The Infant Crier

Tag: Relationships

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

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

    Written with collaboration from her team!

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

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

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

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

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

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

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

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

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

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

    A referral should be made 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  • Pathways to Parenting: Prenatal Bonding in Mothers and Fathers

    Pathways to Parenting: Prenatal Bonding in Mothers and Fathers

    “In giving birth to our babies, we may find that we give birth to new possibilities within ourselves.”
    – Myla and Jon Kabat-Zinn, Everyday Blessings: The Inner Work of Mindful Parenting, 2014

    For many parents, pregnancy represents a time of reorganization that leads to psychosocial growth and the hope of new possibilities.  The coming of a new baby inspires shifts within the psychological worlds of the parents as their emotional ties to the infant begin to take shape. The development of these ties is critical because they are related to parents’ postnatal feelings about the baby (Vreeswijk, Maas, Rijk, & van Bakel, 2014), and they provide psychological fuel for the demanding work of postnatal infant care (Rapael-Leff, 2005).  Importantly, a parent’s prenatal thoughts and feelings about his or her infant are also associated with postnatal parenting behaviors (Dayton, Levendosky, Davidson & Bogat, 2010; Dubber, Reck, Muller & Gawlik, 2015; Hjelmstedt & Collins, 2008).  Just as the infant will ultimately develop an attachment to the parent, the parent develops a complementary caregiving system that provides motivation to protect and nurture the infant (Solomon & George, 1996), and this system comes online during pregnancy.

    To date, the majority of the research informing our understanding of prenatal parent-infant relationship development has been with mothers (Slade, Cohen, Sadler & Miller, 2009).  More recently, prenatal bonding in fathers has also been the subject of research. Across studies, accumulating evidence suggests that: one, pregnancy represents the beginning of the parent-infant relationship for both women and men (Vreeswijk et al., 2014), and two, the quality of this relationship is related to postnatal parenting for both mothers and fathers (Dubber et al., 2015; Hjelmstedt & Collins, 2008). Focusing exclusively on mothers, D.W. Winnicott put it this way:

    I suggest, as you know I do, and I suppose everyone agrees, that ordinarily the woman enters into a phase, a phase from which she ordinarily recovers in the weeks and months after the baby’s birth, in which to a large extent she is the baby and the baby is her. There is nothing mystical about this. After all, she was a baby once, and she has in her the memories of being a baby; she also has memories of being cared for, and these memories either help or hinder her in her own experiences as a mother.

    — Winnicott, 1966 (as cited in Winnicott, 1987)

    In the IMH field we take Winnicott’s words to heart every day in our work with parents and infants; we talk to parents explicitly about their own child rearing histories, and we help them make conceptual links between past and present.  Indeed, attachment theory argues that a parent’s own relational history, described as “memories” by Winnicott and as “Ghosts” or “Angels” by more contemporary authors (Fraiberg, Adelson, & Shapiro, 1975; Lieberman, Padron, Van Horn, & Harris, 2005), is influential in the formation of the parent-infant relationship. Extensive research in the attachment field supports this link (Mayseless, 2006), and our clinical work with families reinforces its importance.

    Pregnancy represents the first point in development when we have clinical access to the parent-infant relationship.  Therefore, whether we are working with expectant parents or helping parents reflect on their prior pregnancy and birth experiences, understanding the role of risk and resilience factors in pregnancy can extend the clinical window backward to the place where the parent-infant relationship first took shape.

    Risk and Resilience in the Lives of Expectant Mothers

    For women, pregnancy involves both physical and psychological processes that contribute to the deepening of the maternal-fetal bond over time (Yarcheski, Mahon, Yarcheski, Hanks, & Cannella, 2009; Slade, et al., 2009; Zeanah, Carr, & Wolk, 1990).  The quality of the mother’s physical health and psychological well-being during pregnancy is fundamentally tied to that of the fetus.  Prenatal risk factors that the mother is exposed to, therefore, have the potential to influence her own health, the health of the fetus and her psychological connection to her unborn baby.  Exposure to intimate partner violence (IPV), for example, increases the risk for infant mortality and morbidity (Sharps, Laughon, & Giangrande, 2007).  It also affects the mother’s psychological tie to the fetus.  IPV exposure during pregnancy is associated with less positive internal working models of the infant for mothers (Huth-Bocks, Levendosky, Theran, & Bogat, 2004), and is ultimately related to less sensitive early parenting behaviors (Dayton, Levendosky, Davidson & Bogat, 2010; Dayton, Huth-Bocks & Busuito, 2016).

