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Safe Start Early Childhood Mental Health Services. Partnering with the Child Welfare System Lisa Blunt, MS, LMHP Chief Operating Officer Child Saving Institute Barbara Jessing, MS, LIMHP Clinical Director Heartland Family Service.

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safe start early childhood mental health services

Safe StartEarly Childhood Mental Health Services

Partnering with the Child Welfare System

Lisa Blunt, MS, LMHP

Chief Operating Officer Child Saving Institute

Barbara Jessing, MS, LIMHP

Clinical Director Heartland Family Service


Babies and toddlers, even before they can speak, can show us, through their interactions with others and their emotions, that they are struggling and need help.  We have to learn to be better observers and more knowledgeable about ways to identify them and provide them with the services they need.

  • Child-Centered Practices for the Courtroom and Community: A Guide to Working Effectively with Young Children and Their Families in the Child Welfare System (Katz, Lederman and Osofsky

How do we bring learning about early attachment into every decision made in the child welfare system?

  • How do we bring the voice and the perspective of young and vulnerable children into the child welfare system?
  • What is your role?
  • Where are you from?
  • Any questions you bring?
attachment informed decisions
Attachment Informed Decisions
  • Every decision made in the child welfare system should be made through the lens of attachment
    • Does this decision SUPPORT healthy attachment of this child?
    • Does this decision SUPPORT timely permanency for this child?
    • Timing of services is critical.
presentation overview
Presentation Overview
  • Clinical assessment of the parent child relationship -- birth to five years
  • Interventions
    • Safe Start Assessment
    • Child-Parent Psychotherapy
    • Family Support
  • Lessons learned in partnering with the Child Welfare System
infants and toddlers in foster care
Infants and Toddlers in Foster Care
  • Separated suddenly and often traumatically from parent
  • Prior history often includes trauma, stress, deprivation
  • Disrupted placements
trauma before and trauma after placement
Trauma Before and Trauma After Placement
  • Trauma exposure leading to removal
  • Inconsistent caregiving in placement
    • Disrupted foster care placements
    • Respite Care
    • Child Care Changes
    • Case Manager turnover
  • Cumulative negative developmental impact
safe start program goals
SAFE STARTProgram Goals
  • To bring the voice and perspective of the young child into the child welfare system
  • To strengthen and repair the parent-child bond;
  • To promote the child’s social and emotional development;
  • To minimize harmful developmental consequences of disruptions in care giving because of abuse or neglect.
safe start early childhood mental health services1
SAFE STARTEarly Childhood MentalHealth Services
  • Parent-Child Relationship Assessment
  • Child- Parent Psychotherapy
  • Family Preservation and Family Support Services
history of safe start project in nebraska
History of Safe Start Project in Nebraska
  • 2005: Douglas County, NE and Zero to Three “Safe Babies” Court Team initiated
  • 2006: Child Saving Institute and Heartland Family Service partnership with Family Drug Treatment Court/Nebraska Department of Health and Human Services
  • 2009-11: Interface with Child Welfare Reform in Nebraska
new source of funding
New Source of Funding
  • SAMHSA Grant Awarded 2010
  • Grantee: Nebraska Supreme Court, Office of Problem Solving Courts; Nebraska Court Improvement Project
  • Eligible participants are clients in Douglas County Juvenile Court Drug Court/Family Drug Court
  • Participating Provider Agencies:
    • Child Saving Institute
    • Heartland Family Service
    • Lutheran Family Services
parent child relationship assessment
Parent-Child Relationship Assessment
  • A structured, observation-based, multi session assessment of the relationship between parent and child
  • Model developed by Joy Osofsky, PhD and colleagues; Louisiana expert in child exposure to violence
  • Based on the “Prevent” Assessment model used in the Miami Safe Start Initiative
assessment components
Assessment Components
    • Initial interview of parent or parents for personal, family, and child history
    • Record Review
    • Structured observation of parent #1 and child
    • Structured Observation of parent #2, foster parent, or other caregiver and child
    • Ages and Stages Questionnaire: Developmental observation and evaluation of child with parent or other caregiver
  • Observation sessions are videotaped
  • Interactions are objectively rated according to specific dimensions of parent child relationship and interaction
parent interview
Parent Interview
  • Psychosocial interview
  • Adult attachment interview and relevance of parent’s early experience to present relationship with child
  • Goal: Insight into parent’s mental representation of child and internal experience of being a parent.
record review child and parent history
Record Review: Child and Parent History
  • Highly relevant to getting a complete picture of parent’s current functioning
  • Understanding “what happened to you” vs “what’s wrong with you?”
observations through one way mirror
Observations through one way mirror
  • Parent directs assigned tasks with prompts from therapist by phone:
    • Free play
    • Bubbles
    • Clean up and transition to new activity
    • Several brief interactions around developmentally appropriate toys of increasing challenge
    • Brief separation (or withdrawal of parent’s face for infant) and reunification of parent from child
  • Therapist ratings are based on these observations
inclusion of both parents and other caregivers
Inclusion of Both Parents and Other Caregivers
  • Reason for referral may relate to abilities of one or both parents
  • If both parents are involved in permanency plan, observations are done with both
  • Observation of other significant caregivers such as foster parent or grandparent is also productive
  • Assessment documents strengths as well as problems; shows child’s relationships with various caregivers
parent child relationship scales joy osofsky phd
Parent Child Relationship ScalesJoy Osofsky, PhD
  • Objective ratings of parent child interaction
  • Used to develop treatment targets
  • Used as measure of outcome of therapy or other recommended interventions
parent observations rated
Positive Affect

