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Pregnancy has been described as the most difficult period in terms of psychological adjustment for fathers (Condon, Boyce, & Corkindale, 2004; Genesoni & Tallandinin, 2009). Therefore, learning to recognize the importance of their role and ways to engage them during pregnancy into postpartum can be challenging. Early childhood prenatal home visiting programs, in collaboration with the medical model of pregnancy care, can play an important role in supporting fathers.

One reason for fathers’ lack of involvement may be due to perinatal programs, especially in the medical arena, which center on responding to the health needs of the mother–child dyad (Dubeau et al., 2011; deMontigny & Lacharite´, 2012). Fathers report that there are not enough resources to support their education or feelings about fathering (St. George & Fletcher, 2011). Antenatal education’s primary focus is on the mother’s prenatal care and education for labor and birth, casting the father as support person rather than involved as a “triad” in the pregnancy plan of care; it does not address both parents’ transition to the role changes of parenthood (May & Fletcher, 2013; St. George & Fletcher, 2011). For example, one study of fathers who did not meet their partners’ expectations during labor and birth found that one reason cited was they were not prepared for their own distress and did not know how to help themselves (Dellman, 2004). Another study found that some maternity care services viewed fathers as “not-patient and not-visitor” (Steen, Downe, Bamford, & Edozien, 2012) while others found that fathers felt overlooked by staff and that their concerns and emotional needs were often not heard (deMontigny & Lacharite´, 2004). Reasons for this, acknowledged by health care professionals, include staff feeling poorly prepared to meet fathers’ needs (deMontigny, et al., 2011; deMontigny & Lacharite´, 2012; Harvey & Pattison, 2013).

Assessing the psychological well-being of fathers during prenatal health care and diagnosing anxiety and emotional problems among fathers during the perinatal period is also not a common practice (Vreeswijk, Mass, Rijk & van Bakel, 2013). Fathers who experience ongoing mental distress in relation to their parenting roles are less likely to develop and maintain supportive relationships with their partner, and thus are less likely to positively engage with the roles and responsibilities of fatherhood, which may disrupt the development of the father-child attachment relationships (Fletcher, 2011). A study of teen fathers found unrecognized psychological symptomatology of anxiety and depression, suggesting they require services as well as the mothers (Quinlivan & Condon, 2004). Fathers who reported more symptoms of depression or anxiety were found to generally have poorer quality of attachment toward the unborn baby (Vreeswijk, Maas, Rijk & Van Bakel, 2013). These studies support others that suggest that mental health screening of fathers during the perinatal period would be beneficial (Field, Diego, Hernandez-Reif, et al., 2006).

Although the majority of fathering studies have focused on the postpartum period, some are now addressing fathers’ changing sense of identity and paternal-fetal attachment during pregnancy, and suggest that some forms of intervention can effectively promote paternal mental health during this time (deMontigny et al., 2006 a, 2006b; deMontigny and Lacharite´, 2008). Professional awareness of the father’s involvement during pregnancy and his transition to parenthood can create opportunities to provide education and social support (Everett, Bullock, Gage, et al. 2006; Fletcher, May, & St. George, 2014) that may improve outcomes for the family (Alio, Lewis, Scarborough, Harris & Fiscella, 2013).

Engaging Fathers

It has been suggested that a father’s commitment to his unborn baby can be measured through the effect that his behavior has on the health and well-being of the mother (Feltcher, et al., 2014). As much as possible, it is helpful to assess the fathers support by planning home visits when he is home. This helps him know that his presence and feelings are equally important. Use eye contact, directing questions to both the father and the mother. Ask how he is doing and his feelings about the unborn baby. Encourage fathers to attend prenatal visits with the mother if she is open to this. If her relationship with the father is strained, explore what she would be comfortable having a home visitor share, if anything, to help involve her partner.

The emerging field of research on fetal competencies can be a guide for home visitors to engage fathers and provide antenatal education. One study found that the quality of the fathers’ thoughts and feelings about the unborn baby were more important in shaping their representations of the baby than the amount of time spent on thinking about the baby (Vreeswijk & colleagues, 2013). Learning that the unborn baby has the ability to hear by the second trimester and that he/she recognizes the father’s voice can be a powerful motivator to engage him in interacting with the baby during pregnancy, supporting the idea that the unborn baby “already knows him” (O’Leary & Parker, 2009). Encourage fathers to find a book to read to the unborn baby at night, sharing that the baby will then recognize his voice postpartum. Above all, regardless of how active the father might be, let the father know that the baby has an awareness of his voice. When he interacts with the mother he is also interacting with his baby.

Fathers also need to learn that the unborn baby can sense someone’s touch as different from the mother’s. Often when the baby moves he/she stops when the dad puts his hands on the mother’s abdomen. Fathers need to be encouraged talk to the baby with simple words such as “this is your dad,” to wait a few seconds after which the baby will often respond with movements. This will help the baby become more real to a father.

Fathers can also learn the importance of supporting the mother to rest. Discuss tasks he might take over to help the mother find more time to rest, such as grocery shopping, cooking, or caring for older siblings. Teach him that resting helps increase the amniotic fluid around the baby. The amniotic fluid is important for lung development as the baby practices breathing patterns in the uterus when swallowing and peeing the fluid. In a real sense both parents hear the message that resting is “feeding the baby” during pregnancy. When the mother breathes, her abdomen is moving the uterus up and down; a behavior that can be translated to parents as “rocking the baby” during pregnancy. Fathers can learn that after birth, holding the baby in a flex position in their hands close to their chest simulates the same rocking the baby felt inside the mother. Now it’s the father’s turn “to hold the baby” close, something all newborns need in the first months.

Partners’ support is also important for breastfeeding as breastfeeding is most successful when the mother has adequate support, and fathers’ support can be the difference in how long a mother nurses. The State of Kentucky initiated a campaign (Kentucky Dads Support Breastfeeding) that offers helpful tips for dads to support breastfeeding including ways to support the mom, such as helping with positioning and burping the baby after feedings (The Nations Health, 2015, p.9).

A father’s internal working model of attachment and representation of ‘mother’ and ‘father’ are to some extent socially shaped (Condon, Corkindale, Boyce, & Gamble, 2013). It is important to explore what fathering means to him; his relationship with his father; what behaviors he wants to keep and what he wants to change for his baby. Offering a discussion to identify and interpret infant communication, and to explore issues of why babies cry and strategies to employ when feeling overwhelmed can be helpful in identifying areas that may interfere with a partnership in parenting (May & Fletcher, 2013). This will help open the topic of family of origin views on discipline and “spoiling a baby” messages from both parents.

Unexpected Outcomes

It is not just fathers in a low-risk pregnancy whose needs must be recognized but fathers who experience an unexpected outcome. Fathers of preterm babies have also reported lack of support and recognition during the crisis of the labor and birth experience (Harvey & Pattison, 2013; Hugill & Harvey, 2012). Fathers of infants who die have been described as “the forgotten bereaved” (Armstrong, 2001; Côté-Aresenault & O’Leary, 2015; McCreight, 2004; Murphy, 1998; O’Leary & Thorwick, 2006, a & b; O’Leary, Thorwick, & Parker, 2012). During these medical situations, the health care providers’ focus is primarily on the mother and baby’s health, often unintentionally neglecting the needs of the father. In both situations the fathers report feeling helpless and left alone (Hugill & Harvey, 2012; O’Leary & Thorwick, 2006, a & b). Fathers, by default, assume the role of the support person as they become the messenger to family and friends while worrying about the health of the mother and baby. When there is a perinatal loss, the father often has the primary role of informing others about the loss, making the funeral arrangements, and coping with siblings at home. By holding back their own emotions to support the mother and siblings, processing their own trauma can be jeopardized (O’Leary, Thorwick & Parker, 2012).

An unexpected outcome of pregnancy occurs in the medical setting but it is when parents return home that healing begins. A home visitor plays an important role as parents move back into their communities, now profoundly changed people with the trauma of the birth of a preterm baby or perinatal loss embedded in their memory. Parents are rarely given resources at the hospital on how to support children at home and, in their own grief, do not know how to cope themselves (O’Leary, 2007). Providing developmentally appropriate resources for the children can be invaluable to parents (see resources for children’s books).
Most parents want to share what happened so it is important to not be afraid to ask about the story. Parents’ need a listening ear and will often replay the trauma many times over the months. The home visitor may be the first person to ask the father’s viewpoint as most people ask how the mother is doing but not the father (O’Leary & Thorwick, 2006b). Asking about a missing baby can be very healing for families. Parents want all their children, living and deceased, recognized and will want and need to talk about this.

Pregnancy Following Loss

In a pregnancy that follows loss, fathers have a different understanding of an unborn child and prenatal attachment, realizing this may be the only time they have with the baby (O’Leary & Thorwick, 2006 a & b; 2008). Some fathers embrace their parental identity prenatally with more involvement, attending antenatal visits to get as much information as they can. Others avoid prenatal visits and some won’t even drive by the hospital where the death occurred. It is common for fathers to become vigilant about fetal movement, asking the mother many times a day if the baby is moving. It is crucial to assess how and where fathers are getting support for themselves. In an effort to protect the mother, who is often the father’s primary source of support, the father will acknowledge holding back his fear and anxiety that the new baby could die (O’Leary & Thorwick, 2006b). Pregnancy for both parents becomes a complex journey of grieving for one baby while trying to attach to a new unborn baby (O’Leary, et al., 2012).

