Infant Mental Health and Early Care and Education Providerscsefel.vanderbilt.edu/documents/rs_infant_mental_health.pdf · depression, and psychological ... influence on children’s

This synthesis has beendeveloped to answer some ofthe most frequently asked

questions that early childhoodproviders have about Infant MentalHealth (IMH) - early social andemotional development - and the IMHsystem. It also provides informationabout where to turn for additionalinformation for promoting IMH whenchildren and families are experiencingchallenges. The synthesis will address:• The definition of IMH• Why it is important that early

childhood providers know aboutIMH

• Approaches to promoting IMH• Prevention of IMH challenges• Focused intervention with children

and families at risk• More intense/tertiary interventions

What is infant mental health?Infant mental health (IMH) is

synonymous with healthy social andemotional development. The terms areused interchangeably throughout thisdocument.

IMH is the developing capacity ofthe child from birth to 3 to experience,regulate (manage), and expressemotions; form close and secureinterpersonal relationships; and exploreand master the environment and learn -all in the context of family, community,and cultural expectations for youngchildren. • Developing capacity is a reminder

of the extraordinarily rapid pace ofgrowth and change in the first 3years of life.

• Infants and toddlers depend heavilyon adults to help them experience,regulate, and express emotions.

• Through close, secureinterpersonal relationships with

parents and other caregivers, infantsand toddlers learn what peopleexpect of them and what they canexpect of other people.

• The drive to explore and masterone’s environment is inborn inhumans. Infants’ and toddlers’active participation in their ownlearning and development is animportant aspect of their mentalhealth.

• The contexts of family andcommunity are where infants andtoddlers learn to share andcommunicate their feelings andexperiences with significantcaregivers and other children. Adeveloping sense of themselves ascompetent, effective, and valuedindividuals is an important aspect ofIMH.

Infant Mental Health and EarlyCare and Education Providers

Research Synthesis

The Center on the Social and EmotionalFoundations for Early Learning

Child Care Bureau

Office ofHead Start

The Center on the Social and Emotional Foundations for Early Learning Vanderbilt University vanderbilt.edu/csefel

used to describe a field of study andpractice that has grown during the lastthree decades into a broad-based,multidisciplinary, and internationaleffort to enhance the social andemotional well-being of very youngchildren (Heffron, 2000).

We know that infants and toddlersexperience the full spectrum of socialemotional functioning ranging fromdevelopment that seems to be on track(e.g. the ability to form satisfyingrelationships with others, play,communicate, learn, and experience arange of human emotions) to socialemotional disorders Therefore,researchers from a wide variety ofdisciplines have engaged in researchand clinical study to build ourknowledge about infant development,caregiver-infant relationships, andenvironmental influences on children’semotional development (Fitzgerald &Barton, 2000). The disciplines of childdevelopment, psychiatry, social work,psychology, health, special educationand others involved in assessing andtreating young children, in both mentalhealth and health care settings, are coredisciplines in IMH. Early care andeducation, early intervention and childwelfare play an important role as well.Each discipline has a uniqueperspective through which it viewsinfants and their development and eachtakes on both unique and overlappingroles in supporting social emotionaldevelopment (Zeanah & Zeanah,2000).

Another way for providers to thinkabout infant mental health is to thinkabout the range of care, education, andfamily support that are offered to veryyoung children (Zeanah, Stafford,Nagle, & Rice, 2005) depending onhow they seem to be getting along(Zeanah, Stafford, & Zeanah, 2005).The levels of care that we discuss inthis paper are promotion andprevention, focused intervention, andtertiary (more intense services):

Promotion and Prevention -encouraging good mental health andsocial emotional wellness

Early childhood care andeducation programs that include familysupport can be effective in thepromotion of infant mental health andprevention of IMH challenges (Zeanah,et al. 2005). We know that infants andtoddlers experience typicaldevelopmental challenges: separationanxiety, stranger anxiety, autonomyissues, management of their emotions,toilet learning, peer conflict, and manymore. While working with families,early care and education providersmake emotional and resource supportavailable for the child and family topromote infant and toddler well-being.

Early childhood programs such asEarly Head Start and child care in bothcenters and homes play an importantrole in the promotion of infant mentalhealth. In addition, home visitingprograms and health-related programssuch as Women, Infants, & Children(WIC) and well-child visits canemphasize the importance of 1)supporting the parent-childrelationship; 2) understanding typicalchild development and each child’sunique temperament; 3) learningpositive behavior support strategies;and 4) working to reduce family stressin order to help promote children’smental health of children.

Focused Intervention - preventing theoccurrence or escalation of mentalhealth problems and minimizingchildren’s social emotionaldevelopmental risk (usually a family-centered process)

Children and families may be atrisk for experiencing challenges totheir mental health (Sameroff, Bartko,Baldwin, Baldwin & Seifer, 1998;Sameroff & Fiese, 2000). Caregivers infamilies may experience chronicillness, homelessness, hospitalization,stress, a history of abuse, attachmentchallenges, short- and long-termdepression, and psychologicalvulnerability (Conroy & Marks, 2003).“Biological factors affecting thechild—such as prematurity, low birthweight, disability, and difficulties in

• Culture influences every aspect ofhuman development, including howIMH is understood, adults’ goalsand expectations for youngchildren’s development, and thechild rearing practices used byparents and caregivers (ZERO TOTHREE Infant Mental Health TaskForce, 2001).

Essentially, infant mental healthfocuses on the optimal social andemotional development of infantsand toddlers within the context ofsecure, stable relationships withcaregivers (Zeanah & Zeanah,2001).

These caregivers include thechild’s birth parents, adoptive parents,foster parents, grandparents, and childcare and education providers as well asother significant adults who share theprimary care and nurturance of infantsand toddlers (Weatherston &Tableman, 2002). IMH, then, has itsroots in the understanding that earlydevelopment is the product of theinfant’s characteristics, caregiver-infantrelationships, and the environmentwithin which these relationshipsunfold. All of these factors influencean infant’s mental health.

