Month: April 2016

The traditional principles of Infant Mental Health (IMH) are instrumental in clinical work with infants and young children across settings.  In my work in a private practice outpatient setting, the Infant Mental Health perspective helps provide a framework for my work with young children and their families.  In this article I will focus on the ways in which IMH principles support my work, while at the same time challenge me to integrate what at times seem to be contradictory stances.  In particular, I will consider the concepts of a non-directive stance and avoidance of an expert role.  Those principles facilitate a sense of understanding, trust, and intimacy central to my work with families.  At the same time, my position as a licensed psychologist leads clients to expect that I will provide guidance and share my expertise regarding certain areas of client functioning.  I will use attention to early indicators of Autistic Spectrum Disorders (ASD) as an area of clinical work that highlights the importance of balancing traditional IMH principles with guided interventions at times.

One core difference between traditional home-based IMH services and private practice is that families come into services in different ways.  Families that work with traditional home visitors may not have sought out services.  Some families have had unfortunate experiences with “the system” that have left them feeling judged, vulnerable, or inadequate.  They may see human service agencies as intrusive and expert advice may feel like criticism.  These families may especially benefit from a supportive, non-directive stance, and from being reminded that they have a unique understanding of their child.

In contrast, parents who come to a private practice setting are generally seeking services voluntarily. They may be scared, confused, and/or overwhelmed by the challenges that they face in parenting.  They seek guidance regarding particular concerns, new ideas, and answers to specific questions.  At such times, the most supportive response is to offer expert guidance that can reduce their distress by offering hope that the challenges that they face can be managed.

Regardless of the setting or type of referral, every case is unique.  There is not one approach that is better or that should be used to the exclusion of the other in any setting.  For example, families who seek services on their own may still feel criticized by advice, and may benefit from a non-directive, supportive stance, whereas families in home-based settings may feel supported and relieved at times by receiving structured guidance.

At times it is essential to balance a traditional IMH approach with a more directive approach.  Specifically, when infants are not typically developing, early intervention is critical.  Families in these situations certainly need a supportive approach as they begin to address possible challenges in their infants’ development.  Yet, timely structured guidance in relation to those challenges is necessary.

For example, early intervention is the key to optimizing development for children with signs of ASD. A significant amount of brain development happens after birth. The brain activity and development in the first year is experience-dependent and explosive, allowing early intervention to have a tremendous impact.  From birth, interaction with others is critical.  It is imperative that the brain be involved in interaction with another human being in order to develop properly. Many of the early signs of ASD involve a lack of, or minimal interest in, relating to others, which limits the interaction needed for optimal brain growth.  Hence, early intervention is vital in order to facilitate interaction with others.

Traditional IMH approaches alone will not sufficiently address the core challenges present with early signs of ASD.  Traditionally, parent-infant intervention provides a nurturing relationship that helps to hold the family and offer support and empathy as they work through difficult emotions.  That process can facilitate healthy attachment and help to strengthen and/or repair disrupted bonds.  However, for infants and toddlers at risk for ASD, this process may not naturally unfold without structured intervention.

Intervention for the core features of ASD targets deficits in reciprocity and mutual engagement.  However, because at-risk infants or toddlers may not respond typically to attempts at engagement, parents need structured guidance to learn how best to facilitate mutual engagement.  At the same time, traditional IMH principles continue to be critical in helping to support families as they begin to recognize and cope with developmental challenges.

In sum, as I work to apply principles of IMH to my private practice work, I continue to integrate seemingly incompatible approaches in clinical work. A non-directive approach with circumscribed use of an expert stance facilitates a collaborative relationship with clients.  Still, I recognize that there are times when clients expect expert guidance regarding specific questions. While different paths to referral may suggest the use of different stances, a non-directive approach may need to be integrated with structured guidance in any setting, depending on the clinical needs of a family at given point in time.  There are times when a more structured approach is more clearly in a family’s best interest, for example when an infant or toddler exhibits signs of ASD.  At the same time, supporting families with traditional IMH principles continues to be essential as they address developmental challenges.  Regardless of the referral issues, each family is unique and may require varying stances in varying circumstances.

 

More more information about the author visit www.annodonnell.com.

You are an infant mental health specialist working with 2 1/2 year old Sammy and his family.  His parents are worried about Sammy’s limited language and his tantrums, which are frequent and seem easily provoked.  You have observed how discouraged his parents have become at his seeming disinterest in playing with them.  Sammy prefers solitary, repetitive play to cuddling or a story with his mom or chase games with his dad.  He loves to build with Legos, but becomes upset when the pieces do not fit together, and it is hard for anyone to figure out how to help him build before he has a meltdown.  You are wondering how to support Sammy’s relationship with his parents when they are struggling to maintain engagement.  Your IMH strategies to support development and relationship do not meet all of Sammy’s needs.  You and Sammy’s parents suspect autism and have decided together to look into possible services.

