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Providing Relationship-Driven Mental Providing Relationship-Driven Mental Health Services in the Birth to 3 PeriodHealth Services in the Birth to 3 Period
San Gabriel San Gabriel Pomona Regional Pomona Regional Center ConferenceCenter Conference
October 7, 2010October 7, 2010
Karen Moran Finello, Karen Moran Finello, Ph.D.Ph.D.
Assoc. Professor of Assoc. Professor of Clinical PediatricsClinical Pediatrics
USC Keck School of USC Keck School of MedicineMedicine
Project Director, Project Director, Project ABC (Project ABC (AAbout bout BBuilding uilding CConnections onnections for Young Children & for Young Children & their Families) & their Families) & Corazon de la Familia Corazon de la Familia Infant-Child Infant-Child InterventionIntervention
[email protected]@chla.usc.edu
Current Approaches Within Current Approaches Within Mental HealthMental Health
Built upon a diagnostic and treatment Built upon a diagnostic and treatment model—medical modelmodel—medical model
Illness approach; great deal of stigmaIllness approach; great deal of stigma General public views mental health as General public views mental health as
associated with disorder & mental illnessassociated with disorder & mental illness Most mental health services began with Most mental health services began with
treatment services for adult populations treatment services for adult populations with serious disorders & were geared down with serious disorders & were geared down for adolescents and school aged childrenfor adolescents and school aged children
Preschool children came into delivery Preschool children came into delivery system late; infants & toddlers are still system late; infants & toddlers are still underserved underserved
Basic Facts Basic Facts (CDC, 2005)(CDC, 2005)
25% of the population around the world will 25% of the population around the world will develop a mental or behavioral disorder at some develop a mental or behavioral disorder at some point in their livespoint in their lives
Mental disorders account for 25% of all Mental disorders account for 25% of all disabilities in the U.S., Canada & Europe & are disabilities in the U.S., Canada & Europe & are a leading cause of premature deatha leading cause of premature death
In the U.S., 22% of the adult population has 1 or In the U.S., 22% of the adult population has 1 or more diagnosable mental disorders in any yearmore diagnosable mental disorders in any year
10% of children in the U.S. have mental 10% of children in the U.S. have mental disorders that cause some level of impairmentdisorders that cause some level of impairment
Mental illnesses cost the U.S. $150 billion each Mental illnesses cost the U.S. $150 billion each yearyear
Report of the Surgeon Report of the Surgeon General on Mental Health General on Mental Health
(1999)(1999)
Mental healthMental health—the successful —the successful performance of mental function, resulting in performance of mental function, resulting in productive activities, fulfilling relationships productive activities, fulfilling relationships with other people, and the ability to adapt with other people, and the ability to adapt to change and to cope with adversity; from to change and to cope with adversity; from early childhood until late life, mental health early childhood until late life, mental health is the springboard of thinking and is the springboard of thinking and communication skills, learning, emotional communication skills, learning, emotional growth, resilience, and self-esteem.growth, resilience, and self-esteem.
Report of the Surgeon Report of the Surgeon General on Mental Health General on Mental Health
(1999)(1999)
Mental illnessMental illness—the term that —the term that refers collectively to all mental refers collectively to all mental disorders. Mental disorders are disorders. Mental disorders are health conditions that are health conditions that are characterized by alterations in characterized by alterations in thinking, mood, or behavior (or some thinking, mood, or behavior (or some combination thereof) associated with combination thereof) associated with distress and/or impaired functioning.distress and/or impaired functioning.
Key Points in ReportKey Points in Report
Mental health is fundamental to Mental health is fundamental to healthhealth. .
Mental disorders are real health Mental disorders are real health conditionsconditions that have an immense that have an immense impact on individuals and families impact on individuals and families throughout the U.S. and the world. throughout the U.S. and the world.
Mental health is often an “after thought” Mental health is often an “after thought” while mental illnesses are “shrouded in while mental illnesses are “shrouded in fear and misunderstanding”fear and misunderstanding”
Surgeon General’s Report attaches Surgeon General’s Report attaches high importance to public health high importance to public health practices that seek to:practices that seek to: identify risk factors for mental health identify risk factors for mental health
problemsproblems mount preventive interventions that mount preventive interventions that
may block the emergence of severe may block the emergence of severe illnessesillnesses
actively promote good mental healthactively promote good mental health
CDC ConclusionCDC Conclusion
Mental health is integral to overall health Mental health is integral to overall health and well being and should be “treated with and well being and should be “treated with the same urgency as physical health”the same urgency as physical health”
Challenges for public health are to:Challenges for public health are to: Identify risk factorsIdentify risk factors Increase public awareness about mental Increase public awareness about mental
disorders & treatment efficacydisorders & treatment efficacy Remove stigmaRemove stigma Eliminate health disparitiesEliminate health disparities Improve access to mental health services for allImprove access to mental health services for all
CDC RecommendationsCDC Recommendations Incorporation of mental health promotion Incorporation of mental health promotion
into chronic disease prevention efforts by into chronic disease prevention efforts by public health agenciespublic health agencies
Collaboration among partners (public Collaboration among partners (public health agencies and other public entities) health agencies and other public entities) to develop comprehensive mental health to develop comprehensive mental health plans to enhance coordination of careplans to enhance coordination of care
Public health agencies should conduct Public health agencies should conduct surveillance and research to improve the surveillance and research to improve the evidence base about mental health in the evidence base about mental health in the U.S.U.S.
What Is Early Childhood What Is Early Childhood Mental Health?Mental Health?
The development of social and The development of social and emotional well-being in children emotional well-being in children birth to five. Includesbirth to five. Includes child behavior, health and developmentchild behavior, health and development family functioningfamily functioning caregiver-child relationshipscaregiver-child relationships
Why Is ECMH Why Is ECMH Important?Important?
Foundation for future social-Foundation for future social-emotional functioning emotional functioning
Provides biologic underpinnings for Provides biologic underpinnings for later coping & later coping & resilience---”hardwires the brain”resilience---”hardwires the brain”
Untreated early problems are Untreated early problems are associated highly with problems associated highly with problems during childhood, adolescence & during childhood, adolescence & adulthoodadulthood
Critical Characteristics Critical Characteristics of ECMHof ECMH
Development of relationships: KEY Development of relationships: KEY to all other areasto all other areas Ability to initiate, discover, & learnAbility to initiate, discover, & learn Development of persistence & attentionDevelopment of persistence & attention Development of coping mechanismsDevelopment of coping mechanisms Development of self-regulationDevelopment of self-regulation Development of emotional rangeDevelopment of emotional range
Families have the most continuous Families have the most continuous and emotionally charged relationship and emotionally charged relationship with the child. Infants and toddlers with the child. Infants and toddlers learn what people expect of them learn what people expect of them and what they can expect of other and what they can expect of other people through early experiences people through early experiences with parents and other caregivers. with parents and other caregivers.
