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Reprinted from The Infant Crier, July-September 2005

John Bowlby described attachment as a fundamental need that has a biological basis. Attachment serves as a protective device for the immature young of many species, including humans. Babies need the care of adults to survive, and they have many built-in behaviors, such as making strong eye contact, cooing and vocalizing, and smiling, that attract adults to them. The primary function of the infant’s attachment behavior is to keep close to a preferred person, in order to maintain a sense of security. When an infant becomes distressed both parent and infant take actions to restore the sense of security. For example, an infant becomes upset and communicates this by looking anxious, crying, or moving closer to her mother. The mother moves towards the baby, soothes her with her voice and picks her up. The baby continues to fuss briefly, then molds to the mother’s body, stops crying and soon begins to breathe more slowly and regularly, indicating a decrease in arousal; her sense of security has been restored. In Bowlby’s terms, the infant’s distress signal, which is functionally an attachment-seeking behavior, activates the mother’s side of the attachment system and the mother takes steps to calm the baby’s distress.

Although the behavioral expression of attachment varies across cultures, attachment is a universal phenomenon in humans. What factors seem to be universal? A baby needs to have an attachment to a primary caregiver (or in many cultures, to a set of primary caregivers). Consistency, sensitivity and contingent responsiveness on the part of the caregivers are essential to the baby’s psychological development. Across cultures, secure-base behavior – the child’s ability to use the caregiver for relief of distress and support for exploration – has been identified as a marker of secure attachment.

How Attachment Develops

Infants make attachments with specific people. Although a newborn may be comforted by anyone who picks her up, she very quickly differentiates her primary attachment figure(s) from others. During the early weeks of life she learns the particular qualities of her mother (assuming the mother is the primary caregiver). Through repeated interactions, she learns to recognize her mother – what her face looks like, what she smells like, what her touch feels like, and how her voice sounds. Through this process the infant’s attachment becomes specific and preferential. In most cultures, infants’ attachments have an order of preference, usually to mother, then father, and then siblings, although infants who are in care full time with a single caregiver often develop an attachment to her that is second only to the mother. Infants and toddlers do form different types of attachment with different caregivers. In cases where a child has an insecure attachment with a mother, a secure attachment with another important caregiver – father, grandparent, or regular child care provider – may take on a compensatory, protective function for the child’s development.

Other Functions of Attachment

In addition to providing a sense of security, the attachment relationship serves other functions that promote the baby’s development.

Regulation of Arousal and Affect

“Arousal” refers to the subjective feeling of being “on alert,” with the accompanying physiological reactions of increased respiration and heartbeat and bodily tension. If arousal intensifies without relief, it begins to feel aversive and the infant becomes distressed. When this happens the infant sends out distress signals and moves toward the caregiver. In a secure attachment the infant is able to draw on the mother for help in regulating distress. The mother’s affective response provides soothing or stimulation to help the infant modulate arousal. Over time, infants and parents develop transactional patterns of mutual regulation to relieve the infant’s states of disequilibrium. Repeated successful mutual regulation of arousal helps the infant develop the ability to regulate arousal through his own efforts. Through the experience of being soothed, the infant internalizes strategies for self-soothing. As development proceeds, good self-regulation helps the child feel competent in controlling distress, negative emotions, and impulses to act out promoting the expression of feelings and communication. By 4-6 months the attachment relationship evolves into a vehicle for sharing positive feelings, and learning to communicate and to play. For example, a 6-month-old infant initiates a game of peek-a-boo (which has been previously taught by her father) by pulling a diaper over her face. Her father responds by saying, “Oh, you want to play, huh?” and pulls the diaper off, saying “peek-a-boo!” and smiling and looking into the baby’s eyes. The baby smiles and begins to wave her arms and kick her feet. The father says warmly, “Oh, you like to play peek-a-boo, don’t you?” The baby vocalizes, then begins to pull the diaper over her face again in order to continue the game. Interactions like this one reveal qualities of attachment relationships that support emotional and cognitive development: mutually-reinforcing, synchronous behaviors on the part of the parent and infant, a high degree of mutual involvement, attunement to each other’s feelings, and attentiveness and empathy on the part of the parent.

A Base for Exploration

From age 1 on, the attachment relationship becomes a base for exploration of the wider environment as well as the child’s developing competencies and her inner world. Attachment theorists consider the motivation to explore and learn about the world and to develop new skills to be as intrinsic in infants as attachment motivation. The confidence with which the child ventures out depends a great deal on her confidence in her attachments. If a toddler has a secure base in her attachment relationship, she will feel free to explore her environment, with the implicit awareness that the caregiver is available if needed.

How Attachment Shapes Future Development

The child gradually develops a working model of attachment based on how he has been cared for and responded to within the attachment relationship. Over the first few years of life, working models become stabilized as expectations of how relationships work, and what one can expect of other people in terms of responsiveness and care. Correspondingly, models of the self in relationships also develop. The young child internalizes assumptions about how effective she is in using relationships, how valued she is, and how worthy of receiving care. The infant whose attachment initiatives have been responded to appropriately over time develops working models which say, in essence: “I can expect that people will respond to me with interest, concern and empathy. My actions are effective in communicating my needs and maintaining my attachments.”

A central component of working models is a view of the self within relationships, which contributes strongly to the child’s self-representation. The child with a history of secure attachment is likely to develop a positive sense of self, while children with insecure attachments are more likely to develop disturbances in the view of self and in the capacity to maintain self-esteem. Working models also include a view of one’s ability to regulate arousal and cope with stress. Infants who have been effectively helped with regulation of arousal through the soothing and contingent responding of their caregivers develop effective internal and social strategies for regulating affect and arousal and become more competent at coping with stress. By contrast, infants who have experienced high levels of arousal and intense affect, without the help of mutual regulation, are likely to internalize a view of the self as ineffective or out of control and to develop maladaptive coping strategies, such as affective numbing or hyper-reactivity leading to aggression and tantrums.

Once established, working models tend to become unconscious. They become filters and organizers of the child’s perceptions about relationships. They increasingly guide how the child appraises what is happening in relationships and how she behaves with others. By the third year, the working models developed through the child’s primary attachment relationships have become relatively stable, and are now applied to other relationships. The 3 year old with a history of secure attachment tends to expect that child care providers will be interested, supportive and responsive. The child with a history of insecure attachment may mistrust the intentions and emotional responsiveness of other adults. In either case, the child unconsciously attempts to organize, shape and perhaps control new relationships to make them fit her internal working models.

