Category: News

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.

Over the past decade advances in developmental biology have provided considerable evidence linking early adversity to negative outcomes.  Children living in poverty face substantially increased risk of early adversity. Stressful environments characterized by elevated levels of chronic environmental and caregiving stressors in the context of poverty can disrupt brain architecture and exacerbate underlying genetic vulnerabilities to affect psychological functioning. Shonkoff and colleagues (2009) define toxic stress as the prolonged exposure to cumulative stressors that disrupt regulation via chronic reactivity of physical stress-response systems. Guided largely by attachment theory and research, supportive caregiving is recognized as a crucial buffer against toxic stressors, reducing the harmful physiological effects of high stress (Shonkoff, 2010). Recent evidence demonstrates the long term positive effects of early attachment-based intervention programs on children’s development in high-risk community samples, enhancing the importance of early community-based intervention implementation to vulnerable populations.

Early Head Start: The Need for Support

Early Head Start (EHS) and other publicly funded programs were designed to promote early parenting and child development among families living in poverty. The prominent goal of EHS is to provide high-quality, comprehensive support services to promote child development and positive, child-parent relationships. Longitudinal data from the Early Head Start Research and Evaluation Project (EHSREP) has demonstrated numerous, consistent, modest program effects on observed parenting for the sample as a whole (Administration for Children and Families, 2002; Love et al., 2005). For example, mothers who received EHS displayed more supportive parenting behaviors towards their children and children who engaged more with their mothers compared to those randomly assigned to the control group. However, recent work has begun to highlight what works for whom in EHS programming effects across the diverse population groups (Raikes, Vogel, & Love, 2013). For example, smaller program effects were found for children with mothers identified as high-risk, according to the EHSREP cumulative demographic risk protocol (Administration for Children and Families, 2002; Raikes, Vogel, & Love, 2013). Furthermore, Berlin and colleagues (2011) found fewer effects of program participation on supportive parenting behaviors for mothers with higher levels of attachment avoidance at baseline compared to mothers with lower levels of attachment avoidance. Researchers and practitioners have suggested that some EHS recipients would benefit from attachment-based parenting services (Raikes, Vogel, & Love, 2013).

ABC as a Supplement to EHS

The Attachment and Biobehavioral Catch-Up (ABC) developed by Dozier and colleagues, targets early parenting behaviors and attachment. The ABC program provides an evidence-based model consisting of structured intervention activities delivered in 10 home-based sessions by a trained parent coach. Specific attachment-related topics are addressed in each session, including demonstrations through video-recorded mother-infant interactions, with the presence of both mother and child. This brief, yet intense program provides parent coaching in reference to three specific behavioral targets for helping parents learn how to: (1) behave in nurturing ways when children are distressed; (2) follow the child’s lead in delighted ways; and (3) avoid behaving in frightening or intrusive ways. A key mechanism of the ABC program is for parent coaches to provide in the moment commenting related to the three target behaviors exhibited during the sessions. This immediate feedback reinforces and supports mothers’ use of target behaviors.

Partners for Parenting Study

As part of Administration for Children and Families Buffering Toxic Stress Research Consortium, the Partners for Parenting (P4P) study is an ongoing Early Head Start-University Partnership, addressing the prevention of toxic stress through attachment-based intervention (Co-Principal Investigators are Lisa Berlin and Brenda Jones Harden). The P4P study consists of a randomized controlled trial investigating the effects of home-based Early Head Start with a supplemental parenting intervention, the Attachment and Biobehavioral Catch-Up (ABC) program. Participants include primarily Spanish and English speaking Latino and African American mother-infant dyads in the Washington, DC metropolitan area receiving home-based Early Head Start services. The goal of the P4P project is to evaluate the effects on parenting behaviors and infant stress regulation via measuring the implementation and sustainability of the ABC program within the Early Head Start context. Initial analyses have reported robust feasibility and acceptance of this model by mothers and EHS staff (Berlin, Jones Harden, Raymond, & Denmark, 2012). Qualitative maternal interviews highlighted the unique benefits of receiving ABC in addition to Early Head Start home visits. Findings are expected to inform community-based intervention researchers, practitioners, and policymakers.

 

References

Administration for Children and Families. (2002). Making a difference in the lives of children and families: The impacts of Early Head Start programs on infants and toddlers and their families. Washington, DC: U. S. Department of Health and Human Services.

