The Infant Crier

Month: April 2017

  • Substance Abuse is at Epidemic Proportions: Perspectives from an Early Head Start Worker

    Substance Abuse is at Epidemic Proportions: Perspectives from an Early Head Start Worker

    My name is Wintra Cain. In case you were wondering, I was born in a blizzard, that’s how I got my name. I am currently employed as an Early Childhood Specialist for the Early Head Start program in Hillsdale County, Michigan. I have a Bachelor of Science degree in Psychology with an Infant Mental Health endorsement, level II. I have been working as a home-visitor with children and their families for the past 16 years. I am very grateful for the topic of discussion in this month’s Infant Crier. Substance abuse is very near and dear to my heart.

    Brent was attending a party at a home he had never been to before. He had just finished “smoking a boat” of meth, in the early morning hours of June 3rd when he encountered a 24 year old man, Zao, whom he had never met before. It was said in court that Zao had been “tweaking-out” on meth and hadn’t slept for the previous 3 nights. That morning around 4 a.m., Zao pulled out a 45 caliber handgun, pointed it at Brent and shot him in the chest. The bullet pierced Brent’s heart and lung, exited his back and traveled through the dining room wall by which he was standing. The police never found the bullet.

    This is not a story about a family on my caseload. This is my story. All of this took place while I was sleeping warmly in my bed. Brent was my brother.

    My life was turned upside-down for a period of time. No one in my family had any awareness that my brother was involved in using hard drugs. I knew he had used marijuana more than a time or two, but never in a million years would I have imagined him using methamphetamine. I was aware, however, that he had previously suffered from an addiction to alcohol which seemed to become solidified while serving in the Marine Corps. Brent came to our mother one day pleading for help. My mom shared with me that she had been praying for that day for quite some time. She willingly and lovingly agreed to take money out of her shallow retirement account in order to fund my brother’s stay at a rehabilitation clinic in Florida. He successfully graduated from the clinic and as far as we knew, he had stopped using alcohol. Unbeknownst to us, somewhere along the way, he must have picked up a fondness for another kind of high.

    My brother was very intelligent. He graduated with a degree in computer science, with honors, although he would have never told you that. He was sensitive, young, handsome and most importantly he was kind. He would always be the first to lend a hand, or some money, or literally the boots off his own two feet, as one of his friends shared with me. Brent would pretty much do anything for anybody. He had so much life left to live.

    I openly share this story in hopes that someone may benefit from it. As a home-visitor, I have had the privilege of working with numerous families. Many of which have borne the burden and the ramifications of substance abuse.  What I have learned is that substance abuse does not discriminate and has devastating consequences, consequences that reach far beyond those who have been directly impacted.

    I have observed a most significant increase in the use and abuse of substances in the families I serve on my Early Head Start caseload. Each of these families, of which I am currently serving, report having been directly or indirectly affected by the use or abuse of substances, ranging from the seemingly innocent use of alcohol, to the controversial use of marijuana, to the abuse of street and prescription drugs.

    This past summer, while I was at a home-visit, a relative in the home overdosed in the bathroom while I was outside working with the children. Yet another family I serve, a foster family, tragically lost the life of the baby’s biological mother because of a heroin overdose. A third young mother on my caseload, battling substance abuse, voluntarily terminated her rights to her very young children. This past spring, a fourth mother had her children removed from her home, due to substance abuse issues. She is currently working toward reunification. A fifth parent I serve lost her cousin, just last week, due to an overdose. The list continues to grow.

    I would like to share with you a little about Ann, a 38 year old mother, on my caseload. She came to me in September 2016. On my first phone call with Ann, she stated she had been staying at a local domestic violence shelter. She had been in an abusive relationship with her unborn baby’s father and was 33 weeks pregnant by him. She had no home, no job and no transportation. She told me she had been praying to God for help and that God had answered her prayers with my phone call. I could hear the enthusiasm in her voice via the phone receiver.

    She shared with me that she was the mother of 3 children, Ava, a girl age 12, Greg, a boy age 11 and Chase, a boy age 4. Ann did not have custody of them. Ava and Greg lived with their father’s mother and Chase lived with his father’s grandmother. Ava’s and Greg’s father was in a sobriety house up north and Chase’s father was in prison due to substance abuse and domestic violence charges. Ann relayed she was eager to secure permanent housing so that she might be able to get Chase back. She stated she was especially concerned about Chase because his great grandmother was elderly and not able to care for him properly.

