Infant Mental Health

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Infant Mental Health Relationship-based
practice

• 2006 Institute Infant Toddler Specialists of
  Indiana (August 25, 2006)
• Jon Korfmacher, Ph.D.
• Erikson Institute (Chicago IL)
• Illinois Association for Infant Mental Health

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Workshop Objectives

• Participants will take away
• Guiding principles and best practices of infant
  mental health
• Three theoretical perspectives in IMH practice
• Red flags and behavioral concerns
• Awareness of IMH interventions and strategies
• Ways to integrate IMH principles into programs

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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).

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However...

• Infant Mental Health must also recognize the
  Dark Side
• Suffering
• Rigidity
• Emde Features define absence of mental health
• Infant Mental Health practice caught in a tension
• Strength-based/Positive development
• Working with families with clinical challenges

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Infant Mental Health Is Important Because

• Development in other domains organized by social
  and emotional development of child
• Infants development begins and continues within
  context of primary relationships
• The sooner the better

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Guiding Principles

• 1. Babies and parents are social creaturesIts
  all about relationships
• 2. Birth to three critical for brain growth and
  formation of personality and sense of self
• 3. Everyone lives in an environmental context
  that affects functioning

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Guiding Principles

• 4. Pregnancy, Birth, and early childhood are
  times when past, present, and future intersect in
  unexpected ways
• 5. Understanding the feelings behind the
  behaviors is important to assessment and
  treatment

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Best Practices in Infant Mental Health Are

• Interdisciplinary
• Relationship-based
• Strengths-based (without ignoring problems)
• Child focused and family centered
• Individualized (not prescriptive)
• Continuous and consistent

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Best Practices in Infant Mental Health Are

• Community-based
• Accessible
• Comprehensive, coordinated, and integrated
• Culturally responsive
• Committed to continuous improvement and
  reflective supervision

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Infant Mental Health Practice Is NOT
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Theoretical Models

• Attachment theory
• Psychodynamic theory
• Ecological/cultural perspective

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1. Attachment Theory

• The lasting and deep emotional relationship
  between child and caregivers
• Begins to develop in infancy
• Focused on sense of security as child begins to
  explore environment

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Attachment
I will help you when you need it
Child gives signals when in need
I will go to you when I need help
Parent is sensitive to cues responds
appropriately
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Functions of Attachment

• Learn basic trust
• Exploration of environment with confidence and
  security
• Self-regulation and management of emotions
• Develop Internal working model of relationships
• Identity formation, sense of self-esteem
• Protective factor against stress and trauma

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2. Psychodynamic Theory

• Ghosts in the Nursery
• Ways of relating to others internalized at an
  early age
• Something occuring in present evokes early
  patterns of relating
• Unconsciously act in the ways we internalized

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Psychodynamic Theory

• Recognizes unconscious motivations
• Recognizes that past is always with us
• Coming to terms with past can improve present
  functioning, including parenting
• Goes back to Guiding Principles

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3. Ecological Theory

• Context, context, context
• Recognizes larger forces at work in influencing
  behavior
• Different levels of context interact

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It takes a village
Policies, Procedures, Regulations
Neighborhood
Community
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Red Flags For IMH Services

• Difficult/unwanted/unplanned pregnancy
• Perinatal depression
• Newborns with feeding, sleeping, regulation
  problems
• Families who have children with special needs

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Red Flags, continued

• Families with few resources or social supports
• Children with social or emotional delays
• Children with possible attachment disorders
• Families with one or more of the Big Three
• Mental Health
• Substance Abuse
• Domestic Violence

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Common Behavioral Concerns

• Crying
• Tantrums
• Sleep
• Toileting
• Eating

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Therapeutic Interventions

• Observation and Assessment
• Concrete support services
• Supportive counseling
• Developmental guidance
• Parent-child interaction guidance

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Therapeutic Interventions

• Problem solving
• Brief crisis intervention
• Psychotherapy
• Parent-infant
• Parent-focused
• Child play therapy (older toddlers)

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Strategies Used By IMH Specialists

• Building relationships and using them as
  instruments of change.
• Meeting with the infant and parent together
  throughout the period of intervention.
• Sharing in the observation of the infants growth
  and development.

