©Children's Research Triangle, 2007 “It’s OK, I’m Fine” : Lessons Learned by Young Children who Experience Infant Mental Health Interventions Cheryl Pratt,

©Children's Research Triangle, 2007

““It’s OK, I’m Fine” :It’s OK, I’m Fine” :Lessons Learned by Young Lessons Learned by Young Children who Experience Children who Experience

Infant Mental Health Infant Mental Health InterventionsInterventions

Cheryl Pratt, PhDCheryl Pratt, PhDLinda Schwartz, PhDLinda Schwartz, PhD


Infant Mental Health

Infants and toddlers Infants and toddlers develop emotionally and develop emotionally and socially within the context socially within the context of their primary relationshipof their primary relationship


Definition of Infant Mental Health

Infant Mental Health is the Appropriate Infant Mental Health is the Appropriate Unfolding of:Unfolding of:

Emotional RegulationEmotional RegulationInterpersonal RelationshipsInterpersonal Relationships

Exploration of the EnvironmentExploration of the Environmentwithin the context of the Familywithin the context of the Family



Is based on the understanding that Is based on the understanding that infants and young children do not exist infants and young children do not exist in isolation, but rather develop and in isolation, but rather develop and experience the world within the context experience the world within the context of relationships and environments.of relationships and environments.



Each infant and young child has unique Each infant and young child has unique social and emotional needs. An social and emotional needs. An appropriate response to these needs appropriate response to these needs provides the opportunity for healthy provides the opportunity for healthy developmentdevelopment


The Parent/Infant/Child The Parent/Infant/Child Relationship should be the Relationship should be the

central focus in helping to foster central focus in helping to foster the healthy development of the the healthy development of the

PSE childPSE child



ModelModel


Secure AttachmentSecure Attachment

This is of crucial importance to the This is of crucial importance to the child’s psychological development—child’s psychological development—and that a warm, sensitive, and that a warm, sensitive, responsive, dependable interaction is responsive, dependable interaction is the key ingredient in developing the key ingredient in developing secure attachmentssecure attachments


The parent’s internal workingThe parent’s internal working

model of attachment is based model of attachment is based

on his/her early experiences on his/her early experiences

along with particular infant along with particular infant

development characteristics.development characteristics.


Functions of AttachmentFunctions of Attachment

Allows child to develop a sense of Allows child to develop a sense of trust, safety and securitytrust, safety and security

A secure base can mitigate future A secure base can mitigate future challenges, stressorschallenges, stressors

Provides a foundation for Provides a foundation for subsequent intimate relationshipssubsequent intimate relationships


Barriers to Healthy Barriers to Healthy AttachmentAttachment

Separation from Separation from caregivercaregiver

Prenatal substance Prenatal substance exposureexposure

Intense pain that Intense pain that cannot be removed cannot be removed by the parentby the parent

Neglectful or abusive Neglectful or abusive parentingparenting

TemperamentTemperament


Attuned Parent-Child Interaction Builds Attuned Parent-Child Interaction Builds the the

Right HemisphereRight Hemisphere

Research has shown that the right Research has shown that the right hemisphere is dominant for:hemisphere is dominant for:

Attachment functionsAttachment functions

Self-regulation and survivalSelf-regulation and survival


Non-conscious processing and Non-conscious processing and communication of social and communication of social and emotional information emotional information

The organization of the most The organization of the most comprehensive and integrated comprehensive and integrated map of the body state available to map of the body state available to the brainthe brain


Just as the left brain communicates its Just as the left brain communicates its states to other left brains via conscious states to other left brains via conscious linguistic behaviors, so the right brain linguistic behaviors, so the right brain nonverbally communicates its nonverbally communicates its unconscious states to other right brains unconscious states to other right brains that are tuned to receive these that are tuned to receive these communicationscommunications


Adult Attachment as it Adult Attachment as it Affects the Attachment of Affects the Attachment of

the Childthe Child A parent’s coherent autobiographical A parent’s coherent autobiographical

narrative is the best predictor of narrative is the best predictor of secure attachment with their childsecure attachment with their child

Interpersonal neurobiology-the non-Interpersonal neurobiology-the non-verbal aspects of the way a parent verbal aspects of the way a parent relates to her childrelates to her child


Therapeutic InterventionsTherapeutic Interventions

Experiential TherapiesExperiential Therapies Family System TherapyFamily System Therapy Parent Psycho-educationParent Psycho-education Insight Oriented TherapyInsight Oriented Therapy Behavior ManagementBehavior Management


