Another surprise, and most controversial, is the new diagnostic name, Autism Spectrum Disorder (ASD).  The new ASD diagnosis underlines the continuity within the DSM-IV Autism, Asperger’s Disorder, Child Disintegrative Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. However, many clinicians voice concern that lumping these disorders may decrease access to care and public understanding. They emphasize that these limitations may lead to greater stigma and less individualized treatment for children, especially those now diagnosed with Asperger’s Disorder.

A third surprise, Disruptive Mood Dysregulation Disorder (DMDD), a new Depressive Disorder, describes children up to age 18 years with “persistent irritability and extreme behavioral dyscontrol”. This common presentation of chronic irritability and severe behavioral dysregulation in children is often comorbid with various psychiatric diagnoses including Attention-Deficit/Hyperactivity Disorder, Posttraumatic Stress Disorder, Depressive Disorder and Bipolar Disorder. DMDD addresses concerns about potential over-diagnosis of Bipolar disorders, especially in young children.

DSM-5’s new organization includes three sections that facilitate clinical decision-making and research:
• Section 1 introduces the DSM-5 and how to use the new manual.
• Section 2 sequences diagnostic chapters developmentally by age. It also groups similar disorders in new chapters, and similar chapters adjacent to each other.
• Section 3 features conditions that require additional research.

Section 1 
DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, provides an overview of the newly conceptualized developmental frame, based on new science that informs both the organization of the chapters and the diagnostic criteria. Research shaping the new organization integrates the following:
• Influence of culture and gender
• Influence of genetic and neurodevelopmental research
• Symptoms occurring across multiple disorders

DSM-5, in addition, focuses on increasing the congruency between the DSM-5 and the proposed International Classification of Disorders, Eleventh Edition (ICD-11) by the World Health Organization (WHO).

Section 2
DSM-5 diagnostic chapters are organized to reflect differences across the lifespan. Neurodevelopmental Disorders are listed first to support early identification and intervention. Chapters below describe changes most helpful in understanding children’s developmental processes:

Neurodevelopmental Disorders (frequently presenting together)
• Intellectual Disability (Intellectual Developmental Disorder)
• Communication Disorders
• Autistic Spectrum Disorder
• Attention-Deficit/Hyperactivity Disorder
• Specific Learning Disorder
• Motor Disorders

Depressive Disorders
• Disruptive Mood Regulation Disorder (new)
• Bereavement (now included to increase appropriate treatment of chronic symptoms)

Trauma and Stressor-Related Disorders (features separate Posttraumatic Stress Disorder criteria for children 6 years and younger)

Section 3 
DSM-5 supports further diagnostic exploration of conditions that require additional research.  It also includes cultural formulations and a glossary.

Summary
DSM-5 integrates new research to advance developmentally informed early identification, age-specific diagnoses and more targeted treatment for children. It also fosters ongoing integrated research to increase understanding of developmental processes and lead to earlier, more accurate and consistent diagnoses and intervention.

For further information, go to:  www.dsm5.org

Submitted by California Center National Advisory Council Member:

Jean Thomas, M.D.
Integrated Therapy Services for Children and Families (ITS)
Clinical Professor, Psychiatry and Behavioral Sciences
George Washington University
Children’s National Medical Center

• Attending a transitional IEP meeting at a school or district office
• Conducting a preschool, day care or home based observation
• Consulting with regional center staff regarding a referral or children in my caseload
• Attending  a multidisciplinary team meeting
• Training clinicians at a public or private agency serving young children
• Working with parents and families in my office or in the field

I find the field of infant mental health invigorating, as it involves complexity and requires clinical thinking across developmental domains and across disciplines. The ability to properly treat each infant and toddler, dyad and family requires assessment and treatment models as complex the work we do: it involves multi-dimensional thinking and practice. Multi-dimensional thinking is by nature transdisciplinary. My own pathway to transdisciplinary practice was through the DIR® certificate program of the Interdisciplinary Council on Development and Learning (ICDL). Founded by Stanley Greenspan, M.D. and Serena Wieder, Ph.D., the groundbreaking work of the DIR® Institute  brought the wisdom of infant mental health  (harnessing growth through relationships) to all aspects of development while training professionals in allied fields (occupational therapy, speech therapy, physical therapy, education, pediatrics, etc.). The training focus involved looking at many aspects (dimensions) of development and how each caregiver and child’s individual differences impact development and social emotional milestones. By working in small groups during our summer institutes, and through regular reflective supervision, practitioners from different disciplines learned a common language, and way to codify how a child’s individual differences impact the growing relationships and their acquisition of social emotional milestones (described as Axis V of the DC:0-3R).

In practical terms, DIR® training provides important tools for understanding how to support caregivers and help the relationship with their children blossom. A large part of this understanding comes from the knowledge base in the fields of speech and language therapy and occupational therapy. With non verbal communication between parent and infant forming the earliest foundation of joint attention, speech and language therapists help us understand, assess and grow the quality of non-verbal communication in dyads and families. Similarly, when joint attention is not coming online, occupational therapists teach us how subtle differences in sensory processing and integration, vision, and the range of praxis (including the ideation, planning, sequencing, executing and adaptation of motor movements) can impact the critical journey of connection and relatedness.

