Early development program: Collaborative structures and processes

Infant Mental Health Journal, Vol. 18(2) 198–208 (1997)© 1997 Michigan Association for Infant Mental Health CCC 0163-9641/97/020198–11

Early Development Program: Collaborative

Structures and Processes

JEAN M. THOMAS, KAREN A. GUSKIN, AND CAROL S. KLASS

Department of Child and Adolescent Psychiatry, Cardinal Glennon Children’s Hospital, 1465 S.Grand, St. Louis, Missouri 63104 affiliated with Saint Louis University School of Medicine

ABSTRACT: The Early Development Program (EDP) provides and coordinates interdisciplinary mental healthand developmental assessment/intervention for children ages zero through 3 years and their families. EDP’s in-terdisciplinary team includes faculty in child and adolescent psychiatry, developmental pediatrics, pediatrics,psychology, developmental psychology, education, nursing, social service, speech and language, and occupa-tional and physical therapy plus trainees in psychiatry, pediatrics, psychology, and education. Children are re-ferred largely by pediatrics; two-thirds are insured by Medicaid and one-third by HMOs and private insurance.Local foundations help support ongoing assessment/intervention. Disruptive behavior is the most frequent refer-ral problem; almost half of those presenting with disruptive behavior also have delays. Using the DiagnosticClassification: 0–3 (DC: 0–3), Disorders of affect, regulatory disorders, traumatic stress disorder, and relation-ship disorders are most often diagnosed; comorbid diagnoses are common. Family-centered intervention in-cludes family-psychodynamic and interactional approaches and facilitated use and development of communityresources.

RESUMEN: El Programa de Temprano Desarrollo (EDP) provee y coordina la evaluación e intervención inter-disciplinarias de salud mental y de desarrollo para niños desde el nacimiento hasta su tercer año de edad y susfamilias. El equipo interdisciplinario de EDP incluye profesores especialistas en siquiatría infantil y del adoles-cente, pediatría del desarrollo, pediatría, sicología, sicología del desarrollo, educación, enfermería, servicio so-cial, habla y lenguaje, así como terapia ocupacional y fisica. Incluye adems aprendices en siquiatría, pediatría,sicología y educación. Los niños en su mayoría son referidos por los pediatras; dos tercios están asegurados porMedicaid y el resto por un HMO o seguros privados. La ayuda que fundaciones locales proveen apoya la con-tinua evaluación/intervención. El problema que más se presenta es el de mal comportamiento; casi la mitad deaquellos que presentan este tipo de conducta tienen también retardos. Usando la Clasificación de Diagnóstico:0-3 (DC: 0-3) se diagnostican más frecuentemente los trastornos en el afecto, los trastornos regulatorios, lostrastornos traumáticos de tensión y los trastornos en la relación; diagnósticos co-patológicos son comunes. Laintervención centrada en la familia incluye acercamientos interaccionales y de sicodinámica familiar, así comoal facilidad de uso y desarrollo de los recursos comunitarios.

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We thank our many colleagues with whom we collaborate and learn. In particular, we thank our Early Devel-opment Program and Zero to Three colleagues, and the reviewers for their helpful comments on this manu-script. We especially thank colleagues who have mentored our Early Development Program process including,Martha Julia Sellers, Ph.D. and Robert J. Harmon, M.D. We also especially thank our assistants Nina LoveKnox and Mary Ellen Jokerst. Correspondence should be addressed to the first author at Cardinal Glennon Chil-dren’s Hospital, 1465 S. Grand, St. Louis, Missouri 63104.

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J. M. Thomas, K. A. Guskin, and C. S. Klass 199