    As I was already feeling overwhelmed by the enormity of Ann’s needs, at our first visit, Ann admitted to her own history with substance abuse. She stated she had previously used Heroin, OxyContin and Vicodin, but had been clean for more than 11 months. She stated she was no longer interested in the unhealthy lifestyle she had been living and quit using substances on her own, but with God as her guide. She remained steadfast in her beliefs and her ability to move beyond her previous life of substance abuse and dysfunctional relationships with men. She stated “Everyone I know, friends and family are abusing substances, so I had to cut ties”.

    In October, Ann mentioned having thoughts of giving her unborn baby up for adoption, due to her lack of housing. She stated “I can’t envision taking my baby with me from home to home, place to place, living on floors and couches.” We spent a few visits talking about her thoughts and feelings regarding the possibility of adoption, after which she decided to keep her baby. She stated “I realized that all this baby really needs is me.”

    Mother and daugherAnn gave birth to a healthy baby girl, Kay, in November 2016. I have observed Ann to be warm, responsive and nurturing toward Kay. Kay, thus far, seems to be developing typically for her age. Ann reports that Kay brings so much happiness to her life. Ann is attending a local church which has afforded her the opportunity to build a new circle of support. Additionally, she has established a rapport with the people from the domestic violence shelter, in which she has been residing since September. She is currently on the cusp of securing housing, largely due to her persistence and determination, as well as the assistance of Community Action Agency’s housing specialist. Ann most recently obtained a job at a local fast food restaurant. She voiced her excitement to me during a visit. She told me she never thought she would be able to work with money again, due to a blemish on her criminal record.

    Ann meets with me regularly as we continue to work on building a rapport with one another. She seems thoroughly interested in the program. She openly shares with me bits and pieces of her childhood history. She confided in me that she felt like her mother never really loved her.

    It’s amazing what this young woman has been able to accomplish. When she gets knocked down, she stands back up. She seems to be overcoming hurdle after hurdle, obstacle after obstacle. I am in awe of her. She has refused to give up and keeps on fighting, fighting for a better life, for her and for her children. She doesn’t have much, but what she does have is faith and I have faith in her.

    It seems many people mistakenly think that those who use drugs lack morals or values or are just “bad” people. Addiction affects people from all walks of life and is a very complex issue. Drugs change brain chemistry which makes quitting very difficult. With proper treatment, however, people can recover and are able to lead productive lives.

    Prevention is the key. As Infant Mental Health (IMH) professionals, given our experience and expertise, we can be an invaluable tool in working with children and their families. Children’s earliest interactions occur within the family. As IMH professionals, working in the home, we are on the frontlines. We are given the opportunity and have the ability to help facilitate a strong bond between parent and child, increase parental involvement in their child’s life, help parents learn the importance of positive discipline, setting clear and consistent boundaries, as well as help in the early identification of developmental or mental health concerns.

    However, further, more-extensive training is needed to address the issue of substance abuse, as well as having greater access to prevention and treatment interventions and facilities. Increased funding is imperative in order to serve all populations of people. Universal services are warranted here. If communities and families are able to intervene early, mental health disorders such as substance abuse might be addressed before the end result is tragedy.

    Strangely, in the midst of writing this article, something unbelievable happened. I received notice that my sister-in-law had been attacked at a restaurant in a nearby town. It was dinner time, around 5 p.m. and in broad daylight. As she entered the front door of the restaurant, an unknown man rapidly approached her and began to assault her, punching her in the face and neck in an attempt to retrieve her purse she was wearing across her body. Fortunately, the employees at the restaurant acted quickly, without hesitation and came to her defense and were able to fend-off her attacker. She was later informed by the police that this man was a frequent offender and he too had been high on meth. Thankfully, she received only minor physical injuries to her face and neck, but I am certain the reverberations of this incident will undoubtedly last a lifetime.

    We can no longer afford to “turn a blind-eye” to the life or death consequences of substance abuse. Substance abuse has, by far, reached epidemic proportions and is taking its toll on our communities. It’s time to take a long, hard, look at ourselves and our communities and ask how we might make a difference. As an Infant Mental Health professional, I am acutely aware that human connection has the capacity to change the trajectory of a life. In thinking about Ann, I remain hopeful that even the smallest interactions amongst people can hold power and meaning and can be transformative.

