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CHEEERS: A Deeper DiveDiving into trauma, attachment

and other depths

Kate Whitaker, MsEd IMH-E® (IV)Tracie Lansing, LMSW

Agenda CHEEERS: A Deeper Dive

∗ Connect CHEEERS to parent-child interactions & attachment milestones

∗ How to Document∗ Assess, Address & Promote∗ CHEEERS Potholes & Trends∗ Use of Reflective Strategies∗ Practice: Mona & Joey

Why CHEEERS Is So Important

∗ 60% - 80% of the parents we serve did not have nurturing relationships with their 1st person…

∗ Many have ACE scores of 4 or more∗ Many have no recollection of what

being nurtured is…∗ Many have lived in survival/brain stem

for most of their lives…∗ ALL have accepted HFA home visiting

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∗ It creates who we are and how we respond to the world –our Internal Working Model…

∗ Attachment styles are formed as early as 7 months, and can be assessed as early as 12 months.

∗ If we cannot have an impact on attachment, we are missing our primary goal!

The Power of Attachment

CHEEERS Defined

∗ CHEEERS is a simple framework for observing and determining the quality of parent-child interactions that ultimately result in the parent-child relationship.

∗ It is the home visitor’s guide to “assess, address and promote” nurturingparent-child relationships.

CuesHoldingExpressionEmpathyEnvironmentRhythmicity/ReciprocitySmiles

Resources: http://www.healthyfamiliesamerica.org/webinars/CHEEERS Helpful Prompts How to Develop Interventions Using CHEEERS Page 85 – Integrated Strategies for Home Visitors Training Manual

LeBonHeur Healthy Families

Additional CHEEERS Support

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Postnatal CHEEERS:How to document

∗ Relationships take two; there should be 3 parts for each CHEEERS component –what the baby does, how the parentresponds and frequency.

∗ CHEEERS can be used for any relationship – between parents and baby, grandparents and baby, and between parents.

∗ Document at least 1 example for all 7 Components for each visit as facts, rather than interpretations.

Prenatal CHEEERSDifferent than Postnatal CHEEERS?

∗ CHEEERS is documented prenatally beginning in the 2nd

trimester at 24 weeks gestation.

∗ Not all aspects of CHEEERS are required to be documented during the prenatal period. While there will be opportunities to observe all 7 domains prenatally, in general, the three E’s (Expression, Empathy andEnvironment) are most commonly observed.

∗ Frequency may not always be evident and is not requiredto be documented for prenatal CHEEERS.

AccreditationPostnatal CHEEERSAssess

6-3.B: Documentation of CHEEERS∗ A factual observation: “Home visitors assess positive

parent-child interaction, attachment, and bonding with all families, utilizing CHEEERS on all home visits.”

∗ All 7 domains of CHEEERS must be documented at each home visit.

∗ Different examples for each of 7 domains.∗ Postnatal CHEEERS must be documented every visit

UNLESS: Baby is not home or Baby is asleep

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Accreditation:Postnatal CHEEERSAddress & Promote

6-3.C: “Home visitors address and promote positive parent-child interaction, attachment, and bonding with all families based on CHEEERS observations.”Once CHEEERS domains have been documented, determine which of the 7 CHEEERS Domains need to be addressed.

∗ Circle each letter that could be strengthened∗ Then develop a Reflective Strategy to use to address the issue∗ Record this simply in the home visit note.∗ ATP = Promote; All other HFA Reflective Strategies = Address

CHEEERS Potholes & Trends

∗ All CHEEERS are positive∗ No sense of the flavor

of the visit∗ Only documented for 1 person

(relationships take 2)

∗ No way to identify which of the CHEEERS domains to address

∗ Limited use of Reflective Strategies (all ATP)

Examples of CHEEERS: Cues

1. Mom stated, “all these toys…. Look at this”. “You like that don’t you?” Mom read some cues when baby reached for a particular ring as evidenced by mom giving a toy that baby was reaching for. Mom had some eye contact as evidenced in play activity. Some of play had baby sit with back to mom while mom supported baby.