Education about fetal competencies to help support attachment to the new baby becomes an important intervention to facilitate fathers engaging prenatally. This provides concrete information to help fathers begin connecting with the new unborn baby while also reinforcing the idea that the deceased baby knew him as his/her parent as well. Their parenting role — and continued bond and attachment to a deceased baby — does not go away just because they are in a new pregnancy (O’Leary, et.al., 2012). This prenatal education also can help individualize the two babies as separate people, and will be reinforced again when the new baby is born alive.

Fathers need labor and birth preparation for a new baby, too. The previous birth that resulted in death can bring symptoms of post-traumatic stress, often heightened for a father who felt helpless to protect the mother and baby (O’Leary, et. al., 2012). At a minimum, touring the birthing area of the hospital can help both parents know what might trigger memories and prevent symptoms of PTSD (Côté-Arsenault & O’Leary, 2015). They need to experience the space, the smells, the sounds — anything that may trigger flashbacks to the previous birth. They then can write a birth plan that reflects what they may need for support (O’Leary, et al, 2012). This helps give parents some control to be more fully present for the birth of the new baby.

After the baby is born, demonstrating newborn competencies (Nugent, 2015) to all fathers is a wonderful way to engage men who may not have been invested during pregnancy. If the father has been actively involved, the baby will know his voice and turn to his face. Most important for fathers who have experienced a previous loss, this will show that the baby is alive, healthy and a different baby. In the cases of loss, be aware a new layer of grief will surface because the deceased baby may be heavy on a father’s mind. The full impact of what he lost in the death of that baby will be seen in the healthy development of the subsequent baby (O’Leary, 2004).

Summary

Prenatal infant mental health programs are an important resource to engage fathers and work alongside the medical community in meeting the needs of all childbearing families. Using what home visitors have done for years needs to be translated into intervention for fathers too. Helping fathers recognize their important role in the relationship with the mother and baby can build stronger, healthier families.

References

Alio, A., Lewis, P., Scarborough, K., Harris, K., & Fiscell, K. (2013). A community perspective on the role of fathers during pregnancy: a qualitative study. BMC Pregnancy and Childbirth, 13:60.
http://www.biomedcentral.com/1471-2393/13/60

Armstrong, D. (2001). Exploring fathers’ experiences of pregnancy after a prior perinatal loss. Maternal Child Nursing, 26(3), 147-153.

Condon, J., Corkindale, C., Boyce, P. & Gamble, E. (2013). A longitudinal study of father-to-infant attachment: antecedents and correlates. Journal of Reproductive and Infant Psychology, 31(1), 15-30.

Côté-Arsenault, D. & O’Leary, J. (2015). Understanding the Experience of Pregnancy Subsequent to Perinatal Loss. In: Wright, P., Limbo, R., & Black, (Ed.), Perinatal and Pediatric Bereavement, Chapter 10; 169-181. Springer Publishing, NY, NY.

Dellman, T. (2004). ‘The best moment of my life’: a literature review of Fathers’ experience of childbirth. Australian Midwifery Journal of the College of Midwives 17 (3), 20–26.

Dubeau, D., Devault, A. and Forget, G. (2009). Fatherhood in the 21st century. Quebec, University Press.

deMontigny, F.,Lacharite´ , C.,2004. Fathers’ perceptions of the immediate post-partal period: what do we need to know? Journal of Obstetric, Gynecologic, and Neonatal Nursing, 33:328–340.

deMontigny, F.,Lacharite´ , C.,Devault,A.,(2012). Transition to fatherhood: modeling the experience of fathers of breast fed infants. Advances in Nursing Science,35, E11–E22.

deMontigny, F., Girard, ME Lacharite, C., Dubeau, D., & Devault, A. (2013). Psychosocial factors associated with paternal postnatal depression. Journal of Affective Disorders, 150(1):44-9. http://dx.doi.org/10.1016/j.jad.2013.01.048

Erlandsson K, Linder H, Haggstrom-Nordin E (2010) Experiences of gay women during their partner’s pregnancy and childbirth. Br J Midwifery 18(2): 99–103.
http://www.magonlinelibrary.com/doi/abs/10.12968/bjom.2010.18.2.46407′)

Everett, K., Bullock, L., Gage, J., Longo, D., Geden, E. & Madsen, R. (2006) Health risk behavior of rural low-income expectant fathers, Public Health Nursing 23(4): 297–306.

Field, T., Diego, M., Hernandez-Reif, M., et al., 2006. Prenatal paternal depression. Infant Behavior and Development 29, 579–583.

Fletcher, R., Bimpani, G., Russell, G., & Keating, D. (2008). The evaluation of tailored email and web-based information for new fathers. Child Care Health & Development, 4(4), 439-446.

Fletcher, R. (2011). The Dad Factor: How Father–Baby Bonding Helps a Child for Life. Finch Publishing, Warriewood, NSW.

Fletcher, R., May, C. & St. George, J. (2014). Fathers’ prenatal relationship with ‘their’ baby and ‘her’ pregnancy—implications for antenatal education. The International Journal of Birth and Parent Education, 1(3), 23-27.

Habib, C. & Lancaster, S. (2006). Transition to Fatherhood: Identity and Bonding in Early Pregnancy. Fathering, 4(3), 235-253.

Hugill, K. & Harvey, M. (2012). Fatherhood in Midwifery and Neonatal Practice. Quay Books. London.

May, C & Fletcher, R. (2013) Preparing fathers for the transition to parenthood: Recommendations for the content of antenatal education. Midwifery 29 474–478.

McCreight, B. S. (2004). A grief ignored: Narratives of pregnancy loss from a male perspective. Sociology of Health and Illness, 26(3), 326-350.

McElligott, M. (2001). Antenatal information wanted by first-time fathers. British Journal of Midwifery, 9:556-558.

Murphy, F. (1998). The experience of early miscarriage from a male perspective. Journal of Clinical Nursing, 7(4), 325-332.

Nugent, K. (2015). The newborn behavioral observation (NBO) system as a form of intervention and support for new parents. Zero to Three, 36(1), 2-10.

O’Leary, JM (2004). Grief and its impact on prenatal attachment in the subsequent pregnancy. Archives of Women’s Mental Health, 7(1), 7-18.

O’Leary, J. & Thorwick, C. (2006a). When pregnancy follows a loss: Preparing for the birth of your new baby. O’Leary, JM. Minneapolis, MN

O’Leary, J., & Thorwick, C. (2006b). “It affects me too.” Fathers experience in a pregnancy after loss. Journal of Obstetrics, Gynecologic, and Neonatal Nursing, 35(1), 78-86.

O’Leary, J, & Thorwick, C. (2008). Attachment to the Unborn Child and Parental Representation of Pregnancy Following Perinatal Loss. Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, 2(3), 292-320.

O’Leary, J (2007) Pregnancy and Infant Loss: Supporting parents and their children. Zero to Three, 27(6), 42-49.

O’Leary, J. & Parker, L. (2009). Parenting your baby before birth: Explore the relationship. Thorwick, C. (Ed.) Minneapolis, MN. Self published: O’Leary

O’Leary, J., Warland, J. & Parker, L. (2012). Childbirth Preparation for Families Pregnant After Loss. International Journal of Childbirth Educations, 27(2) 44-50.

O’Leary, J. & Thorwick, C., Parker, L. (2012). The baby leads the way: Supporting the emotional needs of families’ pregnant following perinatal loss. 2nd edition Ragland, K. (Ed.) Minneapolis, MN Self published: O’Leary.
Available at aplacetoremember.com

Quinlivan, J. & Condon, J. (2005). Anxiety and depression in fathers in teenage pregnancy. Australian & New Zealand Journal of Psychiatry, 39:915-920.

Ramchandani, P., Stein, A., Evans, J., et al., 2005. Paternal depression in the postnatal period and child development: a prospective population study. Lancet 365, 2201–2205.

Ramchandani, P., O’Connor, T.G., Evans, J., et al., 2008. The effects of pre- and postnatal depression in fathers: a natural experiment comparing the effects of exposure to depression on offspring. Journal of Child Psychology and Psychiatry 49, 1069–1078.

Ramchandani, P.G., O’Connor, T.G., Heron, J., et al., 2009. Depression in men in the postnatal period and later child psychopathology: a population cohort study. Journal of the American Academy of Child Psychiatry 47, 390–398.

Ramchandani, P.G., Psychogiou, L., Vlachos, H., et al., 2011. Paternal depression: an examination of its links with father, child and family functioning in the postnatal period. Depression and Anxiety 28, 471–477.

Skari, H.,Skreden,M.,Malt,U.F.,etal.,2002.Comparative levels of psychological distress, stress symptoms, depression and anxiety after childbirth—a prospective population-based study of mothers and fathers. BJOG: An International Journal of Obstetrics and Gynaecology109,1154–1163.