In addition to a focus on thechild’s social emotional development,the term infant mental health is also

The term infant mental healthis also used to describe a fieldof study and practice(Heffron, 2000) and a systemof • prevention of social and

emotional challenges • promotion of social and

emotional health, and• treatment to support a

return to social andemotional health (Zeanah,Stafford, Nagle, & Rice,2005).


sensory processing and regulation -may also present obstacles to healthyemotional development. Thecumulative impact of multiple riskfactors poses a potent threat to infants’and families’ mental health” (Chazan-Cohen, Jerald, & Stark, 2001, p. 7).Zeanah et al. (2005) report on theoutcomes of a number of evidenced-based intervention programs.

Focused intervention includesproviders collaborating with families toassess and employ strategies to supportchildren with challenging behaviors.Early Head Start and Child Careprograms may provide training toprepare early care and educationproviders to offer these types ofprograms. Other programs may employsocial workers or mental healthconsultants to provide focusedintervention.

IntensiveIntervention/Treatment - Moreintense services and supports to helpaddress mental health needs early andprovide intensive services to support areturn to positive developmentalprogress (usually a family-centeredprocess)

Infants, toddlers, and their familiesmay face very challengingcircumstances and experiencetraumatic events—child abuse, posttraumatic stress disorder, violence,ongoing attachment challenges,depression, and health problems - thatcontribute to mental health concernsand that require more focusedintervention with a mental healthprofessional. “Infant mental health isconcerned with risk factors that relateto …serious psychiatric disorders thatcause suffering and developmentalcompromises” (Zeanah & Zeanah,2001, p.16). Infant and toddler care andeducation providers will want topartner with community services toprovide the more intensive services andsupports that children and families andchildren need, whether within theprogram or in the community.

Why are nurturing andresponsive relationships socritical for infants and toddlers?

RELATIONSHIP EXPERIENCES IN THE EARLY

YEARS LAY THE FOUNDATION FOR

DEVELOPMENT

The early years of life lay thefoundation for a child’s lifelongdevelopment. From the time ofconception to the first day ofkindergarten, development proceeds ata pace exceeding that of anysubsequent stage of life (NationalResearch Council and Institute ofMedicine, 2000). It is during this timethat the brain undergoes its mostdramatic growth, and children acquirethe ability to think, speak, learn andreason. Early experiences, includingearly relationships, can and doinfluence the physical architecture ofthe brain, literally shaping the neuralconnections in the infant’s developingbrain (National Scientific Council onthe Developing Child, 2005).Research shows that supportiverelationships have a tangible, long-terminfluence on children’s healthydevelopment, contributing to optimalcognitive and social emotionaldevelopment for infants and toddlers(Zeanah, 2001).

ATTACHMENT RELATIONSHIPS IMPACT SOCIAL

AND EMOTIONAL DEVELOPMENT

Those who study the science ofearly emotional development haveconcentrated much attention on thequality of infants’ first relationships. Inthe earlier definition of infant mentalhealth, “the capacity to form close andsecure interpersonal relationships”

Why is it important for Earlychildhood Providers to knowabout Infant Mental Health?

Early care and education programshave unique opportunities topromote infant mental health. Fromthe way teachers interact withinfants during feeding anddiapering to the way they engageparents in the care of their child,early care and education programsare continuously building andnurturing relationships whichsupport the social emotionaldevelopment of infants and theirprimary caregivers (Chazan-Cohen,Jerald, & Stark, 2001, p. 7)

• Early childhood providers sharewith families the importantresponsibility of promoting andsafeguarding the early socialemotional development of infantsand toddlers.

• The relationship between a childand his/her family will have animpact for the remainder of thatchild’s life.

• Collaborating with families,supporting families, reducing familystress, and providing childdevelopment information throughhome visits and family supportprograms will promote families’understanding of the importance ofearly social emotional development.Supporting families will help toprevent child abuse and neglect,maternal depression, attachmentchallenges, and traumatic events.

• Understanding early socialemotional development will enablea provider to enhance herrelationships with infants andtoddlers in her care.

• Early childhood providers are in acrucial position to be able to identifysigns of problems for infants andtoddlers who may need moreintensive services to support theirdevelopment.

A secure and responsiverelationship between the infant ortoddler and his or her primarycaregivers is the foundation ofmental health in the earliest yearsand the context in which healthysocial and emotional developmentcontinues to flourish (Chazan-Cohen, Jerald, & Stark, 2001, p. 7)

Relationships developed duringinfancy and toddlerhood provide thecontext for supporting thedevelopment of curiosity, self-direction, persistence, cooperation,caring and conflict resolution skills(Lieberman, 1993; Greenough, et. al.,2001) - all important skills in thedevelopment of school readiness(Kaplan-Sanoff, 2000). As a childmatures, supportive relationships withparents and other caregivers who aresensitive to the individual needs ofthat particular child shape the child’sself-image. A strong, positive internalimage provides the young child withthe resilience needed to face life’schallenges.

Another facet of the attachmentrelationship is the central role it playsin the regulation and management ofemotions (Cassidy, 1994; Volling,2001; Egeland & Bosquet, 2001).Because they are not able toindependently manage or easilycontrol their own emotions, youngchildren need the assistance of aprimary caregiver. At birth, infantshave the capacity to express distressthrough crying and other means thatare signals for the caregiver torespond. An attentive caregiver’sresponse to these signals keeps theinfant’s distress within reasonablelimits. The infant can then experiencerelief from overwhelming emotion ascaregivers offer help and support(Egeland & Erikson, 1999).

