1. Early Signs of Vulnerability for Poor Mental Health
Chaya Kulkarni, BAA, M.Ed. Ed.D
Director
Infant Mental Health Promotion

2. Why Am I Here?
Maybe you think you are in the wrong session Director of Infant Mental Health
Was every other session full?
How is this connected to kids in school?
How can this possibly have anything useful for me?
Infants can’t possibly have mental health what is she going to talk about for the next hour?

3. Dispelling the Myths About Infants and Toddlers

4. Infants don’t have mental health
Myth #1
Infants don’t have mental health
Do infants show emotions?
Do infants, even young infants, respond to comfort?
Do infants respond to people?

5. The truth is…..
Infants are born with mental health – it will continue to develop throughout their life

6. Myth #2
Infants won’t remember the negative experiences they have early in life including the emotional ones.

7. The truth is…
Infants are born relationship ready The relationships they have give them experiences that will in fact shape the architecture of their brain The experience an infant has early in life is wired into his/her brain and will impact his/her development throughout their life.

8. Infants are resilient and will easily recover from early adversity.
Myth #3
Infants are resilient and will easily recover from early adversity.

9. The truth is….
While children are resilient, there is a threshold. When infants experience prolonged and frequent trauma their ability to “bounce back” to be resilient will reach its limits. Exposure to frequent and prolonged stress will impact brain development.

10. Myth #4
Early experiences don’t really count – it’s what happens when they start school that really matters.

11. The truth is…
The brain develops rapidly in the first three years of life forming 700 new neural connections every second – that would be before school The greater the number of adverse experiences a very young child has the more likely his/her development will be impacted

12. It is not possible to recognize poor mental health during infancy.
Myth #5
It is not possible to recognize poor mental health during infancy.

13. The truth is…..
There are behaviors that do tell us when a child is experiencing poor mental health – but we need to know what these look like. We have access to various tools referred to as screening tools that can help us know when a child needs a more in-depth assessment from a clinician. These will not diagnose but they will tell us a child needs more assessment.

14. Myth #6
Infants and toddlers who experience neglect and/or abuse are getting the help they need to address their mental health needs.

15. The truth is…..
Very little is done to monitor a young child’s development overall much less their mental health. Other jurisdictions are screening for development including early mental health.

16. Myth #7
Early mental health does not impact mental health later in life.

17. The truth is
The greater the number of early adverse experiences a child has the more likely s/he will experience adversity throughout his/her life.

18. Myth 8
Whatever adversity a child may have experienced before school can be undone by the programs offered to him/her.

19. The truth is….
A child who arrives at school with poor mental health is likely already behind. The gap in developmental outcomes and achievement will continue to increase over time. To change this will require MONUMENTAL resources from the system and the child.

20. When Children Arrive at School
A concern may be expressed about that child’s behavior. Sometimes the concerning behavior is distressing all in the classroom – teacher, other children… That child’s behaviour did not happen when he arrived at school. That child has been on a journey that brought him to that place.

21. While We Can’t Change the Past
There are many things that those in the school system can do to support early mental heath. We can screen for early mental health in our classrooms. We can create plans that can be used by teachers, parents and other resource workers in the classroom to support a child’s social emotional development.

22. But this is major change….
This is about changing:
Our knowledge about mental health
Our policies around early identification of mental health vulnerability
Our practices supporting early mental health.
Our beliefs about mental health – when it begins and what influences.

23. Infants and toddlers are missing from the picture
While there has been an important and impactful effort to raise awareness about mental health these efforts have focused on youth and adults suffering Most people do not realize that for too many, poor mental health begins during the first three years and sets a child on path that can be riddled with mental health challenges

24. Your Context….
Many of you see children when they are on the verge or immersed in a mental health crisis. They are being labeled by others in the system, by their peers, by other parents. They are at a VERY HIGH risk for a life time of poor outcomes physically, emotionally and cognitively

25. Waiting is not a solution
We can begin to work with families to:
Understand the mental health needs of their child
Create plans that will begin to deal with any vulnerabilities. These plans can be used by the teacher, the parents and any other resource staff working with the child
Monitor regularly the child’s development
This is not about academic testing but this will impact academic outcomes for a child