The Nations Health: A publication of the American Public Health Association, May/June, p. 9, www.thenationshealth.org

Vreeswik, C., Mass, J., Rijk, C., van Bakel, H. (2013). Fathers’ experiences during pregnancy: Paternal prenatal attachment and representations of the fetus. Psychology of Men & Masculinity 15(2):1-9. DOI:10.1037/a0033070

Resources http://www.beyondblue.org.au/resources/for-me/men/what-causes-anxiety-and-depression-in-men/new-fathers

Resources for children: http://www.aplacetoremember.com or http://www.centering.com

Relationship-based interventions, like infant mental health, target the caregiving relationship as a way to support infant attachment security and social-emotional development.  In theory, IMH therapists support reflective functioning when they provide developmental guidance, speak for the baby, remain curious about both parents’ and infants’ internal experiences and help parents reflect on and re-process experiences and emotions from their own childhood. As such, reflective functioning is an important construct in IMH research and practice.

Reflective functioning is the capacity to reflect upon internal experiences (thoughts, emotions and intentions) in self and others and to link these internal experiences with behaviors (Rosenblum, McDonough, Sameroff, & Muzik, 2008; Sharp & Fonagy, 2008; Slade, 2005).  A small body of research suggests that reflective functioning is the foundation for parenting sensitivity, which is associated with a variety of positive developmental outcomes, including a secure attachment. Secure attachment, in turn, is related to prosocial behavior, emotion regulation, and psychosocial adjustment (for a review, see Thompson, 2008).  Interventions aimed at increasing reflective functioning, beginning as early as in pregnancy, are of interest to research and to clinicians utilizing infant mental health models.

The effectiveness of these interventions is tested by measuring reflective functioning at the beginning of the intervention, in pregnancy, and then again following intervention after the child has been born. The problem with this is that we do not actually know if reflective functioning remains stable across the transition to parenthood or increases as the parent-child relationship develops, the child’s cues become clearer, or the child develops language. Not knowing if reflective functioning increases naturally as a relationship unfolds makes it difficult to determine if interventions are actually successful.

Research Questions

In the Early Relationships Lab at the Merrill Palmer Skillman Institute we are studying reflective functioning in pregnancy and postpartum to better understand a) whether risk factors influence the ability to be reflective (i.e. a history of maltreatment and depression), b) how reflective functioning supports sensitivity and a secure attachment, c) whether IMH services support parents’ reflective capacity and d) factors that influence stability and change in reflective functioning across the transition to parenting.

Overview of Study Methods

All of our studies assess parental reflective functioning with a one-hour semi-structured interview that asks parents to reflect on their own and their children’s internal experiences. The interview is coded for parents’ use of mental state language (language about their children’s internal mental and feeling states such as the parent commenting on what she thinks her child is thinking or feeling), their ability to link mental states to behavior (such as the parent linking her perceptions of the child’s emotions, goals or intentions to the child’s behavior) and their curiosity to understand other’s minds (Slade, 2005). We are assessing reflective functioning in three studies.

Wayne County Baby Court. We are evaluating whether this collaborative approach is effective at improving safety, permanency and well-being.  Parent-infant dyads receiving Baby Court services work with an infant mental health clinician who is part of a collaborative team that includes the DHHS caseworker and the child’s attorney. The evaluation includes a pre- and post-test parent-child interaction task, a developmental assessment, a clinical interview to assess reflective functioning and parents’ report on their child’s social-emotional development.

The PuRPLE Study. We are testing the stability and change in reflective functioning in a subsample of mothers participating in a larger longitudinal study that assesses fetal brain development, parenting and child development across infancy. Our team has spent the last two years collecting data from women beginning during pregnancy and then again when the infant is seven months. We assess reflective functioning at both time points. Parents also complete a variety of self- report measures about mental health, stress, social support, temperament and parenting.  The dyad participates in the still-face procedure and we also test the infants’ development.

The MACY Study. This longitudinal study (PI: Muzik) followed mothers, with and without histories of child maltreatment, and their infants through the preschool period. The study sought to better understand how trauma shapes mental health, parenting representations, parenting behavior and subsequent child biology and attachment. The MACY team interviewed more than 100 mothers using the Parent Development Interview, which was coded by the team in the Early Relationships Lab. Some self-report data was collected via phone when the infant was four months. Dyads participated in home visits when the infant was 6 months, a lab visit at 15 months and mothers were interviewed by phone when the infant was 18 months.

Results

 Risk and Reflection. Our findings from the MACY study suggest that women who have a history of childhood maltreatment demonstrate a wide range of reflective functioning. Although most women in the study tended to have few demographic risks, for example most were married and college educated, the presence of a single demographic risk factor (low income, low level of education, young or single parent) was associated with lower reflective functioning scores. Contrary to our expectations, maternal reflective functioning was not related to experiencing maltreatment as a child, experiencing multiple types of maltreatment as a child, or having a depression or PTSD Diagnosis (Muzik, et al., 2015; Stacks, et al., 2014).

Reflective Functioning, Parenting and Attachment. Consistent with previous research, our findings from the MACY study suggest that mothers with higher levels of reflective functioning demonstrate more sensitivity and less negativity when interacting with their infants. Further, maternal reflective functioning differed among infant attachment classifications. Mothers of infants classified as secure had higher reflective functioning scores than mothers of infants classified as avoidant or disorganized. The mechanism by which reflective functioning was associated with attachment was through parental sensitivity (Stacks et al., 2014).

The PuRPLE Study is ongoing; however, preliminary findings suggest that mothers with balanced representations of their attachment relationships with their infants have higher prenatal reflective functioning scores than mothers with disengaged representations (Alismail, et al., 2015;).  Further, mothers who had more instances of being reflective throughout their prenatal interview used more attuned mind-minded comments during the still-face procedure, r = .51, p = .02, (Alrajhi, et al., 2015).

Stability and Change in Reflective Functioning. Preliminary results from the PuRPLE study suggest that maternal reflective functioning in pregnancy is highly correlated with postnatal reflective functioning, r  = .74, p  = .001 and that it increases across the transition to parenthood t(30) = -3.80, p = .001. Future analyses will explore factors associated with stability and change. One factor that may support change in RF is IMH treatment. Preliminary findings from 10 Baby Court parents who have completed the pre- and post-test suggest that parental reflective functioning scores increase as a result of treatment, t(9) = -4.81, p = .001.

Conclusions

Across our studies, it appears that parental reflective functioning is related to observed parenting, infant attachment classification, and mother’s working model of her child. Further, mothers who experience maltreatment as children or who have diagnoses of depression and PTSD demonstrate a range of reflective functioning scores. It will be important to understand what factors support parental reflective functioning in the context of these risks that are usually associated with less sensitive parenting. Our findings also suggest that reflective functioning, while generally fairly stable over time, can increase for some parents across the transition to parenthood. One factor that appears to support parental reflective functioning is IMH treatment.

Key Implications for Practice 

• Maternal reflective functioning is associated with parenting quality and attachment.
• Maternal reflective functioning can change over time and IMH treatment may be effective at supporting parental reflective functioning.

 

References

Alismail, F., Wong, K., Villa, A., Antilla, C., Beeghly, M., & Stacks, A. (2015, May).Maternal Attachment Representations of the Infant in the First Year of Life: The Influence of Prenatal Reflective Functioning and Depression.Poster presented at the biennial meeting of the Michigan Association for Infant Mental Health, Kalamazoo, MI.

Alrajhi, N., Costner, S., Stacks, A., Villa, A., Antilla, C. &Beeghly, M. (2015, May). The Role of Reflective Functioning and Maternal Mind Mindedness on Infants’ Language Development in the First Year: Preliminary Findings.  Poster presented at the biennial meeting of the Michigan Association for Infant Mental Health, Kalamazoo, MI.

Muzik, M., Stacks, A. M., Rosenblum, K. L., Huth-Bocks, A., &Beeghly, M. (2015, May).  The Effects of Trauma and Depression on Parenting Representations and Child Outcomes: Findings from the MACY Study. Workshop presented at the biennial meeting of the Michigan Association for Infant Mental Health, Kalamazoo, MI.

Rosenblum, K.L., McDonough, S., Sameroff, A. J. &Muzik, M. (2008). Reflection in thought and action: Maternal parenting reflectivity predicts mind-minded comments and interactive behavior. Infant Mental Health Journal, 29(4), 362-376.

Sharp, C. &Fonagy, P. (2008). The parent’s capacity to treat the child as a psychological agent: Constructs, measures and implications for developmental psychopathology. Social Development, 17(3), 737-754.

Slade, A.  (2005). Parental reflective functioning: An introduction. Attachment and Human Development, 7(3), 269-281.

Stacks, A. M., Muzik, M., Wong, K., Beeghly, M., Huth-Bocks, A., Irwin, J. & Rosenblum, K. L. (2014). Maternal reflective functioning among mothers with maltreatment histories: Links to sensitive parenting and infant attachment security. Attachment and Human Development, 16(5), 515-533.