RÉSUMÉ: Le Programme de Développement Précoce (abrégé EDP en anglais) offre et coordonne uneévaluation/intervention en santé mentale et développement interdisciplinaire pour des enfants âgés de zéro à troisans et leurs familles. L’équipe interdisciplinaire de l’EDP comprend des professeurs en psychiatrie de l’enfant et del’adolescent, en pédiatrie du développement, en pédiatrie, en psychologie, en psychologie du développement, en éd-ucation, en sciences infirmières, en assistance sociale, en langue et orthophonie, en kinésithérapie et ergothérapie,ainsi que des internes en psychiatrie, en pédiatrie, en psychologie et en éducation. Les enfants sont dans l’ensembleenvoyés par des pédiatres. Les trois-quart n’ont que la couverture de sécurité sociale réservée aux failles américainespauvres et un tier d’entre eux ont une mutuelle. Des fondations locales aident à financer toute évaluation/interven-tion suivie. Le problème pour lequel l’on envoie le plus souvent les enfants est un comportement perturbateur.Presque la moitié des enfants présentant un comportement perturbateur ont aussi des retards. En utilisant la Classifi-catio Diagnostique: 0-3 (DC: 0-3), ce sont des Troubles de l’Affect, des Troubles de Régulation, des Troubles deStress Traumatique, et des Troubles Relationnels qui sont le plus souvent diagnostiqués. Des diagnostiques comor-bides sont communs. L’intervention centrée sur la famille inclue des approches psychodynamiques et interaction-nelles familiales, une utilisation facilitée et un développement des ressources communautaires.

ZUSAMMENFASSUNG: Die Frühförderung ermöglicht und koordiniert interdisziplinäre Untersuchung undIntervention im Bereich der seelischen Gesundheit und der Entwicklung für Kinder im Alter zwischen null unddrei Jahren und deren Familien. Seit ihrer Einführung im Jahr 1990 war die Frühförderung ein Teil der Be-mühungen des Komitees: “ZERO TO THREE”, das die diagnostische Klassifikation für das Lebensalte null bisdrei Jahre herausgebracht hat (DC: 0–3). Das Team der Frühförderung besteht aus dem Mitgliedern derAbteilung für Kinder- und Jugendpsychiatrie, der pädiatrischen Entwicklungsneurologie, aus Kinderfachärzten,Pädagogen, Pflegepersonal, Sozialarbeitern, Logopäden, Maßnahmen zur Unterstützung der Wiedere-ingliederung in den Arbeitsprozeß und medizinischer Therapie, sowie Auszubildenden in Psychiatrie, Kinder-heilkunde, Psychologie und Pädagogik. Die Kinder werden überwiegend von Kinderfachärzten überwiesen;zwei Drittel sind bei der allgemeinen Sozialversicherung (Medicaid), ein Drittel bei Firmenkrankenkassen(HMO) und bei privaten Anbietern versichert. Lokale Hilfsvereine unterstützen die Untersuchung und Therapie.Störungen des Sozialverhaltens stellen den häufigsten Überweisungsgrund dar; fast die Hälfte derer, die wegenStörungen des Sozialverhaltens vorgestellt werden sind auch retardiert. Bei Anwendung des DC: 03 werden amhäufigsten Gefühlsstörungen, Regulationsstörungen, traumatische Streßstörungen und Beziehungsstörungen di-agnostiziert; es werden oft mehrere Diagnosen bei einem Patienten erstellt. Die familienbezogene Interventionbenützt psychodynamische und interaktionszentrierte Zugänge und versucht die Inanspruchnahme und die weit-ers Entwicklung von städtischen Einrichtungen zu unterstützen.

The Early Development Proram (EDP) provides and coordinates interdisciplinary men-tal health and developmental assessment/intervention for children ages zero through 3years and their families. EPD’s service, education, and research efforts are directedthrough the Department of Child and Adolescent Psychiatry at Cardinal Glennon Chil-dren’s Hospital in St. Louis, Missouri, in affiliation with Saint Louis University School ofMedicine. In the context of providing services for young children and families, EDP, inaddition, has provided interdisciplinary educational and research opportunities for psychi-atry and pediatric residents, medical students, and students in allied health professions.

Four key theoretical assumptions have guided the development of EDP goals andprocess. These theoretical assumptions include:


200 Infant Mental Health Journal

1. the need to understand and treat the child in the context of the caregiving environ-ment, which includes the parent(s) and family, extended family and friends, the commu-nity, and the culture (Winnicott, 1965);

2. a focus on the transactional biopsychosocial model of development, which impliesthat biological, psychological, and social factors are mutually influencing and togetherdefine the complex development of the child (Sameroff & Chandler, 1975);

3. a relationship perspective that frames the power of relationships in the child’s de-velopment and in the process of collaborative assessment/intervention with the family(Emde, 1985); and

4. the belief that a collaborative interdisciplinary approach facilitates the integrationof knowledge from biological, developmental, and psychosocial research and from psy-chodynamic and systems theories.

