What is IMH? - University of Arizona Department of Pediatrics

Report
Introduction to
Early Childhood
Mental Health
Kathryn Seidler, LMSW
Easter Seals Blake Foundation
Tucson, AZ
7/17/2015
1
A baby alone does not exist. A baby
can be understood only as part of a
relationship.
D.W. Winnicott
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2
Definition of Infant Mental Health.
• Developing the capacity of the
child from birth to age three to
experience, regulate, and
express emotions; form close
and secure interpersonal
relationships; and explore the
environment and learn - all in the
context of family, community and
cultural expectations….Zero to
Three IMH Task Force
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3
CORE CONCEPTS
OF EARLY CHILDHOOD
MENTAL HEALTH
1. Mental health
needs of the 0-6
age population
challenge and defy
our conventional,
individual-based
thinking about
providing therapy
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2. Early Childhood Mental Health
is
FIRST and FOREMOST
about RELATIONSHIPS
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3. We cannot conceive
or consider infants and
toddlers outside of the
relationships they have
with their primary
caregivers.
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6
4. Object Relations Theory
(Mahler)
• Proposes that an internalization of
the caregiver occurs within the
child’s psyche as a mental
representation about self and
caregiver, based on the
relationship and interactions that
occur.
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5. Development
• Early childhood mental health
is understood as a model that
is developmental
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Periods of Development
Prenatal:
conception
to birth
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Infancy &
Toddlerhood:
birth to 2 yrs
Early
Childhood:
2-6 yrs
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5. Development (cont)
•
•
•
•
•
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Is sequential
occurs in different areas
Is individual
Is inter-related
Moves from simple to complex
11
5. Development (cont)
• “Sensitive Periods” between birth
and age 5; children rapidly develop
foundational capabilities upon which
subsequent development develops
• Influenced by biological,
environmental and interpersonal
sources of resiliency and
vulnerability: Nature vs Nurture
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5. Development (cont)
• Research tells us there is a
connection between a child’s early
experiences, life-long health and well
being established through the
development of brain structure in the
early years
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Growing a Healthy Brain
• Nurturing
experiences.
• Good nutrition.
• Intervening early.
• Protection.
• Taking care of the caregiver.
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Pre-natal Development
The nervous system
begins to develop just
before the third week of
gestation.
Talking Reasonably and Responsibly about
Early Brain Development, University of
Minnesota
7/17/2015
(Eliot, 1999)
Cell creation and
movement to the right
spots occur during the
first five prenatal
months.
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Nurture Affects Brain Development
• Nurturing touch promotes
growth and alertness in
babies.
• Presence of a secure
attachment protects toddlers
from biochemical effects of
stress.
• Abused children pay more
attention to angry faces – a
reflection of the brain’s
response.
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5. Development (cont.)
• Failure to provide appropriate
stimulation, consistent responsive
care and opportunities to explore
their environment may cause a
failure in the development of neural
connections and pathways that
facilitate essential learning and selfregulating skills
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5. Development (cont.)
• Exposure to trauma, neglect or
severe stress is damaging to the
developing brain and may result in
learning disabilities, emotional, and
behavioral problems
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5. Development (cont.)
Three Tasks of Early Childhood
1. Emotional Development - negotiating
transition from external to internal selfregulation
• from birth infants must learn to regulate
physiological and emotional functions
• emotion, behavior, and attention are
highly linked, therefore success in one
area can lead to success in another and
difficulty in one can lead to difficulty in
another
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5. Development (cont.)
1. Emotional Development (cont.)
– A child’s ability to regulate is deeply
embedded in his relationships with
others
– In dysfunctional homes, emotional
demands on the infant can be
confusing, conflicting and
overwhelming
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5. Development (cont.)
2. Cognitive Development - acquiring
capabilities that are the foundation for
communication and learning
• babies are wired to learn
• society and parents need to be ready
for the competencies with which the
child arrives
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5. Development (cont.)
2. Cognitive Development
• thinking, social interactions,
relationships and emotions converge
in a powerful way during the second
year of life
• Quality and quantity of verbal and
social stimulation that a child
receives will determine the language
learning process
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5. Development (cont.)
3. Social Development - learning to relate
well to other children and forming
relationships
– secure attachments to caring adults during
infancy and toddler years lay the foundation
for social relationships
– a child’s evolving cognitive, language, and
emotional regulations skills play a role
throughout social skill and relationship
building
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5. Development (cont.)
• Social Development (cont.)
• having positive relationship skills has been
found to be a predictor of popularity with
peers during the preschool years (Sroufe 1983,
1990)
• infants who exhibit ambivalent attachments
may develop into unhappy, easily frustrated
toddlers and preschoolers (Erikson, Sroufe
& Egeland, 1985; Renken et al., 1989)
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5. Development (cont.)
