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Providing Relationship-Driven Mental Health Services in the Birth to 3 Period San Gabriel Pomona Regional Center Conference October 7, 2010.

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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 Conference October 7, 2010

2 Karen Moran Finello, Ph.D.
Assoc. Professor of Clinical Pediatrics USC Keck School of Medicine Project 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 model Illness approach; great deal of stigma General public views mental health as associated with disorder & mental illness Most mental health services began with treatment services for adult populations with serious disorders & were geared down for adolescents and school aged children Preschool 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 lives Mental disorders account for 25% of all disabilities in the U.S., Canada & Europe & are a leading cause of premature death In the U.S., 22% of the adult population has 1 or more diagnosable mental disorders in any year 10% of children in the U.S. have mental disorders that cause some level of impairment Mental illnesses cost the U.S. $150 billion each year Cost 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 problems mount preventive interventions that may block the emergence of severe illnesses actively promote good mental health Although 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 Conclusion Mental 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 factors Increase public awareness about mental disorders & treatment efficacy Remove stigma Eliminate health disparities Improve access to mental health services for all

10 CDC Recommendations Incorporation of mental health promotion into chronic disease prevention efforts by public health agencies Collaboration among partners (public health agencies and other public entities) to develop comprehensive mental health plans to enhance coordination of care Public health agencies should conduct surveillance and research to improve the evidence base about mental health in the U.S.

11 What Is Early Childhood Mental Health?

12 The development of social and emotional well-being in children birth to five. Includes
child behavior, health and development family functioning caregiver-child relationships This 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 functioning Provides biologic underpinnings for later coping & resilience---”hardwires the brain” Untreated early problems are associated highly with problems during childhood, adolescence & adulthood Example: 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 areas Ability to initiate, discover, & learn Development of persistence & attention Development of coping mechanisms Development of self-regulation Development of emotional range Many 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, substance abuse, 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 loss Multiple caregivers Repeat hospitalizations Family instability Substance use in caregiver Domestic violence Environmental stressors Inadequate 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 early Rapid 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 questionnaires Recent 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 factors Developmental level of child Other 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 disorder If 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 levels Neurodevelopmental problems  distress proneness Long periods in low or high arousal states Repeated experiences encoded in implicit memory of what the world is about Perceived threat overloads the brain’s stress management system Are there co-occurring conditions?

20 BEHAVIOR CONCERN? SIGN OF SEIZURE DISORDER? OTHER?
Breathholding Sleep disorders (narcolepsy, night terrors) Tics Migraine headaches Fainting Gastroesophageal reflux Behavior disturbances

21 ROLE OF TEMPERAMENT ON EMOTIONAL REGULATION
Infant temperament determines the intensity of infant response to stimuli Temperament effects how emotions are expressed Temperament may influence which signals baby uses to express positive and negative emotions Temperament also influences how parent responds

22 Measuring Specific Child Characteristics
Dimensions of Temperament: Activity level Regularity of biologic rhythms Approach/withdrawal Adaptability Intensity Sensitivity Mood Distractibility Persistence

23 YOUNG CHILDREN & OUT-OF-HOME CARE
Children under age 5 comprise one-third of all children in out-of-home care Average length of stay in foster care is 2 years In 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 events Need for careful intervention in helping caregiver help child to understand event and recover from it All 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 problems High activity level, irritability, acting out Emotional detachment, unresponsiveness, distance, or numbness Hypervigilance or feeling that danger is present, even when it isn’t Increased mental health issues (e.g., depression, anxiety) An unexpected and exaggerated response when told “no” From Child Welfare Trauma Training Toolkit 25

26 Understanding Children’s Responses
Traumatized children may exhibit: Over-controlled behavior to counteract feelings of helplessness and impotence May 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 behavior May show impulsivity, disorganization, aggression, or other acting-out behaviors From Child Welfare Trauma Training Toolkit 26 26

27 The Influence of Developmental Stage: Young Children
Young children who have experienced trauma may: Become passive, quiet, and easily alarmed Become fearful, especially regarding separations and new situations Experience confusion about assessing threat and finding protection, especially in cases where a parent or caretaker is the aggressor Regress to recent behaviors (e.g., baby talk, bed-wetting, crying) Experience strong startle reactions, night terrors, or aggressive outbursts From Child Welfare Trauma Training Toolkit Child Welfare Trauma Training Toolkit 27 27

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 Toolkit 28

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
Temperament Flexibility Tolerance Environmental Stressors Family dynamics Past experiences as a mother Her own history of child rearing experiences Psychological state Health & well being Help caretakers adjust expectations Many families need to learn limit setting & need help in following through with is Does parent understand “typical” behavior Is caretaker able to maintain a stable, nurturing environment?

