Category: News

  • Leading Side-by-Side: How Shared Leadership Is Reshaping Power, Purpose, and Possibility at MI-AIMH

    Danie Rice, Joni Zieldorff, Stefanie Hill, Meghan Schmelzer, and Rebecca Wheeler

    Author Note: This article is written by a group of colleagues working within and alongside MI-AIMH. It reflects our collective learning and shared belief that leadership in infant and early childhood mental health must evolve in relationship, just as the field itself does. What follows is not a how-to, but a window into one organization’s ongoing journey—shaped by community, reflection, and care. By embracing co-leadership, MI-AIMH is learning how to lead with trust, center lived experience, and build a future rooted in shared power—even when it’s messy, even when it’s hard.


    A New Way of Leading Together

    At first glance, co-leadership might seem like a logistical solution—two people sharing a role, dividing up tasks. But at the Michigan Association for Infant Mental Health (MI-AIMH), it has become something much deeper: a bold and necessary reimagining of how power, care, and leadership are practiced.

    “At its core, co-leadership means sharing power, responsibility, and influence between two or more people,” explained Danie, one of MI-AIMH’s co-executive directors. “But we’re discovering that it’s also deeply rooted in vulnerability, equity, and caring for one another. It challenges the traditional ideas we’ve held about what it means to lead.”

    This isn’t just about two people at the top—it’s about shifting culture across the organization. Kristina Figaro, Chair of MI-AIMH’s Centering Equity Committee, sees this as part of a deeper organizational transformation:  

    “The way Danie and Joni lead together is a model for the kind of equitable and inclusive decision-making we’ve been advocating for in the field. It’s not just about shared power between them—it’s about making space for diverse voices at every level of the organization.”


    Rooted in Collective History 

    Shared leadership is not a new idea. For generations, communities—particularly those rooted in resistance and liberation work—have practiced collective leadership. Grassroots organizing, Black liberation movements, and Indigenous traditions have long centered leadership as a communal, not individual, endeavor.

    At MI-AIMH, this historical lineage is being honored through intentional practice. While Danie and Joni are the first to formally share the title of co-executive directors,  their leadership reflects the kind of collaborative spirit that has long defined the organization’s values.

    The spirit of collaboration has been a part of MI-AIMH since the formation of the organization. What began as a small grassroots network of passionate professionals, united by a shared commitment to the emotional well-being of babies, young children, and the adults who care for them, has grown into a nationally recognized organization. For nearly five decades, MI-AIMH has evolved in relationship with families, practitioners, and a broader, multi-sector community working in Infant and Early Childhood Mental Health (IECMH).

    The co-leadership model builds on this rich legacy—deepening an approach that has always centered care, humility, and a willingness to grow together.

    “Co-leadership gives us permission to say, ‘I don’t have to do this alone. I don’t have to be good at everything,’” Joni shared. It allows us to lean on one another, to rest, to reflect—and to lead from a place of honesty. 

    This honesty extends beyond leadership titles—it shapes how the entire organization shows up. Kandice Moss, Workforce Engagement Facilitator, reflected on how this approach empowers everyone:   “Because they are so intentional about listening, reflecting, and seeking input from all of us, we’ve grown more confident in bringing our ideas to the table.” 


    Expanding Perspective Through Collective Stewardship 

    Part of what makes this leadership model work is MI-AIMH’s commitment to learning—not just from within, but from voices beyond the infant mental health field. The organization regularly partners with business strategists, communications coaches, and other external consultants who bring fresh insight to critical areas like storytelling, sustainability, and long-term planning. For the first time in its history, MI-AIMH has also brought on a Chief Financial Officer to deepen its financial strategy and infrastructure.

    These investments reflect a powerful belief: that leadership is not meant to be carried alone. By inviting in outside perspectives, MI-AIMH models humility, clarity, and shared responsibility—leading not from ego, but in service of something much larger than any one role or person.


    Embracing Complexity with Care

    One of the myths many of us carry is that leaders must always have the answers. Co-leadership challenges that.

    “What happens when co-leaders have different answers?” Joni asked. We’ve had to learn to sit with that discomfort, to trust each other deeply, and to embrace the messiness. That messiness, we’ve found, is often where the most transformative learning happens.

    Leadership, in this model, is not about performance. It’s about practice. About showing up as our full authentic selves. 

    “Reflective consultation has been essential to our work,” said Danie. “It’s our place to process, to feel, to pause. It’s where we can be vulnerable—not just with each other, but with ourselves—and that helps us lead with more clarity and compassion.”


    Healing the Loneliness of Leadership

    Leadership can be isolating. Traditional hierarchies often place a burden of perfection and performance on those at the top. But shared leadership interrupts that pattern.

    “One thing we’ve learned is that co-leadership can actually be a powerful antidote to that isolation,” said Joni. We have someone to bounce ideas off of, someone who truly understands the weight of the work. That shared understanding doesn’t just benefit the leaders—it creates space for collective care.

    Now, staff meetings often begin with check-ins about joy, rest, and well-being—small practices that reflect deeper values. As Danie noted, “Rest is not a luxury. It’s a necessity. And our co-leadership model helps us hold that truth—when one of us needs to pause, the other can hold things down.” Something that Danie and Joni learned through their reflective consultation together. 

    This shift toward more humane leadership is part of a broader arc of transformation. Stefanie Hill, a respected leader and throughout partner within the  MI-AIMH community,  sees it as a continuation of legacy:  

    “The work Danie and Joni are doing now is a reflection of decades of work. Together, they bring the hope of creating spaces for all people, regardless of race or ethnicity.” 


    Looking Ahead: A Commitment to Becoming

    As MI-AIMH continues to evolve, Danie and Joni are committed to holding space for growth—not only for themselves, but for the organization and its mission.

    “This is not about perfection,” Joni said. “It’s about practice. It’s about learning. And it’s about showing up, again and again, for each other and for this work.”

    In the end, what’s emerging at MI-AIMH is not just a new leadership structure, but a new way of being in relationship—with each other, with power, and with the communities they serve.

    “We may not have all the answers,” Danie shared, “but we’re committed to listening, to reflecting, and to building something that’s real, together.” And in that shared commitment lies the potential for a future rooted in community care, where every individual is recognized, valued, and supported, and shared leadership becomes the standard, not the exception. 

  • Supporting and Connecting Those Who Care for Children to Early Intervention Services

    Supporting and Connecting Those Who Care for Children to Early Intervention Services

    Written with collaboration from her team!

    Young children grow and develop at different rates but generally will reach specific developmental milestones (social-emotional, language/communication, cognitive, movement/physical, and self-help) approximately around the same time. When a family or professional has a concern about a child’s development, resources are available to support a child and their family in reaching their full potential. Early On is Michigan’s system for helping infants and toddlers, birth to age 3 and their families, who have developmental delays and/or disabilities or are at risk for delays due to certain health conditions, including infant mental health disorders.  It is designed to help families find the social, health, and educational services that will promote the development of their infants and toddlers with special needs.  

    Mandated by federal legislation, this statewide system called Early On is otherwise referred to as Part C of the Individuals with Disabilities Education Act, (IDEA).  When talking about IDEA Part C and Early On services, you often hear the term “Early Intervention.” The purpose of early intervention is to enable young children to be active and successful participants during the early childhood years and in the future in a variety of settings — in their homes, with their families, in childcare, in preschool, and in the community.  Services are strength-based, family-centered, focused on parent and professional partnerships, provided in a natural environment and based on interagency collaboration.  Interagency collaboration between education and public health, for example, creates a sense of community ownership for supporting children and families and addressing their needs and strengths.  It also reduces duplication of services and allows for greater efficiency in the use of public resources.  

    Services are provided in a natural environment, which can be defined as any place a child and family lives, learns and plays.  This includes settings and activities that are normal for a child’s same-age peers in his/her community who have no disabilities or developmental delays.  

    Young children tend to thrive when they are in familiar surroundings with people and objects that are dear to them and when services are provided during everyday routines.

    An Early On provider supports this intervention through coaching parents/caregivers and early childcare providers.   

    In Michigan, Early On services are free to eligible children and their families. There are multiple ways an infant or toddler may become eligible for Early On, including the presence of a developmental delay or an established condition.  This also includes infant mental health conditions. Infants birth to 2 months qualify for Early On with any delay in development. Children 2 months to age 36 months are eligible with a delay of 20 percent or greater in one or more of the following areas of development: cognitive; physical, including gross and fine motor; communication; social/emotional; and self-care skills.  

    Another way to become eligible for Early On is to have an “established condition,” which is a diagnosed physical or mental condition that has a high probability of resulting in developmental delay.  Infants and toddlers with a diagnosed condition likely to result in a delay qualify for Early On under the category of Established Condition. View a list of conditions that indicate automatic eligibility for Early On supports and services here.  

    Established conditions must be diagnosed by a health care or mental health provider and documented in a medical record.  Mental health providers can diagnose infant mental health conditions that make a child eligible for early intervention.  These mental health conditions consist of the following:  adjustment disorders, depression of infancy and early childhood, diagnosed regulatory disorders, disorders of affect, maltreatment/deprivation disorder, mixed disorders of emotional expressiveness, and post-traumatic stress disorder (PTSD).  

    Some infants and toddlers in Early On with greater developmental delays may also qualify for services through Michigan Mandatory Special Education (MMSE). Eligibility for MMSE services is determined by the Michigan Administrative Rules for Special Education or MARSE. 

    A referral must be made to begin the eligibility process for children to receive Early On services.   Anyone can support a family in making the referral or by offering to make the referral with the family.  You do not need a referral from a physician to start the process.  Either way, the family should be aware and agree to the referral to ensure continued trust and relationship building.

    A referral should be made 

    • When a child isn’t reaching milestones
    • If an established condition exists or
    • When a parent expresses concern 

    Referrals can be made at www.1800earlyon.org or by calling 1-800-EARLYON. You can also contact the Early On coordinator at your county-level intermediate school district, https://eotta.ccresa.org/Contacts.php?id=1. You may want to familiarize yourself with the Early On referral form before talking to families. You can find the form at https://1800earlyon.org/online_referral.php. Families should hear from their local Early On program within 10 calendar days of receipt of referral. 

    Infant mental health clinicians and providers are in a unique position to notice if a child is not developing through typical stages or milestones.  If you have a concern about a child’s development, you have a responsibility to discuss your concerns with the family right away.  Getting intervention early can make a tremendous difference in the child’s quality of life and learning.  

    More than ever, professionals and parents of children with disabilities are being asked to work in partnership. 

    Professionals working with infants and toddlers must be courageous enough to have these sensitive conversations with families and learn to be effective in creating opportunities for children to thrive.  

    A key component to providing effective family-centered early intervention services is being culturally responsive and aware.  Sometimes, these conversations are difficult to initiate with parents. Janice Fialka, LMSW, ACSW is a nationally recognized lecturer, author, and advocate on issues related to parent-professional partnerships, and has put together a website, Dance of Partnership, to assist professionals and parents of children with disabilities in developing strong partnerships. In addition to the resources found on her website, here are several tips on how to talk to parents about their child’s development with cultural considerations at the forefront of your work:  

    Prepare yourself before talking to the parents.  If they speak another language, make sure to find a way to communicate through the language barriers before your first visit.  Here are a few suggestions:  1)  Collaborate with a trusted interpreter if needed. 2)  Consider hiring bilingual staff from some of the highest represented countries in your community.  3) Work with cultural brokers.  4)  Partner with community organizations/ networks to learn about specific cultures.  5)  Find ambassadors to help manage messaging and a culturally responsive approach to families (i.e.  The Immigrant & Refugee Resource Collaborative of Greater Lansing helps identify needs and optimizes opportunities for families new to the country, as well as those who have been here for generations). 

    Be mindful to keep the family as decision makers at the head of your conversation while being respectful of the culture, beliefs, customs and values of the family.  Recognize there are diverse family structures.  Strive to communicate in ways that inclusively support participation of family members.  

    Choose a time and place where you can talk alone with the parents or caregiver(s). Ask the family about their typical day and week and plan a good time to talk around their activities.  

