infant & toddler mental health assessment stacey ryan, lcsw angela m. tomlin, ph.d
TRANSCRIPT
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Infant & Toddler Infant & Toddler Mental HealthMental HealthAssessmentAssessment
Infant & Toddler Infant & Toddler Mental HealthMental HealthAssessmentAssessment
Stacey Ryan, LCSWStacey Ryan, LCSW
Angela M. Tomlin, Ph.D.Angela M. Tomlin, Ph.D.
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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
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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
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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
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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
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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
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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
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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
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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
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The Science of Early Childhood
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
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The Science of Early Childhood
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)
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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?
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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
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Young Children 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
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Young Children in Foster Care
Of all the children who died from abuse and neglect,77% were under 4 years old.
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MH Challenges in Young Children
• Are real• Involve a substantial number of
babies• Can be assessed and treated
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What Infant & Toddler Mental Health is NOT
• Babies on a couch• Talking therapy with toddlers• Seeing a child without parents• Bonding therapies• Developmental therapy
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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
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Areas to Consider When Assessing Young Children• Developmental Levels of Infant or
Child• Quality of Important Relationships• Parent Status (Capacity for
Relationship)• Family Situations
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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
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Infant & Child Development
• Expected order of milestones is knownSkills are traditionally divided into 5 areasThere is much overlap between the areasUneven development across areas is concerning
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Infant & Child Development
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
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Infant & Child Development
• aap.org
• http://thechp.syr.edu/Developmental_checklist.pdf
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Infant & Child Development
• Cognitive• Receptive, Expressive, and
Pragmatic Communication• Fine & Gross Motor• Social-emotional and behavior• Adaptive Skills (Self Help)
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Cognitive Skills• Thinking• Problem Solving• Memory• Attention• Imitation
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Communication• Use of gestures and facial
expressions• Understanding speech• Expressive language• Social or pragmatic aspects of
communication
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Fine & Gross Motor Skills
• Use of hands and arms to manipulate objects
• Balance• Strength and tone• Walking, running, jumping
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Social-emotional and behavior
• Eye contact• Social smile• Relationships/
attachment• Regulation
• Sleep • Feeding• Aggression• Compliance
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Self-Help/Adaptive• Eating• Dressing• Participation in grooming• Toileting
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Ways development can be atypical
• Global delays in development
• Inconsistent development
• Atypical, unusual behaviors—red flags
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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)
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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
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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
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Collecting Information about Infant & Child
Development• Existing records from previous
assessments• Screening and referral• Single discipline developmental
assessment• Multi or interdisciplinary team
assessment
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Existing records:Understanding test
data• Screening or child find results
• First Steps evaluation/Curriculum based assessment
• Normed assessment methods/Clinic or school based
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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/
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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
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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
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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
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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
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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
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Clinic & School Assessments
Cognitive
– BSID-3– DAS– SBIS-5– MSID
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Clinic & School Assessments
Communication
– Rosetti (Caregiver Report)– Preschool Language Scale-4– Informal assessments– AAC
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Clinic & School Assessments
Adaptive Behavior
VABS-2SIB-RABAS
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Clinic & School Assessments
Motor Assessments
Peabody Developmental Motor Scales-2
VMI
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Clinic & School Assessments
Social-Emotional and Behavioral
ITSEABASCCBCL
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Clinic & School Assessments
Autism Assessments
Developmental HistoryADOSChecklists (Gilliam, CARS, MCHAT)
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What to do if…No previous developmental
assessment??• Conduct your own developmental
assessment• Get full E & A thru First Steps• Screen and refer
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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
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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
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Infant-Toddler MSE• Must understand development
• Good observation skills
• Experience with infants and young children
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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
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Infant/Toddler MSE
•Speech and Language
•Thought Processes
•Affect and Mood
•Play
•Cognition
•Relatedness
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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
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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
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Questions about Developmental Assessment?
