infant & toddler mental health assessment stacey ryan, lcsw angela m. tomlin, ph.d

Infant & Toddler Infant & Toddler Mental HealthMental HealthAssessmentAssessment

Stacey Ryan, LCSWStacey Ryan, LCSW

Angela M. Tomlin, Ph.D.Angela M. Tomlin, Ph.D.

ObjectivesParticipants will be able to• Discuss the scope of mental health

problems in young children• Describe what IMH assessment and

treatment is and is not• Explain the importance of social and

emotional development to other developmental areas

Objectives• Select tools and methods for

assessing child development, parent-child relationships, parent capacity for relationship, and family situations

• Demonstrate beginning knowledge of infant-toddler mental health interventions

Is Infant &Toddler Mental Health Really a Problem?

• Yes!• Young children do experience

problems in social emotional competency and even psychopathology

• We are better able to understand and measure these problems

Why we resist this…• We are too worried about

cognitive skills (“ready to learn”)• Stigma associated with mental

health issues• Myth of childhood• Our own discomfort with the idea

Prevalence• Best estimates of serious behavior

concerns in children 2 to 3 years fall between 10 to 15%

• Parent and pediatrician report behavior problems in 10% of 1 to 2 year olds

But won’t these problems go away?

• No!• 37% of 18 mos with extreme

behavior/emotional problems continue to have problems at 30 mos

• Over ½ of 2-3 with psychiatric d/o still have symptoms 2 years out

Long Term Effects• Exposure to poor caregiving,

abuse, or domestic violence can lead to developmental and mental health problems in young children

• Babies, toddlers, and preschoolers can demonstrate depression, PTSD, and disruptive behaviors

The Science of Early Childhood

Development• Babies brains are growing at a

phenomenal rate• The infant brain is “experience

expectant”• Both positive and negative

experiences have significant and long lasting effects

Development• Experience, especially social

experiences, change the way the brain is shaped and functions

• Babies who experience or witness violence have behavioral and physiological changes

Development“Separation from parents, sometimes

sudden and usually traumatic, coupled with the difficult experiences that have precipitated placement in foster care, can leave infants and toddlers impaired in their emotional, social, educational and physical development” (0-3, 2003)

So now we’re thinking…

• OK, maybe babies and toddlers can have emotional concerns…

• And maybe relationship is pretty important…

• But there can’t be that many babies removed from their parents…

• Can there?

Young Children in Foster Care

• 25% of children in foster care are under 5 years old

• 13% of those entering care are under 1 year

• Infants are the faster growing population in foster care

• Once in foster care, babies stay longer than other children

• They are more likely to be abused while in foster care or when returned to parents

• Reunification of babies placed under 3 months is low

Of all the children who died from abuse and neglect,77% were under 4 years old.

MH Challenges in Young Children

• Are real• Involve a substantial number of

babies• Can be assessed and treated

What Infant & Toddler Mental Health is NOT

• Babies on a couch• Talking therapy with toddlers• Seeing a child without parents• Bonding therapies• Developmental therapy

What Infant & Toddler Mental Health IS

• Based on over 50 years of clinical practice

• Informed by recent brain research findings

• Outcome-based interventions• A way to understand children in

their families

Areas to Consider When Assessing Young Children• Developmental Levels of Infant or

Child• Quality of Important Relationships• Parent Status (Capacity for

Relationship)• Family Situations

Infant & Child Development

• A good working knowledge of typical development is needed when you assess young children

• You can’t tell what is atypical if you don’t know what is typical

• Expected order of milestones is knownSkills are traditionally divided into 5 areasThere is much overlap between the areasUneven development across areas is concerning

Ways to learn about development• Have a great memory from college

coursework• Get a child development text• Watch some babies• Review some developmental

checklists online

• aap.org

• http://thechp.syr.edu/Developmental_checklist.pdf

• Cognitive• Receptive, Expressive, and

Pragmatic Communication• Fine & Gross Motor• Social-emotional and behavior• Adaptive Skills (Self Help)