In summary, development itself is complex, involving interconnected neurological processes influenced by personal biology, relationships, experience and the environment.

As a practitioner working with young children and families, understanding how to support relationships in the context of individual differences creates the dimensional framework necessary to work flexibly with families and support social emotional development. Please check out what is happening on a national level to bring much needed multi-dimensional thinking into our homes, clinics and schools.

For more information visit www.Profectum.org

Mona M. Delahooke, Ph.D.
Licensed Clinical Psychologist
DIR® Certificate: ICDL and Profectum Foundation
Profectum Foundation: Senior Faculty Member
Profectum Mental Health Working Group Co-Chair
www.monadelahooke.com

The early kindergarten movement in the United States, begun in the mid-1800’s, was modeled on the play-based early education programs originated by Friedrich Froebel in Germany in 1837.  In the United States, kindergarten programs were typically focused on immigrant populations living in poverty in large cities (Bhavnagri & Krolikowski, 2000). These kindergartens were funded by philanthropic groups and had teachers who taught young children in the mornings and did home visiting in neighborhoods in the afternoons. Home visiting was designed to teach families about child rearing and how to use toys to stimulate learning, and to build community and family relationships. Teachers acted as family advocates with landlords, local stores, and the government. By the 1930′s, demand increased for kindergartens and there was a shift to morning and afternoon kindergarten sessions and the elimination of the home visiting component.

Another early model of home visiting can be found in the origins of public health nursing in America.  Public health nursing was modeled after nurse home visiting programs in England where trained nurses provided health care and social support in specific geographic regions. Florence Nightingale is generally credited as the first person to use the term “health nursing” and to develop and promote training for regional nurses in England (Georgia Dept of Human Resources).  In the United States, community nursing began in the 1870′s with a handful of nurses relying on funding from philanthropies.   Lillian Wald coined the term “public health nurse” and is credited with pioneering public health nursing in the lower east side of Manhattan in the 1890’s (Bekemeier, 2008; Buhler-Wilkerson,1993).  The work was similar to Settlement House efforts and included community activism to address social conditions in impoverished communities.  The public health nursing approach included preventative care and family education until funding shifted from a philanthropic to government base.  Following the funding shift, the philosophical approach changed to that of a medical model focused on obstetrics, well baby care, and health education. For many years, the focus remained on health care with little attention to the social support that is generally included in nurse home visiting programs in Europe. Government funding contributed to a rapid expansion of the public health nursing workforce in the U.S. from the early 1900’s to the 2000’s.

The Settlement House movement began in American in the 1880′s (Adams, 1910; Weiss, 2006). Through this movement, upper class reformers tried to improve the living conditions of the immigrant poor through a broad reach across social and education programs. They attempted to influence the early education of young children, to provide support for families dealing with health and social crises, and to force improvements in environmental conditions such as housing, parks and playgrounds, and trash collection through legislative advocacy and direct service. Settlement House reformers lived and worked in the poverty communities to both better understand the families being served and to model the behaviors and skills that they believed all individuals should possess.  Wealthy women who were part of the Settlement House movement raised funds for day nurseries, advocated for the development of branch libraries, kindergartens, and night classes, taught homemaking and child care skills, provided homeless shelters, and taught English to new immigrants in urban communities.

The Great Depression in the 1930’s had a huge impact on philanthropic organizations, with more than one in three shutting down between 1929 and 1932. The federal government developed a variety of initiatives to assist the millions of citizens who lost their jobs and their homes (Trattner, 1999).  A prosperous period following World War II led to a decline in interest in funding social initiatives, but there was a resurgence in the 1960’s with the federal “War on Poverty” and initiatives such as Head Start and Home Start.  Home visiting programs were funded with a focus on social issues such as poverty and teen parenting, and health issues including the increasing rates of very low birthweight babies due to technological advances in medicine.  Home visiting programs in the 1960’s were often focused on “infant stimulation” intended to reduce intellectual deficits, improve a range of developmental outcomes, and prepare young children for school success.  Many home visiting programs in the 1970’s shifted their focus to include family support with a broader reach towards prevention services aimed at the whole family, harkening back to the days of the Settlement House movement.  These models included attention to access to support services along with promotion of developmentally appropriate parenting practices and parent self-efficacy.

As home visiting programs demonstrated positive outcomes such as reduction in child abuse, recommendations for universal home visiting programs arose in the 1990’s (Krugman, 1993; U.S. Advisory Board on Child Abuse & Neglect, 1991).  Unfortunately, the federal government did not respond to such recommendations, but a wide range of local foundations and state government programs increased their attention and directed funding towards home visiting in poverty communities.  In addition, some state governments provided categorical funding streams for home visiting services aimed at specific populations, such as teen parents and children and families who were part of health and child welfare systems.

