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Introduction toIntroduction toInfant and Early ChildhoodInfant and Early Childhood

Mental HealthMental Health

Division of Child and Family ServicesDivision of Child and Family ServicesEarly Childhood Mental Health ServicesEarly Childhood Mental Health Services

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Training GoalsTraining GoalsAt the end of this training, you will be able to:At the end of this training, you will be able to:

1.1. Define infant mental healthDefine infant mental health2.2. Recognize mental health issues of young Recognize mental health issues of young

childrenchildren3.3. Know how infant mental health issues are Know how infant mental health issues are

assessed and treatedassessed and treated4.4. Understand how to access services in your Understand how to access services in your

community to address mental health and community to address mental health and developmental needs of young childrendevelopmental needs of young children

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Goal #1:Goal #1:

Define infant mental healthDefine infant mental health

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Definition of Infant Mental HealthDefinition of Infant Mental Health

Infancy is technically the period “without Infancy is technically the period “without language”, which is the first year of lifelanguage”, which is the first year of life

Infant mental health covers a broader age Infant mental health covers a broader age range, and there is no universal definitionrange, and there is no universal definition

In Nevada, Early Childhood Mental Health In Nevada, Early Childhood Mental Health Services serves children birth – seven Services serves children birth – seven years and their familiesyears and their families

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Definition of Infant/ Definition of Infant/ Early Childhood Mental HealthEarly Childhood Mental Health

The developing capacity to:The developing capacity to:

experience, regulate and experience, regulate and express emotions, express emotions,

form close and secure form close and secure interpersonal interpersonal relationships andrelationships and

explore the environment explore the environment and learn.and learn.

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#1: Experience, Regulate andExpress Emotions

Initially infants depend on Initially infants depend on adults to regulate their adults to regulate their interaction, attention, and interaction, attention, and behaviorbehaviorGradually the young child Gradually the young child begins to regulate their begins to regulate their emotions through self-emotions through self-monitoring, which increases monitoring, which increases over timeover time

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The Developing Capacity to The Developing Capacity to Regulate and Self-regulateRegulate and Self-regulate

Sameroff & Fiese, 2000Sameroff & Fiese, 2000

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Basics of State Regulation Basics of State Regulation in Infancyin Infancy

Infant Behavioral Infant Behavioral StatesStatesCryCryFussFussAlertAlertWaking ActivityWaking ActivityDrowsyDrowsyActive SleepActive SleepQuiet SleepQuiet Sleep

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Developing CapacityDeveloping Capacityto Give Clear Cuesto Give Clear Cues

Over the first two Over the first two years of life, the child years of life, the child learns to give cues, learns to give cues, both potent and both potent and subtle, about his/her subtle, about his/her interest in any given interest in any given moment in relating to moment in relating to othersothers

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Engagement CuesEngagement Cues

Potent CuesPotent Cues--Babbling, giggling--Babbling, giggling

--Face gazing+--Face gazing+

--Smiling+--Smiling+

--Reaching toward --Reaching toward caregivercaregiver

--Smooth movements--Smooth movements

NCAST, Kathy BarnardNCAST, Kathy Barnard

Subtle CuesSubtle Cues--Brow raising--Brow raising--Eyes wide & bright--Eyes wide & bright--Facial brightening--Facial brightening--Hands open, fingers --Hands open, fingers

slightly flexedslightly flexed--Head raising--Head raising--Stilling of body--Stilling of body

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Disengagement CuesDisengagement Cues

Potent CuesPotent Cues--Back arching--Back arching--Choking, coughing, --Choking, coughing,

spitting upspitting up--Crying, fussing, “No!”--Crying, fussing, “No!”--Halt hand--Halt hand--Head shake--Head shake--Major gaze aversion--Major gaze aversion--Moving away--Moving away

