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Early intervention to address children’s behavioral health issues can help prevent problems from interfering with a child’s development. At the Supporting Parents and Resilient Kids (SPARK) Center at the Boston Medical Center (BMC) Mattapan Campus, the focus is early education and care for infants and young children with special health care and psychosocial needs, with an emphasis on the parent-child relationship. At the October Clinical Conversation, psychologists Martha Vibbert and Alyssa King discussed their approach and its applications in the primary care setting.
Issues that present in the primary care setting
Young children who are experiencing difficulties may present with the following issues:
• Persistent bio-dysregulation – can include disrupted sleep patterns, abnormal feeding or elimination, exaggerated or diminished energy level, emotional dysregulation such as lability and little or no relational capacity
• Out-of-control behaviors – aggression/disobedience, self-injurious activities such as head banging, repetitive actions, such as rocking
• Anxiety – separation difficulties, excessive fears, phobias, severe shyness and social avoidance
The key role of the parent-child relationship
A child’s difficulties can stem from a number of origins, including developmental or physiological problems, trauma, or psychosocial stressors, such as unstable housing or parents working long hours. But the parent-child relationship is “the lens through which everything occurs. We encourage pediatricians to think ‘dyadically’ and consider a two-generation approach,” says Martha Vibbert, PhD, executive director of the SPARK Center.
January 2020NEWS
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MCPAP is funded by the Massachusetts Department of Mental Health.
In this Issue:
Upcoming Clinical Conversations 4Leadership:John Straus, MD Founding Director
Barry Sarvet, MD Medical Director
Beth McGinn Program Manager
Elaine GottliebContributing Writer
Clinical Conversation: October 22, 2019 Presented by Martha Vibbert, PhD, Executive Director, Clinical Psychologist and Alyssa King, PhD, Mental Health Director, Clinical Psychologist
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Early Childhood Behavioral Health: A Two-Generation Approach
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Key interaction elements in the parent-child relationship
During an office visit, the interactions between parent and child can provide valuable information to aid in assessing the problem. Be alert to:
• Parent’s response to child’s vocalizations
• Shared attention and focus: are the parent and child able to focus together?
• Child-directed speech: compare directive versus elicited
• Signs of affection, nurturance, and shared enjoyment – for example, how does the parent respond when child expresses fear, such as of a shot?
• Signs of emotional co-regulation and attunement
• What precipitates and how the parent responds to troubling behaviors
• Quality of parent affect and attitudes – “The way the parent talks about the child is important. Does he/she focus on the positive or negative? If the parent is consistently negative, something isn’t working in the relationship,” says Alyssa King, PhD, SPARK Mental Health Director.
• Parent’s psychological state – are there signs of depression, substance abuse, trauma, or domestic violence? “Part of thinking dyadically is considering the parent’s emotional state whether they are experiencing trauma,” says Dr. King.
• Parental red flags: self-blaming statements, attribution of malevolence intent to the child and remoteness/disengagement. “We take sarcasm directed at the child seriously,” says Dr. King.
Enhancing communication during patient visits
Eliciting information during a brief office visit can be challenging; having a social worker or nurse
present may help. “The family may feel safer with a team approach,” says Dr. Vibbert.
Some ways to have a more productive conversation:
• Establish trust, safety, patience and respect so parents and children are comfortable sharing with you.
• Normalize conversations about attachment and psychological phenomena:
○ Use “inclusive openers” such as “many patients are telling us”
○ Use words like “disappointment,” “anxiety,” “hardships,” “guilt,” “trauma” so they feel familiar and less threatening
• Consider context – ask about the family’s culture, child-rearing traditions, belief systems, knowledge of child development. and socioeconomic and environmental factors.
• Deliver messages that are strength-based, informed by neurodevelopmental knowledge, and focused on positive future outcomes. “Share the latest understanding of the young child’s brain. The way a parent thinks about a child now affects the future,” says Dr. Vibbert.
After observation and information gathering:
• Avoid premature categorization and unidimensional diagnoses
• Resist automatic referrals and “medication” thinking
• Consider the benefits of psychological assessment and intervention as first steps
“Everything you do can contribute to a positive trajectory for accessing mental health care and create a protective momentum to thrive and reduce the stigma of mental health treatment,” says Dr. Vibbert.
Comprehensive evaluation and assessment
Before diagnosis and treatment, a comprehensive evaluation is necessary to choose the appropriate intervention. “You need to understand what is contributing to a child’s presentation,” says Dr. King. “ADHD medication, for example, may be appropriate, but it doesn’t address the parent-child dynamic.”
An evaluation can include:
• A detailed diagnostic interview
• Observation of parent-child interaction
• Functional behavioral assessment
• Structured testing of developmental functioning – “At six to eight months, developmental delays are very concerning as are behaviors used to compensate such as sleep problems and difficulty separating,” says Dr. Vibbert.
• Standardized rating scales for parents or teachers (if applicable)
The benefits of parent-child therapy
Two-generation therapies address the needs of three patients – the child, the parent and the parent-child relationship. Unlike first-line treatments for development and physiological problems, they can address problems related to the condition as well as unrelated issues. These therapies can be effective for many early childhood behavioral and emotional problems.
There are many evidence-based two-generation therapies such as Parent-Child Interaction Therapy and Child-Parent Psychotherapy as well as evidence-informed supportive approaches for parent and child such as Circle of Security and Parenting Journey.
Working with SPARK
The SPARK Center welcomes referrals from pediatricians for any of its services, which include:
• Neurodevelopmental assessments
• Psychodiagnostic evaluations
• School placement advocacy
• Therapeutic, two-generation intervention
• Consultations
Medicaid and private insurance covers services for children over age two (but can be more complicated for babies). SPARK clinicians use DC:0-5 diagnoses, often general ones for insurance purposes. SPARK is participating in a federally funded clinical project that provides no-cost services to children who meet the project criteria.
Pediatricians are also invited to observe parent-child therapies at SPARK.
For more information about SPARK and referring patients or visiting the center, contact Dr. Martha Vibbert at [email protected]
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or 617-414-0501 or Dr. Alyssa King at [email protected] or 617-414-0512.
Clinical ConversationsWe invite you to log in on the fourth Tuesday of each month from 12:15 to 1:15 p.m. to learn more about managing pediatric behavioral health issues in your practice.
Next Clinical Conversations:Tuesday, January 28, 2020Tuesday, February 25, 2020
What’s Happening for you at MCPAP
ASAP-MCPAP Consultation Line
Earlier this month, all enrolled MCPAP providers were sent a small poster to hang as a reminder to call your regular regional MCPAP phone line. MCPAP will directly link you to the Adolescent Substance Use and Addiction Program (ASAP) at Boston Children’s Hospital when there is a SUD or vaping question.
West-Central: 844-926-2727Boston North: 855-627-2763Boston South: 844-636-2727