    “We never touch people so lightly that we do not leave a trace.”- Peggy Tabor Millin

    Response from a Supervisor: Kathryn Sims, M.A., LMSW, IMH-E®

    Wintra Cain, an Early Childhood Specialist with Early Head Start, has described an experience in a client family’s life that parallels an experience in her personal life. Substance abuse permeates our society. It knows no socio-economic boundaries. No boundaries of race, religion, or culture…Few of us are untouched by the substance abuse epidemic.

    As substance abuse has increased in the general population, it has become prevalent in many families involved in in-home infant mental health services. Wintra has shared with us how she used her experience to help her understand what her client, “Ann” experienced. Wintra knows there can be ups and downs; however, she is there to support “Ann” during these up times and will be there to catch this rising star if she stumbles.

    For Wintra, substance abuse touched her heart. She looked through a very personal set of glasses colored by her brother’s experience and death; and another set colored by substance related experiences with other families on her case list; and another set colored by her sister-in-law’s experience being attacked by someone who was on drugs. We all wear emotionally and experience-based glasses. Do they bring things in to focus? Are they rose colored blocking out other colors? Do they dim our vision so we cannot truly see the family sitting on the floor with us? When these thoughts come to mind, share them with your reflective supervisor.

    We cannot “turn a blind-eye” to the life and death consequences of substance abuse. We cannot “turn a blind-eye” to any of the experiences that clear or cloud our vision. Some are so internal that they are second nature and we are surprised when a parent or child shows us how things are for them. We get our “come uppence” when families show us another side, another angle, or another view. Our perspective is widened.

    Substance abuse has touched Wintra in many ways. She leaves us wondering not only about how substance abuse may have touched us, but what else touches us and changes our perspective consciously or unconsciously.

    As a reflective supervisor, I give new therapists a multi-sided dice. Each side represents aspects of any particular family. No matter from what angle one looks at a dice, one sees only what is facing the front. On a 24 sided dice, more than 12 sides are not visible, but are part of the story. “Ann” revealed that she had a substance use history – another angle came into view. “Ann” revealed that she had been clean for 11 months-another angle came into view. “Ann” revealed that she had faith –another angle came into view. And so her story goes…with Wintra beside her family.

  • Perinatal Substance Use: An Update and Reflection on the Importance of Relationship

    Perinatal Substance Use: An Update and Reflection on the Importance of Relationship

    The mother-baby dyad is a beautiful yet vulnerable miracle of humanity that has tremendous potential to shape how infants will grow to view themselves, their relationships and the world. While birth and mothering are joyful events, substance use and addiction can complicate the time surrounding pregnancy and birth with guilt, shame and fear and may disrupt this dyadic process of attachment.1 This article: a) briefly discusses perinatal substance use, with a focus on prenatal opiate exposure and the potentially resulting neonatal abstinence syndrome (NAS), and b) suggests a broad relationship-based approach be embraced by care settings across the perinatal continuum, from inpatient and outpatient clinical areas to community support resources.

    The Recent Landscape 

    Perinatal Substance Use Disorder (PSUD) is a pervasive disease process with far-reaching consequences for women, children, families and communities. Nearly 3 decades ago, maternal crack/cocaine use and the term crack babies led the headlines, with potentially one in ten women between 15 and 30 years of age using cocaine regularly.2  Additionally, Schafer describes, with the behaviors of an infant who is withdrawing from cocaine and a mother who is suffering the addiction, a cycle that is set into motion of “interactional difficulties which would give even the most experienced mother grave problems.”2

    More recently, a significant increase in perinatal opiate dependence and addiction has occurred, either through prescribed or illegally obtained painkillers or narcotics. According to the 2015 National Survey on Drug Use & Health, substance use in pregnancy occurs commonly with 5.3% of pregnant women reporting using “any illicit drug,” 4.1% reporting using marijuana, 1.1% reporting using prescription opiates or painkillers, 0.3% reporting using cocaine and 0.2% reporting using heroin, although these self-reports are likely to be underestimates because of the stigma associated with drug use in pregnancy.3 Of all these drug exposures, newborns who are opiate exposed are most likely to have birth complications, withdrawal and lengthy hospital stays. Specifically, these newborns often experience neonatal abstinence syndrome (NAS), which is a grouping of central nervous, respiratory and digestive system responses to drug withdrawal upon the infant’s separation from the mother’s blood supply at birth.4 Symptoms include extreme irritability; poor sleep; tremors; hypertonia and frantic, uncoordinated sucking. The physiologic symptoms of NAS can also include sneezing, emesis, diarrhea, tachypnea, nasal stuffiness and possible seizures.4

    The way the professional (doctor, nurse, home visitor, human services worker) treats the mother impacts how she feels about herself and affects her ability to care for her baby.