    Strive to be culturally responsive and aware of the family’s personal cultures and values and to understand how these might impact intervention.  Be careful not to attribute behaviors to disability when they are considered developmentally appropriate within the culture of the family.  

    Give the “big picture” and focus on the child’s strengths and the milestones that they are meeting, not just on the deficits and developmental delays.  

    Put yourself in the parents’ shoes.  Realize that it is not easy to hear that your child may be falling behind.  

    Be sure to ask the parents for their perspective on the issue as well and reassure them that it takes time to feel confident and comfortable with the information being discussed.  Remind them you are there to assist them, and fully engage families in developing strategies. 

    Be prepared for a range of feelings from parents, yourself and others as raising children is complicated and feelings can be strong and unexpected, even from you as the professional.  

    Be open-minded and give them plenty of time to respond to your concerns.  

    Acknowledge that learning to handle strong emotions in yourself and others is an important skill.  

    Seek colleagues who will listen and provide the support that you need.  

    Be aware of your body language and that of the parents.  Ask yourself, “Am I communicating openness?”  Be mindful when people appear agitated or “louder.”  This can be a sign that they do not feel heard or understood.  Listen and ask more open-ended questions if this occurs.  

    Pay attention to the types of verbal and gestural cues that you use.  What is considered respectful differs across cultures.  

    Refrain from using jargon and ensure that the parents understand the terms you are using while consciously working to engage in cultural reciprocity.  The goal is that you can provide support that is in harmony with the beliefs and values of each family.  

    Don’t reassure parents too quickly that “everything is going to be fine,” as this can feel dismissive and shows a lack of understanding.  Remember that you do not have the power to fix the situation or take away the pain. 

    Lastly, pay special attention to and include the parent and family’s wishes for the child and remember to develop solutions and options with the family as a team. 

    The goal of early intervention and early childhood special education is to help parents and caregivers support their child’s learning and development using strategies that occur naturally during the child and family’s day.  Early childhood educators, including Infant Mental Health professionals, play a key role in ensuring that every child and family is aware of and has access to the resources, supports, and services that they need. “Don’t worry.  But don’t wait.”  You can be a key person in connecting families with a free screening or evaluation to see if a child is eligible for services through Early On.  To make a referral in collaboration with the family, complete an online form at 1800EARLYOn.org or call 1-800-EARLY ON (327-5966) today. 

  • Bringing awareness to our own relationship with play and exploring its influence on how we create play spaces with young children (3-6 years) and their parents/caregivers.

    Bringing awareness to our own relationship with play and exploring its influence on how we create play spaces with young children (3-6 years) and their parents/caregivers.

    Introduction

    Preschool play is complex and between the ages of 3 and 6 years, imaginative fantasies, narrative language and mentalization all begin to emerge (Davies, 2011; Luby, 2006; Meersand & Gilmore, 2018).  It is during this developmental period that play becomes one of the “primary mediums for communication, relationship building and therapeutic action” (Meersand & Gilmore, 2018, p. 11).  Given the clinical utility of play across multiple early childhood mental health interventions, it’s important to bring awareness to our relationship with play.  Reflecting on our own early childhood play experiences can deepen our understanding of the play experience and the role of others in play.  These reflections can help us gain insight into our work including how we create play spaces to facilitate relationships between young children and parents/caregivers.  

    Exploring Our Play Experiences

    Play is something we begin to experience in infancy and throughout our lifetime. When we play, we experience ourselves and others in different ways that can naturally lead to moments of trust, empathy, regulation, tolerance and/or resolutions.  One of my favorite quotes about play is “Play matters because people matter. It reminds us of our interdependence and gives us a chance to really see other people and, in turn, to be really and truly seen” (Vialet, n.d.).  One way to bring awareness to our relationship with play is to think about the context of our play experiences.  As a young child, where do we remember playing the most (e.g. home, school, neighborhood)?  How often did you play?  Who did you play with (e.g. siblings, parents, peers, others)?   When you think about these memories, take a minute to notice what you are feeling and where in body you are feeling this.  Keeping a journal to write (or draw) your reflections and sharing them with your reflective supervisor can be very helpful in this process.  In thinking about the play itself, did you have a favorite toy, game or other play memory?  Does your favorite memory include non-directive, directive or a combination of both types of play? You may also want to explore the process of play and how you participated in the play.  Did you take the lead in the play?  Were you comfortable taking the lead? How did others participate in your play? When others participated, did you feel seen and/heard?  When exploring these particular aspects, do you notice similar or different feelings than you had before.  If so, add these to your journal and/or artwork and again and/or share with your supervisor.      

    As you explore your play experiences, you may notice a cultural context to them.  In early childhood and throughout adolescence, our play can influence the development of our racial, ethnic, gender or religious identities (Davies, 2011; Meersand & Gilmore, 2018). Our cultural identities can also influence our play, and this includes the exploration of adult roles and social norms in sociodramatic play (Meersand & Gilmore, 2018). Additionally, our cultural identities can shape our play preferences, the time and space allotted for play and/or the availability of play partners (Gosso et al., 2013).  Individual and parent perception about the function of play (Izumi-Taylor et al., 2010) and parent and community investments (Roopnarine & Davidson, 2015) are also cultural aspects to consider. 

    Examining the cultural context of our play helps us to gain insight into the role that our identities have in shaping early childhood play experiences. 

    Given our identities change over time, it may be helpful to think about how our play stayed the same or changed later in childhood and adolescence.  


    Supportive Play Spaces in the Assessment Phase

    An increased awareness of our relationship to play and its cultural context can also generate understanding into how we create and facilitate supportive play spaces.  The assessment phase is often when we begin to bring toys and/or play into the clinical space.  It is important to talk with parents and provide psychoeducation about why we use play as a primary tool with young children ages 3 to 6 years.  It can also be helpful to explore the parent’s experience with play as part of the assessment.  We can ask the child, “What is your favorite toy or game?  We can ask parents if they “had a favorite toy, game or play memory from their childhood?”  Taking notice of what type of play the parent describes and if/how others were involved in the play can lead to other questions like, “Do you play the same game with your child or is there a different game that you like to play?”  These responses can help to assess the types of play the parent has experience with as a child and with their own children.  We can also begin to learn about the possible role of play within the parent-child or other relationship.  

    The use of non-directive/child-centered play in the assessment process is considered an evidenced-based practice (Mortenson & Mastergeorge, 2015).  These observations help clinicians to assess toy or play preferences, play skills (e.g. ability to lead or follow the play) and if/how the play facilitates parent-child interactions.  This can be set up by asking the parent and child to play together for a brief amount of time (maximum of 15 minutes).  A range of toys that facilitate interaction and imagination can be selected by the clinician and the play space can be established with a blanket or an area within the home.  During this time, the clinician’s aim is to observe unless asked to participate by the child or parent. Directive or structured play can also help to assess tolerance and other play skills such as permissiveness.  The toys and materials for these play activities may be different and require the clinician to structure the task and/or provide support throughout.  Processing the play with parents afterwards is very important to building the clinician-parent relationship. However, equally important is the need for you to reflect on your observations or experience being involved in the play.  Knowing your relationship to play will help in this process as you begin to identify what relationship and/or play supports may be needed. 

    Supportive Play Spaces in the Intervention Phase

    As we move into the intervention phase, we need to continue to be intentional about supporting and creating safe play spaces. After checking-in with parents each week, it can be beneficial to prep parents before the play session on the overall aim or focus of the play and their specific role (Farley & Whipple, 2017).  This allows parents/caregivers a space to ask play specific questions, practice play skills (if needed) and gain support for their role in the play process.  Research indicates that when check-ins include prepping parents for the play, it can increase parental engagement in sessions (Farley & Whipple, 2017). 

    Once the play session begins, we need to be aware of our presence within this process. 

    As previously highlighted by DeSchryver (2020), therapeutic presence can be defined as “…as having one’s whole self in the encounter with a client by being completely in the moment on a multiplicity of levels–physically, emotionally, cognitively, spiritually and relationally” (Geller & Greenberg, 2012, p. 7).  It can be difficult to be present while immersed in the playing state of a young child and equally focused on the centrality of relationships. 

    We often reflect on the child and parent’s presence in the play, but it can also be helpful to think about our presence and its potential impact on the play.  

    One way that we can monitor our presence is to reflect on some of the following elements outlined in a tool created by Yasenik & Gardner (2011) to monitor clinical use of self:   

    • Verbal Discussions:   The amount that you were involved in verbal exchanges and who led the discussion and if these discussions were in or outside of the play activity. 
    • Reflective Statements:  The amount that you tracked the play and/or providing reflective content on thoughts/feelings, decision-making, esteem or relationships.
    • Emotionality:  The amount that your responses reflected or mirrored the emotions of the child or parent (this includes voice tone, facial or body gestures or comments made to elaborate expressions). 
    • Physical Self:  The amount you engaged physically into the play, type of contact and level of energy.
    • Interpretations:  The amount you included soft hypotheses and used the play to test these hypotheses or the amount you pointed out a pattern or directly made interpretations to raise a matter to conscience awareness.

    Reflecting on these pieces can help to raise awareness of our play presence and its impact on the play and/or how it facilitates relationships.  Exploring these aspects with parents after the play may also help to increase their awareness into own presence and how they contribute and support the play process. 

    Summary

    Exploring our own play experiences can help us gain a greater awareness of our relationship to play. This awareness can deepen our understanding of our perceptions including the role of others in play.  Through this process, we can learn how play influences the development of our cultural identities and/or how our cultural identities shape our play.  These insights can ground our work and help us to create supportive play spaces that facilitate relationships. During the assessment process, we need to be intentional about gathering information about the child and parent/caregiver’s play experiences and facilitating play observations.  Observations can identify play strengths and areas of need, which allows us to identify specific ways we can help support parents/caregivers.  Within the intervention process, we need to work to actively engage parents/caregivers in the play process by providing psychoeducation and preparing parents/caregivers for each play session. Finally, we need to continually reflect on both our play and relational presence in order to begin “unpacking” the complexities of the parent-child relationships and meanings of play with preschool children and their parents/caregivers. 

    References

    • Davies, D. (2011).  Child Development: A Practitioner’s Guide. The Guilford Press. 
    • DeSchryver (2020, November 10).  The Critical Component in Providing Relationship-Based Services via Telehealth. The Infant Crier. Retrieved from https://infantcrier.mi-aimh.org/therapeutic-presence-the-critical-component-in-providing-relationship-based-services-via-telehealth/
    • Farley, J. & Whipple, E. E. (2017). Expanding Infant Mental Health Treatment Services to At-Risk Preschoolers and their Families Thought the Integration of Relational Play Therapy. Infant Mental Health Journal, 38(5), 669-679.  
    • Geller, S. M. & Greenberg, L. S. (2012). Therapeutic Presence.  American Psychological Association (APA) Publishing. 
    • Gosso, Y. & Carvalho, A. (2013). Play and Cultural Context.  Retrieved from:  https://www.researchgate.net/publication/304626147_Play_and_Cultural_Context
    • Izumi-Taylor, S., Samuelsson, I. P., & Rogers, C. S. (2010). Perspectives of play in three nations. Early Childhood Research and Practice, 12(1), 1–12.
    • Meersand, P. & Karen J. Gilmore (2018).  Play Therapy: A psychodynamic primer for the treatment of young children.  American Psychological Association (APA) Publishing. 
    • Luby, J. L. (2006).  Handbook of Preschool Mental Health.  The Gilford Press. 
    • Roopnarine, J. L. & Davidson, K. L. (2015). Parent-Child Play Across Cultures:  Advancing play research.  American Journal of Play, 7(2), 228-251.  
    • Yasenik, L. & Garner, K. (2011).  Play Therapy Dimensions Model: A decision guide for integrative therapists.  Jessica Kingsley Publishers.
  • Creating a safe haven to stop and feel for early childhood educators and young children

    Creating a safe haven to stop and feel for early childhood educators and young children

    Covid-19 exacerbated the already cracking foundation of our childcare and education systems in the United States, as parents grappled with childcare arrangements while attempting to balance the demands of work and home, children were witnesses to it all. This pandemic has left no one unscathed and that includes our infant and early childhood mental health (IECMH) workforce, the professionals of varying disciplines who have been tasked with caring for our little ones. 