    Symptoms of psychological distress including depression, anxiety and post-traumatic stress disorder (PTSD) can also influence the maternal-fetal bond (Dayton, Hicks, Goletz, Brown, 2017; Luz, George, Vieux & Spitz, 2017).  Estimated rates of clinical depression during pregnancy range from 10% to 30% for mothers (Ashley, Harper, Arms-Chavez, & LoBello, 2016), and untreated depression is associated with less optimal maternal-fetal bonding (Yarcheski, et al., 2009; Alhusen, Gross, Hayat, Rose, & Sharps, 2012). It is important to note, however, that much of this work has been conducted with married or cohabitating Caucasian parents from middle-income socioeconomic groups (Yarcheski, et al., 2009). In light of the economic and racial health disparities in pregnancy and birth outcomes (Lu & Halfon, 2003), more research that extends this work to economically and racially diverse samples of parents is needed.

    Protective factors for healthy and adaptive maternal-fetal bonding have also been identified. For instance, Yarcheski and colleagues (2009) conducted a meta-analytic review and found that, across many independent studies, increased levels of social support were associated with increases in the strength of the maternal-fetal bond.  From biological and psychological perspectives, this finding makes a lot of sense.  In relation to contextual stressors such as violence exposure, social connection has a countervailing influence on the human bio-behavioral regulatory system. Connection with trusted others is physically and psychologically calming and has important biological correlates such as lowering cortisol levels and initiating the release of oxytocin. These biological responses to social connection calm the nervous system and may thereby support the development of the maternal-fetal bond via increases in a mother’s sense of psychological and physical safety.

    Findings from this body of literature have important translational implications for the early parenting field.  IMH interventions during pregnancy that help women free themselves from violent relationships, process and heal from the violence they have been exposed to, and decrease their symptoms of psychological distress are clearly indicated.  Further, and consistent with the central aims of many IMH programs, increasing a mother’s social support network may help promote a positive bond with her unborn baby, ultimately leading to more positive birth outcomes and a healthier postnatal mother-infant relationship.

    The Father’s Prenatal Journey

    The meaning of fatherhood in the United States has changed in important ways over the past few decades (Lamb, 2010).  Men are now more actively involved in the daily lives of their children (Bianchi, 2011), and the importance of fathering to the social-emotional development of children is more frequently acknowledged (Lamb, 2010).  When fathers are involved very early in the lives of their children, they have the opportunity to form foundational and enduring relationships with them, and outcomes for mothers and babies are improved. The positive health effects associated with father involvement begin in pregnancy with improved prenatal, birth, and neonatal health outcomes and significantly lower per-infant healthcare costs (Alio, Salihu, Kornosky, Richman, & Marty, 2010; Salihu, Salemi, Nash, Chandler, Mbah, & Alio, 2013). In contrast, a lack of father involvement in pregnancy is associated with significantly higher infant mortality rates (Alio, Mbah, Kornosky, Wathington, Marty & Salihu, 2011).  Given these compelling findings, supporting the prenatal father-infant bond is an important target of intervention that has the potential to improve birth and relationship outcomes for fathers, mothers and infants.

    Though less is known about the factors that affect the development of the prenatal father-infant bond, preliminary research suggests that psychological distress in fathers, including depression and anxiety, may be one risk factor for lower levels of prenatal bonding (Luz, George, Vieux & Spitz, 2017; Dayton, et al., 2016). Preliminary work also suggests that, on average, fathers may experience higher levels of emotional distance from their unborn babies, relative to mothers (Vreeswijk et al., 2014).  Much of this research has involved samples of middle-class, Caucasian fathers, however. As a result, less is known about how risk factors such as violence and poverty exposure may affect the developing father-infant relationship in pregnancy.

