safe start early childhood mental health services

Safe StartEarly Childhood Mental Health

ServicesPartnering with the Child Welfare System

Lisa Blunt, MS, LMHPChief Operating Officer Child Saving Institute

Barbara Jessing, MS, LIMHPClinical Director Heartland Family Service

Babies and toddlers, even before they can speak, can show us, through their

interactions with others and their emotions, that they are struggling and need help.  We

have to learn to be better observers and more knowledgeable about ways to identify

them and provide them with the services they need. 

Child-Centered Practices for the Courtroom and Community: A Guide to Working Effectively with Young Children and Their Families in the Child Welfare System (Katz,

Lederman and Osofsky

How do we bring learning about early attachment into every decision made in the child welfare system?How do we bring the voice and the perspective of young and vulnerable children into the child welfare system?

Welcome!What is your role?Where are you from?Any questions you bring?

Attachment Informed Decisions

Every decision made in the child welfare system should be made through the lens of attachment

Does this decision SUPPORT healthy attachment of this child?Does this decision SUPPORT timely permanency for this child? Timing of services is critical.

Presentation OverviewClinical assessment of the parent child relationship -- birth to five yearsInterventions

Safe Start AssessmentChild-Parent Psychotherapy Family Support

Lessons learned in partnering with the Child Welfare System

Infants and Toddlers in Foster Care

Separated suddenly and often traumatically from parentPrior history often includes trauma, stress, deprivationDisrupted placements

Trauma Before and Trauma After Placement

Trauma exposure leading to removalInconsistent caregiving in placement

Disrupted foster care placementsRespite CareChild Care ChangesCase Manager turnover

Cumulative negative developmental impact

Goals of Child Welfare System

SAFETY

PERMANENCYWELL BEING

SAFE STARTProgram Goals

To bring the voice and perspective of the young child into the child welfare systemTo strengthen and repair the parent-child bond;To promote the child’s social and emotional development;To minimize harmful developmental consequences of disruptions in care giving because of abuse or neglect.

SAFE STARTEarly Childhood Mental

Health Services

Parent-Child Relationship AssessmentChild- Parent Psychotherapy

Family Preservation and Family Support Services

History of Safe Start Project in Nebraska

2005: Douglas County, NE and Zero to Three “Safe Babies” Court Team initiated2006: Child Saving Institute and Heartland Family Service partnership with Family Drug Treatment Court/Nebraska Department of Health and Human Services2009-11: Interface with Child Welfare Reform in Nebraska

New Source of FundingSAMHSA Grant Awarded 2010Grantee: Nebraska Supreme Court, Office of Problem Solving Courts; Nebraska Court Improvement ProjectEligible participants are clients in Douglas County Juvenile Court Drug Court/Family Drug CourtParticipating Provider Agencies:

Child Saving InstituteHeartland Family ServiceLutheran Family Services

Parent-Child Relationship Assessment

A structured, observation-based, multi session assessment of the relationship between parent and childModel developed by Joy Osofsky, PhD and colleagues; Louisiana expert in child exposure to violenceBased on the “Prevent” Assessment model used in the Miami Safe Start Initiative

Assessment Components

Initial interview of parent or parents for personal, family, and child historyRecord ReviewStructured observation of parent #1 and childStructured Observation of parent #2, foster parent, or other caregiver and childAges and Stages Questionnaire: Developmental observation and evaluation of child with parent or other caregiver

Observation sessions are videotaped Interactions are objectively rated according to specific dimensions of parent child relationship and interaction

Parent InterviewPsychosocial interview Adult attachment interview and relevance of parent’s early experience to present relationship with childGoal: Insight into parent’s mental representation of child and internal experience of being a parent.

Record Review: Child and Parent History

Highly relevant to getting a complete picture of parent’s current functioningUnderstanding “what happened to you” vs “what’s wrong with you?”

Observations through one way mirror

Parent directs assigned tasks with prompts from therapist by phone:

Free playBubblesClean up and transition to new activitySeveral brief interactions around developmentally appropriate toys of increasing challengeBrief separation (or withdrawal of parent’s face for infant) and reunification of parent from child

Therapist ratings are based on these observations

Inclusion of Both Parents and Other Caregivers

Reason for referral may relate to abilities of one or both parentsIf both parents are involved in permanency plan, observations are done with both Observation of other significant caregivers such as foster parent or grandparent is also productiveAssessment documents strengths as well as problems; shows child’s relationships with various caregivers

Parent Child Relationship ScalesJoy Osofsky, PhD

Objective ratings of parent child interactionUsed to develop treatment targetsUsed as measure of outcome of therapy or other recommended interventions

