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NEW DIRECTIONS TOWARD AN INTEGRATION OF EARLY INTERVENTION AND INFANT MENTAL HEALTH Jane D. Hochman, Ed. D. Gilbert M. Foley, Ed.D. HISTORICAL CONTEXT AND THE BIRTH OF A MOVEMENT. EARLY CHILDHOOD: A FIELD IN FORMATION (1860s-1940). Philanthropy and Social Reform

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NEW DIRECTIONS TOWARD AN INTEGRATIONOFEARLY INTERVENTION AND INFANT MENTAL HEALTHJane D. Hochman, Ed. D.Gilbert M. Foley, Ed.D.



Early childhood a field in formation 1860s 1940
EARLY CHILDHOOD: A FIELD IN FORMATION (1860s-1940)

  • Philanthropy and Social Reform

  • Advances in Medicine and Public Health

  • Government Actions

  • The New Science of Child Study

  • The Progressive Education Movement

  • Behaviorism

  • Psychoanalysis

  • Mental Hygiene and Child Guidance


Developments in psychiatry medicine and special education 1940 1960
DEVELOPMENTS IN PSYCHIATRY, MEDICINE AND SPECIAL EDUCATION (1940-1960)

  • Infant Psychiatry/Infant Mental Health

  • Pediatrics and Rehabilitative Therapies

  • Special Education



1960s early federal initiatives laws and policies
1960s - Early Federal Initiatives, Laws and Policies Intervention:

  • 1961: Federal Office Established (BEH)

  • 1965: “ War on Poverty” – Head Start

  • 1967: Early and Periodic Screening Diagnosis and Treatment Program (EPSDT)

  • 1968: Handicapped Children’s Early Education Program ( HCEEP)


The 1970s early programs and policies
The 1970s - Early Programs and Policies Intervention:

  • Early 1970s: A controversy of Models

  • 1975: PL 94-142

  • Late 1970s: Good Practice Models Emerge


The 1980s early childhood becomes law
The 1980s - Early Childhood Becomes Law Intervention:

  • Early 1980s: Outreach Replication Networks and Personnel Preparation

  • PL 99-457

  • Late 1980s: Collaboration


The 1990s idea and later revisions
The 1990s - IDEA and Later Revisions Intervention:

  • Americans with Disabilities Act (ADA)

  • 1990: PL 99-457 renamed Individuals with Disabilities Education Act (IDEA)

  • Early 1990s: Early Intervention Implemented

  • 1995: Early Head Start

  • 1997: Family-Centered > Family-Directed


21st century revisions refinements and challenges
21st Century - Revisions, Refinements, and Challenges Intervention:

  • Revisions to IDEA

  • Economic Challenges

  • New Technology

  • Personnel



Meet martin
MEET MARTIN Intervention:

  • 26 Months Old

  • Charming

  • Dreamy

  • Autistic?

  • Uneven Language Development

  • Weak Pragmatic Skills


Tumult at home
TUMULT AT HOME Intervention:

  • Stormy

  • Father Left

  • Mother Depressed and Searching

  • Babysitters


The child will always tell you sally provence m d
Intervention:THE CHILD WILL ALWAYS TELL YOU”Sally Provence, M.D.

  • Martin Tells a Story to his Occupational Therapist

  • What might it mean?

  • How to React?

  • What to Do?

  • Who may be able to help?

  • Implications for the Service Delivery Paradigm itself?


THE INTEGRATION OF INFANT MENTAL HEALTH (IMH) Intervention:AND EARLY INTERVENTION (EI): Concepts, Characteristics & Rationale


A holistic synergistic frame of reference embrace complexity sally provence m d
A HOLISTIC SYNERGISTIC FRAME OF REFERENCE Intervention:~“Embrace Complexity! ”Sally Provence, M.D.


Models of development
MODELS OF DEVELOPMENT Intervention:

  • Architectonic

    • Hierarchical

    • Linear

    • Epigenetic

  • Organic

    • Unfolding

    • Plastic

  • Transformational

    • Holistic

    • Dynamic


A developmental biopsychosocial transactional model
A DEVELOPMENTAL-BIOPSYCHOSOCIAL-TRANSACTIONAL MODEL Intervention:

  • “Infant as a Work in Progress”


The nature of derailment
THE NATURE OF DERAILMENT Intervention:

  • Cumulative Adversity: A Cascade of Multiple Misfortunes vs. Single Incident/ Disease/Natural History Model of Derailment

  • Healing the Organic-Functional Split

  • Context…


PARITY FOR PSYCHOSOCIAL DOMAIN OF DEVELOPMENT & MENTAL HEALTH IN DEFINING ELIGIBILITY & DELIVERING SERVICE


Infant mental health refers to the multifaceted formative process impacted by myriad forces, including:

  • Totality of development itself

    • Organized as the structure and content of the inner life

    • Arising both from within and without and

    • Expressed in functional behaviors used to mediate between the internal and external world of self and other with affective range, intensity and color.