(Day & Parlakian, 2004)(Day & Parlakian, 2004)
RISKS TO RISKS TO INFANT/CAREGIVER INFANT/CAREGIVER
RELATIONSHIPSRELATIONSHIPS Separation and lossSeparation and loss
Multiple caregiversMultiple caregivers
Repeat hospitalizationsRepeat hospitalizations
Family instabilityFamily instability
Substance use in caregiverSubstance use in caregiver
Domestic violenceDomestic violence
Environmental stressorsEnvironmental stressors
Inadequate support for caregiverInadequate support for caregiver
Why Attend to Risk Factors Why Attend to Risk Factors in Early Childhood?in Early Childhood?
Mental health disorders & diagnoses are Mental health disorders & diagnoses are not as clear during the early years not as clear during the early years (especially first 3 years of life)(especially first 3 years of life)
Neurobiologic vulnerabilities are critical Neurobiologic vulnerabilities are critical to address earlyto address early
Rapid developmental changes sometimes Rapid developmental changes sometimes lead to behavior changes (& changes in lead to behavior changes (& changes in diagnoses)diagnoses)
Environmental support can be effective in Environmental support can be effective in modulating/changing behavior due to modulating/changing behavior due to neurobiologic vulnerabilitiesneurobiologic vulnerabilities
Identifying Infants & Young Identifying Infants & Young Children Who Are At-RiskChildren Who Are At-Risk
Generally done through surveys and Generally done through surveys and questionnairesquestionnaires
Recent research on level of risk in Recent research on level of risk in infancy & developmental problems infancy & developmental problems has shown a high correlation has shown a high correlation between risk and measured delay between risk and measured delay (Scarborough et al, 2008)(Scarborough et al, 2008)
Measuring Child Measuring Child CharacteristicsCharacteristics
Neurodevelopmental factorsNeurodevelopmental factors
Developmental level of childDevelopmental level of child
Other special needs of child (e.g., Other special needs of child (e.g., Communication disorders, Autism & Communication disorders, Autism & other spectrum disorders, PDD)other spectrum disorders, PDD)
BEHAVIOR CONCERN? SIGN BEHAVIOR CONCERN? SIGN OF SEIZURE DISORDER? OF SEIZURE DISORDER?
OTHER?OTHER? BreathholdingBreathholding Sleep disorders (narcolepsy, night Sleep disorders (narcolepsy, night
terrors)terrors) TicsTics Migraine headachesMigraine headaches FaintingFainting Gastroesophageal refluxGastroesophageal reflux Behavior disturbancesBehavior disturbances
ROLE OF TEMPERAMENT ROLE OF TEMPERAMENT ON EMOTIONAL ON EMOTIONAL
REGULATIONREGULATION Infant temperament determines the Infant temperament determines the
intensity of infant response to stimuliintensity of infant response to stimuli
Temperament effects how emotions are Temperament effects how emotions are expressedexpressed
Temperament may influence which signals Temperament may influence which signals baby uses to express positive and negative baby uses to express positive and negative emotionsemotions
Temperament also influences how parent Temperament also influences how parent respondsresponds
Measuring Specific Child Measuring Specific Child CharacteristicsCharacteristics
Dimensions of Temperament:Dimensions of Temperament: Activity levelActivity level Regularity of biologic rhythmsRegularity of biologic rhythms Approach/withdrawalApproach/withdrawal AdaptabilityAdaptability IntensityIntensity SensitivitySensitivity MoodMood DistractibilityDistractibility PersistencePersistence
YOUNG CHILDREN & YOUNG CHILDREN & OUT-OF-HOME CAREOUT-OF-HOME CARE
Children under age 5 comprise one-Children under age 5 comprise one-third of all children in out-of-home carethird of all children in out-of-home care
Average length of stay in foster care is Average length of stay in foster care is 2 years2 years
In some areas, up to 1/3 of children In some areas, up to 1/3 of children who enter the foster care system who enter the foster care system remain in itremain in it
Children Who Experience Children Who Experience TraumaTrauma
Differences exist in reactions by age of child Differences exist in reactions by age of child (preverbal, verbal)(preverbal, verbal)
May see differences in behavior based on where May see differences in behavior based on where child is now living (e.g., role of multiple child is now living (e.g., role of multiple placements)placements)
New knowledge regarding infant’s processing of New knowledge regarding infant’s processing of events and memory of eventsevents and memory of events
Need for careful intervention in helping caregiver Need for careful intervention in helping caregiver help child to understand event and recover from ithelp child to understand event and recover from it
All children who have experienced trauma should All children who have experienced trauma should be referred for MH treatment servicesbe referred for MH treatment services
Traumatized children’s maladaptive coping strategies can Traumatized children’s maladaptive coping strategies can lead to behaviors that undermine healthy relationships lead to behaviors that undermine healthy relationships and may disrupt foster placements, including:and may disrupt foster placements, including:
Sleeping, eating, elimination problemsSleeping, eating, elimination problems High activity level, irritability, acting outHigh activity level, irritability, acting out Emotional detachment, unresponsiveness, distance, or Emotional detachment, unresponsiveness, distance, or
numbnessnumbness Hypervigilance or feeling that danger is present, even Hypervigilance or feeling that danger is present, even
when it isn’twhen it isn’t Increased mental health issues (e.g., depression, Increased mental health issues (e.g., depression,
anxiety)anxiety) An unexpected and exaggerated response when told An unexpected and exaggerated response when told
“no”“no” From From Child Welfare Trauma Training ToolkitChild Welfare Trauma Training Toolkit
25
Understanding Children’s Understanding Children’s ResponsesResponses
Traumatized children may exhibit:Traumatized children may exhibit:
Over-controlled behaviorOver-controlled behavior to counteract feelings of to counteract feelings of helplessness and impotence helplessness and impotence
May be seen in difficulties transitioning and changing May be seen in difficulties transitioning and changing routines, rigid behavioral patterns, repetitive behaviors, routines, rigid behavioral patterns, repetitive behaviors, etc.etc.
