1. Editing and Additions by Debbie Spaeth, LMFT, LPC, LADC - Supervisor Quest MHSA, LLC The Impact of Infant & Early Childhood Mental Health A Presentation by OKAIMH

2. Training Overview Infant Mental Health Relationships Emotion Regulation Development Trauma Brain Development Memory Relationships Impact Treatment Relationships Goals Approach Support Supervision OK-AIMH Zero to Three

3. Infant Mental Health Is  The developing capacity of the infant and toddler to...  Form close and secure relationships.  Experience, regulate, and express emotions.  Explore the environment and learn. ...all in the context of family, community, and cultural expectations for young children.  (Zero to Three Infant Mental Health Task Force).

4. The ACE Pyramid - (Adverse Childhood Experiences) Early Death Disease, Disability and Social Problems Adoption of Health-Risk Behaviors Social, Emotional and Cognitive Impairment Adverse Childhood Experiences This IS IMH!

5. Social, emotional, and cognitive impairment Attachment Disruptions Mistrust Self-Worth Infant/early childhood depression No internal control Emotion regulation problems Decreased exploration/engagement Learning Disabilities

6. Infant Mental Health Attachment Ecological Theory/Cultural Perspective Psycho- dynamics Theoretical Foundations

7. Attachment Theory  The lasting and deep emotional relationship between child and caregivers  Begins to develop in second half of first year of life  Focused on sense of security as child begins to explore environment  Still Face Experiment - showed that an infant will become animated and active when given facial and vocal expressions from another, while a still face and no sound will create frustration and irritation, and then apathy and lingering in the same infant

8. Attachment Child gives signals when in need Parent is sensitive to cues & responds appropriately “I will help you when you need it” “I will tell you when I need help”

9. Functions of Attachment  Trust/Survival  Explore with confidence and security  Self-regulation, manage emotions  Internal working model  Identity/Self Esteem  Protective factor against stress and trauma

10. Ecological Theory  There is CONTEXT for everything  Recognizes larger forces at work in influencing behavior  Different levels of context interaction

11. Policies, Procedures, Regulations Community Neighborhood Culture Family Parent & Child Culture Culture

12. Psychodynamic Theory  “Ghosts in the Nursery” – Fraiberg, S.  Relationship patterns set in childhood  The past is always with us. In infancy and early childhood, past, present, and future intersect in unexpected ways.  Reconciling past can improve present functioning

13. Best Practices in Infant Mental Health Are: Interdisciplinary Relationship - Based Strengths- Based Child Focused & Family Centered Individualized Continuous & Consistent

14. Best Practices in Infant Mental Health Are: Community- Based AccessibleComprehensive CoordinatedIntegrated Culturally Responsive Continually Improving Reflective

15. How you are is more important than what you do. ~ Jeree Pawl

16. What Can we Do? Understanding and Speaking the Language

17. Red Flags For IMH Services  Difficult, unwanted or unplanned pregnancy  Perinatal depression  Newborns with feeding, sleeping, regulation problems  Families who have children with special needs  Families with few resources or social supports  Children with possible attachment disorders  Families with Mental Health, Substance Abuse or Domestic Violence issues

18. How to speak the language Behaviors CryingTantrums Aggression SleepToiletingEating Translations TraumaRelationship Disruption Safety Domestic Violence Substance Abuse

19. Therapeutic Interventions Observation & Assessment Concrete Support Services Supportive Counseling Relationship – Based Developmental Guidance Problem Solving Brief Crisis Intervention Psychotherapy Parent-Infant Parent Focused Child/Filial Play Therapy

20.  Making anticipatory guidance specific to the infant.  Alerting the parent to the infant’s individual accomplishments and needs.  Helping the parent to find pleasure in the relationship with the infant  Allowing the parent to take the lead or determine the agenda  Watching, Waiting, & Wondering  Remaining open, curious, and reflective.  Deborah Weatherston, The Infant Mental Health Specialist, 0- 3 Oct/Nov. 2000. Strategies for IMH Practice

21. Open Curious Reflective IMH Case Discussion

22. Case Scenario Amanda was adopted from Paraguay when she was six months old. An attractive child at two and a half, Amanda has little or no language and seldom interacts with other children or adults. Her mother brings her to a mom- tot program where she finds one or two familiar toys and plays alone. Amanda's mother is a loud woman who frequently inserts herself, without invitation, into other people's conversations. She also refers to the adoption in Amanda's presence and explains that she is extremely shy and very slow. Her attempts to get Amanda to talk by starting her sentences only causes Amanda to withdraw more.