Today’s programs may be funded within the mental health, child welfare, early education, physical health, or developmental disability systems or by private foundation dollars focused on one of these systems.  Although linkages and collaborations are essential for effective service delivery, limitations usually exist in the development of seamless systems of care involving all aspects of health and development (Astuto & Allen, 2009; Finello & Poulsen, 2011).  Despite more than 100 years of home visiting services, most programs find themselves battling the same issues as those seen in the 1800’s.  As Gomby and her colleagues (1999) point out, home visiting programs are being asked to solve broad social problems of enormous magnitude while relying upon individual changes in behavior over short periods of time.  Clearly, we need to be more realistic about goals, outcomes, and what should be considered “success” in the delivery of home visiting services to families over a short period of time.

Click here to read more on the current Home Visiting Program

Coming soon:  “Challenges in Delivering Services through Home Visiting Programs”

Submitted by:  Karen Moran Finello, PhD

References & Further Reading

Adams, J. (1910).  Twenty years at Hull House. New York:  Macmillan.

Astuto, J. & Allen, L. (2009). Home visitation and young children: An approach worth investing in?  Society for Research in Child Development, Social Policy Report, XXIII(IV), 3-21.

Bekemeier, B. (2008).  Nurses on the frontlines of community health.   Northwest Public Health, Spring/Summer. University of Washington School of Public Health & Community Medicine. www.nwpublichealth.org/docs/nph/s2008/bekemeier_s2008.pdf

Bhavnagri, N.P. & Krolikowski, S. (2000).  Home-community visits during an era of reform (1870-1920).  Early Childhood Research & Practice, 2(1).  http://ecrp.uiuc.edu/v2n1/bhavnagri.html.

Buhler-Wilkerson, K. (1993). Bringing care to the people: Lillian Wald’s legacy to public health nursing. American Journal of Public Health, 83(December), 1778–1786.

Finello, K.M. & Poulsen, M.K. (2011). Unique System of Care Issues & Challenges in Serving Children under Age 3 and their Families.  Special Issue of American Journal of Community Psychology, 2011,  DOI 10.1007/s10464-011-9458-6.

Georgia Dept. of Human Resources, Div. of Public Health.  The history of public health nursing in Georgia (1898-2002).  http://health.state.ga.us/pdfs/nursing/Hist.Pub.Hlth.Nurse.web.pdf

Gomby, D.S., Culross, P.L. & Behrman, R.E. (1999).  Home visiting:  Recent program evaluations–Analysis and recommendations.  Future of Children, 9(1), 4-26.

Krugman, R. D. (1993).  Universal home visiting:  A recommendation from the U.S. Advisory Board on Child Abuse & Neglect.  Future of Children, 3(3), 184-191.

Trattner, W.I. (1999). From poor law to welfare state. A history of social welfare in America. (6^th Ed.). New York:  Free Press.

U.S. Advisory Board on Child Abuse & Neglect.  U.S. Dept. of Health & Human Services (1991).  Creating caring communities: Blueprint for an effective federal policy for child abuse and neglect.  Washington, DC:  U.S. Gov. Printing Office.

Weiss, H. (1993).  Home visits:  Necessary but not sufficient.  Future of Children, 3(3), 113-128.

California’s application makes the case for a locally driven approach with three key arguments:

1. California has many diverse regions, each with its own politics, economy, and labor market. A one-size-fits-all approach will not work.
2. To be successful, local Consortia must maintain control over their own improvement process.
3. California must be fiscally responsible and should not agree to any spending commitments beyond the grant period.

CALIFORNIA’S PLAN: LOCAL ACTIVITIES

• Local Quality Rating and Improvement System (QRIS)

Approximately 74 percent of California’s RTT-ELC grant funding will be spent at the local level to support a voluntary network of 17 Regional Leadership Consortia (Consortia), each led by an established organization that is already operating or developing a quality rating and improvement system (QRIS). The 17 Consortia in 16 counties includes: Alameda, Contra Costa, El Dorado, Fresno, Los Angeles, Merced, Orange, Sacramento, San Diego, San Francisco, San Joaquin, Santa Barbara, Santa Clara, Santa Cruz, Ventura, and Yolo. The children under five-years-of-age population of these 16 counties is almost 1.9 million which represent almost 70 percent of the total children birth to five in California.

As part of this grant, the Consortia will bring together organizations in their region with the same goal of improving the quality of early learning and will expand their current areas of impact by inviting other programs to join their QRIS or reaching out to mentor other communities. By joining California’s Race to the Top effort, the Consortia voluntarily agree to align their local QRIS to a common “Quality Continuum Framework” (Framework) based on research-based elements and related assessment and improvement tools. Based on federal requirements and Consortia group consensus, the Consortia also agree to implement in their QRISs three common tiers using the Framework as well as additional locally determined tiers. They will set local goals to improve the quality of early learning and development programs in the following three areas:

1. Child development and readiness for school;
2. Teachers and teaching; and
3. Program and environment quality.

The end goal that unites these Consortia is to: Ensure that children in California have access to high quality programs so that they thrive in their early learning settings and succeed in kindergarten and beyond.

