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Introduction to Early Childhood Mental Health

Kathryn Seidler, LMSW Easter Seals Blake Foundation

Tucson, AZ

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A baby alone does not exist. A baby can be understood only as part of a relationship.

D.W. Winnicott

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Definition of Infant Mental Health.• Developing the capacity of the child

from birth to age three to experience, regulate, and express emotions; form close and secure interpersonal relationships; and explore the environment and learn - all in the context of family, community and cultural expectations….Zero to Three IMH Task Force

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CORE CONCEPTS OF EARLY CHILDHOOD

MENTAL HEALTH

1. Mental health needs of the 0-6 age population challenge and defy our conventional, individual-based thinking about providing therapy

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2. Early Childhood Mental Health is

FIRST and FOREMOST about RELATIONSHIPS

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3. We cannot conceive or consider infants and toddlers outside of the relationships they have with their primary caregivers.

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4. Object Relations Theory (Mahler)

• Proposes that an internalization of the caregiver occurs within the child’s psyche as a mental representation about self and caregiver, based on the relationship and interactions that occur.

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5. Development

• Early childhood mental health is understood as a model that is developmental

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Periods of DevelopmentPrenata

l: concepti

on to birth

Infancy &Toddlerho

od:birth to 2

yrs

Early Childhoo

d: 2-6 yrs

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5. Development (cont)

• Is sequential

• occurs in different areas

• Is individual

• Is inter-related

• Moves from simple to complex

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5. Development (cont)• “Sensitive Periods” between birth and

age 5; children rapidly develop foundational capabilities upon which subsequent development develops

• Influenced by biological, environmental and interpersonal sources of resiliency and vulnerability: Nature vs Nurture

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5. Development (cont)

• Research tells us there is a connection between a child’s early experiences, life-long health and well being established through the development of brain structure in the early years

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• Nurturing experiences.

• Good nutrition.

• Intervening early.

• Protection.

• Taking care of the caregiver.

Growing a Healthy Brain

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Pre-natal Development

(Eli

ot, 1

999)

The nervous system begins to develop just before the third week of gestation.

Cell creation and movement to the right spots occur during the first five prenatal months.

Talking Reasonably and Responsibly about Early Brain Development, University of Minnesota

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Nurture Affects Brain Development

• Nurturing touch promotes growth and alertness in babies.

• Presence of a secure attachment protects toddlers from biochemical effects of stress.

• Abused children pay more attention to angry faces – a reflection of the brain’s response.

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5. Development (cont.)• Failure to provide appropriate

stimulation, consistent responsive care and opportunities to explore their environment may cause a failure in the development of neural connections and pathways that facilitate essential learning and self-regulating skills

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5. Development (cont.)

• Exposure to trauma, neglect or severe stress is damaging to the developing brain and may result in learning disabilities, emotional, and behavioral problems

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5. Development (cont.)

Three Tasks of Early Childhood1. Emotional Development - negotiating

transition from external to internal self-regulation

• from birth infants must learn to regulate physiological and emotional functions

• emotion, behavior, and attention are highly linked, therefore success in one area can lead to success in another and difficulty in one can lead to difficulty in another

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5. Development (cont.)

1. Emotional Development (cont.)

– A child’s ability to regulate is deeply embedded in his relationships with others

– In dysfunctional homes, emotional demands on the infant can be confusing, conflicting and overwhelming

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5. Development (cont.)2. Cognitive Development - acquiring

capabilities that are the foundation for communication and learning

• babies are wired to learn

• society and parents need to be ready for the competencies with which the child arrives

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5. Development (cont.)2. Cognitive Development

• thinking, social interactions, relationships and emotions converge in a powerful way during the second year of life

• Quality and quantity of verbal and social stimulation that a child receives will determine the language learning process

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5. Development (cont.)

3. Social Development - learning to relate well to other children and forming relationships– secure attachments to caring adults during

infancy and toddler years lay the foundation for social relationships

– a child’s evolving cognitive, language, and emotional regulations skills play a role throughout social skill and relationship building

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5. Development (cont.)• Social Development (cont.)

• having positive relationship skills has been found to be a predictor of popularity with peers during the preschool years (Sroufe 1983, 1990)

• infants who exhibit ambivalent attachments may develop into unhappy, easily frustrated toddlers and preschoolers (Erikson, Sroufe & Egeland, 1985; Renken et al., 1989)

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5. Development (cont.)