    As a reflective consultant, I provide group reflective consultation to early childhood educators and the stories I’m hearing week after week in consultation are gut wrenching. As I work in earnest to provide emotional support and a holding container for the overflow of emotion that has been embedded in the bodies of educators, there is often a sense of being overwhelmed and feelings of defeat that permeate the air. 

    More than ever, I hear reports of early childhood educators feeling frustrated at the limited social emotional capacity of the children they work with. 

    There is a push to help children “catch up” without pausing to acknowledge what has slowed them down. 

    What happened to children over the last two years? What has happened within their family over the last two years? Furthermore, what has happened to our IECMH work force over the past two years? We have experienced collective trauma, and many have not taken a moment to process. We are moving from moment to moment in an effort to survive and very little space has been created to stop and feel. 

    Decades of research into child development have highlighted the role of trauma and toxic stress on the developing brain (Nelson et al., 2020).  Increased levels of ongoing stress, often referred to as toxic stress, can noticeably affect the developing brain of infants and toddlers. Changes in normal routines can be traumatic for very young children, particularly for children who don’t have an attentive caregiver who consistently responds to their needs.  Many people were out of work due to the pandemic and the financial ramifications have been significant.  The pandemic has intensified the housing crisis, food insecurity has rapidly increased, all the while rates of intimate partner violence and neglect have increased. Absence of concrete needs such as food, shelter, clothing, and medical care can make it difficult for caregivers to feed, nurture, and protect their children from harm (Weatherston, Ribaudo, 2020). For families of color, these issues are compounded by on-going systematic racism that inadequate access to resources. Adverse childhood experiences can have long-term implications for very young children.  

    In my most recent group reflective consultation, I observed an early educator speak through tears after witnessing three separate incidents of physical aggression between preschoolers and feeling amiss at how to best support these very young children. This educator explained the increasing physical aggression amongst children and struggled to understand where the aggression was stemming from.  It felt important to remind the group of the crucial development that happens within the first 3 years of life.   The brain develops rapidly from the age of birth to 3, and constant stressors during the first three years of life can lead to changes in the brain’s structure and the body’s ability to regulate stress.  Many children have experienced ongoing and pervasive stress, and as such are in constant “fight” or “flight” mode. Children are entering childcare centers and schools and may appear withdrawn, aggressive, or unfocused. Our response can either add to the stress they are experiencing or provide a safe haven for comfort and safety in the face of fear or a threat.

    The revolving door of quarantine, isolation, social distancing, shifting parenting priorities due to work demands, and closed childcare centers, created a mashup of confusion for our very young children.  It has been difficult for adults to predict what will happen next, the constant feeling of uncertainty can feel unsettling and unsafe.  As a consultant, I’m tasked with holding both the social emotional development of the young child in mind, as well as IECMH professional, who is struggling with feelings of needing to do more to support children and their caregivers, while simultaneously feeling tapped out. It’s important to acknowledge these dueling feelings exist. Early childhood educators are feeling the pressure to make up for the two lost years of the pandemic and as a reflective consultant it’s important for us to explore this together.

    Encouraging educators to think about how their lives have been impacted over the last two years and to explore their needs in moving forward, creates space for them to be held and seen and room to think differently about how the children they work with may need to be held. 

    We all are needing a collective sense of safety, after the grief, isolation, and uncertainty this pandemic has caused.  Thinking deeply together about what it means to be and feel safe is crucial in helping children who are struggling with their social emotional development. 

    References: 

    • Nelson C A, Bhutta Z A, Burke Harris N , Danese A, Samara M. (2020). Adversity in childhood is linked to mental and physical health throughout life.BMJ 2020;  371 :m3048
    • Weatherston, D., Ribaudo, J., The Michigan Collaborative for Infant Mental Health Research (2020). The Michigan Infant Mental Health Home Visiting Model. Infant Mental Health Journal, 41(2), 166-177.
  • Letter from past Infant Crier Editor Joan Shirilla, LMSW, IMH-E®

    Letter from past Infant Crier Editor Joan Shirilla, LMSW, IMH-E®

    Infant mental health home visiting — as well as the Michigan Association for Infant Mental Health (MI-AIMH) — evolved from a request by Selma Fraiberg to the director of the Michigan Department of Mental Health (MDMH) in 1972 to fund graduate students to train in the developing Child Development Project in Ann Arbor. Betty Tableman, then a MDMH staff person who later became the Director of Prevention Services, suggested that staff already employed by Michigan community mental health agencies be funded to carry out the new intervention instead. 

    In 1973, six clinicians from CMH agencies across the state formed the first training group, meeting bi-weekly in Ann Arbor under Fraiberg, Vivian Shapiro, and Edna Adelson’s guidance to learn about the infant-parent dyad.  Their work was based on Fraiberg’s intervention with blind children and their families. The work was complex and challenging, and the trainees asked for and received a second year of training.  They took their skills back to their home communities and found that their work had deepened; relationships between infants and parents changed, and development improved while their hunger to learn more increased. 

    The trainees were on fire with their knowledge and wanted to follow Fraiberg’s dictum to “share what they were learning about mothers and babies with their colleagues.” They formed the Michigan Association of Infant Mental Health in 1977 and hosted its first conference with T. Barry Brazelton as the plenary speaker with more than 800 people attending. Wanting to continue to share the developing knowledge and information about service delivery in the state, the Infant Crier was born, again, under the leadership of Betty Tableman, who served as the first editor. Consider that at the time, there was no internet, no email, and no email blasts.  Rather than checking your voice mail, text, or twitter, you would look in your office mailbox for messages taken by department secretaries.  Reading the Infant Crier, which arrived in your mailbox rather than your inbox, became an important way to learn about this growing field and to connect with others sharing your interest and dedication promoting secure attachment relationships for very young children.

    Looking back, we see Betty’s hand in Infant Crier articles that focused on social policy, news clips and emerging clinical content. Deborah Weatherston followed as editor from 1998-2009.  Under her editorial direction, the Infant Crier became a more clinically focused tool to share knowledge, personal reflections, and social policy. It connected those working with infants, very young children, and their families, across disciplines, from across the state and gradually across the country and world. The Infant Crier became a treasured publication to help develop and nurture understanding of infant, young child, and family development, attachment, and relationship-based work. 

    As Debbie transitioned to MI-AIMH’s first Executive Director, Joan Shirilla served as the Associate Editor, beginning in 2002 through 2009. Articles from leaders in the field, such as Barry Wright, Ph.D., Doug Davies, Ph.D., Michael Trout, M.A., Julie Ribaudo, LMSW, and many others shared didactic information and personal reflections about the complex world of very young children and their families. Jeri Lea Lentini, LMSW, also served as co-editor for several years, sharing her wisdom and clinical expertise. She was followed by Jennifer DeSchryver, Psy.D., who served as editor, bringing with her extensive clinical insight and editing skills.

    Joan stepped in as Infant Crier editor in 2013, sharing it for two years with Kerry Baughman, who moved the publication to its more updated online format, making the Infant Crier more accessible and less costly. 

    In 2020, the leadership of the Infant Crier transitioned to Danielle Davey, LMSW, and Kristyn Driver, LMSW, both highly skilled and seasoned IMH clinicians and supervisors. Their passion for the field is apparent in their work and they are eager to provide a platform for both seasoned and new clinicians to share their work and reflections. They are committed to reflecting best practice in the Infant Crier, to offer a deeper exploration of issues of diversity, equity and inclusion in Infant Crier articles. We are excited to introduce our talented new editors and look forward to Infant Crier articles that continue to help us grow as clinicians and people.

    Reference

    Tableman, Betty. Reflections on MI-AIMH’s History. Reflections from the Field. 2017. 11-13. 

  • Letter from the NEW Infant Crier Editors: Danielle Davey, LMSW, IMH-E® and Kristyn Driver, IMH-E®

    Letter from the NEW Infant Crier Editors: Danielle Davey, LMSW, IMH-E® and Kristyn Driver, IMH-E®

    As infant mental health clinicians who have both been in the field for over a decade, we’ve found that the Infant Crier has always been a consistent part of our experience. It has informed our work and has created conversations and deeper relationships that have allowed us to feel more connected within the greater MI-AIMH community. As the new editors of the Crier, we hope to continue to cultivate a space in which all readers will see themselves reflected in the writings of their colleagues and that it will be an avenue to build their own unique connections and relationships within themselves, the organization and the field.

    We’re trained early in our careers to be curious about the interactions between caregivers and young children. Therefore, we have an obligation to understand our own lens, how our cultural experiences shape how we understand and believe what the care of young children involves. We see the writing process as another way to channel the reflective process. It is a way of bringing the implicit to light. When we write, it is from our own perspective. As editors, we will be inviting prospective authors to be more intentional in thinking about who they are, who the other is and how that impacts not only how a relationship unfolded but  how they can share it with the broader community through their writing. 

    The Crier is a tangible record of our history. As the new editors, we’ve spent time deepening our understanding of the history and intent of the Crier and value the work that has been done in support of representation across our field. However we recognize that more work lies ahead for the Crier to fully become an equitable space. As we will be inviting potential writers to be aware of their lens and what their limitations might be, as two white women editing the Crier we are committed to doing the same.

     Our first action step is to create an editorial team of diverse infant and early childhood professionals across the state to ensure that our issue themes, articles and authors reflect multiple perspectives, a wider range of experience and more inclusive wisdom and knowledge. Our hope is this team will open the door to authors we haven’t yet heard from to highlight the range of voices that make up who we are. 

    Working within the infant and early childhood field we often think about the past, its impact on the present and how to intentionally affect the future. We hope the Crier will be an outlet for our field to be thinking about where we’ve been and where we’re going and that it can continue to be the record keeper of our history. 

    Sincerely,

    Danielle Davey, LMSW, IMH-E® & Kristyn Driver, IMH-E®, Infant Mental Health Mentor-Clinical


    As the editors of the Infant Crier, it feels important to highlight the Commitment Statement created by the Centering Equity Committee, as we believe the Crier is another reflective space where we can uphold commitments to equity and inclusion throughout our community.

    The MI-AIMH Centering Equity Committee, which is comprised of the MI-AIMH Executive Director, Central Office Staff, Board Members and Leaders, and Members, declare the following Commitment Statement:

    As a committee, we commit to prioritizing diversity, racial equity and inclusion in all of MI-AIMH’s decision making, policies and practices. We recognize that actions and practices that MI-AIMH as a system has created, developed and engaged-in over time have perpetuated racist and inequitable practices, which has directly caused harm to Black, Brown, and Indigenous People of Color. The MI-AIMH Centering Equity Committee will work to dismantle white supremacy and create a foundation of culturally sensitive, anti-oppressive practices within the organization and among its members. The committee is dedicated to an ongoing critical review of all information disseminated by the organization that excludes, divides and is rooted in oppressive practices. We commit to reflecting and adapting our current practices and systems that have caused harm. The committee will work closely with the broader organization to ensure that voices from all races, cultures and viewpoints are represented within all parts of the organization. We value the diversity and unique perspectives among our membership and the families we serve. The committee will be intentional in amplifying the voices of professionals and communities that have long been excluded from the core of the Infant and Early Childhood Mental Health field and the MI-AIMH organization.

    Initial Action Steps of the Centering Equity Committee:

    1. To hold the MI-AIMH organization and its leaders accountable to uphold equitable practices
    2. To intentionally embed Irving Harris Foundation’s Diversity-Informed Tenets for Work with Infants, Children and Families into all practices carried out by MI-AIMH
    3. To revise racist and oppressive materials, publications and communications
    4. To cultivate reflective spaces to engage in ongoing dialogue in regards to oppression, power, privilege, bias, white supremacy and racism that allows for a culturally reparative parallel process to unfold that reaches systems, professionals, communities, families and children
  • Supporting Feeding Challenges in Young Children through Occupational Therapy and Infant Mental Health Interventions

    Supporting Feeding Challenges in Young Children through Occupational Therapy and Infant Mental Health Interventions

     

    In the 10 years I’ve been an Infant Mental Health clinician, picky eating habits in children top the list of things families come looking for support in. “My kid only eats mac and cheese” or “He won’t eat a vegetable” are common phrases heard at an initial intake appointment. I’ve often wondered:  What is picky eating? Is it behavioral/emotional, relational, medical, sensory or environmental? The answer I’ve discovered upon working with an Occupational Therapist (OT) for the past five years: All of the above. 