26. An Overview of Early Mental Health
Does it really exist?

27. My Objectives for Today
To enhance your knowledge of early mental health – how it develops, what influences it To enhance your practices with young children so that we create opportunities for those in the system to understand each child’s mental health To identify opportunities to create policies that will enable you to support the mental health of TDSB’s youngest pupil

28. What is early mental health?
Early mental health is the social, emotional & cognitive well being of infants and toddlers

29. When does mental health begin?
A child’s mental health begins at conception
An infant, toddler, preschooler or kindergarten child can have serious mental health and emotional problems
An infant who experiences poor mental health this early in life, will be vulnerable for poor mental health throughout life

30. Definitions of trauma Trauma can be the result of: Community violence
Family violence
Child maltreatment

31. Community Violence Violence outside the home, within the neighborhood
Violence committed by people who are not known or related to the child
Exposure to weapons, muggings, the sound of bullets, sexual assaults
Contact with gangs and guns
Being a victim of violence
Summers & Fitzgerald. (2012). Understanding early childhood mental health. United States: Brookes Publishing.

32. Family Violence Violence within the home
Violence between family members
Summers & Fitzgerald. (2012). Understanding early childhood mental health. United States: Brookes Publishing.

33. Child Maltreatment
Physical abuse, sexual abuse, emotional abuse, neglect
Physical abuse includes non-accidental act as that result in injury to a child
Neglect includes absence of care by caregivers, failure to supervise young children, or failure to provide for the basic needs of children
Summers & Fitzgerald. (2012). Understanding early childhood mental health. United States: Brookes Publishing.

34. But can young children experience trauma symptoms?
Yes they most certainly can.
For example, in a study by G. Anne Bogat , Erika DeJonghe, Alytia A. Levendosky, William S. Davidson, Alexander von Eye (September 2005) it was concluded that “infants as young as 1-year-old can experience trauma symptoms as a result of hearing or witnessing IPV.”

35. Definitions Will Vary For our purposes we define trauma as:
“…an event or events that involve actual or threatened death or serious injury to the child or others, or a threat to the psychological or physical integrity of the child or others”
Zero to Three, National Centre for Infants, Toddlers and Families. (2005). Diagnositic classification of mental health and developmental disorders of infancy and early childhood, revised (DC: 0-3R). Washington, DC: Zero to Three.

36. Exposure to trauma can occur once or multiple times, and young children exposed to multiple traumatic events tend to experience worse outcomes than those exposed only once.”
Chu, A.T., & Lieberman,j A.F. (2010). Clinical implications of traumatic stress from birth to age five. Annual Review of clinical Psychology, 6,

37. Early is Essential
There is a strong link between children’s trauma symptoms and the amount of exposure a child has had to traumatic events. The longer and more often a child is exposed to violence, the worse off the child will be socially, emotionally, and psychologically in the long run. Interventions and supports must address both immediate needs and long-term development and relationship issues. The longer we wait to recognize and respond the more likely the impact on a child’s development will be negative

38. What is the impact of early trauma?
affects a young child’s development, behavior and relationships
brain development
when undetected and untreated, will impact short and long term mental and physical health outcomes
Is much harder to recover from the longer it continues undetected and untreated
Often leads to prolonged and frequent stress for the child
For these reasons, early detection and early intervention are critical for young children

39. Trauma Symptoms in Young Children
“Re-experiencing” or playing out memories of the event
Toileting problems
Sleep problems
Eating problems
Verbal or language difficulties
Developmental regression
Withdrawal
Onset of new fears
Aggressive outbursts or increased activity level
Increased clinginess/separation
Anxiety
PTSD
Relationship problems – including poor attachment or attachment disorders
Depression
Dysregulation of stress system
Low self-esteem
Preoccupation with the traumatic event such as bringing up the episode repeatedly or uncontrollably
Increased and prolonged stress

40. Toxic Stress & Brain Development
Toxic stress is the frequent, prolonged activation of the stress response system Triggers the release of chemicals that impair brain development and functioning World wide data on the lifelong implications of stress in early childhood

41. When a child is vulnerable to continued exposure to any of these experiences they are more likely to be traumatized At the time of the trauma the protective factors surrounding a child may help a child overcome and recover from the event But for too many infants and toddlers those factors are not consistently present in their lives