Social Development (cont.)

• Children who are socially competent at the toddler or preschool age have parents who actively help them learn to play

• those who appear socially inept often have parents who view social competence as a function of the school system and devalue the importance of social skills

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6. Parallel Process

• Most parents referred or who seek out infant mental health services have some degree of developmental trauma of their own

• A relationship between the worker/therapist and the parent develops first

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6. Parallel Process (cont.)

• the actions and behavior of the worker toward the parent are geared to acknowledge the unmet developmental needs of the parent

• This behavior attempts to created a “holding environment” where the parent may experience a repair and healing of their own unmet developmental needs.

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6. Parallel Process (cont.)

• The goal is for the parent to learn how to create this “holding environment” for their own child

• Another goal is for the developmental trauma of the parent to not repeat itself in the parent/child relationship

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A relationship between a parent and IMH specialist can be “therapeutic” or healing even though the reason for the relationship is the needs of the child, family support, early intervention or educational needs.

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How do we foster relationships through relationships?

• Corrective Emotional Experiences!!!

• Fostering the idea of the parent’s “self” in relationship with another

• (I am valued, respected, liked!!)

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How do we foster relationships through relationships?

• Behavior Change - “Now that I know what’s good for my baby or child - I’ll do more because I want to pleased or be liked by my home visitor”

• Increased Reflective Function - Ability to think about another’s experience

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Emotional Availability

• Present and attending to other

• Processing other’s behavior

• Responding to other’s behavior– Reflection– Timing– Intensity– Affect

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7. “Ghosts in the Nursery”

• Selma Fraiberg

• the parents’ own internalized mental representations of their childhood, caregivers, and affective history

• good ghosts / bad ghosts

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8. Assessment

• Parent/Caregiver Interview

• Observation/assessment of parent child relationship and interaction

• Standardized Testing

• Address parent’s experience with their own caregivers: “Ghosts in the Nursery”

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8. Assessment (cont.)

• Nurture parent so parent can nurture their child

• Link past experiences with current care of infant

• Interventions and continued assessment of progress

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Infant Mental Health Practice

• Promotion

• Prevention

• Treatment

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PROMOTIONSupporting social-emotional health

• Home Based Programs– Parent-Child Activities– Enhancing parent-child social-emotional

functioning through relationships

• Center Based Programs– Continuity of care– Primary caregiving– Social-emotional assessments

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PREVENTIONAltering specific family risk conditions, or child-parent risk behaviors

– Parent-child interaction guidance– Parent support groups re: discipline– Home visits for depressed parents– Social support to single parents– Linking poor families with services

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TREATMENTProviding intervention for specific disorder or problem

– Parent-infant psychotherapy– Child play therapy– Couples therapy (esp. w/ spousal

violence)– Family therapy– Individual therapy– Substance abuse treatment for parent

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IMH Service Delivery Venues

• Home visitation

• Family support

• Family preservation

• Early intervention

• Child care

• Foster care

• Parenting education

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The Home as a Therapeutic Setting

• S. Fraiberg’s “Kitchen Therapy”

• Family Turf– Intimacy of home– Potential of trust

• Assessment in larger context

• Flexibility

• Incorporation of family resources

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IMH Services in Home-Based Programs

Rationale: Targeting overburdened families

• Importance of engaging multi-risk families during perinatal period

• Linkage between child maltreatment and adverse psychological outcomes

• Evidence re: need for more intensive intervention to address mental health

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IMH Services in Home-Based Programs:Strategies

• Providing social support as an “antidote” to psychological difficulties

• Addressing parental mental health needs through referral process

• Engaging in patient-child interactional activities to promote attachment

• Exploring parental “ghosts” as a means of addressing child maltreatment

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IMH Practice in Home-Based Settings: Parent-Infant Interactional Approach

• Incorporate parent-child interaction in each home visit

• Reflect on moment-to-moment parent-child interactions

• Identify teachable moments in context of parent-child interaction

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IMH Practice in Home-Based Settings: Intervention Process Strategies

• Increased directives of therapist versus insight work done in talk therapy

• Interactive guidance (coaching)

• Use of videotape

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Intervention Process Strategies (cont.)