Experiential TherapiesExperiential Therapies

Self-regulation Self-regulation www.alertprogram.comwww.alertprogram.com

Narrative therapy Narrative therapy www.familyattachment.comwww.familyattachment.com


Family Systems TreatmentFamily Systems Treatment

Focus on parent’s own attachment Focus on parent’s own attachment historyhistory

Model healthy limits, boundaries and Model healthy limits, boundaries and structurestructure

Parents are encouraged to join Parents are encouraged to join support groupssupport groups


Family Systems Treatment Family Systems Treatment (con’t)(con’t)

Treatment team and parents create a Treatment team and parents create a strong and unified collaborative alliancestrong and unified collaborative alliance

Help parents develop positive working Help parents develop positive working relationships with resources in the relationships with resources in the communitycommunity


Parent Psycho-educationParent Psycho-education

Effects of problematic attachment histories on Effects of problematic attachment histories on developmentdevelopment

Developmental expectationsDevelopmental expectations

Parenting skills for the attachment-resistant childParenting skills for the attachment-resistant child

Advocating for servicesAdvocating for services


Insight Oriented TherapyInsight Oriented Therapy

Treatment individually for the foster Treatment individually for the foster parent, adoptive parent, or biological parent, adoptive parent, or biological parentparent

Decision based on cognitive and mental Decision based on cognitive and mental health abilities of the adulthealth abilities of the adult

Assess adults internal working model of Assess adults internal working model of attachmentattachment


Behavior ManagementBehavior Management

Parenting classes/curriculaParenting classes/curricula

Issues-quality and appropriateness of the Issues-quality and appropriateness of the curriculum for special needs childrencurriculum for special needs children

Use of behavioral logs, role modeling, 1:1 Use of behavioral logs, role modeling, 1:1

therapy, videotaping, etc.therapy, videotaping, etc.


Infant Mental Health InterventionsInfant Mental Health Interventions

Concrete Support ServicesConcrete Support Services Brief Crisis Intervention/Problem Brief Crisis Intervention/Problem

SolvingSolving Developmental GuidanceDevelopmental Guidance Parent-Child Interaction GuidanceParent-Child Interaction Guidance Infant-Parent PsychotherapyInfant-Parent Psychotherapy


Parent Child Interaction Guidance

Developed by Dr. Susan McDonoughDeveloped by Dr. Susan McDonough

School of Social Work and Center for School of Social Work and Center for

Human Development at University of Human Development at University of

MichiganMichigan

Goal is to promote and nurture the Goal is to promote and nurture the

care-giving relationshipcare-giving relationship


Defining TreatmentDefining Treatment

Family Defines the ProblemFamily Defines the Problem

Family Defines Intervention Family Defines Intervention SuccessSuccess


Interventionist’s RoleInterventionist’s Role

Offer Assistance in Helping the Offer Assistance in Helping the Family Define the ProblemFamily Define the Problem

Enhance Parent-Infant Interaction Enhance Parent-Infant Interaction through modeling, coaching, and through modeling, coaching, and video feedbackvideo feedback

Monitors Treatment ProgressMonitors Treatment Progress


Treatment ProcessTreatment Process

Assessment of the infant, family, home Assessment of the infant, family, home environment and cultural contextenvironment and cultural context

Family engagement processFamily engagement process Treatment implementationTreatment implementation Monitoring treatment progressMonitoring treatment progress Evaluation of treatment efficacyEvaluation of treatment efficacy


Using Videotape FeedbackUsing Videotape Feedback

Provides salient feedbackProvides salient feedback

Increases awareness of family interactionsIncreases awareness of family interactions

Emphasizing instances of positive Emphasizing instances of positive parenting, acceptance of negative family parenting, acceptance of negative family feelings, and providing new perspectives feelings, and providing new perspectives through discussion of concrete behaviorsthrough discussion of concrete behaviors


ConcernConcern

Parents over-reliance on Parents over-reliance on modeling behaviorsmodeling behaviors


Infant-Parent PsychotherapyInfant-Parent Psychotherapy

Developed by Selma Fraiberg to address Developed by Selma Fraiberg to address mental health problems in infants from birth mental health problems in infants from birth to three years of ageto three years of age

The theoretical target (Stern) is the web of The theoretical target (Stern) is the web of mutually constructed meanings in the mutually constructed meanings in the infant-parent relationshipinfant-parent relationship


The primary therapeutic focus involves the The primary therapeutic focus involves the uncovering of unconscious links between the uncovering of unconscious links between the parent’s psychological conflicts and parent’s psychological conflicts and parenting practices that are gravely mis-parenting practices that are gravely mis-attuned to the baby’s needs and derail the attuned to the baby’s needs and derail the infant’s normative development.infant’s normative development.