Deborah Weatherston, The Infant Mental Health
Specialist, 0-3 Oct/Nov. 2000.
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Strategies, continued

• Offering anticipatory guidance to the parent that
  is specific to the infant.
• Alerting the parent to the infants individual
  accomplishments and needs.
• Helping the parent to find pleasure in the
  relationship with the infant

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Strategies, continued

• Creating opportunities for interaction and
  exchange between parent(s) and infant or
  parent(s) and clinician
• Allowing the parent to take the lead in
  interacting with the infant or determining the
  agendaor topic for discussion.
• Identifying and enhancing the capacities that
  each parent brings to the care of the infant.

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Strategies, continued

• Wondering about the parents thoughts and
  feelings related to the presence and care of the
  infant and the changing responsibilities of
  parenthood.
• Wondering about the infants experiences in the
  present, inquiring and talking.
• Allowing for core relational conflicts and
  emotions to be expressed by the parent holding,
  containing, and talking about them as the parent
  is able.

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Strategies, continued

• Attending and responding to parental histories of
  abandonment, separation, and unresolved loss as
  they affect the care of the infant, the infants
  development and the parents emotional health and
  the early developing relationship.
• Attending and responding to the infants history
  of early care within the developing parent-infant
  relationship.

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Strategies, continued

• Identifying, treating and/or collaborating with
  others if needed , in the treatment of disorders
  of infancy, delays and disabilities, parental
  mental illness and family dysfunction.
• Remaining open, curious, and reflective.

Deborah Weatherston, The Infant Mental Health
Specialist, 0-3 Oct/Nov. 2000.
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Integrating IMH Into Your Program

• Training
• Reflective supervision
• Screening
• Consultation

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Integrating IMH Into Your Program

• Parent involvement
• Parent groups
• Home visiting

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Integrating IMH Into Your Program

• Collaboration
• Community involvement
• Advocacy

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Case 1
Jacob was average in size and weight for a ten
month old.  He was not yet sitting up and rarely
moved from the spot on which his mother laid him
as she joined the playgroup with her two and a
half and three and a half year old sons.  Jacob
frequently remained in the same position for
close to the hour of the group.  Attempts to
engage him with a toy or a smile were
unsuccessful.  He maintained a somewhat glazed,
detached look. Since he never cried, his mother
thought that he was an easy baby and busied
herself with her more active toddlers.  While
other nine and ten months olds would crawl past
him, Jacob seems to stare and remained motionless.
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Case 2
At age two and a half, Adam seemed to love
playing with trucks-as long as he could play
alone and repetitively.  He especially liked to
line the trucks up in a straight line.  He wasn't
talking yet and his parents were concerned. 
Whenever his father tries to play with him, Adam
turned away.  Adam/s father reacted by forcing
his was into Adam's play.  He would build bridges
and tunnels for Adam's cars and he would direct
Adam to drive his truck to a particular point. 
 The harder his father tried, the more Adam shut
him out.  When verbal demands failed, Adam's
father tried to engage physically with bear hugs
and tickles.  This seemed to only agitate Adam
more until his father gave up.  At that point,
Adam would return to his solitary, repetitive
play.  
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Case 3
Amanda was adopted from Paraguay when she was six
months old.  An attractive child at two and a
half, Amanda had little or no language and seldom
interacted with other children or adults. Her
mother brought her to a mom-tot program where she
would find one or two familiar toys and play
alone.  Amanda's mother was a loud woman who
would frequently insert herself uninvited in
other people's conversations.  She also referred
to Amanda's adoption in Amanda's presence and
explained that she was extremely shy and even
slow.  Her attempts to get Amanda to talk by
starting her sentences only caused Amanda to
withdraw more.
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Case 4
Brians parents found Brian difficult to manage. 
At fifteen months, he exhibited enormous energy. 
He would move from toy to toy but never really
with genuine interest or sustained play.  He
would never allow time to closely inspect a toy
and was easily distracted.  Almost in a state of
constant movement, his face often had a worried
expression.  He would point to an object that he
wanted and, once his parents targeted the right
object, he would be pointing to another object. 
Brian was easily startled by loud sounds.  His
parents felt that he was spoiled and a "bad" boy.
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Case 5
Anna was four years old when her parents raised
concern about her defiant attitude and aggressive
tendencies.  She was always invading her
two-year-old sisters space and initiating
conflict.  Although, at time, Anna could be a
sweet and caring child, her preschool teachers
were also expressing concern about her increasing
aggressive play.  Anna's parents had married late
and, to their surprise and great regret, were
unable to have their own biological children.
Both of their children were born with the help of
donor eggs, but they had never processed this
event.  Now, with their four-year-old causing
concern, as well as difficulty, they felt stuck.  
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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?