    Research has shown that children with feeding challenges generally have more difficult temperaments, which leads to relationship conflicts and a lack of maternal confidence and competence in addressing these difficulties (Aviram et al., 2015). Through infant mental health services, a clinician can support children and families through navigating these difficult interactions, which can also address the children’s feeding challenges.  However, psychological support is just one of the many important pieces that goes into addressing this complex issue. 

    In the field of mental health, we are well aware of the ‘anger iceberg,’ the idea that anger is an emotion that tends to be easy to see — the tip of the iceberg — but with many other emotions and experiences hidden below the surface. The field of occupational therapy has a similar metaphor around feeding.

    For feeding therapy to be effective, the OT needs to take into consideration three overarching areas: the 1) psychological experiences with eating, 2) previous experiences with food/eating, and relationships with people around eating, and 3) oral motor skills and abilities to manage foods.  One or a combination of these can be the reason the child is having difficulties.  Due to the complexity of feeding, a team approach is required to have the highest level of success for overcoming challenges.

    As Infant Mental Health clinicians, it is important to understand when it is problem feeding, not just picky eating.

    As part of developmental guidance, and to be generally supportive, we may normalize picky eating, but we must also do our due diligence to help families discern when picky eating rounds the corner into problem feeding and when to refer to appropriate specialists.

    So when would it be considered problem eating? It is not uncommon for toddlers to display preferences for specific foods or refuse to try new things that are introduced. By the age of three, children should have consumed at least 20 foods, with two to three items in each food group, on a consistent basis. Below are red flags for problem feeding; it is recommended that a child be referred to an OT, or other appropriate specialists, if at least two are present. 

    • Restricted diet with little variety  
    • Cries and falls apart when presented with new foods; complete refusal 
    • Refuses entire categories of food textures or nutritional food groups 
    • Almost always eats different foods at a meal than rest of the family; often doesn’t eat with the family 
    • More than 25 steps of the 32 on the Steps to Eating Hierarchy** 
    • Consistently reported by a parent as “picky eater” across multiple well child checkups. 
    • Significant loss of previously eaten foods (as some loss can be considered typical)
    • Signs of aspiration: wet sounding voice after and during eating, sweating, sneezing, coughing, excessive amounts of saliva, etc. If any of these are present, seek medical assistance from a physician.

    If a child is exhibiting any of the above, as well as the signs/symptoms below, a referral to a speech-language pathologist or medical specialist is likely needed. 

    • Ongoing poor weight gain 
    • Ongoing choking, gagging, or coughing during meals 
    • Problems with vomiting 
    • History of traumatic choking incident 
    • Inability to transition to baby food purees by 10 months of age 
    • Inability to accept any table food solids by 12 months of age 
    • Inability to transition from breast/bottle to a cup by 16 months 
    • Has not weaned off baby foods by 16 months 
    • An infant who cries and/or arches at most meals 
    • Family is fighting about food and feeding (i.e. meals are battles)
    • Parent reports repeatedly that the child is difficult for everyone to feed 
    • Parental history of eating disorder, with a child not meeting weight goals 

    We are focusing on occupational therapy interventions for the purpose of this article; however, it is also common for speech-language pathologists to address feeding concerns, specifically as it relates to swallowing/choking/aspirating behaviors. It is important to coordinate with the child’s pediatrician to make sure referrals are made to appropriate specialists. Choking, gagging, vomiting, food coming out their nose, and aspiration during and after eating are very serious concerns and the child may need a swallow study or other assessment to check for anomalies. 

    The following case study highlights how Infant Mental Health and Occupational Therapy disciplines can work together to support the complex needs of infants and toddlers associated with picky and problem eating.  That relationships are the foundation for all successful interventions was apparent through our work together.

    Building an Alliance and Settling In

    Lindsey — Infant mental health clinician

    My work with Chloe and her family began when she was 10 months old, but the family had been involved with my organization for many years before that. Chloe lived with her mother, Sarah; father, Michael, and older brother. Chloe’s brother had been involved in the parent-infant program as a toddler and at age 5 had been diagnosed with autism. Because of that, Sarah was anxious about Chloe’s development  and she was often very uncertain of her parenting skills. Sarah told me at our initial intake, “I don’t trust myself to know what is typical for kids anymore. How could I have missed the signs with her brother for so long?” The grief that comes with an autism diagnosis is often heavy and complex, and I often found myself supporting them during my four years of work with them.  This was not the child she dreamed of having, and I needed to create space to validate her grief and to talk about the guilt she was feeling before she could move forward with possible interventions with Chloe.

    The first two years of work with the family focused a lot on developmental guidance. Sarah and Michael looked forward to the completion of Ages and Stages Questionnaires to monitor Chloe’s development. Sarah continued to be anxious about Chloe, often worried that she would also be diagnosed with autism. For much of the first year of our work together, Chloe’s development was on track. It was into the second year that I began to notice that her language skills were mildly delayed, and our interventions and parent-child focused activities became geared toward supporting her language skills. Sarah and Michael were always very open to learning new ways to support her and would eagerly try to continue the activities outside of our sessions. 

    Along with developmental guidance, emotional support was a predominant core strategy used with Chloe’s parents to encourage their confidence and competence in raising their two children. During my weekly sessions, I would frequently observe the strengths they possessed as a family and notice them out loud. It was important to point out the moments of connection, as they were often difficult for Michael and Sarah to see. I wanted them to know how important they were to their children. Along with in-the-moment commenting, I would frequently use video in our sessions to observe strengths together and build upon them. 

    Sarah especially enjoyed doing art projects with the kids, and we would often videotape these delightful moments. Both Sarah and Michael had good insights into their children’s challenges, but they often felt frustrated and sad over not being sure how to help them. I often noted out loud how much I appreciated their willingness to be vulnerable. Sarah was very playful with her children and loved going out into the community and offering them experiences she did not have growing up. Both of Chloe’s parents had complex trauma histories, and as we got into the second year of our work together, we were able to explore more of the impact those histories had on their relationship with their children, each other, and their home environment.

    The home environment was often very chaotic with little structure. The children did not have a consistent meal and bedtime routine, and we frequently focused on that during our sessions in those first two years. From the time Chloe started becoming independent in her feeding/eating, she would sit in a highchair on the floor in front of the TV. Additionally, because of her mild speech delay and observance of her brother’s challenging behavior, she frequently screamed to get her needs met. Chloe did not have a consistent meal schedule, which resulted in grazing; her family would feed her whenever she screamed. The family also did not typically eat a wide variety of foods, which limited what Chloe was offered. 

    Observation and Further Assessment

    Lindsey

    Around Chloe’s third birthday, Sarah and I started to become increasingly concerned about some of Chloe’s sensory processing issues and picky eating habits. It was something Sarah had brought to the attention of Chloe’s pediatrician on multiple occasions. Chloe frequently would scream when water was splashed in her face; she would not let her hair be brushed or washed so it was constantly matted, and she often refused to wear clothes. She had only 10 foods that she would eat, refusing to try anything new. Her food repertoire consisted of predominantly softer foods, with little variety. She would not eat foods of mixed textures (such as noodles with a meat sauce, instead the sauce had to be a plain marinara), she was very particular about meats (only cheeseburgers from McDonald’s, bologna and hot dogs), yogurt, one fruit and one vegetable. We would expect some pickiness or refusal to try some new items by the time a child is three, but we were not seeing Chloe eat many typical kid foods such as pizza, chicken nuggets, French fries, mac and cheese, etc. While she appeared to be a healthy weight (and trips to the pediatrician confirmed this), I was concerned that this would not be the case for much longer if her diet continued to be so limited. Mealtimes had consistently been a point of stress within the family at this point; Chloe frequently would have tantrums while Sarah would scream at the kids to just eat the food that was given to them. 

    Around this same time, I had hired an OT through a grant, which allowed both an OT and IMH clinician to go on home visits to work together.

    I understood many of the behavioral and relational interventions that would support Chloe’s picky eating, but I began to realize that her needs were outside of my scope of practice and that she needed more intensive intervention from a specialist.  

    I referred Chloe and family to Deb for occupational therapy. 

    I was able to be present during Deb’s initial evaluation, as well as subsequent sessions, which allowed me to gain further understanding on how treatment would look. My initial reaction while observing the evaluation was feeling almost surprised by how much Deb was aware of, and in tune with, Sarah and Chloe’s relationship. I was struck by Deb’s ability to wonder about the parent-child relationship dynamics as she explored what the family’s relationship with food itself was like. 

    Through my work with Deb, I learned ways in which I could enhance what I already knew to support Chloe and her family. Deb and I quickly collaborated on how to support making mealtimes more enjoyable for Chloe and Sarah. Once again, we were able to successfully use videotaping to observe interactions and support these everyday routines. Deb helped me think about how the stress response system and appetite are directly linked together, which we were able to bring to Sarah and Michael during our sessions. The family was receptive to the information and the perspectives Deb and I brought them. Slowly, we began to see subtle improvements and more delight during meals. 

    Collaboration and Occupational Therapy Intervention 

    Deb

    When I first met Chloe and Sarah, I noticed how Chloe was connected to and looked for her mother.  In addition, I noticed how she called for her help when Sarah left the room and not as often with her father.  During the evaluation, her mother was a strong participant and was encouraging to Chloe.  Sarah had insights into the challenges her daughter was having but did not know how to help her.  Their house had many activities and items that could support treatment, and Sarah was a willing participant in evaluation and subsequent treatment sessions. 

    When working with Chloe, it became evident quickly that she had not fully integrated her nervous system.  This was evident by how she was still having difficulties engaging with activities and tasks of a variety of textures through her hands, without having negative reactions or atypical play with them.  For example, Chloe was able to play with water through her hands but could not tolerate it splashing on her face.  Also, she was slow to play with sand and paint.  Initially, she would engage with one or two fingers for a few seconds and then over time she would add more fingers and play for longer periods.  However, even between periods of play, she would wipe her hand or hands off.  Most children at the age of three would dive in with both hands to get messy.  They would not worry about cleaning their hands or be slow to touch either sand or paint textures.  This type of engagement and play that Chloe demonstrated through her hands indicated that they were not integrated from a sensory perspective, which also meant her head and face were not as well, since the nervous system develops from feet to head.  This meant we had to focus on integrating her nervous system before we were going to see change within the areas of grooming/hygiene, bathing, and feeding.  I also had to change the environment and how some of these activities were being performed to create a new pattern since the current patterns were creating a stress response and negative reactions.  This included changing the places activities occurred, who completed them, the tools used during the activity, and interactions/relationship between the parent and child.  It also took recognizing sensory cues and learning to accept when a therapeutic break was required to then allow the task to be completed instead of just pushing through it.

    This model assists across all areas of activities of daily living.  A child will relax when you can create a secure and safe environment, which can then allow for growth and change.  In addition,

    we needed to try and create routine and expectations, which also create security and safety during tasks that children perceive as scary or that create a sense/state of anxiety.

    This was the model used for Chloe’s feeding therapy, which combined sensory integration, transcending the food hierarchy model (Steps to Eating Hierarchy) with a variety of foods, modeling, environmental modification, and parent-child interaction modification.  The sensory integration approach involved increasing exposure and tolerance to a variety of textures through her hands and slowly moving it up her arms toward her head and face, all while monitoring and respecting her interactions and need to clean up.  A play approach was used for adding foods to her very limited repertoire by first increasing tolerance for being in the environment, to breaking it up and playing with it with tools, toys, and hands, then allowing foods to progress up her body till we could get it to her mouth, and then possibly taking a bite and spitting it out.  These are activities we use to progress up the Steps to Eating Hierarchy.  It is a therapeutic approach that allows for exposure to foods at a level of tolerance that a child can manage while learning about the properties of foods without the pressure of eating while working and addressing the different properties of new foods.  It then progresses up to the mouth and eventually to eating a bit of a new food.  