With current autism prevalence rates recently cited as 1 in 42 for boys and 1 in 189 for girls (Centers for Disease Control and Prevention), infant/toddler-family practitioners in any setting – either a home visiting program or center-based early care and education, will find very young children that may need to be assessed or already have a diagnosis of autism.  What we do not always know is how to support families in navigating the system for referral, assessment and treatment when autism spectrum disorder (ASD) is a question.

The Michigan Autism Spectrum Disorders State Plan was developed in 2012 to build the state infrastructure for comprehensive, lifespan supports to individuals with ASD and their families through access to information and resources, coordination of services, and implementation of evidence based practices.  Current practices in screening, referral, evaluation, intervention, insurance coverage, service coordination and training for parents and professionals across systems were identified in this plan, as well as recommendations to address gaps.

As a result, families and providers can find resource information and professionals able to assist them every step of the way, including autism navigation for families online and over the phone through the Autism Alliance of Michigan (contact: navigator@aaoim.org or 1-877-469-2266)  However, we are all learning about this new system and how to minimize confusion for families.

Screening & Referral

Sammy’s parents are anxious, but relieved when their IMH specialist suggests that they screen Sammy for ASD.  It has been an unspoken worry they have carried. Together, they use the M-CHAT ASD screener, which is the first step required in determining eligibility. They had previously declined this screening at his last well-child check-up and at his child care center, and they never enrolled in Early On.  Sammy’s scores confirm their concerns.  Since the family has Medicaid, the IMH worker knows that will make it possible for Sammy to go through the diagnostic evaluation process to determine covered ASD services and/or Applied Behavior Analysis (ABA) eligibility through their local CMH.

Many young children do not have Medicaid, but in 2012 and 2013, Michigan passed legislation aimed at increasing access to early evaluation and treatment services for children with ASD. Now all commercial insurance plans regulated by the state of Michigan must provide coverage of ASD diagnostic evaluations and treatment services related to ASD.

Comprehensive Diagnostic Evaluation

This is a neurodevelopmental review of cognitive, behavioral, emotional, adaptive and social functioning using valid evaluation tools performed by qualified licensed practitioners experienced in diagnosing ASD.  Providers that administer diagnostic evaluations for ASD typically include pediatricians, psychiatrists, and psychologists. The number of qualified licensed professionals who are trained to diagnose is expanding.  For current information of these provider resources in any geographic area please contact your insurance provider or local CMH.

Behavioral Health Treatment Services (BHT)

Effective January 1, 2016, Michigan Medicaid provides coverage of Behavioral Health Treatment (BHT) services, including Applied Behavior Analysis (ABA), for children under 21 years of age with ASD. ABA is currently the only treatment modality covered under BHT. Behavioral assessments supervised by behavior analysts will fine-tune the types of service interventions needed and intensity recommended.  Behavioral intervention services include, but are not limited to, the following evidence-based interventions:

• Peer-mediated social skills training • Functional based interventions
• Antecedent based intervention • Pivotal response training • Reinforcement systems
• Self-management • Social narratives • Video modeling • Parent training
• Prompting • Chaining

Board Certified Behavior Analysts (BCBA’s) supervise the development of the ABA treatment plan carried out by Behavioral Technicians (BT’s).  Additionally, each CMH has an Autism Supports Coordinator to assist them in gaining ready access to information and resources and to locate the services to address unmet needs.  A young child may also need speech/language, occupational or other therapies, and the supports coordinator can assist the family and the child’s team to make decisions about where to find these services.  In some CMH systems, a child’s IMH specialist may also serve as their supports coordinator.

Sammy was determined eligible for ABA services and a plan for 15 hours per week was decided upon with his family to allow time for additionally needed speech/language therapy and the continuation of IMH services to support their stressed relationships.

Resources

This is an evolving service delivery system.  There will likely be changes as implementation takes shape in various communities and CMHP’s learn how to best accommodate needs of individual children and families.  MDHHS provides updated & detailed information here:  www.michigan.gov/autism.