Basic Premises

Because behavioral patterns are not Because behavioral patterns are not internalized as part of the personality internalized as part of the personality structure before the age of 3 years, infants structure before the age of 3 years, infants and toddlers can regain their momentum and toddlers can regain their momentum toward normal development when they are toward normal development when they are no longer the recipient of maladaptive no longer the recipient of maladaptive parenting practicesparenting practices


Because profound personality Because profound personality changes occur throughout the changes occur throughout the lifespan this perspective forms the lifespan this perspective forms the basis for relational approaches to basis for relational approaches to psychotherapy for children and with psychotherapy for children and with adultsadults


Mental Health problems in infancy and Mental Health problems in infancy and early childhood, regardless of their early childhood, regardless of their etiology, need to be addressed in the etiology, need to be addressed in the context of the child’s primary relationship, context of the child’s primary relationship, because the child’s sense of self unfolds because the child’s sense of self unfolds and is sustained by these relationshipsand is sustained by these relationships


Mental Health risk factor in the first 5 years Mental Health risk factor in the first 5 years of life operate in the context of of life operate in the context of transactions between the child and his/her transactions between the child and his/her social environment, including family, social environment, including family, neighborhood, community, and the larger neighborhood, community, and the larger societysociety


Childrearing mores and parenting Childrearing mores and parenting practices are deeply held, often practices are deeply held, often unconscious cultural values about who is a unconscious cultural values about who is a worthy human being and which worthy human being and which characteristics should be encouraged and characteristics should be encouraged and discouraged in raising a childdiscouraged in raising a child


Therapeutic ThemesTherapeutic Themes

Ghosts in the NurseryGhosts in the Nursery

Supporting Affective AttunementSupporting Affective Attunement

Assessing the Child’s and Parent’s Assessing the Child’s and Parent’s Contribution to the Relationship and Contribution to the Relationship and Dyadic FunctioningDyadic Functioning


Intergenerational Transmission of Intergenerational Transmission of PsychopathologyPsychopathology

Ports of Entry in Infant-Parent Ports of Entry in Infant-Parent PsychotherapyPsychotherapy

The Therapeutic Relationship as the The Therapeutic Relationship as the Matrix for TreatmentMatrix for Treatment


DIR ModelDIR Model

Developmental Individual-Developmental Individual-Difference Relationship Based Difference Relationship Based ApproachApproach

Developed by Serena Weider Developed by Serena Weider Ph.D. and Stanley Greenspan Ph.D. and Stanley Greenspan M.D.M.D.


DevelopmentalDevelopmental= Greenspan’s 6 Stages = Greenspan’s 6 Stages of social Emotional Developmentof social Emotional Development

IndividualIndividual-Difference= the unique way a -Difference= the unique way a child processes informationchild processes information

Relationship Based=Relationship Based=learning and learning and facilitating relationships that enable a facilitating relationships that enable a child to progress in his/her developmentchild to progress in his/her development


Stages of Functional Emotional Stages of Functional Emotional Developmental CapacitiesDevelopmental Capacities

Stage One: Regulation and Interest in Stage One: Regulation and Interest in the World First few months of lifethe World First few months of life

Stage Two: Engaging and Relating 2-6 Stage Two: Engaging and Relating 2-6 monthsmonths

Stage Three: Intentionality and Two-Stage Three: Intentionality and Two-Way Communication 6-9 monthsWay Communication 6-9 months


Stage Four: Social Problem-solving, Stage Four: Social Problem-solving, Mood Regulation, and Formation of a Mood Regulation, and Formation of a Sense of Self 9-18 monthsSense of Self 9-18 months

Stage Five: Creating Symbols and Stage Five: Creating Symbols and Using Words and Ideas 18-30 monthsUsing Words and Ideas 18-30 months

Stage Six: Emotional Thinking, Logic, Stage Six: Emotional Thinking, Logic, and a Sense of Reality; 2 ½ years-4-5 and a Sense of Reality; 2 ½ years-4-5 yearsyears


Stage Seven: Multicausal and Stage Seven: Multicausal and Triangular Thinking; early school yearsTriangular Thinking; early school years

Stage Eight Gray-Area, Emotionally Stage Eight Gray-Area, Emotionally Differentiated Thinking; later school Differentiated Thinking; later school age through adolescenceage through adolescence