At the same time, assuming that parental behavior in relation to the child remains relatively constant, the child’s working models are continually being reinforced through ongoing transactions with parents. Although working models can change through changes in parenting style and experiences in new relationships, this becomes increasingly harder after they have become stabilized between ages 3-4. An obvious example is that many children who enter foster care following removal from the parents because of physical abuse behave in ways that seem intended to provoke abusive responses from foster parents. When the child projects working models in this way, the responses of others often reinforce working models, stabilizing them further. For example, if the foster parent reacts negatively (though not abusively) to the abused child’s provoking behavior, the child’s affective experience with a new caregiver feels consistent with abuse, and his working models are confirmed. However, many abused children do not continue to re-enact old relationships, but instead are gradually influenced by the responsive and empathic behavior of new caregivers. Although working models tend to be powerful and persistent, they can be changed through good care.

Longitudinal research by Alan Sroufe and his associates at University of Minnesota has found impressive links between quality of attachment in infancy and later development. Secure attachment in infancy and toddlerhood predicts social competence, good problem solving abilities, and other personality qualities associated with successful adaptation in later childhood, adolescence, and adulthood. Insecure attachment has been similarly linked to problematic behavior and social difficulties in school age children. Although other factors such as infant temperament and environmental risk factors influence outcomes, the overwhelming evidence of empirical studies makes clear that quality of attachment is a fundamental mediator of development.

Attachment Research

Attachment theory has become one of the most important constructs informing the study of human development. I do not have space to discuss the many directions attachment research has taken. (A good review of that research up to 1999 is represented in J. Cassidy & P. R. Shaver (Eds., 1999), “Handbook of Attachment,” New York: Guilford Press). Instead, I will briefly summarize research on patterns of attachment, in particular because it is so relevant to infant mental health practice.

In the 1960’s Mary Ainsworth did an observational field study of mother-infant interaction patterns of the Ganda people of Uganda. She found that two factors – maternal responsiveness and sensitivity, and infant reactions to separation – were the most important indicators of quality of attachment behavior of Ganda mothers and infants. Based on these observations, Ainsworth developed the “Strange Situation” procedure in order to assess the quality of attachment. This procedure aims to create mild but increasing stress on the attachment relationship, in order to observe the 12 to 18 month old infant’s attachment strategies and the degree of security of attachment. The most stressful episodes in the Strange Situation involve the mother’s leaving the infant with a stranger, returning briefly, and then, after the stranger leaves, leaving the baby alone very briefly. Ainsworth found that the infant’s response to the mother’s return was the most sensitive indicator of quality of attachment. Securely attached infants showed characteristic responses when reunited with the mother, and insecurely attached infants also reacted in distinctive ways.

Secure (Group B) infants reacted to the mother’s return with relief and pleasure, immediately seeking comfort from her if they were distressed, and calmed quickly in response to the mother’s soothing. Their history of responsive care gave them confidence their mother would be emotionally available to them following the stress of a brief separation.

Insecure-Avoidant (Group A) infants tended to ignore or avoid the mother at reunion and continued to play in an independent and self-reliant way. Given the normal importance of attachment for an infant, attachment theorists have described the Avoidant pattern as a defensive strategy. Ainsworth’s concurrent double-blind in-home study suggested why an avoidant defense might be needed: the Group A babies were frequently ignored and actively rejected by their mothers, who tended to reject or punish the infant for being distressed. Out of these interactions, Avoidant babies develop precocious defenses against feelings of distress. Distress is split off from consciousness, and the defense mechanism of isolation of affect emerges. Avoidant infants tend not to show upset in situations that are distressing for most infants; rather they appear somber, expressionless or self-contained. The Avoidant pattern should not be equated with non-attachment. Rather, the defensive strategy of avoidance is the baby’s way of staying close to the parent while protecting herself from overt rejection. The Avoidant pattern predicts inappropriate self-reliance and negativity and mistrust in relationships in future development.

Insecure-Ambivalent/Resistant (Group C) infants showed behavior in the Strange Situation that conveyed a strong need for attachment but a lack of confidence in its availability. They reacted with great distress to the separation, could not be soothed by their mothers, and angrily resisted comforting even though they clearly wanted it. The in-home study described the mothers of ambivalent infants as inconsistently responsive to their infants’ attachment-seeking behavior. The infants’ heightened affect and ambivalent behavior reflect their anxious uncertainty about how their parent will respond. The C pattern predicts continuing preoccupation with attachment concerns and problems functioning autonomously in later development.

Mary Main and her colleagues developed a protocol, the Adult Attachment Interview, that reliably assesses attachment styles in parents. What distinguishes “Secure” adults is their ability to speak openly and coherently about, to understand, and to integrate their early attachment experiences. “Insecure” adults (in categories that parallel the A, C, and D infant classifications) have difficulty giving coherent accounts of their own attachment experiences, rely on defensive processes that make integration of experience difficult, and tend to either dismiss the importance of attachment or to remain preoccupied with anxiety about their attachments. Independent assessments of the infants of parents studied using the Adult Attachment Interview show that adults in the Secure category have infants who are also judged secure, while Insecure adults have infants who are classified into one of the insecure categories.

The Attachment Perspective in Infant Mental Health Practice

The utility of the research findings that have validated attachment theory is that they orient us to observe interactional sequences and to look for congruency between parental working models of attachment and infant/child attachment patterns. For example, on a home visit a worker notes that a parent treats her baby roughly while changing his diaper, and seems frustrated over having to care for him. At the same time, the baby does not look at his mother, turning his head away when she comes near. These observations, which must be supported by future observations, suggest an Avoidant attachment.

Parents with working models derived from histories of secure attachment are responsive to their children, who in turn tend to develop secure attachments and positive working models. In contrast, parents who dismiss the importance of attachment are likely to dismiss their children’s needs for comforting and nurturance. When these negative attitudes carry over into caretaking transactions, the infant is likely to adopt the Avoidant pattern.