Berlin, L. J., Jones Harden, B., Raymond, M., & Denmark, N. (2012, June). Buffering children from toxic stress through attachment-based intervention: An Early Head Start-University Partnership. Poster presented at the Head Start National Research Conference, Washington.

Berlin, L. J., Whiteside-Mansell, L., Roggman, L. A., Green, B. L., Robinson, J., & Spieker, S. (2011). Testing maternal depression and attachment style as moderators of early head start’s effects on parenting. Attachment & Human Development, 13(1), 49-67.

Dozier, M., Lindheim, O., & Ackerman, J. (2008). Attachment and biobehavioral catch-up. In L. Berlin, Y. Ziv, L. Amaya-Jackson, & M. T. Greenberg (Eds.), Enhancing early attachments. New York: Guilford.

Love, J. M., Kisker, E. E., Ross, C., Raikes, H., Constantine, J., Boller, K., et al. (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.

Raikes, H. H., Vogel, C., & Love, J. M. (2013). Family subgroups and impacts at ages 2, 3, and 5: Variability by race/ethnicity and demographic risk. Monographs of the Society for Research in Child Development, 78, 64-92.

Shonkoff, J. P. (2010). Building a new biodevelopmental framework to guide the future of early childhood policy. Child Development, 81(1), 357-367.

Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. Journal of the American Medical Association, 301(21), 2252-2259.

Shonkoff, J., & Phillips, D. (Eds.). (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.

A collaborative project to validate and sustain IMH-HV as an evidence-based practice for improving infant, toddler and maternal well-being.

The Challenge.  Recent state and federal legislation now require home visiting programs to meet evidence-based practice standards. Infant Mental Health Home Visiting (IMH-HV) is designated as a promising practice, meaning studies have suggested its efficacy of improving parent-child outcomes, particularly parent-child attachment. However, to allow high-risk Michigan families continued access to IMH-HV, the model must undergo a more rigorous, scientific evaluation meeting federal specifications for improved maternal and infant health and social-emotional well-being; improved child development and school readiness; and reductions in child abuse and neglect.  For this reason, MI-AIMH- in partnership with consultants from the University of Michigan’s Department of Psychiatry and the Michigan Department of Community Health- is developing a proposal for such an evaluation.  A brief overview of the proposed study appears below.

Evaluation.  Led by nationally-recognized experts in infant mental health at the University of Michigan’s Women & Infants Mental Health Program, IMH-HV will undergo a rigorous 3-year, randomized control-trial evaluation in accordance with Michigan Public Act 291 for Voluntary Home Visiting Programs, Affordable Care Act benchmarks, and guidelines for establishing evidence-based practices. We will also examine IMH-HV through the lenses of racial equity and systems (like community mental health and service delivery), to better understand what makes IMH-HV effective across race, culture, and systems.

Medicaid-eligible pregnant women and mothers of infants and toddlers up to 24 months old will be recruited from Wayne and Washtenaw counties to participate in the project.

Outcomes.  Our first and foremost goal is to improve maternal, infant, and toddler well-being. This research project aims to show how greater improvements in infant, toddler and maternal health, social-emotional well-being, and reduced child abuse and neglect are associated with receiving IMH-HV services, and how lasting those improvements are over the course of one year of treatment, setting the foundation for our second goal: to establish IMH-HV as an evidence-based practice.

Impact.  Meeting these outcomes will sustain IMH-HV for high-risk Michigan children and families, and pave the way to expand IMH-HV in other states through eligibility for federal funding as an evidence-based practice.

Investment Needed.  The total investment for this project is $3 million over 3 years, including both direct services to families and evaluation costs.The Ethel & James Flinn Foundation recently awarded the project team a challenge grant to launch this work.

A collaborative endeavor of:

                                          

 

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The following information provides an overview of Infant Mental Health and the IMH-HV model in support of the IMH Home Visit Evaluation Project described above.

As developed in the original model and for the purpose of this evaluation:
Infant Mental Health is the social, emotional, and cognitive well-being of children under age 3 in the context of secure and stable relationships with caregivers.

Infant Mental Health Matters for a Lifetime
Ensuring the emotional well-being of infants is critical to their overall health and development.¹ Predictable, responsive, and nurturing relationships with caring adults help babies develop a sense of security and feel safe exploring the world around them. This curiosity is the base for healthy cognitive and social development.² Over a lifetime, Infant Mental Health matters.

