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Training Those Who Work With Young Children in Early Childhood Mental Health and Social and Emotiona

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Title: Training Those Who Work With Young Children in Early Childhood Mental Health and Social and Emotiona


1
Training Those Who Work With Young Children in
Early Childhood Mental Health and Social and
Emotional Development
  • Paula D. Zeanah, PhD, MSN, RN
  • Assoc. Professor, Dept. of Psychiatry
  • Tulane University School of Medicine
  • LA Office of Public Health

2
(No Transcript)
3
Hitting the High Points in an Hour and a Half
  • Who needs to be trained?
  • What do they do?
  • What do they need to know?
  • Are there core competencies
  • Challenges and strategies

4
Who Is the Workforce?
  • Pediatric and primary care health providers
  • Early childhood care and education professionals
  • Early intervention specialists
  • Child and adult mental health clinicians
  • Child welfare professionals
  • Legislative and policy planners
  • Researchers/teachers

5
Comprehensive Systems Approach to IMH Services
Zeanah, Stafford Nagle, 2005
6
What do they do?
  • Some type of interaction with parents and/or
    infant
  • Most do some type of assessment
  • informal or formal observations
  • screenings
  • extended psychotherapeutic evaluations
  • systems needs assessments

7
What do they do?
  • Most do some type of intervention(s)
  • educational classroom
  • supportive
  • preventive
  • psychotherapeutic
  • legal
  • policy and service planning

8
What do they do?
  • Most do some type of referral/collaboration with
    other agencies/services
  • Some may be involved in research
  • better descriptions of risk groups
  • delineation of deviant/healthy development
  • evaluation of validity of assessments and
    interventions
  • dissemination of findings

9
What do they need to know?
  • What is Infant Mental Health? Why is it
    important?
  • How does it apply to what I do? Im not a mental
    health person!

10
After all, do babies really need psychologists?
11
Definition of Infant Mental Health
  • Infant mental health has been defined as the
    young childs capacity to experience, regulate,
    and express emotions, form close and secure
    relationships, and explore the environment and
    learn.
  • All of these capacities will be best accomplished
    within the context of the caregiving environment
    that includes family, community, and cultural
    expectations for young children.
  • Developing these capacities is synonymous with
    healthy social and emotional development.

12
Why does IMH matter?
  • Early environments matter, and nurturing
    relationships are critical
  • Patterns of attachment between infant and
    caregiver are the most robust predictors of
    subsequent development

13
Rationale for Infant Mental Health
  • Consequences of early adverse experiences are
    substantial.
  • A convergence of findings from neuroscience,
    economics and mental health make clear that early
    intervention is effective.
  • Here and now matters also.

14
Adverse Childhood Experiences
  • Abuse
  • Physical 10.6
  • Sexual 28.3
  • Emotional 20.7
  • Neglect
  • Physical 9.9
  • Emotional 14.8
  • Household Dysfunction
  • Mother treated violently 12.7
  • Household substance abuse 26.9
  • Household mental illness 19.4
  • Parental separation/divorce 23.3
  • Incarcerated household member 4.4

15
Adverse Childhood Events and Adult Depression
Odds Ratio
Adverse Events
Chapman et al, 2004
16
Adverse Childhood Events and Adult Substance Abuse


Self-Report Alcoholism
Self-Report Illicit Drug Use
Dube et al, 2002
Dube et al, 2005
17
Adverse Childhood Events and Adult Ischemic Heart
Disease
Odds Ratio
Adverse Events
Dong et al, 2004
18
Themes
  • Context
  • A baby alone does not exist! Donald W. Winnicott
    (1965)
  • The most important advance in developmental
    research in the last 25 years is the discovery
    and exploration of context. Arnold J. Sameroff
    (1992)
  • Development
  • Rapidity and profundity of development in first
    3 years of life is unprecedented in human life
    cycle
  • Prevention
  • All aspects of assessment and treatment in infant
    mental health have as a primary goal the
    prevention of disturbance and impairment.
  • Health Promotion
  • Concerned with enhancement of factors known to be
    related to positive outcomes.