Under-controlled behaviorUnder-controlled behavior due to cognitive delays or due to cognitive delays or deficits in planning, organizing, delaying gratification, and deficits in planning, organizing, delaying gratification, and exerting control over behaviorexerting control over behavior
May show impulsivity, disorganization, aggression, or May show impulsivity, disorganization, aggression, or other acting-out behaviorsother acting-out behaviors
From From Child Welfare Trauma Training ToolkitChild Welfare Trauma Training Toolkit
26
Understanding Children’s ResponsesUnderstanding Children’s Responses
Young childrenYoung children who have experienced trauma may: who have experienced trauma may:
Become passive, quiet, and easily alarmedBecome passive, quiet, and easily alarmed
Become fearful, especially regarding separations and new Become fearful, especially regarding separations and new situationssituations
Experience confusion about assessing threat and finding Experience confusion about assessing threat and finding protection, especially in cases where a parent or caretaker is protection, especially in cases where a parent or caretaker is the aggressorthe aggressor
Regress to recent behaviors (e.g., baby talk, bed-wetting, Regress to recent behaviors (e.g., baby talk, bed-wetting, crying)crying)
Experience strong startle reactions, night terrors, or Experience strong startle reactions, night terrors, or aggressive outburstsaggressive outbursts
From From Child Welfare Trauma Training Child Welfare Trauma Training ToolkitToolkit
27
The Influence of Developmental Stage:The Influence of Developmental Stage:Young ChildrenYoung Children
Empower caregivers about their role of calming Empower caregivers about their role of calming and reassuring children. and reassuring children.
Educate caregivers about the reasons for, and Educate caregivers about the reasons for, and techniques to manage, children’s emotional techniques to manage, children’s emotional outbursts.outbursts.
Recommend parenting skills training to strengthen Recommend parenting skills training to strengthen caregivers’ ability to handle children’s emotions. caregivers’ ability to handle children’s emotions.
Work with the child to identify and label troubling Work with the child to identify and label troubling emotions and stress that the emotions are normal emotions and stress that the emotions are normal and understandable.and understandable. From From Child Welfare Trauma Training ToolkitChild Welfare Trauma Training Toolkit
28
What Can We Do to Support What Can We Do to Support Young Children Who Have Young Children Who Have
Experienced TraumaExperienced Trauma
CUMULATIVE RISK & CUMULATIVE RISK & CHILD OUTCOMESCHILD OUTCOMES
The greater the number of risk factors, The greater the number of risk factors, the greater the variation in outcome, the greater the variation in outcome, particularly for cognitive development particularly for cognitive development (Sameroff et al, 1987)(Sameroff et al, 1987)
The “compensating force of The “compensating force of opportunity” must also be considered in opportunity” must also be considered in examining child outcomes examining child outcomes (Garbarino & (Garbarino & Ganzel, 2000)Ganzel, 2000)
Complexity of Risk Factors Complexity of Risk Factors ImpactImpact
““Buffer Zone” in Development Buffer Zone” in Development ofof
““Competent” Child and Family!Competent” Child and Family!
One of the most important factors One of the most important factors found to distinguish traumatized found to distinguish traumatized
children with good developmental children with good developmental outcomes from those with poor outcomes from those with poor outcomes is the availability of a outcomes is the availability of a supportive parent or alternate supportive parent or alternate
guardianguardian
(Pynoos et al, 1995)(Pynoos et al, 1995)
Caregiver CharacteristicsCaregiver Characteristics
TemperamentTemperament FlexibilityFlexibility ToleranceTolerance Environmental StressorsEnvironmental Stressors Family dynamicsFamily dynamics Past experiences as a motherPast experiences as a mother Her own history of child rearing experiencesHer own history of child rearing experiences Psychological statePsychological state Health & well beingHealth & well being
EXAMPLE: MOTHERS OF EXAMPLE: MOTHERS OF ABUSED INFANTSABUSED INFANTS
Respond to fewer infant initiativesRespond to fewer infant initiatives
Try to control children more oftenTry to control children more often
Provide less verbal, tactile & vestibular Provide less verbal, tactile & vestibular stimulation during interactionstimulation during interaction
Are less active during free playAre less active during free play
Use more negative affectUse more negative affect
Do not change teaching style to match child’s Do not change teaching style to match child’s ageage
(Westby & Fenske, 2001)(Westby & Fenske, 2001)
Understanding Attachment Understanding Attachment in Young Childrenin Young Children
Primary attachmentPrimary attachment Secondary attachmentsSecondary attachments
AttachmentAttachment
Attachment is a pattern of interaction Attachment is a pattern of interaction that develops over time as the infant that develops over time as the infant
or toddler and caregiver engage.or toddler and caregiver engage.
Attachment 101Attachment 101
Secure attachmentsSecure attachments Insecure attachments (Avoidant)Insecure attachments (Avoidant) Insecure attachments (Ambivalent)Insecure attachments (Ambivalent) Disorganized attachmentsDisorganized attachments
Secure AttachmentsSecure Attachments
Adults are used as a “secure base”Adults are used as a “secure base” Child knows that adults are responsive, Child knows that adults are responsive,
dependable and consistentdependable and consistent Adults will be there when needed and Adults will be there when needed and
share child’s joy in the worldshare child’s joy in the world With peers, child interacts and plays With peers, child interacts and plays
wellwell May cry at separation but settles with May cry at separation but settles with
some helpsome help
Attachment Relationships VignettesAttachment Relationships Vignettes
Vignette 1Vignette 1 When a home visitor arrives, she finds a When a home visitor arrives, she finds a
father & his 5 month old baby deeply engaged father & his 5 month old baby deeply engaged in play on the floor. While she knows that she in play on the floor. While she knows that she needs to get a lot of paperwork filled out needs to get a lot of paperwork filled out during this visit, she also knows that one of during this visit, she also knows that one of her primary jobs is to support the relationship her primary jobs is to support the relationship between these two. She watches as the baby between these two. She watches as the baby reaches & scoots on her tummy for a toy, reaches & scoots on her tummy for a toy, while Dad, on his tummy, too, is building the while Dad, on his tummy, too, is building the excitement & encouraging her but not letting excitement & encouraging her but not letting the excitement get out of hand. She reaches the excitement get out of hand. She reaches the toy and flashes him a smile that says, the toy and flashes him a smile that says, “Being with you is wonderful!”“Being with you is wonderful!”
