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Safe Start Early Childhood Mental Health Services

Safe Start Early Childhood Mental Health Services. Partnering with the Child Welfare System Lisa Blunt, MS, LMHP Chief Operating Officer Child Saving Institute Barbara Jessing, MS, LIMHP Clinical Director Heartland Family Service.

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Safe Start Early Childhood Mental Health Services

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  1. Safe StartEarly Childhood Mental Health Services Partnering with the Child Welfare System Lisa Blunt, MS, LMHP Chief Operating Officer Child Saving Institute Barbara Jessing, MS, LIMHP Clinical Director Heartland Family Service

  2. Babies and toddlers, even before they can speak, can show us, through their interactions with others and their emotions, that they are struggling and need help.  We have to learn to be better observers and more knowledgeable about ways to identify them and provide them with the services they need. • Child-Centered Practices for the Courtroom and Community: A Guide to Working Effectively with Young Children and Their Families in the Child Welfare System (Katz, Lederman and Osofsky

  3. How do we bring learning about early attachment into every decision made in the child welfare system? • How do we bring the voice and the perspective of young and vulnerable children into the child welfare system?

  4. Welcome! • What is your role? • Where are you from? • Any questions you bring?

  5. Attachment Informed Decisions • Every decision made in the child welfare system should be made through the lens of attachment • Does this decision SUPPORT healthy attachment of this child? • Does this decision SUPPORT timely permanency for this child? • Timing of services is critical.

  6. Presentation Overview • Clinical assessment of the parent child relationship -- birth to five years • Interventions • Safe Start Assessment • Child-Parent Psychotherapy • Family Support • Lessons learned in partnering with the Child Welfare System

  7. Infants and Toddlers in Foster Care • Separated suddenly and often traumatically from parent • Prior history often includes trauma, stress, deprivation • Disrupted placements

  8. Trauma Before and Trauma After Placement • Trauma exposure leading to removal • Inconsistent caregiving in placement • Disrupted foster care placements • Respite Care • Child Care Changes • Case Manager turnover • Cumulative negative developmental impact

  9. SAFE STARTProgram Goals • To bring the voice and perspective of the young child into the child welfare system • To strengthen and repair the parent-child bond; • To promote the child’s social and emotional development; • To minimize harmful developmental consequences of disruptions in care giving because of abuse or neglect.

  10. SAFE STARTEarly Childhood MentalHealth Services • Parent-Child Relationship Assessment • Child- Parent Psychotherapy • Family Preservation and Family Support Services

  11. History of Safe Start Project in Nebraska • 2005: Douglas County, NE and Zero to Three “Safe Babies” Court Team initiated • 2006: Child Saving Institute and Heartland Family Service partnership with Family Drug Treatment Court/Nebraska Department of Health and Human Services • 2009-11: Interface with Child Welfare Reform in Nebraska

  12. New Source of Funding • SAMHSA Grant Awarded 2010 • Grantee: Nebraska Supreme Court, Office of Problem Solving Courts; Nebraska Court Improvement Project • Eligible participants are clients in Douglas County Juvenile Court Drug Court/Family Drug Court • Participating Provider Agencies: • Child Saving Institute • Heartland Family Service • Lutheran Family Services

  13. Parent-Child Relationship Assessment • A structured, observation-based, multi session assessment of the relationship between parent and child • Model developed by Joy Osofsky, PhD and colleagues; Louisiana expert in child exposure to violence • Based on the “Prevent” Assessment model used in the Miami Safe Start Initiative

  14. Assessment Components • Initial interview of parent or parents for personal, family, and child history • Record Review • Structured observation of parent #1 and child • Structured Observation of parent #2, foster parent, or other caregiver and child • Ages and Stages Questionnaire: Developmental observation and evaluation of child with parent or other caregiver • Observation sessions are videotaped • Interactions are objectively rated according to specific dimensions of parent child relationship and interaction

  15. Parent Interview • Psychosocial interview • Adult attachment interview and relevance of parent’s early experience to present relationship with child • Goal: Insight into parent’s mental representation of child and internal experience of being a parent.

  16. Record Review: Child and Parent History • Highly relevant to getting a complete picture of parent’s current functioning • Understanding “what happened to you” vs “what’s wrong with you?”

  17. Observations through one way mirror • Parent directs assigned tasks with prompts from therapist by phone: • Free play • Bubbles • Clean up and transition to new activity • Several brief interactions around developmentally appropriate toys of increasing challenge • Brief separation (or withdrawal of parent’s face for infant) and reunification of parent from child • Therapist ratings are based on these observations

  18. Inclusion of Both Parents and Other Caregivers • Reason for referral may relate to abilities of one or both parents • If both parents are involved in permanency plan, observations are done with both • Observation of other significant caregivers such as foster parent or grandparent is also productive • Assessment documents strengths as well as problems; shows child’s relationships with various caregivers

  19. Parent Child Relationship ScalesJoy Osofsky, PhD • Objective ratings of parent child interaction • Used to develop treatment targets • Used as measure of outcome of therapy or other recommended interventions