Although research contributes to our clinical understanding, it is important to distinguish between research instruments and clinical practice. The Ainsworth Strange Situation and Main’s Adult Attachment Interview reliably reveal attachment patterns when applied to individuals in a research setting. However, they are not directly transferable to practice. Research procedures require adherence to protocol, while clinical practice requires the flexibility to respond to the needs and manner of presentation of clients, and emphasizes the importance of developing a collaborative relationship with the parent. Nevertheless, knowledge of attachment patterns derived from research allows the infant clinician to observe for interactions and behavior that suggest a particular type of attachment.

Due to space considerations a bibliography is not included. Complete references are found in D. Davies text (2004). Child Development: A Practitioner’s Guide (2^nd Edition). New York: Guilford Press.

 

EDITOR’S NOTE:

This case study examines the complexities of navigating the child welfare system on behalf of a three-year old. It is made clear quickly that the Infant Mental Health (IMH) therapist has to become familiar with competing individuals, relationships, and issues, as often is the case when working with child welfare involved families. These types of cases can pose many unique challenges that can be difficult to assess in the moment.

An example of one of these challenges, played out in this case study, is the mandated reporting requirement. Most therapists face a time in their clinical career when they are confronted with the difficult decision of when to report suspected abuse and/or neglect; this decision is not always clear. The IMH therapist in this case had numerous concerns about the safety of her three-year old client and relied on her relationships with her reflective supervisor and the foster care worker to relay those concerns. By the conclusion of this case study, it is apparent that the foster care worker did not communicate the therapist’s concerns to anyone, but most specifically, she did not share them with Child Protective Services (CPS) or the lawyer-guardian ad litem (LGAL). Because of the severity of the therapist’s concerns, there was an opportunity for her and her reflective supervisor to consider notifying CPS in addition to the foster care worker all throughout this case. This may have made for an even stronger case about the seriousness of the therapist’s concerns and could have accelerated the process of involving the LGAL.

It is important to address the challenge of this situation, as we know that it is not unique to this case. Many therapists and supervisors struggle with the conflicting roles and relationships that are placed upon them within the legal and foster care systems. In this case study, the route that the therapist took – fiercely advocating for her client’s safety – led to his ultimate security, however, there are many different routes that could have been taken to achieve the same outcome.

It is of additional importance to examine the therapist’s mode of intervention; she utilized the Infant Mental Health Home Visiting (IMH HV) model (Weatherston & Tableman, 2015) as a basis for intervention within this case study. The IMH HV model came out of Selma Fraiberg’s model of “kitchen table therapy” which was coined and created in the 1970’s. It has not escaped our notice, that when Selma Fraiberg created this technique, it was used as a prevention service for parents who were still capable of being good parents, however, needed additional assistance in doing so. As the need and demand for services for 0 – 3 year olds has evolved over the years, traditional IMH services have expanded to incorporate intervention and treatment services. The IMH field has been challenged with how to incorporate the traditional model, created by Selma Fraiberg, into the legal and foster care system.

We invite you, the reader, to utilize the comments window found at the end of this article to share your own experiences, including challenges, successes, and questions, in working with child welfare involved families.

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Three-year-old Jordan* was referred to a Community Mental Health infant mental health program because he was displaying signs of what his foster mother thought might be Post-Traumatic Stress Disorder (PTSD). His symptoms included severe separation anxiety, reoccurring nightmares, shaking, and stomachaches before visits with his biological father, Stan. Jordan would hide under furniture, screaming “Don’t take me! I am scared!” According to the referral, Jordan’s foster mom and teacher had also decided that it was not in his best interest to remain in his Early Head Start (EHS) classroom because of his persistent fear that his foster mother would abandon him there.

  “Don’t take me!  I am scared!”

Jordan’s biological parents had a history of life threatening and extensive domestic violence. He was removed from his parents’ care when he was 18-months old because of extreme neglect and physical abuse. After his removal, Jordan had had unsupervised visits with his mother and separate, supervised, visits with his father. Stan was not supposed to attend the unsupervised visits, but once, after Jordan’s mother invited him over, Stan held a knife to Jordan’s neck in an attempt to get his mother to do something he wanted. Jordan’s mother escaped and called the police. Neither she nor Jordan were physically injured; however, this experience added greatly to Jordan’s experience of trauma. Both parent’s rights were terminated soon afterward. Then, a year after Jordan saw Stan for the last time, Stan appealed his case and his rights were reinstated. A judge ruled that Jordan was to begin having supervised visits with his father again, effective immediately.

When Jordan entered the infant mental health program, he had been having weekly visits with his father for 6-months. Based on the information from the intake referral, it was clear to the therapist that she needed to attend the supervised visits both to observe Jordan and Stan together and to build relationships with them. Stan’s many concerning behaviors and statements were soon evident.

The IMH therapist believed that Jordan was being re-traumatized during the visits by things that his dad would say and do. Specifically, Stan regularly referred to knives and told incredibly violent stories; more often than not, he was part of the stories. The IMH therapist observed Jordan while Stan told these stories. Jordan’s face, which was typically flat and vacant during the visits, would transform. His eyes would widen and his jaw would tighten. If he was engaged in an activity, he would stop and his body would tense. Although he was very still, he looked as though he could run out of the room at any minute if he wanted to. The IMH therapist was aware of her own feelings of fear and wish to flee from the room as well.

The IMH therapist brought her own fears to her next reflective supervision: “How do I balance my feelings of being frightened with my wish to protect Jordan, while understanding my need to first build an alliance with Stan?” The IMH therapist wanted to react and move quickly to keep Jordan safe. The supervisor listened carefully, acknowledging how frightened the IMH therapist felt, and wondered if she might try to understand what explained Stan’s need to tell violent stories that frightened her and Jordan as well.

“How do I balance my feelings of being frightened with my wish to protect Jordan, while understanding my need to first build an alliance with Stan?”

During the next visit, the IMH therapist spoke with Stan about how Jordan might be experiencing hearing his father talk about knives. “That was a scary story. What do you think Jordan is feeling or thinking about what you just said? Could he be remembering past events where there was a knife?” she wondered aloud. Stan dismissed the IMH therapist’s questions and said, “That whole knife thing was long time ago. He was a baby. He’s fine now.” The therapist continued and said, “Just now, when you said, ‘knife,’ I saw Jordan’s face and body tense. Do you see his face right now?” Stan said, “That ain’t nothing. You’re making that up.”