Supportive early emotionalexperiences put the infant on apositive pathway toward schoolreadiness. When children enter school,they must have achieved the emotionaland behavioral self-regulation that willallow them to approach the world withconfidence, curiosity, andintentionality. To be successful inschool they must also have thecapacity to communicate andcooperate with others (NationalResearch Council and Institute ofMedicine, 2000).

refers to the very importantdevelopmental concept of attachment.Attachment is a term used to describethe emotional bond that develops overtime as the infant and primarycaregiver interact (Bowlby, 1969,1982). Researchers describe the infantas biologically inclined to use thecaregiver as a provider of safety,creating a “secure base” for the infant.

For example, a crying infant,frightened by unusual noise, may calmimmediately when picked up by afamiliar caregiver. The adult is theinfant’s secure base. Through repeatedmoments of responsive and sensitivecare, infants learn to trust caregivers(Egeland & Erickson, 1999). With theability to predict that they will besafeguarded, typically developingemotionally healthy infants andtoddlers explore their surroundings butseek out that special person - theirsecure base - at times of threat–danger, illness, exhaustion, orfollowing a separation. When the fearof danger is over, the need to return tothe secure base will decrease, but onlyif the infant can count on the personbeing there if needed. When infants ortoddlers feel secure, they are able toturn their attention to other tasks likelearning how to use the climbingequipment or how to get along withother children (Holmes, 1993). Wheninfants and toddlers have this support,they also can learn how to empathizewith and to act with compassiontoward others.

NURTURING AND RESPONSIVE RELATIONSHIPS

FOSTER POSITIVE SOCIAL EMOTIONAL

DEVELOPMENT

The caregiving relationship is themajor influence on the learning andgrowth that takes place during theearly years. Caregivers, includingearly childhood providers, engage ininteractions that form the infant’s firstrelationships that, in turn, serve asmodels for all future relationships.They are crucial for the developmentof trust, empathy, compassion,generosity, and conscience.

FAMILY-CHILD AND PROVIDER-CHILD

INTERACTIONS LEAD TO HEALTHY SOCIAL

EMOTIONAL DEVELOPMENT

The following is a list adaptedfrom the National Research Counciland Institute of Medicine (2000) thatidentifies some of the interactions thatcharacterize supportive and nurturingrelationships between parent and childor between early childhood providerand child: • Responsive care that contributes to

the child’s developing self-confidence

• Affection and nurturing that buildsthe child’s developing self-esteem

• Protection from harm and threats ofwhich they may be unaware

• Opportunities to experience andresolve human conflictcooperatively

• Support to explore and develop newskills and capabilities

• Exchanges through which childrenlearn the give-and-take of satisfyingrelationships with others

• The experience of being respectedand of respecting others

NURTURING RESPONSIVE RELATIONSHIPS –HOW TO PUT RESEARCH INTO PRACTICE:• To the extent possible, provide

consistent long-term stablerelationships between earlychildhood providers and infants andtoddlers as well as betweenproviders and parents. Considerassigning primary caregivers whotake the lead in the care of specificinfants and toddlers.

• Use a continuity of care modelwhere caregivers remain withinfants and toddlers from infancy tothe late toddler years.

• Initiate practices where staffregularly talk with each other andreflect on how to best providesensitive, responsive care.

• Provide appropriate provider/childratios and small group sizes toensure responsive relationships.

• Engage in professional developmentopportunities to learn more aboutthe importance of relationships andresponsive practice.


Parents who receive strong supportfrom family and significant friendshave better resources with which torespond to their infant’s socialemotional needs. Those who are cutoff, for whatever reason, from sourcesof emotional support and hands-onhelp may find that their isolationcontributes to their stress level andmakes meeting their infant’s needsdifficult or overwhelming. Earlychildhood systems that serve infantsand toddlers and their families havethe opportunity to positivelycontribute to a family’s social supportnetwork and to reduce the level ofstress families may experience (Seibel,Britt, Gillespie, and Parlakian, 2006;Gowen & Nebrig, 2002).

STRESS AND A FAMILY’S CAPACITY TO ADAPT

TO STRESS AFFECT PARENTING

Another major influence on aninfant’s or toddler’s mental health isthe general level of stress a familyexperiences and the family’s capacityto adapt to that stress. Ideally, familiesare able to meet individual members’social, emotional, and physical needs -even during periods of change andupheaval (and the period surroundingthe birth of a child is a period of stressand change for all families!) Whenthere is additional stress fromenvironmental circumstances such aspoverty, poor housing, or communityviolence, or when there are genetic orconstitutional factors that make caringfor a infant particularly challenging,such as prematurity, developmentaldisabilities, or special health careneeds, parents’ capacity to providetheir infant or toddler with consistent,sensitive, responsive care may beadversely impacted.

AN INFANT’S UNIQUE CHARACTERISTICS

INFLUENCE THE PARENTING RELATIONSHIP

Infants and toddlers, as young asthey are, exert a strong influence onrelationships in the family system.Infants come into the world with theirown style of reacting to andparticipating in the world aroundthem. Each infant’s inborn capacity to

Why is it necessary to supportand collaborate with the familywhen promoting children’ssocial and emotionaldevelopment and preventingsocial emotional challenges?

THE FAMILY IS THE PRIMARY INFLUENCE ON

SOCIAL EMOTIONAL DEVELOPMENT

Infants and toddlers depend ontheir parents and other caregivers toprovide the primary foundation fordevelopment. Efforts by a provider tocommunicate and developrelationships with each child’s familydemonstrate respect for and anunderstanding of the family’s key rolein shaping children’s fundamentallearning about themselves, theiremotions and their way of interactingand relating to others (NationalResearch Council and Institute ofMedicine, 2000).

PARENTING IS LARGELY INFLUENCED BY HOW

ONE WAS PARENTED

Providing sensitive, responsiveand consistent parenting is challengingwork. Each child’s family has its owncomposition and history, its ownstrengths and its own ways of copingwith stress and adversity. The varyingdegrees of knowledge, confidence,excitement, anxiety, and sensitivitythat mothers and fathers bring toparenting are powerfully influenced bytheir relationships with their ownmothers and fathers (van IJzendoorn,1995). Providers in early childhoodsystems must be sensitive to the vastrange of life and cultural experiencesthat parents bring to the job ofparenting.

