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What is Infant, Toddler, Early
Childhood Mental Health?
About BHECN
The Behavioral Health Education Center of Nebraska (BHECN,
pronounced “beacon”) was created by the Legislature to address
the shortage of behavioral health professionals in rural and
underserved areas. BHECN recruits & educates students in
behavioral health and trains & retains professionals in the
workforce.
By increasing the number of behavioral health professionals,
improving accessibility of behavioral health care, and building
competence of the workforce, we are improving the health of all
Nebraskans.
Learn more at unmc.edu/bhecn
Keep up with the latest
events and trainings from BHECN:
facebook.com/BHECN
About BHECN
Upcoming Webinars
• Nursing Webinar Series: Suicide and Bullying
• Thursday, May 21 6:00-7:30 pm
• Free nursing contact hours
• Retention Webinar Series
Questions? Amy Holmes [email protected]
Nebraska Association of
Infant Mental Health
(NAIMH)
• State Membership is $25
• Benefits:
– Calendar of related activities
– Webinars. This one is this year’s kick off.
– Web resource links.
– Interdisciplinary connections.
– Online blog by members.
2015 2nd NAIMH Annual
Webinar Topics
June 4 - Shaken Baby Prevention
July 2 - Early Traumatic Brain Injury
August 6 - Difference betweenChild Parent
Psychotherapy and Parent Child Interaction
Therapy
September 3 - A Review of Early Childhood
Assessment Screening Tools
2015 2nd NAIMH Annual
Webinar Topics
October 1 - The Impact of Chronic Toxic Stress in
Early Childhood
November 5 - Executive Functioning in Early
Childhood
December 3 - Effects of Poverty & Developing
Brain in Early Childhood and Across the Life
Span
Presenters
Joy D. Osofsky, Ph.D.
Paul J. Ramsay Chair of Psychiatry
Professor of Pediatrics and Psychiatry
Louisiana State University
Health Sciences Center, New Orleans
Mark Hald, Ph.D.
Options In Psychology, LLC
Nebraska Association
of Infant Mental Health
What Is Infant Mental
Health?
“Infant mental health is the developing capacity of
the child from birth to 3 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 for young children.”
--ZERO TO THREE Infant Mental
Health Task Force, 2001
What Is Infant Mental
Health?
“Infant mental health is synonymous with healthy
social and emotional development.”
--ZERO TO THREE Infant Mental
Health Task Force, 2001
Relationships and
the Brain
“We are
hardwired for
relationships.”
--Allan Schore
Experience Changes the
Brain
• “…our experiences are what create the unique
connections and mold the basic structure of
each individual’s brain.”
– Siegel, D., Hartzell, M. (2003)
• Today will change your brain
Imitation starts at birth
• Mirror neurons
– (Rizzolatti, Fadiga, Fogassi, Gallese. U of
Parma, Italy 1980’s-90’s).
• Ten-minute old newborn doing tongueprotrusion and mouth-opening,
– (Andrew Meltzoff experiments, 1988).
• Neonate imitation
• “Micro events” Microanalysis.
– (Ed Tronic and Marjorie Beeghly 2011).
Early relationships form
the basis of all other
relationships
– Relationships start at birth
• (or even during the prenatal period!) And
• Develop rapidly in the first year
• Parental state of mind
– Still Face Experiment - Observation of the
infant parent relationship
– Edward Tronick (1975)
Neurons that Fire
Together,
Wire Together
(Hebb, 1949)
How the Brain Develops
Newborn – 400 grams
3 Year Old – 1100 grams
Adult – 1500 grams
Image: www.brainconnection.com
© 1999 Scientific Learning Corporation
Brain Development
Pruning
Newborn
Early
Childhood
Later
Childhood
03-012
Synaptic Density
At Birth
6 Years Old
14 Years Old
Rethinking the Brain, Families and Work Institute, Rima Shore, 1997.