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Assessing Quality of Parent-Child Relationship • Attachment: research and clinical
findings
• Tools for assessing relationships
• Suggested observation strategies
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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
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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
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Attachment• Ainsworth/Bowlby introduced the
secure/insecure attachment paradigm
• These research categories only work loosely in a clinic setting
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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)
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Reactive Attachment Disorder
Two Patterns:
• Excessive inhibition, hypervigilant, highly ambivalent behaviors
• Indiscriminate sociability
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Reactive Attachment Disorder
• Both patterns are know to occur in children who have been in foster care and those raised in institutional settings
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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
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Areas to Observe when Assessing Parent and Child
Interactions
Attachment BehaviorsPlay InteractionsDirection/TeachingSeparation/Reunion
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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?
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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?
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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
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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
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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
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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
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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
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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
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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
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PIR-GAS Categories• Well Adapted • Adapted• Perturbed• Significantly
Perturbed• Distressed
• Disturbed• Disordered• Severely Disorder• Grossly Impaired• Documented
maltreatment
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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
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RPCL Areas• Behavioral Quality of Interaction
• Affective Tone
• Psychological Involvement
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RPCL• Overinvolved
• Underinvolved
• Anxious/Tense
• Angry/Hostile
• Verbally Abusive
• Physically Abusive
• Sexually Abusive
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UnderinvolvedBehavior Quality:
• Insensitive/unresponsive to cues• Does not protect child• Child appears uncared for
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UnderinvolvedAffective Tone
• Affect in both partners seems sad, constricted, withdrawn, and flat
• To observer, interactions suggest lack of pleasure
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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
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Physically AbusiveBehavioral Quality:
• Parent physically harms child• Parent regularly fails to meet
child’s basic needs
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Physically AbusiveAffective Tone:
• Reflects anger, hostility, or irritability
• Considerable to moderate tension and anxiety are present
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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
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Additional Parent child tools
• Crowell Procedures
• Parent Child Early Relational Assessment
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Relationship Assessment
Crowell Procedure• Free play• Clean up• Teaching Tasks• Separation/Reunion
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DomainsParent• Emotional
Availability• Nurturance• Protection
Child• Emotional
Regulation• Security• Vigilance
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DomainsParent• Comforting• Teaching• Discipline• Structure/Routine
Child• Comfort-seeking• Learning• Self-control• Self-regulation
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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
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Parent Child Early Relational Assessment
• Parent Domains– Expressed Affect and Mood– Expressed Attitude Toward child– Affective and Behavioral involvement
with child– Parenting Style
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Parent Child Early Relational Assessment
• Infant/Child Domains– Mood/affect– Behavior/adaptive ability– Activity level– Regulatory capacities– Communication– Motoric competence
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Parent Child Early Relational Assessment
• Parent/Child Dyad– Affective quality of interaction– Mutuality– Sense of security in relationship with
parent
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Questions about Relationship Assessment?
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Assessing Parent Capacity for Relationship
• Adult Attachment Interview
• Working Model of the Child Interview
• Parenting Stress Index-Third Edition
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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.
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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
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Adult Attachment Interview
Adult Classification• Secure/
autonomous• Dismissing• Preoccupied• Unresolved/
disorganized
Child Classification• Secure• Avoidant• Resistant/
Ambivalent• Disorganized
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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
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Parenting Stress Index, Third Edition
• Child Domain– Distractibility/hyperactivity– Adaptability– Reinforces Parent– Demandingness– Mood– Acceptability
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Parenting Stress Index, Third Edition
• Parent Domain– Competence– Isolation – Attachment– Health– Role Restriction– Depression– Spouse
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Parent Evaluations…• Most common Psychiatric Dx
– Depression– Personality Disorder
• Developmental/MR• Addictions• Vocational
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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
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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
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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
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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
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Parenting and Cognitive Limitations
• With appropriate supports, most parents with MH can learn to be good parents
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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?”
