Presentation on theme: "Providing Relationship-Driven Mental Health Services in the Birth to 3 Period San Gabriel Pomona Regional Center Conference October 7, 2010."— Presentation transcript:
1 Providing Relationship-Driven Mental Health Services in the Birth to 3 Period San Gabriel Pomona Regional Center ConferenceOctober 7, 2010
2 Karen Moran Finello, Ph.D. Assoc. Professor of Clinical PediatricsUSC Keck School of MedicineProject Director, Project ABC (About Building Connections for Young Children & their Families) & Corazon de la Familia Infant-Child Intervention
3 Current Approaches Within Mental Health Built upon a diagnostic and treatment model—medical modelIllness approach; great deal of stigmaGeneral public views mental health as associated with disorder & mental illnessMost mental health services began with treatment services for adult populations with serious disorders & were geared down for adolescents and school aged childrenPreschool children came into delivery system late; infants & toddlers are still underserved
4 Basic Facts (CDC, 2005)25% of the population around the world will develop a mental or behavioral disorder at some point in their livesMental disorders account for 25% of all disabilities in the U.S., Canada & Europe & are a leading cause of premature deathIn the U.S., 22% of the adult population has 1 or more diagnosable mental disorders in any year10% of children in the U.S. have mental disorders that cause some level of impairmentMental illnesses cost the U.S. $150 billion each yearCost excludes cost of research
5 Report of the Surgeon General on Mental Health (1999) Mental health—the successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity; from early childhood until late life, mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience, and self-esteem.Use of “infant mental heath” term to describe all of the range of issues for very young children is probably doing a disservice in the long run; we need to make adjustments and begin to talk about infant and early childhood mental health from the wellness perspective described here and separately address infant and early childhood mental disorders
6 Report of the Surgeon General on Mental Health (1999) Mental illness—the term that refers collectively to all mental disorders. Mental disorders are health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning.
7 Key Points in Report Mental health is fundamental to health. Mental disorders are real health conditions that have an immense impact on individuals and families throughout the U.S. and the world.Mental health is often an “after thought” while mental illnesses are “shrouded in fear and misunderstanding”
8 Surgeon General’s Report attaches high importance to public health practices that seek to: identify risk factors for mental health problemsmount preventive interventions that may block the emergence of severe illnessesactively promote good mental healthAlthough much more is known through research about mental illness than about mental health,-- This may not be the case for infant/early childhood mental health and mental illness– in fact, the inverse may be true
9 CDC ConclusionMental health is integral to overall health and well being and should be “treated with the same urgency as physical health”Challenges for public health are to:Identify risk factorsIncrease public awareness about mental disorders & treatment efficacyRemove stigmaEliminate health disparitiesImprove access to mental health services for all
10 CDC RecommendationsIncorporation of mental health promotion into chronic disease prevention efforts by public health agenciesCollaboration among partners (public health agencies and other public entities) to develop comprehensive mental health plans to enhance coordination of carePublic health agencies should conduct surveillance and research to improve the evidence base about mental health in the U.S.
12 The development of social and emotional well-being in children birth to five. Includes child behavior, health and developmentfamily functioningcaregiver-child relationshipsThis includes early brain development; preschool relationships with peers; parent child relationship issues including attachment, goodness of fit, etc.