    The education process around feeding is multifaceted and has many layers to create overall changes in feeding, the relationship between food and the person, the person and the environment, and the person and others within the environment, as well as changing current patterns, behaviors, and routines. For this client and her family, there was education about presentation of new foods even at the level of tolerating them in the environment or on her plate, creating a new routine around mealtimes. We worked with the family on establishing consistent times of day for eating because grazing behaviors do not promote a sense of hunger. We also wanted to encourage that at least one meal a day take place as a family. I noticed Lindsey exploring barriers to these two routines with Sarah and Michael, wanting to make sure they were as successful as possible. I could see how understood they felt by her, which led to more success and confidence in their ability to make these changes. 

    One of my top priorities was to move Chloe away from the TV, and instead to a table, in order to make food the most interesting thing happening at mealtimes.  By decreasing distractions, we were able to promote the increased speed of eating, plus being around other people eating allowed for modeling and socialization of mealtime and eating behaviors. It also gave her the opportunity to be around new foods even if they were not on her plate.  

    There was a high degree of education, as well as emotional support provided by Lindsey and me, for Sarah to try and not worry during mealtimes. Often, Sarah was so concerned about what and how much Chloe was eating that Chloe’s stress rose during meals. Ultimately, we just needed her to eat.  Kids pick up their parent’s stress and when the stress response rises it decreases appetite.  This inadvertently creates a power struggle between the parent and child because the parent becomes focused on the child’s eating and then the child just exerts more control over the situation by not eating.

    Lindsey’s knowledge of the family was integral in the development and implementation of all strategies and progress throughout the subsequent treatment sessions.  Her in-depth knowledge of the family allowed for more realistic goals to be determined and for me to gain all relevant client factors that could help and impact progress.  In addition, the relationship she had with both Chloe and Sarah created a sense of safety that allowed the client and her mother to be open to me and create progress within a very difficult area of feeding.  Feeding is so multifaceted that it took the combined skills of Lindsey and me to make a true difference.  I can impact the sensory processing, progress feeding, and create some environment and parent/child modifications, but Lindsey’s knowledge of the parent-child relationship was integral in changing those relationships to then allow the families to be available for my interventions.

    “We don’t have to do it all alone. We were never meant to.” — Brene Brown

    Lindsey

    We wish we could say that all of Chloe’s feeding concerns were addressed by the time we finished working with this family, but just as parent-child relationship work takes time, so does occupational therapy and feeding treatment. Chloe made tremendous progress from a sensory integration standpoint, and she gained three new foods that she would consistently eat, and seven foods that she progressed up the Steps to Eating Hierarchy. Depending on when children ‘fall off’ the normal developmental feeding trajectory, it can take just as long to get back on track. Our work with this family highlighted the importance of professionals working together in collaboration and that we can’t do this work alone. Deb was able to support the family, and myself, in establishing new routines and attitudes around food, which created a building block, or planting of seeds, for us to take with us into our work long after she was gone. 

    References and Resources: 

    1. Aviram et al (2015) Mealtime Dynamics in Child Feeding Disorder: The Role of Child Temperament, Parental Sense of Competence and Paternal Involvement. Journal of Pediatric Psychology, 40(1). Pp. 45-54.
    2. Growing hands-on kids. (n.d.). Retrieved from https://www.growinghandsonkids.com
    3. Kranowitz, Carol Stock. The Out-of-Sync Child: Recognizing and Coping with Sensory Processing Disorder. New York: A Skylight Press Book/A Perigee Book, 2005.
    4. STAR Institute (n.d.) Retrieved from https://www.spdstar.org/
    5. Toomey, Kay & Ross, Erin. (2011). SOS approach to feeding. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 20. 82. 10.1044/sasd20.3.82.

    **Steps to Feeding Hierarchy:   This hierarchy represents the 32 steps it can take a person to eat one bite of a new food.  It is a sequential desensitization approach created by Dr. Kay Toomey and is an evidenced-based approach to feeding therapy. It was established with a copy-write in 1995 (and updated in 2010).  A person moves through the steps with interventions that provide them a safe environment along with the addition of other treatment strategies and theories.  The major steps within the hierarchy are as follows: tolerates, interacts with, smells, touches, tastes, and eating. There are smaller steps within those larger steps, which progress upward from “tolerates” toward “eating,” and a person can start at any level for any food.  After eating a single bite of a food, it can take up to about 30 trials of that food to determine if you like or dislike that food. 

     

  • Risk and resiliency: Failure to Thrive in the First Year of Life

    Reprinted from July-September 1997 issue

    Carol Oleksiak, Thomas M. Horner, Ph.D.

    Intervention: Carol Oleksiak

    Terry was referred to an infant mental health program located in an urban community because a children’s hospital social worker was concerned about his poor weight gain. Although he weighed 6 pounds, 7 ounces when he was born at 33 weeks, he had gained only 5 pounds during the next six months.  Terry was Jane’s fifth child. She reported that she had previously come to the hospital twice because her baby was throwing up after each feeding, and eventually had stopped eating. She tried a third time to get help for her baby at her local medical clinic, which responded by having Terry hospitalized. During his hospital stay he began to eat and gain, and he had hernia surgery. He was discharged after one week and the hospital social worker referred him to our program for home-based services. 

    As I entered this family’s home a few days after Terry was released from the hospital, I reminded myself of this mother’s many attempts to get help for her baby. It helped me to remember the IMH assumption that even in the face of difficulty the family is struggling toward health. The family was large: a single mother and her five children under the age of eight. 

    A slight, timid mother opened the door to the home, a lower flat near a busy airport. The rooms were sparsely furnished. Terry’s next sibling, a two-year-old boy, was not wearing diapers even though he was not yet potty-trained. There were only two beds; Terry’s mother, Jane, stated that she and Terry slept on the couch. There was very little evidence of books or toys. The baby appeared very thin and fragile, his belly distended. He was hypervigilant and watchful. He did not sit alone and often slid to one side when he was propped in a sitting position. However, he seemed curious about a toy that I had brought with me and, when his mother offered it to him, he reached for it, transferring it from one hand to the other. His 25-year-old mother quietly sat on the couch. 

    As I watched them, I wondered how I could begin to help them. She was so shut down and he was so frail. She finally spoke and said, “I think he has a fever.” She was worried because he had just had surgery; I was worried, too. There was no thermometer or Tylenol, so I went to the corner store and purchased some infant Tylenol drops for her. When I returned, she was giving her baby water to keep him from dehydrating. When it was time for me to go, I said, “I’ll be back tomorrow at noon to see how you and the baby are doing.”

    When I arrived the next day, Jane was waiting for me at the window. I understood her wish to have things be better for her baby and her other children, but it was clear that she would need a great deal of support. Jane was unable to accomplish the most basic caregiving tasks.

    I talked with her about becoming a team, that together we would try to understand why her baby was having trouble gaining weight.

    She was able to manage a slight smile and nodded her head. 

    The next day I took the whole family to WIC to get formula for Terry. It was a difficult visit. The appointment took a long time; the children had not eaten breakfast and were hungry. I went next door to the grocery store and bought a bag of apples. It was at this appointment that I noticed that Terry seemed to avert his gaze when I tried to talk to him. I thought it was important to ask Jane if this was something that she had also noticed. She nodded her head in agreement. As a team, we would try to understand Terry’s cues and behaviors. She smiled but said very little. 

    I felt worried about Terry’s health and scared about being able to really help this family. I watched Jane tease Terry with his bottle — offering it and then pulling it away — understanding how difficult it was for her to give him what he needed at that moment. I acknowledged her struggle, saying, “This must be so hard for you.” I repeated this many times during our work together. With recognition of her struggles, Jane began to respond more consistently to her baby.

    Two months later, at eight months old, Terry weighed 14 pounds, 6 ounces, a gain of three pounds! During this time I transported Jane and her children to all their pediatric appointments. I advocated for Jane and her children to be seen by the same pediatrician every time. We added Dr. B. to our “team.” Together, we provided the family with consistent medical care. 

    I struggled. I had so many questions. What got in the way of Jane feeding her baby? What made this baby unable to keep his formula down? Why did he vomit after almost every feeding? I observed Jane teasing the baby with the bottle and withholding his toys during play. When Terry and his mother were together, he often seemed more interested in other things. It was hard at times for Jane to get her baby to play with her. We used videotapes to understand how she and Terry were interacting with each other. 

    In the time that we worked together, I spoke often for the baby as well as for Jane and her other children. I gave support for the concrete needs of the family, e.g. diapers and formula for the baby, clothes for the children and food when they ran out. I visited at least twice per week, and more often if Jane needed to go to the clinic, WIC, the grocery store, or to visit her family. Jane began to listen to me as I talked about Terry’s development and his cues and his behaviors.

    Together we discussed what she thought her baby might be thinking or needing when we observed him. As Jane felt supported and came to trust me, she could respond to her baby’s needs. 

    At 10 months, Terry was a stronger baby. He crawled, pulled himself up on furniture, and could feed himself. He now weighed 15 pounds and showed interest in playing patty cake, could find hidden objects and liked dropping toys as a game. When Terry’s weight gain slowed, Jane agreed to keep a food chart. After eating, Terry would often cry for more food even though his belly looked very distended. We concluded that he couldn’t tell his mother when he was full. I wondered aloud that if she slowed the pace of his feedings it might allow him to feel full. She gave this a try, with positive results. 

    By Terry’s first birthday there were still concerns but also some celebrations and pleasures. He was a much happier baby. He began to communicate, using gestures and simple words. He was getting ready to walk, a much sturdier baby who now weighed 17 pounds and 2 ounces!

    One hot summer day as we sat on the porch watching the children play and eating the popsicles I had brought, Jane revealed that she had once thought Terry was going to be “slow” and only recently did she feel hopeful about him being “OK.” She felt better because he was beginning to do more things and was more responsive to her. Her baby continued to gain weight and enjoyed eating. As Terry grew more healthy and competent, Jane realized that he would survive and was in turn able to be more affectionate and attentive toward him. 

    Jane and I worked together on behalf of Terry and her other children for four years. She continues to keep in contact with me. She calls when she has questions and during Terry’s birthday month. Today he is seven years old and doing well in school. There are no significant developmental delays. After a difficult beginning, Jane and Terry have an enduring relationship with one another. 

     

    Discussion, Thomas M. Horner, Ph.D.

    Terry was referred for infant mental health services when he was 6 months old, an age at which a typical infant weighs 14-15 pounds. The presumption underlying the development of such “typical” infants, though, is that they have lived in ordinary circumstances that are conducive to their physical growth, including weight acquisition. Weight acquisition is a widely used marker of how well physical growth is proceeding in an infant. 

    At the time of the referral, however, Terry’s circumstances were not ordinary. Experienced practitioners are accustomed to the fact that many preterm infants who are born with low (but not extremely low) gestational weight “catch up.”  The point by which the actual “catch-up” will have occurred is usually in the early half of the first year following the expected full-term date. Born significantly preterm, Terry’s weight acquisition had clearly stalled. He entered the hospital, where his eating led to weight gain, and where he also underwent surgery to repair a hernia. Clearly the discharging staff at the hospital were concerned that his gains might not be sustained, and the services of the infant mental health were appropriately sought. Enter Ms. Oleksiak. 

    Ms. Oleksiak’s depiction of Terry’s living circumstances are familiar enough to those who work with slow weight acquisition in infants. Limited material means, a mother who shoulders alone the care of her children, and who is distracted by so many sociofamilial exigencies, and in whom exists a basic cautiousness about the infant mental health provider’s presence and intentions — all are evident as Ms. Oleksiak makes her initial contact. Yet the story of what follows in Ms. Oleksiak’s brief narrative is also a familiar one: the therapist’s pattern of patient observation and listening, her faith in the mother’s drive to be whole (or well, as one might put it), her implicit recognition in her approach that there is much, much more that is operating in the case than simple “failure to thrive” dynamics, and her impulse to help and assist from a perspective of partnership and alliance (Ms. Oleksiak’s “team” approach) — all are the familiar (though sometimes faith challenging!) elements of effective intervention on behalf of nutritionally compromised infants. She knows that Terry has an eating disorder, which may be only partly related to the possibility that there exists a feeding disorder as well. 