CALIFORNIA’S PLAN: STATE ACTIVITIES

In addition to an evaluation to validate the effectiveness of the Consortia QRISs and the three common tiers, California will use a portion of the RTT-ELC grant funds to make the following one-time investments in state capacity:

• Home Visiting:  Provide training to local California Home Visiting Program staff on implementing the Program for Infant/Toddler Care (PITC) practices and on the “Three R’s of Early Childhood: Relationships, Resilience, and Readiness”.

• Screening Tool Distribution: Distribute “Ages and Stages” screening tools and materials to California Department of Education contracted early learning and development programs and local Consortia.

• Curricula Development for Higher Education: Facilitate and coordinate unit-based course alignment for three additional child development unit-based courses: Infant/toddler; children with special needs; and program administration.

• California Collaborative for the Social and Emotional Foundations of Early Learning (CSEFEL): Provide regional support for implementation of the CSEFEL teaching pyramid in local Consortia.

• California Department of Social Services (DSS), Community Care Licensing Division (CCL) Web site: Enhance the DSS, CCL Web site to include educational and training materials for consumers and providers.

• Central Repository for Kindergarten Readiness Information: Update the California Longitudinal Pupil Achievement Data System (CALPADS) to accommodate the Kindergarten entry assessment information (DRDP-SR).

• Program Administration Scale (PAS)/ Business Administration Scale (BAS) Training for Mentors: Provide “Train-the-trainer” instruction on the PAS and the BAS tools to Director Mentors and Family Child Care Home Mentors to support administrative technical assistance to local Consortia, participating centers, and family child care homes.

• Electronic Training Materials on Existing Content: Develop online training materials for existing content in order to diminish access barriers.

• Comprehensive System of Personnel Development for Early Start: Provide coordinated training for early intervention program staff, and support implementation of best practices in developmental and health screening at the local level in collaboration with the local Consortia.

Posted by Leadership Team member: Patsy Hampton, MRA

All names and identifying facts have been changed to preserve confidentiality.

In the last decade, there has been greater focus on the developmental and emotional needs of the infants and toddlers in the child welfare system and Juvenile court dependency proceedings (A Call To Action On Behalf Of A Maltreated Infants and Toddlers, 2011; Lederman, Osofsky & Katz, 2004; Wulczyn, Hislop & Harden, 2002).  There is now a better understanding of the long term affects of abuse and neglect on infants and toddlers and their experiences in the child welfare system (Osofsky & Leiberman, 2011; Lederman & Osofsky, 2008; Lederman & Osofsky, 2004; Lederman, Clyman, Harden & Little, 2002;).  For a large portion of the history of foster care and dependency proceedings, children were not given a voice at all. In fact, court cases which were specifically about maltreatment of children and often resulted in the disruption of children’s lives through placement in foster care and the intrusion of Child Protective Services (CPS) in the lives of their families, rarely had legal professionals that showed reflective capacity about the individual children, their needs and how to ensure that anything other than their basic needs were met; it was simply outside of their scope of practice.  The older children could, when asked, speak about their needs.  The non-verbal population could not and few professionals were asking how they might be heard.

A little over a decade ago however, counties across California found it prudent to appoint attorneys for all minors to represent their best interest in Juvenile dependency legal proceedings (Adoptions and Safe Families Act, 1997).  Although this was a positive step, the attorneys still faced monumental barriers in their representation of infants and toddlers.  The central obstacle for attorneys was the lack of relevant training in understanding and expressing the children’s needs, particularly with non-verbal children.  Because their legal training was not designed to assess and understand the unique and complex needs of infants and toddlers, attorneys often found that they had to rely almost exclusively on reports of outside professional involved in the cases.  In addition, with enormous legal case loads, it was easier to defer cases involving infants and toddlers and concentrate on teenagers who were engaging in risk taking behaviors.   Attorneys strived for application of the best legal standard in the case, but too often the actual voice of the non-verbal child lost, as the attorneys were not trained to hear them.

After attorneys were appointed regularly on a dependency case, an interesting trend began to appear.  Although attorneys were appointed to represent the best interests of the child, their recommendations and advocacy for what they believed to be in the child’s best interest were being discounted or dismissed by the court.  The judicial officers would follow the recommendations of the CPS social worker, particularly in cases where there was a question of the emotional well being of or impact on the child, despite the recommendations of the child’s own attorney.  Simply put, the CPS social worker could offer his/her specialized training of the assessment of the needs of children, in support of the recommendations to the court, whereas the minor’s attorney could not.  The attorneys recognized the need to better situate themselves, not only to be better heard by the court when presenting the child’s voice, but also to provide the best service and practice to the vulnerable children that they represented.