• Moving beyond play

• Developmental guidance in the moment

• Unconditional Positive Regard (C. Rogers)

• Consistent nurturance/validation

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IMH Practice in Home-Based Settings: Staff Issues

• Intensive supervision of staff (1Hr/wk)

• Regular staff training

• Reflective group meetings and case presentations of managers and supervisors

• Use of videos in house visits and supervision

• Supervisory nurturance of staff

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Parent-Infant Mental Health: Promoting Positive Parenting• Empathize with

parental vulnerability around parenting

• Connect with parent’s desire to be a good parent

• Identify and reinforce positive parental behaviors

• Affirm parent’s special role and relationship with their child

• Help parent’s find JOY in caring for their child

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Parent -Infant Mental Health:Supporting the “Dance” (D. Stern)

• Support parental emotional availability

• Encourage affective expression, understanding and sharing

• Promote parental attunement

• Build on joyful activities

• Enhance joint attention and involvement

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ATTACHMENT: the orientation of an infant to the person(s) who meets their biological, emotional, and social needs

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BONDING: the ability of a parent or caretaker to make an emotional commitment to meet the infant’s needs

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Mary Ainsworth• “Strange Situation” technique has become the

major measure by which infant attachment is determined at 12 and 18 months

• Mother and infant enter a toy play room, and during three-minute time periods the baby is first with mother, then with a stranger, then reunited with mother, then alone, then with a stranger, and finally again reunited with mother

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From careful analysis of the reunion behaviors of the infant when the mother enters the room four kinds of attachment patterns have been noted

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Ainsworth’s Attachment Classifications

1 . Secure: B

2 Insecure

• Avoidant = A

• Ambivalent = C

• Disorganized = D

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4 Attachment Classifications for children

0-36 months:

1. Secure (B)

- Infant uses parent as a secure base to explore environment and re-engages the parent upon reunion (separation/reunion task)

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2. Avoidant (A) - Infant does NOT use the parent as a secure base; displays little affect

–explores the environment, but does not seek parent upon reunion

-Under stress, infant does not seek out parent for contact-comfort to reduce stress.

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3. Ambivalent or Resistant (C)

- Infant is in a state of distress and fails to explore the environment

• Infant will alternate between seeking contact with the parent and rejecting the parent

• Infant is under high states of stress on a continuous basis

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4. Disorganized (D) - Infant behavior lacks an observable goal, intention, or explanation in the presence of the parent.

• Infant exhibits interrupted movement, stereotypies (repetitive behaviors), freezing/smiling, falling, and odd postures upon reunion with the parent.

• no coherent strategy to re-engage the parent.

•Parent is considered, at times, to be frightening toward the infant, and parent frequently has a history of abuse of unresolved loss.

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Ainsworth (cont.)

• Mothers of the D babies are reported to often have a history of early trauma and loss in her own life

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4 Attachment Stages: birth to 36 months

1. PRE-ATTACHMENT•early orientation toward voice, smell, and self-regulation from major caregiver•predictability and consistency to strengthen attachment relationship•Initial development of the Arousal/Relaxation Cycle

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2. Recognition and Discrimination: 3-8 months

• Comparison and discrimination skills develop

• stranger anxiety and “Preference for Parent” (PFP)

• Exploration of environment: distance between infant and parent begins

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3. Active Engagement: 8-30 Months

• Separation anxiety: 7-9 months

• object permanence develops

• secure base behaviors 13+ months

• toddler learns social rules (home, childcare, public)

• play skills develop

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4. Partnerships: 30 months +

• Emotional Object Constancy develops around 36 months

• Attachment to adults solidify

• communication, bartering, and compromise between parent and child

• attachment gives emotional foundation to explore the world in greater depth

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Attachment Milestones and Behaviors

• Eye contact/social smile

• cuddle/molding

• reciprocity between infant/parent

• stranger anxiety 5-8 months

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Attachment Milestones and Behaviors

• separation anxiety 7-9 months

• secure base/safe haven 9+ months

• Preference for parent 7+ : Internal Working Model

• Partnership 30+

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Attachment Milestones and Behaviors (cont.)

