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NEW DIRECTIONS TOWARD AN INTEGRATION OF EARLY INTERVENTION AND INFANT MENTAL HEALTH Jane D. Hochman, Ed. D. Gilbert M.

NEW DIRECTIONS TOWARD AN INTEGRATION OF EARLY INTERVENTION AND INFANT MENTAL HEALTH Jane D. Hochman, Ed. D. Gilbert M. Foley, Ed.D. HISTORICAL CONTEXT AND THE BIRTH OF A MOVEMENT. EARLY CHILDHOOD: A FIELD IN FORMATION (1860s-1940). Philanthropy and Social Reform

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NEW DIRECTIONS TOWARD AN INTEGRATION OF EARLY INTERVENTION AND INFANT MENTAL HEALTH Jane D. Hochman, Ed. D. Gilbert M.

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  1. NEW DIRECTIONS TOWARD AN INTEGRATIONOFEARLY INTERVENTION AND INFANT MENTAL HEALTHJane D. Hochman, Ed. D.Gilbert M. Foley, Ed.D.

  2. HISTORICAL CONTEXT AND THE BIRTH OF A MOVEMENT

  3. EARLY CHILDHOOD: A FIELD IN FORMATION (1860s-1940) • Philanthropy and Social Reform • Advances in Medicine and Public Health • Government Actions • The New Science of Child Study • The Progressive Education Movement • Behaviorism • Psychoanalysis • Mental Hygiene and Child Guidance

  4. DEVELOPMENTS IN PSYCHIATRY, MEDICINE AND SPECIAL EDUCATION (1940-1960) • Infant Psychiatry/Infant Mental Health • Pediatrics and Rehabilitative Therapies • Special Education

  5. Institutionalization and Standardization of Early Intervention: 1960-Present

  6. 1960s - Early Federal Initiatives, Laws and Policies • 1961: Federal Office Established (BEH) • 1965: “ War on Poverty” – Head Start • 1967: Early and Periodic Screening Diagnosis and Treatment Program (EPSDT) • 1968: Handicapped Children’s Early Education Program ( HCEEP)

  7. The 1970s - Early Programs and Policies • Early 1970s: A controversy of Models • 1975: PL 94-142 • Late 1970s: Good Practice Models Emerge

  8. The 1980s - Early Childhood Becomes Law • Early 1980s: Outreach Replication Networks and Personnel Preparation • PL 99-457 • Late 1980s: Collaboration

  9. The 1990s - IDEA and Later Revisions • Americans with Disabilities Act (ADA) • 1990: PL 99-457 renamed Individuals with Disabilities Education Act (IDEA) • Early 1990s: Early Intervention Implemented • 1995: Early Head Start • 1997: Family-Centered > Family-Directed

  10. 21st Century - Revisions, Refinements, and Challenges • Revisions to IDEA • Economic Challenges • New Technology • Personnel

  11. MARTIN: A CHALLENGE OF CATEGORIES

  12. MEET MARTIN • 26 Months Old • Charming • Dreamy • Autistic? • Uneven Language Development • Weak Pragmatic Skills

  13. TUMULT AT HOME • Stormy • Father Left • Mother Depressed and Searching • Babysitters

  14. “THE CHILD WILL ALWAYS TELL YOU”Sally Provence, M.D. • Martin Tells a Story to his Occupational Therapist • What might it mean? • How to React? • What to Do? • Who may be able to help? • Implications for the Service Delivery Paradigm itself?

  15. THE INTEGRATION OF INFANT MENTAL HEALTH (IMH) AND EARLY INTERVENTION (EI): Concepts, Characteristics & Rationale

  16. A HOLISTIC SYNERGISTIC FRAME OF REFERENCE~“Embrace Complexity! ”Sally Provence, M.D.

  17. MODELS OF DEVELOPMENT • Architectonic • Hierarchical • Linear • Epigenetic • Organic • Unfolding • Plastic • Transformational • Holistic • Dynamic

  18. A DEVELOPMENTAL-BIOPSYCHOSOCIAL-TRANSACTIONAL MODEL • “Infant as a Work in Progress”

  19. THE NATURE OF DERAILMENT • Cumulative Adversity: A Cascade of Multiple Misfortunes vs. Single Incident/ Disease/Natural History Model of Derailment • Healing the Organic-Functional Split • Context…

  20. PARITY FOR PSYCHOSOCIAL DOMAIN OF DEVELOPMENT & MENTAL HEALTH IN DEFINING ELIGIBILITY & DELIVERING SERVICE

  21. Infant mental health refers to the multifaceted formative process impacted by myriad forces, including: • Totality of development itself • Organized as the structure and content of the inner life • Arising both from within and without and • Expressed in functional behaviors used to mediate between the internal and external world of self and other with affective range, intensity and color.

  22. Infant mental health includes: • Formation of attachments • Inner construction and emerging portrayals of the self and love-objects with feeling • Ability to regulate impulse, affects and the seeds of self-esteem • Capacity to manage anxiety and form flexible and adaptive mechanisms of coping and defense • Ability to form and sustain relationships beyond the immediate attachment system • Ability to experience the world with a range and intensity of feeling.