Insecure (Avoidant) Insecure (Avoidant) AttachmentsAttachments
Caregiver often leaves child to deal Caregiver often leaves child to deal with own feelings (fright, upset, with own feelings (fright, upset, excitement)excitement)
Caregiver may respond but in own Caregiver may respond but in own time, not when child needs responsetime, not when child needs response
Child appears to be very independent Child appears to be very independent but may get frustrated easilybut may get frustrated easily
May have difficulty with peers due to May have difficulty with peers due to aggression, hitting, biting, pushing, aggression, hitting, biting, pushing, screamingscreaming
Avoidant cont’dAvoidant cont’d
Child does not typically build strong Child does not typically build strong connections with child care providerconnections with child care provider
Do not show distress at separation Do not show distress at separation from caregiver and may ignore when from caregiver and may ignore when caregiver comes for pick upcaregiver comes for pick up
Seem too able to take care of own Seem too able to take care of own needsneeds
Insecure (Ambivalent) Insecure (Ambivalent) AttachmentsAttachments
Child may be clingy, demanding, angry, Child may be clingy, demanding, angry, easily frustratedeasily frustrated
Likes to be center of attention and gets Likes to be center of attention and gets upset if others don’t pay attention to themupset if others don’t pay attention to them
May act like a younger childMay act like a younger child Caregiver is inconsistent in response to Caregiver is inconsistent in response to
child’s needs and may go either overboard child’s needs and may go either overboard in responding or not respond at allin responding or not respond at all
Unpredictable caregiving & out of synch Unpredictable caregiving & out of synch with childwith child
Disorganized Disorganized AttachmentsAttachments
Child shows disordered sequences of Child shows disordered sequences of behavior, does things that don’t seem behavior, does things that don’t seem to make sense (reaches out to adult to make sense (reaches out to adult while turning head away to avert while turning head away to avert gaze)gaze)
Shows stilling or freeze behavior and Shows stilling or freeze behavior and repetitive behaviorsrepetitive behaviors
Demonstrates fear of caregiverDemonstrates fear of caregiver May seem very different from one day May seem very different from one day
to nextto next
Disorganized cont’dDisorganized cont’d
May be extremely bossy with peers or May be extremely bossy with peers or may act like the parentmay act like the parent
Caregiver has patterns of Caregiver has patterns of unresponsiveness to child’s needs & unresponsiveness to child’s needs & responses that don’t match child needsresponses that don’t match child needs
Caregivers frequently have untreated Caregivers frequently have untreated mental health issues mental health issues
Child may have been abused or Child may have been abused or neglectedneglected
Important PointsImportant Points
Attachment may be different with Attachment may be different with different adults (mom, grandmother, different adults (mom, grandmother, dad, child care provider)dad, child care provider)
There is typically a “primary” There is typically a “primary” attachment to one personattachment to one person
Should make a referral if the child Should make a referral if the child constantly seems either sad & constantly seems either sad & withdrawn or aggressive & out of withdrawn or aggressive & out of controlcontrol
Special Issues Impacting Special Issues Impacting Relationships & AttachmentRelationships & Attachment Lengthy hospitalizations and repeated Lengthy hospitalizations and repeated
hospitalizations during first two years of hospitalizations during first two years of lifelife
Life threatening special health care needsLife threatening special health care needs PrematurityPrematurity Neurologic problemsNeurologic problems Separation due to parental hospitalization Separation due to parental hospitalization
or deathor death Foster placements (especially multiple Foster placements (especially multiple
placements)placements)
Principles for Developing Principles for Developing Secure Attachments *Secure Attachments *
Comfort children when they are physically Comfort children when they are physically hurt, ill, upset, frightened or lonelyhurt, ill, upset, frightened or lonely
Respond to and notice children so they Respond to and notice children so they learn that their caregivers carelearn that their caregivers care
Give children a sense of trust in the world Give children a sense of trust in the world and the people in itand the people in it
Help children review experiences and Help children review experiences and reenact frightening situations so that the reenact frightening situations so that the memories can be integrated into their memories can be integrated into their self-narrativesself-narratives
Principles cont’dPrinciples cont’d Create and keep alive good, warm, and joyful Create and keep alive good, warm, and joyful
memories because they can help develop secure memories because they can help develop secure attachment relationships. Establish predictable attachment relationships. Establish predictable traditions.traditions.
Help parents understand the importance of Help parents understand the importance of letting children know where they are going and letting children know where they are going and when they will be back. Provide objects to give when they will be back. Provide objects to give security and keep memories of the absent security and keep memories of the absent caregiver alive.caregiver alive.
Try to be as predictable and as positive as Try to be as predictable and as positive as possible in reacting to a child’s behavior.possible in reacting to a child’s behavior.
* From Landy, Sarah. Pathways to Competence (2002)* From Landy, Sarah. Pathways to Competence (2002)
What is “Separation What is “Separation Anxiety?”Anxiety?”
Response to separation from attachment Response to separation from attachment figurefigure
May occur at time of separation or before May occur at time of separation or before it happens (when they get in the car to it happens (when they get in the car to come to the center)come to the center)
May be shown by crying, whining, May be shown by crying, whining, clinging, moodiness, anger depending on clinging, moodiness, anger depending on age and cognitive levelage and cognitive level
Some children have difficulty with all Some children have difficulty with all transitions so will also have trouble at end transitions so will also have trouble at end of day in leaving centerof day in leaving center
Case Study: MaryCase Study: Mary
Most days Mary has a difficult time Most days Mary has a difficult time entering the center. She clings to her entering the center. She clings to her mother and cries. The teacher often mother and cries. The teacher often has to stop what she is doing and has to stop what she is doing and physically take Mary from her physically take Mary from her mother’s arms. After Mary’s mother mother’s arms. After Mary’s mother leaves, Mary often sits in her cubby leaves, Mary often sits in her cubby and watches as others engage in and watches as others engage in activities within the bustling classroomactivities within the bustling classroom
What Can You Do to What Can You Do to Help?Help?
Help caregiver understand how to say Help caregiver understand how to say good bye and to transition childgood bye and to transition child
Build an understanding of each Build an understanding of each child’s response and develop child’s response and develop strategies for this wide range for the strategies for this wide range for the children you work withchildren you work with
Every child is different and may need Every child is different and may need slightly different responses slightly different responses
Remember: One size doesn’t fit all!Remember: One size doesn’t fit all!
Strengthening Strengthening AttachmentsAttachments
Supporting parents with separation Supporting parents with separation issues (on both sides!)issues (on both sides!)