Thompson, R. (2008). Early attachment and later development: Familiar questions, new answers. In  J. Cassidy & P. R. Shaver (Eds). Handbook of Attachment: Theory, Research and Clinical Applications (pp. 348-365). New York: Guilford.

Wong, K., & Stacks, A. M., Ghrist, F., Vila, A., Antilla, C. &Beeghly, M.  (2015, May). Is Reflective Functioning Stable from Pregnancy to Postpartum: Preliminary Findings? .Poster presented at the biennial meeting of the Michigan Association for Infant Mental Health, Kalamazoo, MI.

 Contact Information

For more information contact: Ann M. Stacks at amstacks@wayne.edu

 

 

Infant mental health specialists recognize the unique strengths and needs of each family. An understanding of variations in child temperament can help clinicians provide developmental information that is specific to each baby.  It can also be used to help parents recognize and foster their children’s individual potential. Research confirms that individuals vary in their degree of sensitivity to environmental influence including being more or less impacted by parenting behaviors. Increased sensitivity may be a disadvantage in an unfavorable environment, but it also allows a child to take full advantage of a positive and supportive environment (Belsky & Pluess, 2009). What is generally referred to as a “difficult” temperament has been shown to be associated with this type of increased sensitivity to parenting (Belsky, Bakermans-Kranenburg, & Van Ijzendoorn, 2007).

At the same time, children with difficult temperaments may present the most challenges to receiving an optimal level of care. A difficult temperament is characterized by heightened reactivity and emotionality. Children may react easily and intensely and are often described as easily upset. Research has shown mixed results in terms of the effect a child’s temperament has on parenting. This is particularly important when it comes to so-called “difficult” or challenging temperaments. Some research indicates that children with more reactive temperaments are more taxing for parents and are more likely to receive harsher or less responsive care (Clark, Kochanska, & Ready, 2000; Jaffee et al., 2004). Still, other studies show this same temperament elicits greater responsiveness and maternal involvement (Kochanska, Friesenborg, Lange, & Martel, 2004; Pettit & Bates, 1984; Sroufe, 1985).  This study examines how children’s temperamental predispositions evoke particular responses from parents and the manner in which parental qualities affect their responses to children’s temperament.

Research Questions

First, we were interested in identifying naturally occurring patterns of child temperament and parental response to that temperament. We expected to see that some parents experience pronounced distress in relation to heightened child negative emotionality while others do not. Second, we examined the relationships between the patterns and parenting quality over time.  We hypothesized that highly emotional children may be more likely to experience negative parenting behaviors from highly distressed parents than their less reactive counterparts or from parents who were more satisfied with the parent-child relationship. As a next step, we examined whether additional parent and child characteristics or behaviors distinguished among patterns that included children high in negative emotionality. The aim was to determine factors that distinguish between parents of children high on negative emotionality experiencing higher levels of distress and dissatisfaction in the parenting role from those who do not in order to inform future interventions for so-called “difficult” children.

Overview of Study Methods

The sample included 2,329 Early Head Start eligible children (1,184 males) and their primary caregivers from the National Early Head Start Research and Evaluation (EHSRE) Project (Love et al., 2005).

At enrollment, caregivers were a mean age of 22.6 (SD = 5.77) years and children were a mean age of 15.02 (SD = 1.48) months. Caregivers were 37% White, 34% African American, and 23% Hispanic/Latino, most with no more than a high school education (74.4%). Annual gross income averaged $9,277 (SD = $8,421).

We measured temperament by parent report using the Emotionality Activity Sociability and Impulsivity (EASI) measure (Buss & Plomin, 1984) at 14 months.  Parental distress and parent-child dysfunctional interaction (dissatisfaction with the parent-child relationship) were assessed via parent report using the Parenting Stress Index (Abidin, 1995). Parental Distress refers to distress related to the parenting role and the Parent-Child Dysfunctional Interaction addresses the parent’s dissatisfaction with the parent-child relationship. Some of the questions have to do with whether the child’s behavior is what the parent expected.

To answer the second research question regarding how parent/child patterns are related to parent behaviors, we looked at parental negative regard toward the child during play using a measure called the “3-bag task”. The 3-bag assessment is a videotaped parent-child semi-structured play task that is then coded by an observer. Parental negative regard included things like expression of anger toward the child or disapproval or rejection of the child. We used ratings of parents collected when children were 24 and 36 months old, and when children were five years old.

Results

Patterns of Child Temperament and Parental Response. Consistent with our hypotheses, analyses (Figure 1) revealed variations in patterns of child temperament and parenting distress and/or dissatisfaction.

Figure 1. Patterns of Child Emotionality and Parental Distress/Dissatisfaction

The first group represents what we would think of as “easy” children. They were low on negative emotionality, and their parents experienced very little parenting distress and little dissatisfaction in the parenting role. This is the largest group and contains 83% of the parent-child dyads. The second and third groups were both high on negative emotionality (the “difficult” children), but what distinguishes the third group is the magnitude of the distress and dissatisfaction in the parent that goes with it.

Parental Negative Regard. For the entire sample taken as a whole, parental negative regard exhibited toward the child in the free play episodes decreases over time from child age 24 months to 5 years. The first set of comparisons evaluated possible group differences in change in parental negative regard between the first group, comprised of temperamentally “easy” children and their parents, and the two remaining groups, comprised of highly emotional children and their parents, together. As seen in Figure 2, children in the groups characterized by heightened emotionality tend to experience significantly higher levels of negative regard at 24 months (1.43) than those with a less reactive disposition (1.52) as well as a significantly slower rate of decrease Δχ²(3, N = 2022) = 28.71, p < .001, over time.

Figure 2. Group 1 compared to Groups 2 and 3 Combined

Those in the “difficult” groups experience more parental negative regard to begin with and that negative regard decreases less by the time children are 5 years old. That is, parents were more negative toward their emotionally reactive children at the first assessment and continued to be more negative over time as compared to parents whose children had a less challenging temperament.

The second set of comparisons evaluated possible differences between the two groups that included children with heightened emotionality. This was done to compare highly emotional children with distressed parents to those whose parents did not experience such distress. As seen in Figure 3, highly distressed parents exhibit significantly higher levels of negative regard (1.70) toward their highly emotional children than parents of similar children who are less distressed and more satisfied in the parenting role (1.49). Results also show significant difference between groups, Δχ²(3, N= 331) = 13.91, p = .003, in the rate of decline in parental negative regard over the study period.

Figure 3. Group 2 compared to Group 3

For parents of highly emotional children, those who are highly distressed show much more negativity toward their children at the first assessment than less distressed parents of equally emotional children. These highly distressed parents show very little, if any, lessening of that negativity over time.

Group Differences on Additional Characteristics. Parents in the highly distressed group tended to perceive more behavior problems, F(2,1348) = 68.20, p < .001, in their children despite no significant differences between groups 2 and 3 on observer rated behavior scales. Parents who are better able to accept and interact with their child’s temperament are characterized by greater knowledge of infant development, F(2,1348) = 24.86, p < .001.

Conclusions

Results highlight the importance of parental perception in shaping the emerging parent-child relationship. Parenting behaviors were not impacted by a challenging child temperament, but rather by the parents’ acceptance and response to that temperament. Parents who experienced substantial distress and who saw their relationship with their child as less satisfying exhibited more and longer lasting negative regard toward their children. However, highly emotional children whose parents did not experience such distress and had more positive perceptions of the relationship showed levels of negative regard similar to parents of “easy” children. A notable difference in these more accepting parents of highly emotional children is that they had greater knowledge of child development.

Key Implications for Practice

• Offering developmental guidance in terms of variations in temperament and reactivity could help parents form accurate expectations and improve their understanding of their unique child’s behavior. This could be especially helpful for parents of children with challenging temperaments.
• IMH specialists could offer interaction guidance regarding effective strategies parents could use to model and facilitate self-regulation in their highly emotional children. This could improve parental self-efficacy. At the same time, it could assist these children in successfully managing their tendency toward increased reactivity and emotional response. Strengthening the parent-child relationship can be particularly advantageous for children who are more sensitive to environmental influence.

References

Abidin, R. R. (1995). Parenting stress index, third edition: Professional manual. Odessa, FL: Psychological Assessment Resources.

Belsky, J., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2007). For better and for worse: Differential susceptibility to environmental influences. Current Directions in Psychological     Science, 16(6), 300–304.                 http://doi.org/http://dx.doi.org.proxy2.cl.msu.edu.proxy1.cl.msu.edu/10.1111/j.1467-8721.2007.00525.x

Belsky, J., & Pluess, M. (2009). Beyond diathesis stress: Differential susceptibility to environmental influences. Psychological Bulletin, 135(6), 885–908.
http://doi.org/http://dx.doi.org.proxy2.cl.msu.edu.proxy1.cl.msu.edu/10.1037/a0017376

Buss, A. H., & Plomin, R. (1984). Temperament: early developing personality traits. Hillsdale, N.J: L. Erlbaum Associates.

Clark, A. L., Kochanska, G., & Ready, R. (2000). Mothers’ personality and its interaction with child temperament as predictors of parenting behavior. Journal of Personality and Social Psychology, 79(2), 274–285.