Brain Development
From Neurons to
Neighborhoods: The Science of
Early Childhood Development
Committee on Integrating
the Science of Early
Childhood Development
Board on Children, Youth,
and Families
Institute of Medicine
National Research Council
Center for the Developing Child at
Harvard
How Early Relationships
Come Into Being
• When patterns get constantly repeated, a baby
begins to form prototypes or schemas – a
mathematical average of these events
• This summary of experiences becomes part of
memory
• “Representations of how things happen”
»Daniel Stern, MD, Washington, DC,
2000
How Early Relationships
Come Into Being
• Babies develop generalized memories of ways of
being with people
• These memories happen around the mutual
regulation of meaningful states and experiences
• Excitement, joy anger, anxiety
• Sleep & eating
• Play
• Security
The Unexpected
• Babies notice when expectations are violated
– Still Face Paradigm
Edward Tronick, Ph.D. Harvard University
What Babies
Remember
It’s All About
Relationships
What is most important for healthy social
and emotional development is the
important person (sometimes more than
one) who interacts with the baby and is the
most emotionally invested in the baby
“Who fills this role is far less important
than the quality of the relationship she or
he establishes with the child”
» From Neurons to Neighborhoods, National Academy of Science, 2000
Babies Can Attach To
More Than One Person
Baby can have distinctly different interaction
patterns and patterns of attachment with several
caregivers
Attachment is “relationship specific”
How are Children
Traumatized?
Social Emotional Development is
Impacted by Trauma
Substance
Abuse
Exposure to
disasters
and war
The Adverse Childhood
Experiences (ACE)
Study
• The largest study of its kind ever done
to examine the health and social effects
of adverse childhood experiences over
the lifespan (18,000 participants)
• Trauma exposure / trauma symptoms
associated with a higher number of common
health problems
Demographic Categories
Percent (N = 17,337)
Gender
Female
54%
Male
46%
White
74.8%
Hispanic/Latino
11.2%
Asian/Pacific Islander
7.2%
African‐American
4.6%
Other
1.9%
Race
Age (years)
19‐29
5.3%
30‐39
9.8%
40‐49
18.6%
50‐59
19.9%
60 and over
46.4%
Not High School Graduate
7.2%
High School Graduate
17.6%
Some College
35.9%
College Graduate or Higher
39.3%
Education
Born in 1935 or before
Adverse Childhood Experiences
•Abuse and Neglect (e.g., psychological, physical, sexual)
•Household Dysfunction (e.g., domestic violence, substance
abuse, mental illness)
Impact on Child Development
•Neurobiologic Effects (e.g., brain abnormalities, stress hormone
dysregulation)
•Psychosocial Effects (e.g., poor attachment, poor socialization, poor
self-efficacy)
•Health Risk Behaviors (e.g., smoking, obesity, substance abuse,
promiscuity)
Long-Term Consequences
Disease and Disability
•Major Depression, Suicide, PTSD
•Drug and Alcohol Abuse
•Heart Disease
•Cancer
•Chronic Lung Disease
•Sexually Transmitted Diseases
•Intergenerational transmission of abuse
Data: www.AceStudy.org, www.nasmhpd.org
Social Problems
•Homelessness
•Prostitution
•Criminal Behavior
•Unemployment
•Parenting problems
•Family violence
•High utilization of health and social
services
Children with Developmental
Delays
Significant Adversity Impairs
Development in the First Three
Years
100%
80%
60%
40%
20%
1-2
3
4
5
6
7
Number of Risk Factors
Data Source: Barth, et al. (2008)
Slide courtesy of Ready Nation
Graph Courtesy: Center on the Developing Child at Harvard University
35
The Impact of ACE on an
Urban Pediatric Population
(N = 451)
Burke et al, 2011
Short and Long Term
Effects of Traumatic
Experiences on
Development
• The foundations of many mental health
problems that emerge in childhood and
adulthood are established early in life
(Adverse Childhood Experiences Study)
• What happens to a child is a result of
interaction between early risk factors, a child’s
genetic predisposition, and exposure to
significant environmental adversities
(i.e., harsh, inconsistent parenting as a result of poverty,
exposure to substance abusing parent, poor quality child care,
parental mental illness, institutionalization, etc.)