    From 2000 to 2009, NAS in the United States increased from 1.20 to 3.39 per 1000 hospital births; more recent data suggest a five-fold increase in NAS nationally to nearly 6 per 1000 hospital births, or about one birth every twenty-five minutes experiencing NAS.3

    In Michigan, between 2000 and 2009, there were a total of 1509 infants hospitalized with a diagnosis of NAS. Furthermore, the rate of NAS among Michigan infants increased dramatically “from 41.2 to 289 per 100,000 live births from 2000 to 2009, representing a 601% increase.”5

    Regional perinatal care providers and addiction specialists agree, anecdotally, that current trends have continued with staggering increases in NAS care provided across the state.

    NAS and Attachment Considerations

    NAS can appear as quickly as 24 hours after birth with heroin exposure or as late as 72 to 96 hours after birth with opiate, methadone, or buprenorphine exposure.4 With the onset of NAS, infants are treated in the hospital with close monitoring, comfort measures, supportive care and, perhaps most importantly, with pharmacologic therapy such as methadone or morphine. This lengthy, costly and often uncomfortable process of weaning can demand weeks to months of care in the hospital and likely in a neonatal intensive care unit (NICU) or specialized inpatient pediatric care unit.6

    With the complexities of drug use and PSUD in new mothers, coupled with the separation and fear associated with the NAS clinical course, it is not surprising that many authors note the potential for insecure attachment and relationship challenges between mothers and their infants.1, 7, 8  Attachment within the maternal-infant dyad can be impacted by multiple factors, such as the mother’s past relationship experiences, the mother’s feelings about being a mom, how the mother was cared for as an infant and the mother’s feelings about her birth experience. Therefore, it is clear that drug use and PSUD are severe risk factors to maternal functioning, infant physical and emotional health and the attachment process.

    Hope and New Beginnings 

    Women experiencing PSUD have a chronic brain disease that is well supported in the literature, where relapse is common and expected.9 However, McLellan et al. note that successful treatment with PSUD is comparable to, or better than, compliance with treatment plans for other chronic conditions such as hypertension, diabetes and asthma. Pregnancy and birth promote hope and new beginnings; these elements may play a role in better treatment outcomes during pregnancy and the early postpartum period. As such, a mother experiencing PSUD once explained that she wanted a future for her baby that was different from her own reality; additionally, she stated that her motivation for change was greatest in pregnancy and during her child’s infancy. Therefore, the perinatal and newborn period must be leveraged with optimal care and support for those affected by PSUD and NAS. This care should be provided nonjudgmentally, with compassion and empathy.

    baby011_close upHealth professionals are generally in agreement on the need for physical treatment of NAS and addiction treatment for mothers; likewise, social service entities are clear on the need to ensure immediate protection and safety for newborns. However, what is often lacking in the maternal-infant continuum of care from hospital and healthcare settings to community agencies is a common language and paradigm that seeks to initiate an intentional parallel process of relationship-based care provided to the mother, so as to galvanize the mother to connect and optimally care for her baby. Simply stated, the way the professional (doctor, nurse, home visitor, human services worker) treats the mother impacts how she feels about herself and affects her ability to care for her baby. “It is only when a mother’s emotional needs are considered and supported, that she will be able to attend to her infant’s emotional needs.”10 By broadening the infant mental health (IMH) practice framework across care settings and disciplines, as well as throughout transitions of care (ie, from inpatient to home), a consistent approach to relationship-based care could be realized and used to strengthen the recovery capital of the mother.

    One example of this type of multidisciplinary approach is in Northern Michigan, where IMH, health department, hospital, human service, intermediate school-based, tribal and foster care/adoption entities have formed to create an IMH Training Consortium. This consortium works to provide staff and supervisors across the region with training opportunities 3 times each year that focus on relationship-based principles and attachment concepts that can be applied from beginner to specialist. Further, hospital and health department nurses, alongside child protection workers and other agency representatives, are learning the impact each professional can have using IMH principles of parallel process, holding and relationship-based care, even in one home visit or an 8-hour hospital shift.

