Month: April 2015

Colleen Kraft, MD, a keynote speaker at the 2015 MI-AIMH Biennial Conference, “Caring for the Whole Child: Working Together for the Health and Well-Being of Infants, Toddlers and their Families,” is an expert on the family-centered medical home in pediatrics, with particular emphasis on the use of this model with infants, toddlers, and their families (Kraft, 2013; Rushton & Kraft, 2013).  The family-centered medical home is designed to insure that the needs of the whole child are addressed in a comprehensive, developmentally appropriate, and relationship-oriented context (Kraft, 2013; Rushton & Kraft, 2013).  This model was initially designed for families with children diagnosed with special needs and has now been expanded as a pediatric approach for all children and their families (Malouin, 2013).

The family-centered home relies on collaboration among service providers:  “…the pediatric team works in partnership with a child and the child’s family to help the family and patient access, coordinate, and understand specialty care, educational services, out-of-home care, family support, and other public and private community services that are important for the overall health of the child and the family” (Kraft, 2013, p.16).   The American Academy of Pediatrics (AAP) endorsed the family-centered medical home in its 2012 policy statement “Patient and Family-Centered Care and the Pediatrician’s Role,” citing the multiple benefits of a family-centered approach to pediatric care including long-term medical cost reduction, improved provider satisfaction, and positive health outcomes for children and families.

The implementation of this model in pediatric practice can include specialized screening for familial risk factors, such as those that have been identified as Adverse Childhood Experiences (ACEs); the model also urges attentiveness to developmental history, including a strategic effort to observe developmental characteristics in the context of interactions with providers and caregivers (Kraft, 2013).

In addition to assessment, pediatricians engaged in the family-centered model intervene using a preventive approach designed to foster positive parent-child relationships and to encourage families to engage in activities that promote their child’s development, such as reading and playing (Kraft, 2013). The assessment and intervention is complemented by pediatricians’ efforts to forge relationships with other early childhood service providers via referrals, community needs assessments, and care coordination (Kraft, 2013).  Finally, pediatricians in the family-centered care model of practice coordinate the assessment needs of children diagnosed with special needs and developmental disabilities (Kraft, 2013).

The core principles of the family-centered medical home highlight the relationships between the provider and child and his or her family. The principles emphasize the importance of recognizing and respecting the impact of culture, race, ethnicity, and socioeconomic background on family experiences (AAP, 2012).  The individualization of care is a priority as is the necessity of direct, honest, and compassionate communication from providers (AAP, 2012). Partnering with families and children in all aspects of care as well as insuring that children and families have the necessary supports to promote health and wellness are also described in these principles (AAP, 2012).  Finally, a strengths-based perspective is described as endemic to the family-centered medical home model since the identification and support of current resources and strengths provide families with a sense of autonomy in their efforts to improve their family health outcomes (AAP, 2012).

The relationship-based implications for this model of care are profound.  The AAP and the Maternal Child Health Bureau of the Health Resources and Services Administration commissioned an evaluation of 17 case studies of family-centered medical care homes that had been identified by their peers as being the best examples of this model (Malouin, 2013). The 17 provider agencies represented a variety of settings across the country.  The evaluators examined, in great detail, the various elements of these pediatric practices in order to identify best practice approaches (Malouin, 2013).  The findings showed the highly ranked pediatric providers identified the following features of their practice that support their family-centered medical care: “acknowledges the family as the constant in the child’s life, builds on family’s strengths, supports the child in learning about and participating in his/her care and decision-making, honors cultural diversity and family traditions, recognizes the importance of community-based services, promotes an individual and developmental approach, encourages family-to-family and peer support, supports youth as they transition to adulthood, develops policies, practices, and systems that are family-friendly and family-centered in all settings, and celebrates successes” (Malouin, 2013, pp. 52-53).

The similarities between these family-centered medical home practice behaviors and the practice behaviors essential to infant mental health (IMH) services are striking.  The importance of establishing collaborative relationships with parents is fundamental to the success of IMH work and recognizing the unique nature of each family, including their needs and strengths, is central to IMH practice.  In addition, IMH work emphasizes the necessity of collaborating, invoking a systems perspective that takes into account the family’s environmental context, relationships with community providers and resources, and facilitating linkages when appropriate.  The value of creating real relationships with infants and toddlers and their families where IMH providers can delight in their developmental achievements and highlight a dyad’s growing sense of confidence in their parent-child relationship resonates with the family-centered medical home providers’ emphasis on celebrating the successes of children and families.