33 EXAMPLE: MOTHERS OF ABUSED INFANTS
Respond to fewer infant initiatives Try to control children more often Provide less verbal, tactile & vestibular stimulation during interaction Are less active during free play Use more negative affect Do not change teaching style to match child’s age (Westby & Fenske, 2001)

34 Understanding Attachment in Young Children
Primary attachment Secondary attachments Secondary attachments may include others important to the child including the child care provider

35 Attachment Attachment 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 attachments Type 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 consistent Adults will be there when needed and share child’s joy in the world With peers, child interacts and plays well May cry at separation but settles with some help

38 Attachment Relationships Vignettes

39 Vignette 1 When 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 response Child appears to be very independent but may get frustrated easily May have difficulty with peers due to aggression, hitting, biting, pushing, screaming

41 Avoidant cont’d Child does not typically build strong connections with child care provider Do not show distress at separation from caregiver and may ignore when caregiver comes for pick up Seem too able to take care of own needs Child is avoiding rejection by primary caregiver by being the one who doesn’t reach out Caregiver dislikes “needy” behavior and reinforces independence to extreme

42 Insecure (Ambivalent) Attachments
Child may be clingy, demanding, angry, easily frustrated Likes to be center of attention and gets upset if others don’t pay attention to them May act like a younger child Caregiver is inconsistent in response to child’s needs and may go either overboard in responding or not respond at all Unpredictable 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 behaviors Demonstrates fear of caregiver May seem very different from one day to next

44 Disorganized cont’d May be extremely bossy with peers or may act like the parent Caregiver has patterns of unresponsiveness to child’s needs & responses that don’t match child needs Caregivers frequently have untreated mental health issues Child may have been abused or neglected MH issues include bipolar disorder, depression, unresolved traumas, substance abuse Requires knowing when attachment pattern places relationship in jeopardy—requires MH treatment by a specialized provider

45 Important Points Attachment may be different with different adults (mom, grandmother, dad, child care provider) There is typically a “primary” attachment to one person Should make a referral if the child constantly seems either sad & withdrawn or aggressive & out of control Will 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 life Life threatening special health care needs Prematurity Neurologic problems Separation due to parental hospitalization or death Foster placements (especially multiple placements)

47 Principles for Developing Secure Attachments *
Comfort children when they are physically hurt, ill, upset, frightened or lonely Respond to and notice children so they learn that their caregivers care Give children a sense of trust in the world and the people in it Help children review experiences and reenact frightening situations so that the memories can be integrated into their self-narratives When 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’d Create 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 figure May 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 level Some 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: Mary Most 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 classroom Think 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 child Build an understanding of each child’s response and develop strategies for this wide range for the children you work with Every child is different and may need slightly different responses Remember: 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 connections Endure over time Have special meaning between the two people Create memories and expectations in the minds of the people involved Center 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 stresses Many “ripple effects” may be seen in relationship-based work Tasks 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 style Trust with interventionist may build wider trust with larger community and other professionals on part of caregiver Very difficult to measure ripple effects yet this is critical to capture Language & communication development is heavily influenced by relationships Cognitive mastery effects child’s social interactions with the wider world

56 Samples of relationship-based Interventions

57 Dyadic Therapy & Interventions
Parent Guidance Programs (STEEP; Seeing is Believing; Partnership in Parenting Education) Parent Child Interaction Therapy Interaction Guidance Approaches Family Support Services Attachment 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 caregiver Improving caregiver’s emotional availability—measuring impact of changes in e.a. that might be very subtle (but important to child’s life) is critical Enhancing 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 manner Parental attunement and responsiveness to those in their world is important

59 Developing Ideas About Relationships—Vignette (Myra, Haniya & Tia)
Activity Developing 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 behaviors Provide “corrective emotional experiences” and opportunities to connect her past with the present -(Gowen & Nebring, 2002)

61 Serving children and their families

62 Corazón de La Familia Infant-Child Intervention Program
Strength Based Family Focused Individualized Culturally Responsive Comprehensive Collaborative Relationship-driven Specialists in Serving Very Young Children with Special Health Care Needs

63 Overall Goals To assist families in optimizing the growth & development of their infants, toddlers, and preschoolers To help families become more comfortable and feel success in meeting the needs of their children To provide support to struggling families But first comes FAMILY ENGAGEMENT

