anne heintzelman, ms, ccc-slpp1cdn4static.sharpschool.com/userfiles/servers/server_20536521/f… ·...

Anne Heintzelman, MS, CCC-SLP University of Wisconsin-Madison

Waisman Center, UCEDD

WREIC, Albuquerque , New Mexico September 16, 2015

What is Baby experiencing? What is grandmother experiencing? What are you experiencing?

Gain knowledge of infant, early childhood and family mental health concepts.

Understand how focusing on early relationships can enhance work with families and lead to positive outcomes for communication development.

Gain experience using tools to assess social emotional development and early relationships.

Practice applying infant mental health concepts to identify outcomes and coaching strategies.

The developing capacity of the child from birth to age 5 to:

1) experience, regulate and express emotions,

2) to form close and secure interpersonal relationships and

3) explore the environment and learn - all in the context of family, community and culture

Adapted from Zero to Three: National Center of Infants, Toddlers and Families

(www.zerotothree.org) Wisconsin Alliance for Infant Mental Health, 2014

…relationships are the organizing focus of all early development.

Weston, et al, 1997

Relationships are the context in which learning happens.

The foundation on which skills emerge • Communication • Social Development • Movement • Learning

Focus on relationships leads to successful intervention.

All learning takes place in the context of relationships and is critically affected by the quality of those relationships

(Norman-Murch, 1996)

Affected by our feelings Influenced by hopes and expectations Co-Created….Two-way influence Goodness of Fit The quality of the early relationship is

referred to as Attachment.

Biologically pre- programmed to form attachments

Infant produces innate social behaviors

Stimulate caregiving from adults

Determinant is not food, but Social Responsiveness

Caregiver’s tie to his/her infant

Occurs in the first moments and early days after baby’s birth

One-directional Mother’s/father’s

expression of early love and caring for the baby

Bi-directional Different types of attachments • Secure and Anxious/Disorganized

Lead to different outcomes Early months are critical to

children’s learning and emotional development

Baby attends to sights and sounds. Baby Sends Signals. The parent joins the experience and an

emotional response occurs internally. Parent learns to interpret the Baby’s signals and

responds……Reciprocal Action. Babies develop the capacity to maintain a long

continuous flow of interaction and experience a range of emotions.

Secure attachment: Baby develops trust and sense of who they are in relation to the parent.

http://www.youtube.com/watch?feature=endscreen&NR=1&v=1J9x7B-RMZI

Sensitivity Acceptance Accessibility Cooperation

Defined the types of attachment using the Strange Situation

https://www.youtube.com/watch?v=9HG05AIlH6Y

How does attachment develop and how does it shape later development?

Different types of attachments • Secure • Anxious Resistant • Anxious Avoidant • Disorganized

Lead to different outcomes

Sensitive care

I can count on you

Secure and confident

Erratic Care You’re unreliable

I’m powerless Anxious/Dependent

Unresponsive Care

It’s not OK to show you that

I need you

Aggressive, lacks

empathy

Threat from a caregiver

Will you protect me

or harm me? Dissociation

Moving forward with a relationship-based approach to early intervention

Family/Environmental • Risk and Protective Factors

Parent’s expectations

• Hopes, dreams, beliefs

Relationship

Communication and Social Emotional Skills

Protective Factors: Factors that enhance development of a healthy relationship between parent and child Access to medical care Access to child care Social supports Employment/basic needs Stable relationship/marriage

Risk Factors: Potential barriers or factors that inhibit development of a healthy relationship • Poverty • Biological factors: pre-term delivery,

developmental concerns • Maternal depression Birth experience • Teen-age parents • Family Stress

Taking a deeper look into the FELT Experience of Baby and Mom/Dad through observing and listening.

Parent interview

Baby interview

Beginning of a trusting relationship

Hopes and dreams • Who is this baby to you? Who does she look like? • How did you choose her name? • What’s it like to be her mom? • Who do you want Baby’s mom to be?

Beliefs • Who is your family? What do you value? What are the

most important values you want your child to take from your family?