Cognitive Skills• Thinking• Problem Solving• Memory• Attention• Imitation

Communication• Use of gestures and facial

expressions• Understanding speech• Expressive language• Social or pragmatic aspects of

communication

Fine & Gross Motor Skills

• Use of hands and arms to manipulate objects

• Balance• Strength and tone• Walking, running, jumping

Social-emotional and behavior

• Eye contact• Social smile• Relationships/

attachment• Regulation

• Sleep • Feeding• Aggression• Compliance

Self-Help/Adaptive• Eating• Dressing• Participation in grooming• Toileting

Ways development can be atypical

• Global delays in development

• Inconsistent development

• Atypical, unusual behaviors—red flags

Red Flags in 6 Month Olds:

• Inability to Read Signals

• Persistent Sleep Problems

• Lack of Predictability

• Failure to Imitate Sounds and Gestures

• No Affect, Range of Feelings

• Lack of Stranger Anxiety (8 months)

Red Flags 12-18 Month Olds:

• No Words

• Persistent Sleep Problems

• Withdrawn

• Excessive Rocking

• Prolonged Fears

• No Separation Distress

• Immobile, Low Activity

• No Social Engagement

• Predominant Anger and Outbursts

Red Flags in 18 Months to 3 Year olds

• Eating Problems

• Non Speaking

• Extreme Shyness

• Lack Autonomy

• Failure in Gender Identification

• No Enjoyment in Play

• Poor Problem Solving

• Total Lack of Self Control

• Chaotic Behavior

Collecting Information about Infant & Child

Development• Existing records from previous

assessments• Screening and referral• Single discipline developmental

assessment• Multi or interdisciplinary team

assessment

Existing records:Understanding test

data• Screening or child find results

• First Steps evaluation/Curriculum based assessment

• Normed assessment methods/Clinic or school based

First Steps• Check with the SPOE for the county

the child lived in before placement to see if there is a First Steps E & A

• 1/800-441-STEP

• http://www.in.gov/fssa/first_step/

Tools Used in First Steps

• Goals of assessment in First Steps is to determine if eligible for program and to develop intervention plan

• Curriculum-based tools are typically used

Tools Used in First Steps

• HELP and AEPS are most common• Have an associated curriculum• Are basically a list of skills to be

assessed and taught• Sometimes yield age equivalents

First Steps Documentation You Can

Use• ED Team Report

– Will indicate developmental levels in 5 areas of development

– Will make recommendations for services

• Individual Family Service Plan (IFSP)– Will explain services that the child will receive– Includes information about family routines and

preferences

First Steps and CPS• Indiana now CAPTA compliant• In other states, the influx of referrals

has been a problem for Part C• Some states are using screening tools,

then full assessment if indicated• So far, we are not sure what First Steps

will do with the evaluations in Indiana

Clinic & School Assessments

Independent, clinic-based assessments may have been completed

If child is 3 or near 3, a school assessment might be available

School and clinic evaluations often include norm referenced tools

Cognitive

– BSID-3– DAS– SBIS-5– MSID

Communication

– Rosetti (Caregiver Report)– Preschool Language Scale-4– Informal assessments– AAC

Adaptive Behavior

VABS-2SIB-RABAS

Motor Assessments

Peabody Developmental Motor Scales-2

Social-Emotional and Behavioral

ITSEABASCCBCL

Autism Assessments

Developmental HistoryADOSChecklists (Gilliam, CARS, MCHAT)

What to do if…No previous developmental

assessment??• Conduct your own developmental

assessment• Get full E & A thru First Steps• Screen and refer

Screening & Referral• Screening methods tell you if the

child needs further assessment in a given developmental area

• Many screening tools use caregiver report

• Do not use social-emotional screener for CPS population

Suggested Developmental Screening

Tools• Caregiver Report Methods

– Ages & Stages Questionnaires– PEDS– DOCS

• Direct Assessment of Child– Denver-II– Bayley Infant Developmental Screener– Batelle Developmental Inventory

Screening Test

Infant-Toddler MSE• Must understand development

• Good observation skills

• Experience with infants and young children

Infant Toddler MSE• Appearance• Reaction to Situation • Adaptation:

Exploration and Reaction to Transitions

• Self Regulation• Sensory Regulation• Unusual Behaviors

• Activity Level• Attention Span• Frustration

Tolerance• Expression of

Aggression• Muscle Tone and

Strength• Gross and Fine

Motor Coordination

Infant/Toddler MSE

•Speech and Language

•Thought Processes

•Affect and Mood

•Play

•Cognition

•Relatedness

Do’s and Don’ts• Infants and Toddlers must be evaluated

within the context of relationships with their primary caregivers

• Assessment should always include collaboration with parents and caregivers

• Multiple assessments over time are recommended

• Information from Multiple sources is recommended

Do’s and Don’ts•Standardized Instruments May be used but not be the sole basis of the Evaluation

•Young Children Should Never be Challenged by Separation from Primary Caregivers

•Evaluation should utilize the DC 0-3 system along with DSM IV

Questions about Developmental Assessment?