Subtle CuesSubtle Cues--Defensive posture--Defensive posture--Dull expression--Dull expression--Grimaces, eye blinks--Grimaces, eye blinks--Frown--Frown--Hand behind head, to eye, ear, --Hand behind head, to eye, ear,

back of neckback of neck--Sobering--Sobering--Yawns--Yawns--Head lowering, minor gaze --Head lowering, minor gaze

aversion aversion

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#2: Form Close and SecureInterpersonal Relationships

Infants learn what people expect of them Infants learn what people expect of them and what they can expect of other peopleand what they can expect of other people

Nurturing, protective, stable, and Nurturing, protective, stable, and consistent relationships are essentialconsistent relationships are essential

The state of the adults’ emotional well The state of the adults’ emotional well being and life circumstances profoundly being and life circumstances profoundly impact the quality of infant/caregiver impact the quality of infant/caregiver relationshipsrelationships

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AttachmentAttachment

Secure attachment is a loving emotional Secure attachment is a loving emotional connection with caregiving adults who are connection with caregiving adults who are part of the child’s daily life.part of the child’s daily life.

Attachment begins at birth and continues Attachment begins at birth and continues throughout life.throughout life.

It is difficult to be separated from an It is difficult to be separated from an important attachment figure.important attachment figure.

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Through this attachment, Through this attachment, the child:the child:

Learns to depend on people to meet Learns to depend on people to meet his/her needshis/her needs

Seeks comfort when distressedSeeks comfort when distressed

Learns to express love/affectionLearns to express love/affection

Relies on the caregiver as a safe base Relies on the caregiver as a safe base from which to explore the environmentfrom which to explore the environment

Develops in the areas of emotionality, Develops in the areas of emotionality, social behavior, language and cognitionsocial behavior, language and cognition

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Time Course of Normal Attachment

0 6 12 18 24 30 36 42 48 54

Age in Months

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Goodness of FitGoodness of Fit

Each of us is born with temperamental Each of us is born with temperamental characteristics that tends to persist lifelongcharacteristics that tends to persist lifelong

Caregivers and children who are Caregivers and children who are temperamentally similar will have an easier temperamentally similar will have an easier time developing a good relationship than those time developing a good relationship than those who are temperamentally dissimilarwho are temperamentally dissimilar

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#3: Explore the Environment and Learn

Young children learn Young children learn primarily through interactions primarily through interactions with caregiverswith caregivers

It is important for children to It is important for children to have time playing with their have time playing with their caregivers to maintain a caregivers to maintain a good relationship and to help good relationship and to help them with language and them with language and cognitive developmentcognitive development

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Development in Young ChildrenDevelopment in Young ChildrenIs Vulnerable to StressIs Vulnerable to Stress

Hierarchy of vulnerability:Hierarchy of vulnerability:

emotional developmentemotional development

social developmentsocial development

language developmentlanguage development

cognitive developmentcognitive development

motor developmentmotor development

physical growthphysical growth

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Infant Mental HealthInfant Mental HealthInfant mental health is

synonymous with healthysocial and emotionaldevelopment.

It occurs in the contextof family, communityand cultural expectationsfor the child.

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Goal #2:

Recognize mental health issues of young children

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Facts about Mental Health Facts about Mental Health of Young Childrenof Young Children

Young children are about as likely to have Young children are about as likely to have mental health issues as are older children mental health issues as are older children and adultsand adults

In very young children, mental health In very young children, mental health issues are most often expressed as issues are most often expressed as difficulties with eating, sleeping, and difficulties with eating, sleeping, and regulation of behavioral statesregulation of behavioral states

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As children become older, they As children become older, they increasingly express mental health issues increasingly express mental health issues as more recognizable difficulties with as more recognizable difficulties with moods and behaviorsmoods and behaviors

If mental health issues are left untreated, If mental health issues are left untreated, children often begin to show more general children often begin to show more general delays in the areas of social/emotional delays in the areas of social/emotional functioning, language, cognition and even functioning, language, cognition and even motor and physical developmentmotor and physical development

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How Do I Recognize How Do I Recognize the Need for Mental Health the Need for Mental Health

Treatment?Treatment?