23. Case Questions 1. What concerns does this child's behavior raise for you? 2. What might be the social/emotional concerns for this child? 3. How would you begin addressing these concerns with the parents? 4. What strategies would you use to help this family address their child's social/emotional development? 5. What resources and/or referrals might be useful with this family?

24. The growth of regulation is the cornerstone and foundation that cuts across all parts of development. Emotion Regulation

25.  Development is dependent upon it  Cognitive, Social-Emotional, Physical, Moral  Capacity to be functional when awake.  Capacity for a restorative sleep cycle.  Types of Regulation  Self-regulation – for soothing  Use of “other” – to meet needs  How do Infants Regulate ? They can’t fight or flee!  Nonverbal Cues  Infants first form of language Regulation

26. Theo and the sweetie - http://youtu.be/TZYIJDtt3mU http://youtu.be/TZYIJDtt3mU

27. The Effects of Neglect and a Non-Stimulating Environment on a Child Learning Disabilities

28. Back to School: Back to School 1 hr Listen when you have the time.

29.  All learning happens in relationships. When early relationships are disrupted, the neural circuits necessary for brain development and effective learning are not formed.  50% of the children who are in the foster care system have developmental delays including cognitive, motor, hearing and vision problems, growth retardation, and speech-language delays (this is 4-5x the rate found among all other children).  Most children in foster care who have disabilities were not born with them. They are a result of not being nurtured to develop to their full potential. Learning Disabilities

30.  Physiological Regulation  Mutual Attention (3 mo)  Mutual Engagement - Falling in Love (by 5 mo)  Intentional, two way dance (by 9 mo)  Intentional, gestural communication (by 13 mo)  Intentional, symbolic play with emotional themes (24-36 mo)  Intentional, building bridges and links between themes (36-48 mo) Developmental Milestones

31. Myth: Infants and young children can’t speak so they won’t remember Trauma

32.  National  0-3 is the age group most likely to be maltreated  Most of those maltreated are under 1 year of age  1/3 were harmed during their first week of life  (Zero To Three, 2008)  78% of children who were killed were younger than 4 years of age  11.9% of the deaths were age 4-7  (US Dept of Health and Human Services, Children’s Bureau, 2006)  Oklahoma DHS Custody  In Tulsa 1,079 children age 0-18 in custody  515 are age 0-5 (48%)  State – 3,945 children age 0-5 in custody  (OKDHS 05/11)  State – 12/12 – Total children in out of home care – 9460  3 and under – 3198  5 and under – 4591  Tulsa Co: Total 1232 (3 and under) 436 (5 and under) 608 What is the Prevalence of Infant/Early childhood trauma?

33. Infants store memory within the first weeks of life Infants & Memory

34. Our Primitive Brain

35.  We are hard wired with a fight or flight response  Our amygdala is programmed to respond to threat by releasing stress hormone cortisol.  This is an adaptive system that helps us respond to danger.  Infants store sensory (procedural) memory (sights, sounds, smells, sensations, tastes) from traumatic events.  They have no language to help organize and make sense of these memories, and are at the mercy of stimuli that signal danger to their arousal system.  Parents and children can serve as traumatic reminders for each other. Memory & The Body

36. What does it look like? What do we see? How do we know? Trauma In Infancy

37.  Eyes  Facial expression  Tone of voice  Verbalization rhythm & rate  Posture  Gestures  Body Movement  Timing (Coordination)  Intensity  Modulation Nonverbal Cues: Sensory Information

38.  Help the Adults First  If adults have been traumatized, get them access to help  Aid in finding a calm and safe provider for the infant  Change the State of Arousal to Safety  If understimulated, increase movement and emotions  If nervous, agitated or crying, calm by slowing everything down and find one sensation that soothes  Prioritize improving sleep at night & staying calm when awake  Find safety for the infant in relationships and the environment  Slow down all transitions Infant & Early Childhood Trauma: First Aid

39.  Become a Sensory Detective  Notice what sensations calm and organize and are preferences of the infant  Notice sensations that overwhelm, irritate, or shut down the infant  Provide visual aid to caregivers (video) to increase awareness of their approach as well as the baby’s response  Notice the rate, rhythm, and timing of transitions  Titrate Input According to Infant Response  Respect the fear response  Over time, allow for sensory input that is overwhelming to be present in the same room, unless it is a person that brings danger.  Pair fearful stimuli with sensory and relational, safety and sensory preferences. Infant & Early Childhood Trauma: First Aid