The attorneys of East Bay Children’s Law Offices (EBCLO), a non-profit organization in California’s Bay Area are appointed by the Alameda County Juvenile Court to represent children involved in the dependency proceedings.  EBLCO employs a multidisciplinary approach in its representation of children to best serve in their legal advocacy through the use of attorneys and social workers.  The team model addresses not only legal aspects of the case through the use of lawyers, but also the physical, developmental, psychological and educational needs assessed and addressed by social workers on the child’s team.  Together, the team strives for a holistic approach to advocating for children both within the dependency system and out.

Using this holistic approach, the social workers provide attorneys with a comprehensive psycho-social assessment of the needs of infant and toddler clients who are not able to verbally express their needs.  The social workers also work with the attorneys to create the best and most appropriate plan to advocate for the needs of our small clients and provide them a voice in the dependency proceedings. Although some would argue that our social workers are duplicating the services of the CPS social workers, the primary difference is that the CPS social workers provide an overall assessment of a number of factors and interests in the cases, including the needs and rights of the parents.  Non-verbal children’s voices can be easily overridden and lost when looking at the needs of multiple individuals in a case, particularly when there are competing or conflicting interests in the case.  The multidisciplinary team approach of social workers and attorneys attempts to ensure that the voice of the non-verbal child is always heard and advocated for in the dependency proceedings.  From the eyes of EBCLO, the developmental, social and emotional needs of the child are paramount.

MAKAYLA:

In the case of Makayla, a petite fourteen month old with pensive eyes, her attorney contacted me, the Clinical Director of East Bay Children’s Law Offices, for a consultation.  The CPS social worker was preparing to move her out of state to a relative, although she had spent the majority of her fourteen months in the care of foster parents who wanted to provide her permanency through adoption.  The attorney was worried that this was not in the best interests of Makayla, but as relatives had a preference in regards to placement, he felt unsure how he could address the move.  I began an independent investigation of the case, including meeting with Makayla multiple times, talking with the foster parents, speaking with the relative, observing the relative with Makayla and doing a full examination of Makayla’s experiences and history.

After completing my investigation, I shared my conclusions with the attorney.  Although Makayla demonstrated a secure attachment to her foster parents, she was an anxious and shy toddler.  During her visits with the relative, Makayla was shut down and the relative did little to engage her, despite a multitude of visits and accommodations made to help Makayla feel more comfortable during the visits.  Further, given the out of state home of the relative, there was little hope for a lengthy and thoughtful transition for Makayla.  Weighing these difficulties, the expected trauma and grief for Makayla, against the important significance of being placed with biological family lead me to a clear conclusion. Makayla needed to experience permanency with her foster parents and they would need to be responsible to establish and maintain a relationship with Makayla’s biological family for her benefit as she aged.  The attorney and I were both in agreement that the legal basis for moving Makayla did not outweigh the disruption in attachment and impact on her emotional well being.

The attorney illustrated for the court that, despite the importance of placement with biological family, it would not be in Makayla’s best interest to have her change placements.  He used my assessment of the case, specifically details about Makayla and her experiences and translated it into a legal argument to inform the court about the best interests of Makayla. Instead of focusing on generalized statements about the emotional well being of toddlers, he was able to illustrate specifically this move would not serve Makayla’s best interests.   The court heard and understood the attorney’s argument on behalf of Makayla and ordered that she stay in her current home and for CPS to facilitate a relationship between the foster family and Makayla’s biological family.

KHALIL:

Within EBCLO, it is not just the substantial life-altering decisions that are considered by the multidisciplinary team, but also the day to day decisions that when combined ultimately can have a huge impact on a child’s life trajectory and his/her development.  This impact is often seen around the issues of transitions and visitation.

Khalil had lived with his mother for most of his seven months, prior to being removed from her home.  After being placed with a relative, Khalil began to show signs of attachment difficulties, such as resisting affection and attention from his caregiver and when injuring himself, he failed to seek out an adult to help and comfort him.  He also was experiencing possible sensory integration issues, in the form of sensitivity to loud sounds and bright lights.  After visiting with him and talking at length with his relative, I shared my concerns about his needs with his attorney.  During our consultation, his attorney explained that the parents wanted two visits per week, although Khalil was placed over an hour away.  Based on my investigation, the attorney argued in court that Khalil needed both early childhood mental health services to help him build a secure attachment to his new caregiver and services to address his sensory integration issues.  Further, in regards to the visits, the attorney requested that the court mandate that the parents be given train tickets as they would need to travel to Khalil for the visits.  This would save him the trauma of the long car trip with an unknown transportation worker and the constant upheaval to his schedule.  As both the attorney and I had successfully established a good rapport with the relative, she, at our request, agreed to have the parents visits with Khalil in her home, so she could help support Khalil during the visits.  The court was in agreement with Khalil’s attorney’s recommendations.