• Following/searching

• reaching

• signaling/calling to

• holding/clinging/sitting with

• seeking to be picked up

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Salient Behaviors in the Assessment of Attachment Dx

BEHAVIOR• Showing Affection

• Comfort Seeking

SIGN OF ATTX DX• lack of warm and

affectionate interchanges across a range of interactions

• lack of discrimination showing affection to unfamiliar adults

• lack of comfort seeking when hurt, frightened, or ill, or seeking in ambivalent manner

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Salient Behaviors in the Assessment of Attachment Dx

BEHAVIOR• reliance for help

• Cooperation

SIGN OF ATTX DX• excessive dependence, or

inability to seek and use supportive presence of attachment figure when needed

• lack of compliance with caregiver requests and demands by the child as a striking feature of caregiver child interactions, or compulsive compliance

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Salient Behaviors in the Assessment of Attachment Dx

BEHAVIOR• Exploratory

Behavior

• Controlling Behavior

SIGN OF ATTX DX• failure to check back with

caregiver in unfamiliar settings; exploration limited by child’s unwillingness to leave caregiver

• oversolicitious and inappropriate caregiving bx, or excessively bossy and punitive controlling of caregiver by the child

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Salient Behaviors in the Assessment of Attachment Dx

BEHAVIOR• Reunion

Responses

SIGN OF ATTX DX• failure to re-establish

interaction after separations, including ignoring/avoiding behaviors, intense anger, or lack of affection

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Variables that can impact the attachment process in a negative way:

1. Postpartum emotional health of the mother

2. Prior mental health history, esp. in the areas of mood disorders

3. Lack of social support in the home

4. Unlimited emotional parenting skills by the parent

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Variables that can impact the attachment process in a negative way:5. Infant developmental status

(delays) and/or prematurity or medical problems

6. Changes in the parents’ relationship

7. Other losses experienced by the mother

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Theorists whose ideas help us understand

IMH:

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Eric Erikson

• Trust vs. Mistrust (0-12 mos.)

• Autonomy vs. Shame and Doubt (13-36 mos.)

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Margaret Mahler• Details stages in infant emotional growth

and development

• Infants move from a close physical relationship with the mother to a “hatching” period , tuning in to the outside world

• “Practicing” subphase, during which they count on the primary loved caregiver as a secure base as they explore their world

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Mahler (cont.)

• From age 1.5 to 3 years babies’ cognitive abilities permit them to think about and struggle to make sense of separation problems

• Baby yearns for a return to the closeness originally enjoyed, yet powerful urges compel baby in this “rapprochement” period to be a special, separate individual with wishes and desires all their own

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Mahler (cont.)

• A wise caregiver tunes into the need of baby to support their growing autonomy while still providing the nurturing responsivity and body-loving care that permit the toddler to develop beyond “rapprochement” into what is called “CONSTANCY”

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Mahler (cont.)

• The beginning of constancy occurs when the toddler can hold opposing emotional feelings (at the same time loving and feeling angry with the caregiver) in balance

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Mahler (cont.)• Constancy helps child to support lengthy

daily separations from parents who are both resented and loved

• Constancy helps toddlers come to terms with strong differences between their own and adult wishes and preferences

• Babies learn to integrate and accept dualities of feelings and still retain a clear sense of a loving relationship

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John Bowlby

• Father of “attachment theory”: proposes that infants build nonverbal, internal working models of early relationships with each caregiver

• These models are unconscious, yet they serve as templates for expecting other close relationships later in life to be similar (depressed or happy, kind or cruel, orderly or chaotic)

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Bowlby (cont.)

• When the baby’s attachment figure is present emotionally for her, she can explore freely and the quality of her play will be more focused and creative

• When the attx. figure disappears or is rejecting, the quality of play suffers

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Alicia F. Lieberman

• Wrote “The Emotional Life of the Toddler”

• Quotes Freud: “Mental health consists of loving well and working well” to remind us that children’s work is their play.

• Babies are by naturally social creatures

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Lieberman (cont.)

• Individual differences are an integral component of babies’ functioning

• Every individual exists in a particular environmental context that deeply affects the person’s functioning

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Lieberman (cont.)

• Infant mental health practitioners make an effort to understand how behaviors feel from the inside, not how they look from the outside

• The intervenor’s own feelings and behaviors have a major impact on the intervention

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Temperament: 2 Models

• Thomas and Chess (1977)

• Rothbart (1981)

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“Goodness of Fit”

What happens when the baby’s temperament is not a good fit with their caregiver’s?

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Resources and Websites

• zerotothree.org• arizonabond.org• ITMHCA.org• Handbook of Infant Mental Health, 2nd

Ed. (Zeanah, 2005)• Infant and Early Childhood Mental

Health: a Comprehensive, Developmental Approach to Assessment and Intervention (Greenspan and Wieder, 2005)