40.  Provide Sensory Comfort  Surround infant with sensory avenues of comfort; sounds, tastes, movements, touch pressure, sights  Healing is non-linear, non-prescriptive  Re-exposure First Aid  Honor fear response  Stay with child until no longer afraid  Recognize that fear and trauma can be masked  Remember that misbehavior is communication  Listen to child and accept feelings, and reassure.  Help the child find ways to have control (flashlight, nightlight) Infant & Early Childhood Trauma: First Aid

41. No parent writes on their “to do” list for the day, “Lose it with my child.” We do the best with the tools we’re given. Trauma’s impact on relationship

42.  Areas to Focus On  BUILD ON STRENGTHS!  View the parent-child relationship as your client  Provide assistance with problems of living  Help caregiver provide physical and emotional safety  “Join, Partner” with the family. Use this language  Help the dyad construct their “story”  Provide reflective developmental guidance  Increase parent’s insight by speaking for the baby  Anticipate and recognize developmental (cognitive, socio-emotional) delays for the parent. Adjust your approach to meet their needs  Notice what the parent is “bringing” to sessions and follow their lead  Find space for your own reflective process about the work How can we impact relationship?

43. Putting it all together

44. Child Parent Psychotherapy Evidence Based Practice Model

45. Where have we been? Where are we going? Goals of CPP

46. CPP Goals  Encouraging normal development  Engagement with present activities  Reaching toward future goals  Maintaining regular levels of affective arousal  Establishing trust in bodily sensations  Achieving reciprocity in intimate relationships

47. CPP goals (trauma related)  Increased capacity to respond realistically to threat  Differentiation between reliving and remembering  Normalization of the traumatic response  Placing the traumatic experience in perspective

48. The foundation  Safety first  Physical safety  Safe shelter  Food  Protective orders  Psychological safety  Maladaptive strategies: substance abuse  Affect regulation  Issues of limits and discipline

49. SAFETY RAPPORT RELATIONSHIPS

50.  Safety in the relationship: Parent as the protective shield  Safety in the environment  Safety in the Relationship: Appropriate Response to Dangerous Behaviors  Safety in the Relationship: Parent as Legitimate Authority Figure Setting the Stage for Treatment

51. SAFETY RAPPORT RELATIONSHIPS AFFECT REGULATION ENCOURAGE NORMAL DEVELOPMENT UNDERSTAND BEHAVIOR RECIPROCITY IN RELATIONSHIPS TRUST IN BODILY SENSATIONS

52. Treatment Planning  Early trauma treatment goals:  Coping strategies to help with symptoms  Coping strategies to help with reminders  Later in treatment:  Mind-body connection – Understanding the meaning of behaviors  Construction of narrative  Increased flexibility and trust in relationships

53. CPP - Central Principals of Intervention  Considers the impact of the intervention on both members of the dyad  It is the parent who has the rightful place as the child’s guide through life and through this trauma. In CPP the therapist facilitates the parent’s confident assumption of that role.

54. Core Interventions in CPP  Concrete assistance with problems of daily living.  Modeling protective behavior  Unstructured developmental guidance  Emotional support  Interpretation – Linking past & present  Ghosts and angels  Constructing the trauma narrative  Reflective support/supervision

55. SAFETY RAPPORT RELATIONSHIPS AFFECT REGULATION ENCOURAGE NORMAL DEVELOPMENT UNDERSTAND BEHAVIOR RECIPROCITY IN RELATIONSHIPS TRUST IN BODILY SENSATIONS PLACING TRAUMATIC EVENT IN PERSPECTIVE _________________________________ DIFFERENTIATING BETWEEN RELIVING AND REMEMBERING ___________________________________________ MAKING MEANING OF THE EVENT ___________________________________________________ NORMALIZING THE TRAUMATIC RESPONSE _______________________________________________________ INCREASE CAPACITY TO RESPOND REALISTICALLY TO THREAT ___________________________________________________________

56.  “My thirty-five-year-old son told me recently that he has had nightmares in which the Gestapo come up his stairs. You realize what this means? My son was born and raised in America. But he dreams my nightmare, my life.”  A German-born psychoanalyst and a survivor of a concentration camp (1988) (Terr, 1990) Shared trauma

57. Principles of Early Development  Young children cry and cling in order to communicate an immediate need for parental proximity and care.  Separation distress is an expression of the child’s fear of losing the parent.  Children want to please their parents, fear their disapproval, and respond well to praise.

58. Principles of Early Development  Young children are afraid of being hurt and of losing parts of their bodies.  Young children feel responsible and blame themselves when the parent is upset or angry for whatever reason.  Children imitate their parents because they want to be like them.