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Screening Adults for MH
Observe:
Hygiene and dressAbility to prepare mealsMoney managementTidiness and Cleanliness of HomeAbility to relate to others
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Parents with AddictionEffects on Family Interactions• More conflict• More family problems• Less structure and discipline• Increased expectations for child
independence• More physical discipline (boys)
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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
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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
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Family Situations• Strengths• Weaknesses• Risk Factors• Cultural factors
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Risk Factors• Poverty• Domestic Violence• Community Violence• Lack of Support• Reluctance to Accept Help• Inconsistent Care giving Experiences
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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
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Cultural Issues• Always view the cultural
framework as a set of tendencies or possibilities
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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
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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
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Results of Child Evaluation
• DSM categories that work
• DC 0-3 R Axis One dx
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• Should babies and toddlers be “Diagnosed”?
• If no, how can we bill?• If yes, what diagnoses can be
considered?
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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
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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
fears
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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%
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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
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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
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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
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Suggested Report Format
• Identifying Information
• Referral Source
• Presenting Issues/Concerns
• Assessment Components and Sources of Information
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Suggested Report Format
• Family History
• Current Living Arrangements/Concerns
• Developmental Domains
• Present Functioning/Mental Status Exam
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Suggested Report Format
•Parent Caregiver Interactional Patterns
•Maternal Issues Affecting Child
•Paternal Issues Affecting Child
•Summary/Diagnostic Findings
•Recommendations
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IMH Interventions
• Core Concepts• Contributions• Strategies• Approaches
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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)
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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.
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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
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Infant Factors• Individuality of each Infant• Temperament Characteristics• Sensory Functioning
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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
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Contribution of the Relationship
• Fit between expectations and reality
• Flexibility in the parent and the infant
• Degree of conflict or disappointment
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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
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Cultural Factors• Understanding context so that
stereotypes or assumptions aren’t made
• Differences in dealing with feeding, sleeping, crying and conflicts.
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InterventionsIntervention Strategies include• Building an Alliance• Meeting Material Needs• Supportive Counseling• Development of Life Skills and Social
Support• Developmental Guidance• Infant Parent Psychotherapy
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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
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Providing for Material Needs
• Facilitates access to community agencies
• Assists with transportation• Forms alliances with other
professionals on behalf of family
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Supportive Counseling• Observing• Listening• Feeling• Responding
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Development of Skills and Support
• Develops Social Supports• Models Problem Solving Skills• Models Decision Making Skills• Teaches Problem Solving
Processes
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Developmental Guidance
• Provides Information• Speaks for Infant• Encourages Observation and
Interaction• Models Appropriate Interaction• Encourages Developmentally
Appropriate Activities
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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
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Intervention Methods• Interaction Guidance• Infant-Parent
Psychotherapy• Floortime
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Interaction Guidance• Susan McDonough, Ph.D. MSW• For high risk families• Relationship-based• Use of videotape• Focus on positive interaction
between parent and child
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Infant-Parent Psychotherapy
• Alicia Lieberman• Don’t Hit My Mommy! A Manual for
Child-Parent Psychotherapy with Young Witnesses of Family Violence
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Floortime• Stanley Greenspan, MD & Serena
Weider, PhD• Use of play at specific
developmental levels• Play as communication• Following the child’s lead
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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
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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
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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
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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
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For more on foster care• Mary Dozier, Ph.D.
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Reflective Supervision• Reflective Supervision is clinical
supervision using a reflective-practice model
• Considered essential in infant-toddler work
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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
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Reflective Supervision• “A safe place to process complex
situations and emotions”
Linda Gilkerson
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Components of Reflective Supervision
• Reflection
• Collaboration
• Regular Meetings
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Questions about Treatment
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Next steps….• What do you want to do for follow
up?• Phone consultation?• Additional Training?• General vs Case-specific?• Your Ideas?
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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.