Social Development (cont.)
• Children who are socially competent at
the toddler or preschool age have
parents who actively help them learn to
play
• those who appear socially inept often
have parents who view social
competence as a function of the school
system and devalue the importance of
social skills
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6. Parallel Process
• Most parents referred or who seek out
infant mental health services have
some degree of developmental
trauma of their own
• A relationship between the
worker/therapist and the parent
develops first
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6. Parallel Process (cont.)
• the actions and behavior of the worker
toward the parent are geared to
acknowledge the unmet developmental
needs of the parent
• This behavior attempts to created a
“holding environment” where the parent
may experience a repair and healing of
their own unmet developmental needs.
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6. Parallel Process (cont.)
• The goal is for the parent to learn how
to create this “holding environment”
for their own child
• Another goal is for the developmental
trauma of the parent to not repeat
itself in the parent/child relationship
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A relationship between a
parent and IMH specialist can
be “therapeutic” or healing
even though the reason for
the relationship is the needs
of the child, family support,
early intervention or
educational needs.
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How do we foster relationships
through relationships?
• Corrective Emotional Experiences!!!
• Fostering the idea of the parent’s
“self” in relationship with another
• (I am valued, respected, liked!!)
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How do we foster relationships
through relationships?
• Behavior Change - “Now that I know
what’s good for my baby or child - I’ll
do more because I want to pleased or
be liked by my home visitor”
• Increased Reflective Function - Ability
to think about another’s experience
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Emotional Availability
• Present and attending to other
• Processing other’s behavior
• Responding to other’s behavior
– Reflection
– Timing
– Intensity
– Affect
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7. “Ghosts in the Nursery”
• Selma Fraiberg
• the parents’ own internalized
mental representations of their
childhood, caregivers, and
affective history
• good ghosts / bad ghosts
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8. Assessment
• Parent/Caregiver Interview
• Observation/assessment of parent child
relationship and interaction
• Standardized Testing
• Address parent’s experience with their
own caregivers: “Ghosts in the Nursery”
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8. Assessment (cont.)
• Nurture parent so parent can nurture
their child
• Link past experiences with current
care of infant
• Interventions and continued
assessment of progress
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Infant Mental Health Practice
• Promotion
• Prevention
• Treatment
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PROMOTION
Supporting social-emotional health
• Home Based Programs
– Parent-Child Activities
– Enhancing parent-child social-emotional
functioning through relationships
• Center Based Programs
– Continuity of care
– Primary caregiving
– Social-emotional assessments
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PREVENTION
Altering specific family risk conditions, or
child-parent risk behaviors
– Parent-child interaction guidance
– Parent support groups re: discipline
– Home visits for depressed parents
– Social support to single parents
– Linking poor families with services
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TREATMENT
Providing intervention for specific disorder or
problem
– Parent-infant psychotherapy
– Child play therapy
– Couples therapy (esp. w/ spousal
violence)
– Family therapy
– Individual therapy
– Substance abuse treatment for parent
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IMH Service Delivery Venues
•
•
•
•
•
•
•
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Home visitation
Family support
Family preservation
Early intervention
Child care
Foster care
Parenting education
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The Home as a Therapeutic Setting
• S. Fraiberg’s “Kitchen Therapy”
• Family Turf
– Intimacy of home
– Potential of trust
• Assessment in larger context
• Flexibility
• Incorporation of family resources
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IMH Services in Home-Based
Programs
Rationale: Targeting overburdened families
• Importance of engaging multi-risk
families during perinatal period
• Linkage between child maltreatment
and adverse psychological outcomes
• Evidence re: need for more intensive
intervention to address mental health
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IMH Services in Home-Based Programs:
Strategies
• Providing social support as an “antidote”
to psychological difficulties
• Addressing parental mental health needs
through referral process
• Engaging in patient-child interactional
activities to promote attachment
• Exploring parental “ghosts” as a means of
addressing child maltreatment
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IMH Practice in Home-Based Settings:
Parent-Infant Interactional Approach
• Incorporate parent-child interaction in
each home visit
• Reflect on moment-to-moment parentchild interactions
• Identify teachable moments in context of
parent-child interaction
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IMH Practice in Home-Based Settings:
Intervention Process Strategies
• Increased directives of therapist versus
insight work done in talk therapy
• Interactive guidance (coaching)
• Use of videotape
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Intervention Process Strategies (cont.)
• Moving beyond play
• Developmental guidance in the moment
• Unconditional Positive Regard (C.