  20. Positive Affect Withdrawn/ Depressed Irritability/Anger/ Hostility Intrusiveness Behavioral Responsiveness Emotional Responsiveness Positive Discipline Separation and Reunion Parent Observations Rated

  21. Positive Affect Withdrawn/ Depressed Anxious/Fearful Anger/Hostility/ Irritability Non-Compliance Toward Parental Instruction Aggression Toward Parent Enthusiasm Persistence with Task Reunion: Emotional and Behavioral Responsiveness Child Observations Rated

  22. Developmental and Behavioral Status • Achenbach Child Behavior Checklist • CBCL • Ages 1 ½ or older • Ages and Stages • ASQ 3 (2 months and up) • ASQ SE (Social and Emotional Development)

  23. How can the parent transition the child from one task to another? • How does the child respond to a parent’s directive? • “Bubbles” are a great measure of how much joy and pleasure there is in this relationship

  24. Max, Age 3Bubbles and Clean Up

  25. How enthusiastic is the child? • How persistent is the child, faced with a difficult task? • How does the parent respond to child frustration? • Emotional • Behavioral

  26. A Challenging Task:Madison, Age 5

  27. How does the parent prepare the child? • How does the child respond? • How does the child cope?

  28. Separation and Reunion:Max, age 3

  29. How does the child respond to the withdrawal of parent attention? • How energetic and emotional is the child’s reaction? • What is the emotional tone of the reunion?

  30. Addie, 7 months“Still Face”

  31. Assessment Report and Recommendations • Report is KEY COMMUNICATION • To Judge, Case Manager, and Provider • To Parents • Summary of presenting issue and results/recommendations • Relational treatment needs: • how to build on the strengths in the parent child relationship • what specific issues are to be addressed in the dyadic therapy, if recommended        • Developmental intervention needs 

  32. Follow Up Options • Child Parent Psychotherapy • Other referrals as appropriate for therapy, parent education and support • Parent Support and Education Programs • Family Support • Substance Abuse or Mental Health Treatment

  33. 26 week course of dyadic therapy Promote and strengthen a close, safe, and nurturing relationship between parent and child Observation, guidance, and coaching of the parent Deals with parent’s unresolved early abuse or trauma which interferes in the present Promotes adjustment/attachment as child transitions from foster care to home One hour weekly, in office Child –Parent PsychotherapyAlicia Lieberman and Patricia Van Horn

  34. CPP Techniques • Behavior-based interventions • Parent support and coaching • Interactive parent-child play • Verbal interpretation of transactions between parent and child.

  35. Parent View of CPP

  36. Treatment Outcomes • Improved parent-child relationship • Progress toward permanency goals • Improvement in child developmental status • Reduction of abuse/neglect

  37. Family Support • Family Support Specialist integral member of treatment team • Opportunity to reinforces generalization of skills gained in CPP • Observations inform CPP process

  38. Lessons Learned …

  39. Challenges with the Child Welfare System • Mandated parent treatment • Lack of clarity of clinician role • Scope and limits of confidentiality • Different perceptions of best interests • “The contagion of dysfunctionality” • Alicia Lieberman and Patricia Van Horn

  40. Our Challenges • Massive changes in the child welfare system co-occurred with our efforts to implement • Changes in administration, workers, foster parents • Groundhog Day: constantly restating our case • Like trying to fill a bucket with a hole in it

  41. Lessons Learned with Child Welfare • “Parallel Process” • System under high stress: “trauma contagion” • As children and families struggle to survive – so does the system; so does the worker

  42. However… • The same skills that help us with traumatized and attachment-disrupted children and parents.. • .. Help us deal with a traumatized system

  43. Key Ingredients • Patience • Trust • Psycho-education on the impact of trauma (including trauma contagion) • Relationship building • Good self care and community with like minded colleagues

  44. Positives • Key Judges have been supportive • Zero to Three support for family drug court • Model Court initiated new program development • Systemic training of court personnel across the state • “Critical Mass” is building • Brain development and science foundation

  45. Evaluation findings for the ZERO TO THREE Safe Babies Court Team Project • Children participating in court teams leave foster care three times as fast as the comparison sample…. • Reunification is most common for Court Team Babies (38%) whereas adoption is most common for comparison group (41%) • “Moving Young Children From Foster Care to Permanent Homes”. Kimberly McCombs-Thornton; Zero to Three Journal; May 2012, Volume 32, Number 5

  46. Key Factors In Success • Judicial Leadership • Regular Court Team Staffings (cases reviewed at least monthly)

  47. Thanks ! • To Dr. Joy Osofsky for teaching and mentoring us through this process • To the families we learn from • To the volunteer parents and children who agreed to be videotaped

  48. Presenter Information • Lisa Blunt, MS, LMHP • Chief Operating Officer • Child Saving Institute • lblunt@chlldsaving.org • 402-553-6000 • Barbara Jessing, MS, LIMHP • Clinical Director • Heartland Family Service • bjessing@heartlandfamilyservice.org • 402-553-3000

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