NEW DIRECTIONS NEW DIRECTIONS TOWARD AN TOWARD AN

INTEGRATIONINTEGRATIONOFOF

EARLY INTERVENTION EARLY INTERVENTION AND AND

INFANT MENTAL INFANT MENTAL HEALTHHEALTH

Jane D. Hochman, Ed. D.Jane D. Hochman, Ed. D. Gilbert M. Foley, Ed.D.Gilbert M. Foley, Ed.D.

2

HISTORICAL CONTEXT HISTORICAL CONTEXT AND THE BIRTH OF A AND THE BIRTH OF A

MOVEMENTMOVEMENT

3

EARLY CHILDHOOD: A EARLY CHILDHOOD: A FIELD IN FORMATION FIELD IN FORMATION

(1860s-1940)(1860s-1940) Philanthropy and Social ReformPhilanthropy and Social Reform Advances in Medicine and Public Advances in Medicine and Public

HealthHealth Government ActionsGovernment Actions The New Science of Child StudyThe New Science of Child Study The Progressive Education MovementThe Progressive Education Movement BehaviorismBehaviorism PsychoanalysisPsychoanalysis Mental Hygiene and Child GuidanceMental Hygiene and Child Guidance

4

DEVELOPMENTS IN DEVELOPMENTS IN PSYCHIATRY, MEDICINE PSYCHIATRY, MEDICINE

AND SPECIAL EDUCATION AND SPECIAL EDUCATION (1940-1960)(1940-1960)

Infant Psychiatry/Infant Mental HealthInfant Psychiatry/Infant Mental Health Pediatrics and Rehabilitative TherapiesPediatrics and Rehabilitative Therapies Special EducationSpecial Education

5

Institutionalization and Institutionalization and Standardization of Early Standardization of Early

Intervention:Intervention: 1960-Present 1960-Present

6

1961: Federal Office Established 1961: Federal Office Established (BEH)(BEH)

1965: “ War on Poverty” – Head Start1965: “ War on Poverty” – Head Start 1967: Early and Periodic Screening 1967: Early and Periodic Screening

Diagnosis and Treatment Program Diagnosis and Treatment Program (EPSDT)(EPSDT)

1968: Handicapped Children’s Early 1968: Handicapped Children’s Early Education Program ( HCEEP)Education Program ( HCEEP)

1960s - Early Federal 1960s - Early Federal Initiatives, Laws and Initiatives, Laws and

PoliciesPolicies

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The 1970s - Early Programs The 1970s - Early Programs and Policiesand Policies

Early 1970s: A controversy of Early 1970s: A controversy of ModelsModels

1975: PL 94-1421975: PL 94-142 Late 1970s: Good Practice Models Late 1970s: Good Practice Models

EmergeEmerge

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The 1980s - Early The 1980s - Early Childhood Becomes LawChildhood Becomes Law

Early 1980s: Outreach Replication Early 1980s: Outreach Replication Networks and Personnel PreparationNetworks and Personnel Preparation

PL 99-457PL 99-457 Late 1980s: CollaborationLate 1980s: Collaboration

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The 1990s - IDEA and Later The 1990s - IDEA and Later RevisionsRevisions

Americans with Disabilities Act (ADA)Americans with Disabilities Act (ADA) 1990: PL 99-457 renamed Individuals 1990: PL 99-457 renamed Individuals

with Disabilities Education Act (IDEA)with Disabilities Education Act (IDEA) Early 1990s: Early Intervention Early 1990s: Early Intervention

ImplementedImplemented 1995: Early Head Start1995: Early Head Start 1997: Family-Centered > Family-1997: Family-Centered > Family-

DirectedDirected

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21st Century - Revisions, 21st Century - Revisions, Refinements, and Refinements, and

ChallengesChallenges Revisions to IDEARevisions to IDEA Economic ChallengesEconomic Challenges New TechnologyNew Technology Personnel Personnel

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MARTIN: A CHALLENGE OF MARTIN: A CHALLENGE OF CATEGORIESCATEGORIES

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MEET MARTINMEET MARTIN

26 Months Old26 Months Old CharmingCharming DreamyDreamy Autistic?Autistic? Uneven Language DevelopmentUneven Language Development Weak Pragmatic SkillsWeak Pragmatic Skills