13 Why Is ECMH Important?Foundation for future social-emotional functioningProvides biologic underpinnings for later coping & resilience---”hardwires the brain”Untreated early problems are associated highly with problems during childhood, adolescence & adulthoodExample: Bavarian Longitudinal Study indicates a strong predictive link between high levels of irritability (crying, sleeping probs) at 4 weeks of age and diagnosis of MH problems during preschool and school aged period
14 Critical Characteristics of ECMH Development of relationships: KEY to all other areasAbility to initiate, discover, & learnDevelopment of persistence & attentionDevelopment of coping mechanismsDevelopment of self-regulationDevelopment of emotional rangeMany factors can affect social emotional development, including developmental delays or serious health issues with the baby, or an environment with multiple risk factors (ex. poverty, substanceabuse, adult mental health issues, domestic violence)All areas hinge on the relationships in the young child’s life to become fully developed and for external support as the child is developing his/her own internal capacity
15 Families have the most continuous and emotionally charged relationship with the child. Infants and toddlers learn what people expect of them and what they can expect of other people through early experiences with parents and other caregivers.(Day & Parlakian, 2004)
16 RISKS TO INFANT/CAREGIVER RELATIONSHIPS Separation and lossMultiple caregiversRepeat hospitalizationsFamily instabilitySubstance use in caregiverDomestic violenceEnvironmental stressorsInadequate support for caregiver
17 Why Attend to Risk Factors in Early Childhood? Mental health disorders & diagnoses are not as clear during the early years (especially first 3 years of life)Neurobiologic vulnerabilities are critical to address earlyRapid developmental changes sometimes lead to behavior changes (& changes in diagnoses)Environmental support can be effective in modulating/changing behavior due to neurobiologic vulnerabilities
18 Identifying Infants & Young Children Who Are At-Risk Generally done through surveys and questionnairesRecent research on level of risk in infancy & developmental problems has shown a high correlation between risk and measured delay (Scarborough et al, 2008)
19 Measuring Child Characteristics Neurodevelopmental factorsDevelopmental level of childOther special needs of child (e.g., Communication disorders, Autism & other spectrum disorders, PDD)Remember that is crucial to distinguish between annoying, age appropriate behaviors and behaviors which are symptoms of disorderIf child is special needs, must adjust behavioral expectations accordingly (e.g., corrected chronological age for premature infants/toddlers; looking at children with dd at their developmental levelsNeurodevelopmental problems distress pronenessLong periods in low or high arousal statesRepeated experiences encoded in implicit memory of what the world is aboutPerceived threat overloads the brain’s stress management systemAre there co-occurring conditions?
20 BEHAVIOR CONCERN? SIGN OF SEIZURE DISORDER? OTHER? BreathholdingSleep disorders (narcolepsy, night terrors)TicsMigraine headachesFaintingGastroesophageal refluxBehavior disturbances
21 ROLE OF TEMPERAMENT ON EMOTIONAL REGULATION Infant temperament determines the intensity of infant response to stimuliTemperament effects how emotions are expressedTemperament may influence which signals baby uses to express positive and negative emotionsTemperament also influences how parent responds
22 Measuring Specific Child Characteristics Dimensions of Temperament:Activity levelRegularity of biologic rhythmsApproach/withdrawalAdaptabilityIntensitySensitivityMoodDistractibilityPersistence
23 YOUNG CHILDREN & OUT-OF-HOME CARE Children under age 5 comprise one-third of all children in out-of-home careAverage length of stay in foster care is 2 yearsIn some areas, up to 1/3 of children who enter the foster care system remain in it
24 Children Who Experience Trauma Differences exist in reactions by age of child (preverbal, verbal)May see differences in behavior based on where child is now living (e.g., role of multiple placements)New knowledge regarding infant’s processing of events and memory of eventsNeed for careful intervention in helping caregiver help child to understand event and recover from itAll children who have experienced trauma should be referred for MH treatment services
25 Understanding Children’s Responses Traumatized children’s maladaptive coping strategies can lead to behaviors that undermine healthy relationships and may disrupt foster placements, including:Sleeping, eating, elimination problemsHigh activity level, irritability, acting outEmotional detachment, unresponsiveness, distance, or numbnessHypervigilance or feeling that danger is present, even when it isn’tIncreased mental health issues (e.g., depression, anxiety)An unexpected and exaggerated response when told “no”From Child Welfare Trauma Training Toolkit25