    In practice, this IMH-informed approach to care has strengthened the way mothers and infants experiencing NAS are cared for in one local hospital. When a baby who is in the hospital with NAS has been stabilized medically in the NICU, the mother and baby are transferred to a unit with private rooms and rooming-in for parents to care for their infant while being mentored and supported by hospital staff. While the baby is medically managed, nurses and social workers are also intentionally nurturing the mother with education on NAS, support, encouragement and meals. This is an example of parallel process in a hospital setting, and it provides an opportunity to strengthen the relationship within the mother-baby dyad. Furthermore, it has been found that the duration and severity of NAS can be reduced through maternal skin-to-skin contact and breastfeeding.11 By helping the mother learn her baby’s cues and encouraging her to be present as the most important primary caregiver in the hospital, she may begin to see what a difference she can make in her baby’s recovery.

    In closing, collaborative, cross-disciplinary IMH informed training and practice frameworks that are steeped in relationship-based principles can benefit mothers and babies affected by PSUD and NAS. The way a mother experiencing PSUD is treated and her view of herself as being a capable (or incapable) mom will impact how her relationship and attachment with her baby develops. Even in a highly clinical hospital or specialized community setting, care providers can benefit from relationship-based education, so as to better encourage and promote mothers’ beliefs that they themselves are their babies’ best and most important medicine.

    References

    1. Bromberg SR, Frankel KA. Perinatal support in substance abuse: the requirements of relationship and reflection. Zero to Three. 2009;29:22-27.
    2. Schafer W. Cocaine: How it works, how it affects pregnancy, intrauterine development and the neonate. The Infant Crier. 1989; CD-ROM:352-354.
    3. National Institute on Drug Abuse. Dramatic increases in maternal opioid use and neonatal abstinence syndrome [Infographic]. 2015. https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-useneonatal-abstinence-syndrome. Accessed Feb. 15, 2017.
    4. Hudak M, Tan R. Neonatal drug withdrawal. Pediatrics. 2012;129:e540-e560.
    5. Michigan Department of Community Health. Neonatal drug withdrawal among Michigan Infants [Fact sheet]. 2011. www.michigan.gov/documents/mdch/NWS_FactSheet_final_6.25.13_431275_7.pdf. Accessed Feb. 16, 2017.
    6. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal Abstinence Syndrome and associated health care expenditures: United States, 2000-2009. JAMA. 2012;307:1934-1940.
    7. Parolin M, Simonelli A. Attachment theory and maternal drug addiction: the contribution to parenting interventions. Front Psychiatry. 2016;7:152.
    8. Porreca A, DePalo F, Simonelli A, Capra N. Attachment representations and early interactions in drug addicted mothers: a case study of four women with distinct adult attachment interview classifications. Front Psychol. 2016;7:346.
    9. McLellen AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: Implications for treatment, insurance and outcomes evaluation. JAMA. 200;284:1689-1695.
    10. Shirilla J. Personal correspondence.
    11. Knopf A. Experts: Baby’s mother is the best treatment for NAS. (2016). Child Adol Psych Update. 2016;18:1-4.
  • Reflections on MI-AIMH’s History

    Reflections on MI-AIMH’s History

    In 1970, there were no infant mental health home visitors in community mental health (CMH) agencies in Michigan. But there was a growing body of information about infancy that developed during the 1960s and a growing number of professionals across the country seeking to apply this information in various fields of human services. In Michigan, there was Selma Fraiberg, a social worker and lay analyst, establishing the Child Development Project, an atypical part of the University of Michigan Department of Psychiatry. In 1972, she received a federal grant to translate to mothers and infants “who needed to find each other” what she had learned from blind babies and their parents.

    Infant mental health home visiting in Michigan—as well as the Michigan Association for Infant Mental Health (MI-AIMH)—evolved from a simple request by Selma Fraiberg to the director of the Department of Mental Health in 1972. She wanted grant funds for graduate students. The director, a psychiatrist, was sufficiently intrigued to send me (as the staff member responsible for a small amount of federal funds for innovative services) to investigate. Appreciating the warmth and commitment of my hosts and convinced by their intriguing (if somewhat mysterious) videotapes, I returned to suggest that, in lieu of graduate students who most likely would not stay in Michigan, the Department fund training of staff already employed by Michigan community mental agencies, so that this new intervention could become part of the CMH service continuum. Selma’s staff overcame her reluctance.