Withdrawn/ Depressed

Irritability/Anger/ Hostility


Behavioral Responsiveness

Emotional Responsiveness

Positive Discipline

Separation and Reunion

Parent Observations Rated
child observations rated
Positive Affect

Withdrawn/ Depressed


Anger/Hostility/ Irritability

Non-Compliance Toward Parental Instruction

Aggression Toward Parent


Persistence with Task

Reunion: Emotional and Behavioral Responsiveness

Child Observations Rated
developmental and behavioral status
Developmental and Behavioral Status
  • Achenbach Child Behavior Checklist
    • CBCL
    • Ages 1 ½ or older
  • Ages and Stages
    • ASQ 3 (2 months and up)
    • ASQ SE (Social and Emotional Development)

How can the parent transition the child from one task to another?

  • How does the child respond to a parent’s directive?
  • “Bubbles” are a great measure of how much joy and pleasure there is in this relationship

How enthusiastic is the child?

  • How persistent is the child, faced with a difficult task?
  • How does the parent respond to child frustration?
    • Emotional
    • Behavioral

How does the parent prepare the child?

  • How does the child respond?
  • How does the child cope?

How does the child respond to the withdrawal of parent attention?

  • How energetic and emotional is the child’s reaction?
  • What is the emotional tone of the reunion?
assessment report and recommendations
Assessment Report and Recommendations
    • To Judge, Case Manager, and Provider
    • To Parents
  • Summary of presenting issue and results/recommendations
    • Relational treatment needs:
      • how to build on the strengths in the parent child relationship
      • what specific issues are to be addressed in the dyadic therapy, if recommended       
    • Developmental intervention needs 
follow up options
Follow Up Options
  • Child Parent Psychotherapy
  • Other referrals as appropriate for therapy, parent education and support
    • Parent Support and Education Programs
    • Family Support
    • Substance Abuse or Mental Health


child parent psychotherapy alicia lieberman and patricia van horn
26 week course of dyadic therapy

Promote and strengthen a close, safe, and nurturing relationship between parent and child

Observation, guidance, and coaching of the parent

Deals with parent’s unresolved early abuse or trauma which interferes in the present

Promotes adjustment/attachment as child transitions from foster care to home

One hour weekly, in office

Child –Parent PsychotherapyAlicia Lieberman and Patricia Van Horn
cpp techniques
CPP Techniques
  • Behavior-based interventions
  • Parent support and coaching
  • Interactive parent-child play
  • Verbal interpretation of transactions between parent and child.
treatment outcomes
Treatment Outcomes
  • Improved parent-child relationship
  • Progress toward permanency goals
  • Improvement in child developmental status
  • Reduction of abuse/neglect
family support
Family Support
  • Family Support Specialist integral member of treatment team
  • Opportunity to reinforces generalization of skills gained in CPP
  • Observations inform CPP process
challenges with the child welfare system
Challenges with the Child Welfare System
  • Mandated parent treatment
  • Lack of clarity of clinician role
  • Scope and limits of confidentiality
  • Different perceptions of best interests
  • “The contagion of dysfunctionality”
    • Alicia Lieberman and Patricia Van Horn
our challenges
Our Challenges
  • Massive changes in the child welfare system co-occurred with our efforts to implement
  • Changes in administration, workers, foster parents
  • Groundhog Day: constantly restating our case
  • Like trying to fill a bucket with a hole in it
lessons learned with child welfare
Lessons Learned with Child Welfare
  • “Parallel Process”
  • System under high stress: “trauma contagion”
  • As children and families struggle to survive – so does the system; so does the worker
  • The same skills that help us with traumatized and attachment-disrupted children and parents..
  • .. Help us deal with a traumatized system
key ingredients
Key Ingredients
  • Patience
  • Trust
  • Psycho-education on the impact of trauma (including trauma contagion)
  • Relationship building
  • Good self care and community with like minded colleagues
  • Key Judges have been supportive
  • Zero to Three support for family drug court
  • Model Court initiated new program development
    • Systemic training of court personnel across the state
  • “Critical Mass” is building
  • Brain development and science foundation
evaluation findings for the zero to three safe babies court team project
Evaluation findings for the ZERO TO THREE Safe Babies Court Team Project
  • Children participating in court teams leave foster care three times as fast as the comparison sample….
  • Reunification is most common for Court Team Babies (38%) whereas adoption is most common for comparison group (41%)
  • “Moving Young Children From Foster Care to Permanent Homes”. Kimberly McCombs-Thornton; Zero to Three Journal; May 2012, Volume 32, Number 5
key factors in success
Key Factors In Success
  • Judicial Leadership
  • Regular Court Team Staffings (cases reviewed at least monthly)
Thanks !
  • To Dr. Joy Osofsky for teaching and mentoring us through this process
  • To the families we learn from
  • To the volunteer parents and children who agreed to be videotaped
presenter information
Presenter Information
  • Lisa Blunt, MS, LMHP
    • Chief Operating Officer
    • Child Saving Institute
    • 402-553-6000
  • Barbara Jessing, MS, LIMHP
    • Clinical Director
    • Heartland Family Service
    • 402-553-3000