Helping families to recognize Helping families to recognize behavioral signs that child is upset behavioral signs that child is upset about separationabout separation
Relationships are Different Relationships are Different from Interactions (CSEFEL from Interactions (CSEFEL
slide)slide) Relationships:Relationships:
Have emotional connectionsHave emotional connections Endure over timeEndure over time Have special meaning between the two Have special meaning between the two
peoplepeople Create memories and expectations in Create memories and expectations in
the minds of the people involvedthe minds of the people involved
Exercise (Personal)Exercise (Personal)
Exercise on personal history of Exercise on personal history of relationshipsrelationships
What is the Intent of What is the Intent of Relationship-Based WorkRelationship-Based Work
Most interventions are designed to Most interventions are designed to improve (or repair) very young child-improve (or repair) very young child-caregiver relationships through a variety caregiver relationships through a variety of mechanisms, with the majority focused of mechanisms, with the majority focused on creating change in dyadic interactions, on creating change in dyadic interactions, supporting and strengthening supporting and strengthening development within both child and family, development within both child and family, and reducing child and caregiver stressesand reducing child and caregiver stresses
Many “ripple effects” may be seen in Many “ripple effects” may be seen in relationship-based workrelationship-based work
Samples of relationship-Samples of relationship-based Interventionsbased Interventions
Dyadic Therapy & InterventionsDyadic Therapy & Interventions Parent Guidance Programs (STEEP; Parent Guidance Programs (STEEP;
Seeing is Believing; Partnership in Seeing is Believing; Partnership in Parenting Education)Parenting Education)
Parent Child Interaction TherapyParent Child Interaction Therapy Interaction Guidance ApproachesInteraction Guidance Approaches Family Support ServicesFamily Support Services Attachment Work (Circles of Security, etc)Attachment Work (Circles of Security, etc) Many home visitation modelsMany home visitation models
Focus of Relationship-based Focus of Relationship-based WorkWork
Changing attachment style by Changing attachment style by focusing on consistency and focusing on consistency and responsiveness in caregiverresponsiveness in caregiver
Improving caregiver’s emotional Improving caregiver’s emotional availability—measuring impact of availability—measuring impact of changes in e.a. that might be very changes in e.a. that might be very subtle (but important to child’s life) subtle (but important to child’s life) is criticalis critical
Enhancing structure & routines in Enhancing structure & routines in young children’s livesyoung children’s lives
ActivityActivity
Developing Ideas About Developing Ideas About Relationships—Vignette (Myra, Relationships—Vignette (Myra,
Haniya & Tia)Haniya & Tia)
WHAT CAN A CLINICIAN WHAT CAN A CLINICIAN DO?DO?
Listen to mother’s storiesListen to mother’s stories Reflect on how her early experiences Reflect on how her early experiences
may have shaped her ideas of self may have shaped her ideas of self and her relationships and may and her relationships and may account for present behaviorsaccount for present behaviors
Provide “corrective emotional Provide “corrective emotional experiences” and opportunities to experiences” and opportunities to connect her past with the present connect her past with the present
-(Gowen & Nebring, 2002)-(Gowen & Nebring, 2002)
Serving children and their Serving children and their familiesfamilies
Corazón de La Familia Corazón de La Familia Infant-Child Intervention Infant-Child Intervention
ProgramProgram Strength BasedStrength Based Family FocusedFamily Focused IndividualizedIndividualized Culturally ResponsiveCulturally Responsive ComprehensiveComprehensive Collaborative Collaborative Relationship-drivenRelationship-driven Specialists in Serving Very Young Specialists in Serving Very Young
Children with Special Health Care NeedsChildren with Special Health Care Needs
Overall GoalsOverall Goals
To assist families in optimizing the To assist families in optimizing the growth & development of their growth & development of their infants, toddlers, and preschoolersinfants, toddlers, and preschoolers
To help families become more To help families become more comfortable and feel success in comfortable and feel success in meeting the needs of their childrenmeeting the needs of their children
To provide support to struggling To provide support to struggling familiesfamilies
Primary Targeted Primary Targeted OutcomesOutcomes
Health & development of at risk Health & development of at risk children under age 5children under age 5
Mental health & behavior issues in Mental health & behavior issues in children under 5children under 5
Family support & advocacyFamily support & advocacy
Role of Home VisitorRole of Home Visitor
To support, nurture and “contain” To support, nurture and “contain” familiesfamilies
To offer a “corrective emotional To offer a “corrective emotional experience”experience”
(Jones Harden, 1997)(Jones Harden, 1997)
Engagement with Families: Engagement with Families: Building a RelationshipBuilding a Relationship
Think about:Think about: How family entered the systemHow family entered the system Did they choose you or were they Did they choose you or were they
“assigned” “assigned” How would you feel about a stranger How would you feel about a stranger
entering your home to provide “help” entering your home to provide “help” with your child?with your child?
Tomika vignetteTomika vignette
What questions do you have?What questions do you have? What do you think Tomika is What do you think Tomika is
experiencing?experiencing? What do you think Loretta is feeling?What do you think Loretta is feeling? What do you think Nina is feeling? What What do you think Nina is feeling? What
do you do when you feel this way?do you do when you feel this way? What strategies would you use to What strategies would you use to
develop a partnership with mom in develop a partnership with mom in behalf of Tomika’s social emotional behalf of Tomika’s social emotional development?development?
Difficulties/Barriers in Difficulties/Barriers in Working with Families in Working with Families in
their Homestheir Homes PrivacyPrivacy Time/Travel issuesTime/Travel issues Limitations set by space in homeLimitations set by space in home Embarrassment of familyEmbarrassment of family Boundary issuesBoundary issues Staying on taskStaying on task Keeping focus on WHO is client while Keeping focus on WHO is client while
meeting needs of other family membersmeeting needs of other family members
Stressors of Home Stressors of Home VisitingVisiting
Overwhelming needs within familiesOverwhelming needs within families Unpredictability of workUnpredictability of work Safety issuesSafety issues Transportation issuesTransportation issues Draining nature of being the Draining nature of being the
nurturer if not provided nurturance nurturer if not provided nurturance within programwithin program
ChallengesChallenges
Need to move quickly—babies can’t Need to move quickly—babies can’t wait; period of rapid developmentwait; period of rapid development
Must work towards goal of “good Must work towards goal of “good enough” parentingenough” parenting
Must understand developmental Must understand developmental functioning of EVERY family functioning of EVERY family member (Jones, 1995)member (Jones, 1995)
Relationships are the key to changeRelationships are the key to change
Practice ChallengesPractice Challenges
““How much more difficult it is to How much more difficult it is to change those behaviors that change those behaviors that individuals may not believe need individuals may not believe need changing” Gomby et al. (1999)changing” Gomby et al. (1999)
Environmental/contextual factors Environmental/contextual factors play an important role in play an important role in childrearing (other children seen in childrearing (other children seen in neighborhood, relatives with neighborhood, relatives with childrearing beliefs, economic and childrearing beliefs, economic and educational issues)educational issues)
Service ChallengesService Challenges Must be careful not to focus solely on Must be careful not to focus solely on
“child-centered” interventions OR on “child-centered” interventions OR on “family-centered” interventions—must be “family-centered” interventions—must be responsive to where both child and parent responsive to where both child and parent “are” in order to work in a truly “are” in order to work in a truly collaborative and meaningful stylecollaborative and meaningful style
Must have knowledge and awareness of Must have knowledge and awareness of strategies of other disciplines and know strategies of other disciplines and know when young child needs (& family is ready when young child needs (& family is ready for) other specialty servicesfor) other specialty services
Must be able to determine the line Must be able to determine the line between “too much” and “not enough”—between “too much” and “not enough”—More is not always better!More is not always better!