Infant mental health includes
Infant mental health includes: process impacted by myriad forces, including:

  • Formation of attachments

  • Inner construction and emerging portrayals of the self and love-objects with feeling

  • Ability to regulate impulse, affects and the seeds of self-esteem

  • Capacity to manage anxiety and form flexible and adaptive mechanisms of coping and defense

  • Ability to form and sustain relationships beyond the immediate attachment system

  • Ability to experience the world with a range and intensity of feeling.


Infant mental health includes con t
Infant mental health includes: (con’t) process impacted by myriad forces, including:

  • Appropriate assessment of social-emotional functioning and the well-being of the family

  • A role for mental health members of the team to function in therapeutic as well as assessment and referral capacities


Family centered relationship based perspective
FAMILY-CENTERED RELATIONSHIP-BASED PERSPECTIVE process impacted by myriad forces, including:


The centrality of relationships
THE CENTRALITY OF RELATIONSHIPS process impacted by myriad forces, including:

“A baby cannot exist alone, but is essentially part of a relationship.”

D. W. Winnicott

  • The Family is a Network of intimate Relationships

  • The development of the baby is to large extent dependent on the well being of the relationships that compose the cradle of “holding” and nurturance.


A self family centered copernican universe
A Self-Family/Centered Copernican Universe process impacted by myriad forces, including:

Community

Relationship Network

Family

Child


Family stress distress
FAMILY STRESS & DISTRESS process impacted by myriad forces, including:

  • Loss-Grief

  • Personal Mythology

  • Reframing the Representation of the Child


Family stress distress con t
FAMILY STRESS & DISTRESS (con’t) process impacted by myriad forces, including:

  • Damage and Reparation/Fear and Wish: Unseen Forces in the Family Psyche

  • Uncertainty About the Future

  • Amplified Demands of Daily Life


Relationship based psychotherapeutically informed approach to service delivery
RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY INFORMED APPROACH TO SERVICE DELIVERY

  • Identifies the relationship as the “Unit of Service”

  • Provides comprehensive, intensive, continuous, supportive and engagement-focused services

  • Addresses the expected and unexpected stress, coping and adjustment reactions and general well being of families


Relationship based psychotherapeutically informed approach to service delivery con t
RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY- INFORMED APPROACH TO SERVICE DELIVERYTO SERVICE DELIVERY (con’t)

  • Addresses the meaning the child holds for the family

  • Works through the alliances of caregivers to the child and support systems to the caregivers

  • Works from the inside out:

    • addressing history, representation, affective states and the forces of fantasy


Relationship based psychotherapeutically informed approach to service delivery con t1
RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY- INFORMED APPROACH TO SERVICE DELIVERY (con’t)

  • As well as the outside in:

    • Addressing resources, knowledge, skill, coping and concrete services

    • Multi-Modal


Relationship based psychotherapeutically informed approach to service delivery con t2
RELATIONSHIP-BASED PSYCHOTHERAPEUTICALLY TO SERVICE DELIVERY (con’t)INFORMED APPROACH TO SERVICE DELIVERY (con’t)

  • Embraces parenthood as a developmental process

  • Supports every member of the team to deliver his or her discipline-specific services in a relationship-based psychotherapeutically –informed style


A multi cross disciplinary team model of staffing the transdisciplinary approach
A MULTI-CROSS-DISCIPLINARY TEAM MODEL OF STAFFING TO SERVICE DELIVERY (con’t)~The Transdisciplinary Approach

  • Role Extension

  • Role Release

  • Reflective Supervision

    • Intervention as Enacted Thought

  • A Cardinal Feature of an Integrated Model


Demands of the work
DEMANDS OF THE WORK TO SERVICE DELIVERY (con’t)

  • Hopefulness

  • Readiness to Cope with Negative or Troubled Experiences of Both Parents and Practitioners

  • Preparedness Concerns

  • Range of Reactions

  • Availability of Resources


Parent practitioner relationships in early intervention unseen forces
PARENT-PRACTITIONER RELATIONSHIPS IN TO SERVICE DELIVERY (con’t)EARLY INTERVENTION:UNSEEN FORCES



Transference and countertransference
TRANSFERENCE AND COUNTERTRANSFERENCE THAN THEIR DESIGNATED ROLES

  • “ Transference consists of the ‘experiencing of feelings, drives, attitudes, fantasies and defenses toward a person in the present which do not befit that person but are a repetition of reactions originating in regard to significant persons of early childhood, unconsciously displaced onto figures in the present ‘ ” ( Greenson, 1967, p. 155)


Transference and countertransference con t
TRANSFERENCE THAN THEIR DESIGNATED ROLESAND COUNTERTRANSFERENCE, con’t.