CONNECTION WITH FAMILY AND FRIENDS

SUPPORTS PARENTING

Parents’ ability to support theirchildren’s social emotionaldevelopment also is affected by thedegree to which they are in regularcontact with extended family andfriends as well as by the extent towhich this network is able to providepractical help and emotional support.

adapt to the world outside the wombaffects the interactions that the infantexperiences with parents and primarycaregivers as well as the quality ofthese growing relationships. The needsand demands of a particular infant willbe viewed through the lens of thefamily’s unique history and culture.One family may experience a childcharacteristic (e.g. shyness) asdifficult, while another family mayexperience the same characteristic asendearing. Parents and providers willwant to observe and discuss thechildren’s unique characteristics andtheir influence on them.

CULTURE HAS A STRONG IMPACT ON

PARENTING

One of the most challengingdimensions of providing high qualitycare in early childhood systems is theneed to be attuned to and supportiveof the increasing cultural diversity ofchildren and families served. Culture,which influences every aspect ofhuman development and is one of themost powerful influences on socialemotional development, is made up ofthe shared beliefs, values, and goals ofa group of people (Kalyanpur &Harry, 1999). It involves an integratedpattern of behavior that includesthoughts, communications, practices,beliefs, values, customs, ways ofinteracting, roles, and expectedbehaviors of an ethnic, racial,religious, or social group (Cross,Bazron, Dennis, & Isaacs in Day &Parlakian, 2004). Culture istransmitted through succeedinggenerations and is dynamic. The effectof culture on family functioning isreflected in child-rearing practices,family roles, perceptions aboutsupports and stressors, views aboutnormal development, and the meaningattributed to children’s behavior. Oneof the most frequently studied aspectsof cultural values is the way in whichfamily members think about andemphasize independence orinterdependence. When providersunderstand cultural differences thatinfluence the ways parents promote


families’ communication style andexpression of emotion.

RESPECT AND EMPATHY INFLUENCE

PARENTAL FUNCTIONING

When parents feel that their ownconcerns are accepted and respectedand when efforts are made tounderstand their perspective and meettheir needs, they are more capable ofdoing the same for their children(Parlakian & Seibel, 2002). Whenproviders seek to build the parent’scompetence and confidence withrespect and empathy and the parentfeels secure in relationships withproviders, the parent’s investment,enjoyment, and commitment in therelationship with the child will beenhanced.

TAKING THE CHILD’S FAMILY INTO

CONSIDERATION–HOW TO PUT RESEARCH

INTO PRACTICE:• Develop a family-provider

partnership to create responsiveprograms that meet the family’sneeds, priorities, and concerns.Families must be actively involvedin the planning, implementation,and monitoring of the servicesbeing offered (Cornwell &Korteland, 1997). When earlychildhood providers value andsupport family members, theymodel strategies for parents to

value and support their children. • Recognize the family’s major

influence on infants’ and toddlers’social emotional development.Families exert an enormous impacton development throughout the lifespan through their interactions,their guidance strategies, theirprovision of comfort,understanding of typicaldevelopment, and the quality ofattachment between them and theirchildren,

• Take steps to learn about thefamily’s relationships, history,stress level, capacity to adapt tostress, the individual characteristicsof the infant or toddler, and thefamily’s unique culture.

dependence or independence, they willunderstand why one child may staynear them much of the time whileanother child plays independently withtoys most of the time.

In order to support the socialemotional development of infants andtoddlers and their relationships withtheir families, it is important for earlychildhood providers to try tounderstand what meaning a familyassigns to the expression of aparticular emotion or behavior. Forexample, a family may believe thatwhen an infant cries, she should beimmediately picked up and respondedto. Another family may believe thatthe infant should have a little time towork through her emotions prior tobeing picked up. Differences in suchchild rearing beliefs and practices cancreate tension and confusion whenthey are not discussed openly andsensitively (Pawl & Dombro, 2001).

CULTURE INFLUENCES COMMUNICATION AND

THE EXPRESSION OF EMOTION

One major characteristic ofculture is communication style.Findings from cross-cultural researchsuggest that basic human emotions areuniversal (Ekman, 1994 in Trawick-Smith, 2003). Broadly speaking,emotions such as fear, anger, andhappiness are part of humaninteractions in all cultural groups.Variations emerge in the way that theyare expressed or communicated.Beginning from birth, children learnappropriate ways of expressingemotion based on cultural and familynorms. Emotional expressions thattend to vary across cultures areanimation, intensity of emotionalexpression, volume (loudness) ofspeech, directness of questions,directness of eye contact, touching,use of gestures, and physicalproximity/distance or zone of personalspace with which people feelcomfortable (Day & Parlakian, 2004).Relationships and communication willbe more likely to flourish whenproviders observe and understandcultural difference in children’s and

• Be willing to adapt care practices tosupport the nurturing efforts of thefamily by, for example, holding orcarrying an infant more frequentlyif that is the parent’s preference.

• Identify and respect the strengths ofindividual family members and thefamily as a whole.

• Focus simultaneously on theemotional needs of parents andfamily members as well as theemotional needs of the infant ortoddler.

• Seek frequent feedback fromfamilies on their perspectives inorder to continually reassess theappropriateness of the caregivingenvironment being provided.

What knowledge and skills aremost important when promotinginfant mental health?

INFANT AND TODDLER PROVIDERS NEED

SPECIALIZED SKILLS

All early childhood providers whowork with infants, toddlers, and theirfamilies need specialized knowledgeand skills to address the uniquedevelopmental needs of children birthto three and their families (Fenichel &Eggbeer, 1990; Michigan Associationfor Infant Mental Health, 2002). Boththe excitement and challenge ofworking with this population stemfrom the fact that all areas ofdevelopment are interconnected.Because all areas of development arelinked, understanding development is acomplex task. There are also manyinterconnections between infants andtheir caregivers, between the familyand the community, and among parentsand the array of professionalsconcerned with very young childrenand their families.