The family-centered medical home is relationship-driven in that the pediatricians are encouraged to assess and support parent-child relationships through the authentic and conscientious establishment of a relationship with parents (AAP, 2012; Kraft, 2013; Malouin, 2013; Rushton & Kraft, 2013).  In addition, the family-centered medical home model highlights the value of establishing strong relationships with community-based resources and providers in order to create a nest of sorts that will support the developing child and his or her family (Kraft, 2013; Malouin, 2013).  This model reflects a growing attention to the value of relationships, in terms of their longitudinal impacts on health and wellness, and it provides a new opportunity for IMH and early childhood professionals to further expand their work in the context of these pediatric practices.  We look forward to learning more about the family-centered medical home in the context of work with infants and toddlers from Dr. Kraft on May 18^th at the 2015 Biennial MI-AIMH Conference in Kalamazoo.

 

 References

American Academy of Pediatrics (2012). Patient and family-centered care and the pediatrician’s role. Pediatrics, 129(2), 394-404.

Kraft, C. (2013). Building brains, forging futures: A call to action for the family-centered medical home. Zero to Three, September, 16-21.

Malouin, R. (2013). Positioning the Family and the Patient at the Center: A Guide to Family and Patient Partnership in the Medical Home. Elk Grove Village, IL: American Academy of Pediatrics, National Center for Medical Home Implementation.

Rushton, F.E & Kraft, C. (2013). Family support in the family-centered medical home: An opportunity for preventing toxic stress and its impact in young children. Child Abuse and Neglect, 37S, 41-50.

 

 

 

The Australian Association for Infant Mental Health West Australian Branch Incorporated (AAIMHI WA) has purchased a license from the Michigan Association for Infant Mental Health (MI-AIMH) to begin using the MI-AIMH Competency Guidelines® as standards to promote infant mental health (IMH) in Western Australia (WA). WA is leading the way internationally as the first Affiliate of the World Association for Infant Mental Health (WAIMH) outside the United States of America to have a licensing agreement to use the MI-AIMH Competency Guidelines®.

The launch of the AAIMHI WA Competency Guidelines® is a joint initiative between AAIMHI WA and the Government of Western Australia Mental Health Commission (WA MHC). The WA MHC has a number of functions including development and provision of mental health policy and advice to the government, leading the implementation of the Mental Health Strategic Policy, and providing grants, transfers and service contract arrangements.

The launch of the AAIMHI WA Competency Guidelines® will also include the release of The Workforce Competency Based Training Project, which has its genesis in collaboration between The Western Australian Mental Health Commission (WA MHC) and AAIMHI WA. This project was an innovative response to the growing awareness in the professional community of the need to up skill those working with infants, young children, and their families. A significant finding was that WA has a dedicated workforce that is open to change and is aware of the need to develop best practice guidelines for working with infants, young children, and families. This key finding supports AAIMHI WA’s focus on workforce development and the need to adopt a set of competency guidelines that are internationally recognized as the gold standard in IMH. To this end, AAIMHI WA purchased a license from the MI-AIMH to begin using the MI-AIMH Competency Guidelines® under the auspices of AAIMHI WA.

WA MHC supporting the AAIMHI WA Competency Working Group

The WA MHC awarded the AAIMHI WA Competency Working Group with a grant in December 2014 to support implementation of the AAIMHI WA Competency Guidelines® by providing funding for 12 months of reflective practice supervision for members of the Working Group (approximately 25,000 AUS Dollars). The Working Group was formed in October 2014, following purchase of the license from MI-AIMH. The group represents a range of disciplines across a number of agencies working in perinatal and IMH. It also includes members from rural regions of WA.

The purpose of the Working Group is to support the implementation of the AAIMHI WA Competency Guidelines® into the WA workforce across promotion, prevention, intervention, and treatment levels of service. Responsibilities include:

• In collaboration with MI-AIMH and consultation with key stakeholders, review and modify the MI-AIMH Competency Guidelines®, as needed, to assure that all terms and provisions are culturally appropriate for the WA context.

• Critically review and modify the MI-AIMH Competency Guidelines®, as needed, to assure that all terms and provisions are culturally appropriate for Aboriginal and Torres Strait Islanders.

• Implement the AAIMHI WA Competency Guidelines® in WA, in collaboration with stakeholders, and develop partnerships for working collaboratively across services and agencies to build workforce capacity in the promotion of IMH in WA.

• Provide advice and links to people and information on the AAIMHI WA Competency Guidelines® and how they can guide training and building IMH Competencies across all levels of service provision.

• Share and disseminate information on events, announcements, and initiatives that relate to the AAIMHI WA Competency Guidelines® and building workforce capacity in IMH in WA.

• Develop a training model for the AAIMHI WA seminar series and other trainings offered by AAIMHI WA that is developmental and meets specific competencies within the AAIMHI WA Competency Guidelines®.