26 Understanding Children’s Responses Traumatized children may exhibit:Over-controlled behavior to counteract feelings of helplessness and impotenceMay be seen in difficulties transitioning and changing routines, rigid behavioral patterns, repetitive behaviors, etc.Under-controlled behavior due to cognitive delays or deficits in planning, organizing, delaying gratification, and exerting control over behaviorMay show impulsivity, disorganization, aggression, or other acting-out behaviorsFrom Child Welfare Trauma Training Toolkit2626
27 The Influence of Developmental Stage: Young Children Young children who have experienced trauma may:Become passive, quiet, and easily alarmedBecome fearful, especially regarding separations and new situationsExperience confusion about assessing threat and finding protection, especially in cases where a parent or caretaker is the aggressorRegress to recent behaviors (e.g., baby talk, bed-wetting, crying)Experience strong startle reactions, night terrors, or aggressive outburstsFrom Child Welfare Trauma Training ToolkitChild Welfare Trauma Training Toolkit2727
28 What Can We Do to Support Young Children Who Have Experienced Trauma Empower caregivers about their role of calming and reassuring children.Educate caregivers about the reasons for, and techniques to manage, children’s emotional outbursts.Recommend parenting skills training to strengthen caregivers’ ability to handle children’s emotions.Work with the child to identify and label troubling emotions and stress that the emotions are normal and understandable.From Child Welfare Trauma Training Toolkit28
29 CUMULATIVE RISK & CHILD OUTCOMES The greater the number of risk factors, the greater the variation in outcome, particularly for cognitive development (Sameroff et al, 1987)The “compensating force of opportunity” must also be considered in examining child outcomes (Garbarino & Ganzel, 2000)
30 Complexity of Risk Factors Impact “Buffer Zone” in Development of “Competent” Child and Family!
31 One of the most important factors found to distinguish traumatized children with good developmental outcomes from those with poor outcomes is the availability of a supportive parent or alternate guardian(Pynoos et al, 1995)
32 Caregiver Characteristics TemperamentFlexibilityToleranceEnvironmental StressorsFamily dynamicsPast experiences as a motherHer own history of child rearing experiencesPsychological stateHealth & well beingHelp caretakers adjust expectationsMany families need to learn limit setting & need help in following through with isDoes parent understand “typical” behaviorIs caretaker able to maintain a stable, nurturing environment?
33 EXAMPLE: MOTHERS OF ABUSED INFANTS Respond to fewer infant initiativesTry to control children more oftenProvide less verbal, tactile & vestibular stimulation during interactionAre less active during free playUse more negative affectDo not change teaching style to match child’s age(Westby & Fenske, 2001)
34 Understanding Attachment in Young Children Primary attachmentSecondary attachmentsSecondary attachments may include others important to the child including the child care provider
35 AttachmentAttachment is a pattern of interaction that develops over time as the infant or toddler and caregiver engage.
36 Attachment 101 Secure attachments Insecure attachments (Avoidant) Insecure attachments (Ambivalent)Disorganized attachmentsType of attachment relates to how children behaves with both primary caregiver and with others (even peers)Can be different with different caregivers (e.g., secure with mother; insecure with dad)
37 Secure Attachments Adults are used as a “secure base” Child knows that adults are responsive, dependable and consistentAdults will be there when needed and share child’s joy in the worldWith peers, child interacts and plays wellMay cry at separation but settles with some help
39 Vignette 1When a home visitor arrives, she finds a father & his 5 month old baby deeply engaged in play on the floor. While she knows that she needs to get a lot of paperwork filled out during this visit, she also knows that one of her primary jobs is to support the relationship between these two. She watches as the baby reaches & scoots on her tummy for a toy, while Dad, on his tummy, too, is building the excitement & encouraging her but not letting the excitement get out of hand. She reaches the toy and flashes him a smile that says, “Being with you is wonderful!”What might the home visitor do to promote the development of this relationship?