19
Infants develop within multiple contexts
Historical
Social
culture
Cultural
Family
INFANT
Neurobiological
20
Biological Contexts
  • Intrinsic factors that affect infants
    development
  • genetic influences
  • prenatal maternal health
  • temperament/constitution
  • physical health
  • physical attributes
  • neurobiology/brain development

21
Development
  • In a mere 36 months, infants change from totally
    dependent newborns to complex creatures able to
  • come and go as they please,
  • understand that they can share thoughts,
    feelings, and intentions with others
  • express themselves abstractly using symbols
  • empathize with others

22
Developmental Context
  • First three years of life the most rapid period
    of development
  • Wide range of normal
  • Determining what is delay, deviation, abnormal
    not always clear or easy
  • Yet, early adversity can have longstanding impact
    on cognitive, physical, social, behavioral and
    emotional development

23
Development
Protective factors
Favorable outcome
caregiving relationships social class IQ
Unfavorable outcome
poverty parental mental illness parental
substance abuse abuse/neglect teenage
parenthood low birthweight
Risk factors
24
Early intervention effects
Change from a high-risk to a low-risk trajectory
Adaptive behavior
Delinquency Substance abuse Psychiatric
sequellae School failure
Intervention
25
Relationship Context
  • THE MOST IMPORTANT CONTEXT
  • Through the relationship the infant
  • learns how to interact with others
  • develops a sense of his competence and self-worth
  • begins to experience and understand the world
  • is exposed to risk and protective factors

26
The Attachment Relationship
  • Infants can have more than one attachment
    relationship (but not unlimited)
  • Infants may have different types of attachment
    relationships (secure, insecure, disorganized)
    with different caregivers
  • The relationship forms via the myriad of daily
    interactions between caregiver and infant

27
Attachment Relationship, contd
  • Infant-caregiver relationship reflected in
    observable interactions and each individuals
    subjective experience of being with the other
  • Anything that can impact either individual can
    also impact the relationship

28
Environmental Context
  • Physical environment may determine availability
    of/access to resources
  • Poverty a strong negative influence on early
    experience b/c of environmental and psychosocial
    stresses associated
  • Cultural and ethnic influences affect parenting
    beliefs, expectations and behaviors and roles

29
Environmental Context
  • Physical environment may determine
    availability/access to resources
  • Poverty a strong negative influence on early
    experience b/c of environmental and psychosocial
    stresses associated
  • Cultural and ethnic influences affect parenting
    beliefs, expectations and behaviors and roles

30
Essence of infant mental health
  • Primary caregiving relationships most important
    predictor of psychological and social outcomes in
    young children
  • All caregiving relationships matter
  • Caregivers will help support mental health of
    young children when they
  • Provide sensitive and responsive care
  • Know and value child as an individual
  • Place needs of the child ahead of their own needs
  • Keep the baby in mind (mindfulness)

31
Goals of Infant Mental Health
  • Reduce or eliminate suffering here and now
  • Prevent adverse outcomes
  • School failure
  • Delinquency
  • Psychiatric disorders
  • Developmental delays and deviance
  • Partner violence
  • Premature parenthood
  • Abusive/neglectful parenting
  • Health outcomes
  • Enhance social competence
  • Promote resilience

32
Social Competence and Resilience
  • The ability to adapt successfully to differing
    social environmental demands.
  • Resilience (a special form of competence)
  • achieving positive outcomes despite high-risk
    status
  • maintaining competent functioning despite
    stressful life circumstances
  • recovering from traumatic events and experiences
  • Quality of relationship with primary caregiver is
    single most important predictor of outcome

33
Psychopathology in Early Childhood
34
Disorders in Early Childhood
  • Until recently, the idea of disorders in early
    childhood was not widely accepted
  • Now two diagnostic classifications are in use and
    providing a basis for studies of construct
    validity
  • Research Diagnostic Criteria (2003)
  • DC 0-3-Revised (2005)

35
Prevalence of Psychiatric Disorder in 2 to
5-year-old Children
36
High magnitude events (ever)
  • Death of loved adult 20.9
  • Grandparent 10.8
  • Aunt/uncle 3.7
  • Other loved adult 6.2
  • Parent 0.2
  • Child hospitalized 16.4
  • Motor vehicle accident 9.9
  • Serious fall 9.5
  • Burned 7.9

Egger, 2004
37
Stressful life events are common
  • Every child had experienced at least one low
    magnitude stressor in the last 3 months
  • 52.5 had experienced at least one high magnitude
    stressor during their lifetime
  • No gender or race differences in prevalence of
    life events
  • Older children more likely to have experienced a
    high magnitude stressor
  • But 42 of 2 year olds had experienced a high
    magnitude stressor

Egger, 2004
38
Cumulative stressors and psychiatric disorders
Egger, 2004
39
PTSD in Infants and Young Children
  • Young children display similar symptom clusters
    to adults, but they manifest differently
  • The traumatic responses of very young children
    are not adequately captured by DSM-IV criteria
  • Symptoms may change as developmental functions
    emerge