2. Baby looked up at dad. Dad smiled and hugged baby all of the visit.

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Examples of CHEEERS: Cues

1. Mom stated, “all these toys…. Look at this”. “You like that don’t you?” Mom read some cues when baby reached for a particular ring as evidenced by mom giving a toy that baby was reaching for. Mom had some eye contact as evidenced in play activity. Some of play had baby sit with back to mom while mom supported baby.

2. Baby looked up at dad. Dad smiled and hugged baby all of the visit.

Examples: Holding

1. Baby was held at arm’s length. As mom was holding baby in the air, baby turned her head away. This represented holding style for most of the visit.

2.Mom held baby during the visit.

Examples: Holding

1. Baby was held at arm’s length. As mom was holding baby in the air, baby turned her head away. This represented holding style for most of the visit.

2.Mom held baby during the visit.

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Examples: Expression

1. Mom talked to child most of the visit.

2. Child asked, “What is that?” when pointing at the ball. Mom said, “that’s a ball; a red ball.” Baby smiled. This represented language for most of the visit.

Examples: Expression

1. Mom talked to child most of the visit.

2. Child asked, “What is that?” when pointing at the ball. Mom said, “that’s a ball; a red ball.” Baby smiled. This represented language for most of the visit.

Empathy

1. Baby cried when he tripped over a toy. Dad said, “ you have to toughen up - you are OK”! Baby continued to cry. This represented half of the visit.

2. Not observed

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Empathy

1. Baby cried when he tripped over a toy. Dad said, “ you have to toughen up - you are OK”! Baby continued to cry. This represented half of the visit.

2. Not observed

Examples: Environment

1.There were lots of developmentally appropriate toys in the room, books, stacking blocks, keys

2.Dad showed baby the picture book he made for baby. Baby pointed at his own picture and said, “baby”. This type of play occurred most of the visit.

Examples: Environment

1.There were lots of developmentally appropriate toys in the room, books, stacking blocks, keys

2.Dad showed baby the picture book he made for baby. Baby pointed at his own picture and said, “baby”. This type of play occurred most of the visit.

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Rhythm & Reciprocity

1. Mom shook several toys with no breaks for baby. Baby began to fuss. Mom continued to show baby new toys for most of visit.

2. Slow pace. At times, dad might be too directive.

“Serve & return”

Rhythm & Reciprocity

1. Mom shook several toys with no breaks for baby. Baby began to fuss. Mom continued to show baby new toys for most of visit.

2. Slow pace. At times, dad might be too directive.“Serve & return”

Smiles (joy)

1. Baby laughed and smiled at dad throughout the visit. dad spent most of the visit coloring with him and smiling.

2. Dad and child smiled most of the visit

Mutual engagement is the greatest joy for any child

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Smiles (joy)

1. Baby laughed and smiled at dad throughout the visit. dad spent most of the visit coloring with him and smiling.

2. Dad and child smiled most of the visitMutual engagement is the

greatest joy for any child

CHEEERS & Reflective StrategiesTip Sheet

Quick Review of the Reflective Strategies

∗ Reflective Strategies may be used for any issue...yet there are some that might be better than others.

∗ CHEEERS Tip Sheet – “go-to” Reflective Strategies listed, however any strategy may work – the key?∗ Walk through the steps

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When to use: Reflective Strategies - Primary focus

1. SATP

2. Explore & Wonder

3. Problem Talk

4. Feel, Felt, Found

5. Normalizing

6. Accentuate the Positive

1. For a common belief

2. For any skill or strength

3. When I see a problem

4. Missed cues

5. When I want to increase a behavior

6. For strong feelings

When to use: Reflective Strategies - Primary focus

1. SATP

2. Explore & Wonder

3. Problem Talk

4. Feel, Felt, Found

5. Normalizing

6. Accentuate the Positive

1. For a common belief

2. For any skill or strength

3. When I see a problem

4. Missed cues

5. When I want to increase a behavior

6. For strong feelings

Prenatal CHEEERS: Getting Started with the

HFA Reflective Strategies

v Strategic Accentuate the Positive (SATP): Use SATP to increase a parent behavior you want to see more of in support of the prenatal attachment and healthy lifestyle choices.