Next steps for AAIMHI WA

The next step for AAIMHI WA is to purchase a workforce recognition initiative, the MI-AIMH Endorsement for Culturally Sensitive, Relationship-Based Practice Promoting Infant Mental Health® license (Endorsement®), from MI-AIMH. In preparation, members of the Working Group will work towards earning the MI-AIMH Endorsement®.  Criteria for MI-AIMH Endorsement® include committing to group based reflective supervision in IMH, participating in competency-informed trainings, and working with infants, young children, and their families using a relationship based IMH model of practice. Following purchase of the Endorsement® license by AAIMHI WA, and with technical assistance from MI-AIMH, members of the Working Group will implement the Endorsement® system in WA. They will also have a qualification that recognizes their capacity to provide reflective practice supervision to practitioners in WA working in the field of IMH across disciplines and levels of service.

The WA MHC has provided funding for the 12 members of the Working Group to receive two-hour group based reflective supervision, monthly, for 12 months. Beulah Warren is providing the monthly reflective supervision for all three groups via Skype. Part of the funding also includes an intensive face-to-face, one-day reflective practice supervision workshop with Beulah. Each group has had their first reflective supervision session in January of this year and participated in an intensive face-to-face reflective supervision workshop in February 2015.

 Click here to view the Workforce Competency Based Training Project Report

“So, what is Reflective Supervision or Consultation, anyway?” I am asked, yet again.  I take a deep breath and orient myself to whom I am speaking.  A mental health clinician unfamiliar with early childhood mental health?  Someone who offers early care, education, or support services of a different kind?  Is it a program supervisor or administrator?  Someone who is responsible for workforce development policy and who needs to know what value reflective practices, including supervision or consultation, can offer to their system?  Is it a student or new staff person?

My answer will be slightly different for each of these individuals because they each come to that question from a unique place.  However, a brief dilemma statement can help move the conversation forward to get a glimpse into what reflective supervision/consultation (RS/C) is and how it might be important to enhancing the quality of service they offer.

Here are a few good ones:

*A new staff person appears uncomfortable speaking with a parent about their baby’s observable atypical development.
*An experienced staff person is having difficulty engaging a particular family.
*A clinician who has worked with older children and their families is now working in an infant mental health (IMH) program; she is observed picking up the baby to play when she walks into one of her families’ homes and launching into conversation with the parent about whether the agreed upon time for parent-infant play was spent since she was last there.
*An infant/toddler caregiver feels overwhelmed by a toddler who refuses to stop hurting other children in her care.
*A supervisor has a staff person who is extremely inconsistent in meeting with him.

You might find yourself easily able to see how these dilemma statements could be used to engage in a dialogue that sheds light on how RS/C addresses the issues of relevance.  Each of them is a real practice example of an opportunity to engage in mutual exploration, to clarify experiences and perspectives, and to uncover possibilities for further focus.

Let’s now consider aspects of RS/C that can inform any responses you might offer:

1. What do we mean when we talk about RS/C?
2. What are its core processes?
3. Why do we believe it is so important to the provision of quality relationship-based services to infants, toddlers, and families, as well as to the growth and health of the professional?
4. How do we use this important relationship process to manage all that there is to balance? In RS/C we try to balance:

*Attention to the self with attention to the work,
*Attention to the supervisory relationship, with the practitioner-family relationship, with the parent-baby relationship (to what each partner brings to those relationships), and the weird thing we call “parallel process” by which one influences all the others,
*Attention to what is there, what is missing, and to whether all perspectives are represented,
*Attention to emotions stimulated and to thoughts that emerge to be explored,
*Attention to noticing and holding the experience that is there, and also to help support openness to explore what we do not know yet.

What do we mean when we talk about RS/C?

Without citing the literature here, I will summarize by saying that it is a collaborative relationship for learning and support that requires true participation between supervisor and supervisee or consultant and consultee(s).  Its most basic expectations are that it:

*Is safe and mutually respectful,
*Is consistent and frequent enough to create continuity and familiarity,
*Pays attention to the emotional experience and thoughts of the supervisee,
*Pays attention to all of these relationships — supervisor and practitioner, practitioner and family, parent/caregiver and very young child,
*In addition to helping supervisees increase their understanding about a family or dilemma in their work, it provides a “holding environment” within which they can tolerate a bit of ambiguity (and sometimes anxiety or other difficult feelings) long enough to be curious, to be open, and to notice and explore what might be observed in the baby, caregiver, and self.

It may or may not be obvious, but BOTH supervisor and supervisee must be willing to engage in this way.

What are the core processes in RS/C?

