Introduction to Early Childhood Mental Health Kathryn Seidler, LMSW Easter Seals Blake Foundation Tucson, AZ

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Introduction to Early Childhood Mental
HealthKathryn Seidler, LMSW Easter Seals Blake
FoundationTucson, AZ
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• A baby alone does not exist. A baby can be
  understood only as part of a relationship.
• D.W. Winnicott

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Definition of Infant Mental Health.

• Developing the capacity of the child from birth
  to age three to experience, regulate, and express
  emotions form close and secure interpersonal
  relationships and explore the environment and
  learn - all in the context of family, community
  and cultural expectations.Zero to Three IMH Task
  Force

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CORE CONCEPTS OF EARLY CHILDHOOD MENTAL HEALTH

• 1. Mental health needs of the 0-6 age population
  challenge and defy our conventional,
  individual-based thinking about providing therapy

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2. Early Childhood Mental Health is FIRST
and FOREMOST about RELATIONSHIPS
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3. We cannot conceive or consider infants and
toddlers outside of the relationships they have
with their primary caregivers.
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4. Object Relations Theory (Mahler)

• Proposes that an internalization of the caregiver
  occurs within the childs psyche as a mental
  representation about self and caregiver, based on
  the relationship and interactions that occur.

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5. Development

• Early childhood mental health is understood as a
  model that is developmental

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Periods of Development
Early Childhood 2-6 yrs
Prenatal conception to birth
Infancy Toddlerhood birth to 2 yrs
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5. Development (cont)

• Is sequential
• occurs in different areas
• Is individual
• Is inter-related
• Moves from simple to complex

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5. Development (cont)

• Sensitive Periods between birth and age 5
  children rapidly develop foundational
  capabilities upon which subsequent development
  develops
• Influenced by biological, environmental and
  interpersonal sources of resiliency and
  vulnerability Nature vs Nurture

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5. Development (cont)

• Research tells us there is a connection between a
  childs early experiences, life-long health and
  well being established through the development of
  brain structure in the early years

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Growing a Healthy Brain

• Nurturing experiences.
• Good nutrition.
• Intervening early.
• Protection.
• Taking care of the caregiver.

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Pre-natal Development
The nervous system begins to develop just before
the third week of gestation. Cell creation and
movement to the right spots occur during the
first five prenatal months. Talking Reasonably
and Responsibly about Early Brain Development,
University of Minnesota
(Eliot, 1999)
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Nurture Affects Brain Development

• Nurturing touch promotes growth and alertness in
  babies.
• Presence of a secure attachment protects toddlers
  from biochemical effects of stress.
• Abused children pay more attention to angry faces
  a reflection of the brains response.

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5. Development (cont.)

• Failure to provide appropriate stimulation,
  consistent responsive care and opportunities to
  explore their environment may cause a failure in
  the development of neural connections and
  pathways that facilitate essential learning and
  self-regulating skills

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5. Development (cont.)

• Exposure to trauma, neglect or severe stress is
  damaging to the developing brain and may result
  in learning disabilities, emotional, and
  behavioral problems

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5. Development (cont.)

• Three Tasks of Early Childhood
• 1. Emotional Development - negotiating
  transition from external to internal
  self-regulation
• from birth infants must learn to regulate
  physiological and emotional functions
• emotion, behavior, and attention are highly
  linked, therefore success in one area can lead to
  success in another and difficulty in one can lead
  to difficulty in another

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5. Development (cont.)

• 1. Emotional Development (cont.)
• A childs ability to regulate is deeply embedded
  in his relationships with others
• In dysfunctional homes, emotional demands on the
  infant can be confusing, conflicting and
  overwhelming

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5. Development (cont.)

• 2. Cognitive Development - acquiring capabilities
  that are the foundation for communication and
  learning
• babies are wired to learn
• society and parents need to be ready for the
  competencies with which the child arrives

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5. Development (cont.)

• 2. Cognitive Development
• thinking, social interactions, relationships and
  emotions converge in a powerful way during the
  second year of life
• Quality and quantity of verbal and social
  stimulation that a child receives will determine
  the language learning process

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5. Development (cont.)

• 3. Social Development - learning to relate well
  to other children and forming relationships
• secure attachments to caring adults during
  infancy and toddler years lay the foundation for
  social relationships
• a childs evolving cognitive, language, and
  emotional regulations skills play a role
  throughout social skill and relationship building

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5. Development (cont.)

• Social Development (cont.)
• having positive relationship skills has been
  found to be a predictor of popularity with peers
  during the preschool years (Sroufe 1983, 1990)
• infants who exhibit ambivalent attachments may
  develop into unhappy, easily frustrated toddlers
  and preschoolers (Erikson, Sroufe Egeland,
  1985 Renken et al., 1989)

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5. Development (cont.)