v Feel, Felt, Found, Would this Work for You?: Use when a parent expresses a strong feeling or emotional reaction, to support parents in regulating their feelings and to expand their emotional vocabulary.

v Problem Talk: Use when you see a problem, the parent identifies a problem and when you want to learn more about your CHEEERS observations.

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CHEEERS & Reflective Strategies: Holding

Baby was held at arm’s length. As mom was holding baby in the air, baby turned her head away. This represented holding style for most of the visit.

What strategy(ies) could you use?∗Strategic Accentuate the Positives “SATP”∗Explore & Wonder

CHEEERS & Reflective Strategies: Empathy

Baby cried when he tripped over a toy. Dad said, “ you have to toughen up - you are OK”! Baby continued to cry. This represented half of the visit.

What strategy(ies) could you use?∗Problem Talk∗Feel, Felt, Found, Would This Work for You∗Normalizing

CHEEERS & Reflective Strategies:

Rhythm & Reciprocity Mom shook several toys with no breaks for baby. Baby began to fuss. Mom continued to show baby new toys for most of visit.

What strategy(ies) could you use?∗ Normalizing∗ Explore & Wonder

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∗ True Life Story∗ You will review home visit notes re: CHEEERS∗ Not to worry how poorly they are written – focus

on content∗ Key questions to ask yourself:

∗ What does the relationship look like?∗ Where do I need to support the parent-child relationship?

Ready to practice?

Mona & JoeyCues Mom stated, “all these toys…. Look at this”. “You like that don’t you?” Mom

read some cues when baby reached for a particular ring as evidenced by mom giving a toy that baby was reaching for. Mom had some eye contact as evidenced in play activity. Some of play had baby sit with back to mom while mom supported baby.

Holding Mom sat with baby on floor in close contact while playing with age appropriate toys. Mom sat with baby and held baby up while playing with stacking rings, book, and other age appropriate toys.

Expression Mom referred to baby in loving tones. Example: “Hey Jo-Jo”, “Good job”, “You took it off”, “Pretty boy”. Baby looked at mom several times during play.

Empathy During play, baby hit head. Mom replied, “oop, boom” in sing-song voice. Baby began to fall and mom stated, “Whoa” in sing-song voice – and “watch your head”.

Environment Age appropriate toys available – book, stacking blocks, keys, etc.Rhythmicity/Reciprocity

Baby initiated most of activities – he held the book and mom spoke to baby.

Smiles Mom smiled at baby, some verbal sounds returned. Mom talked to baby (see other documentation).

Practice: Mona & Joey

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∗ How are you feeling?

∗ How accurate was the CHEEERS?

∗ What does the relationship look like?

∗ Assess: Where do I need to support the parent-child relationship (which CHEEERS domains)?

∗ Address & Promote: What ReflectiveStrategy(ies) would you use?

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CHEEERS & Attachment Milestones

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Clearly, if we want to make a difference for families, we need to focus on attachment and the parent-child

relationship.

Handout: Attachment Milestones

Questions?

kwhitaker@preventchildabuse.orgtlansing@preventchildabuse.org

Implementation and Accreditation - Kathleen Strader, DirectorChristi Peeples Juanita Arnold Kathy Astin Leah McCallister Amy Russell

Training and Professional Development - Kate Whitaker, DirectorEllie JimenezLynn Kosanovich Patti Torchia Tracie Lansing Maritza Noriega

Cyd Wessel – National Director of HFACarla Snodgrass – Director of OperationsPhyllis Medrano – Network Support

HFA National Office

healthyfamiliesamerica.org Staff Email: firstinitiallastname@preventchildabuse.org

Thank you!