The Diversity-Informed Infant Mental Health Tenets in California

Maria Seymour St. John and Ayannakai Nalo

The 163,696 square mile region that presently comprises the State of California has historically been the homeland of many native peoples and tribes including the Modoc, Shasta and Wintu; the Pomo, Ohlone, Miwak and Yokuts; and the Serrano, Cahuilla, and Quechen, among hundreds of others. It was part of Mexico before it was one of the United States. And the lifeblood of many immigrant communities, often themselves grossly disenfranchised, contributed to the infrastructure and cultural and economic wealth of the State. California’s borders have been contested, it’s natural resources multiply claimed, and it’s political and cultural status variously defined.

California’s infants are reared in families speaking more than 200 languages. Their parents represent all present-day census race categories and hundreds of ethnic groups and national origins. California’s percentage of multiracial people is one of the highest in the country. In order to ethically and effectively support this vibrant and diverse multicultural state, California’s infant/family workforce must be equipped with tools that help us to collectively:

  • Honor and celebrate human diversity;
  • See the historical and socio-political contexts that shape families’ experiences;
  • Appreciate the complexity of cultural identities;
  • Collaborate and practice cross-culturally;
  • Value and cultivate expertise in a wide range of traditions, discourses, and practices;
  • Continually expand our linguistic competence across disciplines;
  • Close gaps between practice-based learning with families, policy-production impacting families, research about families, and systems of care serving families.

We must also be prepared to collaboratively:

  • Eliminate barriers to infant/family health and well-being for all cultural groups;
  • Register and respond to the intergenerational sequelae of historical and present-day trauma;
  • Ensure universal access to services;
  • Create institutional climates that are welcoming across cultures.

The California Center for Infant/Family and Early Childhood Mental Health’s Compendium of Training Guidelines, Personnel Competencies, and Professional Endorsement Criteria for Infant-Family and Early Childhood Mental Health does not include a separate knowledge domain pertaining to “cultural competence.” Instead, every knowledge domain includes items related to culture, suggesting that consideration of cultural issues is an inextricable element of all knowledge domains within the field. But how are professional capacities related to culture best developed?

Many powerful frameworks, approaches, and curricula have been developed to help people become more attuned to and skilled at addressing issues of culture. Diverse terms include “cultural competence,” “cultural humility,” “social justice,” “anti-racism” “equity and inclusion,” “race, power and privilege,” “cultural attunement” and others. Some of these approaches originated in grassroots political organizing efforts, some hail from organizational psychology, others were created to address systemic race-based disparities in health, school achievement, or socioeconomic status.

The Irving Harris Foundation’s Diversity-Informed Infant Mental Health Tenets (Tenets) is a framework developed specifically for the infant/family workforce created collaboratively by a group of infant mental health workers through a project of the foundation. The original Tenets article notes that in order “to create a just and equitable society for the infants and toddlers with whom its members work, the infant mental health field must intentionally address some of the racial, ethnic, socioeconomic, and other inequities embedded in society” (St. John, Thomas, & Noroña, 2012). The Tenets are a set of “guiding principles outlining standards in the field and pointing the way to a just society via engaged professional practice (St. John, Thomas, & Harris, 2012, p. 13).” The Tenets are reproduced here with permission from the Irving Harris Foundation and may be accessed at the website: www.imhdivtenets.org.

The authors believe that the Tenets are a “good fit” for the California infant/family workforce and a critical resource for those on the pathway to endorsement.

DIVERSITY-INFORMED INFANT MENTAL HEALTH TENETS

©2012, Irving Harris Foundation. Reprinted with permission.

1. Self-Awareness Leads to Better Services for Families:
Professionals in the field of infant mental health must reflect on their own culture, personal values, and beliefs, and on the impact racism, classism, sexism, able-ism, homophobia, xenophobia, and other systems of oppression have had on their lives in order to provide diversity- informed, culturally attuned services on behalf of infants, toddlers, and their families.

2. Champion Children’s Rights Globally:
Infants are citizens of the world. It is the responsibility of the global community to support parents, families, and local communities in welcoming, protecting, and nurturing them.

3. Work to Acknowledge Privilege and Combat Discrimination:
Discriminatory policies and practices that harm adults harm the infants in their care. Privilege constitutes injustice. Diversity-informed infant mental health professionals work to acknowledge privilege and to combat racism, classism, sexism, able-ism, homophobia, xenophobia, and other systems of oppression within themselves, their practices, and their fields.

4. Recognize and Respect Nondominant Bodies of Knowledge:
Diversity-informed infant mental health practice recognizes nondominant ways of knowing, bodies of knowledge, sources of strength, and routes to healing within diverse families and communities.

5. Honor Diverse Family Structures:
Families define whom they are comprised of and how they are structured; no particular family constellation or organization is inherently optimal compared to any other. Diversity-informed infant mental health practice recognizes and strives to counter the historical bias toward idealizing (and conversely blaming) biological mothers as primary caregivers while overlooking the critical child-rearing contributions of other parents and caregivers including fathers, second mothers, foster parents, kin and felt family, early care and educational providers, and others.

6. Understand That Language Can Be Used to Hurt or Heal:
Diversity-informed infant mental health practice recognizes the power of language to divide or connect, denigrate or celebrate, hurt or heal. Practitioners strive to use language (including “body language,” imagery, and other modes of nonverbal communication) in ways that most inclusively support infants and toddlers and their families, caregivers, and communities.

7. Support Families in Their Preferred Language:
Families are best supported in facilitating infants’ development and mental health when services are available in their native languages.