Brain.   A baby’s relationship with his parents plays an important role in how his brain develops. Too much stress (from trauma, abuse, or neglect) can reprogram his rapidly developing brain so that his body’s stress response system is constantly activated. ³

Body.  When the body’s stress response system is constantly activated, the stress becomes toxic. Toxic stress in early childhood can alter the way DNA is read and cause physiologic disruptions that persist into adulthood. It is linked to adult health problems like heart disease, asthma, autoimmune diseases, liver cancer and depression.⁴

Behavior.  Without secure attachment relationships, a child will have more difficulty coping with stress and adapting to change, putting him at greater risk for challenging behaviors and unhealthy habits later on, such as smoking, drinking, and drug abuse.⁵

Infant Mental Health Home Visiting (IMH-HV) is a voluntary home visiting model delivered by clinically-trained, master’s level professionals who provide weekly home visits to Medicaid-eligible pregnant women and families with infants.  Almost all families served by IMH-HV have past or present experiences (such as unresolved losses,trauma, grief or depression) that threaten the new relationship with their baby.

 

IMH-HV has 3 unique characteristics that separate it from other home visiting models:

• Infant-parent psychotherapy offers parents the opportunity to express and understand their feelings from past or present trauma, loss, abuse, neglect, or depression that threaten to interrupt the development of secure, stable, and enduring parent-child relationships.

• Clinically trained, masters-level professionals with an IMH-Endorsement®, specially trained to provide preventative and therapeutic interventions to help families address unresolved issues that may disrupt a baby’s healthy development.

• Eligible families may be very high risk (i.e. complex and co-occurring needs such as poverty, depression, domestic violence), have more than one child, and/or enroll anytime from pregnancy through a child’s 2nd birthday.

IMH-HV also provides case management, developmental guidance, emotional support, life skills, and social support. IMH-HV’s goals are to help parents build secure attachment relationships with their babies; promote a child’s healthy growth and cognitive development; and reduce child abuse and neglect. IMH-HV is a unique service of the Michigan Department of Community Health, provided statewide by 46 community mental health provider agencies.

How IMH-HV Makes a Difference

1550 families throughout Michigan receive Infant Mental Health Home Visiting annually.

Babies who have more secure attachment with their parents are less likely to be neglected or abused, and are behaviorally and cognitively better prepared for school.6

Putting babies first saves lives and dollars. Preventing just one child from being a victim of abuse or neglect saves as much as $210,000 over a lifetime.7

 

[1]Davidov M., Grusec JE (2006). 2Lally, Ronald J. (2010) ³Center on the Developing Child. Harvard University. (2012). ⁴Shonkoff, JP, Garner AS, et al. (2012); Kraft, Colleen (2013). ⁵Schore, Allan N. (2001); Shonkoff,, JP, et al. (2012).  ⁶ Cinchetti D., Rogosch F.A., Toth, S.L. (2006), Davidov M., Grusec J.E. (2006). Tamis-LeMonda, C.S., Bornstein, M.H., Baumwell L. (2001.) ⁷ Centers for Disease Control and Prevention (2012)  ⁸IMH-E^®epresents the nationally recognized Endorsement for Culturally Sensitive, Relationship-Focused Practice Promoting Infant Mental Health®, based on an interdisciplinary set of Competency Guidelines®, developed in Michigan, and adopted by 18 other state IMH associations.

Text4baby is the largest mobile health initiative in the nation and is designed to promote maternal and child health. Women who text “BABY” (or “BEBE” for Spanish) to 511411 receive three free text messages a week, timed to their due date or their baby’s birth date, through pregnancy and up until the baby’s first birthday. The messages, which have been developed in collaboration with government and nonprofit health experts, address topics such as immunization, nutrition, birth defect prevention, and safe sleep. Text4baby also includes features such as appointment reminders, interactive features, fun quizzes, urgent health alerts, and support for accessing resources. The participating wireless phone companies have waived standard messaging fees, so text4baby is free for their customers.
Text4baby is made possible through a public-private partnership. Johnson & Johnson is the founding sponsor. Founding partners include National Healthy Mothers, Healthy Babies Coalition, Voxiva, CTIA – The Wireless Foundation, and Grey Healthcare Group (a WPP company). Learn more about the program at www.text4baby.org.