40 Insecure (Avoidant) Attachments Caregiver often leaves child to deal with own feelings (fright, upset, excitement)Caregiver may respond but in own time, not when child needs responseChild appears to be very independent but may get frustrated easilyMay have difficulty with peers due to aggression, hitting, biting, pushing, screaming
41 Avoidant cont’dChild does not typically build strong connections with child care providerDo not show distress at separation from caregiver and may ignore when caregiver comes for pick upSeem too able to take care of own needsChild is avoiding rejection by primary caregiver by being the one who doesn’t reach outCaregiver dislikes “needy” behavior and reinforces independence to extreme
42 Insecure (Ambivalent) Attachments Child may be clingy, demanding, angry, easily frustratedLikes to be center of attention and gets upset if others don’t pay attention to themMay act like a younger childCaregiver is inconsistent in response to child’s needs and may go either overboard in responding or not respond at allUnpredictable caregiving & out of synch with child
43 Disorganized Attachments Child shows disordered sequences of behavior, does things that don’t seem to make sense (reaches out to adult while turning head away to avert gaze)Shows stilling or freeze behavior and repetitive behaviorsDemonstrates fear of caregiverMay seem very different from one day to next
44 Disorganized cont’dMay be extremely bossy with peers or may act like the parentCaregiver has patterns of unresponsiveness to child’s needs & responses that don’t match child needsCaregivers frequently have untreated mental health issuesChild may have been abused or neglectedMH issues include bipolar disorder, depression, unresolved traumas, substance abuseRequires knowing when attachment pattern places relationship in jeopardy—requires MH treatment by a specialized provider
45 Important PointsAttachment may be different with different adults (mom, grandmother, dad, child care provider)There is typically a “primary” attachment to one personShould make a referral if the child constantly seems either sad & withdrawn or aggressive & out of controlWill need to work with the family to get them into MH treatment (or even for assessment)
46 Special Issues Impacting Relationships & Attachment Lengthy hospitalizations and repeated hospitalizations during first two years of lifeLife threatening special health care needsPrematurityNeurologic problemsSeparation due to parental hospitalization or deathFoster placements (especially multiple placements)
47 Principles for Developing Secure Attachments * Comfort children when they are physically hurt, ill, upset, frightened or lonelyRespond to and notice children so they learn that their caregivers careGive children a sense of trust in the world and the people in itHelp children review experiences and reenact frightening situations so that the memories can be integrated into their self-narrativesWhen working individually with parents, provider needs to encourage all of the above without “teaching” how to do it. Speaking for the child; using the child’s voice; complimenting good parenting helps build relationships and strengthens caregiver’s tendency to do such things again.
48 Principles cont’dCreate and keep alive good, warm, and joyful memories because they can help develop secure attachment relationships. Establish predictable traditions.Help parents understand the importance of letting children know where they are going and when they will be back. Provide objects to give security and keep memories of the absent caregiver alive.Try to be as predictable and as positive as possible in reacting to a child’s behavior.* From Landy, Sarah. Pathways to Competence (2002)
49 What is “Separation Anxiety?” Response to separation from attachment figureMay occur at time of separation or before it happens (when they get in the car to come to the center)May be shown by crying, whining, clinging, moodiness, anger depending on age and cognitive levelSome children have difficulty with all transitions so will also have trouble at end of day in leaving center“face saving” may prohibit crying in preschooler so we cannot assume there is no anxiety just because the child doesn’t cry—he may exhibit distress in other ways (acting out throwing things, etc)
50 Case Study: MaryMost days Mary has a difficult time entering the center. She clings to her mother and cries. The teacher often has to stop what she is doing and physically take Mary from her mother’s arms. After Mary’s mother leaves, Mary often sits in her cubby and watches as others engage in activities within the bustling classroomThink about the reasons the child might have difficulties and share your thoughts with the person next to you. Rewrite the scenario to reflect a more positive relationship between the teacher and child.
51 What Can You Do to Help?Help caregiver understand how to say good bye and to transition childBuild an understanding of each child’s response and develop strategies for this wide range for the children you work withEvery child is different and may need slightly different responsesRemember: One size doesn’t fit all!How many of your own children liked lots of warning before things were going to happen so they could “get ready?”How many needed to have no time to “worry” and needed to just have things sprung upon them?