The goals of EDP service are based on the above central assumptions. To facilitate thechild’s healthy development, EDP works collaboratively with the family to:

1. create a family-centered therapeutic process;2. build on the child’s and family’s biopsychosocial strengths; and3. develop an ongoing mutual process of learning about and helping the child.EDP is an evolving, transactional (mutually influencing) interdisciplinary service, edu-

cational, and research program shaped over time by local and national demographic, cul-tural, and institutional contexts. Service, education, and research domains are conceivedas an integrated whole. Assessment/intervention is designed and implemented as a unitand conceptualized as a process rather than an outcome. During assessment/intervention,using a one-way mirror, the interdisciplinary faculty, residents, and students observe andreflect upon the process as it occurs. These observations become a part of the process ofunderstanding the child and family.

EDP STRUCTURE

Child and Family Demographics

Cardinal Glennon Children’s Hospital is a 190-bed tertiary care hospital serving chil-dren in the inner city, suburban, and regional areas. Pediatricians and pediatric subspe-cialists on the hospital medical staff refer more than half of the children (54%) to EDP.Psychiatrists and psychologists both within the hospital and the region refer an additional22%. Social services, educators, speech and language specialists together refer 16%. Par-ents self-refer 8% of the children.

Approximating the hospital demographics, the children are 64% Caucasian, 26% African-American, and the rest of Latin or Asian origin or multiracial. Medicaid insures 67%, privateinsurers and HMOs, 33%. Children’s ages at intake are 2% from 0 to 11 months, 8% from 12to 23 months. 41% from 24 to 35 months, and 49% from 36 to 47 months.

Disruptive behavior is the primary referral concern for 84%. Of those presenting with disruptive behavior, 61% present with parental concerns about disruptive behav-ior only; 39% present with concerns about behavior and delay. Delay alone is the presenting concern for 9%; other concerns are central for 7% of the children. This heterogeneous group of children has a variety of biological and psychosocial risk factors:



1. Environmental problems, including traumatic, neglectful, and abusive experiencesand socioeconomic disadvantage;

2. Constitutional/maturational delays, including language, motor, and sensory inter-gration problems; and

3. Parent–child relationship problems (Thomas & Tidmarch, 1997).These risk factors contribute to known developmental pathways to behavioral difficultiesin young children (Fonagy, 1996).

Assessment/Intervention Team

The core faculty includes the Director, who is a child and adolescent psychiatrist; anearly education specialist; a research developmental psychologist; and a clinical nursespecialist, who is the coordinator of clinical EDP services. Team members from other de-partments contributing to the clinical and educational efforts include a developmental pe-diatrician; two psychologists, including a family therapy educator; a child psychoanalyst;an occupational therapist who is a sensory integration specialist; and a speech and lan-guage therapist. Specialists from neurology, neonatology, family therapy, and physicaltherapy are invited to participate or are consulted as needed. Trainee members of the as-sessment/intervention team consist of child and adolescent psychiatry residents, generalpsychiatry residents, pediatric residents, medical students, and interns in family therapy,psychology, and social work.

Assessment/Intervention Structure

Assessment/intervention begins with the referral. At that time, the nurse coordinatorcollects intake information, encourages all primary caregivers and siblings to partici-

pate in the assessment/intervention process, and discusses procedures, including videotaping of the initial session. Forms to collect psychosocial and developmental history are sent with standardized instruments to arrive 1 week before the scheduled assessment/intervention. The standardized instruments used include the Child Behav-ior Checklist 2–3 (Achenbach, Edelbrock, & Howell, 1987), Parenting Stress Inventory—Short Form (Abidin, 1995), an Emotion Regulation Checklist (Shields & Cicchetti, 1995), and the Center for Epidemiological Studies Depression Scale (Radloff, 1977). Several days prior to the assessment/intervention the resident/case manager calls the family to answer questions, to remind the family to bring a snack and a favorite toy for the child, and to begin to build a relationship between the resi-dent/case manager and the family.

