Title: Training Those Who Work With Young Children in Early Childhood Mental Health and Social and Emotiona
1Training 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)
3Hitting 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
4Who 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
5Comprehensive Systems Approach to IMH Services
Zeanah, Stafford Nagle, 2005
6What 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
7What do they do?
- Most do some type of intervention(s)
- educational classroom
- supportive
- preventive
- psychotherapeutic
- legal
- policy and service planning
8What 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
9What 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!
10After all, do babies really need psychologists?
11Definition 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.
12Why 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
13Rationale 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.
14Adverse 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
15Adverse Childhood Events and Adult Depression
Odds Ratio
Adverse Events
Chapman et al, 2004
16Adverse Childhood Events and Adult Substance Abuse
Self-Report Alcoholism
Self-Report Illicit Drug Use
Dube et al, 2002
Dube et al, 2005
17Adverse Childhood Events and Adult Ischemic Heart
Disease
Odds Ratio
Adverse Events
Dong et al, 2004
18Themes
- 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.
19Infants develop within multiple contexts
Historical
Social
culture
Cultural
Family
INFANT
Neurobiological
20Biological Contexts
- Intrinsic factors that affect infants
development - genetic influences
- prenatal maternal health
- temperament/constitution
- physical health
- physical attributes
- neurobiology/brain development
21Development
- 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
22Developmental 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
23Development
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
24Early intervention effects
Change from a high-risk to a low-risk trajectory
Adaptive behavior
Delinquency Substance abuse Psychiatric
sequellae School failure
Intervention
25Relationship 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
26The 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
27Attachment 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
28Environmental 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
29Environmental 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
30Essence 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)
31Goals 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
32Social 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
33Psychopathology in Early Childhood
34Disorders 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)
35Prevalence of Psychiatric Disorder in 2 to
5-year-old Children
36High 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
37Stressful 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
38Cumulative stressors and psychiatric disorders
Egger, 2004
39PTSD 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
40Comorbidity of PTSD in Early Childhood
78.6 of disorders had their onset after trauma
exposure
41Predictors of Aggression 2-9 Years
- Lower social class
- Less maternal education
- Reduced sensitivity
- Harsh and punitive parenting
- Depressive symptoms
- Fewer child centered attitudes
42Consequences of aggression
- Gilliam (2005) Pre-K students expelled at a rate
3x higher than K-12 peers (6.67 v. 2.09)
43Infant Mental Health Services
44Infant 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
46What 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
47Core Competencies
- What is the content that everyone needs to know?
- What is discipline specific?
- What is agency specific?
- Should there be credentialling?
48Core Competencies, contd
- Several groups/organizations have undertaken to
delineate core competencies - Different approaches
- Define target audiences
- Define levels of responsibilities
- Define domains of competencies
49Define 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
50Define 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
51Define 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
52Core 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
53Core 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
54Core Competency Content
- Relationship-based practice
- Professional-client relationship
- Impact of culture and values
- Boundaries
- Transference, counter-transference
- Self-awareness
- Reflective supervision
55Core Competency Content
- Working with others/systems
- Building relationships
- Communication skills
- Systems and community resources knowledge
- Sharing/disseminating knowledge
56Discipline-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
57Challenges
- 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.
58Challenges, 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
59Challenges
- 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
60Challenges, 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?
61Credentialling
- Discussions beginning some states have
certificate programs - No national credentialling to date
62Strategies
- 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)
63Strategies
- 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
64LA 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
65LA 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)
66Intensive 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
67Lessons 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!
68Lessons 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!
69Lessons 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
70Conclusions
- 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.
71Conclusions
- 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!
72Conclusions
- 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
73Resources
- 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)
74Contact Information
- References upon request
- Paula Zeanah
- pzeanah_at_tulane.edu 504-988-5405
- pzeanah_at_dhh.la.gov 504-219-4630
75Acknowledgments
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
76AcknowledgementsLA 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