42. Traumatic events/experiences
One parent is an abuser
Second parent removes child and her/himself from the situation
Parent accesses support
Parental death
Other family members step in and provide the response the baby needs
Protective Factors that may mitigate minimize impact
Baby or Toddler who has recovered from traumatic experience/event

43. Traumatic events/experiences
Mother dies
Father emotionally vulnerable/ no one else to respond (examples)
Limited/weakProtective Factors
Baby or Toddler unable to recover from trauma
Infant or Toddler suffering from poor mental health

44. Relationship/attachment
Trauma
Stress
Brain
development
Overall health
Overall development
Relationship/attachment

45. Why Do We Make Reasoning Errors?
Emotional reasons Cognitive reasons

46. Common Errors in Reasoning
Halo effect Filtering or confirmation bias (Munro) Desensitization & depersonalization Allure of available or vivid evidence Vanity effect Perseverance effect Imposing meaning or causality
See Society for Judgement and Decision Making at
Munro, Eileen (2008) Lessons from research on decision-making. In: Lindsey, Duncan and Shlonsky, Aron, (eds.) Child welfare research: advances for practice and policy. Oxford University Press, New York, NY; Oxford, UK, pp ISBN
E. Munroe website:

47. Cause & Effect Error

48. How Can We Improve Practice?
Accept that we are worse at making decisions than we think we are Train practitioners to be comfortable with dissonant views Train practitioners to use empirical evidence correctly Encourage reflective supervision Create feedback mechanisms

49. Your role in understanding a child’s development
Depending on your role you may or may not be able to diagnose You can implement a developmental screen either in partnership with the biological family, the foster family, through your own observations or a combination of any two of the above You can be trained on how to implement both a screen and curriculum based assessment tool

50. Your role in understanding a child’s development
You can reach out to community agencies such as Early Years Centres, children’s mental health agencies and ask for guidance with the creation of a developmental plan to support the needs of a child You can refer parents to programs in the community that provide guidance around parenting and supporting development

51. Poor Mental Health Can Impact Health Outcomes – Short and Long Term
We know that when young children experience poor mental health the impact is also on their physical health and well being According to researchers at Harvard, children who experience poor mental health experience higher rates of illnesses throughout life.

52. Health Outcomes: Physiological /Medical Challenges
You can be the FIRST RESPONDER
You cannot diagnose
You can make referrals to the appropriate professional who can diagnose
You can be making observations that can be shared with other professionals (with parental consent) that could be very helpful – for instance, a child with poor muscle tone making observations of movements, any pain the child experiences etc… can be helpful to a clinician
You can be reviewing medical records
You can be consulting with/to the other disciplines involved with the case (with the appropriate consents)

53. Historically what has neglect/abuse looked like?
A baby with broken bones A toddler with healing fractures and other unexplained injuries An underweight infant An unkempt, dirty toddler A baby who has been shaken within inches of his/her life This is what we all looked for and when these things were absent we often thought all was okay

54. We are good at looking for hazards
Typically, when concerned we look for the hazards. But where the mental health of young child is concerned the absence of “normal things, experiences” should be as concerning to us as the hazards that are present – the absence of a warm blanket in the toddlers crib during winter needs to be a concern

55. Neglect and maltreatment lead to poor mental health for infants
We know much more…
Neglect and maltreatment lead to poor mental health for infants

56. Emotional Deprivation in Infancy : Study by Rene A. Spitz, 1952

57. What Does all of this Mean?
The Absence of Normal Can’t Be Ignored
Monitor the child’s development and provide activities to support development while he is involved with your agency
Connections Count - Be connected to resources and professionals who can step in with the expertise you don’t have.
Be aware of the interventions that are available to your agency and therefore the children.
Educate, Educate, Educate!!! The Judge, The Lawyers, Your Team
Advocate for babies and toddlers as a unique group with unique needs

58. Development Counts but Who is Watching?
“Developmental structures are incorporated into later developmental structures, so that early competence tends to foster later competence, and early incompetence tends to promote later incompetence” (Cicchetti & Cohen, 1995; Waters & Sroufe, 1983) If this is the case how is that we don’t monitor development and respond to what a child needs?