Assessment/intervention consists of at least two 2-hr assessment/intervention sessions.The first session is a videotaped psychiatric and psychosocial evaluation followed by amodified Parent-Child Early Relational Assessment (PCERA) (Clark, 1985). Two resi-dents and the attending psychiatrist jointly interview the family. One resident focuses pri-marily on the interview process and the other on observing and interacting with the child.Additional trainees, interdisciplinary faculty, and visiting professionals, using a one-waymirror, observe throughout the assessment/intervention process. The initial assessment/in-tervention session focuses on developing therapeutic relationships, understanding thefamily’s referral concerns and explicit and implicit expectations of the assessment/inter-vention, and building on strengths. Trainees accustomed to prioritizing collection of med-ical, developmental, and psychosocial information need repeated support in shifting the



focus to developing relationships and a therapeutic process and intervening when oppor-tunities arise. Fostering intervention throughout the process gives the family a sense ofbeing helped and increases the team’s understanding of interpersonal resources andstyles, which is more important to the preventive intervention process than historical de-tails that may be collected later.

Following the family interview, the evaluating team joins the observing team behindthe one-way mirror and together they observe the modified PCERA, which primarily con-sists of a 20 min parent–child free play session, which is extended to focus onparent–child dyads and the whole family together when possible. The team looks forstrengths of the child, of the parent(s), and especially interactive strengths of the family.Following the free play observation, the entire team discusses diagnostic hypotheses andstrategies for addressing the family’s explicit and implicit expectations of the assess-ment/intervention and beginning to build with the family a mutual understanding of con-cerns and a family-centered approach to further assessment, therapeutic collaboration,and referral. Then the interview team rejoins the family to address their concerns and ex-pectations and to plan for the second session.

The second session, often flexibly scheduled, builds on mutual understanding and elab-orates the mutually devised treatment plan, which was discussed and initiated the previ-ous session. The second session may include grandparents, other extended family,friends, teachers, and agency workers who provide significant family supports. Additionalspecialized assessments including developmental pediatrics, speech and language, occu-pational therapy, and psychometrics are scheduled flexibly to address specific areas ofconcern and implement the treatment plan. As appropriate, daycare observation and inter-ventions that focus on teacher’s concerns, build on teachers’s strengths, and facilitatepartnership between teachers and parents may be implemented by the resident/case man-ager and early educational specialist. These assessments and structures comprise theframework within which assessment/intervention takes place. Below are detailed some ofthe strategies and processes used to achieve the three overarching goals of EDP.

EDP ASSESSMENT/INTERVENTION PROCESS

Creating a Family-Centered Therapeutic Process

EDP creates a family-centered therapeutic process that focuses on parents’ concerns,motivations, and explicit and implicit expectations. EDP respects that parents know theirchild best, are the central influence in their child’s life, and have unique values. Beforethe assessment/intervention begins, observers introduce themselves to the family to be-come part of the assessment/intervention team and part of the family’s EDP experience.As the interview begins, the family is encouraged to focus on the child as needed. Profes-sionals interact with the child when the child approaches but respect the parents’ valuesand style and facilitate the parents’ central role with the child. Parents are involved in thediscovery process, in observing the child with the team and thinking with the team aboutthe meaning of the child’s behavior. In the videotaped play session, the child is observedwith each of his or her parents and with the family as a whole, including siblings. Familyand extended family play sessions have provided a delightful window into the family’s in-teractive warmth and creativity. Following the play observation, to keep the focus on thefamily’s experience, the team asks the parents to compare and contrast this play sessionwith the way things usually go at home (Clark, 1985).



Building on Biopsychosocial Strengths

EDP works collaboratively with the family to identify the child’s and family’s biopsy-chosocial strengths and vulnerabilities, and then build on strengths. Interdisciplinary fac-ulty and trainees bring their unique observational skills and expertise to EDPassessment/intervention. The family play session provides a systematic interdisciplinaryobservational experience. A structured protocol adapted from the PCERA guides traineeand faculty observation of parent–child interactions. An additional protocol adapted fromtwo sources (DeGangi, DiPietro, Greenspan, & Portes, 1991; Zero to Three, 1994) helpsscreen for delays and sensory, sensory-motor, and other processing difficulties. In addi-tion to vulnerabilities, all team members are asked to focus their attention on strengths.Some focus on the child’s strengths, some on the parents’ strengths, and some on the in-teractional strengths. Following the family play session, the trainee and faculty team dis-cuss observations among themselves and provide input for the evaluators who, infocusing on the interview process, may have missed important interactional, behavioral,and physical cues. Observations of the interview and play session are then shared with theparents to focus on concerns and strengths of the child, parents, and family interactions.As the team listens for, observes, and reinforces what works, they use specifics of “what,”“why,” and “how” the parents facilitate the child’s intrinsic curiosity, quest for mastery,and need for connectedness. The team facilitates the parents staying in control. Parents’solutions are the focus. (Thomas, Clark, & Harmon, 1993)

