The Impact of Infant & Early Childhood Mental Health A Presentation by OKAIMH

1. The Impact of Infant & Early Childhood Mental HealthA Presentation by OKAIMH • Editing and Additions by • Debbie Spaeth, LMFT, LPC, LADC - Supervisor • Quest MHSA, LLC

2. Infant Mental Health • Relationships • Emotion Regulation • Development • Treatment • Relationships • Goals • Approach • Support • Supervision • OK-AIMH • Zero to Three • Trauma • Brain Development • Memory • Relationships • Impact Training Overview

3. Infant Mental Health Is • The developing capacity of the infant and toddler to... • Form close and secure relationships. • Experience, regulate, and express emotions. • Explore the environment and learn. • ...all in the context of family, community, and cultural expectations for young children. • (Zero to Three Infant Mental Health Task Force).

4. Early Death This IS IMH! Disease, Disability and Social Problems Adoption of Health-Risk Behaviors Social, Emotional and Cognitive Impairment Adverse Childhood Experiences The ACE Pyramid - (Adverse Childhood Experiences)

5. Attachment Disruptions Mistrust Self-Worth Infant/early childhood depression No internal control Emotion regulation problems Decreased exploration/engagement Learning Disabilities Social, emotional, and cognitive impairment

6. Infant Mental Health Attachment Ecological Theory/Cultural Perspective Psycho-dynamics Theoretical Foundations

7. Attachment Theory • The lasting and deep emotional relationship between child and caregivers • Begins to develop in second half of first year of life • Focused on sense of security as child begins to explore environment • Still Face Experiment - showed that an infant will become animated and active when given facial and vocal expressions from another, while a still face and no sound will create frustration and irritation, and then apathy and lingering in the same infant

8. Attachment “I will help you when you need it” Child gives signals when in need Parent is sensitive to cues & responds appropriately “I will tell you when I need help”

9. Functions of Attachment • Trust/Survival • Explore with confidence and security • Self-regulation, manage emotions • Internal working model • Identity/Self Esteem • Protective factor against stress and trauma

10. Ecological Theory • There is CONTEXT for everything • Recognizes larger forces at work in influencing behavior • Different levels of context interaction

11. Policies, Procedures, Regulations Community Neighborhood Culture Family Parent & Child Culture Culture

12. Psychodynamic Theory • “Ghosts in the Nursery” – Fraiberg, S. • Relationship patterns set in childhood • The past is always with us. In infancy and early childhood, past, present, and future intersect in unexpected ways. • Reconciling past can improve present functioning

13. Interdisciplinary Relationship -Based Strengths- Based Continuous & Consistent Individualized Child Focused & Family Centered Best Practices in Infant Mental Health Are:

14. Community-Based Accessible Comprehensive Culturally Responsive Integrated Coordinated Continually Improving Reflective Best Practices in Infant Mental Health Are:

15. How you are is more important than what you do. ~ Jeree Pawl

16. What Can we Do? • Understanding and • Speaking • the Language

17. Red Flags For IMH Services • Difficult, unwanted or unplanned pregnancy • Perinatal depression • Newborns with feeding, sleeping, regulation problems • Families who have children with special needs • Families with few resources or social supports • Children with possible attachment disorders • Families with Mental Health, Substance Abuse or Domestic Violence issues

18. Behaviors Translations Crying Tantrums Sleep Toileting Eating Aggression Trauma Relationship Disruption Safety Substance Abuse Domestic Violence How to speak the language

19. Observation & Assessment Concrete Support Services Supportive Counseling Brief Crisis Intervention Problem Solving Relationship –Based Developmental Guidance • Psychotherapy • Parent-Infant • Parent Focused • Child/Filial • Play Therapy Therapeutic Interventions

20. Strategies for IMH Practice • Making anticipatory guidance specific to the infant. • Alerting the parent to the infant’s individual accomplishments and needs. • Helping the parent to find pleasure in the relationship with the infant • Allowing the parent to take the lead or determine the agenda • Watching, Waiting, & Wondering • Remaining open, curious, and reflective. • Deborah Weatherston, The Infant Mental Health Specialist, 0-3 Oct/Nov. 2000.

21. IMH Case Discussion • Open • Curious • Reflective

22. Case Scenario Amanda was adopted from Paraguay when she was six months old.  An attractive child at two and a half, Amanda has little or no language and seldom interacts with other children or adults. Her mother brings her to a mom-tot program where she finds one or two familiar toys and plays alone.  Amanda's mother is a loud woman who frequently inserts herself, without invitation, into other people's conversations.  She also refers to the adoption in Amanda's presence and explains that she is extremely shy and very slow.  Her attempts to get Amanda to talk by starting her sentences only causes Amanda to withdraw more.

23. Case Questions 1.  What concerns does this child's behavior raise for you? 2.  What might be the social/emotional concerns for this child? 3.  How would you begin addressing these concerns with the parents? 4.  What strategies would you use to help this family address their child's social/emotional development? 5.  What resources and/or referrals might be useful with this family? 

24. Emotion Regulation • The growth of regulation is the cornerstone and foundation that cuts across all parts of development.

25. Regulation • Development is dependent upon it • Cognitive, Social-Emotional, Physical, Moral • Capacity to be functional when awake. • Capacity for a restorative sleep cycle. • Types of Regulation • Self-regulation – for soothing • Use of “other” – to meet needs • How do Infants Regulate ? They can’t fight or flee! • Nonverbal Cues • Infants first form of language

26. Theo and the sweetie -http://youtu.be/TZYIJDtt3mU

27. Learning Disabilities • The Effects of Neglect and a Non-Stimulating Environment on a Child

28. Back to School: Back to School 1 hr • Listen when you have the time.

29. Learning Disabilities • All learning happens in relationships. When early relationships are disrupted, the neural circuits necessary for brain development and effective learning are not formed. • 50% of the children who are in the foster care system have developmental delays including cognitive, motor, hearing and vision problems, growth retardation, and speech-language delays (this is 4-5x the rate found among all other children). • Most children in foster care who have disabilities were not born with them. They are a result of not being nurtured to develop to their full potential.