The following is a list of skillsthat are critical to competent servicesto infants and their families, whetherthey are provided in center or home-based child care, Early Head Start, orhome-based settings:• Observing – carefully watching

behavior and communication in a


• Enduring responsive relationshipsare critical for development

• Parenthood is a developmentalprocess

Providers often wish to “beeverything” to the infant and family(for beginning practitioners this is oftenexpressed as the feeling that mastery ofsome specific new technique wouldmake them infinitely more effective).This desire to be an expert collides withthe realization that knowing one’slimits and seeking to learn from andcollaborate with other professionals andwith parents are true signs ofcompetence. The more one learns aboutany aspect of the development ofinfants and toddlers, the more onerealizes how much more there is toknow.

REFLECTIVE SUPERVISION SUPPORTS

COMPETENCE IN INFANT AND TODDLER

PROVIDERS

In addition to ongoing training,infant and toddler providers will benefitfrom receiving reflective supervision.Work with, and within, relationshipsrequires opportunities for stepping backand reflecting on what is happening.Reflective supervision is the heart ofreflective practice. It takes placebetween a supervisor and a superviseeand is characterized by active listeningand thoughtful questioning by bothparties. It happens on a regularschedule and can be done withindividuals or groups, by supervisors orby peers (Gilkerson & Shahmoon-Shanok, 2000). While not easy to putinto place in early childhood settings, itcan provide essential support for qualityservices.

ENSURING THAT EARLY CHILDHOOD PROVIDERS

WHO WORK WITH INFANTS AND TODDLERS

HAVE THE NECESSARY KNOWLEDGE AND

SKILLS - HOW TO PUT THE RESEARCH INTO

PRACTICE:Seek to learn the specialized knowledgeand skills unique to the emotional andsocial needs of infants and toddlers(and their families) in the first threeyears of life.

variety of activities with adults andpeers over the course of a day;noticing behavior, rituals and dailygive-and-take in the parent-childrelationship

• Listening – tuning in to parents asthey share, verbally and in bodylanguage, their thoughts, feelingsand reactions

• Reflecting - on the meaning ofbehaviors, experiences, andcommunications from or about theinfant

• Building self-awareness –reflecting on one’s own reactions,thoughts and feelings to learn howto be emotionally present andresponsive without becomingemotionally involved

• Seeking collaboration andsupervision - both within andacross disciplines with colleaguesand mentors to extend one’sknowledge and have a safe place toexamine both positive and negativefeelings aroused by working withinfants and families

• Mastering important knowledgeand skills - studying, askingquestions, and reflecting on thechild, the parent(s), the parent-childrelationship, the child’s family, andthe community in which the childand family live (Fenichel &Eggbeer, 1990; Gilkerson &Shahmoon-Shanok, 2000).

INFANT AND TODDLER PROVIDERS NEED TO

MASTER A CORE KNOWLEDGE BASE

The daily activities of earlychildhood providers working withinfants and toddlers may vary butthere are a set of core concepts whichunderlie all sound practice withchildren and families in the first threeyears of life. These concepts help toorganize what is known about infantsand families and suggest what is yet tobe discovered or understood. The coreconcepts include: • Genetic and environmental factors

work together to influencedevelopment

• Healthy infants are born preparedto form warm emotionalrelationships

• Make sure there are opportunitiesfor reflective supervision toincrease caregivers’ competence andcapacity to think through a situation,consider different approaches,observe carefully to figure outwhich approach might work best, trysomething and then evaluatewhether it works - all the whilebeing able to describe what is beingdone and for what reasons.

• Support infant and toddlerproviders’ competence by ensuringthat they also have the opportunityto discuss issues or concerns withparents and with peers.

What are some of the thingsthat caregivers should considerwhen trying to understand childbehavior that might beconsidered challenging?

INFANT AND TODDLER BEHAVIOR HAS MEANING

Infants and toddlers developexpectations about relationshipsthrough their everyday interactions withimportant adults. All children want tofeel protected, cared for, understood,and loved. In the absence of disabilitiesor serious health care issues, veryyoung children whose needs are metwill achieve important developmentalmilestones in all domains ofdevelopment. However, if their needsare not met, development likely will beadversely impacted. When their socialand emotional needs are not met,infants and toddlers may struggle withways to return to a feeling of wellbeing. This struggle and their attemptsto communicate their distress mayresult in behavior that is challenging forcaregivers. In other words, all behaviorhas meaning as children try tocommunicate what they are feeling. Itis the provider’s job to interpret whatthey are “saying.”

There are infants and toddlers whohave personal histories that provide lessthan positive lessons about their worldand about relationships. Some childrenhave learned that their needs will notalways be met. Some have learned that


VERY YOUNG CHILDREN LEARN CULTURALLY

ACCEPTABLE BEHAVIORS

Children are born prepared tolearn and they do learn a great deal inan incredibly short amount of time.They learn when it is appropriate to eatwith fingers and when it is appropriateto use spoons; when it is appropriate towear clothing and when it isappropriate to wear pajamas. Theylearn all the rules of the family andculture in which they live. They learnthat toys are shared, but nottoothbrushes; it is acceptable to laughat some things, but not at others;sometimes adults tease and sometimesthey are serious. Infants and toddlerslearn what behavior is expected ofthem through their relationships withfamily members and other caregivers.They learn all of this as vulnerable,dependent, and curious creatures whoboth strive for an emotional connectionwith those that care for them and striveto master their physical environment(National Research Council andInstitute of Medicine, 2000).