• Social Development (cont.)
• Children who are socially competent at the
  toddler or preschool age have parents who
  actively help them learn to play
• those who appear socially inept often have
  parents who view social competence as a function
  of the school system and devalue the importance
  of social skills

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6. Parallel Process

• Most parents referred or who seek out infant
  mental health services have some degree of
  developmental trauma of their own
• A relationship between the worker/therapist and
  the parent develops first

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6. Parallel Process (cont.)

• the actions and behavior of the worker toward the
  parent are geared to acknowledge the unmet
  developmental needs of the parent
• This behavior attempts to created a holding
  environment where the parent may experience a
  repair and healing of their own unmet
  developmental needs.

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6. Parallel Process (cont.)

• The goal is for the parent to learn how to create
  this holding environment for their own child
• Another goal is for the developmental trauma of
  the parent to not repeat itself in the
  parent/child relationship

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A relationship between a parent and IMH
specialist can be therapeutic or healing even
though the reason for the relationship is the
needs of the child, family support, early
intervention or educational needs.
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How do we foster relationships through
relationships?

• Corrective Emotional Experiences!!!
• Fostering the idea of the parents self in
  relationship with another
• (I am valued, respected, liked!!)

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How do we foster relationships through
relationships?

• Behavior Change - Now that I know whats good
  for my baby or child - Ill do more because I
  want to pleased or be liked by my home visitor
• Increased Reflective Function - Ability to think
  about anothers experience

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Emotional Availability

• Present and attending to other
• Processing others behavior
• Responding to others behavior
• Reflection
• Timing
• Intensity
• Affect

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7. Ghosts in the Nursery

• Selma Fraiberg
• the parents own internalized mental
  representations of their childhood, caregivers,
  and affective history
• good ghosts / bad ghosts

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8. Assessment

• Parent/Caregiver Interview
• Observation/assessment of parent child
  relationship and interaction
• Standardized Testing
• Address parents experience with their own
  caregivers Ghosts in the Nursery

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8. Assessment (cont.)

• Nurture parent so parent can nurture their child
• Link past experiences with current care of infant
• Interventions and continued assessment of
  progress

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Infant Mental Health Practice

• Promotion
• Prevention
• Treatment

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PROMOTION Supporting social-emotional health

• Home Based Programs
• Parent-Child Activities
• Enhancing parent-child social-emotional
  functioning through relationships
• Center Based Programs
• Continuity of care
• Primary caregiving
• Social-emotional assessments

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PREVENTIONAltering specific family risk
conditions, or child-parent risk behaviors

• Parent-child interaction guidance
• Parent support groups re discipline
• Home visits for depressed parents
• Social support to single parents
• Linking poor families with services

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TREATMENTProviding intervention for specific
disorder or problem

• Parent-infant psychotherapy
• Child play therapy
• Couples therapy (esp. w/ spousal violence)
• Family therapy
• Individual therapy
• Substance abuse treatment for parent

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IMH Service Delivery Venues

• Home visitation
• Family support
• Family preservation
• Early intervention
• Child care
• Foster care
• Parenting education

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The Home as a Therapeutic Setting

• S. Fraibergs Kitchen Therapy
• Family Turf
• Intimacy of home
• Potential of trust
• Assessment in larger context
• Flexibility
• Incorporation of family resources

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IMH Services in Home-Based
ProgramsRationale Targeting overburdened
families

• Importance of engaging multi-risk families during
  perinatal period
• Linkage between child maltreatment and adverse
  psychological outcomes
• Evidence re need for more intensive intervention
  to address mental health

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IMH Services in Home-Based Programs

• Strategies
• Providing social support as an antidote to
  psychological difficulties
• Addressing parental mental health needs through
  referral process
• Engaging in patient-child interactional
  activities to promote attachment
• Exploring parental ghosts as a means of
  addressing child maltreatment

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IMH Practice in Home-Based Settings
Parent-Infant Interactional Approach

• Incorporate parent-child interaction in each home
  visit
• Reflect on moment-to-moment parent-child
  interactions
• Identify teachable moments in context of
  parent-child interaction

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IMH Practice in Home-Based Settings
Intervention Process Strategies

• Increased directives of therapist versus insight
  work done in talk therapy
• Interactive guidance (coaching)
• Use of videotape

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Intervention Process Strategies (cont.)