What Works?What Works? Heinicke (1999): must address multiple domains, Heinicke (1999): must address multiple domains,
including “adaptave capacities of the mother” and including “adaptave capacities of the mother” and “caregiver/child interaction” “caregiver/child interaction”
More comprehensive interventions have a stronger More comprehensive interventions have a stronger impact impact
Minimum of weekly visits for at least 6 months Minimum of weekly visits for at least 6 months durationduration
Mixed findings regarding efficacy by background of Mixed findings regarding efficacy by background of home visitor (professional level, paraprofessional)home visitor (professional level, paraprofessional)
Trust, interest and the degree of family involvement Trust, interest and the degree of family involvement are crucial factors. Thus, the are crucial factors. Thus, the qualityquality of participation of participation may be more important than the may be more important than the quantityquantity. (Beckwith, . (Beckwith, 2000)2000)
What works? Cont’dWhat works? Cont’d
Generic home visiting cannot Generic home visiting cannot adequately meet the needs of adequately meet the needs of psychologically vulnerable families. psychologically vulnerable families. Visits must be intensive, specialized Visits must be intensive, specialized and coordinated.and coordinated.
Most Important Lessons Most Important Lessons LearnedLearned
Establishing a partnership with families is Establishing a partnership with families is accomplished more easily when you meet accomplished more easily when you meet them “on their own turf” and are them “on their own turf” and are responsive to their needsresponsive to their needs
Families are eager to do what is best for Families are eager to do what is best for their babiestheir babies
Through home visiting, we are able to Through home visiting, we are able to reach hard to reach populations who will reach hard to reach populations who will not respond to other types of service not respond to other types of service provisionprovision
Lessons learned cont’d Lessons learned cont’d
Home based service delivery is not a good fit Home based service delivery is not a good fit for all professionals and paraprofessionalsfor all professionals and paraprofessionals
Therapeutic alliance is crucial to effective Therapeutic alliance is crucial to effective home visitinghome visiting
Must respect and understand culture of each Must respect and understand culture of each family with whom you workfamily with whom you work
Must focus on emotional needs of parents, tooMust focus on emotional needs of parents, too ““Relationships hold the potential to help people Relationships hold the potential to help people
grow and change” (Shahmoon-Shanok, 2005)grow and change” (Shahmoon-Shanok, 2005)
Evaluating Child & Evaluating Child & Family Need for Family Need for
InterventionIntervention
Screening Infants & Young Screening Infants & Young Children For Social-Children For Social-Emotional ProblemsEmotional Problems
Common toolsCommon tools UsesUses Advantages & disadvantagesAdvantages & disadvantages Moving from screening to referral Moving from screening to referral
for assessment and treatment for assessment and treatment
What is a “Tool”What is a “Tool”
an implement used in the practice of an implement used in the practice of a vocation; the means whereby some a vocation; the means whereby some act is accomplishedact is accomplished
any instrument of use or service. any instrument of use or service. means to end: means to end: something used as a something used as a
means of achieving somethingmeans of achieving something
How to Choose a How to Choose a Screening ToolScreening Tool
Reason for screenReason for screen Training, time & cost of Training, time & cost of
administration (ease of use issues)administration (ease of use issues) Specific concerns related to child, Specific concerns related to child,
family or risk issuesfamily or risk issues Setting where tool will be usedSetting where tool will be used Appropriateness for children served Appropriateness for children served
in the program (language, etc)in the program (language, etc)
Psychometric PropertiesPsychometric Properties
Reliability (results are stable & dependable Reliability (results are stable & dependable across administrations or respondents)across administrations or respondents)
Validity (accurate measurement of what it Validity (accurate measurement of what it intends to measure)intends to measure)
Sensitivity (probability of correctly identifying Sensitivity (probability of correctly identifying problem)problem)
Specificity (probability of correctly identifying Specificity (probability of correctly identifying typical development)typical development)
False Positives (screening says there is a False Positives (screening says there is a disorder; assessment doesn’t find one)disorder; assessment doesn’t find one)
False Negatives (screening doesn’t find disorder False Negatives (screening doesn’t find disorder that is there)that is there)
Standardized vs Standardized vs Nonstandardized ToolsNonstandardized Tools
What was the standardization What was the standardization sample for the tool?sample for the tool?
Does this match the child you will be Does this match the child you will be using it with?using it with?