At their most effective, adults areable both to support the completedependency of the newborn andincreasingly respect and support thegrowing autonomy of the toddler.Toddlers are constantly watching thepeople they trust to help them learnhow they should behave. They see howadults treat one another and otherchildren to figure out how they willact. They constantly assess adults’reactions to them for messages aboutlove and their own worth. For infantsand toddlers, getting no response at allto their actions may send the messagethat they are not worth being cared for.The deeper the adult’s understandingof patterns of typical development, theeasier it will be to respond withsensitivity and consistency (Lerner &Dombro, 2005).

CHALLENGING BEHAVIORS ARE OFTEN

ASSOCIATED WITH ACTING OUT OR SOCIAL

WITHDRAWAL

The characteristics or patterns ofbehavior that early childhood providersfind difficult to respond to are often

their needs may not be met in a lovingor nurturing way. A child’s internalstruggle or feelings of distress, hisefforts to cope, may show as behaviorsthat are difficult for caregivers toaccept or manage. The child’s inabilityto communicate or ask for what isneeded may be a consequence of age,of the child’s having had little successin getting his needs attended to, or ofsome undiagnosed physical problem(e.g. trouble hearing or problems withregulating different systems in hisbody). A child might pull away from aninteraction to insure his own safety.Another may strike out because hebelieves that he must fend for himself.The intensity of challenge that thesebehaviors present to caregivers isevidence of how intensely these veryyoung children will strive tocommunicate their emotional needs.

CAREGIVERS DEFINE CHALLENGING BEHAVIOR

“Challenging behavior” for aninfant or toddler can be defined as anybehavior that feels overwhelming toand that challenges a provider’s,child’s, or family’s sense ofcompetence (Early Head Start NationalResource Center, 2006; Wittmer &Petersen, 2006). It is important to pointout that behavior that is of concern toone caregiver may not affect another inthe same way or to the same degree,depending on the internal response ofthe caregiver, his or her own childhoodand parenting experiences, and priorexperiences with a variety of youngchildren.

Challenging patterns of behaviormay have many causes including thoseassociated with the infant’s geneticconstitution, with relationships theinfant has, or with the physicalenvironment in which care is provided.The cause of the behavior may not befully understood by any of the child’scaregivers. Yet the reality of the child’sneed for sensitive and responsive carerequires that both parents and providerscooperatively develop strategies forunderstanding and managing thebehavior.

related to the perception that thebehaviors are of greater frequency,intensity and duration than that of a“normal” or “typical” child. Twocategories of challenging behaviorsare often identified by parents andcaregivers: acting out or aggressivebehaviors and social withdrawalbehaviors. Acting out behaviors mayinclude: inconsolable crying, fussing,frequent tantrums, pushing, hitting,biting other children, frequentlythrowing things or knocking thingsdown, destroying materials, andfrequently refusing to participate inplay or routine activities. Socialwithdrawal behaviors include pullingaway while being held, rarely cooing,babbling or talking, looking sad, notshowing a preference for the caregiver,not making eye contact, whining,being overly compliant or avoidantwith the caregiver, not usingcommunication skills that have beenpreviously used, and difficulties withsleeping and eating (Kelly,Zuckerman, Sandoval & Buchlman,2003).

TEMPERAMENT HAS AN IMPACT ON BEHAVIOR

It is important to understand theimpact of inborn, biologicaldifferences on the behavior ofindividual children. Each infant isborn with a personal style, a typicalway of approaching or reacting to theworld (Chess & Thomas, 1996).Learning about temperament can helpproviders understand more about theseinborn traits that play a major role ineach child’s pattern of behavior andmay eventually have a major influenceon self esteem. Temperament does notpredetermine behavior nor is it an“excuse” for behavior. However,being alert to and knowledgeableabout temperament traits can helpadults not only understand whychildren react to events differently butalso provide help in knowing whatkind of individualized support thechild could benefit from.

In literature on the relationshipbetween social emotional developmentand school readiness, an easy


relationships with caregivers (Olson,Bates & Sandy, 2003; Chess &Thomas, 1996). The compatibilitybetween the temperament traits of achild and the temperament traits of aprovider or parent may influence theadults’ reactions to a particular childand expectations for that child’sbehavior. For example, a caregiverwith an intense, active and adaptabletemperament may need to reduce thevolume of her voice, provideadditional quiet activities, and providewarnings for transitions for an infantor toddler who is less intense, lessactive and may have trouble adaptingto new situations or experiences. Theability of the caregiver to be flexible,to adapt responses to the temperamentof an individual child is key to theprobability that a child will receivesensitive, responsive care. In addition,caregivers who understand theinfluence of a particular child’stemperament on their own emotionalreactions to that child are more able tothoughtfully modify their responses(Early Head Start National ResourceCenter, 2006).

CAREGIVERS NEED KNOWLEDGE OF CHILD

DEVELOPMENT

As infants grow and develop, allof their abilities - cognitive, language,motor, social and emotional - becomemore sophisticated and complex.There are times in the first three yearswhen maturation itself creates periodsof unsettled behavior in children. Forexample, toddlers increasinglyunderstand the effects of their actionson others as they become more awareof the peers and adults in their world.A toddler’s “no” can be challenging toa caregiver who wants that child tocomply, yet the toddler isdemonstrating her maturity byasserting her growing independence.She is testing limits and boundaries.Learning how to support children’sgrowing independence and at the sametime provide a reasonably positive andcalm experience for all children in agroup can test the skills of even aseasoned provider.

temperament and personality areconsidered protective factors forschool success. Conversely, a difficulttemperament and personality areconsidered to be risk factors for poorschool performance (Huffman,Mehlinger, & Kkerivan, 2000).Positive parent and provider practiceswith very young children of alltemperament types may help thosechildren, regardless of temperament,avoid developing behavior patternsthat progress to poor relationshipswith peers and teachers at school.