Evidence from ACE
Study Suggests:
Adverse childhood experiences are the
most basic cause of health risk behaviors,
morbidity, disability, mortality, and
healthcare costs.
Web site: www.acestudy.org
Vincent J. Felitti, M.D.
Robert F. Anda, M.D.
Why Early Relationships
Are Important
• Babies who had a positive experience
with their primary caregiver will transfer
those positive expectations to
subsequent caregivers, making it easier
for the new caregiver to understand the
baby’s needs
• Early relationships form the basis for all
later relationships
» Dozier, M., et.al (2001), Child Development, 72(5); Emde, IMHJ
Why Early Relationships
Are Important
• Babies who had a negative experience
with their caregiver will “continue to
have low expectations for nurturing care
and behave in ways that do not elicit
nurturance”
• With sensitive foster mothering, the
baby can still learn that its needs can
be met and become securely attached
» Dozier, M., et.al (2001). Child Development, 72(5)
Why Early Relationships
Are Important
• Early micro-experiences become the building
blocks of the baby’s emotional bond with the
caregiver
• This “emotional bond” is attachment
Why Early Relationships
Are Important
• The hallmark of this important
relationship is the readily observable
fact that this special adult is not
interchangeable with others
• Babies grieve when their attachment
relationships are disrupted
– Neurons to Neighborhoods, National Academy of Science, 2000
What Is Attachment?
• Feeling of security and protection
• Preferred attachment evident after 7-9
months
• Operative throughout life
• Even as adults, our early experience
with attachment affect how we
approach intimacy
Goals of the Attachment
System
• External goal – caregiver’s presence
• Reduces young child’s fear in novel
or challenging situations
• Enables the child to explore (the
world) with confidence
Goals of the Attachment
System
• Internal goal – sense of self
• Strengthen a young child’s sense of
competence and efficacy
• “Stay here so I can do it myself”
–Neurons to Neighborhoods, National
Academy of Science, 2000
Infants At Risk
•
•
•
•
•
•
•
Poverty
Mental illness
Maternal depression
Substance abuse
History of domestic violence
Chaotic families
Parental history of poor attachments
Salient Behaviors for
Assessing Attachment
•
•
•
•
•
•
•
Showing affection
Comfort seeking
Return for help
Cooperation
Controlling behavior
Exploration
Reunion response
Showing Affection
Lack of warm and affectionate interchanges
across a range of interactions; promiscuous
affection with relatively unfamiliar adults
Comfort Seeking
Lack of comfort seeking when hurt, frightened, or
ill, or comfort seeking in odd or ambivalent
manner
Reliance for Help
Excessive dependence, or inability to seek and
use supportive presence of attachment figure
when needed
Cooperation
Lack of compliance with caregiver requests and
demands by the child as a striking feature of
caregiver-child interactions, or compulsive
compliance
Exploratory Behavior
Failure to check back with caregiver in unfamiliar
settings, or exploration limited by child’s
unwillingness to leave caregiver
Controlling Behavior
Oversolicitous and inappropriate caregiving
behavior, or excessively bossy and punitive
controlling of caregiver by the child
Reunion Responses
Failure to re-establish interaction after
separations, including ignoring/avoiding
behaviors, intense anger, or lack of affection
“Good Relationships
Are Catching”
“How you are is as important as what you do.”
—Jeree Pawl
Supporting Infant Mental
Health
•
•
•
•
Embrace the complexity of an infant’s and
a family’s special needs and
characteristics
Embrace the complexity of family,
community and cultural practices and
values
Build upon strengths—remind and
reinforce caregivers of their skill and
competency
Recognize the importance of reflective
supervision in this very complex work for
those who work with and care for the
children and families.