40
Comorbidity of PTSD in Early Childhood
78.6 of disorders had their onset after trauma
exposure
41
Predictors of Aggression 2-9 Years
  • Lower social class
  • Less maternal education
  • Reduced sensitivity
  • Harsh and punitive parenting
  • Depressive symptoms
  • Fewer child centered attitudes

42
Consequences of aggression
  • Gilliam (2005) Pre-K students expelled at a rate
    3x higher than K-12 peers (6.67 v. 2.09)

43
Infant Mental Health Services
44
Infant Mental Health Services
Zeanah, Stafford Nagle, 2005
45
Infant Mental Health Services
  • Universal (Context, screening and referral)
  • Primary care settings
  • Child care settings
  • WIC programs
  • Indicated (Preventive interventions)
  • Nurse Family Partnership
  • Selected (Treatment)
  • Trauma

46
What Do Professionals Need to Know?
  • Importance of relationships
  • Development, especially social-emotional
  • Risk/protective factors
  • Psychopathology
  • Assessment and intervention
  • Impact of values, culture
  • Systemsmultidisciplinary and transdisciplinary


47
Core Competencies
  • What is the content that everyone needs to know?
  • What is discipline specific?
  • What is agency specific?
  • Should there be credentialling?

48
Core Competencies, contd
  • Several groups/organizations have undertaken to
    delineate core competencies
  • Different approaches
  • Define target audiences
  • Define levels of responsibilities
  • Define domains of competencies

49
Define Target Audiences
  • Example Texas Health and Human Services
    Commission defined three domains
  • Child/Family e.g., family, case managers,
    educational personnel, behavioral specialists,
    health care
  • Community e.g., Community Resource Coordination
    groups, wraparound trainers, political and
    community leaders, higher education
  • Policy/State faith-based alliances, medical
    associations, advocacy organizations, insurance
    providers, Medicaid providers

50
Define Levels of Responsibilities
  • Wisconsin Initiative for IMH (3 levels)
  • Any person working w/children/families
  • Developmental professionals
  • Licensed mental health therapists
  • Michigan Association of IMH (4 levels)
  • Limited contact w/parents/caregivers
  • Case managers, home visitors
  • Mental health professionals
  • Educators, administrators, program/policy dev.
  • examples only

51
Define Domains of Competencies
  • Vermont Northern Lights Career Development
    Center
  • Child development
  • Families and communities
  • Teaching and learning
  • Healthy and safe environments
  • Professionalism and program organization

52
Core Competencies Content
  • Some consistency
  • Social and emotional development
  • Along with cognitive, physical and communication
    development
  • Unique needs of children
  • Importance of relationships
  • Attachment, family systems, other theories
  • Disorders
  • Impact of risk conditions

53
Core Competency Content
  • Assessment strategies
  • Formal/informal observation, screening
  • Formal assessment procedures
  • Diagnosis/diagnostic classifications
  • Interventions
  • Developmental guidance, parenting education,
    behavioral interventions, referrals,
    parent-infant psychotherapy

54
Core Competency Content
  • Relationship-based practice
  • Professional-client relationship
  • Impact of culture and values
  • Boundaries
  • Transference, counter-transference
  • Self-awareness
  • Reflective supervision

55
Core Competency Content
  • Working with others/systems
  • Building relationships
  • Communication skills
  • Systems and community resources knowledge
  • Sharing/disseminating knowledge

56
Discipline-Specific
  • Classroom strategies for teachers
  • Screening tools and clinic interventions for
    primary health care providers
  • Crisis management and development of long term
    relationships with clients for home visitors
  • Education strategies for parent education
    programs

57
Challenges
  • Large number of people to train
  • Wide range of skills/knowledge/interests/goals
  • The issue of language and communication
  • IMH/social-emotional development a new field
    not in basic training of most disciplines even
    now.

58
Challenges, contd
  • Lack of enough experts to conduct training
  • Appropriate assessment tools, as well as valid
    interventions, may not be available
  • Brief training may not be enough
  • Concepts seem simple, but the focus on
    relationships is a paradigm shift for most
    professionals

59
Challenges
  • Need for supervision
  • Reflective supervision different than traditional
  • Boundary issues always present
  • Personal and professional values also deeply
    intertwined with the clinical work
  • Professionals often get over their heads and do
    not know it, or dont know what else to do

60
Challenges, contd
  • There may not be a continuum of care/referral
    sources
  • Some ethical dilemmas
  • Is it appropriate to screen if there arent
    services?
  • Is it appropriate not to screen, given the known
    potential impact of many risk factors, such as
    maternal depression, domestic violence, substance
    abuse?