64 Primary Targeted Outcomes
Health & development of at risk children under age 5 Mental health & behavior issues in children under 5 Family 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 system Did 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
Privacy Time/Travel issues Limitations set by space in home Embarrassment of family Boundary issues Staying on task Keeping focus on WHO is client while meeting needs of other family members

69 Stressors of Home Visiting
Overwhelming needs within families Unpredictability of work Safety issues Transportation issues Draining nature of being the nurturer if not provided nurturance within program

70 Challenges Need to move quickly—babies can’t wait; period of rapid development Must work towards goal of “good enough” parenting Must 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 Challenges Must 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 style Must have knowledge and awareness of strategies of other disciplines and know when young child needs (& family is ready for) other specialty services Must 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 impact Minimum of weekly visits for at least 6 months duration Mixed 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’d Generic 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 needs Families are eager to do what is best for their babies Through 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 paraprofessionals Therapeutic alliance is crucial to effective home visiting Must respect and understand culture of each family with whom you work Must 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 tools Uses Advantages & disadvantages Moving 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 accomplished any 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 screen Training, time & cost of administration (ease of use issues) Specific concerns related to child, family or risk issues Setting where tool will be used Appropriateness 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 administration Utility 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 families Monitoring on routine level Documentation to assist referral process “Warm” referrals Process must stay focused on child & family needs & wishes (family centered & culturally competent) Coordination for full assessment Collaboration with other disciplines

85 Discussion Ideas 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 all Prevention—aimed at reduction of risk; includes family support, parent ed & info; mentoring of caregivers, screening & referral Early 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 nurseries Includes 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 family Developmental 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 environment Advocacy on behalf of child and family

87 Promotion Strategies May 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 day Insure family has access to basic needs (Maslow) Insure access to high quality early care and learning opportunities Can cross over to prevention strategies esp when mother has problems and young child is not yet “diagnosable” for MH services Describe some of Corazon work with families

88 ROUTINES & RITUALS Rituals 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 develop Help to shape family relationships by connecting members to each other & defining their relationships Provide “communication, commitment, and continuity” (Fiese, 2002, pg 10)

89 TYPES OF RITUALS Food rituals (regular dinner; specific place at the table; particular food associated with specific celebrations or ethnic heritage) Bedtime rituals Separation rituals (good byes, etc) Religious/spiritual rituals Discuss 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 events Celebrations generally involve rites of passage & family holidays Both 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 development Mental 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 depression Work with mothers who have mental health diagnoses including depression Intervention 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 discharge STEEP or Seeing is Believing is example

93 Treatment Strategies Interaction Guidance & other types of dyadic therapy Parent Child Interaction Therapy Incredible Years Program (again may be a preventive strategy, too) Trauma-focused Cognitive Behavioral Therapy (TF-CBT) Therapeutic preschools and nurseries MH consultation to programs serving infants & young children MH Tx services are typically provided by a licensed MH clinician with specialty training in IFECMH Some 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)

94 Designing Interventions

95 Developing an Intervention
Family needs Fit for child and family Time that interventions will take Who will implement? How will change be sustained/supported? Consistency of consequences (both positive & negative)

96 Caregiver Expectations
Appropriateness Stress in environment Flexibility (e.g., 6 meals not 3) Time/attention for child & self Understanding of child characteristics

97 The Behavior Itself Context: When?
Frequency: How often? Context: When? Severity: How disturbing? (and to whom?) Potential replacement behaviors Current (& 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 for Discuss 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, acknowledgement Offering choices, avoiding power struggles Preparing for transitions

101 Developmental Strategies cont’d
Teaching negotiation (when/then) Importance of consistency Role of compromise

102 Increasing Desirable Behaviors
Are expectations of”desired” behaviors developmentally appropriate? Time Attention Reinforcement of desirable behaviors Modeling desired behaviors Evaluating & breaking power struggles Patience

103 Evaluating On-Going Process
Allowing time Replacing with new intervention if original intervention doesn’t work for child/family Providing alternative ideas along the way Continued 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 addressed Caregiver’s relationships with others must also be addressed Interventions can’t wait—more success with earlier interventions Programs need to be of sufficient length & intensity to be effective Services need to be individualized and target experiences of both child and caregiver Length & 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 unfold Intensity & duration should be dependent on need and may vary greatly from dyad to dyad It 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 intervention Measuring 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)

107 We can’t do this work alone!

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 illness Need 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 health Critical 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 providers Resource sharing across disciplines to enhance quality of services and improve referral mechanisms Marketing of mental health as part of overall public health approaches

110 Website links www.vanderbilt.edu/csefel/modules.html

111 REFERENCES Batshaw, 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.


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