Signs in the Baby that
Emotional Needs are Not
Being Met
•
•
•
•
•
•
Sad or bland affect (emotions)
Lack of eye contact
Non-organic failure to thrive
Lack of responsiveness
Prefers “stranger” to familiar caregiver
Rejects being held or touched
Signs of Emotional
Problems in Toddlers or
Preschoolers
•
•
•
•
•
Dysregulated, aggressive behaviors
Problems with and deficits in attention
Lack of attachment; indiscriminate attachment
Sleep problems or disorders
All beyond what is “usual” behavior for children of
this age
Observation of Infants and
Young Children is
Important
• Play is the language of infants and toddlers
• Observation is the main “tool” to understand the
emotional life (inner world) of the young child
• Observations allows us to understand
children’s thoughts and feelings
Behaviors to Observe
include
• Eye contact between parent/caregiver and
infant
• Holding patterns of caregiver
• Mutual touching of caregiver & infant
• Talking and other communication patterns
between caregiver and infant
• Responsiveness and reciprocity (give and take)
between caregiver and infant
• Sensitivity of both caregiver and infant to each
other
How observation helps
us understand parentchild relationships
• Does the infant or young child have a full
range of affect (emotions)?
• Does the young child have any signs of
abuse, neglect, or inadequate care?
• How does the infant relate to the
caregiver/parent?
• How does the parent/caregiver relate to the
infant?
• How does the infant relate to the examiner?
Relationship Based
Intervention
“There is no such thing as a baby”
Winnicott
The Importance of
Developing TraumaInformed Systems
(NCTSN; Judge Michael Howard and Dr. Frank Putnam,
Ohio, 2009)
• A Trauma-Informed System of Care
acknowledges and responds to the role of
trauma in the development of emotional,
behavioral, educational, and physical difficulties
in the lives of children and adults
• The System recognizes and avoids inflicting
secondary trauma
Secondary Trauma
• Secondary trauma occurs when child serving
systems re-traumatize a child through policies
and procedures
• Examples:
• From child welfare: multiple placements;
handcuffing parents in front of their
children; visitation; change of caseworkers;
foster care
• From pediatrics: unavoidable separations
of young children from caregivers; medical
trauma
Implementation of
Trauma-Informed
Systems
Build Collaborative Partnerships for Children
When Problems are
Identified – especially
with young children
exposed to trauma
• Do not assume the 0-5 year old child is too
young to have problems that can be treated
• Do not assume they will “grow out of them”
• Refer for relationship based evaluations
• Refer for evidence based interventions and
psychotherapeutic interventions for young
children
Interventions that Heal: and
are available in Nebraska
communities.
Child-parent psychotherapy helps a young child
learn to trust again.
• Circle of Security Parenting
• Home Visiting supports: e.g. Six Pence,
Healthy Families America, Parents Interacting
with Infants.
• Early Head Start. Head Start. Other high quality
early childhood programing.
• Rooted In Relationships programs
Secondary
Traumatization and
Burnout (aka
compassion fatigue)
• In health care providers
• doctors, nurses, residents
• In mental health care clinicians
• In child welfare
Prevention
• Maintain adequate self-care
• Know and honor your personal limitations
• Exercise compassion for yourself
• Learn to say “no.”
• Take time off
• Maintain appropriate boundaries
• Stay emotionally connected without becoming
over-involved – “Who’s needs am I meeting?”
Irving B. Harris
“Pushing Kids into
the River”
Resources
National
– www.zerotothree.org
– www.nctsn.org
– http://developingchild.harvard.edu/
Nebraska
– http://www.nebraskainfantmentalhealth.org/
– http://www.answers4families.org/
– http://www.nebraskachildren.org/
– http://www.firstfivenebraska.org/
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