 

For further information: 

For additional assistance, please contact a staff member from the MDHHS Behavioral Health and Developmental Disabilities Administration:

Brie Elsasser
Autism Behavioral and Transition Specialist
Email: ElsasserB@michigan.gov
Phone: (517) 373-7289

Linda Fletcher
Autism Medical Specialist
ASD/DD HRSA Grant Project Coordinator
Email: FletcherL@michigan.gov
Phone: (517) 373-9018

Morgan VanDenBerg
Autism Behavioral and Early Childhood Specialist
E-mail: VanDenBergM@michigan.gov
Phone: (517) 373-1813

 

Citations

Autism Coverage Reimbursement Act. MCL §550.1835 – 1837. 2012.
http://www.legislature.mi.gov/documents/2011-2012/publicact/pdf/2012-PA-0101.pdf (accessed 9/19/14).

O.I. Lovaas. Teaching Individuals with Developmental Delays: Basic Intervention Techniques (Austin, TX: PRO-ED Inc., 2003).

The National Standards Project (NSP) is a program that compiles and reviews the research on evidence-based behavioral and educational treatments for individuals (below 22 years of age) with ASD. The NSP was developed by the National Autism Center in conjunction with national experts, and is used by some insurers to guide coverage policies. NSP is also used by some parents, educators, and providers to develop informed treatment decisions.

Jimmy, a 5 ½ year old boy with autism, was transitioning to kindergarten. This non-verbal child with a hyper-reactive sensory system would be leaving our self-contained university-based preschool special education program and heading back to his home school district. For about a year, Jimmy had been spending part of his week in a private general education preschool classroom with the support of our staff.  This opportunity to learn alongside his typically developing peers enhanced his engagement and play skills. Buoyed by the power of inclusion, Jimmy’s parents were strong proponents of his inclusion in a general education kindergarten classroom in his school district. The staff in the district knew Jimmy’s diagnosis and had observed him squeezing his arms and making loud “eee” sounds frequently throughout the day. They knew Jimmy as a child with autism and they did not agree with the placement in a general education kindergarten classroom.

This push back about including Jimmy is understandable when you examine the international research literature on teacher’s beliefs about including students diagnosed with autism. Teachers believe that students with autism require the most significant accommodations and are substantially more difficult to include in general education classes than students with other disabilities (Cook, 2001; Sansosti & Sansosti, 2012; Stoiber, Gettinger, & Goetz; 1998). The literature also reveals that general education teachers—both pre-service (Barned, Knapp, & Neuharth-Pritchett, 2011; Busby, Ingram, Bowron, Oliver, & Lyons, 2012; Doody & Connor, 2012) and in-service (Cook, 2001; Humprhey & Symes, 2013; Lindsay, Proulx, Thomson, & Scott, 2013; Stoiber et al., 1998; Teffs & Whitbred, 2009) believe they lack adequate understanding of students with autism. Finally, the two diagnostic criteria for autism (repetitive, unusual behaviors and challenges with social communication) are the characteristics that general education teachers find most challenging (Al-Shammari, 2006; Arif, Niazy, Hassan & Ahmed, 2013; Busby et al., 2012; Drysdale, Williams, & Meany, 2007; Helps, Newsom-Davis, & Callias, 1999; Humphrey & Symes, 2013; McGregor & Campbell, 2001; Robertson, Chamberlain, & Kasari, 2003, Rodriguez, Saldaña, & Moreno, 2012; Segall & Campbell, 2012; Teffs & Whitbred, 2009).

These types of beliefs impacted the district’s decision to support Jimmy’s transition to a general education classroom.  Our interdisciplinary team as well as Jimmy’s parents had worked collaboratively for two years so that we could understand Jimmy and attune to his internal state rather than his overt behaviors (Schore, 2001). Using transdisciplinary practices we had focused on developing Jimmy’s capacity to experience, regulate (manage), and express emotions; form close and secure interpersonal relationships; explore and master the environment and learn. So how were we going to share all of this information?  How could we turn this transition into a teachable moment for the staff in the school district?

At that time, I was enrolled in an infant mental health certificate program and was immersed in reading seminal pieces that used first-person narrative to help the reader gain an enhanced understanding of the child’s internal life (Fraiberg, Adelson & Shapiro, 1975; Carter, Osofsky & Hann, 1991; Stern, 1990). I decided to use this strategy to help the district’s team attend to the numerous sensory, motor, and affective behaviors in a way that might allow them to think about why Jimmy was or was not doing something, or how he might be feeling when he was not engaged. A few days before the transition-planning meeting I wrote a profile of Jimmy from his perspective as I, my teammates and Jimmy’s parents understood it.

Hello, my name is Jimmy and I’m 5 and ½ years old.  I can’t make too many words to communicate with other people and this is very frustrating for me because I know a lot of things and have ideas about what I want to do.  Sometimes I will look at someone, point to an object or nod my head to tell others that I need something or to answer a question.  I’m getting better at using pictures and a few words to stand for ideas in my head. 