CONCLUSION

The lives of infants and toddlers are inextricably altered by abuse and neglect and involvement in the dependency system (Osofsky & Lieberman, 2011; Lederman & Osofsky, 2004; Clyman, Harden & Little, 2002; Wulczyn, Hislop & Harden, 2002). The examples mentioned are just two of many, in which the voices of infants and toddlers were heard in the dependency proceedings due to the multidisciplinary team approach employed by EBCLO.  Without the multidisciplinary approach, history has shown that attorneys do not have the specialized training to always hear the voices of infants and toddlers and even when they do, the court was more inclined to follow the recommendations of the CPS social worker involved in the case.  The independent investigation done by the EBCLO social worker, the collaboration between the attorney and the social worker and the attorney’s artful translation of the investigation into legal language, allows the Juvenile court to clearly see and understand the best interests for each of the smallest clients that comes before it.  This best practice approach allows for the voices to be heard by all and hopefully and ultimately leads to the best outcome for these vulnerable children.

Sarah Lusardi
Clinical Director
East Bay Children’s Law Offices

REFERENCES

American Humane Association, Center for the Study of Social Policy, Child Welfare League of America, Children’s Defense Fund & ZERO TO THREE. (2011). A Call to Action on Behalf of Maltreated Infants and Toddlers.

Clyman, R., Harden, B.J., & Little, C. (2002). Assessment, Intervention, and Research with Infants in Out-Of-Home Placement.  Infant Mental Health Journal, 23 (5), 435-453.

Lederman, Cindy & Osofsky, Joy. (2008).  A Judicial-Mental health Partnership to Heal Young Children in Juvenile Court.  Infant Mental Health Journal, 29 (1), 36-47.

Lederman, Cindy & Osofsky, Joy. (2004).  Infant Mental Health Interventions in Juvenile Court; Amelioration the Effects of Maltreatment and Deprivation. Psychology, Public Policy and Law, 10 (1), 162-177. doi: 10.1037/1076-8971.10.1.162

Lederman, C., Osofsky, J & Katz, L. (2004). When the Bough Breaks the Cradle Will Fall: Promoting the Health and Wellbeing of Infants and Toddlers in Juvenile Court. Clinical Psychologist, 8 (1), 10-14.

Lemon, Nancy. (1999). The Legal System’s Response to Children Exposed to Domestic Violence. The Future of Children; Domestic Violence and Children, 9 (3), 67-83.

Osofsky, Joy & Lieberman, Alicia. (2011). A Call for Integrating a Mental Health Perspective Into Systeems of Care for Abused and Neglected Infants and Young Children. American Psychologist, 66 (2), 120-139.

White, Andrew. (2005-2006). A Matter of Judgment: Deciding the Future of Family Court in NYC. Child Welfare Watch, 12, 1-23.

Wulczyn, F., Hislop, K.B., & Harden, B.J. (2002). The Placement of Infants in Foster Care.  Infant Metnal Health Journal, 23 (5), 454-475.

Untreated depression during pregnancy is associated with adverse fetal outcomes, including low birth weight, prematurity, and decreased Apgar scores, while significantly raising the risk of maternal morbidity and vulnerability to postpartum illness (Bonari, 2004; Marcus, Flynn, Blow & Barry, 2003). Untreated anxiety during gestation elevates cortisol levels in the expectant mother that can affect fetal brain development or cause conduct and behavioral disturbances in that child as much as four years postpartum (Glover, 2011). In addition, the mother experiencing the disturbing symptoms of an antenatal mood or anxiety disorder is less likely to be attentive to regular prenatal care and more likely to use substances to manage the uncomfortable effects of depression or anxiety; she may even seek to terminate her pregnancy as a way of relieving her intolerable distress.

During the early weeks and months of the postpartum period, a mother and her infant are emotionally and psychologically entwined.  A mother’s capacity to attune herself to her baby’s needs creates meaning and gives voice to the infant’s experience. It is in response to the attachment figure’s appropriate reading of his/her signals that infants begin to acknowledge the existence of self. Based on a subjective appraisal of maternal reliability and responsiveness, the infant makes a pre-verbal evaluation not only of the caregiver’s ability to provide protection and care, but also of self and how much he or she deserves that protection and care, what attachment research refers to as an “internal working model,” of relationships. (Bowlby, 1988).

Because postpartum depression alters perception, causing frequent distortions in thought and impairment in judgments, it inevitably changes the sensitivity and consistency of a mother’s responsiveness. Consequently, the depressed mother may fail to respond appropriately or even at all to her baby’s signals for connection. At the other extreme, she may be overly intrusive or hostile towards her infant. Mothers with a perinatal depression often describe feeling emotionally disconnected or detached as they find themselves “going through the motions” of providing care for their infants.   It is the specialness of this very first attachment experience, in which the infant learns about trust and safety, that becomes the template for all other intimate attachments across the lifespan and lays a foundation for the infant’s psychological health.