Issue is pervasive, meaning it occurs Issue is pervasive, meaning it occurs across settingsacross settings

Issue is persistent, meaning it occurs more Issue is persistent, meaning it occurs more days than not for 2-4 weeksdays than not for 2-4 weeks

Issue has a negative impact on a child’s Issue has a negative impact on a child’s daily functioningdaily functioning

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Overview of CommonOverview of CommonMental Health IssuesMental Health Issues

Sleeping Disorders Sleeping Disorders Eating DisordersEating DisordersAttention Deficit Hyperactivity Disorder (ADHD)Attention Deficit Hyperactivity Disorder (ADHD)Post Traumatic Stress Disorder (PTSD)Post Traumatic Stress Disorder (PTSD)Deprivation/Maltreatment Disorder (DMD), Deprivation/Maltreatment Disorder (DMD), Reactive Attachment Disorder (RAD) and Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder Disinhibited Social Engagement Disorder (DSED).(DSED).DepressionDepression

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Sleeping DisordersSleeping Disorders

– Sleep onsetSleep onset

– Night wakingNight waking

– Night TerrorsNight Terrors

– NightmaresNightmares

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Typical Sleep Needs Typical Sleep Needs of Young Childrenof Young Children

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Eating DisordersEating Disorders

Eating– to be diagnosed, Eating– to be diagnosed, must result in weight loss must result in weight loss or inadequate weight gainor inadequate weight gain– Difficulties of state regulationDifficulties of state regulation– Difficulties with caregiver Difficulties with caregiver

relationshiprelationship– Sensory issues with food Sensory issues with food

texturestextures– Problems associated with Problems associated with

medical issuesmedical issues

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Symptoms of ADHDSymptoms of ADHD

Craving high-intensity sensory stimulationCraving high-intensity sensory stimulation

High need for motor discharge: impulsiveHigh need for motor discharge: impulsive

High activity levelHigh activity level

Seeking constant contact with people & Seeking constant contact with people & objectsobjects

RecklessnessRecklessness

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True ADHD is believed to be present from True ADHD is believed to be present from birth, and to occur even in the absence of birth, and to occur even in the absence of major environmental stressors. However, major environmental stressors. However, some of the symptoms of ADHD (high some of the symptoms of ADHD (high level of motor activity, lack of focused level of motor activity, lack of focused attention) can occur as part of an anxiety attention) can occur as part of an anxiety response to environmental stressors. response to environmental stressors. Therefore it is important to see the child in Therefore it is important to see the child in a stable environment over a period of a stable environment over a period of several months before making this several months before making this diagnosis.diagnosis.

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PTSD: Definition of Trauma

An event involving actual or An event involving actual or threatened death or serious injury or threatened death or serious injury or threat to the physical or threat to the physical or psychological integrity of the child or psychological integrity of the child or another person. another person. It may be a sudden & unexpected It may be a sudden & unexpected event (e.g. car wreck), a series of event (e.g. car wreck), a series of connected events (e.g. repeated connected events (e.g. repeated domestic violence) or an enduring domestic violence) or an enduring situation (e.g. chronic sexual abuse).situation (e.g. chronic sexual abuse).

from DC: 0-3Rfrom DC: 0-3R

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Symptoms of PTSDSymptoms of PTSD

reliving the trauma, in children often reliving the trauma, in children often through post-traumatic playthrough post-traumatic play avoiding reminders of the traumaavoiding reminders of the trauma intense emotional responses to reminders intense emotional responses to reminders

of the traumaof the trauma maintaining hypervigilance, startling easilymaintaining hypervigilance, startling easily numbing of affectnumbing of affect difficulties falling and staying asleep, difficulties falling and staying asleep, nightmaresnightmares

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Many stressful events in Many stressful events in children’s lives do not children’s lives do not rise to the level of rise to the level of trauma, but may lead to a trauma, but may lead to a variety of other mental variety of other mental health issues, with health issues, with symptoms that may symptoms that may appear similar in some appear similar in some respects to those of respects to those of PTSD.PTSD.