When people ask me questions and I can’t respond it makes me feel uncomfortable. Many times I have to grab my arms, squeeze my body and make a loud “eee” sound when I feel like this.  I usually need help answering the questions or at least I need a choice of pictures so I can show them my answer. 

I feel better when I get to do things with my body like jumping, climbing or crawling before I have to sit down to work or to be part of a group.  It makes my body feel calmer and I feel like I am stronger and can do more things with my hands and fingers.

I am most comfortable when things are familiar to me and I know what is going to happen next.  For example, I know that after I play in the morning we will have circle time.  Then I will wash my hands and sit at the table for snack. Sometimes things change.  It really helps when people tell me and show me what will be different.  They usually use the picture schedule.  When things are really different and nobody tells me ahead of time I get scared and confused.  I might cry or fall down or kick.  I might even go to the window and look outside.  I need to get away from everything that is confusing me.  I really don’t know what to do or how to tell people how confused I am. 

 I really love writing my name on things I have made; it shows everyone it is mine.  It helps when people remind me to write darker or when someone puts boxes on the paper for each letter.  I like letters and I know them all and can even put them in alphabetical order.  I can read some words like my classmates’ names.

 I like being around other kids my age.  It is fun to watch what they are doing.  Sometimes I even try to copy them but lots of times I can’t do that by myself.  I want to tell them, “Please understand me and slow down.  I am trying really hard and I want to learn.”

 Jimmy was included in a general education kindergarten where his parents used this profile to explain Jimmy to his classmates and their parents. They helped all the new people in Jimmy’s life look at his behaviors through a lens of understanding rather than through the lens of autism. Similar to our interdisciplinary team, his new teachers worked hard to understand Jimmy’s hyper-reactive sensory system and delayed motor planning as the sources of his “unusual” behaviors and limited verbal communication. Over the years I have used this exercise of writing first person profiles of young children as a transition tool for schools, as the foundation of a parent workshop series and as part of my teaching in the field of teacher education (Catalano, Hernandez & Wolters, 2002).

This reframing is theoretically grounded in the work of Stanley Greenspan (2006) and is currently part of the brilliant Self-Reg™ framework developed by Stuart Shanker (2015) which is a practical paradigm through which parents, teachers and other allied professionals can better understand children as well as themselves (www.self-reg.ca). Adults with autism who are able to communicate are helping us think differently about young children who struggle with social communication and have repetitive patterns of behavior (Fleischman & Fleischman, 2012; Grandin & Panek, 2013). Rather than viewing a child’s behavior as a criteria for a diagnosis, early childhood professionals and parents must wonder about what each behavior tells us about a child’s inner life.  Many voices are asking us to inquire within each unique individual and reexamine how we understand autism (Donvan & Zucker, 2016; Hamlin, 2016; Prizant, 2015; Whitman, 2004; Silberman, 2015).

For more information visit the Center for Autism and Early Childhood Mental Health at Montclair State University.

References

Al-Shammari, Z. (2006). Special Education Teachers’ Attitudes Toward Autistic Students in the Autism School in the State of Kuwait: A Case Study. Journal of Instructional Psychology, 33(3), 170-178.

Arif, M.A., Niazy, A., Hassan, B. & Ahmed, F. (2013). Awareness of Autism in Primary School Teachers. Autism Research and Treatment, 2013, 1-5. doi: 10.1155/2013/961595

Barned, N. E., Knapp, N. F., & Neuharth-Pritchett, S. (2011). Knowledge and attitudes of early childhood pre-service teachers regarding the inclusion of children with  autism spectrum disorder. Journal of Early Childhood Teacher Education, 32(4), 302-321. doi: 10.1080/10901027.2011.622235

Busby, R., Ingram, R., Bowron, R., Oliver, J., & Lyons, B. (Winter 2012). Teaching elementary children with autism; addressing teacher challenges and preparation needs. Rural Education, 27-35.

Carter, S.L., Osofsky, J.D., & Hann, D.M. (1991). Speaking for the baby: A Therapeutic intervention with adolescent mothers and their infants. Infant Mental Health Journal, 12 (4), 291-301.

Catalano, C.G., Hernandez, P.R., & Wolters, P. (2002). Who am I?: A child’s self-statement. Exceptional Parent Magazine, April, 60-65.

Cook, B. G. (2001). A comparison of teachers’ attitudes toward their includedstudents with mild and severe disabilities. The Journal of Special Education, 34(2), 203-213. doi: 10.1177/002246690103400403

Donvan, J. & Zucker, C. (2016). In a Different Key: The Story of Autism. New York, NY: Crown Publishing.