Length of tool—Length of tool— Age range for administrationAge range for administration Utility questionUtility question
Potential Screening Tools Potential Screening Tools for Social-Emotional Issuesfor Social-Emotional Issues
Ages & Stages Questionnaire –Social Ages & Stages Questionnaire –Social Emotional (ASQ-SE)Emotional (ASQ-SE)
Temperament and Atypical Behavior Temperament and Atypical Behavior Rating Scale Screener (TABS)Rating Scale Screener (TABS)
Devereux Early Childhood Devereux Early Childhood Assessment (DECA)Assessment (DECA)
Brief Infant Toddler Social-emotional Brief Infant Toddler Social-emotional Assessment (BITSEA)Assessment (BITSEA)
Next Steps After Next Steps After ScreeningScreening
Sharing information with familiesSharing information with families Monitoring on routine levelMonitoring on routine level Documentation to assist referral processDocumentation to assist referral process ““Warm” referralsWarm” referrals Process must stay focused on child & Process must stay focused on child &
family needs & wishes (family centered & family needs & wishes (family centered & culturally competent)culturally competent)
Coordination for full assessmentCoordination for full assessment Collaboration with other disciplinesCollaboration with other disciplines
DiscussionDiscussion
Ideas for determining when families Ideas for determining when families need help; red flags; when & how to need help; red flags; when & how to referrefer
Early Childhood Mental Early Childhood Mental Health Service RangeHealth Service Range
Promotion—aimed at maximizing Promotion—aimed at maximizing resilience; appropriate for allresilience; appropriate for all
Prevention—aimed at reduction of risk; Prevention—aimed at reduction of risk; includes family support, parent ed & info; includes family support, parent ed & info; mentoring of caregivers, screening & mentoring of caregivers, screening & referralreferral
Early Intervention—aimed at the earliest Early Intervention—aimed at the earliest possible entry point (pre-diagnosis) possible entry point (pre-diagnosis)
Treatment—aimed at existing conditions Treatment—aimed at existing conditions which are generally severe; includes wide which are generally severe; includes wide range of approaches from dyadic therapy range of approaches from dyadic therapy to therapeutic nurseriesto therapeutic nurseries
Promotion StrategiesPromotion Strategies
May include provision of support to May include provision of support to caregivers (emotional or concrete)caregivers (emotional or concrete)
Linkage or provision of concrete Linkage or provision of concrete resources (food, housing)resources (food, housing)
Developmental guidanceDevelopmental guidance ““Listening”Listening” Helping strengthen family Helping strengthen family
environment through establishment of environment through establishment of routines, rituals and organization of routines, rituals and organization of dayday
ROUTINES & RITUALSROUTINES & RITUALS
Rituals are the “patterns of everyday Rituals are the “patterns of everyday routines that make up the shared lives of routines that make up the shared lives of parents and their children” parents and their children” (Klass, 2003, pg. 258)(Klass, 2003, pg. 258)
Provides a safe and predictable space for Provides a safe and predictable space for children as they developchildren as they develop
Help to shape family relationships by Help to shape family relationships by connecting members to each other & connecting members to each other & defining their relationshipsdefining their relationships
Provide “communication, commitment, Provide “communication, commitment, and continuity” (Fiese, 2002, pg 10)and continuity” (Fiese, 2002, pg 10)
TYPES OF RITUALSTYPES OF RITUALS
Food rituals (regular dinner; specific Food rituals (regular dinner; specific place at the table; particular food place at the table; particular food associated with specific celebrations or associated with specific celebrations or ethnic heritage)ethnic heritage)
Bedtime ritualsBedtime rituals Separation rituals (good byes, etc)Separation rituals (good byes, etc) Religious/spiritual ritualsReligious/spiritual rituals
FAMILY TRADITIONS & FAMILY TRADITIONS & CELEBRATIONSCELEBRATIONS
Traditions are defined as regularly Traditions are defined as regularly occurring events occurring events
Celebrations generally involve rites Celebrations generally involve rites of passage & family holidaysof passage & family holidays
Both provide members with sense of Both provide members with sense of shared identity, connections, and shared identity, connections, and continuitycontinuity
(Klass, 2003)(Klass, 2003)
Prevention StrategiesPrevention Strategies
The field of prevention has now The field of prevention has now developed to the point that developed to the point that reduction of risk, prevention of reduction of risk, prevention of onset, and early intervention are onset, and early intervention are realistic possibilities. (Surgeon realistic possibilities. (Surgeon General’s Report, 1999)General’s Report, 1999)
Prevention strategies are effective in Prevention strategies are effective in reducing the impact of risk factors reducing the impact of risk factors and improving social and emotional and improving social and emotional developmentdevelopment
Prevention/Early Prevention/Early Intervention StrategiesIntervention Strategies
Work with new mothers with post-partum Work with new mothers with post-partum depressiondepression
Work with mothers who have mental Work with mothers who have mental health diagnoses including depressionhealth diagnoses including depression
Intervention services at earliest possible Intervention services at earliest possible point to keep young children from “going point to keep young children from “going off the cliff” (SED diagnosis)off the cliff” (SED diagnosis)
Developmental guidance and other similar Developmental guidance and other similar strategies may fit both prevention and e.i.strategies may fit both prevention and e.i. ““Purple Crying” materials at hospital dischargePurple Crying” materials at hospital discharge STEEP or Seeing is Believing is exampleSTEEP or Seeing is Believing is example
Treatment StrategiesTreatment Strategies Interaction Guidance & other types of Interaction Guidance & other types of
dyadic therapydyadic therapy Parent Child Interaction TherapyParent Child Interaction Therapy Incredible Years Program (again may be a Incredible Years Program (again may be a
preventive strategy, too)preventive strategy, too) Trauma-focused Cognitive Behavioral Trauma-focused Cognitive Behavioral
Therapy (TF-CBT)Therapy (TF-CBT) Therapeutic preschools and nurseriesTherapeutic preschools and nurseries MH consultation to programs serving MH consultation to programs serving
infants & young childreninfants & young children
Designing InterventionsDesigning Interventions
Developing an InterventionDeveloping an Intervention
Family needsFamily needs Fit for child and familyFit for child and family Time that interventions will takeTime that interventions will take Who will implement?Who will implement? How will change be How will change be
sustained/supported?sustained/supported? Consistency of consequences (both Consistency of consequences (both
positive positive & negative)& negative)
Caregiver ExpectationsCaregiver Expectations
Appropriateness Appropriateness Stress in environmentStress in environment Flexibility (e.g., 6 meals not 3) Flexibility (e.g., 6 meals not 3) Time/attention for child & selfTime/attention for child & self Understanding of child Understanding of child
characteristicscharacteristics
The Behavior ItselfThe Behavior Itself
Frequency: How often? Frequency: How often?
Context: When?Context: When?
Severity: How disturbing? (and to Severity: How disturbing? (and to
whom?)whom?)