Stage Nine: A Growing Sense of Self Stage Nine: A Growing Sense of Self and Reflection on an Internal Standard; and Reflection on an Internal Standard; puberty, early adolescencepuberty, early adolescence


Stages of DIR InterventionStages of DIR Intervention

Stage One: Facilitate Shared Attention Stage One: Facilitate Shared Attention and Regulationand Regulation

Stage Two: Facilitate Engagement and Stage Two: Facilitate Engagement and RelatingRelating

Stage Three: Facilitate Purposeful Stage Three: Facilitate Purposeful Emotional InteractionsEmotional Interactions

Stage Four: Facilitate Shared Problem-Stage Four: Facilitate Shared Problem-SolvingSolving

Stage Five: Facilitate Creating IdeasStage Five: Facilitate Creating Ideas


FloortimeFloortime

First Goal-Follow the Child’s Lead While First Goal-Follow the Child’s Lead While Challenging the Child at the Same TimeChallenging the Child at the Same Time

Second Goal- Bring the Child into a Second Goal- Bring the Child into a Shared WorldShared World

Creating Learning Environments: Creating Learning Environments: Floortime: All the Time and EverywhereFloortime: All the Time and Everywhere


Other Curriculum InterventionsOther Curriculum Interventions

Circle of Security Intervention -20 week group Circle of Security Intervention -20 week group based parent intervention program designed to based parent intervention program designed to alter the developmental pathway of at-risk alter the developmental pathway of at-risk parents and their childrenparents and their children

PIPE curriculum used in Early Head Start where PIPE curriculum used in Early Head Start where the emphasis is on the relationship and the emphasis is on the relationship and parenting skills to facilitate normal development parenting skills to facilitate normal development in children 0-3in children 0-3


STEEP (Steps Toward Effective, Enjoyable STEEP (Steps Toward Effective, Enjoyable Parenting) a preventive intervention program Parenting) a preventive intervention program for expectant parents and continues over the for expectant parents and continues over the child’s first year of lifechild’s first year of life

David’s Olds Public Health Home Visitor’s David’s Olds Public Health Home Visitor’s ProgramProgram

Wait-Watch- and Wonder ProgramWait-Watch- and Wonder Program


Do-Watch-Listen-Say: Social and Do-Watch-Listen-Say: Social and Communication Intervention for Children Communication Intervention for Children with Autism (Kathleen Ann Quill)with Autism (Kathleen Ann Quill)

PCIT-Dr. Sheila- Eyberg-2-7 years of PCIT-Dr. Sheila- Eyberg-2-7 years of age based on operant theory, traditional age based on operant theory, traditional child psychotherapy, and early child psychotherapy, and early childhood developmentchildhood development


Parent Group at CRTParent Group at CRT

Provision of safe holding and Provision of safe holding and facilitating environment for both the facilitating environment for both the parent and childparent and child

Goal to build trust and strengthen Goal to build trust and strengthen relationshipsrelationships

Provide empathetic and supportive Provide empathetic and supportive experiencesexperiences


Explore how past relational dynamics Explore how past relational dynamics influence interpersonal relationshipsinfluence interpersonal relationships

Use of maternal/parental reflective Use of maternal/parental reflective functioning (Fonagy, Target and Steele)functioning (Fonagy, Target and Steele)

Slade’s “keeping the baby in mind”Slade’s “keeping the baby in mind”


Child Group Goals: Developmental Facilitation Goals: Developmental Facilitation

techniques and to enhance parent-child techniques and to enhance parent-child relationshipsrelationships

Use of Greenspan’s Floortime/DIR modelUse of Greenspan’s Floortime/DIR model Increase mutual, shared engagement to Increase mutual, shared engagement to

increase more complex interactions increase more complex interactions “opening and closing the circles of “opening and closing the circles of communication”communication”


Dyadic Group

Gentle interactive guidance and Gentle interactive guidance and positive reinforcement positive reinforcement

Use of speaking for the infant/child Use of speaking for the infant/child Focus on a holding and facilitating Focus on a holding and facilitating

environmentenvironment Use of mutual engagement, co-Use of mutual engagement, co-

regulation, and affect attunementregulation, and affect attunement


Case Study Case Study

Joey and Geri K.Joey and Geri K.


Documents

©Children's Research Triangle, 2007 “It’s OK, I’m Fine” : Lessons Learned by Young Children who Experience Infant Mental Health Interventions Cheryl Pratt,