One framework for understandingtemperament identifies nine traits thatappear to be biologically based,remain fairly constant over time, andaffect a child’s reactions to otherpeople and the environment (Thomas,Chess, Birch, Hertzig & Korn, 1963).Together, these nine traits areconsidered key components of thechild’s temperament:• Activity level: natural, child-

initiated amount of physicalmovement

• Biological rhythms: regularity ofchild’s eating, sleeping, andelimination patterns

• Approach and withdrawal:child’s initial reactions to a newsituation

• Mood: prevalence of calm,cheerful interest or sadness orirritability

• Intensity of reaction: energy levelor vitality of emotional expressions

• Sensitivity: level of response tosensory experiences such as light,sound, textures, smells, tastes

• Adaptability: the child’s ease inadjusting to changes in routines orin recovering from being upset

• Distractibility: how easily thechild’s attention is diverted fromhis previous focus

• Persistence: how well a child canstay with an activity that becomessomewhat frustrating

THE CAREGIVER’S TEMPERAMENT IS

IMPORTANT AS WELL

An infant’s temperamentinfluences behavior and may have amajor impact on evolving

Most infants and toddlers haveunhappy moments, but they usuallyhave the capacity to calm down andenjoy being with their peers. Theemergence of social and emotionalcontrol depends in part on the supportthe child has had to master hisimmediate reactions to events andbegin to use self-calming, thinking, andeventually communication skills as away of coping. Some researchers see ayoung child’s every expression ofdistress as an opportunity forinteraction that will build relationshipswith an important adult which will, inturn, further extend the child’s socialemotional development (Robinson &Acevedo, 2001).

SCREENING AND ASSESSMENT ARE IMPORTANT

The use of valid screening andassessment procedures to identifyconcerns and delays early is anessential part of a system to supporthealthy early development. Thoseprograms that use on-going assessment(i.e. tools to gain information about achild’s strengths, needs, familyresources and priorities) and screeningtools are in a good position to identifysocial and emotional concernseffectively and early (Early Head StartNational Resource Center, 2002).Early care and education providers canuse curriculum-based assessments on afrequent basis to assess thedevelopmental strengths and needs ofchildren. On-going assessmentprovides specific and timelyinformation to caregivers and parentsabout a child’s progress and possibleneed for support within the program.Providers use the information to plan aprogram that meets children’sindividual needs. These assessmentprocesses can support programs toindividualize services to address thesocial emotional outcomes for eachchild

Screening tools are assessmentsthat determine if a child’sdevelopmental skills are progressing asexpected, provide information aboutoverall child development, and indicateto caregivers and parents if a child


process. Review the followingquestions with the staff and familymembers present.

• What is the child experiencing?What is the child’s perspective onthe situation? What strengths can beobserved in the child’s developmentor behavior patterns?

• What, when, where, how and withwhom is the undesirable behavioroccurring?

• What needs is the childcommunicating? What is thepurpose of the child’s behavior?What is the meaning of the child’sbehavior?

• What do I (we) want the child todo?

• Who are the relationships that areimportant to the child? Who canemotionally support the child?

5. Determine an individualizedconsistent plan for intervention

6. Continue observation anddocumentation to provide data forevaluating improvement andensuring the consistency of theintervention

7. Consult with a mental healthprofessional if the child is notresponding and the persistence,frequency, and duration of thebehavior is not improving (seebelow for a more detaileddescription of the role of the mentalhealth consultant)

Determine whether further referralto community resources is necessarythrough discussion with family, thesupervisor, and a mental healthconsultant (Early Head Start NationalResource Center, 2006).

This protocol assumes thatphysical health issues have beenaddressed by a physician and that thereis no clear physical health explanationfor the child’s behavior. At times, sucha protocol may uncover additionalhealth issues (e.g. frequent ear aches,vision problems) to explore as possibleexplanations for the observed behavior.Regardless of the etiology of thechallenging behavior, the precedingquestions can lead providers andfamilies to a deeper understanding ofthe child’s experience.

needs a more in-depth evaluation.Screening tools typically are used atthe beginning of a program year.Providers can contribute importantinformation to the screening processby observing children in care inmultiple activities during the day. If ascreening tool indicates that a childneeds a more in-depth evaluation, s/heis referred to an assessment team. Theresults of a formal assessment processinform the daily interactionexperiences as well as neededspecialized services (O’Brien, 2001).

For more information aboutscreening and assessment instruments,caregivers can go to • http://www.abcdresources.org/

Activities/IdentifyingRisk/Peer_Resources.php .

• http://www.first5caspecialneeds.org/documents/IPFMHI_CompendiumofScreeningTools.pdf

• http://www.acf.hhs.gov/programs/opre/ehs/perf_measures/index.html

USE A PROGRAM PROCESS FOR

UNDERSTANDING CONCERNING BEHAVIOR

When an infant’s or toddler’s behaviorappears, over time, to be disruptingsocial emotional development,providers are right to be concerned.Having a program process or protocolabout what to do can provide a timely,systematic and organized approach togathering additional information aboutthe behavior in order to make gooddecisions about what to do next. Sucha protocol is based primarily ondocumented observations by themultiple staff providing services to thechild and family. The protocolincludes ongoing communication withparents.

Programs should developprotocols for addressing challengingbehaviors (Wittmer & Petersen, 2006). 1. Maintain ongoing observation and

documentation of every child2. Assess the quality of the

environment and provider-childinteractions

3. Meet with the family to deepen andshare understanding. Maintainongoing communication with thefamily throughout the inquiry

Providers’ increased understandingwill help them make changes in theirinteractions or in the environment tosupport the child’s increasing sense ofself-worth and self-control. Reflectingon the questions at times other thanwhen the behavior is occurring permitsmore thoughtful and thoroughconsideration of the child’s experienceand that of his/her family. In addition,a standardized process provides a timeto plan for any additional resources thatwill be needed to provideindividualized care for the child.

UNDERSTANDING CHALLENGING BEHAVIOR -HOW TO PUT THE RESEARCH INTO PRACTICE:• Recognize that challenging behavior

is any behavior that feelsoverwhelming and challenges achild’s or a caregiver’s sense ofcompetence.