    And so, in the fall of 1973, six clinicians from CMH agencies began bi-weekly trips to Ann Arbor to meet with Edna Adelson. Group 1 included two supervisors of children’s services, mid-level clinicians, and one newly minted professional. They observed a normally-attached infant and parent and were encouraged to share what they were learning about normal and aberrant attachment with their community colleagues. Seeking to understand the essence of the intervention, they revolted, demanding more clarity. They enrolled their first service families, having received from their public health colleagues referrals that were more problematic (according to Selma) than any served by the Child Development Project. They asked for, and received, a second year of training (1974–1975) from Vivian Shapiro.

    The next year, staff from another six agencies stepped forward for training and in 1978– 1979, an additional 11 trainees. We offered a unique training opportunity with no idea where it would lead. We just asked the participants to go back and put the knowledge and skills they were gaining into practice.

    With the loss of federal funding (newly contingent on an experimental/control design), in 1980 Selma closed the Child Development Project and departed for San Francisco General Hospital. Barry Wright and William Schafer stepped up as trainers. The initiation of a small state appropriation for prevention projects (sponsored by Representative Joe Young, Sr. in response to lobbying by Beth Leeson from the Mental Health Association in Michigan) provided grant funds to underwrite staff in additional CMH agencies.

    Over time, a series of state decisions institutionalized infant mental health home visiting, moving sites from project status to an integral part of CMH programming for children:

    • In 1986, Director Patrick Babcock determined that after three years, satisfactory projects would shift to ongoing funding for CMH agencies
    • In 1995, specifications for infant mental health home visiting were incorporated into the Medicaid Manual
    • In 2009, infant mental health home visitors were required to achieve MI-AIMH Endorsement at Level II (Level III preferred)

    Michigan Association for Infant Mental Health

    A significant factor in the development, maintenance and expansion of infant mental health principles and practice has been the presence and actions of the Michigan Association for Infant Mental Health.

    Happy baby with globe,isolated on a white background.

    MI-AIMH (then known as MAIMH) owes its existence to an obscure official at the University of Michigan who insisted that the first conference could not be held without an organizational sponsor. So, the first and second group of community-based clinicians, who had completed their training at Selma Fraiberg’s Child Development Project at the University of Michigan but wanted to share their excitement, created MAIMH. In a spirit of optimism and bravado, they named the conference “The first annual…” T. Barry Brazelton was the featured speaker and 800 people attended from all over the country (there were then no competing opportunities).

    The conference was the group’s second organized effort to carry out Selma’s dictum to “share what they were learning about mothers and babies with their colleagues.” (The success of the first effort—presentations by Edna Adelson and Vivian Shapiro in the basement conference room of the Ann Arbor Bank—led to the decision to undertake the broader effort.)

    And so was formed the first Board, with Michael Trout as President. For the first six years, Alice Carter (an infant mental health specialist in Washtenaw County from the first group of trainees) successfully planned and organized the annual conference, drawing over a thousand attendees in the second and third years.

    Struggling with organizational issues, MAIMH was discovered by academicians Hiram Fitzgerald (Michigan State University), Robert Boger (Wayne State University) and Thomas Horner (University of Michigan) who joined the Board. MAIMH gratefully accepted ownership of the Infant Mental Health Journal, which was created in 1980 and initially edited by Jack Stack, MD, from Gratiot County. Michael Trout became involved in the organization of the International Association for Infant Mental Health which morphed into the World Association (1992). Chapters were formed in metro Detroit and elsewhere in Michigan. Quarterly meetings for infant mental health home visitors were initiated, managed by Pat Rhea (Livingston CMH) and Sandra Greenwood (North Central CMH). MAIMH (later named MI-AIMH) issued its first publications and organized a video library.

    In 1982, Hiram Fitzgerald moved from board member to part-time Executive Officer, providing an address and space— initially in his office—for clerical support (Judy Reynolds Karandjeff, Dolores Fitzgerald, Suzie Pavick and Melanie Smith). From the beginning, MI-AIMH has emphasized publications, organizing information and sharing insights with others. The existence of MI-AIMH—providing a home for isolated practitioners, enhancing practice, creating credibility through its conferences and publications and demystifying the infant mental health approach—has been a significant factor in supporting infant mental health home visiting through the growth and development of the state program. MI-AIMH has uniquely encouraged grass roots practitioners to write of their experiences, to train and mentor others, to manage and grow a professional organization, to develop an Endorsement® process and to spawn a national organization, the Alliance for Infant Mental Health®. We await with anticipation its accomplishments in the next forty years!