59. Monitor Development
In the US every child under the age of three is entitled to a developmental screening and service plan. Monitoring development is not difficult – IMHP will gladly train you and your team to do this! Create a developmental plan that can be shared with those caring for the child. This ensures some consistency of expectations and also supports the child’s development appropriately

60. Do Screen for Development
You can screen for development including mental health using tools such as (but not limited to):
ASQ 3
ASQ SE
Brief Infant-Toddler Social Emotional Assessment (BITSEA)
Eyberg Child Behavior Inventory
Vineland Social-Emotional Early Childhood Scales

61. Make Use of What Might Be Dead Time
With the resources available you can be a bridge to the services and supports a child and family may need. Make the appropriate referrals. While waiting for services to kick in, create a plan that supports the child’s development and gives caregivers something to focus on.

62. What is ASQ:SE?
Parent- or caregiver-completed screening tool that encourages parental/caregiver involvement Series of questionnaires for children ages 3 months to 5 ½ years Tool to accurately identify children at risk for social-emotional delay
Parent/caregiver completed: To be qualified to complete ASQ:SE, caregivers need to have at least 20 hours of contact with the child during the week.
It is important to consider multiple perspectives.
Ask participants, “Why is it important to consider more than one perspective?” Possible reasons include the following:
Children exhibit different behaviors in different environments.
People have different expectations for certain behaviors.
New moms, cultural differences, “goodness of fit” issues, temperament, experienced versus new child care providers
ASQ-3™ and ASQ:SE Training Materials by Jane Squires, Jane Farrell, Jantina Clifford, Suzanne Yockelson, and Elizabeth Twombly
Copyright © 2010 Paul H. Brookes Publishing Co. All rights reserved. stages.com

63. Domains on ASQ:SE and Ages & Stages Questionnaires® (ASQ-3™)
Social-emotional development
ASQ-3 (screens 5 domains)
Communication
Gross motor
Fine motor
Problem solving
Personal-social
Review the slide.
ASQ:SE was developed as a companion tool to the ASQ to address the need for age-appropriate tools to monitor very young children’s behavior and to address parental concerns.
ASQ-3™ and ASQ:SE Training Materials by Jane Squires, Jane Farrell, Jantina Clifford, Suzanne Yockelson, and Elizabeth Twombly
Copyright © 2010 Paul H. Brookes Publishing Co. All rights reserved. stages.com

64. Types of Assessment
Screening assessment Diagnostic assessment Curriculum-based (programmatic, ongoing) assessment
Because of all of the confusion regarding the different purposes and types of assessments available, it is helpful to spend some time talking about definitions.
There are three different types of assessments available in the early childhood field:
Screening assessment
Diagnostic assessment
Curriculum-based (i.e., programmatic, ongoing) assessment
Each type of assessment has a different purpose.
ASQ-3™ and ASQ:SE Training Materials by Jane Squires, Jane Farrell, Jantina Clifford, Suzanne Yockelson, and Elizabeth Twombly
Copyright © 2010 Paul H. Brookes Publishing Co. All rights reserved. stages.com

65. Screening Professional Assessment Near Cutoff Well below cutoff
Above Cutoff
Near Cutoff
Well below cutoff
Professional
Assessment
Continue to Monitor (Re-Screen) & use Curriculum-Based Assessment to develop learning plans
This is an example of how screening with ASQ:SE fits into a system to help identify children with potential developmental delays. The process starts at the top by screening all children, and then children fall into 3 categories:
Beyond Cutoff (Below on ASQ-3, Above ASQ:SE).
Near Cutoffs (Monitor Zone of ASQ-3).
Not Near Cutoffs. (Above ASQ-3 Monitor Zone, Well Below ASQ:SE).
Children who fall above the cutoff are sent to local Part B or Part C Early Intervention/Early Childhood Special Education, health or mental health agencies for further Diagnostic testing.
NOTE: One of the dilemmas you will encounter when screening for social-emotional delays is the lack of appropriate referral agencies—especially for babies and toddlers. You can start with EI/ECSE agencies, but also consider referrals to parenting programs, health or mental health agencies. We are pioneers in this field and need to use tools to justify our referrals, document the need for services and advocate to our agencies/government for the need for more services.
Children who fall near the cutoffs are either sent for diagnostic testing or are monitored closely. Parent concerns are followed up on. Children who are not near the cutoffs are also monitored. In some programs (e.g., Early Head Start), children may also be assessed with a curriculum-based assessment tool to determine potential goals.
Eligible
Not Eligible
ASQ-3™ and ASQ:SE Training Materials by Jane Squires, Jane Farrell, Jantina Clifford, Suzanne Yockelson, and Elizabeth Twombly
Copyright © 2010 Paul H. Brookes Publishing Co. All rights reserved. stages.com

