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Editing and Additions byDebbie Spaeth, LMFT, LPC, LADC - SupervisorQuest MHSA, LLC
The Impact of Infant & Early Childhood Mental
HealthA Presentation by OKAIMH
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
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).
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!
Social, emotional, and cognitive impairment
Attachment DisruptionsAttachment Disruptions
MistrustMistrust
Self-WorthSelf-Worth
Infant/early childhood depressionInfant/early childhood depression
No internal controlNo internal control
Emotion regulation problemsEmotion regulation problems
Decreased exploration/engagementDecreased exploration/engagement
Learning DisabilitiesLearning Disabilities
InfantMentalHealth
AttachmentEcological
Theory/Cultural Perspective
Psycho-dynamics
Theoretical Foundations
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
Attachment
Child gives signals when in needChild gives signals when in need
Parent is sensitive to cues & responds appropriatelyParent is sensitive to cues & responds appropriately
“I will help you when you need it”
“I will help you when you need it”
“I will tell you when I need help”
“I will tell you when I need help”
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
Ecological Theory
There is CONTEXT for everything
Recognizes larger forces at work in influencing behavior
Different levels of context interaction
Policies, Procedures, Regulations
Community
Neighborhood
Culture
Family
Parent & Child
Cultu
re
Cultu
re Culture
Culture
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
Best Practices in Infant Mental Health Are:
InterdisciplinaryRelationship -
BasedStrengths-
Based
Child Focused & Family
CenteredIndividualized
Continuous & Consistent
Best Practices in Infant Mental Health Are:
Community-Based
Accessible Comprehensive
CoordinatedIntegratedCulturally
Responsive
Continually Improving
Reflective
How you are is more important than what you do.
~ Jeree Pawl
What Can we Do?Understanding and
Speaking
the Language
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
How to speak the language
Behaviors
Crying Tantrums Aggression Sleep Toileting Eating
Translations
Trauma Relationship Disruption
Safety Domestic Violence
Substance Abuse
Therapeutic Interventions
Observation &
Assessment
Concrete Support Services
Supportive Counseling
Relationship –Based
Developmental Guidance
Problem SolvingBrief Crisis
Intervention
Psychotherapy•Parent-Infant•Parent Focused•Child/Filial •Play Therapy
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
OpenCuriousReflective
IMH Case Discussion
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.
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?
The growth of regulation is the cornerstone and foundation that cuts across all
parts of development.
Emotion Regulation
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
Theo and the sweetie -http://youtu.be/TZYIJDtt3mU
The Effects of Neglect and a Non-Stimulating Environment on a Child
Learning Disabilities
Back to School: Back to School 1 hr
Listen when you have the time.
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
Physiological RegulationMutual 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
Myth: Infants and young children can’t speak so they won’t remember
Trauma
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?
Infants store memory
within the first weeks
of lifeInfants & Memory
Our Primitive Brain
We are hard wired with a fight or flight responseOur 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
What does it look like?
What do we see? How do
we know?Trauma In Infancy
EyesFacial expressionTone of voiceVerbalization rhythm & ratePosture
GesturesBody MovementTiming
(Coordination)IntensityModulation
Nonverbal Cues: Sensory Information
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
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
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
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
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?
Child Parent Psychotherapy
Evidence Based Practice Model
Where have we been? Where are we going?
Goals of CPP
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
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
The foundation
Safety firstPhysical safety
Safe shelterFoodProtective orders
Psychological safetyMaladaptive strategies: substance abuseAffect regulation Issues of limits and discipline
SAFETY
RAPPORT
RELATIONSHIPS
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
SAFETY
RAPPORT
RELATIONSHIPS
AFFE
CT R
EG
ULA
TIO
N
EN
CO
UR
AG
E N
OR
MA
L DEV
ELO
PM
EN
T
UN
DER
STA
ND
BE
HA
VIO
R
REC
IPR
OC
ITY IN
RELA
TIO
NSH
IPS
TR
US
T IN
BO
DILY
SEN
SA
TIO
NS
Treatment Planning
Early trauma treatment goals:Coping strategies to help with symptomsCoping strategies to help with reminders
Later in treatment:Mind-body connection – Understanding the meaning of behaviors
Construction of narrativeIncreased flexibility and trust in relationships
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.