FROM THE WEBSITE:
The Text4baby service includes over 250 messages with the most critical information that experts want pregnant women and moms with infants under one to know. The comprehensive set of messages address:

• Prenatal Care
• Safe sleep
• Immunization
• Breastfeeding (Breastfeeding Content Fact Sheet)
• Nutrition
• Oral Health
• Immunization
• Family Violence
• Physical Activity
• Safety
• Injury Prevention
• Mental Health
• Substance Abuse
• Developmental Milestones
• Labor & Delivery
• Car Seat Safety
• Exercise

Women who sign up at any point during pregnancy receive a “starter pack” with six messages containing critical information and encouragement to connect to care.

As an IMH clinician providing home-based therapy services, I recently had the privilege of building a strong therapeutic relationship with an amazing woman who was able to make remarkably courageous decisions for her family. This is our story. (Identifying information has been changed to protect the family.)
Sarah is a 20-year-old mother of a 17-month-old girl born via cesarean section after an unexpected pregnancy with a man who is not involved and who denies that he is the father. Hannah came into foster care at 7 months when Sarah “called Child Protective Services to tell her that I was going to be homeless the next day and said it was time to take her.” At the time of Hannah’s birth, Sarah was in a relationship with Jake, who was identified as the father on the birth certificate. A paternity test concluded that he was not the biological father, and Child Protective Services initially got involved when he became irate in the hospital. He participated in supervised visitation during Hannah’s first month in care but shortly afterward broke up with Sarah and signed off his rights.

Meanwhile, Sarah reported not being able to handle her postpartum depression and care for her daughter. She often worked and stayed with friends while Hannah stayed with Sarah’s grandmother, who has significant mental health issues; Jake, who has a traumatic brain injury and significant mental health issues, or Jake’s family. With many different caregivers, Hannah lacked consistency in her first 7 months of life. Still, throughout my relationship with Sarah, I never doubted her love and dedication to her daughter, though her mental health and history of trauma got in her way of being able to provide Hannah the emotional support she needed.

I became involved when the foster care worker and Sarah called into Community Mental Health to request Infant Metal Health Services, which the local judge had been requiring for all children 0-3 removed for abuse or neglect. I met them within the week and completed an IMH assessment in a tiny room at the foster care agency. My first impression when I met the family was that they appeared comfortable together, as evidenced by Hannah having fallen asleep on her mom. During that first visit, Sarah shared loving stories of her daughter with an optimistic attitude. I was unsure how to move forward or how I might be helpful to her, but decided I would open their case and provide home-based IMH services based on the fact that Hannah had been removed from her mother. My role as an IMH worker for Community Mental Health is to help provide resources, developmental guidance, interaction guidance, support and parent infant psychotherapy. For the first several months with Sarah I was confused and didn’t feel like we were getting anywhere or that I was able to provide any of those basic Infant Mental Health pieces. Therapeutically it appeared that nothing had changed as a result of our sessions for either myself as a clinician or for Sarah as a mother. I met with Sarah separately at a local fast food restaurant (her choice) and visited her during supervised visitation at the agency. It took months before I felt like we were making progress, and in all that time Sarah was never approved for unsupervised visitation with her daughter, even with me present.

When I would meet with Sarah independently, her stories about her past were sparse and confusing. During the visits with her daughter, Sarah would often ask her to crawl toward her for hugs or cuddles – seeking to satisfy her own attachment needs. I knew that I was building a trusting relationship, but wondered if she would open the door to let me in as I hung here in the doorway, trying to figure out how this dyad got to this place. Sarah had started antidepressants and was working a stable job, but I didn’t see much of a shift in her presentation during our therapeutic sessions. Her interactions with her daughter continued to be similar from week to week and her self-esteem and self-image after having maintained a stable job didn’t shift as I would have expected it to. I was stuck and wasn’t sure what kept me hanging in there, but this dyad had a story to tell. Looking back, however, I am certain that it was reflective supervision that allowed me to continue our work together.