A mother’s depression is a traumatic event for the growing infant who experiences the withdrawal and disengagement of this most important attachment figure.  Babies respond to their terror that they have been “left,” with valiant attempts to draw their mothers back into the relationship. An infant’s heighted awareness of his/her mother’s change in affect has never been demonstrated more clearly than in “The Still Face Experiment (Tronick,  Alys, Adamson, Wise & Brazelton, 1978) in which mothers were asked to maintain an expressionless face  as if they were depressed and to remain unresponsive to their infants for an extended period of time.  In reaction to their mothers’ withdrawal,  infants becomes noticeably distressed and alarmed and will even make desperate attempts to re-engage their mothers by assuming her depressed expression in what has been termed a “microdepression (Stern, 1994).  When infants’ repeated pleas to solicit some response from their mothers fails, they eventually withdraw physically and emotionally.

Research indicates that the infants of depressed mothers generally tend to be less engaged and re at greater risk for depression and anxiety themselves (Field, Healy, Goldstein, Perry & Bendell, et al). During infancy, they may cry more, soothe less easily, and have more problems with feeding and sleeping, in addition to possible delays in language and motor development. They’re apt to make less eye contact and be less responsive to their mothers. As they get older, they may display more behavioral symptoms like temper tantrums and extreme separation anxiety. The school-age children of depressed mothers may experience more academic as well as behavioral problems; they may be hyperactive, easily distracted and overly aggressive.  In the classroom, they may have any number of cognitive deficits that interfere with learning and ultimately lead to feelings of low self-esteem. Socially, they may have tremendous difficulty making friends.

“Existing in the heart and mind of another” and “feeling felt,” (Fosha, 2003) are critical to an infant’s healthy psychological development and the attachment security that protects against the development of psychopathology.   Mothers who suffer with perinatal illness are far less able to provide the quality of attunement that is so necessary for the development of that secure attachment, leaving their infants vulnerable to emotional and behavioral difficulties as they grow.  It is possible to begin determining a woman’s risk for a perinatal mood or anxiety disorder, even before conception, and to continue to screen and identify potential problems throughout pregnancy and into the first year postpartum.  Recognition of illness, early intervention and appropriate treatment are key to diminishing the severity of these potentially life-threatening disorders. When left untreated, perinatal illness creates emotional havoc for the entire family, leaving long-term psychological scars, particularly for the developing infant.

Diana Lynn Barnes, Psy.D LMFT
The Center for Postpartum Health
President, Postpartum Support International (2002-2004).
Training Faculty, Los Angeles Perinatal Mental Health Task Force

REFERENCES

1. Bonari, L.; Bennett, H.; Einarson, A.; & Koren, G. (2004). The risks of untreated depression during pregnancy. California Family Physician, 50, 37-39.
2. Bowlby, J. (1988). A secure base: The origins of attachment theory. London: Routledge.
3. Field, T.; Healy, B.; Goldstein, S.; Perry, S.; Bendell, D. et al (1988). Infants of depressed mothers show  “depressed behavior” even with non-depressed adults. Child Development, 59(6), 1569-1579.
4. Fosha, D (2000). The transforming power of affect: A model for accelerated change. New York: Basic Books.
5. Glover, V. (2011). Prenatal stress and the origins of psychopathology: An evolutionary perspective. Journal of Child Psychology and Psychiatry, 52(4), 356-367.
6. Marcus, S.M.; Flynn, H.A.; Blow, F.C.;  & Barry, K.L. (2003). Depressive symptoms among pregnant women screened in obstetric settings. Journal of Women’s Health, 12(40), 373-380.
7. Stern, D.N. (1994). One way to build a clinically relevant baby. Infant Mental Health Journal, 15(1), 9-25.
8. Tronick e.; Als, H.; Adamson, L.; Wise, S.; & Brazelton, T.B. (1978). The infant’s response to entrapment between contradictory messages in face-to-face interaction. Journal of the American Academy of Child Psychiatry, 17(10, 1-13).

Please contact the Center if you have any questions, info@cacenter-ecmh.org.

Supporting the Growth of Reflective Practice

Reflective practice is a way of engaging in service delivery that spans disciplines and systems. Reflective practice as described by Schon, Dewey, and others encourages perspective taking, examination and awareness of self, and the development of critical thinking skills needed to make decisions that help tailor services to individual needs.

Reflective practice is promoted as a key element in delivery of effective services to diverse populations of infants, children, and families. Reflective practice improves engagement with clients and helps practitioners see differences and strengths that might not ordinarily be perceived. Reflective practice helps to access the “how” of doing things that includes unconscious or unspoken processes. Some describe reflective practice as the bridge from theory to practice. In other words, reflective practice offers processes that help practitioners take concepts that they know and believe and apply them to real-life situations fraught with complexity.

In describing reflective practice, Schon talks about the distinction between reflection in action and reflection on action. Reflection in action is the capacity to think, consider, and reflect in the moment. Reflection in action includes a well-developed ability not to act immediately even when there are pulls to do so. Reflection on action is the creation of a space alone or with others to look back on something that has happened and consider motivations, consequences of any action taken, pacing, and personal presses that may have been present.