On several other visits, the IMH therapist observed Stan scare Jordan purposefully and laugh when Jordan appeared hurt or sad. One incident was especially difficult. A small table tipped over and fell on Jordan. Jordan cried and looked first at the IMH therapist and then at his father. Stan laughed and taunted him, “Don’t be a baby!” and did not move to be near Jordan. The IMH therapist spoke aloud for Jordan, who was still crying, “That was scary, dad. The table fell on me and I am hurt.” Stan said, “I was toughened up like that when I was a kid and that’s how I’m raisin’ him.” “No kid should be toughened up or frightened like that. I am sorry that happened to you,” the IMH therapist said softly. She paused and both were quiet. She continued, offering developmental guidance about appropriate ways to talk with a 3-year-old, including the type and content of information that Jordan could understand. Again, Stan dismissed the IMH therapist’s concerns; it seemed as though he was unable to take on the perspective of others.

The supervised visits went on over the next two months, and Stan periodically related violent incidents that he had recently been involved in. Once, the IMH therapist observed Jordan look at his father, with his eyes large and his voice weak, and ask, “If I go to your house again, are you going to lock me in the basement again?” The IMH therapist waited for Stan to respond. Instead, he laughed and replied, “I only did it a couple times and I was joking.”   The therapist replied, “Stan, Jordan looks terrified. Look at him. His facial expression tells me that he did not think it was a joke. I am very worried about what that experience was like for Jordan. He continues to show us, week after week, that he is fearful of you when you say terrifying things and I am very concerned that these are the types of things he believes you will do to him if he lives with you again.” She was extraordinarily concerned at this point about Stan, the possibility that he might regain custody of his little boy, and the possibility of abuse.

Following this visit with Stan, the IMH therapist reported her concerns about emotional abuse to Child Protective Services (CPS), citing many of the concerning statements she had heard Stan say to Jordan during their visits together. The IMH therapist was incredibly disheartened and troubled when she received a letter in the mail a week later stating that what she described did not meet the definition of abuse and neglect.

At the same time, the IMH therapist balanced the complexities of building a relationship with Jordan and his foster mother, Ms. Stewart, within his foster home. The IMH therapist arrived on the same day and at the same time each week. Jordan and Ms. Stewart came to anticipate the therapist’s arrival and would wait for her at the window. Trust between Jordan, Ms. Stewart, and the IMH therapist was beginning to form. Ms. Stewart shared how relieved she felt that the IMH therapist was “really listening to her.” She believed that the IMH therapist was taking her concerns about Jordan seriously. During their visits, the IMH therapist observed Jordan smile, laugh, play and interact, as she would expect a 3-year old to do.

Within these same visits, the IMH therapist also observed the anxiety and panic that Jordan experienced when Jordan’s foster mother left the room. He threw his body on the floor and screamed, “Don’t leave me! Don’t leave me!” The IMH therapist observed Ms. Stewart go to him and calmly explain what she was going to do and that she’d be back in a few moments. The IMH therapist observed Jordan’s body remain tense as he added, “You won’t come back!” Although she returned in a few minutes, it took Jordan twenty minutes to calm down. All the while, his foster mother sat next to him, rubbing his back, and using her words to attempt to comfort him. Ms. Stewart shared, “This is how he acts every single day. He did this every morning when I dropped him off at Early Head Start. There wasn’t anything that I could say or do that would convince him that I would come back. That’s why we had to take him out of the program.” The IMH therapist said quietly, “That must have been so difficult for Jordan and for you. He was very, very frightened when you left him.”

The IMH therapist also was in regular, weekly, contact with Jordan’s foster care worker. Each time they spoke, the IMH therapist emphasized her concerns about Jordan’s well being, sharing specific observations of Stan’s behaviors and comments. On one particular call, she shared that she had made a CPS report with concerns about emotional abuse. She elaborated aloud, “Jordan asked Stan if he was going to lock him in his basement if he were to return to Stan’s home. He appeared absolutely terrified when he asked Stan this.” The foster care worker sounded surprised but shared that she had concerns as well; however, her main concerns were specific to Stan’s inability to behave age-appropriately with Jordan. She went on to say that Stan was following his treatment plan, which included getting his own mental health treatment and regularly attending the supervised visits, and said that neither she nor her supervisor felt that the foster care agency had much of a basis to terminate his rights at this time.

After a few months continuing this way, the therapist told her supervisor that she felt stuck and discouraged because Stan’s behaviors and Jordan’s reactions were not changing. The therapist was still incredibly worried about Jordan’s well-being and continued to believe that Jordan was being re-traumatized by his visits with Stan. The therapist wondered with her reflective supervisor about the depth of treatment that could occur given the limited reflective capacity that Stan had demonstrated so far within individual sessions with the therapist and the supervised visits with Jordan. Ultimately, they decided that the therapist should shift gears and use her time to advocate on Jordan’s behalf with court professionals. The therapist needed to ensure that Jordan would be safe. Only then would he be ready to process his trauma.

The therapist approached Jordan’s foster care worker with her plan and shared that she hoped that the two of them could join forces and advocate for Jordan. Unfortunately, Jordan’s foster care worker and supervisor felt “their hands were tied” since Stan’s rights had been reinstated. Despite her concerns, the foster care worker said she wouldn’t ask for termination of rights.

The therapist believed that she needed to continue to advocate for Jordan despite the foster care worker’s stance. Stan signed a release agreeing that she could speak with the child’s lawyer-guardian ad litem (LGAL), who had been working on the case for the previous two years. But before the therapist was able to express her concerns during a telephone conversation, the LGAL said that she was happy with Jordan’s progress – noting that the foster care worker had reported that Stan had actively been participating in his treatment plan and attending all supervised visits – and that she thought Jordan might eventually be returned to his father’s care. When the therapist reported that she had many concerns about Jordan’s and Stan’s relationship and ultimately Jordan’s safety and that she wanted to talk with her in person, the LGAL seemed surprised but agreed to meet. Upon hanging up the phone, the therapist wondered if the LGAL hadn’t known that anyone was concerned about Jordan’s situation or well-being.

