Infant Mental Health & Relationship-based practice

1. Infant Mental Health & Relationship-based practice 2006 Institute: Infant Toddler Specialists of Indiana(August 25, 2006) Jon Korfmacher, Ph.D. Erikson Institute (Chicago IL) Illinois Association for Infant Mental Health

2. Workshop Objectives • Participants will take away: • Guiding principles and best practices of infant mental health • Three theoretical perspectives in IMH practice • Red flags and behavioral concerns • Awareness of IMH interventions and strategies • Ways to integrate IMH principles into programs

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. However... Infant Mental Health must also recognize “the Dark Side” • Suffering • Rigidity • Emde: Features define absence of mental health Infant Mental Health practice caught in a tension • Strength-based/Positive development • Working with families with clinical challenges

5. Infant Mental Health Is Important Because • Development in other domains organized by social and emotional development of child • Infant’s development begins and continues within context of primary relationships • The sooner the better

6. Guiding Principles 1. Babies and parents are social creatures—It’s all about relationships 2. Birth to three critical for brain growth and formation of personality and sense of self 3. Everyone lives in an environmental context that affects functioning

7. Guiding Principles 4. Pregnancy, Birth, and early childhood are times when past, present, and future intersect in unexpected ways 5. Understanding the feelings behind the behaviors is important to assessment and treatment

8. Best Practices in Infant Mental Health Are: • Interdisciplinary • Relationship-based • Strengths-based (without ignoring problems) • Child focused and family centered • Individualized (not prescriptive) • Continuous and consistent

9. Best Practices in Infant Mental Health Are: • Community-based • Accessible • Comprehensive, coordinated, and integrated • Culturally responsive • Committed to continuous improvement and reflective supervision

10. Infant Mental Health Practice Is NOT:

11. Theoretical Models • Attachment theory • Psychodynamic theory • Ecological/cultural perspective

12. 1. Attachment Theory • The lasting and deep emotional relationship between child and caregivers • Begins to develop in infancy • Focused on sense of security as child begins to explore environment

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

14. Functions of Attachment • Learn basic trust • Exploration of environment with confidence and security • Self-regulation and management of emotions • Develop Internal working model of relationships • Identity formation, sense of self-esteem • Protective factor against stress and trauma

15. 2. Psychodynamic Theory • “Ghosts in the Nursery” • Ways of relating to others internalized at an early age • Something occuring in present evokes early patterns of relating • Unconsciously act in the ways we internalized

16. Psychodynamic Theory • Recognizes “unconscious” motivations • Recognizes that past is always with us • Coming to terms with past can improve present functioning, including parenting • Goes back to “Guiding Principles”

17. 3. Ecological Theory • Context, context, context • Recognizes larger forces at work in influencing behavior • Different levels of context interact

18. Culture Culture Culture Child Child Care Parent Family Culture It takes a village Policies, Procedures, Regulations Neighborhood Community

19. Red Flags For IMH Services • Difficult/unwanted/unplanned pregnancy • Perinatal depression • Newborns with feeding, sleeping, regulation problems • Families who have children with special needs

20. Red Flags, continued • Families with few resources or social supports • Children with social or emotional delays • Children with possible attachment disorders • Families with one or more of the “Big Three” • Mental Health • Substance Abuse • Domestic Violence

21. Common Behavioral Concerns • Crying • Tantrums • Sleep • Toileting • Eating

22. Therapeutic Interventions • Observation and Assessment • Concrete support services • Supportive counseling • Developmental guidance • Parent-child interaction guidance

23. Therapeutic Interventions • Problem solving • Brief crisis intervention • Psychotherapy • Parent-infant • Parent-focused • Child play therapy (older toddlers+)

24. Strategies Used By IMH Specialists • Building relationships and using them as instruments of change. • Meeting with the infant and parent together throughout the period of intervention. • Sharing in the observation of the infant’s growth and development. Deborah Weatherston, The Infant Mental Health Specialist, 0-3 Oct/Nov. 2000.