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TUMULT AT HOMETUMULT AT HOME

StormyStormy Father LeftFather Left Mother Depressed and SearchingMother Depressed and Searching BabysittersBabysitters

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““THE CHILD WILL ALWAYS THE CHILD WILL ALWAYS TELL YOUTELL YOU””

Sally Provence, M.D.Sally Provence, M.D. Martin Tells a Story to his Occupational Martin Tells a Story to his Occupational

TherapistTherapist What might it mean?What might it mean? How to React?How to React? What to Do?What to Do? Who may be able to help?Who may be able to help? Implications for the Service Delivery Implications for the Service Delivery

Paradigm itself?Paradigm itself?

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THE INTEGRATION OF THE INTEGRATION OF INFANT MENTAL HEALTH INFANT MENTAL HEALTH

(IMH) (IMH) ANDAND

EARLY INTERVENTION EARLY INTERVENTION (EI): Concepts, (EI): Concepts,

Characteristics & Characteristics & RationaleRationale

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A HOLISTIC A HOLISTIC SYNERGISTIC FRAME OF SYNERGISTIC FRAME OF

REFERENCEREFERENCE

~~““Embrace Complexity!Embrace Complexity! ” ”

Sally Provence, M.D.Sally Provence, M.D.

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MODELS OF MODELS OF DEVELOPMENTDEVELOPMENT

ArchitectonicArchitectonic HierarchicalHierarchical LinearLinear EpigeneticEpigenetic

OrganicOrganic UnfoldingUnfolding PlasticPlastic

TransformationalTransformational HolisticHolistic DynamicDynamic

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A DEVELOPMENTAL-A DEVELOPMENTAL-BIOPSYCHOSOCIAL-BIOPSYCHOSOCIAL-

TRANSACTIONAL MODELTRANSACTIONAL MODEL ““Infant as a Work in Progress”Infant as a Work in Progress”

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THE NATURE OF THE NATURE OF DERAILMENTDERAILMENT

Cumulative Adversity: A Cascade of Cumulative Adversity: A Cascade of Multiple Misfortunes vs. Single Multiple Misfortunes vs. Single Incident/ Disease/Natural History Incident/ Disease/Natural History Model of DerailmentModel of Derailment

Healing the Organic-Functional SplitHealing the Organic-Functional Split

Context…Context…

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PARITY FOR PARITY FOR PSYCHOSOCIAL DOMAIN PSYCHOSOCIAL DOMAIN

OF DEVELOPMENT & OF DEVELOPMENT & MENTAL HEALTH IN MENTAL HEALTH IN

DEFINING ELIGIBILITY DEFINING ELIGIBILITY & DELIVERING SERVICE& DELIVERING SERVICE

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Infant mental health refers to Infant mental health refers to the multifaceted formative the multifaceted formative process impacted by myriad process impacted by myriad

forces, including:forces, including: Totality of development itselfTotality of development itself

Organized as the structure and content Organized as the structure and content of the inner lifeof the inner life

Arising both from within and without Arising both from within and without and and

Expressed in functional behaviors used Expressed in functional behaviors used to mediate between the internal and to mediate between the internal and external world of self and other with external world of self and other with affective range, intensity and color. affective range, intensity and color.

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Infant mental health Infant mental health includes:includes:

Formation of attachmentsFormation of attachments Inner construction and emerging portrayals Inner construction and emerging portrayals

of the self and love-objects with feelingof the self and love-objects with feeling Ability to regulate impulse, affects and the Ability to regulate impulse, affects and the

seeds of self-esteemseeds of self-esteem Capacity to manage anxiety and form Capacity to manage anxiety and form

flexible and adaptive mechanisms of coping flexible and adaptive mechanisms of coping and defenseand defense

Ability to form and sustain relationships Ability to form and sustain relationships beyond the immediate attachment systembeyond the immediate attachment system

Ability to experience the world with a range Ability to experience the world with a range and intensity of feeling.and intensity of feeling.