    Ms. Oleksiak’s entrance into Terry’s and his mother’s lives transformed itself from the start into a growth-augmenting process; operating from within the subjective domains of her clients, she was able to assist, advise, advocate and guide — all in the service of enhanced eating and growth. She aligned her observational stance with Terry’s in order to convey to his mother ideas as to how she might approach his troublesome eating behavior — his tendency to distract himself during eating, his reaction to her seemingly innocent but frustrating teasing with the bottle, and his general tendency to avert his gaze. Such infants frequently defeat their nutritional needs, particularly when their appetitional dynamics have been suppressed by depression, or when they are insufficient to impel nutritionally secure eating. 

    Ms. Oleksiak’s holistic approach — one that entailed involvement with the family and acting within and throughout the large sphere of events and circumstances surrounding Terry’s eating and weight acquisitions, e.g. visits with the pediatrician to recruit him to the “team” — was essential to his ability to recapture a positively accelerating weight trajectory. Her use of videotapes to bring perspectives to the eating and interactive situation was, perhaps, certainly important to the mother’s permitting Terry a greater share of the lead-taking in eating. It also contributed greatly to the mother’s being able to develop a communication/feeding framework that was more nutrition-augmenting and enhancing than existed at the outset of their work together. 

    By one year of age, Terry’s weight is said to be still quite low relative to his age-mates, but he is growing and his abilities and interests in social communication are emerging. Ms. Oleksiak is the truly wonderful facilitator of this, being the skilled accompanist, rather than the conductor, of Terry’s developmental performances and his mother’s caretaking performances. She has not taken Terry’s weight alone as an index of her, or his, or his mother’s success at life. She has dealt with an eating disorder of infancy, but she has also enhanced a realm of communicative and psychologically significant contacts he has with his mother and others. She has worked with the relationship not to undo causes of the eating disorder but to assist in their joint dealing with it and to foster its life-enhancing functions. 

    Ms. Oleksiak remained at or near their sides for four years, a continuity of care that is not only remarkable but truly exemplary. Nearly seven years after entering his life she is aware that Terry is on a secure developmental track. His weight as such is no longer the issue. He has achieved an adjustment and ability to accept life’s challenges, including those that come with being who he is, physically and otherwise. 

     

    General comments: a more general consideration on non-organic failure to thrive

    Terry is like so many infants who are born into circumstances in which their parents are distracted by many exigencies or collateral demands. These circumstances are so familiar that they frequently form the basis of an intervention that implicitly holds the mother responsible for the infant’s failure to gain weight. No doubt, there are mothers who are neglectful. But there are circumstances where the mother, distracted as she was in Terry’s case, is not responsible for her infant’s failures to gain weight adequately or at a pace that is even roughly commensurate with comparably aged infants. Such mothers often “seem” neglectful, and they are often, due to expediency, classified as such.

    As infant mental health specialists we must discipline ourselves not only to set aside presumptions as to the causes of infant failure to thrive, but also to recognize that eating in infancy is not solely a matter of someone’s simply feeding her/him. 

               I have, over the years, developed a differentiated approach to infant failure to thrive, one that distinguishes between eating and feeding. A truly infant-centered point of view requires that the infant mental health specialist acknowledge that as much as anyone feeds infants, infants eat. From the outset of their lives, eating is an active process governed not only by the appetitional dynamics of the infant, but also by the eating repertoires of behavior infants possess. This repertoire may be “skilled” insofar as the infant has the behavioral capacities to orient to and to “connect with” food, or it may be comparatively “unskilled” insofar as the infant either lacks these capacities or possesses capacities that are impaired either by circumstances or by intrinsic defect. 

    Although no one would avoid trying to link together the seeming “causes” and “effects” in an infant’s behavioral and affective adjustment, the natural tendency on our parts to construct just such linkages frequently results in our forming premature (and sometimes erroneous) judgments as to what has “gone wrong” when we encounter infants classifiable as failing to thrive. Terry’s aversion to the bottle could have been brought about by early patterns of maternal intrusiveness that “caused” him to learn to avoid the bottle, to avoid eye contact, to avoid social exchange, and the like. But it is also possible (and more likely in my experience) that Terry himself possessed inherent patterns of gaze and social communication that made him less likely to effectively organize his food orienting and food seeking behavior around and within the food-presenting contexts created by his mother.

    Why would Terry not eat when food was presented? Is it simply depression, which we know can alter appetitional urges, satisfactions, and mechanics. Or is it the condition that is causing his fever, which we know can alter appetite. Is it perhaps that the food itself is not interesting to him? Is this his mother’s “fault?” Perhaps a case can be made (whether or not correct) that Terry’s mother lacks the ability or disposition to excite his interests, or to present food in ways that satisfy his appetitional (and ultimately, his nutritional) needs. There are such parents. But is it also possible that Terry’s appetitional dynamics are intrinsically different from what we ordinarily encounter in infants who are obviously hungry and who “know what to do” to be fed. It may be that he does not feel the urgencies of hunger in a way that we quite naturally expect them to be in an infant. We are not prepared — until we have allowed such possibilities to exist — to recognize that such infants lack, or seem to lack, part or all of a hunger drive. They do not clamor for, nor do they directly seek, food, sometimes even after rather strikingly long periods of not eating. If such an infant happens to seek food when s/he is hungry, s/he may demonstrate what appears to be a very low threshold of satiety, that is, having only just begun to eat s/he may close off eating as though s/he were now “full.”

    At the core of Ms. Olkesiak’s approach to Terry was at least a tacit recognition and acceptance that Terry’s eating was just that, Terry’s eating. In other words, she allowed Terry to be Terry, while offering advice and guidance to his mother that defined her not as the cause of the eating disorder but as the one and only figure who would be instrumental in his thriving — emotionally and nutritionally — the best that he could. Ms. Oleksiak’s approach sought to bring the best from Terry’s mother without ascribing the worst in her. That Ms. Oleksiak’s assistance in these regards led to changes in how Terry’s mother presented food to him, and to changes as to how Terry’s eating was to be augmented, in no way “confirms” that the mother was the “cause” of 1) the eating dynamics themselves, or 2) Terry’s inability to gain weight at a pace commensurate with the growth charts. 

    In truth, the fact that things improved in the affective-interactive sphere, while Terry continued to gain weight at a pace far below his agemates suggests that the eating/nutritional dynamics that were operative were originally as disconnected from the affective-emotional sphere as they were connected to it. 

    This is, of course, a point that many infant mental health specialists, and many Protective Services case workers, fail to consider when dealing with infants in nutritional distress associated with failure to gain weight. Fortunately Ms. Oleksiak did not fail to consider it. 

    This is not to say that there are not instances in which maternal neglect, willful deprivation, or simple incompetent provisions of food, are operative. But it is to say that there are infants whose intrinsic patterns of eating foster an illusion that a given mother — who herself may be depressed, distracted, burdened heavily, or otherwise non-optimal in her interactive and emotionally communicative dynamics — is at fault in the matter of her infant’s failure to gain weight. Recognition of the fact that infants do have unique styles and dynamics of eating, which are in turn connected to their respective and unique appetitional-behavioral dynamics, has caused some in the field to reconsider the use of the term “feeding disorder” to describe such conditions. Increasingly clear is the fact that they are dealing in such cases with eating disorders. 

    Eating disorders are, after all, disorders of eating, and we must be careful not to quickly ascribe their roots to psychoaffective and socioaffective domains that, while crucially relevant to amelioration, are not necessarily causal. 

    In most instances, problematic eating is a transient thing, perhaps an offshoot of a serious illness or surgery, or an accompaniment of an illness, say, or the pain of an ear infection, etc. In some instances, however, problematic eating belongs to the endowed behavioral repertoire of the infant. In any of these instances, chronic problematic eating is demoralizing, and the behaviors of parenteral demoralization then arise. When the latter are first encountered by the infant mental health specialist, they form an illusion that the parent is somehow causally inattentive, or causally disruptive, to a point that she is at fault rather than at a loss as to how to overcome the impasse of the infant’s failure to gain weight. Ms. Oleksiak’s case report is a splendid example of where this illusion was not peremptory of her therapeutic assessment, planning, and intervention. 

    Failure to thrive in infancy is more than simply a challenging disorder. In the past decades, the increased rates of survivorship of extreme preterm birth generally entail to the infant not only an altered course of emerging behavioral dynamics associated with coping with impositions of early extrauterine, but adjustments associated with any number of mechanical and surgical procedures imposed in the service of keeping her/him alive. In these cases infant mental health specialists are increasingly having to confront conditions, including medical, that far exceed the knowledge traditionally directed to determining simply whether or not a given parent is “fit” enough to care for an infant. Moreover, with the widening knowledge that has accumulated in regard to the early primary ego repertoire of infants — including aspects of what is widely called temperament, but including as well aspects of infant-directed attention, social interest, and social communication — infant mental health specialists are faced with having to account more fully and in more detailed fashion for the infant’s own contribution to problems of development or adjustment. 

    But this is what makes infant mental health truly infant mental health: taking the infant’s point of view, allowing for individual and sometimes perplexing differences between infants, and, in the end, coming to the infant’s assistance in helping a given parent make things go better. 

    Can there have been a better example of this than Ms. Oleksiak’s account of her work with Terry and his mother? 

  • Therapeutic Presence: The Critical Component in Providing Relationship-Based Services Via Telehealth

    Therapeutic Presence: The Critical Component in Providing Relationship-Based Services Via Telehealth

    COVID-19 has dramatically shifted how we provide clinical and supervisory services to families and mental health practitioners.  Home- and office-based in-person meetings have been replaced with video and telephone calls.  Never before has the idea of “how we are is as important as what we do” in our clinical work been so important to remember (Pawl & St. John, 1995).

    In this time of social distancing and subsequent provision of services via virtual formats, we are challenged to discover new ways of being present over a screen or the telephone.

    We have been tasked with figuring out how to hold onto our core ways of being with others while at the same time to let go of ideas of operating under the premise of “business as usual.”  We have had to pull all of our resources for creativity, compassion, flexibility, and adaptability to the forefront of our work over the past several months and the unknowable future for many of us.  Meeting virtually no longer seems like a temporary arrangement to help families, but has become part of the fabric of how most of us are working for the foreseeable future.  A central challenge before us remains: How do we embody relational principles of “how we are” over a screen when meeting with families and supervisees so that they can experience feeling truly met with by us?

    How We Are

    Of course we should always strive to consciously embody how we are with others in our clinical work; however, working virtually demands that we be especially mindful of fully and authentically embodying our “how we are” to share with others over a computer screen or the telephone.  Our “how we are” includes being fully present, emotionally regulated, safe, reflective, and focused on the centrality of relationships (Pawl & St. John, 1995).  We must strive to be open and responsive to each individual’s experience of sheltering in place; tolerate and organize their feelings as they ride an unpredictable emotional roller-coaster; create a sense of safety in being together in whatever way might be available at any given time; continue to seek understanding of how behaviors, feelings, and thoughts shift in response to how things are in the home and the outside world, and keep in mind the critical importance of having a safe and trusted relationship in which to feel held, no matter the format in which it is experienced.

    As we stretch to find new ways of maintaining a sense of connection during this time of extended social isolation, we must consider how to help others feel held in mind; to know that they are not alone as they navigate through this frightening time under such extreme stress, pressure, and vulnerability.  It is the felt experience of being held in another’s mind that is especially salient here.  An important aspect of being held in another’s mind includes being “spoken to over distance … tethered across space and out of mutual sight” (Pawl, 1995, p.5).  A sense of connection is created by being consistently held in another’s mind, which is by definition a way to sustain that sense of “not-alone” when physically apart from one another.  Current research suggests that irregular, brief, unscheduled contact with clients can strengthen the therapeutic relationship and lets them know that they are in your thoughts even when you are not meeting at a scheduled appointment time (Caldwell, 2020).  A quick text to check in with parents or supervisees may be important to consider during these unpredictable times.  Of course there are a host of valid clinical reasons to think this option through carefully in reflective supervision, and it may not be appropriate for every family, but from a relational perspective, it may be an important option to consider to help others feel held in mind during extended periods of quarantine and social isolation.