61
Credentialling
  • Discussions beginning some states have
    certificate programs
  • No national credentialling to date

62
Strategies
  • Top down (e.g., Floridas approach)
  • Statewide strategic plan
  • Identified three levels of practitioners
  • Developed training aimed at the three levels
  • (see FSUs Center for Prevention and Early
    Intevention)

63
Strategies
  • Bottom up (e.g., Louisianas approach)
  • Initially, IMH services/research aimed at extreme
    risk children/significant expertise
  • Awareness of IMH issues at LA OPH
  • 30 hour IMH training for frontline staff
  • IMH consultants to Nurse Family Partnership
  • Intensive IMH training for consultants
  • Growth of IMH services and interest

64
LA Approach
  • 5-day training for front line non-mental health
    clinicians
  • Social-emotional development, attachment theory
    and classifications, values
  • Family development, cultural/ethnic influences,
    parenting styles and roles
  • Psychopathology
  • Assessment (environment, infant, parent,
    relationship)
  • Interventions universal, specialized
    techniques, referrals, working with difficult
    clients, values

65
LA Approach, contd
  • 5-days, over several weeks or months, allows
    information to be absorbed
  • Also increased trust between presenters and
    learners
  • Often taps into personal issues
  • Need for additional supports to implement
    information (e.g., forms that include
    relationship observations, Bright Futures, Keys
    to Caregiving)

66
Intensive IMH Training
  • Aimed at licensed, experienced mental health
    clinicians
  • One year training (part time), including
    didactics, experiential, and supervision
  • Focus on specific assessment and therapeutic
    intervention techniques for IMH
  • Use of real world clients/cases

67
Lessons Learned
  • Training cant be quick
  • Follow-up and supervision/guidance needed
  • Reflective supervision
  • Ongoing support to deflect isolation, feeling
    overwhelmed, burnout
  • Training one type of group can facilitate
    learning
  • Videos really help!

68
Lessons Learned, contd
  • When lack of resources, be selective begin
    where
  • Need is greatest, or
  • Most professional strength, or
  • Communities willing to get on board
  • Need a championor group of individuals-- who
    get it and can effectively advocate
  • It is important to take advantage of momentum!

69
Lessons Learned
  • Partnershipsmay be easier said than done
  • Health/mental health
  • Child care/health/mental health
  • Universities with state agencies
  • Often similar goals/approaches in silo agencies
  • Patience, consistently meeting, developing the
    relationships

70
Conclusions
  • Infant mental health emphasizes the importance of
    caregiving relationships.
  • Healthy caregiving relationships promote social
    competence in young children social competence
    in children promotes adaptive outcomes, including
    school success.
  • Evidenced based interventions are available to
    promote infant mental health within families and
    within health, childcare, and preschool settings.

71
Conclusions
  • Training needs to consider not only specific
    content but supervision and ongoing support
  • Personal and professional values constantly
    present and need to be addressed
  • Need for IMH training in basic professional
    training
  • Need for evidence-based training methods
  • Remember Its all about relationships!

72
Conclusions
  • the quality of the parental care which a child
    receives in his earliest years is of vital
    importance for his future mental health.
  • what is believed to be essential for mental
    health is that an infant and young child should
    experience a warm, intimate and continuous
    relationship with his mother (or mother
    substitute) in which both find satisfaction and
    enjoyment.
  • John Bowlby 1952
  • Its déjà vu all over again!
  • Yogi Berra

73
Resources
  • www.zerotothree.org
  • Bright Futures
  • State infant mental health organizations
  • World Association of Infant Mental Health
  • UCLA documents on ECCS
  • Tulane Institute of Infant and Early Childhood
    Mental Health (www.infantinstitute.org)

74
Contact Information
  • References upon request
  • Paula Zeanah
  • pzeanah_at_tulane.edu 504-988-5405
  • pzeanah_at_dhh.la.gov 504-219-4630

75
Acknowledgments
Institute of Infant and Early Childhood Mental
Health at Tulane
  • Letia Bailey
  • Allison Boothe
  • Neil Boris
  • Melanie Bronfin
  • Mary Margaret Gleason
  • Angela Keyes
  • Joaniko Kochi
  • Julie Larrieu
  • Marva Lewis
  • Devi Miron
  • Geoff Nagle
  • Michael Scheeringa
  • Suzy Sonnier
  • Anna Smyke
  • Valerie Wajda-Johnston
  • Eban Walters
  • Charles H. Zeanah

76
AcknowledgementsLA Office of Public Health
  • Joan Wightkin
  • Jean Takenaka
  • Jean Valliere
  • Cheryl Williams
  • NFP Nurses and staff
  • Rodney Wise
  • Mary Craig
  • Sharon Howard
  • OPH Nurses and staff
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