59. Principles of Early Development  Young children say no to establish autonomy, not to be disrespectful.  Young children harbor the conviction that parents know everything and are always right.  Young children need clear and consistent limits to their dangerous or culturally inappropriate behaviors in order to feel safe and protected.

60. “In every nursery, there are ghosts. They are the visitors from the unremembered past of the parents; the uninvited guests at the christening.” ~Selma Fraiberg Ghosts in the Nursery

61. The Intersection of Ghosts and Trauma  Parent experiences traumatic event in childhood  Parent develops traumatic expectations as a result of the event  Parent’s personality develops in line with defenses and expectations based on trauma  Early trauma becomes a ghost in the nursery

62. Child-Parent Psychotherapy  What predicts whether the parent’s past will be repeated with the child?  Repression and isolation of the affect associated with childhood suffering  Remembering saves the parent from repeating the past  Remembering allows the parent to identify with the child rather than the aggressor  Fraiberg, 1980

63. Child-Parent Psychotherapy  Treatment Modalities  Developmental guidance – education integrated with psychotherapeutic work  Guidance is selected based on therapist’s assessment of what is needed to foster attachment  Therapist acts as a bridge or interpreter between the parent and the baby  Fraiberg, 1989

64. Child-Parent Psychotherapy  Treatment modalities  Psychotherapeutic intervention  Form working alliance with the parent  Recognize that the parent may respond to the baby based on past experiences in which they were abused or neglected.  Therapist helps identify the feelings that are being played out in the parent’s relationship with the baby  Therapist frees the parent to identify with his/her own childhood experience and liberates the baby from that experience  Fraiberg, 1980

65. Resilience Factors  Positive relationship with at least one parent  Positive relationships with other adults  At least one safe haven in the community  Rutter, 1993

66. Impact of Trauma on Parent-Child Relationship  Loss of sense of security  Changes parent and child’s view of each other  Victim  Persecutor  Non-helpful bystander  Traumatic reminders  Traumatic expectations

67. Changes in Parent-Child Relationship after Trauma  Impaired affect regulation  Either partner may develop new negative attributions based on trauma experience  Changes to internal working models  Traumatic expectations  Parent and child may serve as traumatic reminders for one another  Pynoos,1997

68. strengths based culturally competent Assessment

69.  Child Functioning  Pre-trauma  Post-trauma  Caregiving System  Ecology Assessment Policies, Procedures, Regulations Community Neighborhood Culture Family Parent & Child

70. Treatment Planning  Safety first  Physical safety  Safe shelter  Food  Protective orders  Psychological safety  Maladaptive strategies: substance abuse  Affect regulation  Issues of limits and discipline

71. Treatment Planning  Early trauma treatment goals  Coping strategies to help with symptoms  Coping strategies to help with reminders  Later in treatment  Mind-body connection  Construction of narrative  Increased flexibility and trust in relationships

72. “Do unto others as you would have others do unto others.” Jeree Pawl (1998) Reflective Practice

73.  “Don’t just do something. Sit there.” ~Jeree Pawl Reflective Practice

74.  REFLECT ON:  Process of treatment  Process of individual sessions  Therapist’s role with the dyad  Emotional responses that dyad arouses  MUST CONSIDER:  Agency’s contribution of reflective space and clinician’s willingness to engage in supervision Self Reflection

75.  A trusting relationship between supervisor and practitioner  Consistent and predictable  Encourages details about the infant, parent and emerging relationship  Is a listening environment in which participants remain emotionally present  Supervisors teach/guide and provide nurturance/support Reflective Supervision

76.  Focuses on integration of emotion and reason  Fosters the reflective process to be internalized by the supervisee  Explores the parallel process and to allow time for personal reflection  Attends to how reactions to the content affect the process  Best Practice Guidelines for Reflective Supervision/Consultation (OK- AIMH, www.okaimh.org) Reflective Supervision

77.  www.nctsn.org www.nctsn.org  www.zerotothree.org www.zerotothree.org  www.okaimh.org www.okaimh.org  Don't Hit My Mommy!: A Manual for Child-Parent Psychotherapy with Young Witnesses of Family Violence (Lieberman, VanHorn, 2005) Don't Hit My Mommy!: A Manual for Child-Parent Psychotherapy with Young Witnesses of Family Violence  Psychotherapy with Infants and Young Children: Repairing the Effects of Stress and Trauma on Early Attachment (Lieberman, VanHorn, 2011) Psychotherapy with Infants and Young Children: Repairing the Effects of Stress and Trauma on Early Attachment  CPP portions of this presentation adapted from Lieberman/Van Horn CPP Training Manual for the National Child Traumatic Stress Network. Resources/Readings