Rogers)
• Consistent nurturance/validation
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IMH Practice in Home-Based Settings:
Staff Issues
• Intensive supervision of staff (1Hr/wk)
• Regular staff training
• Reflective group meetings and case
presentations of managers and supervisors
• Use of videos in house visits and supervision
• Supervisory nurturance of staff
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Parent-Infant Mental Health:
Promoting Positive Parenting
• Empathize with
parental vulnerability
around parenting
• Connect with parent’s
desire to be a good
parent
• Affirm parent’s
special role and
relationship with their
child
• Help parent’s find JOY
in caring for their
child
• Identify and reinforce
positive parental
behaviors
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Parent -Infant Mental Health:
Supporting the “Dance” (D. Stern)
• Support parental
emotional
availability
• Encourage
affective
expression,
understanding and
sharing
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• Promote parental
attunement
• Build on joyful
activities
• Enhance joint
attention and
involvement
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ATTACHMENT: the orientation of an
infant to the person(s) who meets their
biological, emotional, and social needs
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BONDING: the ability of a parent
or caretaker to make an
emotional commitment to meet
the infant’s needs
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Mary Ainsworth
• “Strange Situation” technique has become the
major measure by which infant attachment is
determined at 12 and 18 months
• Mother and infant enter a toy play room, and
during three-minute time periods the baby is
first with mother, then with a stranger, then
reunited with mother, then alone, then with a
stranger, and finally again reunited with
mother
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From careful analysis of the
reunion behaviors of the infant
when the mother enters the
room four kinds of attachment
patterns have been noted
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Ainsworth’s Attachment
Classifications
1 . Secure: B
2 Insecure
• Avoidant = A
• Ambivalent = C
• Disorganized = D
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4 Attachment
Classifications for children
0-36 months:
1. Secure (B)
- Infant uses parent as a secure
base to explore environment and
re-engages the parent upon
reunion (separation/reunion task)
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2. Avoidant (A)
- Infant does NOT use the parent
as a secure base; displays little
affect
–explores the environment, but
does not seek parent upon
reunion
-Under stress, infant does not
seek out parent for contactcomfort to reduce stress.
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3. Ambivalent or Resistant (C)
- Infant is in a state of distress
and fails to explore the
environment
• Infant will alternate between
seeking contact with the parent and
rejecting the parent
• Infant is under high states of stress
on a continuous basis
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4. Disorganized (D) - Infant behavior
lacks an observable goal, intention,
or explanation in the presence of the
parent.
• Infant exhibits interrupted movement,
stereotypies (repetitive behaviors),
freezing/smiling, falling, and odd postures
upon reunion with the parent.
• no coherent strategy to re-engage the parent.
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•Parent is considered, at times, to be
frightening toward the infant, and parent
frequently has a history of abuse of unresolved
loss.
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Ainsworth (cont.)
• Mothers of the D babies are reported
to often have a history of early
trauma and loss in her own life
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4 Attachment Stages:
birth to 36 months
1. PRE-ATTACHMENT
•early orientation toward voice, smell, and
self-regulation from major caregiver
•predictability and consistency to
strengthen attachment relationship
•Initial development of the
Arousal/Relaxation Cycle
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2. Recognition and
Discrimination: 3-8 months
• Comparison and discrimination
skills develop
• stranger anxiety and “Preference
for Parent” (PFP)
• Exploration of environment:
distance between infant and parent
begins
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3. Active Engagement:
8-30 Months
•
•
•
•
Separation anxiety: 7-9 months
object permanence develops
secure base behaviors 13+ months
toddler learns social rules (home,
childcare, public)
• play skills develop
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4. Partnerships: 30 months +
• Emotional Object Constancy
develops around 36 months
• Attachment to adults solidify
• communication, bartering, and
compromise between parent and
child
• attachment gives emotional
foundation to explore the world in
greater depth
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Attachment Milestones and
Behaviors
• Eye contact/social smile
• cuddle/molding
• reciprocity between infant/parent
• stranger anxiety 5-8 months
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Attachment Milestones and
Behaviors
• separation anxiety 7-9 months
• secure base/safe haven 9+ months
• Preference for parent 7+ : Internal
Working Model
• Partnership 30+
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Attachment Milestones and
Behaviors (cont.)