• Moving beyond play
• Developmental guidance in the moment
• Unconditional Positive Regard (C. Rogers)
• Consistent nurturance/validation

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IMH Practice in Home-Based Settings Staff
Issues

• Intensive supervision of staff (1Hr/wk)
• Regular staff training
• Reflective group meetings and case presentations
  of managers and supervisors
• Use of videos in house visits and supervision
• Supervisory nurturance of staff

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Parent-Infant Mental Health Promoting Positive
Parenting

• Empathize with parental vulnerability around
  parenting
• Connect with parents desire to be a good parent
• Identify and reinforce positive parental
  behaviors

• Affirm parents special role and relationship
  with their child
• Help parents find JOY in caring for their child

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Parent -Infant Mental HealthSupporting the
Dance (D. Stern)

• Support parental emotional availability
• Encourage affective expression, understanding and
  sharing

• Promote parental attunement
• Build on joyful activities
• Enhance joint attention and involvement

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ATTACHMENT the orientation of an infant to the
person(s) who meets their biological, emotional,
and social needs
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BONDING the ability of a parent or caretaker to
make an emotional commitment to meet the infants
needs
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Mary Ainsworth

• Strange Situation technique has become the
  major measure by which infant attachment is
  determined at 12 and 18 months
• Mother and infant enter a toy play room, and
  during three-minute time periods the baby is
  first with mother, then with a stranger, then
  reunited with mother, then alone, then with a
  stranger, and finally again reunited with mother

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From careful analysis of the reunion behaviors of
the infant when the mother enters the room four
kinds of attachment patterns have been noted
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Ainsworths Attachment Classifications

• . Secure B
• Insecure
• Avoidant A
• Ambivalent C
• Disorganized D

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4 Attachment Classifications for children 0-36
months

• 1. Secure (B)
• - Infant uses parent as a secure base to explore
  environment and re-engages the parent upon
  reunion (separation/reunion task)

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• 2. Avoidant (A)
• - Infant does NOT use the parent as a secure
  base displays little affect
• explores the environment, but does not seek
  parent upon reunion
• -Under stress, infant does not seek out parent
  for contact-comfort to reduce stress.

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• 3. Ambivalent or Resistant (C)
• - Infant is in a state of distress and fails to
  explore the environment
• Infant will alternate between seeking contact
  with the parent and rejecting the parent
• Infant is under high states of stress on a
  continuous basis

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• 4. Disorganized (D) - Infant behavior lacks an
  observable goal, intention, or explanation in the
  presence of the parent.
• Infant exhibits interrupted movement,
  stereotypies (repetitive behaviors),
  freezing/smiling, falling, and odd postures upon
  reunion with the parent.
• no coherent strategy to re-engage the parent.
• Parent is considered, at times, to be frightening
  toward the infant, and parent frequently has a
  history of abuse of unresolved loss.

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Ainsworth (cont.)

• Mothers of the D babies are reported to often
  have a history of early trauma and loss in her
  own life

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4 Attachment Stages birth to 36 months

• 1. PRE-ATTACHMENT
• early orientation toward voice, smell, and
  self-regulation from major caregiver
• predictability and consistency to strengthen
  attachment relationship
• Initial development of the Arousal/Relaxation
  Cycle

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2. Recognition and Discrimination 3-8 months

• Comparison and discrimination skills develop
• stranger anxiety and Preference for Parent
  (PFP)
• Exploration of environment distance between
  infant and parent begins

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3. Active Engagement 8-30 Months

• Separation anxiety 7-9 months
• object permanence develops
• secure base behaviors 13 months
• toddler learns social rules (home, childcare,
  public)
• play skills develop

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4. Partnerships 30 months

• Emotional Object Constancy develops around 36
  months
• Attachment to adults solidify
• communication, bartering, and compromise between
  parent and child
• attachment gives emotional foundation to explore
  the world in greater depth

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Attachment Milestones and Behaviors

• Eye contact/social smile
• cuddle/molding
• reciprocity between infant/parent
• stranger anxiety 5-8 months

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Attachment Milestones and Behaviors

• separation anxiety 7-9 months
• secure base/safe haven 9 months
• Preference for parent 7 Internal Working Model
• Partnership 30

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Attachment Milestones and Behaviors (cont.)

