four: Social Problem-solving, Mood Regulation, and Formation of a Sense of Self 9-18 months Stage Five: Creating Symbols and Using Words and Ideas 18-30 months Stage Five: Creating Symbols and Using Words and Ideas 18-30 months Stage Six: Emotional Thinking, Logic, and a Sense of Reality; 2 ½ years-4-5 years Stage Six: Emotional Thinking, Logic, and a Sense of Reality; 2 ½ years-4-5 years

43. ©Children's Research Triangle, 2007 Stage Seven: Multicausal and Triangular Thinking; early school years Stage Seven: Multicausal and Triangular Thinking; early school years Stage Eight Gray-Area, Emotionally Differentiated Thinking; later school age through adolescence Stage Eight Gray-Area, Emotionally Differentiated Thinking; later school age through adolescence Stage Nine: A Growing Sense of Self and Reflection on an Internal Standard; puberty, early adolescence Stage Nine: A Growing Sense of Self and Reflection on an Internal Standard; puberty, early adolescence

44. ©Children's Research Triangle, 2007 Stages of DIR Intervention Stage One: Facilitate Shared Attention and Regulation Stage One: Facilitate Shared Attention and Regulation Stage Two: Facilitate Engagement and Relating Stage Two: Facilitate Engagement and Relating Stage Three: Facilitate Purposeful Emotional Interactions Stage Three: Facilitate Purposeful Emotional Interactions Stage Four: Facilitate Shared Problem- Solving Stage Four: Facilitate Shared Problem- Solving Stage Five: Facilitate Creating Ideas Stage Five: Facilitate Creating Ideas

45. ©Children's Research Triangle, 2007 Floortime First Goal-Follow the Child’s Lead While Challenging the Child at the Same Time First Goal-Follow the Child’s Lead While Challenging the Child at the Same Time Second Goal- Bring the Child into a Shared World Second Goal- Bring the Child into a Shared World Creating Learning Environments: Floortime: All the Time and Everywhere Creating Learning Environments: Floortime: All the Time and Everywhere

46. ©Children's Research Triangle, 2007 Other Curriculum Interventions Circle of Security Intervention -20 week group based parent intervention program designed to alter the developmental pathway of at-risk parents and their children Circle of Security Intervention -20 week group based parent intervention program designed to alter the developmental pathway of at-risk parents and their children PIPE curriculum used in Early Head Start where the emphasis is on the relationship and parenting skills to facilitate normal development in children 0-3 PIPE curriculum used in Early Head Start where the emphasis is on the relationship and parenting skills to facilitate normal development in children 0-3

47. ©Children's Research Triangle, 2007 STEEP (Steps Toward Effective, Enjoyable Parenting) a preventive intervention program for expectant parents and continues over the child’s first year of life STEEP (Steps Toward Effective, Enjoyable Parenting) a preventive intervention program for expectant parents and continues over the child’s first year of life David’s Olds Public Health Home Visitor’s Program David’s Olds Public Health Home Visitor’s Program Wait-Watch- and Wonder Program Wait-Watch- and Wonder Program

48. ©Children's Research Triangle, 2007 Do-Watch-Listen-Say: Social and Communication Intervention for Children with Autism (Kathleen Ann Quill) Do-Watch-Listen-Say: Social and Communication Intervention for Children with Autism (Kathleen Ann Quill) PCIT-Dr. Sheila- Eyberg-2-7 years of age based on operant theory, traditional child psychotherapy, and early childhood development PCIT-Dr. Sheila- Eyberg-2-7 years of age based on operant theory, traditional child psychotherapy, and early childhood development

49. ©Children's Research Triangle, 2007 Parent Group at CRT  Provision of safe holding and facilitating environment for both the parent and child  Goal to build trust and strengthen relationships  Provide empathetic and supportive experiences

50. ©Children's Research Triangle, 2007  Explore how past relational dynamics influence interpersonal relationships  Use of maternal/parental reflective functioning (Fonagy, Target and Steele)  Slade’s “keeping the baby in mind”

51. ©Children's Research Triangle, 2007 Child Group  Goals: Developmental Facilitation techniques and to enhance parent- child relationships  Use of Greenspan’s Floortime/DIR model  Increase mutual, shared engagement to increase more complex interactions “opening and closing the circles of communication”

52. ©Children's Research Triangle, 2007 Dyadic Group  Gentle interactive guidance and positive reinforcement  Use of speaking for the infant/child  Focus on a holding and facilitating environment  Use of mutual engagement, co- regulation, and affect attunement

53. ©Children's Research Triangle, 2007 Case Study Joey and Geri K. Joey and Geri K.

54. ©Children's Research Triangle, 2007