Doody, O. & Connor, M.O. (2012).  Influence of teacher practice placement on one’sbeliefs about intellectual disability: a student’s reflection. British Journal of Learning Support, 27 (3), 113-118. doi: 10.1111/j.1467-9604.2012.01523.x

Drysdale, M. T. B., Williams, A., & Meany, G.J. (2007). Teachers’ perceptions ofintegrating students with behavior disorders: challenges and strategies, Exceptionality Education Canada, 17(3) pp.35-60.

Fleischman, A. & Fleischman, C. (2012). Carly’s Voice: Breaking Through Autism. New York, NY: Touchstone/Simon & Schuster.

Fraiberg, S., Adeleson, E. & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problem of impaired infant mother relationships. Journal of the American Academy of Child Psychiatry, 14, 387-422.

Grandin, T. & Panek, R. (2013). The Autistic Brain: Thinking Across the Spectrum. Arlington, TX: Future Horizons.

Greenspan, S.I. & Wieder, S. (2006). Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate and Think.  Cambridge, MA: A Merloyd Lawrence Book.

Hamlin, T. (2016). Autism and the Stress Effect: A 4-Step Lifestyle Approach to Transform Your Child’s health, Happiness and Vitality. Philadelphia, PA: Jessica Kingsley Publishers.

Helps, S., Newsom-Davis , I. C., &  Callias, M. (1999). Autism: The teacher’s view. Autism, 3: 287-298. doi: 10.1177/1362361399003003006

Humphrey, N. & Symes, W. (2013). Inclusive education for pupils with autistic spectrum disorders in secondary mainstream schools: teacher attitudes, experience and knowledge. International Journal of Inclusive Education, 17(1), 32–46. doi:10.1080/ 13603116.2011.580462

Lindsay, S., Proulx, M., Thomson, N. & Scott, H. (2013). Educators’ challenges of including children with autism spectrum disorder in mainstream classrooms. International Journal of Disability, Development and Education, 60(4), 347-362. doi:10.1080/ 1034912X.2013.846470

McGregor, E., & Campbell, E. (2001). The attitudes of teachers in Scotland to the integration of children with autism into mainstream schools. Autism, 5, 189-207. doi: 10.1177/1362361301005002008

Prizant, B.P. (2015). Uniquely Human: A Different Way of Seeing Autism. New York, NY: Simon & Schuster.

Robertson, K., Chamberlain, B., & Kasari, C. (2003). General education teachers’ relationships with included students with autism. Journal of Autism and Developmental Disorders, 33(2), pp. 123-130.

Rodríguez, I. R., Saldaña, D. and Moreno, F. J. (2012). Support, inclusion and special education teachers’ attitudes toward the education of students with autism spectrum disorders. Autism Research and Treatment, 1-8. doi:10.1155/2012/259468

Sansosti, J.M., & Sansosti, F.J. (2012). Inclusion for students with high-functioning autism spectrum disorders: Definitions and decision-making. Psychology in the Schools, 49(10), 917-931. doi: 10.1002/pits.21652

Schore, A. (2001).  Effects of a secure attachment relationship on right braindevelopment, affect regulation, and infant mental health. Infant Mental Health Journal. Michigan Association for Infant Mental Health, 22 (1-2), 7-66.

Segall, M.J., & Cambell, J.M. (2012). Factors relating to education professionals’ classroom practices for the inclusion of students with autism spectrum disorders. Research in Autism Spectrum Disorder, 6, 1156-1167.  doi: 10.1016/j.rasd.2012.02.007

Shanker, S. (2015). www.self-reg.ca.

Silberman, S. (2015).  NeuroTribes: The Legacy of Autism and the Future of Neurodiversity. New York, NY: Penguin Random House.

Stern, D.N. (1990). Diary of a Baby. New York: Basic Books.

Stoiber, K. C., Gettinger, M., & Goetz, D. (1998). Exploring factors influencing parents’ and early childhood practitioners’ beliefs about inclusion.  Early Childhood Research Quarterly, 13(1), 107-124. doi: 10.1016/S0885-2006(99)80028-3

Teffs, E., & Whitbread, K. (2009). Level of preparation of general education teachers to include students with autism spectrum disorders. Journal of Current Issues in Education,12(10), retrieved from http://cie.asu.edu/ojs/index.php/cieatasu/article/view/172/4. Date accessed: 01 Jul. 2014.

Whitman, T.L. (2004). The Development of Autism: A Self-regulatory Perspective. New York, NY: Jessica Kingsley Publishers.