Jaffee, S. R., Caspi, A., Moffitt, T. E., Polo-Tomas, M., Price, T. S., & Taylor, A. (2004). The Limits of Child Effects: Evidence for Genetically Mediated Child Effects on Corporal Punishment but Not on Physical Maltreatment. Developmental Psychology, 40(6), 1047–1058
http://doi.org/http://dx.doi.org.proxy1.cl.msu.edu/10.1037/0012-1649.40.6.1047

Kochanska, G., Friesenborg, A. E., Lange, L. A., & Martel, M. M. (2004). Parents’ Personality and Infants’ Temperament as Contributors to Their Emerging Relationship. Journal of  Personality and Social Psychology, 86(5), 744–759.
http://doi.org/http://dx.doi.org.proxy1.cl.msu.edu/10.1037/0022-3514.86.5.744

Love, J. M., Ross, C., Raikes, H., Constantine, J., Boller, K., Brooks-Gunn, J., … Vogel, C. (2005). The Effectiveness of Early Head Start for 3-Year-Old Children and Their Parents: Lessons for Policy and Programs. Developmental Psychology, 41(6), 885–901.

Pettit, G. S., & Bates, J. E. (1984). Continuity of Individual Differences in the Mother-Infant Relationship from Six to Thirteen Months. Child Development, 55(3), 729–739.
http://doi.org/10.2307/1130125

Sroufe, L. A. (1985). Attachment Classification from the Perspective of Infant-Caregiver Relationships and Infant Temperament. Child Development, 56(1), 1–14.
http://doi.org/10.2307/1130168

Contact Information

For more information contact: Danielle Dalimonte-Merckling at dalimon5@msu.edu.

 

Introduction     

Family-based early intervention is crucial for children who have delays or disabilities, including those who have hearing loss (Division for Early Childhood, 2014; Moeller, Carr, Seaver, Stredler-Brown, & Holzinger, 2013). Many of these families receive support and early intervention services through Part C of the Individuals with Disabilities Education Act; in Michigan these services are provided by the Early On® program. Best practices suggest that early intervention service providers work directly with parents in order to support positive parent-child interactions (Moeller et al., 2013; Spencer & Marschark, 2010; Division for Early Childhood, 2014). For families who have children with hearing loss, this includes providing parents with unbiased support regarding communication options, and encouraging parents to provide language-rich environments for their children (Joint Committee on Infant Hearing, 2007; Yoshinaga-Itano, 2014). When families are more directly involved in early intervention, parents have more positive feelings about their ability to support their children and more satisfaction with the early intervention services they receive (Dunst, Trivette, & Hamby, 2007). However, little is known about parents’ experiences and feelings about the early intervention services they receive in the state of Michigan related to their children’s hearing loss. Learning more about parents’ views of the strengths and areas of improvement for these early intervention services provides an opportunity to better understand how to meet the needs of these children and their families.

Research Questions

In order to better understand the early intervention experiences of parents who have infants and toddlers with permanent hearing loss, we asked:

• What did parents most appreciate about the early intervention services they and their child received and their service provider(s)?
• What ways did parents feel that the early intervention services or their interactions with their service provider(s) should be improved?

Overview of Study Methods

We partnered with Early On® to recruit families in order to learn more about their experiences with early intervention for their children who had permanent hearing loss. Criteria for being in the study included the following: (a) children had to be between 12 and 30 months of age, be enrolled in an early intervention program, and have no cognitive delays or additional disabilities, and (b) both of their parents had to use English as their primary language and have typical hearing, since mismatches between parents’ and children’s hearing statuses puts these children at greater risk for delayed language development (Spencer, Erting, & Marschark, 2000; Meadow-Orlans, 1997; Meadow-Orlans & Spencer, 1996). Children could have any degree of hearing loss, and families could be using any form of communication with their children (e.g., signed, spoken or combination of both). To make participation easier for families, only one parent per family was asked to participate in the study. Twelve parent-child dyads who lived throughout the state of Michigan participated. Children’s degree of hearing loss ranged from mild to profound, and most families were using spoken language with their children and supplementing this with the use of signs.

In order to learn about families’ experiences, we conducted home visits which included semi-structured parent interviews. Parents were asked about what they like the most and find most useful about the early intervention services they receive and the service providers with whom they interact, as well as their ideas about ways in which these early intervention services could be improved. Based on these interviews, we searched for themes in parents’ responses related to the research questions stated above.

Results

Parents reported that their early intervention experiences had been primarily positive, mostly due to the supportive relationships they developed with their service providers. Some parents, however, noted areas where their services or experiences should be improved, such as an increase in the amount of services and receiving information that is more specific to their child’s disability. Figure 1 shows the patterns in parents’ interview responses regarding strengths of the early intervention services they and their children receive and aspects of these services they felt should be improved.                                                                              

                                        Figure 1

 

Strengths of early intervention. One of the most common responses from parents during interviews was that they are generally very satisfied with the services they receive, and with the interpersonal relationships they had developed with their service providers. Parents felt that overall, they were benefiting from the knowledge their service providers had to offer. They expressed appreciation for service providers’ words of advice, ideas for what to do at home with their children, and the different resources to which Early On® service providers referred them. Parents also expressed that they felt their service providers were capable and competent; parents especially appreciated service providers who knew sign language, and who had previous experience or training related to working with children with hearing loss.

Parents’ satisfaction with their early intervention services was also related to how they personally felt about their service providers. Parents spoke positively about service providers who made them feel reassured and comforted, and with whom they felt could relate well. Other major strengths of their early intervention service providers included patience, openness, and supportiveness. Parents especially appreciated feeling like their service providers genuinely cared about them and their children. For example, one parent said, “They care about what the parents go through, too, in the process. And they care about if it’s difficult or hard; they know that it’s hard and it’s a struggle sometimes. So, the fact that they just are genuinely caring about the whole situation and understanding is the most important thing to me because I don’t get involved with anything if I feel uncomfortable.”

Areas for improvement. While parents were thankful to be working with Early On®, most parents did report areas where they felt their services should be improved. A common theme throughout the interviews included parents’ desire for more of the services they already received; parents wanted more visits from service providers, additional advice and information on what they could be doing to help their child, and new ways to connect with other parents of children with hearing loss. In addition, some parents discussed their desire to work with service providers who are fluent in the use of American Sign Language and who have additional expertise relate to serving children who have hearing loss. For example, one parent who was not receiving support from his service providers to learn American Sign Language said, “I guess if I could change anything, if I could have got assistance from early intervention in terms of learning sign language myself. That was something we totally had to do on our own.” Lastly, while parents were appreciative of receiving advice and reassurance about general parenting issues and questions, some expressed that they would like to receive more information about their child’s hearing loss, as well as detailed information that is specifically relevant to their children’s unique needs because of his/her hearing loss. Some parents said they felt that the advice they received was very general, or applicable to many infants and toddlers instead of being specific to the needs of their child with hearing loss.

Conclusions

Overall, the parents interviewed for this study shared many strengths and positive experiences about their early intervention services and service providers; they reported feeling very satisfied with the services that they receive. Parents appreciate their interactions with their service providers, whom they often described as warm and caring individuals. The primary areas for improvement that parents identified included the need for more visits and services, a desire to work with service providers who are fluent in the use of American Sign Language, and the need for more nuanced, disability-specific information.

Key Implications for Practice

• Developing caring, personal relationships with parents is essential to parents’ reports of positive early intervention experiences.
• Each family who has a child with hearing loss should have access to an early intervention service provider who is fluent in the use of American Sign Language and has experience working with children who have hearing loss.
• Early intervention service providers should seek out opportunities to learn more about the specific, nuanced information that may be most helpful for parents who have children with permanent hearing loss and relay that information to parents. See Moeller et al. (2013) and Yoshinaga-Itano (2014) listed in the References section for an excellent overview and ideas for additional reading. In addition, Cruz et al. (2013) is a great resource that provides examples of language strategies parents use while interacting with their children. For instance, parents’ use of the strategy called parallel talk is shown to be beneficial for the language development of children with hearing loss; therefore, encouraging parents to discuss, via spoken and/or signed language, what their children are interested in or attending to is one way to support positive parent-child communication for these families.

 

Contact Information
For more information about this study contact: Kalli Decker, Kalli.Decker@montana.edu.

 

References

Cruz, I., Quittner, A.L., Marker, C., DesJardin, J. L., & CDaCI Investigative Team. (2013). Identification of effective strategies to promote language in deaf children with cochlear implants. Child Development, 84, 543-559. doi:10.1111/j.1467-8624.2012.01863.x

Division for Early Childhood. (2014). Recommended practices in early intervention and early childhood special education. Retrieved from http://www.dec-sped.org/recommendedpractices

Dunst, C. J., Trivette, C. M., & Hamby, D. W. (2007). Meta-analysis of family-centered helpgiving practices research. Mental Retardation and Developmental Disabilities Research Reviews, 13, 370-378. doi: 10.1002/mrdd.20176

Joint Committee on Infant Hearing. (2007). Year 2007 position statement: Principles and guidelines for early intervention after confirmation that a child is deaf or hard of hearing. Pediatrics, 120, 898-921. doi: 10.1542/peds.2007-2333

Moeller, M. P., Carr, G., Seaver, L. Stredler-Brown, A., & Holzinger, D. (2013). Best practices in family-centered Early Intervention for children who are deaf or hard of hearing: An international consensus statement. Journal of Deaf Studies and Deaf Education, 18, 429-445. doi: 10.1093/deafed/ent034

Spencer, P.E., & Marschark, M. (2010). Evidence-based practice in educating deaf and hard-of-hearing students. New York: Oxford University Press.