Assessing Quality of Parent-Child Relationship • Attachment: research and clinical

findings

• Tools for assessing relationships

• Suggested observation strategies

Relationship Problems vs Mental Health DX

• Do not assume that all of these children will have an attachment problem

• Relationship problems and other MH problems can co-occur

• Can have MH concern with good relationship

Attachment• Attachment means a specific relationship

between one child and one adult• It only refers to a relationship that occurs

when the adult is in a caregiving role for that child

• Children can have attachment problems that do not reach the level of a disorder

• Attachment problems predict problems with future relationships

Attachment• Ainsworth/Bowlby introduced the

secure/insecure attachment paradigm

• These research categories only work loosely in a clinic setting

Reactive Attachment Disorder

What it is:

• Markedly disturbed and developmentally inappropriate social relatedness in most contexts

• Presumed due to pathogenic care (maltreatment, lack of consistency)

Two Patterns:

• Excessive inhibition, hypervigilant, highly ambivalent behaviors

• Indiscriminate sociability

• Both patterns are know to occur in children who have been in foster care and those raised in institutional settings

Parent-Child Observations

• Most important to have a routine process

• Multiple observations over time are best

• If possible, see parent and child in different settings

Areas to Observe when Assessing Parent and Child

Interactions

Attachment BehaviorsPlay InteractionsDirection/TeachingSeparation/Reunion

Observing Attachment Behaviors

• Does the child seem to feel safe, secure, and comfortable? Can the child explore, play with toys, interact with the examiner?

• What does the caregiver do to help the child get comfortable?

• Can the child and the caregiver share enjoyment?

• How does the child respond when the caregiver restricts her?

Observing Play Behavior

• Who leads the play?• Is the play mutual? • Is the play reciprocal?• Does the parent provide scaffolding?• Is the affect positive or negative?• Is the play sustained?

Observing Teaching Parent and child most often asked

to clean up/Or a teaching task– How does parent explain the task?– Does child follow instructions?– How does parent handle refusals?– Does parent provide scaffolding?– Emotional tenor of interaction

Separation/Reunion• Parent can be asked to leave room

briefly• Purpose is to elicit attachment

behaviors at both points• Avoid if it would be too stressful

Clinical Attachment Systems

• DC 0-3 R offers a system of classification for young children

• Includes Relationship Classification• Can help us know what to look for

in assessing the relationship and interactions between a young children and parents

DC 0-3R Relationship Assessment

• Overall functional level of child and parent• Level of distress of child and parent• Adaptive flexibility of child and parent• Level of conflict and resolution between

child and parent• Effect of the quality of the relationship on

the child’s developmentDC 0-3R, 2005

DC0-3R Tools for Assessing Parent-infant

Relationship• Parent-Infant Relationship Global

Assessment Scale (PIR-GAS)

• Relationship Problems Checklist

DC 0-3 R, 2005

• zerotothree.org

PIR-GAS• Used by a clinician to make a judgment

about relationship classification • Range from well-adapted to severely

impaired• Need to identify frequency, intensity,

and duration of problems to classify the problem

PIR-GAS• So not have to know etiology of

problems to use classification• Is a seen as a current description

of relationship that can change

PIR-GAS Categories• Well Adapted • Adapted• Perturbed• Significantly

Perturbed• Distressed

• Disturbed• Disordered• Severely Disorder• Grossly Impaired• Documented

maltreatment

Relationship Problems Checklist (RPCL)

• Helps the clinician document the presence or absence of problems in a relationship

• Helps support the following descriptors of relationship

• Can be used for more than one primary relationship

RPCL Areas• Behavioral Quality of Interaction

• Affective Tone

• Psychological Involvement

RPCL• Overinvolved

• Underinvolved

• Anxious/Tense

• Angry/Hostile

• Verbally Abusive

• Physically Abusive

• Sexually Abusive

UnderinvolvedBehavior Quality:

• Insensitive/unresponsive to cues• Does not protect child• Child appears uncared for

UnderinvolvedAffective Tone

• Affect in both partners seems sad, constricted, withdrawn, and flat

• To observer, interactions suggest lack of pleasure

UnderinvolvedPsychological Involvement:

• Parent does not demonstrate awareness of infant cues by behavior or in discussion with others

• Parent with history of emotional deprivation or neglect

Physically AbusiveBehavioral Quality:

• Parent physically harms child• Parent regularly fails to meet

child’s basic needs

Physically AbusiveAffective Tone:

• Reflects anger, hostility, or irritability

• Considerable to moderate tension and anxiety are present

Physically AbusivePsychological Involvement:

• Parent exhibits and/or describes anger or hostility toward child

• Child may have tendency toward concrete behavior

• Periods of closeness vs distance

Additional Parent child tools

• Crowell Procedures

• Parent Child Early Relational Assessment

Relationship Assessment

Crowell Procedure• Free play• Clean up• Teaching Tasks• Separation/Reunion

DomainsParent• Emotional

Availability• Nurturance• Protection

Child• Emotional

Regulation• Security• Vigilance

DomainsParent• Comforting• Teaching• Discipline• Structure/Routine

Child• Comfort-seeking• Learning• Self-control• Self-regulation

Parent Child Early Relational Assessment

• For birth to 5 years• Parent and child are videotaped

during interaction in 4 5 minute segments (feeding, structured task, free play, and separation/reunion)

• Observations are scored on Likert scale

• Parent Domains– Expressed Affect and Mood– Expressed Attitude Toward child– Affective and Behavioral involvement

with child– Parenting Style

• Infant/Child Domains– Mood/affect– Behavior/adaptive ability– Activity level– Regulatory capacities– Communication– Motoric competence

• Parent/Child Dyad– Affective quality of interaction– Mutuality– Sense of security in relationship with

parent

Questions about Relationship Assessment?

Assessing Parent Capacity for Relationship

• Adult Attachment Interview

• Working Model of the Child Interview

• Parenting Stress Index-Third Edition

Working Model of the Child

• Structured interview that assesses parents’ internal representations of a their relationship to a specific child.

• Parent responds to 19 questions• Responses are rated and scored• Overall interviewed is rated as

balanced, disengaged and distorted.

Adult Attachment Interview

• Semi-structured interview that assesses person’s way of thinking current and past relationship

• Parent status on AAI predicts child security of attachment

Adult Attachment Interview

Adult Classification• Secure/

autonomous• Dismissing• Preoccupied• Unresolved/

disorganized

Child Classification• Secure• Avoidant• Resistant/

Ambivalent• Disorganized

Parenting Stress Index, Third Edition

• Parent checklist; 120 items• Child Domain • Parent Domain• Total Stress• Assess for defensive responding• Screener available• Large body of research

• Child Domain– Distractibility/hyperactivity– Adaptability– Reinforces Parent– Demandingness– Mood– Acceptability

• Parent Domain– Competence– Isolation – Attachment– Health– Role Restriction– Depression– Spouse

Parent Evaluations…• Most common Psychiatric Dx

– Depression– Personality Disorder

• Developmental/MR• Addictions• Vocational

Parent Psychiatric Evaluations

• Depression and PD can result in significant effects on children

• Attachment problems are common• Behavior concerns are often

significant• Child possibly at risk for

developing psychiatric dx

Cognitive Limitations• Significantly below average

cognitive and adaptive skills• Ranges from mild to profound• Most individuals with mental

handicap who are parents are likely to be in the mild to moderate range

Parenting and Cognitive Limitations

• IQ relates to parenting behavior when below 55-60

• MH in parent increases chances of mental handicap in child

• Families with parent with MH are increasing

Parenting and Cognitive Limitation

• Need for direct assistance• Difficulties with transfer of

knowledge• Hard to keep track of multiple issues• May lack basic academic skills• Lack of knowledge about children• Abuse potential unclear

Parenting and Cognitive Limitations

• With appropriate supports, most parents with MH can learn to be good parents

Screening Adults for MH

Ask about parents’ school history:

“How far did you go in school?” “Were you able to finish school?”“Did anyone in the family receive extra

help at school?”“Do you remember what kind of help you

received in school?”