The IMH therapist recalled that Jordan’s foster care worker had videotaped some of her observations of Jordan. She encouraged the foster care worker to share this video with the LGAL so that the therapist and LGAL could watch the video together. The LGAL started the meeting a bit defensively, talking about her observations of Jordan and Stan and saying, “within those few minutes that I was present, he always seemed fine, so I assumed he was.” The therapist shared her observations and concerns, including a videotape Jordan’s foster care worker had taken immediately before one of Jordan’s visits with Stan. In the video, Jordan can be seen visibly shaking and saying that he is scared to see his dad. He said, “I don’t want to see him EVER AGAIN! I want to stay home forever.” Jordan was also heard saying that his stomach hurt and that he didn’t want to go. The LGAL appeared shocked and thanked the therapist for sharing the video. She explained that during her observations, once every three months, she did not pick up on the fact that Jordan seems “terrified of his father,” which is what she said she strongly believed after seeing the video.

The therapist asked the LGAL if there was anything else that she should do to advocate for Jordan, and, ultimately, help Jordan feel safer. The LGAL stated that the therapist could encourage the foster care worker to let the prosecutor see the same video, but noted that Stan’s attorney would also need a copy of it. Within a day, the therapist contacted the foster care worker and asked her to make copies of the video and to make sure that Stan received one. Next, the therapist met with the prosecutor, who agreed to collaborate with her and helped create questions that the therapist could answer in court so that observers could understand the concerns about Jordan. They decided that the therapist should also share these questions with the LGAL.

On the day the IMH therapist was to appear in court, she and her reflective supervisor made plans to keep her safe; she was concerned and scared about Stan’s reaction to her testimony. During the permanency planning hearing, the prosecutor and LGAL both asked the IMH therapist the questions they had rehearsed: “Will you share with the court what you have observed of Jordan prior to visits with his father?” “Can you please share with the court your concerns of dad bringing up violent stories during supervised visits in front of Jordan?” “What have you observed Jordan’s reactions to be of these stories?” “Have you discussed with Stan the concerns of him sharing these stories in front of Jordan, and has he been able to make any changes to the stories he shares since your discussion?” At the hearing’s conclusion, the judge determined that supervised visits were not in Jordan’s best interest and that Stan’s parental rights would be terminated. The judge concluded by saying, “Jordan has made it very clear in the best way he knows how, that these visits are harmful to him. Stan has been given plenty of time and support to make changes to help Jordan feel safer in his presence and he has not been able to make these changes. Jordan has been more than patient over the last two years as we gave Stan another chance to parent his son. It is in Jordan’s best interest that he is given the chance to move forward with adoption by his foster family and continue in therapy.”

Relieved with this result, the therapist and foster mom decided to share the news with Jordan together. After Jordan’s foster mother told him that he wouldn’t have to meet with his father anymore, he smiled broadly and said, “Really!? I don’t have to go anymore!? You promise!?” The therapist knew she had made the right decision to press forward and work to keep Jordan safe.

“Really!? I don’t have to go anymore!? You promise!?” 

Jordan had been living with his foster family – who wanted to adopt him – for 2½ years when Stan’s rights were terminated. Now, the work to develop a narrative for Jordan and help him work through the trauma he had experienced could begin.

It has been three years since the therapist was introduced to Jordan; two years since his last visit with his father; and 1½ years since Jordan was officially adopted by his foster parents. Through extensive home visit services provided by the therapist, which include play therapy, supportive counseling, developmental guidance, advocacy, emotional support and infant-parent psychotherapy, when appropriate, Jordan has been able to work through his trauma and to develop a secure attachment relationship with both of his adoptive parents. Jordan is now 6-years old, thriving in kindergarten, and engaging in activities within the community.

 

*Names and certain details of this story have been changed to protect the privacy of the families described.

Kerry Baughman is stepping down as Co-Editor of the Infant Crier as she assumes new responsibilities as Director of Northwest Michigan Community Action Agency’s (NMCAA) 10 county Head Start and Early Start program.

Under Kerry’s leadership, the Infant Crier changed from a paper document to an online edition making it immediately accessible to readers and providing a more interesting and appealing newsletter. She developed a year-long theme focusing on infant mental health research in Michigan, the first time this was a focus in the Infant Crier. Her technical skills, editing, thoughtful reflection and attention to detail have resulted in outstanding issues over the last 3 years.

Kerry is an active member of MI-AIMH, serving as President of the NW Michigan Association for Infant Mental Health since 2013 and previously serving as the NW MI chapter representative to the MI-AIMH board. She was also an active member of the NW MI IMH Training Consortium. She has been a home visitor, Great Start Collaborative Coordinator, and, for the past 7 years, Manager of NMCAA’s Early Head Start program. Her commitment to promoting early developing relationships, staff training and endorsement, and reflective supervision make her an outstanding choice for her new responsibilities. Although we will miss her skill and leadership for the Infant Crier, it is exciting that she will continue to promote infant and early childhood mental health across northern Michigan.

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

Screening & Referral

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

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

Comprehensive Diagnostic Evaluation

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

Behavioral Health Treatment Services (BHT)

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

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

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

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

Resources

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

 

For further information: 

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

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

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

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

 

Citations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The MI-AIMH Board of Directors is very pleased to welcome Cathy Liesman, Ph.D., IMH-E (IV) as President and Rosalva Osorio, L.M.S.W., IMH-E (III), as Vice President of the Michigan Association for Infant Mental Health Board.

Cathy is currently the Chief Operating Officer at Development Centers, Inc. (DCI) in Detroit and has had administrative responsibilities at DCI since its founding in 1983. She has a Ph.D. in Psychology and is endorsed at Level IV-Policy Mentor. Cathy has served on the MI-AIMH Board of Directors for 20 years as President, Social Action Committee Chair and Treasurer. She was the recipient of the Betty Tableman Award in 2001 for her advocacy work and has cherished her connections to her many MI-AIMH colleagues throughout her career.

Cathy describes advocating for relationship-based work, services for young children and MI-AIMH as her avocation. Her skills in relationship-based work extend from relationships with families to working within and across systems as she has supervised, secured grants, developed programs and successfully advocated for children and families. She helped to grow Development Centers, Inc. into the comprehensive agency that it is today serving over 11,000 persons and their families each year in mental health, vocational, Head Start and prevention programming.