The creation of space and time to reflect back often allows the practitioner to remember essential details, drill down into a process, and consider what might be altered in the next encounter. In this way, the reflective process is a tool for continuous professional growth as well as service improvement as the practitioner thinks, analyzes, and is supported in taking what has been learned from self reflection and applying it in the next encounter. The willingness to engage in this reflection on action is an indicator of a provider’s interest in honing intervention skills, self-knowledge, and scope of practice.

Infant and early childhood programs have had a strong focus on the use of reflective practice and the kinds of organizational structures that support this practice approach. These structures may include regularly scheduled individual supervision/facilitation meetings, team meetings, or group sessions. Reflective practice can take place in both informal and formal ways. In many settings, reflective practice becomes a way of doing business not only in service delivery, but also in the administration of the program and in the support of staff. Ideally, agencies provide enough space and support for the regular practice of reflective process skills so that these become second nature to staff and are infused into informal exchanges and program practices

High quality supervision is closely linked to effective program implementation drivers described by Fixsen, Blase, and others working on program implementation research. These researchers have shown repeatedly that implementation of high quality programs is connected to a strong support structure that is carrying out a variety of roles and making sure that clients are getting the services described and promised in the program description. We believe that by developing the quality of reflective supervision skills, programs invest in better outcomes for communities served.

Reflective Practice Facilitation: Skills to Hold the Processes

In most programs, more formal structures such as individual reflective supervision or team meetings blend reflective practice elements with administrative supervision and mentoring to provide reflective practice facilitation on an ongoing basis. This blending of the reflective process elements with the nuts and bolts of service delivery is considered one of the most challenging skill sets to acquire. Reflective supervision can occur in either a blended model with reflective and administrative elements or in a model that separates  these functions.

Advancing Clarity About Reflective Practice Facilitation Competency

The group that worked on the Revised California Training Guidelines and Personnel Competencies for Infant-Family and Early Childhood Mental Health (Guide PDF) from 2007–2009 firmly embraced reflective practice and reflective supervision in both training and service environments considering this practice as a critical element in competency development. Ironically, there were no specific competencies for this activity that had been described as central to learning about working with infants and young children. To address this deficit, a set of competencies and an endorsement system for supervision were developed by group members and published in 2009, the Revised California Training Guidelines and Personnel Competencies for Infant-Family and Early Mental Health, Revised.

These standards were drawn from descriptions and writings in the field and influenced heavily by the early work of Emily Fenichel and others that describe reflective supervision as characterized by regularity, collaboration, and reflection. Standards were set in California for group size, and the California competencies outline specific skills and abilities for supervisors to learn about, practice, and master. Because “supervision” has a legal connotation in many settings, the term “reflective practice facilitation” has been adopted. The term reflective practice facilitation is synonymous with the term reflective supervision.

The California Center’s Commitment to Competency in Reflective Practice Facilitation

The California Center has a strong commitment to promoting quality reflective practice facilitation processes across systems. The endorsement system is inclusive of infant family and early childhood mental health specialists and transdisciplinary infant family and early childhood practitioners in order to provide a strong message that reflective practice facilitation must be central in all disciplines and sectors.

Because of this strong commitment, the California Center is in the process of developing reflective practice facilitation training materials including DVDs that will be available in the summer of 2012. Watch this website for details.

Posted by Leadership Team member: Mary Claire Heffron, PhD

References

Dewey, J. 1933. How We Think. Boston: D.C. Heath and Company.

Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. 2005. Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network.

Schon, D. 1983. The Reflective Practitioner: How Professionals Think in Action. London: Temple Smith.

Schon, D. 1987. Educating the Reflective Practitioner. San Francisco: Jossey-Bass.

After careful review of the Mental Health Core Provider endorsement category and consideration and discussion of feedback from the field, the Leadership Team of the California Center determined that the name of the category should be changed to more accurately capture the training, experience and type of work of these transdisciplinary practitioners with infant-family and early childhood mental health training and experience.

This highly skilled group of practitioners includes professionals from multiple health and human service, developmental and education disciplines who provide direct services to pregnant women, infants, toddlers and preschoolers and their families. These practitioners have the most frequent contact with infants and very young children and their families and are the most likely individuals to provide promotion and preventive mental health interventions. These transdisciplinary practitioners infuse infant-family and early childhood mental health principles into their disciplinary practice and also are likely to partner with and make referrals to Infant-Family and Early Childhood Mental Health Specialists.

Therefore, to better reflect the skills and training of professionals working in multiple systems, we have changed the name of the Mental Health Core Provider category to Transdisciplinary Mental Health Practitioner.

Some Transdisciplinary Mental Health Practitioners will be endorsed as advanced based on their experience, training, knowledge and other related degrees or certifications.  Those candidates previously endorsed as Mental Health Core Providers will be reviewed and receive a new endorsement either as a Transdisciplinary Infant-Family or Early Childhood Mental Health Practitioner or an Advanced Transdisciplinary Infant-Family or Early Childhood Mental Health Practitioner.

Posted by Leadership Team members:
Karen Moran Finello, PhD and Patsy Hampton, MRA

Please contact the Center if you have any questions, info@cacenter-ecmh.org.