Parent Observations Rated

Positive AffectWithdrawn/ DepressedIrritability/Anger/ HostilityIntrusiveness

Behavioral ResponsivenessEmotional ResponsivenessPositive Discipline Separation and Reunion

Child Observations Rated

Positive AffectWithdrawn/ DepressedAnxious/FearfulAnger/Hostility/ Irritability Non-Compliance Toward Parental Instruction

Aggression Toward Parent EnthusiasmPersistence with Task Reunion: Emotional and Behavioral Responsiveness

Developmental and Behavioral Status

Achenbach Child Behavior Checklist

CBCL Ages 1 ½ or older

Ages and StagesASQ 3 (2 months and up)ASQ SE (Social and Emotional Development)

How can the parent transition the child from one task to another?How does the child respond to a parent’s directive?“Bubbles” are a great measure of how much joy and pleasure there is in this relationship

Max, Age 3Bubbles and Clean Up

How enthusiastic is the child?How persistent is the child, faced with a difficult task?How does the parent respond to child frustration?

EmotionalBehavioral

A Challenging Task:Madison, Age 5

How does the parent prepare the child?How does the child respond?How does the child cope?

Separation and Reunion:Max, age 3

How does the child respond to the withdrawal of parent attention?How energetic and emotional is the child’s reaction?What is the emotional tone of the reunion?

Addie, 7 months“Still Face”

Assessment Report and Recommendations

Report is KEY COMMUNICATIONTo Judge, Case Manager, and ProviderTo Parents

Summary of presenting issue and results/recommendations

Relational treatment needs: how to build on the strengths in the parent child relationshipwhat specific issues are to be addressed in the dyadic therapy, if recommended

Developmental intervention needs      

Follow Up Options

Child Parent PsychotherapyOther referrals as appropriate for therapy, parent education and support

Parent Support and Education ProgramsFamily SupportSubstance Abuse or Mental Health

Treatment

Child –Parent PsychotherapyAlicia Lieberman and Patricia Van Horn

26 week course of dyadic therapyPromote and strengthen a close, safe, and nurturing relationship between parent and childObservation, guidance, and coaching of the parentDeals with parent’s unresolved early abuse or trauma which interferes in the presentPromotes adjustment/attachment as child transitions from foster care to homeOne hour weekly, in office

CPP TechniquesBehavior-based interventionsParent support and coachingInteractive parent-child playVerbal interpretation of transactions between parent and child.

Parent View of CPP

Treatment Outcomes

Improved parent-child relationshipProgress toward permanency goalsImprovement in child developmental statusReduction of abuse/neglect

Family SupportFamily Support Specialist integral member of treatment teamOpportunity to reinforces generalization of skills gained in CPP Observations inform CPP process

Lessons Learned …

Challenges with the Child Welfare System

Mandated parent treatmentLack of clarity of clinician roleScope and limits of confidentialityDifferent perceptions of best interests“The contagion of dysfunctionality”

Alicia Lieberman and Patricia Van Horn

Our Challenges

Massive changes in the child welfare system co-occurred with our efforts to implementChanges in administration, workers, foster parentsGroundhog Day: constantly restating our caseLike trying to fill a bucket with a hole in it

Lessons Learned with Child Welfare

“Parallel Process”System under high stress: “trauma contagion”As children and families struggle to survive – so does the system; so does the worker

However…The same skills that help us with traumatized and attachment-disrupted children and parents.... Help us deal with a traumatized system

Key IngredientsPatienceTrustPsycho-education on the impact of trauma (including trauma contagion)Relationship buildingGood self care and community with like minded colleagues

PositivesKey Judges have been supportiveZero to Three support for family drug courtModel Court initiated new program development

Systemic training of court personnel across the state

“Critical Mass” is buildingBrain development and science foundation

Evaluation findings for the ZERO TO THREE Safe Babies Court Team

ProjectChildren participating in court teams leave foster care three times as fast as the comparison sample….Reunification is most common for Court Team Babies (38%) whereas adoption is most common for comparison group (41%)

“Moving Young Children From Foster Care to Permanent Homes”. Kimberly McCombs-Thornton; Zero to Three Journal;

May 2012, Volume 32, Number 5

Key Factors In SuccessJudicial LeadershipRegular Court Team Staffings (cases reviewed at least monthly)

Thanks !To Dr. Joy Osofsky for teaching and mentoring us through this processTo the families we learn from To the volunteer parents and children who agreed to be videotaped

Presenter InformationLisa Blunt, MS, LMHP

Chief Operating OfficerChild Saving Institutelblunt@chlldsaving.org402-553-6000

Barbara Jessing, MS, LIMHP

Clinical DirectorHeartland Family Servicebjessing@heartlandfamilyservice.org402-553-3000