52 Strengthening Attachments Supporting parents with separation issues (on both sides!)Helping families to recognize behavioral signs that child is upset about separation
53 Relationships are Different from Interactions (CSEFEL slide) Have emotional connectionsEndure over timeHave special meaning between the two peopleCreate memories and expectations in the minds of the people involvedCenter on the Social and Emotional Foundations for Early Learning
54 Exercise (Personal) Exercise on personal history of relationships Who did I go to???
55 What is the Intent of Relationship-Based Work Most interventions are designed to improve (or repair) very young child-caregiver relationships through a variety of mechanisms, with the majority focused on creating change in dyadic interactions, supporting and strengthening development within both child and family, and reducing child and caregiver stressesMany “ripple effects” may be seen in relationship-based workTasks of development are impacted by relationships (exploration of infant/toddler’s world is affected by attachment pattern; self-regulation skills build from maternal and dyadic regulation; engagement with others may be modeled and again affected by attachment styleTrust with interventionist may build wider trust with larger community and other professionals on part of caregiverVery difficult to measure ripple effects yet this is critical to captureLanguage & communication development is heavily influenced by relationshipsCognitive mastery effects child’s social interactions with the wider world
57 Dyadic Therapy & Interventions Parent Guidance Programs (STEEP; Seeing is Believing; Partnership in Parenting Education)Parent Child Interaction TherapyInteraction Guidance ApproachesFamily Support ServicesAttachment Work (Circles of Security, etc)Many home visitation models
58 Focus of Relationship-based Work Changing attachment style by focusing on consistency and responsiveness in caregiverImproving caregiver’s emotional availability—measuring impact of changes in e.a. that might be very subtle (but important to child’s life) is criticalEnhancing structure & routines in young children’s lives“teasing” by teen parents; turn taking, reciprocity; measuring emotion regulation and social referencing(postulated to be very important & related to enhanced relationships, improved development, beliefs about trust in relationships and reliability in the world, better regulation and organization—but we need to quantify this in more meaningful ways through formal measurement in our work)Measures of nurturance, emotional availability and ability to help child learn to modulate are crucial as are similar measures of the clinician’s role in nurturing the caregiver and being emotionally available in a trusting mannerParental attunement and responsiveness to those in their world is important
59 Developing Ideas About Relationships—Vignette (Myra, Haniya & Tia) ActivityDeveloping Ideas About Relationships—Vignette (Myra, Haniya & Tia)
60 WHAT CAN A CLINICIAN DO? Listen to mother’s stories Reflect on how her early experiences may have shaped her ideas of self and her relationships and may account for present behaviorsProvide “corrective emotional experiences” and opportunities to connect her past with the present-(Gowen & Nebring, 2002)
62 Corazón de La Familia Infant-Child Intervention Program Strength BasedFamily FocusedIndividualizedCulturally ResponsiveComprehensiveCollaborativeRelationship-drivenSpecialists in Serving Very Young Children with Special Health Care Needs
63 Overall GoalsTo assist families in optimizing the growth & development of their infants, toddlers, and preschoolersTo help families become more comfortable and feel success in meeting the needs of their childrenTo provide support to struggling familiesBut first comes FAMILY ENGAGEMENT
64 Primary Targeted Outcomes Health & development of at risk children under age 5Mental health & behavior issues in children under 5Family support & advocacy
65 Role of Home Visitor To support, nurture and “contain” families To offer a “corrective emotional experience”(Jones Harden, 1997)
66 Engagement with Families: Building a Relationship Think about:How family entered the systemDid they choose you or were they “assigned”How would you feel about a stranger entering your home to provide “help” with your child?
67 Tomika vignette What questions do you have? What do you think Tomika is experiencing?What do you think Loretta is feeling?What do you think Nina is feeling? What do you do when you feel this way?What strategies would you use to develop a partnership with mom in behalf of Tomika’s social emotional development?From CSEFEL module on Inf/Todd
68 Difficulties/Barriers in Working with Families in their Homes PrivacyTime/Travel issuesLimitations set by space in homeEmbarrassment of familyBoundary issuesStaying on taskKeeping focus on WHO is client while meeting needs of other family members
69 Stressors of Home Visiting Overwhelming needs within familiesUnpredictability of workSafety issuesTransportation issuesDraining nature of being the nurturer if not provided nurturance within program
70 ChallengesNeed to move quickly—babies can’t wait; period of rapid developmentMust work towards goal of “good enough” parentingMust understand developmental functioning of EVERY family member (Jones, 1995)Relationships are the key to change
71 Practice Challenges“How much more difficult it is to change those behaviors that individuals may not believe need changing” Gomby et al. (1999)Environmental/contextual factors play an important role in childrearing (other children seen in neighborhood, relatives with childrearing beliefs, economic and educational issues)
72 Service ChallengesMust be careful not to focus solely on “child-centered” interventions OR on “family-centered” interventions—must be responsive to where both child and parent “are” in order to work in a truly collaborative and meaningful styleMust have knowledge and awareness of strategies of other disciplines and know when young child needs (& family is ready for) other specialty servicesMust be able to determine the line between “too much” and “not enough”—More is not always better!