Screening Adults for MH

Observe:

Hygiene and dressAbility to prepare mealsMoney managementTidiness and Cleanliness of HomeAbility to relate to others

Parents with AddictionEffects on Family Interactions• More conflict• More family problems• Less structure and discipline• Increased expectations for child

independence• More physical discipline (boys)

Parents with AddictionRelation to child abuse• Child abuse professionals report that

substance abuse contributes to between ½ and ¾ of child abuse

• Alcohol addiction related to physical abuse; cocaine addiction to sexual abuse

• Children exposed to drugs prenatally are 2-3 times more likely to be abused or neglected

Parents with Addiction• Children of addicted parents are more

likely to be in foster care and to stay longer

• Children of addicted parents more likely to be depressed, anxious, and have psychiatric diagnoses

• Children of addicted parents have more problems in school

Family Situations• Strengths• Weaknesses• Risk Factors• Cultural factors

Risk Factors• Poverty• Domestic Violence• Community Violence• Lack of Support• Reluctance to Accept Help• Inconsistent Care giving Experiences

Risk Factors• Negative Maternal Attitude Toward

Pregnancy• High level of perceived social stress• Loss of previous child, history of child

maltreatment• Young Maternal Age and Single Marital

Status• Marital Discord

Cultural Issues• Always view the cultural

framework as a set of tendencies or possibilities

Cultural shapes beliefs and practices

• What and how a family is • How children are to behave• How children are to be treated • Ideas related to health and disability• How to relate to professionals• Communication styles

Considering Culture• Recognize and understand cultural

paradigms• “The family” as defined by the

family has a contribution to make in understanding a child

• Demonstrating willingness to learn about different cultures helps

Results of Child Evaluation

• DSM categories that work

• DC 0-3 R Axis One dx

• Should babies and toddlers be “Diagnosed”?

• If no, how can we bill?• If yes, what diagnoses can be

considered?

Psychiatric Diagnoses• DSM IV TR Diagnoses such as

depression, PTSD, adjustment disorders, and disruptive behavior disorder, NOS can be used

• Some efforts to modify criteria are in progress

PTSD • Items that require verbalization of inner

experience are revised• Fewer symptoms required• Items that involve memory reworded• Social withdraw replacements feelings of

detachment• Temper tantrums added to arousal items • May have delays, regression, increased

Depression• Appear less happy; sad; irritable; angry• Change in activity• Problems with appetite and sleep• Derive less pleasure from play and other

activities; play themes often involve death, killing

• Developmental regression in nearly 40%

Disruptive Behavior Disorders

• Persistent pattern of resistance to caregivers (defiant noncompliance)

• Deliberate attempts to annoy caregivers• Negative emotionality (chronic negative

mood or emotional dysregulation)• Aggression• Deliberate, pervasive, frequent, and severe

rule breaking• Poor social competency

Psychiatric DiagnosesAs an alternative: DC: 0 to 3• 5 Axis System• Considers primary dx and

relationship status• Multiple crosswalks to DSM-IV and

ICM-9 available for billing needs

DC 0 to 3• Axis I: Primary Diagnosis• Axis II: Relationship Disorder• Axis III: Medical and Developmental

Disorders and Conditions• Axis IV: Psychosocial Stressors• Axis V: Functional Emotional

Developmental Level

Suggested Report Format

• Identifying Information

• Referral Source

• Presenting Issues/Concerns

• Assessment Components and Sources of Information

• Family History

• Current Living Arrangements/Concerns

• Developmental Domains

• Present Functioning/Mental Status Exam

•Parent Caregiver Interactional Patterns

•Maternal Issues Affecting Child

•Paternal Issues Affecting Child

•Summary/Diagnostic Findings

•Recommendations

IMH Interventions

• Core Concepts• Contributions• Strategies• Approaches

Core Concepts Regarding

Interventions• Since all areas of development

take place within the framework of interaction between the infant and caregivers the treatment relationship needs to always include parents/caregivers (including foster parents)

Core Concepts for Intervention

• The parent’s capacity to nurture an infant is dependent to a great degree on the support that is available as well as the ability to use the support available.