8. Allocate Resources to Systems Change:
Diversity and inclusion must be proactively considered in undertaking any piece of infant mental health work. Such consideration requires the allocation of resources such as time and money for this purpose and is best ensured when opportunities for reflection with colleagues and mentors as well as ongoing training and consultation are embedded in agencies, institutions, and systems of care.

9. Make Space and Open Pathways for Diverse Professionals:
Infant mental health workforces will be most dynamic and effective when culturally diverse individuals have access to a wide range of roles, disciplines, and modes of practice and influence.

10. Advance Policy That Supports All Families:
Diversity-informed infant mental health practitioners, regardless of professional affiliation, seek to understand the impact of social policies and programs on diverse infants and toddlers and to advance a just policy agenda for and with families

 

References:

Irving Harris Foundation. (2012). Diversity-informed infant mental health tenets. Retrieved from www.imhdivtenets.org

St. John, Thomas & Noroña. (2012). Infant mental health professional development: Together in the struggle for social justice. Zero to Three, November.


Author Biographies:

Maria Seymour St. John, PhD, MFT, is associate clinical professor in the Department of Psychiatry, University of California, San Francisco, and director of training at the Infant-Parent Program, Zuckerberg San Francisco General Hospital. Endorsed as a Reflective Practice Mentor by the California Center for Infant-Family and Early Childhood Mental Health, Dr. St. John writes, teaches, practices, and consults in the areas of infant-parent psychotherapy, reflective supervision, and the application of postcolonial, feminist, queer, and psychoanalytic theories in infant mental health. She has developed the Parent-Child Relationship Competencies (St. John, 2010), a framework for relationship-focused clinical assessment and treatment planning. Dr. St. John has been active in the collaborative process that gave rise to the Irving Harris Foundation’s Diversity-Informed Infant Mental Health Tenets and works with groups and individuals to facilitate integration and implementation of the Tenets across diverse spheres of practice.

Ayannakai Nalo, LCSW, is the manager of Early Intervention Services at University of California San Francisco Benioff Children’s Hospital Oakland and a faculty member of the Irving B. Harris Early Childhood Mental Health Training Program. The California Center for Infant-Family and Early Childhood Mental Health has endorsed Ms. Nalo as a Reflective Practice Mentor. Ms Nalo feels committed to integrating diversity-informed principles from the Irving Harris Foundation’s Diversity-Informed Infant Mental Health Tenets and other sources into reflective supervision and infant mental health services. As a member of the Harris Foundation Professional Development Network, Ms. Nalo also trains organizations and mentors individuals in the implementation of the Tenets across infant and early-childhood mental health providers and public health fields.

maria-st-john-ayannakai-nalo

A Brief History of Home Visiting in the United States

In the United States, the origins of home visiting can be traced to several developments in the 1800’s, including the kindergarten, public health nursing and settlement house movements.   Although there were some broad similarities between the three movements, each had a slightly different focus and used different kinds of individuals to deliver services. Original funding sources were primarily philanthropic, with government funding coming later as programs demonstrated efficacy and grew in size and scope.  Because of the philanthropic sources of funding, a great deal of advocacy to improve the health, education, and environmental conditions of individuals within poverty communities was carried out by the programs. Today’s home visiting programs reflect the important influence and emphases of the pioneering work in the 1800’s. The roots of advocacy and interagency collaboration can also be seen in these early programs.

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

Karen Moran Finello photo

 

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. (6th 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.

 

Race to the Top-Early Learning Challenge (RTT-ELC)

California was awarded a $52.6 million federal Race to the Top = Early Learning Challenge (RTT-ELC) Grant in December 2011 and the California Department of Education, Child Development Division is taking the lead in implementing the activities of this grant. California was among 10 states awarded these funds to improve early learning and development.
California’s RTT-ELC grant implements a unique approach that builds upon California’s local and statewide successes to create sustainable capacity at the local level to meet the needs of our early learners, with a focus on those with the highest needs. It supports a locally driven quality improvement process that encourages regional assessment, goal setting, and monitoring of progress that could lead to real change.

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.

 

Patsy Hampton photo

Posted by Leadership Team member: Patsy Hampton, MRA

Serving the Best Interests of Infants and Toddlers in the Juvenile Court Dependency System: A Multidisciplinary Team Approach.

This article looks at one legal organization’s attempt to apply best practices in representing infants and toddlers, children ages zero to three, in the dependency proceedings by employing a multidisciplinary team approach for the legal advocacy of these children.

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

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.

Feature: California Center Advisory Council Member– JULIE LARRIEU, PhD

California Center Advisory Council Member– JULIE LARRIEU, PhD is a national leader in providing multidisciplinary intervention to infants and their families who have experienced early trauma.  In Louisiana, their infant team has developed a model to collaborate and effectively work with child welfare and court systems.  Visit www.tulaneinfantteam.org for further information.  Also visit the Tulane Institute of Infant and Early Childhood Mental Health at www.infantinstitute.org to follow Dr. Larrieu’s additional practice in infant mental health.

Perinatal Depression effects on Attachment and Attunement

The relationship between a mother and her infant begins in utero. The quality of their affective dialogue is largely governed by fluctuating hormones, environmental stresses and the expectant mother’s psychological history.  The state of a woman’s mental health during both pregnancy and the postpartum period is critical, not only for her well-being, but for the overall health of her infant in utero and in the years following childbirth. When maternal mental health is compromised by perinatal illness, the security of attachment that is so necessary for healthy cognitive, social, and psychological development is disrupted. Disruptions in the growing attachment between a mother and her baby can begin as early as conception and continue into the postpartum period with grave consequences, particularly for that infant’s mental health across the lifespan.

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.

Headshot - Diana Lynn Barnes, Psy.D

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).

 

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