  23. Infant mental health includes: (con’t) • Appropriate assessment of social-emotional functioning and the well-being of the family • A role for mental health members of the team to function in therapeutic as well as assessment and referral capacities

  24. FAMILY-CENTERED RELATIONSHIP-BASED PERSPECTIVE

  25. THE CENTRALITY OF RELATIONSHIPS “A baby cannot exist alone, but is essentially part of a relationship.” D. W. Winnicott • The Family is a Network of intimate Relationships • The development of the baby is to large extent dependent on the well being of the relationships that compose the cradle of “holding” and nurturance.

  26. A Self-Family/Centered Copernican Universe Community Relationship Network Family Child

  27. FAMILY STRESS & DISTRESS • Loss-Grief • Personal Mythology • Reframing the Representation of the Child

  28. FAMILY STRESS & DISTRESS (con’t) • Damage and Reparation/Fear and Wish: Unseen Forces in the Family Psyche • Uncertainty About the Future • Amplified Demands of Daily Life

  29. RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY INFORMED APPROACH TO SERVICE DELIVERY • Identifies the relationship as the “Unit of Service” • Provides comprehensive, intensive, continuous, supportive and engagement-focused services • Addresses the expected and unexpected stress, coping and adjustment reactions and general well being of families

  30. RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY- INFORMED APPROACHTO SERVICE DELIVERY (con’t) • Addresses the meaning the child holds for the family • Works through the alliances of caregivers to the child and support systems to the caregivers • Works from the inside out: • addressing history, representation, affective states and the forces of fantasy

  31. RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY- INFORMED APPROACH TO SERVICE DELIVERY (con’t) • As well as the outside in: • Addressing resources, knowledge, skill, coping and concrete services • Multi-Modal

  32. RELATIONSHIP-BASED PSYCHOTHERAPEUTICALLYINFORMED APPROACH TO SERVICE DELIVERY (con’t) • Embraces parenthood as a developmental process • Supports every member of the team to deliver his or her discipline-specific services in a relationship-based psychotherapeutically –informed style

  33. A MULTI-CROSS-DISCIPLINARY TEAM MODEL OF STAFFING~The Transdisciplinary Approach • Role Extension • Role Release • Reflective Supervision • Intervention as Enacted Thought • A Cardinal Feature of an Integrated Model

  34. DEMANDS OF THE WORK • Hopefulness • Readiness to Cope with Negative or Troubled Experiences of Both Parents and Practitioners • Preparedness Concerns • Range of Reactions • Availability of Resources

  35. PARENT-PRACTITIONER RELATIONSHIPS IN EARLY INTERVENTION:UNSEEN FORCES

  36. EARLY INTERVENTION PRACTITIONERS REPRESENT MORE TO FAMILIES THAN THEIR DESIGNATED ROLES

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

  38. TRANSFERENCEAND COUNTERTRANSFERENCE, con’t. • Communicated via the infant through the care-giving style • Identified via Inappropriate Attributions

  39. TRANSFERENCE AND COUNTERTRANSFERENCE con’t. • Intensity • Ambivalence • Capriciousness • Tenacity

  40. OPTIMAL DISTANCE, #1 • There is NO absolute optimal distance • A relative position influenced by history, culture, and temperament • Differs family to family

  41. OPTIMAL DISTANCE, #2 • A Range Between Remoteness and Excessive Closeness Relatively Free of Ambivalence • Reality-Based Middle Ground • Ongoing Self-Regulating Relational Range

  42. OPTIMAL DISTANCE, #3:REMOTENESS • Unconscious Desire to “Shield” • Illusion of Safety in Distance

  43. OPTIMAL DISTANCE, #4:TOO MUCH CLOSENESS • Over-Identification and Fusion • Excessive Nurturing • Defense Against Guilty Feelings

  44. OPTIMAL DISTANCE, #5: AMBIVALENCE(most disturbed) • Shadowing • Darting • Unreliable

  45. OPTIMAL DISTANCE, #6: PRACTITIONERS MUST…. • Tolerate Anxious Uncertainty • Use Own Emotional Experiences as a Guide • Have Capacity to Observe, Listen and Reflect • Ask oneself two important questions………..

  46. OPTIMAL DISTANCE, #6con’t • “ Am I Maintaining an environment of safety, security, compassion, and support for the infant and parents?” “ Am I impeding the family’s self-awareness, self-sufficiency, and self-determination?”

  47. PRACTICE SUGGESTIONS FOR NON-MENTAL HEALTH PRACTITIONERS

  48. MAKE NO ASSUMPTIONS ASSUMPTIONS

  49. BEGIN WHERE THE FAMILY IS • …Not Where you Wish it Would Be • Beware of halo effect or tendency for countertransference fantasies • Successful Family-Practitioner Relationships Progress from A Base of Security.

  50. PRESENTING YOURSELF TO THE FAMILY • Titles of Address • Initial Introduction • Dress Code • Safety Concerns …Formality and informality reflect remoteness, excessive closeness, or optimal distance…

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