73 What Works?Heinicke (1999): must address multiple domains, including “adaptave capacities of the mother” and “caregiver/child interaction”More comprehensive interventions have a stronger impactMinimum of weekly visits for at least 6 months durationMixed findings regarding efficacy by background of home visitor (professional level, paraprofessional)Trust, interest and the degree of family involvement are crucial factors. Thus, the quality of participation may be more important than the quantity. (Beckwith, 2000)
74 What works? Cont’dGeneric home visiting cannot adequately meet the needs of psychologically vulnerable families. Visits must be intensive, specialized and coordinated.
75 Most Important Lessons Learned Establishing a partnership with families is accomplished more easily when you meet them “on their own turf” and are responsive to their needsFamilies are eager to do what is best for their babiesThrough home visiting, we are able to reach hard to reach populations who will not respond to other types of service provision
76 Lessons learned cont’d Home based service delivery is not a good fit for all professionals and paraprofessionalsTherapeutic alliance is crucial to effective home visitingMust respect and understand culture of each family with whom you workMust focus on emotional needs of parents, too“Relationships hold the potential to help people grow and change” (Shahmoon-Shanok, 2005)
77 Evaluating Child & Family Need for Intervention
78 Screening Infants & Young Children For Social-Emotional Problems Common toolsUsesAdvantages & disadvantagesMoving from screening to referral for assessment and treatment
79 What is a “Tool”an implement used in the practice of a vocation; the means whereby some act is accomplishedany instrument of use or service.means to end: something used as a means of achieving something
80 How to Choose a Screening Tool Reason for screenTraining, time & cost of administration (ease of use issues)Specific concerns related to child, family or risk issuesSetting where tool will be usedAppropriateness for children served in the program (language, etc)
81 Psychometric Properties Reliability (results are stable & dependable across administrations or respondents)Validity (accurate measurement of what it intends to measure)Sensitivity (probability of correctly identifying problem)Specificity (probability of correctly identifying typical development)False Positives (screening says there is a disorder; assessment doesn’t find one)False Negatives (screening doesn’t find disorder that is there)
82 Standardized vs Nonstandardized Tools What was the standardization sample for the tool?Does this match the child you will be using it with?Length of tool—Age range for administrationUtility question
83 Potential Screening Tools for Social-Emotional Issues Ages & Stages Questionnaire –Social Emotional (ASQ-SE)Temperament and Atypical Behavior Rating Scale Screener (TABS)Devereux Early Childhood Assessment (DECA)Brief Infant Toddler Social-emotional Assessment (BITSEA)
84 Next Steps After Screening Sharing information with familiesMonitoring on routine levelDocumentation to assist referral process“Warm” referralsProcess must stay focused on child & family needs & wishes (family centered & culturally competent)Coordination for full assessmentCollaboration with other disciplines
85 DiscussionIdeas for determining when families need help; red flags; when & how to refer
86 Early Childhood Mental Health Service Range Promotion—aimed at maximizing resilience; appropriate for allPrevention—aimed at reduction of risk; includes family support, parent ed & info; mentoring of caregivers, screening & referralEarly Intervention—aimed at the earliest possible entry point (pre-diagnosis)Treatment—aimed at existing conditions which are generally severe; includes wide range of approaches from dyadic therapy to therapeutic nurseriesIncludes a range of strategies:Provision of emotional support to family in crisis (may include newly diagnosed child, repeated hospitalization of ill child, help with understanding child’s needs and care requirements)Provision of concrete resources (basic needs must be met before psychological issues can be addressed)—may help to facilitate development of a working relationship between IPMH Specialist and familyDevelopmental guidance (may be viewed as both promotion and prevention strategy)Efforts to enhance parent/child attachment (prevention and intervention, depending on where dyad is on continuum)Intervention may include therapeutic services (dyadic therapy, family therapy, play therapy), help with behavior management & regulation, assistance with organizing chaotic environmentAdvocacy on behalf of child and family