Five months into our work together I requested that I supervise Sarah and Hannah’s visits so that there would not be any other workers involved. This was a turning point. Without others in the room, Sarah was able to be open and honest and share her struggles. She was like a sponge to new knowledge about her daughter and though she didn’t ask questions, she was always ready to try something new. She picked up on my modeling very quickly, and I felt that things really started moving. While she sat on the couch and asked her daughter to come to her, I sat on the floor and gently engaged Hannah with the educational toys Sarah had provided. I applauded her for having baby supplies and fun toys and I would invite her into the play by talking for Hannah. When she would ask Hannah to come and give her a hug or to come and crawl to her and she chose not to, I would talk for Hannah saying “Oh, Mom, come down here and play with me. I am just not ready for a hug yet but I would love it if you rolled the ball to me.” Sarah caught right on and sat down on the floor and began rolling the ball. Hannah smiled with delight and increased her proximity to her mother. Sarah’s demeanor changed and her confidence grew. During visitations, Sarah was getting her own needs met, likely through our relationship and in her engagement with her daughter, while also meeting her daughter’s needs. We had a few bumps in the road as I felt that she tested my strength to continue by blaming me for continued supervised visitation, but we worked through those moments and I felt as though they strengthened the therapeutic relationship and deepened our work together. When she tried to push me away, I continued to support her through her frustration and fear and tried to prove that our relationship could withstand those big feelings. I would have not been able to stay in this space for Sarah without the support I found in reflective supervision, where I was able to express my concerns, worries and my own big feelings.

Hannah was bright and engaging and achieved all of her developmental milestones on time. She learned to crawl, pull to a stand, walk and begin to use words like “mom” during our work together, and Sarah proudly showed off her accomplishments during each visit. In the beginning the visits often had uncomfortable moments when Sarah would seek out Hannah to hug her and Hannah would resist because she was actively engaged in the many awesome toys that Sarah provided. This caused Sarah to feel rejected, but we were able to process through these feelings and she was ultimately able to identify when she needed her needs met and separate that and ensure she was tuned in with her daughter and able to meet her needs in the relationship. This was a turning point for Hannah as evidenced by her increased comfort in seeking out her mother to meet her exploration as well as attachment needs more and more in each visit. It was around this time that Sarah was granted one unsupervised visitation in her home with her daughter.

During our conversations, Sarah acknowledged that she had had many intimate partners, and throughout the past 12 months she began to talk about feeling shame about having been with so many different men. She has been able to put words to her sadness and fear of being alone. Sarah does not report any history of abuse or neglect but stories of her past provide evidence of a less than ideal childhood. She grew up in her grandmother’s home after her mom “couldn’t take care of us because she always left with different guys.” She did not have a relationship with her father and although she visits him occasionally, she does not have any memories as a child with him. Sarah does not view her childhood as being traumatic or hard, and describes it as “not as bad as other people.” But her grandmother, because of emotional instability and unmanaged bipolar disorder, was deemed an “unfit placement” for Hannah, providing further evidence that growing up with her grandma may likely have been quite tumultuous for Sarah.

After 9 months of our working together, Sarah started talking about how she didn’t think she would be able to become “emotionally stable” enough for her daughter in the amount of time required by the Court and worried that she would not get Hannah back. We sat with these feelings and emotions after she lost the privilege of unsupervised visits because of a questionable relationship. She talked with her family, who encouraged her to keep trying to regain custody, and she quickly went back to talking about how hard she was working to get Hannah back (and she really was working hard!).  Soon after Sarah shared with me that she was realizing that she couldn’t do it, meaning she couldn’t prove that she was emotionally stable enough or be emotionally stable enough to provide stability for her daughter and to meet her needs that she now recognized. She wanted to sign off on her parental rights and had already talked with Hannah’s foster parents over the past several days asking if they would consider adopting her daughter. They reported that they would love to adopt and Sarah seemed to feel like she was making the best decision for both her and Hannah’s sake. Following my time at the visit, she told the caseworker her decision and, in a court session five days later, her grandmother joined her in signing off on her rights. Sarah wanted things to move as quickly as possible and didn’t want others trying to convince her otherwise. For me, this was a really tricky time. I wanted to be supportive but was not informed she had signed off on her rights until I showed up for our scheduled visit time and she was not there. I later talked with the caseworker and Sarah and continued to try and be supportive despite not having known such big changes had actually occurred. I wondered if she worried about my thoughts and feelings around her terminating her own rights since my daughter was just a few months younger, but I hung in there, continuing to show her our relationship could withstand this too. This was hard, but ultimately I knew it was the hard stuff that needed to happen and it felt right.

Since Sarah signed off on her rights, I have continued to see her on a weekly basis. I worry about her emotional stability and have seen some worrisome behaviors like drinking, having multiple partners during a few short days and offering to pay other’s bills while not having enough money for her own needs. However, I also have seen a lost mother dealing with postpartum depression struggling to meet more than just her child’s physical needs transform into a responsible, much more stable, loving, caring mother who made a challenging decision about what she thought was best for her and her child. While she continues to have some worrisome behaviors, overall Sarah has been able to make significant changes through our work together. She shared recently that she felt like she had failed by signing off on her rights. Through our relationship she was able to accept that she had made the decision that was best for her daughter and that deep down inside, she knew from the very beginning that raising her daughter on her own was too much for her to handle.