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Infant mental health Infant mental health includes: (con’t)includes: (con’t)

Appropriate assessment of social-Appropriate assessment of social-emotional functioning and the well-emotional functioning and the well-being of the familybeing of the family

A role for mental health members of A role for mental health members of the team to function in the team to function in therapeutictherapeutic as well as assessment and referral as well as assessment and referral capacitiescapacities

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FAMILY-CENTERED FAMILY-CENTERED RELATIONSHIP-BASED RELATIONSHIP-BASED

PERSPECTIVEPERSPECTIVE

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THE CENTRALITY OF THE CENTRALITY OF RELATIONSHIPSRELATIONSHIPS

“ “A baby cannot exist alone, but A baby cannot exist alone, but is essentially part of a relationship.”is essentially part of a relationship.”

D. W. WinnicottD. W. Winnicott The Family is a Network of intimate The Family is a Network of intimate

RelationshipsRelationships The development of the baby is to large The development of the baby is to large

extent dependent on the well being of the extent dependent on the well being of the relationships that compose the cradle of relationships that compose the cradle of “holding” and nurturance.“holding” and nurturance.

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A Self-Family/Centered A Self-Family/Centered Copernican UniverseCopernican Universe

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FAMILY STRESS & FAMILY STRESS & DISTRESSDISTRESS

Loss-Grief Loss-Grief Personal MythologyPersonal Mythology Reframing the Representation of the Reframing the Representation of the

ChildChild

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FAMILY STRESS & FAMILY STRESS & DISTRESS (con’t)DISTRESS (con’t)

Damage and Reparation/Fear and Damage and Reparation/Fear and Wish: Unseen Forces in the Family Wish: Unseen Forces in the Family PsychePsyche

Uncertainty About the FutureUncertainty About the Future Amplified Demands of Daily LifeAmplified Demands of Daily Life

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RELATIONSHIP-BASED, RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY PSYCHOTHERAPEUTICALLY INFORMED APPROACH TO INFORMED APPROACH TO

SERVICE DELIVERYSERVICE DELIVERY Identifies the relationship as the “Unit Identifies the relationship as the “Unit

of Service”of Service” Provides comprehensive, intensive, Provides comprehensive, intensive,

continuous, supportive and continuous, supportive and engagement-focused servicesengagement-focused services

Addresses the expected and unexpected Addresses the expected and unexpected stress, coping and adjustment reactions stress, coping and adjustment reactions and general well being of familiesand general well being of families

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Addresses the meaning the child holds Addresses the meaning the child holds for the familyfor the family

Works through the alliances of Works through the alliances of caregivers to the child and support caregivers to the child and support systems to the caregiverssystems to the caregivers

Works from the inside out:Works from the inside out: addressing history, representation, addressing history, representation,

affective states and the forces of fantasyaffective states and the forces of fantasy

RELATIONSHIP-BASED, RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY- PSYCHOTHERAPEUTICALLY-

INFORMED APPROACHINFORMED APPROACHTO SERVICE DELIVERY TO SERVICE DELIVERY

(con’t)(con’t)

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As well as the outside in:As well as the outside in: Addressing resources, knowledge, skill, Addressing resources, knowledge, skill,

coping and concrete servicescoping and concrete services Multi-ModalMulti-Modal

RELATIONSHIP-BASED, RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLPSYCHOTHERAPEUTICALLY- INFORMED APPROACH Y- INFORMED APPROACH

TO SERVICE DELIVERY TO SERVICE DELIVERY (con’t)(con’t)

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RELATIONSHIP-BASED RELATIONSHIP-BASED PSYCHOTHERAPEUTICALLPSYCHOTHERAPEUTICALL

YYINFORMED APPROACH TO INFORMED APPROACH TO SERVICE DELIVERY (con’t)SERVICE DELIVERY (con’t) Embraces parenthood as a Embraces parenthood as a

developmental processdevelopmental process Supports every member of the team to Supports every member of the team to

deliver his or her discipline-specific deliver his or her discipline-specific services in a relationship-based services in a relationship-based psychotherapeutically –informed stylepsychotherapeutically –informed style

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A MULTI-CROSS-A MULTI-CROSS-DISCIPLINARY TEAM DISCIPLINARY TEAM MODEL OF STAFFINGMODEL OF STAFFING

~~

The Transdisciplinary The Transdisciplinary ApproachApproach Role ExtensionRole Extension