She is very excited about serving as MI-AIMH’s president as she believes that MI-AIMH has a critical role in workforce development and support of the professionals in multiple disciplines who work with very young children and their families. She sees MI-AIMH as a “wonderful vehicle” for the collaborative work of cross-system advocacy for best practice and services for very young children and their families. Cathy is excited about the talent of current board members who bring a diversity of skill, talent and discipline. She explains that each person’s skills are needed to continue to move MI-AIMH forward with the refining of MI-AIMH within Michigan as well as the promotion of the national organization, the Alliance for the Advancement of Infant Mental Health.  Cathy believes it is important for individuals to be ambassadors of MI-AIMH and relationship-based work. “It is the depth of who we reach as individuals that makes our work so far reaching.”

As the current president Cathy offers stability, knowledge of organizations and a commitment to continue to work for the growth accomplished by the staff and board.

Rosavla Osorio is a Clinical Director at The Children’s Center, one of two contracted providers of Detroit-Wayne Mental Health Authority dedicated solely to children’s services. Prior to her current position she was Program Supervisor for Infant Mental Health Services at Southwest Counseling Solutions, where she “fell in love with infant mental health.” Rosalva earned a Masters of Social Work at the University of Michigan and is endorsed at Level III, Infant Mental Health Specialist.

She greatly appreciates the reflective process in infant mental health as a way for clinicians to learn about themselves and be a “tuning fork” for families with very young children.  She describes a family she worked with for 3 years that helped her understand and value infant mental health. She recalls the joy the family experienced when their medically fragile young child learned to sit up and then walk. His mom, who initially felt defeated and inadequate, came to see herself as competent and important to her toddler. Rosalva wants to help other young children and their families find joy together.

Rosalva explains that she experienced “ghosts” from her family of origin and that the birth of her daughter, Isalia, now 12, was an opportunity to grow and change to become better.  She understood that being a young mother would be hard but wanted to be her best for Isalia. “She is my biggest piece of artwork, my biggest joy.” She has been intentional and reflective in her parenting and acknowledges that this is an important part of infant mental health work.  She is grateful to Jennifer DeSchryver, Psy.D., who served as consultant when Rosalva was at Southwest Counseling Solutions. She saw Rosalva’s talent and passion and recommended her for a board position.

Rosalva believes that each of us has talent to bring to the infant mental health field. “I get so passionate about being a change agent,” she stated, “so I speak up. People see things in me that I didn’t see in myself.”   She recalls being intimidated when she joined the board 3 years ago, yet finding it “humbling and an honor” to work with people she admired. She soon realized that “we are all human and all learning.”  She believes being a part of change is about creating relationships and hopes that other MI-AIMH members will step out of their comfort zone to advocate on behalf of infants, toddlers and their families. She is excited to continue to move MI-AIMH forward wanting it to be the first place that everyone goes to for information about infants, toddlers and their families. Rosalva will serve for one year as Vice President and then move into the MI-AIMH Presidency.

Mothers’ and fathers’ engagement and support for young children after they experience distress teaches young children valuable skills in coping with negative emotions (Eisenberg, Cumberland, & Spinrad, 1998). This process is particularly critical in early childhood when these skills are emerging and in low-income, high stress populations (Raver, 2004).  Although dyadic (parent-child) regulation processes have been well studied, less is known about emotion socialization in the context of triads (mothers, fathers, and children) in this population. Among older children and their families, as well as among wealthier counterparts, research shows that characteristics such as family stress and parents’ psychopathology are related to how mothers and fathers support their children’s expression and management of negative emotions (Nelson, O’Brien, Blankson, Calkins, & Keane, 2009). In our work, we are investigating if triadic engagement (mother, father, and child) after stressful events is a context for family emotion socialization.  In short, we are interested in how joint interactions between family members serve as a context for children’s learning about emotions.  We expect that parents’ psychopathology and family stress will impact the quality of these family interactions.

Research Questions

In the current study, we explore the following research question: What factors in parental reports of their own mental health, as well as in their perceptions of their children and families’, predict their capacity to engage with their young children following a stressor? We are particularly interested in how parents provide emotional support to their young children after a stressful experience, especially when in the presence of another parent, and the ways in which “repairs” are made in interactions (such as when a disruption in the interaction occurs if a parent misinterprets a child’s cue).  Such supports and repairs are thought to promote children’s early emotional development, though this idea has not been investigated in the context of triads.

Overview of Study Methods

The current study describes data collected in a broader, ongoing study (Toddlers’ Emotional Development in Young Families; TEDY; PI: Bocknek) from urban families (89% African American) recruited from WIC centers. Two-year-old children (M=26.73 months), their biological mothers, and secondary caregivers (67% biological fathers) enrolled. Eighty-three percent of families reported annual incomes of $20,000 or less, and 16% were married. Both parents reported on child behavior, family functioning, and psychopathology. In addition, the families participated in a set of observed interaction tasks. The current study includes only those families in which the biological father participated (N=45) and describes data coded during a structured play task where mother-father-child triads reunited after a short separation and blew bubbles together for three minutes.

Behaviors were coded using a microsocial coding system that captured the occurrence of social bids and responses among children and parents [e.g., child vocalizing to parent and parent responding in a meaningful way; parent giving a direction and child promptly following the direction].  The duration of engagement among family members was also coded.  Specifically, the percent of time all three members of the triad were actively engaged (e.g., harmoniously interacting in a joint activity) with each other was assessed. Results suggested that families were relatively engaged most of the time (i.e., on average, families were engaged for 50.79% of the task). Indicators of engagement included reciprocal discussion, physical orientation toward each other, reciprocal activity involvement, and showing interest in what the other family members are doing (interrater reliability: k=.75). In addition, mothers as well as fathers self-reported on a set of questions pertaining to their own mental health, their perceptions of their children’s behavior, and their family dynamics. In the current study, we present data from parent reports of their own posttraumatic stress disorder (PTSD) and depression symptoms, as well as their assessment of their child’s temperament, their co-parenting relationship, and chaos in the family/home environment.