87 Promotion StrategiesMay include provision of support to caregivers (emotional or concrete)Linkage or provision of concrete resources (food, housing)Developmental guidance“Listening”Helping strengthen family environment through establishment of routines, rituals and organization of dayInsure family has access to basic needs (Maslow)Insure access to high quality early care and learning opportunitiesCan cross over to prevention strategies esp when mother has problems and young child is not yet “diagnosable” for MH servicesDescribe some of Corazon work with families
88 ROUTINES & RITUALSRituals are the “patterns of everyday routines that make up the shared lives of parents and their children” (Klass, 2003, pg. 258)Provides a safe and predictable space for children as they developHelp to shape family relationships by connecting members to each other & defining their relationshipsProvide “communication, commitment, and continuity” (Fiese, 2002, pg 10)
89 TYPES OF RITUALSFood rituals (regular dinner; specific place at the table; particular food associated with specific celebrations or ethnic heritage)Bedtime ritualsSeparation rituals (good byes, etc)Religious/spiritual ritualsDiscuss examples of rituals from participants’ lives—both growing up and those established with their own children
90 FAMILY TRADITIONS & CELEBRATIONS Traditions are defined as regularly occurring eventsCelebrations generally involve rites of passage & family holidaysBoth provide members with sense of shared identity, connections, and continuity(Klass, 2003)B-day celebrations with unique cake for each family member; Quincenaria; Sweet Sixteens; Bar Mitzvahs; First Communions; etc
91 Prevention Strategies The field of prevention has now developed to the point that reduction of risk, prevention of onset, and early intervention are realistic possibilities. (Surgeon General’s Report, 1999)Prevention strategies are effective in reducing the impact of risk factors and improving social and emotional developmentMental health is inexorably linked with general health, child care, and success in the classroom and inversely related to involvement in the juvenile justice system.1999)Scientific methodologies in prevention are increasingly sophisticated, and the results from high-quality research trials are as credible as those in other areas of biomedical and psychosocial science.Prevention does work; for example, improving parenting skills through training can substantially reduce antisocial behavior in children (Patterson et al., 1993).
92 Prevention/Early Intervention Strategies Work with new mothers with post-partum depressionWork with mothers who have mental health diagnoses including depressionIntervention services at earliest possible point to keep young children from “going off the cliff” (SED diagnosis)Developmental guidance and other similar strategies may fit both prevention and e.i.“Purple Crying” materials at hospital dischargeSTEEP or Seeing is Believing is example
93 Treatment StrategiesInteraction Guidance & other types of dyadic therapyParent Child Interaction TherapyIncredible Years Program (again may be a preventive strategy, too)Trauma-focused Cognitive Behavioral Therapy (TF-CBT)Therapeutic preschools and nurseriesMH consultation to programs serving infants & young childrenMH Tx services are typically provided by a licensed MH clinician with specialty training in IFECMHSome of the strategies listed (e.g., IY) are designed so that they may be provided by non-MH specialists (such as EHS teachers)Level of intervention provided may depend on skill set of clinician (EBP’s may provide the specialty focused training in a single arena that a new clinician may need to function adequately)MH consultation allows other non-MH trained providers (such as pediatricians, DCFS line staff, preschool teachers) to gain the strategies needed to assist young children and their families in a more cost efficient manner; more funding needs to be developed to permit such strategies and to support their implementation (ongoing support to the consultee)
95 Developing an Intervention Family needsFit for child and familyTime that interventions will takeWho will implement?How will change be sustained/supported?Consistency of consequences (both positive & negative)
96 Caregiver Expectations AppropriatenessStress in environmentFlexibility (e.g., 6 meals not 3)Time/attention for child & selfUnderstanding of child characteristics
97 The Behavior Itself Context: When? Frequency: How often?Context: When?Severity: How disturbing? (and to whom?)Potential replacement behaviorsCurrent (& future) consequences for child/family