Role ReleaseRole Release Reflective SupervisionReflective Supervision

Intervention as Enacted Thought Intervention as Enacted Thought A Cardinal Feature of an Integrated A Cardinal Feature of an Integrated

ModelModel

34

DEMANDS OF THE DEMANDS OF THE WORKWORK

HopefulnessHopefulness Readiness to Cope with Negative or Readiness to Cope with Negative or

Troubled Experiences of Both Troubled Experiences of Both Parents and PractitionersParents and Practitioners

Preparedness ConcernsPreparedness Concerns Range of ReactionsRange of Reactions Availability of ResourcesAvailability of Resources

35

PARENT-PRACTITIONER PARENT-PRACTITIONER RELATIONSHIPS IN RELATIONSHIPS IN

EARLY INTERVENTION:EARLY INTERVENTION:UNSEEN FORCESUNSEEN FORCES

36

EARLY INTERVENTION EARLY INTERVENTION PRACTITIONERS PRACTITIONERS

REPRESENT MORE TO REPRESENT MORE TO FAMILIES THAN THEIR FAMILIES THAN THEIR

DESIGNATED ROLESDESIGNATED ROLES

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TRANSFERENCE AND TRANSFERENCE AND COUNTERTRANSFERENCECOUNTERTRANSFERENCE

“ “ Transference consists of the Transference consists of the ‘experiencing of feelings, drives, ‘experiencing of feelings, drives, attitudes, fantasies and defenses attitudes, fantasies and defenses toward a person in the present which toward a person in the present which do not befit that person but are a do not befit that person but are a repetition of reactions originating in repetition of reactions originating in regard to significant persons of early regard to significant persons of early childhood, unconsciously displaced childhood, unconsciously displaced onto figures in the present ‘ ” onto figures in the present ‘ ” ( Greenson, 1967, p. 155)( Greenson, 1967, p. 155)

38

TRANSFERENCETRANSFERENCEAND AND

COUNTERTRANSFERENCCOUNTERTRANSFERENCE, con’t.E, con’t.

Communicated via the infant Communicated via the infant through the care-giving stylethrough the care-giving style

Identified via Inappropriate Identified via Inappropriate AttributionsAttributions

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TRANSFERENCE TRANSFERENCE AND AND

COUNTERTRANSFERENCCOUNTERTRANSFERENCE con’t.E con’t.

IntensityIntensity AmbivalenceAmbivalence CapriciousnessCapriciousness TenacityTenacity

40

OPTIMAL DISTANCE, #1OPTIMAL DISTANCE, #1

There is There is NONO absolute optimal absolute optimal distancedistance

A relative position influenced by A relative position influenced by history, culture, and temperamenthistory, culture, and temperament

Differs family to familyDiffers family to family

41

OPTIMAL DISTANCE, #2OPTIMAL DISTANCE, #2

A Range Between Remoteness and A Range Between Remoteness and

Excessive Closeness Relatively Excessive Closeness Relatively Free of AmbivalenceFree of Ambivalence

Reality-Based Middle GroundReality-Based Middle Ground Ongoing Self-Regulating Relational Ongoing Self-Regulating Relational

Range Range

42

OPTIMAL DISTANCE, #3:OPTIMAL DISTANCE, #3:REMOTENESSREMOTENESS

Unconscious Desire to “Shield”Unconscious Desire to “Shield” Illusion of Safety in DistanceIllusion of Safety in Distance

43

OPTIMAL DISTANCE, #4:OPTIMAL DISTANCE, #4:TOO MUCH CLOSENESSTOO MUCH CLOSENESS

Over-Identification and FusionOver-Identification and Fusion Excessive NurturingExcessive Nurturing Defense Against Guilty FeelingsDefense Against Guilty Feelings

44

OPTIMAL DISTANCE, #5: OPTIMAL DISTANCE, #5: AMBIVALENCE AMBIVALENCE(most disturbed)(most disturbed)

ShadowingShadowing DartingDarting UnreliableUnreliable

45

OPTIMAL DISTANCE, OPTIMAL DISTANCE, #6: #6: PRACTITIONERS PRACTITIONERS

MUST….MUST…. Tolerate Anxious UncertaintyTolerate Anxious Uncertainty Use Own Emotional Experiences as Use Own Emotional Experiences as

a Guidea Guide Have Capacity to Observe, Listen Have Capacity to Observe, Listen

and Reflectand Reflect Ask oneself two important Ask oneself two important

questions………..questions………..