Core Interventions in CPP
Concrete assistance with problems of daily living.
Modeling protective behaviorUnstructured developmental guidanceEmotional supportInterpretation – Linking past & presentGhosts and angelsConstructing the trauma narrativeReflective support/supervision
SAFETY
RAPPORT
RELATIONSHIPS
AFF
EC
T R
EG
ULA
TIO
N
EN
CO
UR
AG
E N
OR
MA
L DEV
ELO
PM
EN
T
UN
DER
STA
ND
BEH
AV
IOR
REC
IPR
OC
ITY IN
RELA
TIO
NSH
IPS
TR
UST IN
BO
DILY
SEN
SA
TIO
NS
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___________________________________________________________
“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
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.
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.
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.
“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
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
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
Child-Parent Psychotherapy
Treatment ModalitiesDevelopmental guidance – education integrated with psychotherapeutic workGuidance 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
Child-Parent Psychotherapy
Treatment modalitiesPsychotherapeutic 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
Resilience Factors
Positive relationship with at least one parentPositive relationships with other adultsAt least one safe haven in the communityRutter, 1993
Impact of Trauma on Parent-Child Relationship
Loss of sense of securityChanges parent and child’s view of each
otherVictim PersecutorNon-helpful bystander
Traumatic remindersTraumatic expectations
Changes in Parent-Child Relationship after Trauma
Impaired affect regulationEither partner may develop new negative
attributions based on trauma experienceChanges to internal working modelsTraumatic expectations
Parent and child may serve as traumatic reminders for one another
Pynoos,1997
strengths based culturally competent
Assessment
Child FunctioningPre-traumaPost-trauma
Caregiving SystemEcology
Assessment
Policies, Procedures, Regulations
Community
Neighborhood
Culture
Family
Parent & Child
Treatment Planning
Safety firstPhysical safety
Safe shelterFoodProtective orders
Psychological safetyMaladaptive strategies: substance abuseAffect regulation Issues of limits and discipline
Treatment Planning
Early trauma treatment goalsCoping strategies to help with symptomsCoping strategies to help with reminders
Later in treatmentMind-body connectionConstruction of narrativeIncreased flexibility and trust in relationships
“Do unto others as you would have others do unto others.” Jeree Pawl(1998)
Reflective Practice
“Don’t just do something. Sit there.”~Jeree Pawl
Reflective Practice
REFLECT ON:
Process of treatment Process of individual sessionsTherapist’s role with the dyadEmotional responses that dyad arouses
MUST CONSIDER:Agency’s contribution of reflective space and clinician’s willingness to engage in supervision
Self Reflection
A trusting relationship between supervisor and practitionerConsistent and predictableEncourages details about the infant, parent and emerging
relationship Is a listening environment in which participants remain
emotionally presentSupervisors teach/guide and provide nurturance/support
Reflective Supervision
Focuses on integration of emotion and reasonFosters the reflective process to be internalized by the
superviseeExplores the parallel process and to allow time for personal
reflectionAttends to how reactions to the content affect the process
Best Practice Guidelines for Reflective Supervision/Consultation (OK-AIMH, www.okaimh.org)
Reflective Supervision
www.nctsn.orgwww.zerotothree.orgwww.okaimh.org
Don't Hit My Mommy!: A Manual for Child-Parent Psychotherapy with Young Witnesses of Family Violence (Lieberman, VanHorn, 2005)
Psychotherapy with Infants and Young Children: Repairing the Effects of Stress and Trauma on Early Attachment (Lieberman, VanHorn, 2011)
CPP portions of this presentation adapted from Lieberman/Van Horn CPP Training Manual for the National Child Traumatic Stress Network.
Resources/Readings