• Following/searching
• reaching
• signaling/calling to
• holding/clinging/sitting with
• seeking to be picked up

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Salient Behaviors in the Assessment of Attachment
Dx

• BEHAVIOR
• Showing Affection
• Comfort Seeking

• SIGN OF ATTX DX
• lack of warm and affectionate interchanges across
  a range of interactions
• lack of discrimination showing affection to
  unfamiliar adults
• lack of comfort seeking when hurt, frightened, or
  ill, or seeking in ambivalent manner

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Salient Behaviors in the Assessment of Attachment
Dx

• BEHAVIOR
• reliance for help
• Cooperation

• SIGN OF ATTX DX
• excessive dependence, or inability to seek and
  use supportive presence of attachment figure when
  needed
• lack of compliance with caregiver requests and
  demands by the child as a striking feature of
  caregiver child interactions, or compulsive
  compliance

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Salient Behaviors in the Assessment of Attachment
Dx

• BEHAVIOR
• Exploratory Behavior
• Controlling Behavior

• SIGN OF ATTX DX
• failure to check back with caregiver in
  unfamiliar settings exploration limited by
  childs unwillingness to leave caregiver
• oversolicitious and inappropriate caregiving bx,
  or excessively bossy and punitive controlling of
  caregiver by the child

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Salient Behaviors in the Assessment of Attachment
Dx

• BEHAVIOR
• Reunion Responses

• SIGN OF ATTX DX
• failure to re-establish interaction after
  separations, including ignoring/avoiding
  behaviors, intense anger, or lack of affection

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Variables that can impact the attachment process
in a negative way

• 1. Postpartum emotional health of the mother
• 2. Prior mental health history, esp. in the areas
  of mood disorders
• 3. Lack of social support in the home
• 4. Unlimited emotional parenting skills by the
  parent

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Variables that can impact the attachment process
in a negative way

• 5. Infant developmental status (delays) and/or
  prematurity or medical problems
• 6. Changes in the parents relationship
• 7. Other losses experienced by the mother

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Theorists whose ideas help us understand IMH
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Eric Erikson

• Trust vs. Mistrust (0-12 mos.)
• Autonomy vs. Shame and Doubt (13-36 mos.)

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Margaret Mahler

• Details stages in infant emotional growth and
  development
• Infants move from a close physical relationship
  with the mother to a hatching period , tuning
  in to the outside world
• Practicing subphase, during which they count on
  the primary loved caregiver as a secure base as
  they explore their world

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Mahler (cont.)

• From age 1.5 to 3 years babies cognitive
  abilities permit them to think about and struggle
  to make sense of separation problems
• Baby yearns for a return to the closeness
  originally enjoyed, yet powerful urges compel
  baby in this rapprochement period to be a
  special, separate individual with wishes and
  desires all their own

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Mahler (cont.)

• A wise caregiver tunes into the need of baby to
  support their growing autonomy while still
  providing the nurturing responsivity and
  body-loving care that permit the toddler to
  develop beyond rapprochement into what is
  called CONSTANCY

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Mahler (cont.)

• The beginning of constancy occurs when the
  toddler can hold opposing emotional feelings (at
  the same time loving and feeling angry with the
  caregiver) in balance

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Mahler (cont.)

• Constancy helps child to support lengthy daily
  separations from parents who are both resented
  and loved
• Constancy helps toddlers come to terms with
  strong differences between their own and adult
  wishes and preferences
• Babies learn to integrate and accept dualities of
  feelings and still retain a clear sense of a
  loving relationship

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John Bowlby

• Father of attachment theory proposes that
  infants build nonverbal, internal working models
  of early relationships with each caregiver
• These models are unconscious, yet they serve as
  templates for expecting other close relationships
  later in life to be similar (depressed or happy,
  kind or cruel, orderly or chaotic)

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Bowlby (cont.)

• When the babys attachment figure is present
  emotionally for her, she can explore freely and
  the quality of her play will be more focused and
  creative
• When the attx. figure disappears or is rejecting,
  the quality of play suffers

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Alicia F. Lieberman

• Wrote The Emotional Life of the Toddler
• Quotes Freud Mental health consists of loving
  well and working well to remind us that
  childrens work is their play.
• Babies are by naturally social creatures

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Lieberman (cont.)

• Individual differences are an integral component
  of babies functioning
• Every individual exists in a particular
  environmental context that deeply affects the
  persons functioning

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Lieberman (cont.)

• Infant mental health practitioners make an effort
  to understand how behaviors feel from the inside,
  not how they look from the outside
• The intervenors own feelings and behaviors have
  a major impact on the intervention

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Temperament 2 Models

• Thomas and Chess (1977)
• Rothbart (1981)

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Goodness of Fit

• What happens when the babys temperament is not a
  good fit with their caregivers?

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Resources and Websites

• zerotothree.org
• arizonabond.org
• ITMHCA.org
• Handbook of Infant Mental Health, 2nd Ed.
  (Zeanah, 2005)
• Infant and Early Childhood Mental Health a
  Comprehensive, Developmental Approach to
  Assessment and Intervention (Greenspan and
  Wieder, 2005)