    To address the relative paucity of prenatal studies of fathering in contexts of risk, ongoing research at the Motown Family Relationships laboratory located at Wayne State University’s Merrill Palmer Skillman Institute, is currently investigating prenatal relationship development in urban-dwelling fathers, with the goal of informing early interventions with fathers.  A central finding of this work is that a father’s belief in the importance of early fathering to the health and well-being of the infant is robustly associated with stronger prenatal bonding: Fathers who believe that early fathering is important tend to report experiencing stronger bonds with their unborn infants (Dayton, Hicks, Goletz, Brown, 2017). This is an important finding because fathers in low-income groups are exposed to social narratives that describe fathering primarily in economic terms, and poverty-exposed fathers are clearly disadvantaged in this respect. Furthermore, qualitative data from this study suggest that many fathers have a difficult time grasping their importance during infancy and tend to view their parenting role as more influential when their children are older (i.e., preschool aged and above) (Dayton, et al., 2016). Helping fathers understand the importance of their early relationship with their infant beginning in pregnancy can help shift the narrative from fathering as a mainly financial role to the importance of the early father-infant relationship in promoting the healthy development of the infant.

    These cumulative findings have significant implications for IMH work with fathers and their families.  Most important, there is a need for early intervention protocols that communicate to fathers the centrality of the early father-infant relationship as a foundation on which the long-term parent-child relationship is built.  IMH practitioners are ideally positioned to engage fathers in clinical work and to help fathers negotiate the barriers that may prevent them from full involvement with their infants.  However, it is important to acknowledge that the vast majority of IMH workers are women. As women, our own histories have likely resulted in feelings and beliefs about the relative importance of fathers in the lives of infants and young children.  To authentically engage with fathers, therefore, we must examine our own feelings and challenge our own biases.  A mother-centric approach has dominated the IMH field since its inception.  Shifting our individual and collective views about early fathering will help move the field toward a more balanced family-centric approach and, ultimately, improve the lives of the families we care so deeply about.

    References

    Alhusen, J. L., Gross, D., Hayat, M. J., Rose, L., & Sharps, P. (2012). The role of mental health on maternal‐fetal attachment in low‐income women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41(6), E71-E81.

    Alio, A. P., Salihu, H. M., Kornosky, J. L. , Richman, A. M., & Marty, P. J. Feto-infant health and survival: Does paternal involvement matter? (2010).  Maternal and Child Health Journal, 14(6), 931-937.

    Alio, A. P., Mbah, A. K., Kornosky, J. L., Wathington, D., Marty, P. J, & Salihu, H. M. (2011).  Assessing the impact of paternal involvement on racial/ethnic disparities in infant mortality rates. Journal of Community Health: The Publication for Health Promotion and Disease Prevention, 36(1), 63-68.

    Ashley, J. M., Harper, B. D., Arms-Chavez, C. J., & LoBello, S. G. (2016). Estimated prevalence of antenatal depression in the US population. Archive of Women’s Mental Health, 19(2), 395-400.

    Bianchi, S, M. (2011). Family change and time allocation in American families. The ANNALS of the American Academy of Political and Social Science, 638, 21-44.

    Dayton, C. J., Levendosky, A. A., Davidson, W. S., & Bogat, G. A. (2010). The child as held in the mind of the mother: The influence of prenatal maternal representations on parenting behaviors. Infant Mental Health Journal, 31(2), 220-241.

    Dayton, C. J., Buczkowski, R. S., Muzik, M., Goletz, J., Hicks, L., Walsh, T., & Bocknek, E. L. (2016). Expectant fathers’ beliefs and expectations about fathering as they prepare to parent a new infant. Social Work Research: Special Issue on Social Work with Men and Fathers, 40(4), 225-236.