    Therapeutic Presence

    The concept of therapeutic presence is one that not only cuts across theoretical orientations as one of the most fundamental requirements for effective clinical work, but it can also cut across mediums in which therapeutic services are provided.  Therapeutic presence is defined “… as having one’s whole self in the encounter with a client by being completely in the moment on a multiplicity of levels — physically, emotionally, cognitively, spiritually, and relationally” (Geller & Greenberg, 2012, p.7).  Bringing our full presence to a virtual encounter with a family or supervisee is essential to creating and sustaining the sense of being together that we might otherwise take for granted when meeting in person.  By bringing our presence in an open and receptive state and then consciously focusing our sustained and sensitive attention on others, we are able to help them “feel felt with” by us (Furman, 1992; Siegel, 2010).

    How do we access our presence and capacity to attune to others when working virtually?  We need to actively protect our ability to attend from any outside distractions — phone silenced, email and text notifications on the computer turned off — and to have a designated workspace from where we can sit comfortably.  It can be helpful to find a few quiet moments before a session to anchor your feet firmly on the ground and take a few deep breaths to clear your mind so that you can be in that open and receptive state from which you can then consciously turn your attention and attune to the people you are meeting with on the screen or on the phone.

    In relationship-based work with families, we aim to bring our therapeutic presence and subsequent attunement to multiple relationships and the complex, interconnected experiences of the parent, child, and provider.  We strive to support parents in their relationships with their children and to help strengthen the attachment between them, and offering our presence is a necessary aspect of this process.  Siegel and Bryson (2020) emphasize the importance of presence in parenting, what they refer to as a parent’s capacity for “showing up,” and how parental presence is a foundation for developing a secure attachment relationship between parent and child.

    By keeping in mind the centrality of presence in fostering healthy relationships and secure attachments, we can strive to provide this relational presence with the clients and supervisees with whom we meet.

    Self-Care and Self-Reflection

    We can only embody our “how we are” and offer our full attuned presence when we also prioritize our self-care.  We need to actively seek out the support we need in order to be truly and fully present in our work with others.  Being present for and with others is an active, emotional labor, and being present with others over screens can be even more emotionally labor-intensive.  When we are with others in person, we are able to make use of subtle, non-verbal cues that we are not even consciously aware of.  We can see the whole person in their whole environment, which allows a more relaxed presence to unfold.

    Over a screen, we have to work harder to project our presence to be felt by others.  We may end up feeling depleted and exhausted by Telehealth sessions in ways that we didn’t anticipate.

    For these reasons, we need to pay close attention to how we schedule our appointments, give ourselves breaks from looking at screens as needed, and be mindful of how we refuel ourselves when not working. In other words,  how do we practice self-care?

    Self-care can look different for each of us — it can be about finding ways to connect with others or with nature, creating time to get lost in a book, moving our bodies, meditating, practicing yoga, talking with trusted colleagues, and/or meeting with our reflective supervisors and consultants.  “Self-care is any action you purposefully take to improve your physical, emotional or spiritual well-being.  By making time for self-care, you prepare yourself to be your best so you can share your gifts with the world” (Brownn, 2020).

    We need to be mindful of how the change in the contextual frame in which we operate impacts ourselves and our clients and supervisees: how virtual ways of being together can initially feel uncomfortable or awkward, how the felt experience of being together might shift in both tangible and intangible ways, and how our relationships with others might be influenced over time.  I would suggest that it is only after we wrestle with and accept our own experience can we then invite supervisees and parents to join us in being curious about how these same shifts impact themselves, their children, and the relationships between them.  We need to appreciate what is being asked of all of us — supervisors, direct service providers, and families — to gently and compassionately “name it to tame it” (Siegel & Bryson, 2011) in order to help internally organize the experience for each of us during this unpredictable time in the world, so that all of us have the opportunity to feel held in the mind of another.

    Summary

    Some of our “what we do” needs to be adjusted and altered when working with families over video or telephone, but our “how we are” is a constant, no matter the format we use to meet with others.  We truly can offer these ways of how we are in relationships — our therapeutic presence — whether we are meeting with clients, supervisees, and/or students, and whether we are meeting them in their homes, in offices, or over computer screens or the telephone.  These ways of how we are with others are as important, if not more, than what we do, and thankfully are not defined by our physical proximity to each other, but by our embodied ways of being fully and therapeutically present when we meet with one another.

    References

    Brownn, E.  Retrieved May 4, 2020, from http://www.eleanorbrownn.com

    Caldwell, B. (April 15, 2020). The Value of Between-Session Contact. Simple Practice. https://www.simplepractice.com/blog/contact-helps-therapeutic-relationship/?utm_medium=email&utm_source=sp-blog&utm_campaign=20200417-paid-trial-leads-blog-update-value-between-session-contact&utm_content=body-link-3-sp-blog-post

    Furman, E. (1992). On feeling and being felt with. The Psychoanalytic Study of the Child, 47, 67-84.

    Geller, S. M. & Greenberg, L. S. (2012). Therapeutic Presence. Washington, DC: American Psychological Association.

    Pawl, J.H. (1995). The Therapeutic Relationship as Human Connectedness: Being held in another’s mind.  ZERO TO THREE, 15 (4), 1, 3-5.

    Pawl, J. H. & St John, M. (1995). How You Are Is as Important as What You Do. Washington, DC: ZERO TO THREE.

    Siegel, D. J. (2010).  The Mindful Therapist. New York, NY: W. W. Norton & Company.

    Siegel, D.J. & Bryson, T. P. (2011). The Whole-Brain Child: 12 Revolutionary Strategies to Nurture Your Child’s Developing Mind.  New York, NY: Delacorte Press.

    Siegel, D.J. & Bryson, T. P. (2020). The Power of Showing Up: How Parental Presence Shapes Who Our Kids Become and How Their Brains Get Wired. New York, NY: Penguin Random House LLC.

  • The Intersection of Leadership and Vulnerability: Making the Case for Reflective Supervision/Consultation for Policy and Systems Leaders

    The Intersection of Leadership and Vulnerability: Making the Case for Reflective Supervision/Consultation for Policy and Systems Leaders

    Introduction

    Reflective Supervision/Consultation (RS/C) has been widely recognized as a key component in the provision of quality infant mental health (IMH) informed services.  RS/C can be described simply as a “relationship for learning” (Shahmoon-Shanok, 2006, p. 343).  Just as we know that babies can only learn and grow in the context of relationships, we believe that the same is true for professionals.

    RS/C is a time for supervisees to examine their own reactions to the work with vulnerable babies and families and to use their new understanding to inform the services they provide.  As supervisees experience (and are invited to reflect on) their own learning and growth in the context of the supervisory relationship, they are able to harness the power of relationships in their own work with families.  As supervisees begin to feel safe, known and understood by their supervisor, they may find they are better able to quiet their inner experience, allowing more openness and curiosity about the experience of the baby and of the parent(s).  As the parent (or caregiver) is able to feel seen and known with the service provider, the parent may find that more space is available to consider the perspective of the baby.  In infant mental health work, this relational occurrence is described as the parallel process.  Essentially, the parallel process describes the way in which relationships impact relationships.

    In this field, it has come to be expected that direct service professionals are aware of how their relationships are impacting their work with the baby and his/her relationships with primary caregivers.  This article will argue for an expansion of our thinking for a more comprehensive parallel process. This includes the assertion that it is best practice for leaders of programs, organizations and systems to have the opportunity to experience RS/C in order to advance this systematic awareness on behalf of babies and the adults who care for them.

    Reflective Supervision/Consultation has become a crucial support for professionals in many settings, including early care and education, home visiting, infant early childhood mental health consultation, early intervention, behavioral health, general mental health here and many more.  It seems that funders and organizations have begun to recognize its value for frontline workers and, though less often, for their direct supervisors.  However, the concept, for leaders in policy and program administration, has not yet been fully embraced.  There are likely many reasons for this gap in professional support.  First, building RS/C into systems and providing it to all employees does come at a financial cost.  If the organization is not yet convinced of the value for those not providing direct services, it may be even more difficult to rationalize the additional cost of paying for qualified providers and the staff time that is spent in RS/C. Second, typically the conversations, published articles and research about the value of RS/C has centered on service providers and the direct impact on babies and families. This could give the false impression that its value is limited to the very immediate relationships between provider and family, and provider and supervisor.  Lastly, for those leaders who did not enter into the workforce with a human services or clinical background, the idea of RS/C as a way to reflect on one’s own thoughts and feelings may feel foreign and uncomfortable.  It may, in fact, not align with their values and beliefs around a leader feeling the need or pressure to be strong, tough and already possessing the answers.

    If we remember the core IMH principle that all learning and growth happens in the context of (safe, healthy) relationships and we believe that relationships impact relationships, then it seems logical that the need for RS/C would not stop with direct service providers and supervisors.  In the absence of RS/C, how will a leader have the space to explore the work in more depth, to manage annoyance at a particularly stubborn employee, to practice slowing down and listening deeply to one’s own internal process as well as that of the team?  How will the leader be allowed to experience the vulnerability that inevitably arises when one is on the cusp of learning something new that might require them to change their practice?  What is lost if one does not have the support to venture into that new territory of learning? Taken one step further, if this leader does have RS/C, but the leader’s supervisor does not, then what happens to the parallel process?

    Ultimately, how are those we serve impacted by this lack of reflection at the highest levels of a system? We believe it is the babies and families who will inexorably bear the burden of this cost.

    These are important questions that lead us to assert that all professionals in the infant and early childhood system, including and arguably especially leaders, should be receiving consistent, relationship-based RS/C.

    What Makes A Good Leader in Infant and Early Childhood Mental Health (IECMH) Systems?

    First and foremost, leaders in IECMH systems are charged with keeping babies and families in mind, even though they are in a distanced role from them.  As policies for service provision and staff development are created and implemented, strong leaders should be asking themselves for nearly every decision, “How will this impact the infants, young children and families we are serving?”   In order to allow for this space to consider the vulnerability of babies and families, leaders must be willing to look inward and make space for their own sense of vulnerability.  It can be difficult to reflect on our own early experiences of feeling powerless and voiceless.  And yet our ability to do so allows us to hold deep empathy for those we serve, a key trait of quality service provision.  Second, leaders at all levels must be attuned to the staff and teams they lead:  What are their strengths and areas for growth? How do they best learn and grow? This level of attunement requires careful observation, listening, the ability to stay open to new information and integrate it into one’s thinking and decision-making.

    The final skill, though we acknowledge there are many more, we believe is essential to strong leadership is awareness of one’s own biases; biases related to race, gender, sexual orientation, religious beliefs, political ideology, parenting, etc. Each one of us interacts with the world through our own unique lens, which is inevitably tinted by our life experiences.  As a result, explicitly and implicitly, we assign value, prioritize, and make decisions based on our own values and beliefs.  As a leader in a system, it is critical that one is aware of these values, beliefs, and biases and how they impact the creation and implementation of policy and program administration. RS/C offers the rare space to identify and examine these biases with a trusted other. Intentionally doing so creates the opportunity to not only recognize differences between self and others within and throughout the system, but also to identify ways to capitalize on these differences in order to enhance each layer of the system. This allows leaders to navigate the complex relationships within agencies, departments and organizations more effectively and efficiently to ultimately offer the highest quality supports and services for families.

    RS/C with a consistent and skilled consultant allows a supervisee/consultee to engage in careful and thoughtful exploration of the work. It invites supervisee/consultees to be curious about the experiences of others and about their own experiences. Carefully placed reflections and questions invite supervisee/consultees to consider blind spots, things they may have missed, and perspectives not yet considered.  It seems to us an obvious conclusion that RS/C is immensely beneficial for any leader, and especially for those involved with systems and programs serving infants, young children and families.

    Next, we will share our work together as an illustration of how RS/C benefits leaders and systems in powerful and pivotal ways.  We offer our story with the hope that it will inspire you to consider your own work and the ways in which RS/C already has been, or could be, beneficial.