30. Developmental Milestones • Physiological Regulation • Mutual Attention (3 mo) • Mutual Engagement - Falling in Love (by 5 mo) • Intentional, two way dance (by 9 mo) • Intentional, gestural communication (by 13 mo) • Intentional, symbolic play with emotional themes (24-36 mo) • Intentional, building bridges and links between themes (36-48 mo)

31. Trauma • Myth: Infants and young children can’t speak so they won’t remember

32. What is the Prevalence of Infant/Early childhood trauma? • National • 0-3 is the age group most likely to be maltreated • Most of those maltreated are under 1 year of age • 1/3 were harmed during their first week of life • (Zero To Three, 2008) • 78% of children who were killed were younger than 4 years of age • 11.9% of the deaths were age 4-7 • (US Dept of Health and Human Services, Children’s Bureau, 2006) • Oklahoma DHS Custody • In Tulsa 1,079 children age 0-18 in custody • 515 are age 0-5 (48%) • State – 3,945 children age 0-5 in custody • (OKDHS 05/11) • State – 12/12 – Total children in out of home care – 9460 • 3 and under – 3198 • 5 and under – 4591 • Tulsa Co: Total 1232 (3 and under) 436 (5 and under) 608

33. Infants & Memory • Infants store memory within the first weeks of life

34. Our Primitive Brain

35. Memory & The Body • We are hard wired with a fight or flight response • Our amygdala is programmed to respond to threat by releasing stress hormone cortisol. • This is an adaptive system that helps us respond to danger. • Infants store sensory (procedural) memory (sights, sounds, smells, sensations, tastes) from traumatic events. • They have no language to help organize and make sense of these memories, and are at the mercy of stimuli that signal danger to their arousal system. • Parents and children can serve as traumatic reminders for each other.

36. Trauma In Infancy • What does it look like? What do we see? How do we know?

37. Nonverbal Cues: Sensory Information • Eyes • Facial expression • Tone of voice • Verbalization rhythm & rate • Posture • Gestures • Body Movement • Timing (Coordination) • Intensity • Modulation

38. Infant & Early Childhood Trauma: First Aid • Help the Adults First • If adults have been traumatized, get them access to help • Aid in finding a calm and safe provider for the infant • Change the State of Arousal to Safety • If understimulated, increase movement and emotions • If nervous, agitated or crying, calm by slowing everything down and find one sensation that soothes • Prioritize improving sleep at night & staying calm when awake • Find safety for the infant in relationships and the environment • Slow down all transitions

39. Infant & Early Childhood Trauma: First Aid • Become a Sensory Detective • Notice what sensations calm and organize and are preferences of the infant • Notice sensations that overwhelm, irritate, or shut down the infant • Provide visual aid to caregivers (video) to increase awareness of their approach as well as the baby’s response • Notice the rate, rhythm, and timing of transitions • Titrate Input According to Infant Response • Respect the fear response • Over time, allow for sensory input that is overwhelming to be present in the same room, unless it is a person that brings danger. • Pair fearful stimuli with sensory and relational, safety and sensory preferences.

40. Infant & Early Childhood Trauma: First Aid • Provide Sensory Comfort • Surround infant with sensory avenues of comfort; sounds, tastes, movements, touch pressure, sights • Healing is non-linear, non-prescriptive • Re-exposure First Aid • Honor fear response • Stay with child until no longer afraid • Recognize that fear and trauma can be masked • Remember that misbehavior is communication • Listen to child and accept feelings, and reassure. • Help the child find ways to have control (flashlight, nightlight)

41. Trauma’s impact on relationship • No parent writes on their “to do” list for the day, “Lose it with my child.” We do the best with the tools we’re given.

42. How can we impact relationship? • Areas to Focus On • BUILD ON STRENGTHS! • View the parent-child relationship as your client • Provide assistance with problems of living • Help caregiver provide physical and emotional safety • “Join, Partner” with the family. Use this language • Help the dyad construct their “story” • Provide reflective developmental guidance • Increase parent’s insight by speaking for the baby • Anticipate and recognize developmental (cognitive, socio-emotional) delays for the parent. Adjust your approach to meet their needs • Notice what the parent is “bringing” to sessions and follow their lead • Find space for your own reflective process about the work

43. Putting it all together

44. Child Parent Psychotherapy • Evidence Based Practice Model

45. Goals of CPP • Where have we been? Where are we going?

46. CPP Goals • Encouraging normal development • Engagement with present activities • Reaching toward future goals • Maintaining regular levels of affective arousal • Establishing trust in bodily sensations • Achieving reciprocity in intimate relationships

47. CPP goals (trauma related) • Increased capacity to respond realistically to threat • Differentiation between reliving and remembering • Normalization of the traumatic response • Placing the traumatic experience in perspective

48. The foundation • Safety first • Physical safety • Safe shelter • Food • Protective orders • Psychological safety • Maladaptive strategies: substance abuse • Affect regulation • Issues of limits and discipline

49. RAPPORT SAFETY RELATIONSHIPS

50. Setting the Stage for Treatment • Safety in the relationship: Parent as the protective shield • Safety in the environment • Safety in the Relationship: Appropriate Response to Dangerous Behaviors • Safety in the Relationship: Parent as Legitimate Authority Figure