Throughout this process I had a few visits with Hannah in her foster family’s home. The foster parents, who are working on adoption, are warm and loving and have a lot of support in raising her. Although they are new at parenting, they are open to feedback and suggestion and have proven to be a strong support for Sarah. Initially the foster parents and agency had all committed to allowing Sarah to see Hannah but shortly after termination they changed their minds, reportedly saying that it was not in her best interest to see her mother. I talked with the foster mother and expressed concern about what a loss this must be for Hannah and how confusing it must be at 19 months. In addition, the foster mother reported that they would no longer refer to Sarah as “Mom” and would explain the situation when she is much older. Again I provided her thoughts that this would be extremely confusing and that helping Hannah understand that she has a birth mom and an adoptive mom as two separate but loving people in her life would be in her best interest. I felt uncharacteristically bold and suggestive of what was in Hannah’s best interest but felt passionate about the importance of continuing to include Sarah in her life as a positive support and caring parent. Although the foster parents still seemed firm in their decision to stop contact, a few weeks later I heard from Sarah that she had been able to see her daughter after the foster parents had invited her to a doctor’s appointment. Victory! While I wish I would be able to continue to work with this mom and support her relationship with her daughter, unfortunately our work has come to an end. Our authorizations have expired and while we have achieved the goal of permanency for her daughter, I have left the door open for future therapeutic work together.

It was through the process of individual and group reflective supervision that I was able to make sense of Sarah’s presentation and behaviors, the foster family’s experience and the foster agency’s role as well as my own feelings and reactions in the various relationships with this family. Halfway through our work together it became clear that helping Sarah explore her feelings about voluntarily relinquishing Hannah was the needed focus.  I never offered that as a suggestion to Sarah but supported her emotions as she explored feelings that she had not had a chance to deal with previously. Through her honesty and trust in our therapeutic relationship, Sarah grew tremendously, and I felt as though I was able to grow as a clinician as well.

While working with a family that has lost temporary custody presents many challenges for the worker, the challenges that the family faces are excruciatingly hard. As a caseworker and IMH therapist it adds an enormous load to the work that often has to be done in a very short time. I am grateful that we have achieved stability for Hannah and have hope that through Sarah’s experience in our relationship, she is able to continue to focus on healing and taking care for herself.

Question: I am a professional and a married mom with two wonderful boys, ages 3 and 1. The 3-year-old struggles with severe separation anxiety every time I go to work. He wants me to be the person who does everything for him. He throws a fit if his father or grandmother diapers him or helps him dress. Getting out of the house in the morning is so emotionally exhausting that it’s affecting my job. We have a strong bond and spend one-on-one time together every day, but this aspect of parenting is so hard. Now my other boy is starting to behave the same way.

Answer: Is your 3-year-old close to the person who takes care of him while you are at work? Your confidence in his caregiver can reassure him that everything will be OK until you return. If you have doubts, your boy will pick up on them.
If you give in to his tantrums, you are sending the message – even though unintentionally- that he’s right to want you and no one else.
At 3, your boy is old enough to understand that you still exist when you are not in sight. But a reminder will help. Let him know where you are going. Describe your workplace so he can picture you there. Give him a photo of you, or an old small scarf of yours, and tell him to hug it tight or keep it in his pocket.
Does he have a favorite stuffed animal or doll? If not, let him pick one- just one- and encourage him to hold it close when he is feeling sad or frightened.
Remind him that you always come back and that you always will. Show him examples of other things that go away and come back, like the sun and the moon and the stars, the day and the night.
Read him a book about young children that are looking for their mothers (“Are You My Mother?” by P.D. Eastman) or running away from them (“The Runaway Bunny,” by Margaret Wise Brown)- the flip side of the same coin.

Distributed originally by The New York Times Syndicate with permission to circulate, copy and redistribute through MI-AIMH.

Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

When I trained at Fraiberg’s Child Development Project in the late ‘70s, it was easy to imagine that there was one model of infant parent psychotherapy to be learned and mastered. Training was naturally an integral part of our work since the entire field of infant mental health was a new development. Much has changed in infant mental health training since then, with elements that are encouraging as well as worrisome.