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DMD/RAD/DSED: EnvironmentDMD/RAD/DSED: Environment

Normal attachment during early Normal attachment during early childhood can be disrupted childhood can be disrupted by specific conditions:by specific conditions:

1.1. Several changes of primary Several changes of primary caregiver, such that the child caregiver, such that the child can not develop a focused can not develop a focused attachmentattachment

2.2. Extreme caregiving by a Extreme caregiving by a consistent caregiver which consistent caregiver which does not result in the child does not result in the child learning to trust peoplelearning to trust people

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DMD/RAD/DSED: Relatedness DMD/RAD/DSED: Relatedness Patterns Patterns

Sustained suspicion Sustained suspicion (DMD/RAD)(DMD/RAD)

IndiscriminantIndiscriminant approaches/closenessapproaches/closeness (DMD/DSED)(DMD/DSED)

Mixture of previous two Mixture of previous two patterns (DMD)patterns (DMD)

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Attachment Issues Can BeAttachment Issues Can BeAssociated with Poor OutcomesAssociated with Poor Outcomes

Increased risk of juvenile (and adult) Increased risk of juvenile (and adult) justice involvementjustice involvementDifficulties coping with stressDifficulties coping with stressIncreased risk of dangerous behaviorsIncreased risk of dangerous behaviorsProblematic peer relationshipsProblematic peer relationshipsReduced likelihood of maintaining a Reduced likelihood of maintaining a stable, loving relationship with an adult stable, loving relationship with an adult partnerpartnerPoor parenting skillsPoor parenting skills

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Symptoms of DepressionSymptoms of Depression

Change in mood– can be either Change in mood– can be either depressed or irritabledepressed or irritable Loss of interest in many activitiesLoss of interest in many activities Persistent, at least some of the time Persistent, at least some of the time uncoupled from sad/upsetting experiencesuncoupled from sad/upsetting experiences Pervasive across activities, settings or Pervasive across activities, settings or relationshipsrelationships Symptoms cause child distress, impair Symptoms cause child distress, impair functioning or impede developmentfunctioning or impede development

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Goal #3:Goal #3: Know how infant mental health Know how infant mental health issues are assessed and treatedissues are assessed and treated

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Specific Issues to ReferSpecific Issues to Referto Infant Mental Healthto Infant Mental Health

Difficulties with soothing and Difficulties with soothing and comfortingcomfortingPersistent issues in the Persistent issues in the regulation of eating or sleepregulation of eating or sleepPoor mood regulationPoor mood regulationDifficulties with relatedness, Difficulties with relatedness, including attachment issuesincluding attachment issuesTrauma, especially loss of a Trauma, especially loss of a primary caregiverprimary caregiverBehaviors that pose a Behaviors that pose a danger to self or othersdanger to self or others

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Why Refer Young Children to Why Refer Young Children to Developmental and Mental Health Developmental and Mental Health

ServicesServicesVery young children can and do Very young children can and do suffer from trauma, abuse, neglect, suffer from trauma, abuse, neglect, loss, stress and lack of opportunityloss, stress and lack of opportunity When these issues are identified When these issues are identified and treated early, outcomes are and treated early, outcomes are better than when services are better than when services are delayed.delayed.Most young children who receive Most young children who receive mental health services do not have mental health services do not have the stigma of lifelong labels.the stigma of lifelong labels.

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How to Refer a Child for ServicesHow to Refer a Child for Services

In Nevada, Child and In Nevada, Child and Family Teams (CFT’s) Family Teams (CFT’s) make decisions about what make decisions about what services a child needs. If services a child needs. If you think a child in your you think a child in your care needs services, you care needs services, you must begin with your DFS must begin with your DFS caseworker, and ask for a caseworker, and ask for a CFT to discuss the need CFT to discuss the need for services.for services.