Yoshinaga-Itano, C. (2014). Principles and guidelines for early intervention after confirmation that a child is deaf or hard of hearing. Journal of Deaf Studies and Deaf Education, 19, 143-175. doi: 10.1093/deafed/ent043

The second year of life is a period for significant growth in empathy-related behaviors including prosocial behaviors (e.g. sharing, helping, comforting others in distress), empathic concern or affective expression of concern (e.g. facial expressions), and cognitive attempts to understand others’ internal states (Knafo, Zahn-Waxler, Van Hulle, Robinson, & Rhee, 2008; Zhan-Waxler, Robinson, & Emde, 1992).  Throughout childhood, empathy enables children to engage in socially appropriate and adaptive peer interactions and contributes to overall mental health and functioning. However, recent research suggests that emergence of affective and cognitive indicators of empathy are present as early as 8 to 10 months of age (Roth-Hanania, Davidov, & Zahn-Waxler, 2011), emphasizing the significance of the early months in life for the emergence and development of empathy-related behaviors.

The quality of the parent-child relationship has been linked to early expressions of concern for others. Toddlers, who display higher empathy-related behaviors, such as concern for others’ distress, have experienced more contingent and sensitive maternal responsiveness as infants (Spinrad & Stifter, 2006).  Parents scaffold children’s empathy-related behaviors through multiple processes including modeling and social interactions. Parents, who are aware of their children’s sadness and anger and validate their children’s negative emotions, tend to use emotion talk, such as labeling their children’s negative emotions, and to facilitate problem solving. These parents are said to act similar to a coach and are referred to as emotion coaches (Gottman, Fainsilber-Katz & Hooven, 1996).  Conversely, parents who believe sadness and anger are harmful emotions tend to encourage denial and avoidance of such emotions in their children and adopt a somewhat dismissive style in their responsiveness to negative emotions, which may be maladaptive in spite of good intentions.  Parental coping with children’s fear, sadness, and anger include positive strategies such as encouragement of emotional expression, or negative strategies such as punishment and minimization of negative emotions. These parenting behaviors are related to children’s ability to express concern for others in distress and help alleviate others’ pain (Davidov & Grusec, 2006).

Mentalization-related attributes, such as mind-mindedness (i.e., making mind-related comments about infants’ intentions and behaviors) and mental state talk (i.e., using language that describes wishes, thoughts, and feelings including words such as want, need, sad, happy, think, remember) in conversations with children, have been associated with children’s ability to accurately perceive beliefs, intentions, and emotions in others (Meins et al., 2002; Taumoepeau & Ruffman, 2006). Also, children’s own use of mental state language is an essential tool used to understand and share significant experiences with others (Fivush, & Baker-Ward, 2005). Thus, parenting behaviors such as parents’ emotion coaching and their mind-minded and mental state comments are likely related to very young children’s empathy-related behaviors.

Research Questions

In Study 1, we examined the ways in which maternal beliefs about sadness and anger, as well as coping with children’s negative emotions, contribute to preschoolers’ expressions of prosocial behaviors.

In Study 2, we investigated the contributions of maternal emotion coaching beliefs and toddlers’ internal state language to toddlers’ expressions of empathy. This is important, first, because low-income children are at higher risk for poor social-emotional outcomes. Second, limited attention has been given to the study of mental state language in children younger than 3-5 years.

Overview of Study Methods

Study 1 was conducted at the Michigan State University Child Development Laboratories. In this study of 37 mothers and preschoolers, (MomAge = a mean of 34 years, SD = 5.77; ChildAge = a mean of 52.6 months, SD= 8.43) we have assessed maternal beliefs about their children’s experience of sadness and anger with the Maternal Emotional Styles Questionnaire (Lagacé-Séguin & Coplan, 2005).  This questionnaire includes subscales that assess emotion coaching beliefs (i.e. the parent encourages and supports the child’s expression of emotions) and emotion dismissing beliefs (i.e. the parent disregards the child’s expressions of emotions). Additionally, we assessed the range of strategies for responding to children’s negative emotions via the Coping with Children’s Negative Emotion Scale (Fabes, Eisenberg, & Bernzweig, 1990).  Coping strategies included focusing with the child on the problem at hand, encouraging the child’s expression of emotion, minimizing the child’s emotions, punishing the child for the expression of negative emotions, and, finally, mothers becoming distressed themselves. Children’s empathy was assessed using the Empathy Questionnaire (Rieffe, Ketelaar, & Wiefferink, 2010) consisting of three subscales related to Emotion Contagion, Attention to Others’ Feelings, and Prosocial Behaviors. Currently, we provide preliminary results focused on maternal emotion beliefs, their emotion coping strategies, and children’s prosocial behaviors.

Study 2 utilized data from a larger social-emotional curriculum development and evaluation study (Brophy-Herb et al., 2005). In this study of 167 mothers and toddlers (MomAge = mean of 27 years, SD = 7.67; ChildAge = mean of 18.69 months, SD = 8.97), we assessed maternal beliefs about their children’s experience of sadness and anger with the Maternal Emotional Styles Questionnaire (Lagacé-Séguin & Coplan, 2005), and the empathy subscale of the Infant-Toddler Social-Emotional Assessment (ITSEA; Carter & Briggs-Gowan, 2000). We also asked mothers to respond to a list of words representing mental state language and tell us which words their toddlers knew and understood.  Specifically, we asked mothers to comment on the total number of cognitive state mental words (e.g. words like think and know) and emotion action words (e.g. words like crying and smiling) the child knew and understood.

Results

Study 1.  Multiple regression analyses showed that maternal emotion coaching beliefs were significantly related to mothers’ emotion-focused reactions to children’s expressions of negative emotions (β = .53, p = .005) and to their problem-focused reactions (β = .70, p = .019). These findings suggest that when mothers believe that sadness and anger are important emotions to validate and process with their children, they are more likely to focus on the emotional content of their children’s challenging daily emotional experiences and, subsequently, act in more emotionally-comforting ways. These parents also facilitate their children’s problem-solving skills as a coping mechanism when expressing strong emotions. Our results further revealed that maternal emotion-dismissive beliefs were significantly related to mothers’ minimizing reactions (β =. 84, p = .000) suggesting that parents who believe negative emotions are harmful tend to minimize their children’s expressions of sadness, fear, and anger by asking their children to ignore their emotional experiences. Comments such as “You’re fine.  Stop crying.” minimize the child’s experience of the emotion.  Consistent with our hypothesis, mothers’ distressed reactions in response to their children’s negative emotions were significantly and negatively associated with children’s prosocial behaviors (β = – 0.25, p = .011).

Study 2.  Multiple regression analysis revealed that, after controlling for the child’s age, sex, and maternal cumulative risk (e.g. poverty, low education, welfare receipt, lack of support, young age at entry into parenthood), the total number of emotion action words toddlers knew and understood (e.g., cry, hurt) (β = 0.03, p = .000), and the total number of cognitive words (e.g., know, remember) (β = 0.29, p = .000), were significantly related to mothers’ reports of their toddlers’ expressions of empathy. Furthermore, mothers’ emotion coaching beliefs were significantly related to toddlers’ empathy (r = .228, p = .01).

Conclusions

Study 1 results highlight the important role that parents’ individual beliefs about negative emotions play in their approach to processing children’s negative emotions, which maybe important contributors to children’s capacity to tolerate negative emotions in self and others. Furthermore, our results suggest that a parent’s own capacity to regulate his or her own distress when faced with their children’s intense emotional distress helps to facilitate children’s motivation to help others in distress. A parent who becomes distressed or responds to the child’s negative emotions with anger or anxiety is modeling such emotional responses.  Moreover, the parent is likely missing opportunities to support the child’s development of important regulatory skills that may contribute to building a capacity for empathy and prosocial behaviors.

Study 2 findings support the notion that for toddlers under 24 months, the ability to know and understand mental state language may be an important component of their capacity to understand others’ mental states and express empathic concern. Consequently, facilitating mental state talk in toddlers, especially words describing emotional expressions and cognitive states, might serve as a linguistic foundation for their understanding of others’ mental states and expression of concern for their distress.

Key Implications for Practice

• Promoting parents’ comfort with young children’s expressions of strong emotions may help parents to respond in emotionally-supportive ways to their children and may help parents’ scaffold children’s growing capacities to respond with empathy to others.

• Parents can facilitate empathy-related behaviors by commenting on infants’ and toddlers’ behaviors using mental state language that reflect children’s internal mental states (i.e. their feelings, intentions, goals, and desires).