    Dayton, C. J., Huth-Bocks, A. C., & Busuito, A.  (2016). The influence of interpersonal aggression on maternal perceptions of infant emotions:  Associations with early parenting quality.  Emotion, 16(4), 436-448.

    Dayton, C. J., Hicks, L., Goletz, J., & Brown, S. (2017). Prenatal bonding and child abuse potential: Risk and resilience in vulnerable, pregnant mothers and fathers.  Oral presentation at the annual meeting of the Society for Social Work and Research. New Orleans, Louisiana.

    Dubber, S., Reck, C., Müller, M., & Gawlik, S. (2015). Postpartum bonding: the role of perinatal depression, anxiety and maternal–fetal bonding during pregnancy. Archives of Women’s Mental Health, 18(2), 187-195.

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

    Hjelmstedt, A., & Collins, A. (2008). Psychological functioning and predictors of father–infant relationship in IVF fathers and controls. Scandinavian Journal of Caring Sciences, 22(1), 72-78.

    Huth‐Bocks, A. C., Levendosky, A. A., Theran, S. A., & Bogat, G. A. (2004). The impact of domestic violence on mothers’ prenatal representations of their infants. Infant Mental Health Journal, 25(2), 79-98.

    Kabat-Zinn & Kabat-Zinn, (2014).  Everyday Blessings:  The Inner Work of Mindful Parenting. New York: Hachette Books.

    Lamb, M. E. (Ed.) (2010). The Role of the Father in Child Development (5th ed.). Hoboken, NJ: Wiley.

    Lieberman, A., Padrón, E., Van Horn, P., & Harris, W.W. (2005). Angels in the nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 26, 504–520.

    Lu, M. C., & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A life-course perspective. Maternal and Child Health Journal, 7(1), 13-30.

    Luz, R., George, A., Vieux, R., & Spitz, E. (2017). Antenatal determinants of parental attachment and parenting alliance: How do mothers and fathers differ? Infant Mental Health Journal, 38(2), 183-197.

    Mayseless, O. (Ed.). (2006).  Parenting representations: Theory, research, and clinical implications.  New York:  Cambridge University Press.

    Raphael-Leff, J. (2005). Psychological Processes of Childbearing. London: The Anna Freud Centre.

    Salihu, H. M., Salemi, J. L., Nash, M.C., Chandler, K., Mbah, A. K., & Alio, A.P. (2014). Assessing the economic impact of paternal involvement: A comparison of the generalized linear model versus decision analysis trees. Maternal and Child Health Journal, 18(6), 1380-1390.

    Sharps, P. W.,  Laughon, K.,  & Giangrande, S. K.  (2007).  Intimate partner violence and the childbearing year: Maternal and Infant Health Consequences.  Trauma, Violence & Abuse, 8(2), 105-116.

    Slade, A., Cohen, L. J., Sadler, L. S., & Miller, M. (2009). The psychology and psychopathology of pregnancy: Reorganization and transformation. In C. H. Zeanah, Jr. (Ed.), Handbook of Infant Mental Health (pp. 22-39). New York: Guilford Press.

    Solomon, J., & George, C. (1996). Defining the caregiving system: Toward a theory of caregiving. Infant Mental Health Journal, 17(3), 183-197.

    Vreeswijk, C. M. J. M.; Maas, A. J. B. M.; Rijk, C. H. A. M.; Braeken, J.; van Bakel, H. J. A. (2014).  Stability of fathers’ representations of their infants during the transition to parenthood.  Attachment & Human Development, 16(3), 292-306.

    Winnicott, D.W. (1987). Babies and their Mothers. New York: Addison-Wesley.

    Yarcheski, A., Mahon, N. E., Yarcheski, T. J., Hanks, M. M., & Cannella, B. L. (2009). A meta-analytic study of predictors of maternal-fetal attachment. International Journal of Nursing Studies, 46(5), 708-715.

    Zeanah, C.H., Carr, S., & Wolk, S. (1990). Foetal movements and the imagined baby of pregnancy: Ar