• Following/searching
• reaching
• signaling/calling to
• holding/clinging/sitting with
• seeking to be picked up
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Salient Behaviors in the
Assessment of Attachment Dx
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BEHAVIOR
• Showing Affection
SIGN OF ATTX DX
• Comfort Seeking
• lack of comfort seeking
when hurt, frightened, or
ill, or seeking in
ambivalent manner
• lack of warm and
affectionate interchanges
across a range of
interactions
• lack of discrimination
showing affection to
unfamiliar adults
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Salient Behaviors in the
Assessment of Attachment Dx
BEHAVIOR
• reliance for help
• Cooperation
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SIGN OF ATTX DX
• excessive dependence, or
inability to seek and use
supportive presence of
attachment figure when
needed
• lack of compliance with
caregiver requests and
demands by the child as a
striking feature of
caregiver child
interactions, or
compulsive compliance
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Salient Behaviors in the
Assessment of Attachment Dx
BEHAVIOR
• Exploratory
Behavior
• Controlling
Behavior
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SIGN OF ATTX DX
• failure to check back with
caregiver in unfamiliar
settings; exploration
limited by child’s
unwillingness to leave
caregiver
• oversolicitious and
inappropriate caregiving
bx, or excessively bossy
and punitive controlling of
caregiver by the child
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Salient Behaviors in the
Assessment of Attachment Dx
BEHAVIOR
• Reunion
Responses
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SIGN OF ATTX DX
• failure to re-establish
interaction after
separations, including
ignoring/avoiding
behaviors, intense
anger, or lack of
affection
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Variables that can impact
the attachment process in a
negative way:
1. Postpartum emotional health of the
mother
2. Prior mental health history, esp. in the
areas of mood disorders
3. Lack of social support in the home
4. Unlimited emotional parenting skills by
the parent
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Variables that can impact
the attachment process in a
negative way:
5. Infant developmental status
(delays) and/or prematurity or
medical problems
6. Changes in the parents’
relationship
7. Other losses experienced by the
mother
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Theorists whose ideas
help us understand
IMH:
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Eric Erikson
• Trust vs. Mistrust
(0-12 mos.)
• Autonomy vs. Shame and Doubt
(13-36 mos.)
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Margaret Mahler
• Details stages in infant emotional growth
and development
• Infants move from a close physical
relationship with the mother to a
“hatching” period , tuning in to the
outside world
• “Practicing” subphase, during which they
count on the primary loved caregiver as a
secure base as they explore their world
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Mahler (cont.)
• From age 1.5 to 3 years babies’ cognitive
abilities permit them to think about and
struggle to make sense of separation
problems
• Baby yearns for a return to the closeness
originally enjoyed, yet powerful urges
compel baby in this “rapprochement”
period to be a special, separate individual
with wishes and desires all their own
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Mahler (cont.)
• A wise caregiver tunes into the need
of baby to support their growing
autonomy while still providing the
nurturing responsivity and bodyloving care that permit the toddler to
develop beyond “rapprochement”
into what is called “CONSTANCY”
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Mahler (cont.)
• The beginning of constancy
occurs when the toddler can hold
opposing emotional feelings (at
the same time loving and feeling
angry with the caregiver) in
balance
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Mahler (cont.)
• Constancy helps child to support lengthy
daily separations from parents who are
both resented and loved
• Constancy helps toddlers come to terms
with strong differences between their own
and adult wishes and preferences
• Babies learn to integrate and accept
dualities of feelings and still retain a clear
sense of a loving relationship
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John Bowlby
• Father of “attachment theory”: proposes
that infants build nonverbal, internal
working models of early relationships with
each caregiver
• These models are unconscious, yet they
serve as templates for expecting other
close relationships later in life to be
similar (depressed or happy, kind or cruel,
orderly or chaotic)
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Bowlby (cont.)
• When the baby’s attachment
figure is present emotionally for
her, she can explore freely and the
quality of her play will be more
focused and creative
• When the attx. figure disappears
or is rejecting, the quality of play
suffers
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Alicia F. Lieberman
• Wrote “The Emotional Life of the
Toddler”
• Quotes Freud: “Mental health
consists of loving well and working
well” to remind us that children’s
work is their play.
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• Babies are by naturally social
creatures
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Lieberman (cont.)
• Individual differences are an integral
component of babies’ functioning
• Every individual exists in a particular
environmental context that deeply
affects the person’s functioning
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Lieberman (cont.)
• Infant mental health practitioners
make an effort to understand how
behaviors feel from the inside, not
how they look from the outside
• The intervenor’s own feelings and
behaviors have a major impact on
the intervention
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Temperament: 2 Models
• Thomas and Chess (1977)
• Rothbart (1981)
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“Goodness of Fit”
What happens when the
baby’s temperament is not a
good fit with their caregiver’s?
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Resources and Websites
•
•
•
•
zerotothree.org
arizonabond.org
ITMHCA.org
Handbook of Infant Mental Health, 2nd
Ed. (Zeanah, 2005)
• Infant and Early Childhood Mental
Health: a Comprehensive,
Developmental Approach to
Assessment and Intervention
(Greenspan and Wieder, 2005)
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