Developing an Ongoing Mutual Process of Learning About and Helping the Child

Although, in practice, EDP assessment and intervention are a single entity, for ease ofdiscussion in this section, diagnostic process and treatment are detailed separately. Bothare conceptualized as critical parts of the process of developing an ongoing mutual rela-tionship with the goal of learning about and helping the child. Specific strategies, such asreview of the videotaped play session with parents and professional, typically serve thedual functions of diagnosis and treatment. The ongoing mutual process of learning aboutand helping the child supports parents in learning to trust their own competencies as par-ents and their child’s capacity for healthy development.

Diagnostic Process

Diagnostic formulation is an ongoing process of developing with the family a mutualunderstanding of the child’s problems, risk and protective factors, and interventions thattarget specific risk factors. This process is essential to effective intervention with youngchildren. EDP uses the Diagnostic Classification of Mental Health and DevelopmentalDisorders of Infancy and Early Childhood (DC: 0–3) (Zero to Three, 1994) to supple-ment the Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV)(American Psychiatric Association, 1994). DC: 0–3 offers an evolving, developmentallyappropriate multiaxial system based on preliminary data collected over 6 years by an in-terdisciplinary task force of Zero to Three/National Center for Infants, Toddlers, andFamilies. DC: 0–3 provides organizing principles that focus attention on the complexitiesof the diagnostic process and help target intervention on specific risk and protective fac-tors of young children. (Zero to Three, 1994)


The DC: 0–3 multiaxial framework is designed to focus attention on key aspects of thechild’s experience and assist in organizing clinical concerns. DC: 0–3 Axes I and II havebeen most helpful in formulating recommendations for intervention with EDP childrenand families, especially those presenting with disruptive behaviors. Axis I, the PrimaryDiagnosis, describes the disorder within the child, that is, the internal experience and/orthe dysfunctional behavioral expression of distress. Axis II, Relationship Classification,describes the specific relationship with one or more primary caregivers. Diagnosis of a re-lationship disorder documents relational concerns within a specific dyadic relationship.(Zero to Three, 1994)

DC: 0–3 Axes I and II provide guidance by identifying specific risk factors to be tar-geted for intervention. For example, on Axis I, traumatic stress disorder identifies envi-ronmental risk, suggesting that social interventions will be central; disorders of affectidentify interactional risk, suggesting that psychological interventions that focus on fam-ily relationships will be central; and regulatory disorders identify constitutional/matura-tional risk, suggesting that biological (medical and developmental) interventions will becentral. Axis II Relationship Classification helps to focus psychological intervention onspecific relationships concerns.

Treatment

Treatment is “socio-bio-psychological.” The order differs from the usual, biopsychoso-cial, to prioritize physical safety and emotional security, the first targets of social interven-tion, then biological (medical and developmental) intervention, and then psychologicalintervention. All three domains are important for most cases; in some, one or two domainsmay require emphasis (Thomas, 1995; Thomas & Tidmarsh, 1997).

Social interventions. Physical safety and emotional security must be prioritized for all child and family victims of trauma. Healing begins and healthy development pro-gresses when the traumatized child feels safe and secure. Helping the parent, who is often cotraumatized, feel safe and secure is often the most important first step. Parent-ing strengths, limit setting, and self-calming techniques are supported within the contexts of family therapy. Building the family’s ties to community resources is a nec-essary step. Hospital-based parenting groups are led by the clinical nurse specialist; similar daycare-based groups are led by the early education specialist (Klass, Guskin,& Thomas, 1995). Child and adolescent psychiatry residents may colead these parent-ing groups. Additional intervention in daycare and therapeutic nursery settings include observation and consultation with teachers and facilitated parent– teacher collabora-tions coordinated by the early education specialist alone or with a resident (Klass et al. 1995). Marital conflict and parental psychiatric symptoms, when untreated, are highly predictive of a child’s ongoing problems with aggression (Campbell, 1995). External referral for individual parent therapy, substance abuse treatment, and/or medication may be necessary. Social service referrals are occasionally needed to facilitate neces-sary family changes; primary relationships are kept constant whenever possible (Thomas & Tidmarsh, 1997).