25. Strategies, continued • Offering anticipatory guidance to the parent that is 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

26. Strategies, continued • Creating opportunities for interaction and exchange between parent(s) and infant or parent(s) and clinician • Allowing the parent to take the lead in interacting with the infant or determining the “agenda”or “topic for discussion.” • Identifying and enhancing the capacities that each parent brings to the care of the infant.

27. Strategies, continued • Wondering about the parent’s thoughts and feelings related to the presence and care of the infant and the changing responsibilities of parenthood. • Wondering about the infant’s experiences in the present, inquiring and talking. • Allowing for core relational conflicts and emotions to be expressed by the parent; holding, containing, and talking about them as the parent is able.

28. Strategies, continued • Attending and responding to parental histories of abandonment, separation, and unresolved loss as they affect the care of the infant, the infant’s development and the parent’s emotional health and the early developing relationship. • Attending and responding to the infant’s history of early care within the developing parent-infant relationship.

29. Strategies, continued • Identifying, treating and/or collaborating with others if needed , in the treatment of disorders of infancy, delays and disabilities, parental mental illness and family dysfunction. • Remaining open, curious, and reflective. Deborah Weatherston, The Infant Mental Health Specialist, 0-3 Oct/Nov. 2000.

30. Integrating IMH Into Your Program • Training • Reflective supervision • Screening • Consultation

31. Integrating IMH Into Your Program • Parent involvement • Parent groups • Home visiting

32. Integrating IMH Into Your Program • Collaboration • Community involvement • Advocacy

33. Case 1 Jacob was average in size and weight for a ten month old.  He was not yet sitting up and rarely moved from the spot on which his mother laid him as she joined the playgroup with her two and a half and three and a half year old sons.  Jacob frequently remained in the same position for close to the hour of the group.  Attempts to engage him with a toy or a smile were unsuccessful.  He maintained a somewhat glazed, detached look. Since he never cried, his mother thought that he was an easy baby and busied herself with her more active toddlers.  While other nine and ten month’s olds would crawl past him, Jacob seems to stare and remained motionless.

34. Case 2 At age two and a half, Adam seemed to love playing with trucks-as long as he could play alone and repetitively.  He especially liked to line the trucks up in a straight line.  He wasn't talking yet and his parents were concerned.  Whenever his father tries to play with him, Adam turned away.  Adam/s father reacted by forcing his was into Adam's play.  He would build bridges and tunnels for Adam's cars and he would direct Adam to drive his truck to a particular point.   The harder his father tried, the more Adam shut him out.  When verbal demands failed, Adam's father tried to engage physically with bear hugs and tickles.  This seemed to only agitate Adam more until his father gave up.  At that point, Adam would return to his solitary, repetitive play.

35. Case 3 Amanda was adopted from Paraguay when she was six months old.  An attractive child at two and a half, Amanda had little or no language and seldom interacted with other children or adults. Her mother brought her to a mom-tot program where she would find one or two familiar toys and play alone.  Amanda's mother was a loud woman who would frequently insert herself uninvited in other people's conversations.  She also referred to Amanda's adoption in Amanda's presence and explained that she was extremely shy and even slow.  Her attempts to get Amanda to talk by starting her sentences only caused Amanda to withdraw more.

36. Case 4 Brian’s parents found Brian difficult to manage.  At fifteen months, he exhibited enormous energy.  He would move from toy to toy but never really with genuine interest or sustained play.  He would never allow time to closely inspect a toy and was easily distracted.  Almost in a state of constant movement, his face often had a worried expression.  He would point to an object that he wanted and, once his parents targeted the right object, he would be pointing to another object.  Brian was easily startled by loud sounds.  His parent’s felt that he was spoiled and a "bad" boy.

37. Case 5 Anna was four years old when her parents raised concern about her defiant attitude and aggressive tendencies.  She was always invading her two-year-old sisters space and initiating conflict.  Although, at time, Anna could be a sweet and caring child, her preschool teachers were also expressing concern about her increasing aggressive play.  Anna's parents had married late and, to their surprise and great regret, were unable to have their own biological children. Both of their children were born with the help of donor eggs, but they had never processed this event.  Now, with their four-year-old causing concern, as well as difficulty, they felt stuck. 

38. 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?