98 Structure of Intervention* Start with parents’ subjective experience: what have they tried, what has worked, how are they feeling, what are they looking forDiscuss with families to determine what they want and need—for some families, more “ideas” and direction may be needed (“I need to hear from an expert”); others may feel criticized by “experts”
99 Structure cont’d * Discuss plans/additional services/follow-up Always end with time for reflection on baby and self*Gilkerson (2008)
100 Developmental Strategies Taking charge with children (boundaries; limit setting)Use of praise, encouragement, acknowledgementOffering choices, avoiding power strugglesPreparing for transitions
101 Developmental Strategies cont’d Teaching negotiation (when/then)Importance of consistencyRole of compromise
102 Increasing Desirable Behaviors Are expectations of”desired” behaviors developmentally appropriate?TimeAttentionReinforcement of desirable behaviorsModeling desired behaviorsEvaluating & breaking power strugglesPatience
103 Evaluating On-Going Process Allowing timeReplacing with new intervention if original intervention doesn’t work for child/familyProviding alternative ideas along the wayContinued support for caregiver/implementor
104 What Do We Know About Treatment Approaches What Do We Know About Treatment Approaches? (Egeland & Bouquet, 2001; Zeanah, Stafford & Zeanah, 2005)Treatment is more successful if other issues (e.g., poverty, substance abuse, housing) is also addressedCaregiver’s relationships with others must also be addressedInterventions can’t wait—more success with earlier interventionsPrograms need to be of sufficient length & intensity to be effectiveServices need to be individualized and target experiences of both child and caregiverLength & intensity includes frequency of services, length of therapeutic engagement, complete duration of services
105 One Size Doesn’t Fit All Critical issues for service delivery programs are how to choose intervention strategies that fit the population served, how to individualize interventions to specific families, and how to adapt them over time as dyadic changes unfoldIntensity & duration should be dependent on need and may vary greatly from dyad to dyadIt is rare to see referral problems all in a single category ( e.g., the only referral problem seen in 75 toddlers referred is aggression). Some clinical interventions work best with specific types of problems so a small agency may be implementing 5 different intervention strategies based on problems seen and “fitting” the dyad to the most closely matching interventionMeasuring changes in parent in learning to deal with the ghosts in their pasts and in minimizing their impact on present day functioning and relationships is critical piece that is often overlooked or measured in a very gross way
106 Such individualized approaches to interventions are highly recommended clinically but do not fit most evaluation models that currently exist(Actually they create havoc for evaluators hired to come into community agencies and measure outcomes that were not planned in advance)
108 Need for a Shift in Public Opinion Must build community awareness that mental health is essential to overall health and well being; it is not the same as mental disorder or mental illnessNeed to shift from emphasis on treatment to consideration of entire spectrum of service needs & involve relevant partners at each level to reduce stigma and gain acceptance of mental healthCritical to evaluate cost savings of promotion and prevention and promote this with the public
109 Building the Connections Collaborations with pediatricians and other primary care providersResource sharing across disciplines to enhance quality of services and improve referral mechanismsMarketing of mental health as part of overall public health approaches
111 REFERENCESBatshaw, M.L & Perret, Y.M. (1993). Children with disabilities: A medical primer, 3rd edition. Baltimore: Paul H. Brookes Publishing Co.Fiese, B.H. (2002) Routines of daily living and rituals in family life: A glimpse of stability and change during the early child-raising years. Zero To Three, 22(4),Klass, C.S. (2003) The home visitor’s guidebook, 2nd ed. Baltimore: Paul H. Brookes Publishing Co.Landy, Sarah (2002). Pathways to competence. Baltimore: Paul H. Brookes.Luckasson, R. et al. (1992). Mental retardation: Definition, classification and systems of support (9th ed). Washington, D.C: Amer Assn on Mental Retardation.Prizant, B.M., Wetherby, A.M., & Roberts, J.E. (2000). Communication problems (pg ) In C.H. Zeanah (Ed.), Handbook of Infant Mental Health, 2nd ed. New York: Guilford.