• Evaluate the quality of theenvironment, curriculum, andprovider-child interactions todetermine if the caregivingenvironment is contributing to achild’s challenging behavior.

• Support young children’s healthybehaviors by focusing on theirrelationships with family members,providers, and peers. Teach thedesired behavior rather than usenegative commands; modelappropriate behavior; and manageyour own emotional reactions.

• Explore your concerns with thefamily and ask reflective questionsto attempt to better understand whatthe child might be communicatingthrough his/her behavior.

• Understand the impact oftemperament and culture on both thechild’s and the caregiver’s behavior.

• Adapt caregiving behavior based onthe infant’s or toddler’s needs andtemperament.

WHAT SHOULD CAREGIVERS DO WHEN MORE

INTENSE INTERVENTIONS ARE NEEDED?Some infants, toddlers, and their

families suffer from trauma, abuse,depression, violence, and poorattachment histories without muchsupport from the community (Emde,2001). Providers are in a unique


child care centers that have an ongoingrelationship with a mental healthconsultant derive multiple benefits,including reduced child expulsion rates(Gilliam, 2005), reduced staff turnover,reduced rates of staff stress (Brennan,Bradley, Allen, Perry, & Tsega, 2005)and increased staff effectiveness inmanaging challenging behavior (Alkon,Ralmer, & MacLennan, 2003).

Early childhood mental healthprofessionals may be staff members orconsultants to a program. While theyare valuable in responding to situationswhere a variety of interventionapproaches have been unsuccessful,they should be consulted at the veryearliest stages of concern. Recentresearch demonstrates that mentalhealth professionals are most effectivein assisting with challenging behaviorwhen they are fully integrated into theregular operation of the child careprogram (Green, Everhart, Gordon, &Garcia Gettman, 2006; Green, Simpson,Everhart, Vale, & Gettman, 2004).However, funding limitations, ashortage of appropriately preparedprofessionals and/or managementconsiderations may require thatprograms seek early childhood mentalhealth consultation from sources outsidethe program which directly serves thechild (Stark, Mann, & Fitzgerald, 2007).

Early childhood mental healthconsultants from an outside source aregenerally asked to advise programs inone of two ways. One approach focuseson a particularly challenging childand/or the child’s family. The otheraddresses a general program issue thatimpacts the mental health of staff,children, or families (Cohen &Kaufmann, 2000). The services ofexperienced and well trained infant andearly childhood mental healthprofessionals have the potential to offerprograms help with problem solving,support for the creation of thoughtfulintervention plans, coaching forpractices that promote infant mentalhealth, access to screening andassessment tools, and suggestions foradditional community referrals to aidchildren and/or family members.

position to recognize when childrenare in need of special help and whentheir ongoing behavior warrants areferral for more intense servicesprovided within the program or in thecommunity. For example, parents andfamily members who experiencetrauma and post traumatic stressdisorder may need intense programs torepair the parent-child relationship(Appleyard & Osofsky, 2003;Schecter, Myers, Brunelli, Coates,Zeanah, Davies, et al., 2006).Programs that work with mothers whoexperience post-partum depressioninclude both the mother and the infantto “foster a healthy mother–infantrelationship by promoting increasedmaternal sensitivity, improvedmother–infant interactions, acceptanceof the infant, and increased maternalself-efficacy” (Nylen, Moran,Franklin, & O’Hara, 2006).

Staff members can assist oneanother by creating a team to discussthe behavior in question, by poolingtheir knowledge, providing additionalobservations of the child’s behavior,and supporting the caregiver inworking to address the challengingbehavior.

MENTAL HEALTH CONSULTANTS CAN BE

HELPFUL ALL ALONG THE WAY

Early childhood providers reportthat more children with emotional anddevelopmental difficulties are enteringtheir programs each year (Yoshikawa& Knitzer, 1997) and that they do notfeel equipped to deal with thesespecial needs (Knitzer, 1996). Mentalhealth professionals can be a valuablepart of a process to reduce or avoidfuture behavioral problems and toenhance the capacity of providers tofoster the well-being of all childrenserved by a program. Typically, aconsultant will use information drawnfrom observations and from parentsand providers caring for identifiedchildren. In collaboration withproviders, they will then beginformulating hypotheses about themeaning of behavior that ischallenging (Johnston & Brinamen,2006). Research demonstrates that

COMMUNITY PARTNERS ARE AN IMPORTANT

ASSET

As professionals plan andimplement a response to an infant’s ortoddler’s behavior, it may be necessaryto adjust the frequency or intensity oftheir interventions-or even rethink thestrategy itself. , For example, a childmay need more positive attention fromteachers. However, if providers havetried several ideas with consistentefforts and the behavior is notimproving - or becomes worse - theprogram protocol should include stepsfor referral to services in thecommunity. If regular consultationfrom an infant and early childhoodmental health consultant is notavailable, community partners whoserve very young children and theirfamilies can assist the program and thefamily in providing timely responses toidentified needs. These communitypartners might include an infant mentalhealth program, a child care expulsionprevention service, a communitymental health clinic, early interventionservices, or a department of socialservices. Focused therapeutic workwith the family may be useful, and onrare occasions, behavioral or medicalinterventions may be required for thevery young child (Early Head StartNational Resource Center, 2006).

SECURING THE INTENSIVE SERVICES THAT ARE

NEEDED - PUTTING THE RESEARCH INTO

PRACTICE:• Ensure that the program has a

system of quality improvement inplace.

• Ensure that the program has aformal and standardized protocol orprocess for timely and systematicscreening and assessment andintervention, or referral when thereare concerns about an infant’s ortoddler’s social emotionaldevelopment.

• Establish on-going partnershipswith a mental health consultant,community agencies, and othersystems and services that cansupport the child’s development andprovide intensive support forfamilies.


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Infant Mental Health and Early Care and Education Providerscsefel.vanderbilt.edu/documents/rs_infant_mental_health.pdf · depression, and psychological ... influence on children’s