We are learning to tease these apart now through various research efforts taking place across the country.  Observable elements of RS/C are being codified in a tool under current development by Christopher Watson, Ph.D., along with colleagues at the University of Minnesota and others working in states who have purchased a license to use the MI-AIMH Endorsement ®.  This tool, called the Reflective Interaction Observation Scale (RIOS), seems to capture the core processes quite well.

The first core process is the mutual attempt to Understand the Story that is being presented about the baby, family, and the work with them, in a way that looks beyond a superficial presentation and considers the influence of history and current contexts.  A supervisor and supervisee hope to avoid rushing to judgment as they try to get the best handle on what is happening in order to figure out where they are and what to do next.  This can be one of the hardest things to do in the push to solve the problem, allowing us to move away from the feeling of confusion or the discomfort of not knowing.

The ability to understand and use Parallel Process is another important element in RS/C.  In IMH, we believe that the most therapeutic thing about what we do is the relationship we offer.  We believe that this is true whether we are IMH practitioners acting as therapists or as IMH-informed practitioners working in other systems or disciplines.  We hope that the quality of the relationship that the practitioner offers to the family is a new experience that can be taken in by the caregiver and the baby as a source of regulation, consistency, acceptance, appreciation, curiosity, etc., and that the caregiver, having been really seen in this way by the practitioner, will be more able to do this for their very young child.

How can a practitioner do this for a caregiver in a consistent, genuine way if they do not experience this “being seen” and accepted when vulnerable, when clear and strong, when sad or anxious, or when not knowing?  Short answer, I do not think they can.  The supervisor/consultant’s offer of this relationship to the supervisee makes it more possible for him or her to be with the caregiver and very young child in a unique way through this parallel process.  It allows them to also use observations about the affective experience at the level of the supervisor and/or supervisee to tell them something about the affective experience of baby and family members.

This adds a layer of quality that goes above and beyond diagnostic formulation and carrying out well-designed treatment plans.  This wondering about the effects of relationships upon relationships helps inform the work.  The RS/C relationship should help the supervisee pay attention to his or herself in the work in order to increase use of self.

Holding the Baby in Mind is the next element.  We all naturally tend to gravitate toward a particular interactive partner in our observations and perspectives.  When families or other caregivers are particularly overburdened, or supervisees are overwhelmed by worries, either in their own lives or in response to what the caregivers present, it is easy to lose sight of the baby.  Is it too overwhelming to wonder how the baby experiences these things?  Is it too sad or frightening?  What does the baby bring to the equation?  What does the baby mean to the caregiver?

The baby as an interactive partner tells us much about what is important in the work with a family.  A supervisor/consultant may have to notice when there are little observations or curiosity about the baby in his/herself, or in the supervisee, and engage in gentle inquiry about this.

The Working Alliance is the term used to describe some of the other characteristics of great import to the RS/C process.  This is something that has to be built.  I think it starts most hopefully with assuming best intent of the other on the part of both supervisor and supervisee.  This is easier said than done sometimes – because of past relationships or the lack of confidence of a new supervisor or of a new supervisee, or of mismatch in style, personality, training, or cultural expectations.

Just as is true in a new practitioner-family relationship, trust and safety have to be grown and tested in order for real comfort to emerge.  A pair will have to negotiate how to set their agenda and goals, what the expectations of each other are, how to use their time, and ask for information.  They will celebrate accomplishments. They will have to sort through many experiences — of observing and wondering together, of sitting with silence, of not knowing when the pressure to know feels urgent, or of inquiring about what might be missing. They will need to acknowledge their own feelings as they emerge in order to better understand what is happening in the work and be willing and able to manage intense feelings.  They will have to learn how to repair when there are mis-attunements or misunderstandings and to learn and try out new skills. It is a developmental process for each supervisee and supervisor, for each RS/C relationship, and even within that, perhaps for each new type of dilemma.

So, we come full circle as we have looked at these core processes, or elements, and all there is to balance to this final question – Why is RS/C so important to the provision of quality relationship-based services, as well as to the growth and health of the professional?

This is the vehicle for truly supported learning where relationship affects relationship, and where competencies — theory and knowledge and skills and reflection — can be tried out in a supported way.  Supervisees do this with the help of the supervisor, parents and other caregivers do this with the help of the practitioner, and babies do this with the help of those who care for them.  None of us learn from experience alone, rather it is the reflection on experience that teaches.

 

Reference

Watson, C., Gatti, S., Harrison, M., & Hennes, J. (2014). Reflective supervision and its impact on early childhood Intervention. In Advances in Early Education and Day Care: Early Childhood and Special Education, Vol. 18. (Eds. E. Nwokah & J. Sutterby). Emerald Group Publishing:  United Kingdom. pp. 1-26.