Potential replacement behaviorsPotential replacement behaviors
Current (& future) consequences for Current (& future) consequences for
child/familychild/family
Structure of Structure of Intervention*Intervention*
Start with parents’ subjective Start with parents’ subjective experience: what have they tried, experience: what have they tried, what has worked, how are they what has worked, how are they feeling, what are they looking forfeeling, what are they looking for
Discuss with families to determine Discuss with families to determine what they want and need—for some what they want and need—for some families, more “ideas” and direction families, more “ideas” and direction may be needed (“I need to hear from may be needed (“I need to hear from an expert”); others may feel an expert”); others may feel criticized by “experts”criticized by “experts”
Structure cont’d *Structure cont’d *
Discuss plans/additional Discuss plans/additional services/follow-upservices/follow-up
Always end with time for reflection Always end with time for reflection on baby and selfon baby and self
*Gilkerson (2008) *Gilkerson (2008)
Developmental Developmental StrategiesStrategies
Taking charge with children Taking charge with children (boundaries; limit setting)(boundaries; limit setting)
Use of praise, encouragement, Use of praise, encouragement, acknowledgementacknowledgement
Offering choices, avoiding power Offering choices, avoiding power strugglesstruggles
Preparing for transitionsPreparing for transitions
Developmental Strategies Developmental Strategies cont’dcont’d
Teaching negotiation (when/then)Teaching negotiation (when/then) Importance of consistencyImportance of consistency Role of compromiseRole of compromise
Increasing Desirable Increasing Desirable BehaviorsBehaviors
Are expectations of”desired” behaviors Are expectations of”desired” behaviors
developmentally appropriate?developmentally appropriate?
TimeTime
AttentionAttention
Reinforcement of desirable behaviorsReinforcement of desirable behaviors
Modeling desired behaviorsModeling desired behaviors
Evaluating & breaking power strugglesEvaluating & breaking power struggles
PatiencePatience
Evaluating On-Going ProcessEvaluating On-Going Process
Allowing timeAllowing time Replacing with new intervention if Replacing with new intervention if
original intervention doesn’t work for original intervention doesn’t work for child/familychild/family
Providing alternative ideas along the Providing alternative ideas along the wayway
Continued support for Continued support for caregiver/implementorcaregiver/implementor
What Do We Know About What Do We Know About Treatment Approaches? Treatment Approaches?
(Egeland & Bouquet, 2001; Zeanah, Stafford & Zeanah, 2005)(Egeland & Bouquet, 2001; Zeanah, Stafford & Zeanah, 2005) Treatment is more successful if other Treatment is more successful if other
issues (e.g., poverty, substance abuse, issues (e.g., poverty, substance abuse, housing) is also addressedhousing) is also addressed
Caregiver’s relationships with others must Caregiver’s relationships with others must also be addressedalso be addressed
Interventions can’t wait—more success Interventions can’t wait—more success with earlier interventionswith earlier interventions
Programs need to be of sufficient length & Programs need to be of sufficient length & intensity to be effectiveintensity to be effective
Services need to be individualized and Services need to be individualized and target experiences of both child and target experiences of both child and caregivercaregiver
One Size Doesn’t Fit AllOne Size Doesn’t Fit All
Critical issues for service delivery Critical issues for service delivery programs are how to choose programs are how to choose intervention strategies that fit the intervention strategies that fit the population served, how to population served, how to individualize interventions to specific individualize interventions to specific families, and how to adapt them over families, and how to adapt them over time as dyadic changes unfoldtime as dyadic changes unfold
Intensity & duration should be Intensity & duration should be dependent on need and may vary dependent on need and may vary greatly from dyad to dyadgreatly from dyad to dyad
Such individualized approaches to Such individualized approaches to interventions are highly interventions are highly recommended clinically but do not recommended clinically but do not fit most evaluation models that fit most evaluation models that currently existcurrently exist
We can’t do this work We can’t do this work alone!alone!
Need for a Shift in Public Need for a Shift in Public OpinionOpinion
Must build community awareness that Must build community awareness that mental health is essential to overall health mental health is essential to overall health and well being; it is not the same as mental and well being; it is not the same as mental disorder or mental illnessdisorder or mental illness
Need to shift from emphasis on treatment Need to shift from emphasis on treatment to consideration of entire spectrum of to consideration of entire spectrum of service needs & involve relevant partners at service needs & involve relevant partners at each level to reduce stigma and gain each level to reduce stigma and gain acceptance of mental healthacceptance of mental health
Critical to evaluate cost savings of Critical to evaluate cost savings of promotion and prevention and promote this promotion and prevention and promote this with the publicwith the public
Building the ConnectionsBuilding the Connections
Collaborations with pediatricians Collaborations with pediatricians and other primary care providersand other primary care providers
Resource sharing across disciplines Resource sharing across disciplines to enhance quality of services and to enhance quality of services and improve referral mechanismsimprove referral mechanisms
Marketing of mental health as part Marketing of mental health as part of overall public health approachesof overall public health approaches
Website linksWebsite links
www.vanderbilt.edu/www.vanderbilt.edu/csefelcsefel//modules.htmlmodules.html
www.projectabc-la.org
REFERENCESREFERENCES
Batshaw, M.L & Perret, Y.M. (1993). Batshaw, M.L & Perret, Y.M. (1993). Children with Children with disabilities: A medical primer, 3disabilities: A medical primer, 3rdrd edition edition. Baltimore: Paul H. . Baltimore: Paul H. Brookes Publishing Co.Brookes Publishing Co.
Fiese, B.H. (2002) Routines of daily living and rituals in family Fiese, B.H. (2002) Routines of daily living and rituals in family life: A glimpse of stability and change during the early child-life: A glimpse of stability and change during the early child-raising years. raising years. Zero To ThreeZero To Three, , 22(422(4), 10-13.), 10-13.
Klass, C.S. (2003) Klass, C.S. (2003) The home visitor’s guidebook, 2The home visitor’s guidebook, 2ndnd ed ed. . Baltimore: Paul H. Brookes Publishing Co. Baltimore: Paul H. Brookes Publishing Co.
Landy, Sarah (2002). Landy, Sarah (2002). Pathways to competencePathways to competence. Baltimore: . Baltimore: Paul H. Brookes.Paul H. Brookes.
Luckasson, R. et al. (1992). Luckasson, R. et al. (1992). Mental retardation: Definition, Mental retardation: Definition, classification and systems of support (9classification and systems of support (9thth ed ed). Washington, ). Washington, D.C: Amer Assn on Mental Retardation.D.C: Amer Assn on Mental Retardation.
Prizant, B.M., Wetherby, A.M., & Roberts, J.E. (2000). Prizant, B.M., Wetherby, A.M., & Roberts, J.E. (2000). Communication problems (pg 282-297) In C.H. Zeanah (Ed.), Communication problems (pg 282-297) In C.H. Zeanah (Ed.), Handbook of Infant Mental Health, 2Handbook of Infant Mental Health, 2ndnd ed ed. New York: Guilford.. New York: Guilford.