66. Why Screen Social-Emotional Development?
In the US Part C of IDEA calls for the social-emotional area to be assessed and services provided if necessary Programs such as Head Start mandate that this area be addressed in their performance standards Links to early social emotional behaviors and subsequent outcomes In Ontario we don’t have a “Part C” so what happens will vary across the Province
ASQ-3™ and ASQ:SE Training Materials by Jane Squires, Jane Farrell, Jantina Clifford, Suzanne Yockelson, and Elizabeth Twombly
Copyright © 2010 Paul H. Brookes Publishing Co. All rights reserved. stages.com

67. Why Screen Social-Emotional Development?
Links exist between earliest emotional development and later social behavior (Cicchetti & Cohen, 1995a, 1995b; Reynolds, Temple, Robertson, & Mann, 2001) Behaviors, even in infancy, signal the need for intervention (Shonkoff & Phillips, 2000) Links exist between early risk factors, poor outcomes, and violence (Conroy & Brown, 2004) By 3rd grade, programs for children with antisocial behavior are mostly ineffective (Greenberg et al., 2003; Walker, 2004)
Cicchetti, D., Cohen, D. (1995).  Developmental psychopathology.  Vol. 1:  Theory and method and, Volume 2: Risk, disorder, and adaptation.  New York: Wiley.
Conroy, Maureen A; Brown, William H. Early Identification, Prevention, and Early Intervention with Young Children At Risk for Emotional or Behavioral Disorders: Issues, Trends, and a Call for Action. [References]. [Journal; Peer Reviewed Journal] Behavioral Disorders. Vol 29(3) May 2004,
Greenberg, Mark T; Weissberg, Roger P; O'Brien, Mary Utne; Zins, Joseph E; Fredericks, Linda; Resnik, Hank; Elias, Maurice J. Enhancing school-based prevention and youth development through coordinated social, emotional, and academic learning. [References]. [Journal; Peer Reviewed Journal] American Psychologist. Vol 58(6-7) Jun-Jul 2003,
Reynolds, Arthur J; Temple, Judy A,; Robertson, Dylan L; Mann, Emily A. Long-term effects of an early childhood intervention on educational achievement and juvenile arrest: A 15-year follow-up of low-income children in public schools. [References]. [Journal; Peer Reviewed Journal] JAMA: Journal of the American Medical Association. Vol 285(18) May 2001,
Walker, Hill M. Commentary: Use of Evidence-Based Intervention in Schools: Where We've Been, Where We Are, and Where We Need to Go. [References]. [Journal; Peer Reviewed Journal] School Psychology Review. Vol 33(3) 2004,
ASQ-3™ and ASQ:SE Training Materials by Jane Squires, Jane Farrell, Jantina Clifford, Suzanne Yockelson, and Elizabeth Twombly
Copyright © 2010 Paul H. Brookes Publishing Co. All rights reserved. stages.com

68. ASQ-3

69. Ages and Stages – 3 Questionnaire

70. ASQ:SE

71. Ages and Stages: Social-Emotional Questionnaire

72. Developmental Program Plans

75. Connections Count
You can’t be all things to all children and their families – so who else can step in? Have your school update their list of resources – there may be new programs that you are not aware of. Connect to programs such as ECE who may be able to provide students who can provide some developmental guidance to some children.

76. When Intervening Do it Early and Generously
As mentioned early intervention is paramount if you want to have an impact that will change a child’s developmental trajectory Provide interventions and supports generously. Parenting is hard for most of us. For those struggling, the support they may need to make the changes the child needs may require significant supports – early is best and be generous if you are serious

77. Look at Your Agency
Does your agency have best practice guidelines in place specific to infants and toddlers?

78. Educate! Educate! Educate!
IMHP will be creating a brief that will be available to agencies and will provide salient points to share with Judges and others.
Other training resources will also be developed
Including:
Training curricula and modules for Child Welfare
Developmental Program Planning Worksheets
Temperament training and resources
Infant Mental Health Resources