editing and additions by debbie spaeth, lmft, lpc, ladc - supervisor quest mhsa, llc the impact of...

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?

Putting it all together

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