Biological (medical and developmental) interventions. Developmental testing and intervention are required when delay is suspected. Nearly half of EDP children presenting with disruptive behavior have developmental delay; many are recognized at referral and others are identified by EDP’s interdisciplinary team. Delays in speech




and language; fine and gross motor skills; and sensory, sensory-motor, and other central nervous system processing difficulties are common. Treatment by speech and language therapists or occupational therapists trained in sensory integration provides the child with increased physical and behavioral controls. These services are provided internally as part of the EDP interdisciplinary program; external referrals are also common and often include services provided within therapeutic public and private school programs. In addition, psychiatric medications are prescribed when symptoms are severe and unresponsive to other interventions (Thomas & Tidmarsh,1997).

Psychological interventions. Because infants and young children must be understoodand treated within the context of the caregiving environment (Winnicott, 1965), psycho-logical interventions focus centrally on relationships. The caregiver is always central tothe treatment team. Therefore, intervention must begin with supporting the parent and un-derstanding parental concerns and responses to frustration. Residents, faculty, andresident– faculty teams provide interaction guidance (McDonough, 1993) and parent–infant therapy (Fraiberg, 1980). Interaction guidance highlights parent–child interac-tional strengths and targets change in the parent–child interactions directly (McDonough,1993). Parent– infant therapy, utilizing psychodynamic theory, targets change in parentalmental representations (Fraiberg, 1980). Research suggests that psychotherapies targetingparent–child interaction directly and those targeting parental mental representations areequally effective (Stern, 1995). EDP experience suggests that interaction guidance is of-ten more helpful for children with regulatory disorders and parent– infant psychotherapyis often more helpful for children with disorders of affect. Combinations of these two ap-proaches are also helpful.

EDUCATION

The educational component of EDP includes clinical experiences, didactics, supervision,and research. The EDP Case Conference/Seminar focuses on group supervision and didacticsrelevant to interdisciplinary training in mental health assessment and treatment of infants andyoung children. EDP faculty, including the directing child and adolescent psychiatrist, theearly education specialist, and the developmental psychologist, are joined by a psychologistspecializing in family therapy and a child analyst who together design and colead the inter-disciplinary and intertheoretical course. The format and process of the course are guided bythe trainees and faculty as they collaboratively design 12 sessions to define: “What does atrainee need to know to be competent in evaluating and treating infants, very young childrenand their families?” This collaborative process has been an opportunity for professional de-velopment much relished by the faculty. Trainees presenting a case choose a faculty supervi-sor to help them organize the case materials, including a genogram, videotape vignettes,discussion of parental and professional concerns, and discussion of intervention approachesand strategies. Reading materials are chosen to augment case presentations. Trainees are sup-ported in listening to the chorus of the various faculty points of view, hearing their ownvoices, and developing their own points of view and integrations of their cases. In addition togroup supervision provided through the EDP Case Conference/Seminar, child and adolescentpsychiatry residents have individual supervisors who specialize in psychodynamic and fam-ily systems therapies. Residents frequently elect cotherapy with faculty, live supervision


through a one-way mirror, and videotaping of their own work for later supervision. Theprocess of organizing thoughts about education and services for presentation at nationalmeetings and for publication has motivated a regular assessment of EDP process.

RESEARCH

Research has included ongoing data collection for the Zero to Three Diagnostic Classi-fication Task Force, evaluation of services and training, and in the last 2 years, researchon children presenting with disruptive behaviors. The research team includes faculty, resi-dents, and students. EDP-based research serves multiple functions: educational tool, en-hancement of clinical services, and information dissemination.