    Our Reflective Process

    When we began our reflective consultation experience together, we both came firmly grounded in IMH principles.  We share a passion for and commitment to supporting babies, young children and families.  Because of this, we were able to start with a shared language and perspective. What felt unique was that Meghan was no longer working directly or even closely with children and families. Part of her new reflective work became bridging her felt experience with parent-child relationships and attachment frameworks to her systems work.  This intentional linking over time helped us consider the eventual impact of Meghan’s work on the vulnerable young children and families whom the system serves. What felt similar was being rooted in relationship, development and the power of the parallel process. For example, when Meghan tapped into feelings of being overwhelmed with new professional expectations of her and her own evolving professional needs, we were able to easily make connections and contemplate how the baby is impacted when a parent’s expectations and capacity to offer support may shift along with each developmental milestone, depending upon the extent of how the parent’s own needs are being met.

    At other times, we did not explicitly link our work to a baby or family and instead relied on our trust in the parallel process in different ways.

    There is another way of conceptualizing “the baby” in policy and systems work that is also useful.  The baby represents, among other things, vulnerable persons or populations who do not yet have a voice, but whose needs are clear.

    This can be found either through data or anecdotally. For example, looking at the data that infants, toddlers and preschoolers are expelled from child care and preschool at 13 times the rate of children K-12 combined, and further that Black boys are expelled three times more than their white peers, it is evident that young children, and specifically African Americans, have a deep and complex experience that calls for radical systems change. This can feel like an enormous and daunting task for systems leaders to undertake.  RS/C offers the space to support  leaders in recognizing and processing evocative emotions that can result from startling data such as this in order to re-energize their own sense of agency, to stay connected with those in the system who are muted and disempowered, and to keep this work moving forward.

    The following excerpt exemplifies how we used the reflective space to support Meghan in her role as a leader in a large system. This particular example is in relationship to Meghan and her team of colleagues; however, these concepts hold true to any variation of systems relationships.

    We began our first session in person but most of the subsequent sessions were done virtually. This conversation took place about two years into our relationship.  A foundational relationship had been built for exploration and growth together and we had settled into a comfortable rhythm during our monthly RS/C sessions.

    Meghan’s Perspective

    “Our ability to be daring leaders will never be greater than our capacity for vulnerability.” (Brown, 2018, p 11)

    My first experience of professional reflection was during my work as an Infant Mental Health home-based therapist. It was emotionally intense, intimate and clinical. This was also my introduction to the felt experience of RS/C. Often in the midst of overwhelmingly evocative emotions such as grief and despair, secondary trauma and hopeless incompetence, RS/C offered me the space to learn how to lean into the vulnerability of really feeling these emotions instead of running from them. I learned that only then could I regain a sense of organization, piece together a coherent narrative and most important, guide my work with the babies and families I was there to support. The magic of the parallel process came to life, and with it came the realization that RS/C is the unique vehicle to explore it. This experience was foundational to discovering and tapping into my best professional self. Therefore, when I found an opportunity to move into systems work, my biggest fear was to lose touch with the families, with “the baby” and with this reflective side of me. I knew I would need to find a new way to meet this professional need in this leadership role. For me, this meant finding a RS/C provider who could support me in this new systems world.

    It may seem obvious, but one of the first lessons I learned is that systems are simply made up of people, and thus innumerous relationships. Therefore, the same IMH relationship-based principles apply — parallel process, rupture and repair, and the need for authentic connection to inspire high-quality work. This realization gave me comfort. I appreciated the familiarity of those IMH frameworks and recognized that working at a systems level required innovative ways of executing them in this new environment. As I began my new leadership role, I also embarked on a new reflective relationship with Faith, quite literally.

    “In the absence of authentic connection -we suffer.” (Brown, 2018, p. 25)

    As I began this new season of my career, I believed that I had a plan for how I could maintain my own professional need for connection. I knew this was a crucial element I needed in order to meet expectations set for me and  guide my work with others. However, as the work progressed, I noticed that I continued to miss the deeper emotional side of the process; the powerful experience of holding and “being with” others in a more profound way and of myself being seen in a more authentic way. Because of my deep appreciation of the parallel process, I quickly recognized that this void had begun to negatively impact my work, one of my greatest fears. This prompted me to reevaluate what I needed in order to be able to  be more authentic and effective.

    My fear of failure was realized and exposed during a particular meeting when I felt that I wasn’t communicating effectively with my team. I felt reflectively rusty and that was a big red flag. Working with my team, familiar thoughts and feelings flared up in my chest like a wave of heartburn. “What if I’m not a good enough leader? What if I can’t give my team what each of them needs to do this work well? What if I fail at finding a way to keep this work going?” I began to internalize the notion that if I was not a good enough leader in this state systems position, if I couldn’t meet the needs of my team, the consequences would be exponentially deeper. If I was not able to find a way to sustain this work, the consequences would be exponentially greater. The weight of responsibility washed over me, and I felt overwhelmed not only by the needs of the metaphorical baby, but by the thousands of babies all over the state who would suffer if I was not enough. That narrative was paralyzing. I felt stuck, unable to even prioritize what task to begin next.

    I brought all of these complex feelings and thoughts to Faith during our next session. I didn’t yet know how to organize them, but I trusted that by leaning into my vulnerability and sharing this in our reflective space, Faith would contain and validate these overwhelming emotions in a way that allowed me to process each of them, safe from judgment. And by doing so, albeit uncomfortably at times, only then could I join in her wonderings to move me from rigidity to action.

    Faith’s Perspective

    In working with Meghan, I found myself wondering: How do those who lead embrace vulnerability? What do they need from us?  How do we encourage their willingness to dip into the reflective space, into their emotional experience, on behalf of the babies, families and staff they serve? How do I use the familiar frame of RS/C to support Meghan in her leadership role? Over time, Meghan and I created a shared language that allowed us to explore all of these dimensions of the work together.

    Meghan’s particular experience  felt so familiar. Who among us has not felt like the world, the systems we work within and their problems, are so big and we are so small?  I am aware that when we are working within complex systems, it can be hard to slow down, to focus on one thing and organize our many layered thoughts and feelings.  Working in large systems requires us to always be holding many perspectives and needs in mind, to be thinking on our toes, and to be willing to take risks.  It can feel overwhelming and heavy.  As she talked, I noticed a feeling rising within me that paralleled Meghan’s.  If these feelings had words, they would say to me, “Oh gosh, this is too big.  I’m not sure how to help.  Maybe another consultant would know what to do.”  I had been here before, many times, and I knew I could use my own experience to inform me as I supported Meghan.

    When Meghan quieted and gave me the cue that she was ready for me to respond, I first took a deep breath.  I allowed a few moments of stillness and quiet.  Once we both had a chance to quietly breathe and re-center, I reflected to Meghan the emotional experience I heard her name — a sense of feeling overwhelmed and how that was leading her to feel  an intense sense of urgency. She agreed that this was how it was feeling to her, and that she was having a hard time regulating and organizing her thoughts.  This felt uncomfortable for her, as she was confused and could not figure out next steps when she was in this place.  As Meghan continued to describe the pressure she was feeling and the sense of being lost in all of the responsibilities, I was reminded of times in the past when she had come to our sessions with similar feelings. I had walked with her before through this process and knew she possessed the capacity to see herself through.  Since this emotional journey felt familiar, I decided to share that observation with her and wondered what she thought about that.  She immediately seemed to calm; her shoulders relaxed and she took a deep breath.  I asked her what she was thinking and feeling as she  remembered past conversations we had.  Meghan said she remembered that this is a familiar place of initial anxiety that she goes to, and she always finds a way through when she has the time and space to process.  I wondered with her if perhaps she comes to this place often because of how deeply she cares about the work, about her colleagues, and about the babies and caregivers she knows her staff are impacting.  Yes, she said, of course.  As we talked, she realized this place of feeling overwhelmed was not something she needed to fight her way out of.  It gave her important information. It reminded her that she was feeling strongly about something, and it offered her the opportunity to ground herself in her passion for the work. Our deeply felt desire to be helpful and make a difference for babies and families can be overwhelming, and it can also be energizing.  Once she felt like she had made sense and found some meaning in her strong reactions to this particular situation, her next steps became clear to her.  As her RS/C provider, I had the honor of holding the space while she made her way to a new place that allowed her to make a plan and feel empowered.

    Shifting Outcomes/Resolution

    RS/C is “A relationship in which strengths are emphasized and vulnerabilities are partnered.” (Shahmoon-Shanok, 2006, p. 343)

    Meghan’s reflective experience was very much rooted in the attachment-informed developmental need for a secure base — she needed to touch the wall of being in the reflective space in order to hold the emotional sense of urgency and discomfort of those doing the work directly with young children and the adults who care for them. She needed to find the balance of keeping the flame of urgency present, and yet not allow it to get to a point of overwhelming paralysis. This sense of urgency driven by the immediate needs of all of those babies, of their rapidly developing brains and attachment relationships, can often dampen with the distance and slow-moving evolution of systems work. Meghan was also searching for a way to continue to have hope and agency in order to effectively support the professionals within her system who  are responsible for nurturing our babies and young children and their families.

    Once she was able to “touch in,” to settle into that familiar and safe reflective space, she could then mentally prepare differently for the next team meeting. Here, she could foreshadow the possible triggering of the familiar internal narratives of self-doubt and incompetence. With the element of surprise inhibited, she could prepare a subtle regulation exercise that could re-ground her in that moment. During the next meeting, when the familiar feelings began to percolate, Meghan was able to respond rather than react.  She was able to recognize the physical sensations, name the parallel emotions, and lean into and contain them in a more controlled way. This allowed her to have the emotional energy to attune to the needs of the team, rather than expending that energy managing her own emotional response. As a result of this mental shifting, she was able to hear, validate and meet the needs of the team more effectively. This galvanized her belief that the responsibility of the growth and development of the team begins with her own willingness and capacity to embrace vulnerability.

    In our further reflections, we wondered together what the consequences may have been if Meghan had not had the opportunity to process her emotional reactions through RS/C.  What would her actions have looked like had she gotten stuck in the emotional mud of negativity? Certainly, it would have taken much longer, if ever, for her to effectively identify her own needs in order to be able to see more clearly the needs of the team. Undoubtedly, it would have led to creating patterns of miscommunication, rigidity, perhaps even feelings of rejection on both or all sides of the parallel process. Regardless of the specific path, we are certain that without the space to intentionally reflect, the negative reverberations would have been felt by many, including the babies and families we work so tirelessly to serve.

    Conclusion

    The familiar phrase, “You can’t give what you don’t get,” still holds true in systems work. How can those who lead learn the value of leaning into vulnerability in the absence of having that repeated felt experience? Direct service providers and their supervisors are regularly asked to venture into the reflective space with a trusted mentor in service of their work with vulnerable babies and families.  But what about those who supervise them?

    It is imperative for those creating policies and practices to keep “the baby” and all of the corresponding relationships in mind. Having access to RS/C space allows leaders to tolerate discomfort, mistakes, rupture, and vulnerability, all of which are necessary to access creativity, attunement, growth and mitigate bias.

    Over the past two decades, the IECMH field has evolved to embrace RS/C as best practice for many varied roles. We believe the same expectation and support should exist for systems leaders as well.  Relationships impact relationships, and systems leaders will always be a part of the relational orbit surrounding direct service providers, families and babies.  Therefore, “how they are,” and not just what they do, matters greatly.  RS/C for leaders is a crucial strategy that needs to be woven throughout all levels of the system if we are to continue improving quality and outcomes in IECMH-informed services for our little ones and those who care for them.

    References

    Alliance for the Advancement of Infant Mental Health. (2018). Best practice guidelines for reflective supervision/consultation. Retrieved from https://www.allianceaimh.org/reflective-supervisionconsultation

    Brown, B. (2012). Daring Greatly. New York, NY: Penguin Group (USA) Inc.

    Shahmoon-Shanok, R. (2006). Reflective supervision for an integrated model: What, why & how? In G. Foley & J. Hochman (Eds.), Mental health in early intervention: A unity of principles and practice (pp. 343-381). San Francisco: Jossey-Bass.