In the early days, many who came into the field had a background in psychodynamic psychotherapy, which was still the predominant therapeutic model. Those who came from a background in child development were grounded in Bowlby’s attachment theory.  Bowlby’s notion of “working models” nicely spanned developmental, psychoanalytic and cognitive-behavioral conceptualizations. For the working clinician, however, the upshot of Bowlby’s work was to understand the importance of relationships, for the child, the parent and the therapist. The centrality of relationships in infant mental health has important implications for training and education, particularly as it runs counter to major trends in graduate training and agency practice. The result is that training in infant mental health is even more challenging, as well as essential, than before.

There are encouraging trends for infant mental health training. Intellectually, attachment theory is more developed, validated, and diversified than before. With the current work on disorganized attachment, the Adult Attachment Interview, and conceptualizations of attachment disorders in young children, the theory describes parents and children much more like those seen in infant mental health programs. There is a much greater understanding of the role of trauma in the development of both baby and parent. Additionally, newer therapeutic approaches can contribute useful pieces to infant-parent psychotherapy, but they must be adapted to our goal of changing and strengthening infant-parent relationships.

Dan Stern’s elegant formulation of different interventions targeting different portals in the infant/parent relationship has saved the field from unnecessary polarization between interventions. It seems well understood that there is not ONE model to learn, but multiple formulations of problems and interventions. The result, however, is that the therapist needs more sophistication—integrating, alternating and adroitly shifting approaches to choose the most promising intervention in the moment.

While attachment theory and the practice of working with parents and infants keep us focused on the centrality of relationships, much of the academic world has moved in other directions. With greater emphasis on cognitive-behavioral approaches, “manualized” interventions and brief therapy, new graduates coming to infant mental health often come with quite different experiences. They have been taught more about cognition and behavior, less about affect. They know more about behavioral outcomes and less about a relational focus. They are more familiar with treatment manuals and less about “being with.” They may be less likely to have been in therapy themselves. They may have had no experience with reflective supervision. Countertransference may be a foreign concept.

We are challenged, more than ever, to train and educate infant mental health practitioners to focus on the relational process, with infants, parents, colleagues and supervisors. In addition to providing knowledge, trainers and supervisors can assume less about what new infant mental health professionals know about themselves and their personal histories. With agencies under greater stress and practitioners under greater pressure, it is even more important, but perhaps more difficult, to create a haven of safety to support the therapeutic process.

Providing infant mental health service teaches one that the real work happens before there is anything resembling traditional therapy. Perhaps I am now more cognizant of the work that must precede meaningful training and supervision. We may have to fight for truly reflective training and supervision when these things are not seen as priorities or “a given.” It is exciting to have more and more meaningful and relevant information to include in infant mental health training. At the same time, it is a great challenge to provide training to therapists who have had little preparation to be reflective. And it is a further challenge to provide supervision to therapists who are overextended and appear to have little time to think deeply about themselves or the work that they are doing in ways that support relatedness and self-awareness.

“Nurturing Children and Families: Building on the Legacy of T. Berry Brazelton,” edited by Barry M. Lester and Joshua D. Sparrow, invites readers to reflect on and celebrate the remarkable contributions that T. Berry Brazelton has made to the advance of science and the nurturing of infants, children and their families. The book introduces us to significant concepts that have changed how scientists and practitioners view babies and witness the relational nature of human development over the span of his 50 year career. Most important to mention here: individual differences in infancy and the dynamics of newborn behavior; the infant’s contributions to his or her own course of development; the power of the parent-child relationship to influence health, growth and change; and the importance of shared observation and meaning making in early work with families. Brazelton’s pioneering spirit has transformed practice, inviting pediatricians, nurses, psychologists, social workers, home visitors, early care and education professionals and many others to be open, curious, and thoughtful in their observations, interactions and affective responses to infants and families. Of great importance is Brazelton’s therapeutic stance that has guided generations of parents to feel confident and competent as they cared for their babies in the early years.

The book is laid out in three separate parts. Part I discusses Brazelton’s accomplishments in terms of behavioral and developmental research. Part II explores innovations in clinical intervention, including a section about infant mental health and the treatment of trauma. Part III discusses the implications of Brazelton’s work for professional development, systems of care, and policy. Chapter by chapter, the book is a masterful collection of writings from among the most respected scientists and clinical leaders in the infant and family field. Each contributor invites readers to think more deeply about early development, relational contexts, and touchpoints for optimal growth and change. What follows is a brief introduction to each part.