Almost since its inception in 1990, EDP has been a data collection site for the Zero toThree effort that created the DC: 0–3 (Zero to Three, 1994). The development of the pro-gram’s service, education, and research arms has been integrally tied to this organization.Trainees and faculty have benefited from this participation through increased knowledgeabout young children and exposure to structured tools for observation. Collaborationswith multiple Zero to Three colleagues and with the Diagnostic Classification Task Forcehave inspired growth in all components of EDP.

EDP services and training have also been evaluated, using feedback from families andtrainees. Evaluation of the first year of services was conducted via phone interviews ofthe families by a medical student on a summer research fellowship. From this evaluationthe team developed recommendations including the need (1) to listen to parent’s expecta-tions, (2) to explicitly link assessment and intervention, (3) to provide feedback and de-velop a treatment plan in manageable pieces, (4) to provide ongoing family casemanagement including regular and as needed contact with EDP, and (5) to provide com-munity linkages.

Evaluation of the first year of required EDP training was conducted by written question-naire and interview of the four child and adolescent psychiatry residents. The traineesidentified their new competencies in observing, understanding, and treating young childrenand their families. They also appreciated that EDP, especially the Case Conference/Semi-nar was helping them to integrate biological, psychodynamic, and family systems ap-proaches for older children as well as younger ones. Trainees identified that although theinterdisciplinary work increased competency, supportive guidance, and immediate feed-back, it was sometimes overwhelming, decreased a sense of ownership, and felt intrusive.New structures, strategies, and processes emerging from the evaluative process includedincreased focus on each trainee’s unique concerns and strengths, increased availability ofsupervision, and increased structures to facilitate autonomy and flexibility.

Disruptive behaviors have been a focus of research attention because 84% of EDP chil-dren present with primary parental concerns about disruptive behavior; many of thesechildren also present with hyperactivity. Children with hyperactive and disruptive behav-ior of multiple origins are frequently misdiagnosed with Attention-Deficit/HyperactivityDisorder (ADHD) (Thomas, 1991; 1995; Thomas & Tidmarsh, 1997). EDP research inthis area uses DC: 0–3 to begin clarifying the multiple risk factors associated with hyper-active and disruptive behavior in this heterogeneous group of children with symptomssuggestive of ADHD.




FUTURE DIRECTIONS AND CONCLUSIONS

Although EDP children are diverse with respect to geography (city, suburban, and re-gional), medical need, and the complexity of family stressors, multiply stressed families,including foster care families, comprise more than half of the EDP population. Providingcoordinated, supportive services over time for these families has been the central chal-lenge for EDP faculty over the program’s entire 6 years. For families whose expectationsinclude abandonment, pursuit by the therapist over time is sometimes needed to establishthe parent’s sense of trust in the therapeutic relationship and then in herself as a compe-tent parent. In addition, providing ongoing parenting groups increases the continuity ofcare for families that have difficulty keeping regular follow-up appointments.

Over time, many families have felt helped, discontinued services, and then returned forhelp with related concerns several years later. Some of these follow-up visits have beeninitiated because of stress in the family that has increased the child’s symptoms or be-cause a younger child has had problems similar to those of the child seen in EDP. Othervisits have been initiated because of teacher’s concerns about learning and behavior in theelementary grades. Repeat psychiatric, developmental pediatric, speech and language,and psychometric assessment often provide new information and elucidate earlier con-cerns, including learning disorders that were not diagnosable at ages 2 or 3. In addition,as new information about processing difficulties has become available and the team hasestablished a closer alliance with the sensory integration specialist, new opportunities forintervention are explored.

EDP continues to evolve in response to new information, external fiscal and politicalpressures, and collaborative efforts with trainees and colleagues. EDP’s service, educa-tion, and research efforts have been guided by an ongoing commitment to preventive in-tervention and the four theoretical assumptions stated in the introduction. Theseassumptions that emphasize the context of the caregiving environment, the biopsychoso-cial model of development, the power of relationships, and the need for a collaborative in-terdisciplinary approach have supported the development of EDP’s process andstructures. EDP services are designed as a family-centered therapeutic process that buildson biopsychosocial strengths and creates an ongoing mutual process of learning aboutand helping the child. In EDP, families and professionals learn together how to helpyoung children develop to their fullest potential.

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Documents

Early development program: Collaborative structures and processes