For more information about this study contact  Neda Senehi at senehine@msu.edu

References

Brophy-Herb, H., Onaga, E., Fitzgerald, H., Van Egeren, L., Horodynski, M., &Shirer, K. (2005). Enhancing early social emotional development in infants and toddlers using a relationship based model: The BEES curriculum project. Administration for Children and Families: Award # 90YF0055/01, unpublished.

Carter, A. S., & Briggs-Gowan, M. J. (2000). Infant toddler social and emotional assessment (ITSEA) manual. New Haven, CT: Yale University.

Davidov M., Grusec J. E., (2006). Untangling the Links of Parental Responsiveness to Distress and Warmth to Child Outcomes. Child Development, Volume 77, Number 1, Pages 44 – 58.

Fabes, R. A., Eisenberg, N., & Bernzweig, J. (1990) Coping with Children’s Negative Emotions Scale (CCNES): Description and scoring. Available from authors. Arizona State University.

Fivush, F., & Baker-Ward, L., (2005) The Search for Meaning: Developmental Perspectives on Internal State Language in Autobiographical Memory, Journal of Cognition and Development, 6:4, 455-462.

Gottman, J. M., Katz, L. F., & Hooven, C. (1996). Parental meta-emotion philosophy and the emotional life of families: Theoretical models and preliminary data. Journal of Family Psychology, 10(3), 243-268.

Knafo, A., Zahn-Waxler, C., Van Hulle, C., Robinson, J. L., & Rhee, S. H. (2008). The developmental origins of a disposition toward empathy: Genetic and environmental contributions. Emotion, 8, 737–752.

Meins, E., Fernyhough, C., Wainwright, R., Das Gupta, M., Fradley, E., & Tuckey, M. (2002). Maternal mind–mindedness and attachment security as predictors of theory of mind understanding. Child development, 73(6), 1715-1726.

Zahn-Waxler, C., Radke-Yarrow, M., Wagner, E., & Chapman, M. (1992). Development of concern for others. Developmental Psychology, 28, 126–136.

Rieffe, C., Ketelaar, L., & Wiefferink, C.H. (2010). Assessing empathy in young children; construction and validation of an empathy questionnaire (EmQue).Personality and Individual Differences, 49, 362-367.

Roth-Hanania, R., Davidov, M., & Zahn-Waxler, C. (2011). Empathy development from 8 to 16 months: Early signs of concern for others. Infant Behavior and Development, 34(3), 447-458.

Spinrad, T. L., & Stifter, C. A. (2006). Toddlers’ empathy-related responding to distress: Predictions from negative emotionality and maternal behavior in infancy. Infancy, 10(2), 97-121.

Taumoepeau, M., & Ruffman, T. (2006). Mother and infant talk about mental states relates to desire language and emotion understanding. Child development, 77(2), 465-481.

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

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

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

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

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

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

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

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

 

 References

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

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

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

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

 

 

 

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

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

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

WA MHC supporting the AAIMHI WA Competency Working Group

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

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

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

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

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

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

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

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

Next steps for AAIMHI WA

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

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

 Click here to view the Workforce Competency Based Training Project Report

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

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

Here are a few good ones:

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

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

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

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

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

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

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

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

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

What are the core processes in RS/C?

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

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

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

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

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

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

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

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

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

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

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

 

Reference

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

Promoting Cross Collaborative Research Efforts and Implications for Excellence in Practice

The Michigan Infant/Toddler Research Exchange (MITRE) is comprised of researchers from Central Michigan University, Eastern Michigan University, Michigan State University, Wayne State University, and the University of Michigan whose research focuses on infants, toddlers, their families and caregivers.

MITRE faculty reflect diverse disciplinary backgrounds in human development, early childhood education, pediatrics, nursing, psychiatry, psychology, social work, and family therapy. Faculty utilize a variety of theoretical and conceptual frameworks in their studies, including infant mental health, attachment theory, transactional models of development and gene X environment models to better understand how intersections between biological, psychosocial, familial, cultural and community contexts influence children’s growth and development. Faculty study a range of topics including early social-emotional development, motor development, early obesity risk, family processes and functioning associated with infant/toddler development, parental and caregiver reflective functioning, and early language and communication skills in the context of parent-child relationships. MITRE researchers have strong interests in the implications of research for best practices in early intervention and support programs and in early education environments and they are involved in community-based research efforts working in collaboration with programs such as Early Head Start, Head Start, Community Mental Health, pediatric and family clinics, and local childcare and early education facilities. The goals of the MITRE are to provide a forum for Michigan researchers to (a) discuss key issues in applied research focused on infants, toddlers, families, and caregivers and to share resources and exchange ideas, (b) foster cross-university research, and (c) to serve as a resource for the state in research to practice initiatives.

To learn more about MITRE, visit http://www.beeslab.org/mi-infanttoddler-research-exchange.html.

Over the coming year, MITRE will be contributing a series to the Infant Crier. The series topics include: attachment-based interventions, reflective functioning and mentalization, individual differences in development, fathers, emotion socialization, and families in trauma. We hope you enjoy the series.

There is a significant need for effective, evidence-based and practice-informed interventions to support parenting among high risk, overburdened families, and programs that focus both on enhancing sensitive parenting as well as improving parent mental health have a substantial potential for positive impact on a broad range of outcomes, including parental, child and family system functioning.  For example, increasing a parent’s ability to accurately perceive, interpret and respond to his/her infant’s cues has been shown to improve child attachment security, whereas sensitively augmenting protective factors such as enhancing coping skills or access to support and clinical care can ameliorate some of the common consequences of parental mental illness.  Infant mental health (IMH) home visiting, as practiced in Michigan, is a strong model of intensive intervention to address exactly the concerns faced by at-risk families.  However, not all families are eligible or ready to engage in the IMH program, for example, due to internal barriers such as a history of trauma and wariness about engaging with providers.  Thus there remains a need for treatment-engagement interventions that work to address and minimize barriers, and for those in need, provide a safe context for connecting to providers and entry into more intensive care.

The need for evidence-based and practice-informed strategies aimed to enhance both parenting and parent mental health also presents rich opportunities for research-provider partnerships in the development and evaluation of new and existing program models.   We describe here two preventive intervention programs that were developed in Michigan and are currently implemented at multiple sites across the state.  Both were developed, implemented, and evaluated in close collaboration with community providers across the state, and thus provide an illustration of meaningful academic-community partnership, with a common focus on meeting the needs of Michigan’s vulnerable families through best-practice service delivery.   Mom Power (Muzik et al., in press) is a brief multifamily group preventive intervention designed to engage high-risk mothers of infants and young children, and Strong Military Families (Rosenblum & Muzik, 2014) is an adaptation of the Mom Power model, specifically designed to meet the needs of military and veteran families with young children.

Mom Power: a Multifamily Preventive Intervention Approach to Engaging High-Risk Traumatized Mothers with Young Children

Mom Power is a manualized (Muzik, Rosenblum, Schuster, & Ribaudo, 2013) brief multifamily parenting and self-care group intervention program for high-risk mothers with infants and young children; the program involves three individual and ten 2½-hour-long group sessions.  Most of the mothers who participate in the program have trauma histories and/or mental health problems of their own, including a high prevalence of maternal depression, anxiety and posttraumatic stress.  The intervention aims to 1) increase sensitive parenting, 2) teach positive stress coping to alleviate mental health symptoms, and 3) facilitate social support and connections to community resources.  Mom Power is based on 5 key therapeutic “pillars”:  (1) Social Support is enhanced by creating a shared group experience, with opportunities for informal relationship building during shared meal-times and the Mom Group, as well as through involvement of other parenting support individuals in the mothers’ natural network. (2) Given the central importance of attachment relationships in early development, the Parenting Education curriculum emphasizes responsiveness and sensitivity to young children’s separation experiences.  In the Mom Group, participants are introduced to key topics in parenting and child development, observe video interactions and apply concepts learned, engage in activities designed to develop and practice skills, and reflect on interactions with their own children.  Parents are introduced to attachment concepts, with an emphasis on helping parents identify children’s emotional needs and provide a secure base and safe haven as needed.  In addition, group leaders emphasize the need for “Balanced Parenting,” that is, encouraging parents to integrate being both “strong and in charge” as well as “warm and kind” in their everyday interactions with their children.  (3) The Self-Care/Stress-Reduction curriculum addresses mothers’ needs for hands-on strategies for reducing their own levels of stress in order to provide Balanced Parenting and support their children’s needs.  Each Mom Group session includes hands-on practice of evidence-based stress-reduction “skills” including guided breathing, relaxation, or mindfulness. This has the added benefit of helping mothers prepare for reuniting with their children in a calm, relaxed state. (4) Child Routines and Parent-Child Interaction are supported by a child curriculum that emphasizes creating safe, predictable routines; acknowledging “goodbyes” when mothers leave for their class; developmentally appropriate play-based activities; and observation of and support for reunions when mothers return from their group.  These brief separations and reunions provide an opportunity for “real-time” practice, negotiating feelings about separations and return, and helping mothers to identify and respond to their children’s needs for support. Mothers are encouraged to anticipate, observe, and reflect upon these separations and reunions, as well as identify ways they might want to “try something new” to address their children’s feelings during separation/reunion at the next session.  (5) Individual meetings with mothers are held mid-way through the 10-week intervention to provide opportunities for Connecting Families to Care, including individualized referrals to relevant community resources, including mental health home visiting when indicated.  The program incorporates circles of support and caring with clear attention to the parallel process: we aim to provide a secure base and safe haven to the mothers in part by ensuring attention to the needs of staff for safe haven and secure base, with regular debriefing and use of reflective supervision for parent and child group leaders.