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OPTIMAL DISTANCE, #6OPTIMAL DISTANCE, #6con’tcon’t

“ “ Am I Maintaining an environment Am I Maintaining an environment of safety, security, compassion, and of safety, security, compassion, and support for the infant and parents?”support for the infant and parents?”

“ “ Am I impeding the family’s self-Am I impeding the family’s self-awareness, self-sufficiency, and self-awareness, self-sufficiency, and self-determination?”determination?”

47

PRACTICE SUGGESTIONS PRACTICE SUGGESTIONS FOR NON-MENTAL FOR NON-MENTAL

HEALTH PRACTITIONERSHEALTH PRACTITIONERS

48

MAKE NO MAKE NO ASSUMPTIONSASSUMPTIONS

ASSUMPTIONSASSUMPTIONS

49

BEGIN WHERE THE BEGIN WHERE THE FAMILY ISFAMILY IS

……Not Where you Wish it Would BeNot Where you Wish it Would Be Beware of halo effect or tendency for Beware of halo effect or tendency for

countertransference fantasiescountertransference fantasies Successful Family-Practitioner Successful Family-Practitioner

Relationships Progress from A Base Relationships Progress from A Base of Security.of Security.

50

PRESENTING YOURSELF PRESENTING YOURSELF TO THE FAMILYTO THE FAMILY

Titles of AddressTitles of Address Initial IntroductionInitial Introduction Dress CodeDress Code Safety ConcernsSafety Concerns

……Formality and informality reflect Formality and informality reflect remoteness, excessive closeness, or remoteness, excessive closeness, or optimal distance…optimal distance…

51

SHARING SHARING INFORMATIONINFORMATION

Mutual Understanding of the Mutual Understanding of the languagelanguage

Definition of TermsDefinition of Terms Attention to Cultural MoresAttention to Cultural Mores

52

GUIDELINES FOR MAKING GUIDELINES FOR MAKING MENTAL HEALTH MENTAL HEALTH

REFERRALSREFERRALS

ABSOLUTESABSOLUTES DangerDanger Abuse or NeglectAbuse or Neglect Parents with Diagnosed Mental Parents with Diagnosed Mental

Health DisordersHealth Disorders

53

GUIDELINES FOR MAKING GUIDELINES FOR MAKING MENTAL HEALTH MENTAL HEALTH

REFERRALSREFERRALS PROFESSIONAL JUDGMENT PROFESSIONAL JUDGMENT

REQUIRED:REQUIRED: Intensity of SymptomsIntensity of Symptoms Degree of Psychic SufferingDegree of Psychic Suffering Degree of Compromised FunctioningDegree of Compromised Functioning Frequency of Occurrence of Conditions Frequency of Occurrence of Conditions

or observed symptomsor observed symptoms Intractability of SymptomsIntractability of Symptoms The Symptoms in ContextThe Symptoms in Context

54

Apply Principles of Responsibility and Apply Principles of Responsibility and ReciprocityReciprocity

Practitioner>Family>Child>PractitionePractitioner>Family>Child>Practitionerr

Administration > TeamAdministration > Team Within teamWithin team

((Relationships Among Staff Reflect Demands Relationships Among Staff Reflect Demands and Stress)and Stress)

RELATIONSHIP RELATIONSHIP BOUNDARIESBOUNDARIES

55

IDEA STILL SUPPORTSIDEA STILL SUPPORTS

Supra-organizational perspectiveSupra-organizational perspective Interagency CollaborationInteragency Collaboration TeamingTeaming

56

HOWEVER , UNITY OF EI HOWEVER , UNITY OF EI AND MH REQUIRESAND MH REQUIRES

Closer Alliances among practitioners Closer Alliances among practitioners from both “ worlds”from both “ worlds”

Holistic OrganizationsHolistic Organizations Fluid Interchange among the Fluid Interchange among the

Multiple DisciplinesMultiple Disciplines Systems CoordinationSystems Coordination

57

A Self-Family/Centered A Self-Family/Centered Copernican UniverseCopernican Universe

58