Integrating IMH Principles with Work with Special Needs Families: Early Signs of ASD

By Ann O'Donnell, Psy.D.

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

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

3468443878_ee5fe8937f_tIn contrast, parents who come to a private practice setting are generally seeking services voluntarily. They may be scared, confused, and/or overwhelmed by the challenges that they face in parenting.  They seek guidance regarding particular concerns, new ideas, and answers to specific questions.  At such times, the most supportive response is to offer expert guidance that can reduce their distress by offering hope that the challenges that they face can be managed.

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

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

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

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

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

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


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