Core Concepts Regarding

Interventions• Interventions are based on:

– The Contribution of the Infant– The Contribution of the Caregiver– The Contribution of the “Fit”– The Contribution of Stress and

Cultural Factors

Infant Factors• Individuality of each Infant• Temperament Characteristics• Sensory Functioning

Contribution of Caregiver

• Desire for a Child• Timing of arrival of Child• Expectations regarding baby• Perception of child• The real infant vs. the imagined

infant

Contribution of the Relationship

• Fit between expectations and reality

• Flexibility in the parent and the infant

• Degree of conflict or disappointment

Contribution of Stress Factors

• What is the role of stress within the family

• Understanding cumulative effects of stress

• Dealing with stress may be the first point of entry

Cultural Factors• Understanding context so that

stereotypes or assumptions aren’t made

• Differences in dealing with feeding, sleeping, crying and conflicts.

InterventionsIntervention Strategies include• Building an Alliance• Meeting Material Needs• Supportive Counseling• Development of Life Skills and Social

Support• Developmental Guidance• Infant Parent Psychotherapy

Building Trust• Consistency• Providing Telephone Support• Observes, Listens, Accepts, Nurtures• Visits Regularly• Identifies and Meets Material Needs Infant Mental Health Services: Supporting

Competencies Reducing Risks

Providing for Material Needs

• Facilitates access to community agencies

• Assists with transportation• Forms alliances with other

professionals on behalf of family

Supportive Counseling• Observing• Listening• Feeling• Responding

Development of Skills and Support

• Develops Social Supports• Models Problem Solving Skills• Models Decision Making Skills• Teaches Problem Solving

Processes

Developmental Guidance

• Provides Information• Speaks for Infant• Encourages Observation and

Interaction• Models Appropriate Interaction• Encourages Developmentally

Appropriate Activities

Infant Parent Psychotherapy

• Assists the Parents to: Develop new and healthier patterns of Interaction

• Identify feelings and put them into words

• Understand reactions, defenses and coping strategies

• Form Corrective Attachment Relationship

Intervention Methods• Interaction Guidance• Infant-Parent

Psychotherapy• Floortime

Interaction Guidance• Susan McDonough, Ph.D. MSW• For high risk families• Relationship-based• Use of videotape• Focus on positive interaction

between parent and child

Infant-Parent Psychotherapy

• Alicia Lieberman• Don’t Hit My Mommy! A Manual for

Child-Parent Psychotherapy with Young Witnesses of Family Violence

Floortime• Stanley Greenspan, MD & Serena

Weider, PhD• Use of play at specific

developmental levels• Play as communication• Following the child’s lead

Special Issues for Foster Parents

• Foster parents may have been told not to get too close to children in care

• In past, it was believed that it was confusing for children to feel too close to foster parents

Attachment to Foster Parents

• Now we believe that attachments to foster parents should be encouraged

• It can be hard for children to have separations from parents

• But the long term effects of no attachments at all are more damaging

Attachment to Foster Parents

• Foster parents should be encouraged to help the child develop a healthy attachment

• The child will be able to extend this attachment to birth family, new foster family, or adoptive family

Ways to Help Foster Parents

• Help foster parents understand that the child needs them even when they do not show it

• Understand that rejecting behaviors are old coping methods

For more on foster care• Mary Dozier, Ph.D.

Reflective Supervision• Reflective Supervision is clinical

supervision using a reflective-practice model

• Considered essential in infant-toddler work

Reflective Skills• Listening• Demonstrating empathy• Promoting reflection• Observing the parent-child relationship• Respecting role boundaries• Respond thoughtfully • Understand, regulate, and use one’s

one feelings

Reflective Supervision• “A safe place to process complex

situations and emotions”

Linda Gilkerson

Components of Reflective Supervision

• Reflection

• Collaboration

• Regular Meetings

Questions about Treatment

Next steps….• What do you want to do for follow

up?• Phone consultation?• Additional Training?• General vs Case-specific?• Your Ideas?

For Later Questions…• atomlin@iupui.edu

• yphrdir@cmhcinc.org

Infant & Toddler Infant & Toddler Mental HealthMental HealthAssessmentAssessment

Infant & Toddler Infant & Toddler Mental HealthMental HealthAssessmentAssessmentStacey Ryan, LCSWStacey Ryan, LCSW

Angela M. Tomlin, Ph.D.Angela M. Tomlin, Ph.D.

infant & toddler mental health assessment stacey ryan, lcsw angela m. tomlin, ph.d

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