Part I introduces the reader to the transformations in research and practice that are attributed to T. Berry Brazelton. Barry Lester describes existing paradigms that Brazelton challenged and praised the “new lens through which we see and study children based on his scientific contributions.” p. 3. Joshua Sparrow follows with an illuminating chapter in which he examines Brazelton’s transformative ideas about infants and observation, individual differences, culture and development, and collaborative consultation. Part I continues with a focus on advances in fetal and newborn behavior, self-regulatory and relational processes, regression and reorganization in infancy, and neuroscience perspectives on developmental models. The range of topics is stunning, reflecting the depth and breadth of Brazelton’s thinking by colleagues and authors, Kathryn Barnard, Tiffany Field, Daniel Stern, Ed Tronick, Stanley Greenspan, Allan Shore, and Jerome Kagan, to name a few.

Part II includes discussions of innovative clinical interventions for infants and parents that are relationship based: Touchpoints®, Nurse Family Partnerships (NFP), the care of preterm infants (NIDCAP), the use of the Neonatal Behavioral Assessment Scale (NBAS) to encourage parent-infant interaction. Charles and Paula Zeanah, Joy and Howard Osofsky, Dante Cicchetti and Sheree Toth offer perspectives on infant mental health. They address core concepts that reflect Brazelton’s considerable contributions to our understanding of the field. It is clearly a multidisciplinary field that focuses on strengths; it is relational; it is observational, collaborative and insightful.

The discussion about “ghosts in the nursery” and angels in this section, written by Alicia Lieberman and William Harris, has particular meaning for the infant mental health community. They align the thinking and work of two important pioneers, T. Berry Brazelton and Selma Fraiberg:

“Brazelton observed, Fraiberg observed – and both intervened, each as a different segment of the health – pathology spectrum. Brazelton promoted awe, pleasure, and competence in parents who were often seeing the wondrous capacities of their babies for the first time. Through their babies’ responses to them, parents developed a reinforcing sense of self-efficacy. Fraiberg focused on parents whose capacity to connect to the unique individuality of their baby was thwarted by their negative attributions, rooted in their own childhood experiences of having felt unprotected and unloved. Brazelton was working through a lens of optimism, using the baby’s competence to help parents discover their own; Fraiberg was focusing on the mother’s psychopathology, using the baby’s potential to help the mother escape from entrapment in her own past. Together, they created a chiaroscuro that honors the complexity of what Daniel Stern calls ‘the first relationship.’” P. 243-44.

Their work led to the relationship as a focus for the promotion and practice of infant mental health, a significant shift in the delivery of developmental and clinical services for infants, toddlers and families. We are challenged by the authors in Part III to take the principles of relationship work, so central to Brazelton and Fraiberg, and apply them across disciplines, systems, and organizations to effect continued growth and change through collaboration in this rich and rapidly expanding field.

Part III contributors discuss the implications of Brazelton’s work across disciplines and systems of care. Libby Zimmerman offers observations about developing the infant mental health workforce; Jayne Singer and John Hornstein discuss Touchpoints® for early care and education providers; Constance Keefer examines early innovations in behavioral/developmental pediatric training. Change is the focus for the concluding chapters. Change in service delivery in a hospital environment is addressed by Myra Fox; improving healthcare service delivery with relationship-based nursing practices is presented by Ann Stadtler, Julie Novak, and Joshua Sparrow; Daniel Pederson and Jack Shonkoff translate the science of early childhood development into policy and practice.

I turned the last page of this extraordinary collection and drew a deep, reverent breath. What a remarkable man T. Berry Brazelton is. He has contributed so much to shared understanding of the importance of infancy and the power of nurturing relationships to growth, health, and change. Sarah Lawrence-Lightfoot’s concluding reflections are heartfelt:

“As we honor and learn from the luminous life and work of Berry Brazelton,we take his lessons and make them our own, hearing the echoes of his teachings and giving them our singular voice and commitment. Now is the time. Now is always.” P. 362

This remarkable collection will enrich every infant mental health professional’s understanding of the legacy of T. Berry Brazelton and his influence on the infant mental health field.

 

WAIMH Perspectives in Infant Mental Health, Vol. 21(2), June 2013. Reprinted here with permission.