Results

Exposure to Trauma

Mothers as well as fathers reported high rates of exposure to potentially traumatic psychosocial events (e.g., family and community violence). Mothers were more likely than fathers to report histories of sexual and non-sexual assault by family members or intimates while fathers were more likely to report non-sexual assault by strangers and imprisonment. Both mothers and fathers reported high rates of potentially traumatic loss (e.g., unexpected death of a relative). See Table 1 for rates of exposure to potentially traumatic events.

Predictors of the Quality of Triadic (Family) Engagement

Parental psychopathology and stress. Mothers’ (but not fathers’) severity of PTSD symptoms was negatively associated with triadic (family) engagement. However, fathers’ (but not mothers’) reports of the chaos in the family environment was negatively associated with triadic engagement. Interestingly, parental depression was not significantly associated with engagement.

Child behavior. Fathers’ (but not mothers’) reports of children’s inhibitory control (an early form of self-regulation related to temperament style) was associated with family engagement.

Discussion/ Conclusions

These results suggest that families may be less likely to be engaged with each other following stress when mothers have higher PTSD symptoms, or when fathers perceive child or family disorganization. The research literature describes mixed findings as to whether or not PTSD symptoms impact parenting, though depression is typically a more consistent predictor of low parenting quality (Muzik, Bocknek, Richardson, Rosenblum, Thelen, & Seng, 2015). However, in the current sample, maternal PTSD emerged as a significant predictor of family engagement while depression did not. Because we measured engagement following a stressful event, the likelihood of transient PTSD symptoms being triggered was heightened. Appleyard and Osofsky (2003) have argued that parental PTSD may be associated with less sensitive parenting when parents are preoccupied with, and struggling to regulate, their own reactions to the stressful event. Our findings point to the primary role that mothers may play in reorganizing their families after occurrence of stress. Furthermore, these findings emphasize that mothers’ psychopathology is a significant risk factor for the family.

Fathers’ perceptions of their children and their homes were also significant predictors of the degree to which families positively re-engaged after the stressor task. From a theoretical perspective, scholars highlight the critical role that perception plays in helping families adapt to stress, such that greater adaptation occurs when family members believe that coping is possible because internal and external environments are predictable (Lavee, McCubbin, & Patterson, 1985). These findings suggest that fathers may play an important role in helping families to positively perceive internal resources to adapt. Furthermore, fathers’ perceptions compared to mothers’ may be more impactful on triadic engagement as function of the higher variability of overall paternal engagement compared to maternal engagement in this population.

Key Implications for Practice 

This study underscores the need to intervene with mothers and fathers in different ways in multi-stressed families.

• Parents’ mental health requires significant support as means to support whole family adaptation, and posttraumatic stress disorder requires a special emphasis among populations in urban poverty for whom the risk for trauma is high.
• Parental perceptions about their children’s and families’ capacity for adaptation may significantly impact engagement after stress and therefore there is likely a significant link between parental perception of coping capacities and parenting behaviors.

References

Appleyard, K., & Osofsky, J. D. (2003). Parenting after trauma: Supporting parents and caregivers in the treatment of children impacted by violence. Infant Mental Health Journal, 24(2), 111-125.

Eisenberg, N., Cumberland, A., & Spinrad, T. L. (1998). Parental socialization of emotion. Psychological Inquiry, 9(4), 241-273.

Lavee, Y., McCubbin, H. I., & Olson, D. H. (1987). The effect of stressful life events and transitions on family functioning and well-being. Journal of Marriage and The Family, 49(4), 857-873.

Muzik, M., Bocknek, E. L., Richardson, P., Broderick, A., Rosenblum, K. L., Thelen, K., & Seng, J. S. (2013). Mother-infant bonding in the first six months postpartum: The primacy of psychopathology in women with child abuse and neglect histories. Archives of Women’s Mental Health, 16(1), 29-38.

Nelson, J. A., O’Brien, M., Blankson, A. N., Calkins, S. D., & Keane, S. P. (2009). Family stress and parental responses to children’s negative emotions: Tests of the spillover, crossover, and compensatory hypotheses. Journal of Family Psychology, 23(5), 671-679.

Raver, C. C. (2004). Placing Emotional Self-Regulation in Sociocultural and Socioeconomic Contexts. Child Development, 75(2), 346-353.

Contact Information

For more information about this study contact:  Erika London Bocknek, PhD, LMFT, IMH-IV; Erika.Bocknek@wayne.edu

Table 1

Rates of Trauma Exposure Reported by Mothers and Fathers

Trauma Type	Mothers	Fathers
Serious accident, fire, explosion	41.7%	47.2%
Natural disaster	26.7%	23.1%
Non-sexual assault by family member/someone you know	43.3%	30.8%
Non-sexual assault by stranger	26.7%	46.2%
Sexual assault by family member/someone you know	30.0%	13.5%
Sexual assault by stranger	11.7%	0%
Military combat or war zone	0.0%	3.8%
Sexual contact with someone 5 years or more older when you were younger than 18	30.0%	25.0%
Imprisonment	10.0%	26.9%
Torture	3.3%	5.8%
Loss of loved one in unexpected or traumatic way	61.7%	68.2%
Other (includes infant loss, parent loss, gunshot wound, violent relationship)	9.1%	10.3%

 

 

In this research brief we will present research that explores family factors predicting parents’ negative responses to toddlers’ emotions.  It is important to learn more about mothers’ and fathers’ negative response as we understand that these responses impact the way that children are socialized to understand and express emotion.  Parental emotion socialization practices are thought to be a function of parenting and family processes embedded in the family context¹.  We examined (1) parents’ beliefs about when and to what extent children should express emotions², (2) parents’ handling of their own emotions^1,3,4, and (3) the co-parenting relationship⁵— each of which reflect key processes in the family context that likely influence parents’ socialization practices, particularly how parents respond to toddlers’ expressions of emotions such as anger, fear, and sadness. As defined by Gottman², parental beliefs about emotion can include dismissing attitudes such that children’s expressions of strong emotions such as anger, sadness or fear are met with anger, sarcasm or shaming. Generally, these types of reactions to children’s emotions are thought to be detrimental to children’s emotional development while more supportive responses are considered more optimal.  Parents’ skills in regulating their own emotions, particularly in front of children, are also powerful emotion socialization agents.  Imagine a parent who models dysregulated anger, such as screaming in anger rather than modeling how to more constructively express anger.  Parents who have difficulties managing their own powerful feelings are more likely to respond to their children’s expressions of emotions in a negative fashion⁴.  Likewise, the co-parenting relationship can be characterized by hostility and anger that spills over into parenting behaviors^6,7.  Triangulation, for example, occurs when one parents pulls the child into parental conflict by forcing the child into an alliance against the other parent.  Examples of triangulation include things like one parent saying negative things about the other parent to the child and degrading the other parent.  Triangulation is very harmful for the child because it places the child  in the impossible circumstance of having to negotiate and deal with conflict between the parents⁸.  The ways that parents raise the child together is called the co-parenting relationship.  The co-parenting relationship is sometime characterized by very negative processes such as triangulation. 