  • Communicated via the infant through the care-giving style

  • Identified via Inappropriate Attributions


Transference and countertransference con t1
TRANSFERENCE THAN THEIR DESIGNATED ROLESAND COUNTERTRANSFERENCE con’t.

  • Intensity

  • Ambivalence

  • Capriciousness

  • Tenacity


Optimal distance 1
OPTIMAL DISTANCE, #1 THAN THEIR DESIGNATED ROLES

  • There is NO absolute optimal distance

  • A relative position influenced by history, culture, and temperament

  • Differs family to family


Optimal distance 2
OPTIMAL DISTANCE, #2 THAN THEIR DESIGNATED ROLES

  • A Range Between Remoteness and Excessive Closeness Relatively Free of Ambivalence

  • Reality-Based Middle Ground

  • Ongoing Self-Regulating Relational Range


Optimal distance 3 remoteness
OPTIMAL DISTANCE, #3: THAN THEIR DESIGNATED ROLESREMOTENESS

  • Unconscious Desire to “Shield”

  • Illusion of Safety in Distance


Optimal distance 4 too much closeness
OPTIMAL DISTANCE, #4: THAN THEIR DESIGNATED ROLESTOO MUCH CLOSENESS

  • Over-Identification and Fusion

  • Excessive Nurturing

  • Defense Against Guilty Feelings


Optimal distance 5 ambivalence most disturbed
OPTIMAL DISTANCE, #5: THAN THEIR DESIGNATED ROLES AMBIVALENCE(most disturbed)

  • Shadowing

  • Darting

  • Unreliable


Optimal distance 6 practitioners must
OPTIMAL DISTANCE, #6: THAN THEIR DESIGNATED ROLESPRACTITIONERS MUST….

  • Tolerate Anxious Uncertainty

  • Use Own Emotional Experiences as a Guide

  • Have Capacity to Observe, Listen and Reflect

  • Ask oneself two important questions………..


Optimal distance 6 con t
OPTIMAL DISTANCE, #6 THAN THEIR DESIGNATED ROLEScon’t

  • “ Am I Maintaining an environment of safety, security, compassion, and support for the infant and parents?”

    “ Am I impeding the family’s self-awareness, self-sufficiency, and self-determination?”



Make no assumptions
MAKE NO ASSUMPTIONS THAN THEIR DESIGNATED ROLES

ASSUMPTIONS


Begin where the family is
BEGIN WHERE THE FAMILY IS THAN THEIR DESIGNATED ROLES

  • …Not Where you Wish it Would Be

  • Beware of halo effect or tendency for countertransference fantasies

  • Successful Family-Practitioner Relationships Progress from A Base of Security.


Presenting yourself to the family
PRESENTING YOURSELF TO THE FAMILY THAN THEIR DESIGNATED ROLES

  • Titles of Address

  • Initial Introduction

  • Dress Code

  • Safety Concerns

    …Formality and informality reflect remoteness, excessive closeness, or optimal distance…


Sharing information
SHARING INFORMATION THAN THEIR DESIGNATED ROLES

  • Mutual Understanding of the language

  • Definition of Terms

  • Attention to Cultural Mores


Guidelines for making mental health referrals
GUIDELINES FOR MAKING MENTAL HEALTH REFERRALS THAN THEIR DESIGNATED ROLES

  • ABSOLUTES

  • Danger

  • Abuse or Neglect

  • Parents with Diagnosed Mental Health Disorders


Guidelines for making mental health referrals1
GUIDELINES FOR MAKING MENTAL HEALTH REFERRALS THAN THEIR DESIGNATED ROLES

  • PROFESSIONAL JUDGMENT REQUIRED:

    • Intensity of Symptoms

    • Degree of Psychic Suffering

    • Degree of Compromised Functioning

    • Frequency of Occurrence of Conditions or observed symptoms

    • Intractability of Symptoms

    • The Symptoms in Context


RELATIONSHIP BOUNDARIES THAN THEIR DESIGNATED ROLES

  • Apply Principles of Responsibility and Reciprocity

  • Practitioner>Family>Child>Practitioner

  • Administration > Team

  • Within team

    (Relationships Among Staff Reflect Demands and Stress)


Idea still supports
IDEA STILL SUPPORTS THAN THEIR DESIGNATED ROLES

  • Supra-organizational perspective

  • Interagency Collaboration

  • Teaming


However unity of ei and mh requires
HOWEVER , UNITY OF EI AND MH REQUIRES THAN THEIR DESIGNATED ROLES

  • Closer Alliances among practitioners from both “ worlds”

  • Holistic Organizations

  • Fluid Interchange among the Multiple Disciplines

  • Systems Coordination


A self family centered copernican universe1
A Self-Family/Centered Copernican Universe THAN THEIR DESIGNATED ROLES

Community

Relationship Network

Family

Child


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