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Evaluation typically involvesEvaluation typically involvesseveral sessionsseveral sessions

Parent interviews for family history Parent interviews for family history

Direct observation & reports of family Direct observation & reports of family interaction/functioninginteraction/functioning

Direct observation & reports of child’s Direct observation & reports of child’s characteristics & development, including areas characteristics & development, including areas of concernof concern

General assessment of child: ability to regulate General assessment of child: ability to regulate mood and self-soothe, relatedness, sensory mood and self-soothe, relatedness, sensory function, motor tone and motor planningfunction, motor tone and motor planning

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Diagnosis of Young ChildrenDiagnosis of Young Children

DSM-V was not DSM-V was not developed with developed with particular attention to particular attention to young childrenyoung children

DC: 0-3R has been DC: 0-3R has been developed by Zero to developed by Zero to Three as a Three as a developmentally developmentally sensitive alternative sensitive alternative for young childrenfor young children

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Infant Mental HealthInfant Mental HealthSpecialists Provide:Specialists Provide:

Family therapy involvingFamily therapy involving

child and parent/caregiver child and parent/caregiver

Developmental guidanceDevelopmental guidance

Advocacy for child & familyAdvocacy for child & family

Early relationship assessment & supportEarly relationship assessment & support

Emotional support for caregiversEmotional support for caregivers

Connection to other resourcesConnection to other resources

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Therapeutic InterventionsTherapeutic Interventions

Help caregivers establish/maintain Help caregivers establish/maintain good schedules & routinesgood schedules & routinesImprove attachment between Improve attachment between

child and caregiverchild and caregiverPromote caregiver’s realistic Promote caregiver’s realistic developmental expectations for developmental expectations for

childchildAddress family systems issuesAddress family systems issuesAddress caregiver mental health, Address caregiver mental health, substance abuse & domestic substance abuse & domestic violence issuesviolence issues

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The Importance of a Family ApproachThe Importance of a Family Approachto Treatmentto Treatment

Children learn in relationshipsChildren learn in relationships Relationships with caregivers are the Relationships with caregivers are the most important relationships children have most important relationships children have until their teenage yearsuntil their teenage years Changes in the structure of the Changes in the structure of the environment and the behavior of important environment and the behavior of important caregivers toward the child contribute caregivers toward the child contribute most to changes in the child’s behavior most to changes in the child’s behavior and/or moodand/or mood

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Additional Therapeutic ServicesAdditional Therapeutic Services

Basic Skills Training (BST)Basic Skills Training (BST)

Psychosocial Rehabilitation (PSR)Psychosocial Rehabilitation (PSR)

Day Treatment and After School ServicesDay Treatment and After School Services

Psychiatric MedicationsPsychiatric Medications

Partial HospitalizationPartial Hospitalization

Psychiatric HospitalizationPsychiatric Hospitalization

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Goal #4:Goal #4:

Understand How to Access Understand How to Access Services in the Community Services in the Community

to Address Mental Health andto Address Mental Health andDevelopmental NeedsDevelopmental Needs

of Young Childrenof Young Children

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Resources for Young ChildrenResources for Young Childrenin Clark Countyin Clark County

Mental Health ServicesMental Health Services-- Early Childhood Mental Health, DCFS-- Early Childhood Mental Health, DCFS

if fee-for-service Medicaid or uninsuredif fee-for-service Medicaid or uninsured

486-7764486-7764

-- Medicaid HMO’s and private insurance -- Medicaid HMO’s and private insurance providersproviders

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Services for children with Services for children with developmental delays:developmental delays:

--Nevada Early Intervention Services--Nevada Early Intervention Services children birth to 36 months 486-7670children birth to 36 months 486-7670

--CCSD Child Find children 33 months +--CCSD Child Find children 33 months + 799-7463799-7463