Research Questions

We were interested in how these three socialization contexts– parents’ emotion dismissing beliefs, parents’ dysregulatory problems, and co-parenting—were independently and in interaction related to mothers’ and fathers’ responses to toddlers’ expressions of anger, fear and sadness.

Methods

Participants included 83 couples (Mage mothers = 31.96 years, SD = 4.62; Mage fathers = 33.88 years, SD = 5.25) with toddlers (Mage = 29.06 months, SD = 4.40), reflecting a primarily Caucasian, middle class sample. Mothers and fathers separately completed measures of co-parenting behaviors (Co-parenting Questionnaire⁹, triangulation subscale), difficulties in parents’ emotion regulation (Difficulties in Emotion Regulation Scale¹⁰), parents’ emotion dismissing beliefs (Emotion-Related Parenting Styles Questionnaire¹¹), and parents’ self-reported responses to toddlers’ expressions of anger, sadness and fear represented  in a series of vignettes (Coping with Toddlers’ Negative Emotion Scale¹²).

Results

Parental age and income were not significantly related to the outcomes and were dropped from further analyses.  Child age and gender were not significantly related to parental responses to toddlers’ emotions but were retained for conceptual integrity. Both mothers’ and fathers’ own emotion regulation difficulty were not significantly related to parental responses to toddlers’ emotions.  We were surprised at this result.   Most parents, though, rated themselves as being very high in emotion regulation skills (and self-reports may not reflect what is actually happening or what the parents’ emotion regulation skills really are).  For fathers, perceptions of triangulation and emotion dismissing beliefs were related to their unsupportive responses to toddler emotions.  This model explained about 25% of the variances in fathers’ unsupportive reactions to toddlers’ anger, fear and sadness.  Similarly, for mothers, triangulation in the co-parenting relationship and emotion dismissing beliefs related to their unsupportive responses to toddlers’ emotion. However, for mothers only, the interaction between maternal perceptions of triangulation and paternal emotion dismissing beliefs was significantly related to mothers’ unsupportive responses, explaining about 30% of the variance in mothers’ negative responses to toddlers’ anger, sadness and fear. As illustrated in the figure below, when mothers reported a conflictual co-parenting relationship (characterized by triangulation) and when fathers had strong emotion dismissing beliefs, mothers responded more negatively to toddlers emotions.

Figure 1. Paternal emotion dismissing beliefs moderate relations between mothers’ perceived triangulation in the co-parenting relationship and their unsupportive responses to toddlers’ negative emotions. Mothers use more unsupportive responses when they perceive triangulation in the co-parenting relationship and when fathers’ have emotion dismissing beliefs.

Discussion

For both mothers and fathers, their own emotion dismissing beliefs and their perceptions of triangulation (such as the other parent was using their child as a pawn or ally in response to a conflictual parenting relationship) were related to unsupportive responses to toddlers’ emotions.  Collectively, this suggests that multiple dimensions of the emotional climate in the home are related to parents’ early emotion socialization behaviors. In our study, negative climate in the home clearly related to parents’ harsh responses to toddlers’ strong emotions. Interestingly, mothers were influenced by fathers’ dismissing beliefs in interaction with their perceptions of triangulation in the co-parenting relationship.  This is somewhat surprising because some of our prior work suggests that fathers tend to be more heavily impacted by mothers’ behaviors than mothers are by fathers¹³.  It may be that in the earliest years of parenting mothers are particularly sensitive to the dynamics in the parenting relationship.  Towards the end of toddlerhood, parenting tends to fall into relatively stable patterns.  Prior to that point, however, parenting behaviors may be more vulnerable to the evolving dynamics as a couple transitions to parenthood. In summary, results underscore the strong influence of the co-parenting relationship and beliefs about emotions for both mothers and fathers, but also highlight the ways in which complex interactions differentially influence the socialization practices of mothers and fathers.  Home visitors can play an important role in educating parents about findings like this and helping parents navigate the early family environment.¹⁴

Key Points:

• Emotion socialization in the home reflects multiple contexts including parents’ own beliefs and behaviors, and the emotional climate of the co-parenting relationships.

• Supporting parents in exploring their own beliefs about emotions and the expression of emotions may play a key role in helping parents develop supportive responses to toddlers’ strong emotions.

• Home visitors can support positive emotion socialization by promoting emotional strengths in the parenting and the co-parenting relationship. Supporting parenting partners in developing positive tools to manage the co-parenting relationship has benefits for toddlers’ early emotional development.

 

References

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8. Feinberg ME. The internal structure and ecological context of coparenting: A framework for research and intervention. Parenting: Science and Practice. 2003;3(2):95-131.
9. Margolin G. Coparenting Questionnaire. Unpublished instrument, University of Southern California, Los Angeles. 1992.
10. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment. 2004;26(1):41-54.
11. Paterson AD, Babb KA, Camodeca A, et al. Emotion-Related Parenting Styles (ERPS): A short form for measuring parental meta-emotion philosophy. Early Education & Development. 2012;23(4):583-602.
12. Spinrad T, Eisenberg N, Kupfer A, Gaertner B, Michalik N. The coping with negative emotions scale. Paper presented at: International Conference for Infant Studies2004.
13. Cho S, Brophy-Herb, H., & Vallotton, C. Actor and partner effects in the relationship between maternal and paternal parenting behaviors in toddlerhoodunder review.
14. Kolak AM, Volling BL. Parental Expressiveness as a Moderator of Coparenting and Marital Relationship Quality*. Family Relations. 2007;56(5):467-478.