The Mom Power program was developed in close collaboration with several community based health clinics in Southeastern Michigan, and with support from the Department of Community Health. The curriculum was developed iteratively through an iterative process of getting input from Mom Power intervention facilitators, as well as the participating mothers who experienced the program.  Thus, the curriculum is founded both on bottom-up (input from community) and top-down (theory-driven and evidence-based) principles. As the model was trial implemented through Community Mental Health, other agencies expressed interest, underscoring the demand for this type of brief treatment-engagement, preventive intervention model.  Yet from a research perspective, there was a need for continued evaluation of the model to build the evidence-base and confirm its efficacy for improving parenting and parent mental health.  We thus employed a “hybrid” approach to evaluation, that is, engaging in dissemination of the model through community provider training and concurrent ongoing evaluation of the efficacy of the model through involvement of providers in evaluation activities.  This approach allows us to identify not only whether the program works in rigorously controlled ‘scientifically ideal’ circumstances, but also how it is implemented and its efficacy in ‘real world’ contexts of community-based practice.

Results of this evaluation undertaking have been very encouraging.  Our pilot data indicated that not only was Mom Power associated with improvements in parenting (including capacity for reflective parenting), stress coping, and mental health, but that these results were most pronounced for women who entered the program with histories of interpersonal trauma and/or mental health diagnoses—precisely the families the program was designed to reach (LePlatte et al., 2012; Muzik et al., in press). In addition, our pilot data also confirmed our clinical intuition that participants’ engagement and satisfaction with the intervention was high; in fact, treatment engagement with Mom Power was in the 65-73% range across race/ethnicity groups of Caucasian and African-American mothers (Muzik et al., 2014). However, the initial pilot study compared mothers who graduated from the Mom Power program (i.e., attended at least 7 of the 10 group sessions) against those who dropped out prematurely. In order to evaluate more rigorously, we therefore, together with our community partners in the southeastern Michigan region, undertook a more stringent evaluation, conducting what is referred to as a “randomized clinical trial”, that is, we recruited women from the community and assigned them randomly to either the Mom Power program or to a waitlist condition.  In the waitlist condition women received weekly mailings that conveyed the content without the “warm overlay” of active group involvement; these families were eligible to participate in the Mom Power program in the “next round” of delivery, after we finished the assessments that allowed us to observe whether women in Mom Power or the waitlist group differed on key outcomes.  Importantly, for ethical reasons, all women were eligible for any referral indicated and provided including home based IMH services; that is, no family was ever denied access to treatment, but only some were assigned immediately to the Mom Power preventive intervention.  As with our initial pilot study we observed that, compared to the waitlist control condition, participation in Mom Power was associated with significant reductions in mental health symptoms and parenting stress and improvement in mother-infant bonding.  In addition, mothers assigned to Mom Power were more likely to receive additional referrals for services (approximately half of all mothers in Mom Power, but only 9% of women in the waitlist condition were referred to additional services including IMH).

This type of randomized controlled study represents a strong test for the efficacy of the intervention.  Just as importantly, the “real world” applicability of this approach was strengthened by the fact that Mom Power was delivered by trained community IMH providers in their agency settings.  This allowed us to learn from providers about what makes this work, as well as what barriers exist to community-based implementation, so that we can strengthen these facilitators and reduce barriers in subsequent implementations.  This also contributes to the likelihood that the model can be sustainably delivered beyond the duration of the research study, an important goal for us as researchers and clinicians.  Indeed, we are very pleased that Mom Power is now offered at multiple sites as a billable program service, independent of our research collaborations.

A Unique Adaptation of the Mom Power Model:  Strong Military Families

Military parents make a dual commitment to protect their children and protect our nation. Yet these families face special challenges in balancing military and family life.  Military children and families sacrifice and serve alongside service members, and the need for support and a strong community continues during the period of reintegration after the service member returns.  As one father shared: “He was born and I was deployed before he was walking. And when I came back, he was standing, gripping onto (his mother’s) leg –- looking at me like, ‘That’s who?’ She had to tell him, ‘That’s Daddy.’” Another father commented, “When I came back, it was difficult … trying to find that closeness and trying to find that reconnect.”

Indeed, more than 12,000 Michigan National Guard troops have been deployed since 9/11.  Michigan’s military community is vast – recently ranking ninth of all states in the number who have served in Iraq and Afghanistan — and underserved – ranking last among states in providing services to veterans and their families. The steep rise in rates of child abuse, divorce, depression, PTSD, and suicide during and following deployment highlights the need for support, yet due to geographic dispersion in civilian communities National Guard families often lack access to mental health services. Separation from one parent, coupled with heightened distress in the at-home parent, places young children at particular risk.  Although often eagerly anticipated, reunification also poses challenges, including adjusting to the parent-soldier’s return, reestablishing roles and routines, and, if necessary, accommodating to combat-related injuries.

Despite overwhelming need, tailored interventions for military families with young children are rare; thus, promising practices that incorporate evidence-based strategies can fill a critical void.  We therefore developed the Strong Military Families model, an adaptation of the 10-week multi-family Mom Power group intervention, tailored for military families with young children and to include both mothers and fathers (Rosenblum & Muzik, 2014).  The intervention incorporates evidence-based strategies to reduce parental stress and social isolation, enhance parenting, and connect families with resources, thereby improving mental health outcomes.

Strong Military Families is a program of the University of Michigan Department of Psychiatry and Depression Center’s Military Support Programs and Networks (M-SPAN), which has a successful track record of developing and implementing mental health programs for military families, and is well-connected with military service providers across the state.  However, in order to reach families with young children and sustain services across the state it was clear that we needed to again implement an evaluation approach that involved collaboration with community partners who serve families with young children.  We therefore established a collaboration with the Michigan Department of Community Health and with a number of regional collaborators, which include but are not limited to Easter Seals in Oakland County, the Judson Center in Macomb, and the Community Action Agency in Jackson County.  Funding to support the development and initial evaluation of Strong Military Families included support from the national Welcome Back Veterans initiative as well as the National Institutes of Health, while the regional Flinn Foundation and Great Start Collaborative Macomb provided support for disseminating the model and building capacity to deliver this service at specific sites in Southeastern Michigan.   Consistent with the Mom Power evaluation, our pilot data are very encouraging and indicate improvements in parent mental health, parenting, and child outcomes.  We are now finishing up collection of data in a larger clinical trial contrasting waitlist families from those who complete the multifamily group.  While this is underway we are simultaneously working to identify new and innovative ways to reach families in geographically diverse regions.  For example, with recent support from the Justin Verlander “Wins for Warriors” Foundation we will be launching a pilot adaptation of a weekend “Wins for Warriors Strong Military Families Weekend Retreat,” which will allow us to engage and support families from diverse geographic regions via delivery of a weekend version of the Strong Military Families in northern Michigan.

One of the many important “take home” messages from the work we have done with Strong Military Families is that fathers and couples express a desire for and can benefit from involvement in this type of a multifamily group model approach.  We are therefore currently working with collaborators at UM and Wayne State to identify ways of adapting this model to meet the needs of civilian community, urban fathers of young children as well.

Ultimately, we believe that the Mom Power and Strong Military Families models hold promise not only as solid, evidence-based practices for engaging vulnerable families and for improving parenting, parent mental health, and child outcomes, but also as models for partnership between researchers and providers to ensure that best practice models are not only “evidence-based” but also reflect real world “practice-informed” approaches to this important work.

 

References:

LePlatte, D., Rosenblum, K., Stanton, E., Miller, N., Muzik, M. (2012).  Mental Health in Primary Care for Adolescent Patients.  Mental Health in Family Medicine, 9, 39-45.

Muzik, M. , Rosenblum, K., Schuster, M. & Ribaudo, J. (2013). Mom Power Curriculum (Unpublished Manual). [Note: Training in the model is available; contact muzik@med.umich.edu or katier@med.umich.edu with questions or for more information.]

Muzik, M., Schmicker, M., Alfafara, E, Dayton, C, Schuster, M, & Rosenblum, KL. (2014).  Predictors of Treatment Engagement to a Parenting Intervention among Caucasian and African-American Mothers. Journal of Social Service Research,40 (5); 662-680.

Muzik, M. , Rosenblum, K., Alfafara, E., Schuster, M., Miller, N., Waddell, R. & Kohler, E. (in press). Mom Power: An Intervention to Enhance Parenting and Mental Health in High-Risk Mothers. Archives of Women’s Mental Health.

Rosenblum, K. & Muzik, M. (2014).  STRoNG Military Families: A multifamily group intervention for military families with young children.  Psychiatric Services, 65, 399.