Insight (awareness of and ability to read Baby’s cues) • What has Baby told you about herself?

What was it like to be born? How does Baby experience this parent?

• Movements, touch, tone of voice, gaze

What’s it like to be held by this parent?

What cues does Baby send?

How does the parent respond to Baby’s needs? • Fed, comforted, changed, entertained, quieted

What is the felt experience of the baby?

What is the mother’s felt experience?

https://www.youtube.com/watch?v=xxnVq5vj0MU

Temperament and Goodness of Fit

Parent-Child Interaction

Communication Skills

Social Emotional Skills

Coping and Resilience • Emotionality, reactivity, self-regulation, activity

level, sociability, approach-withdrawl, adaptability

• Major elements are present early in life and become stable later

• Temperament dimensions are inherited and biological

Infant Toddler Temperament Tool (IT3) http://ecmhc.org/temperament/

How well do the Parent’s and the Child’s temperaments work together?

Goodness of Fit can become a source of friction between caregiver and child.

What is the parent’s capacity to adjust to the child’s temperament? • Adapt the environment for the child • Provide support and encouragement to the child

Parent Child Early Relationship Assessment (PCERA)

Parenting Interactions with Children: Checklist of Observations Linked to Outcomes (PICCOLO)

Nursing Child Assessment Satellite Training (NCAST)

Indicator of Parent Child Interaction (IPCI)

Infant Toddler Temperament Tool (IT3) Brief Infant Toddler Social Emotional

Assessment (BITSEA) Vineland Social Emotional Scale ASQ SE Devereaux Early Childhood Assessment

(DECA-I/T) Greenspan Social Emotional Growth

Chart

Using Assessment Data and Observations to develop a plan

Development occurs in the context of a

secure relationship

Outcomes focused on the child and parent

Outcomes focused on the RELATIONSHIP • Key Players: Child, Parent, Ourselves

Enhance the RELATIONSHIP between parent and child • Develop parental insight and responsiveness

• Develop flexibility or ability to make environmental adjustments

Lead to improved communicative competence for child • Clearer cues/communication • Responsiveness to parent’s attempts to

engage • Increased frequency of back-and-forth

interactions (play and communication) • Improved ability to regulate his/herself and

others • Expanded play skills/exploration

Identify and address barriers that interfere with caregiver’s relationship with the child • When two states of mind come together: looking

back—looking forward (Martha Erikson, 2014)

Identify supports and how to access them

Increase Parent’s confidence and self-reflection

Relationship-Based Coaching

To acknowledge and improve existing knowledge and practices, develop new skills, and promote continuous self-assessment and learning on the part of the coachee. (Rush & Sheldon, 2011)

Developmental guidance • Matching Parent expectations with Baby’s

capacity

Assistance in observing Baby’s cues, strengths, risks

Guidance in putting words to the felt experience: fear, pleasure, sadness, joy

Play • developmental factors, social engagement and

reciprocity Affective interaction

• facial expression, tone of voice, physical contact, gaze

Communication input Environment

• supporting child’s exploration and parent’s comfort and ability to be present

Sensitivity • Recognizing Baby’s cues • Acknowledge parent observations

Insight….Wonder with the Parent • I wonder what you see? • I wonder what it means? • I wonder what is it like for you, for Baby?

“Minding the Baby”/mentalizing (Arietta Slade, 2008) http://mtb.yale.edu/

Observe Baby’s cues

Make meaning/Reflect

Respond to Baby’s signals

Voice Baby’s competencies

Re-framing

Facilitate realistic expectations

Strategies to enhance parent’s ability to reflect on the child’s experience • Voice • Be present • Mirror the baby

Wonder with the parent to draw on his/her past experiences. • I wonder … • Help me understand…

Empathy paying attention to boundaries

“Exploring the past, looking to the future” (Martha Erickson, 2002)

9 1/2-month old and his mother Feeding tube placed at birth due to Failure

to Thrive • Cyst in stomach identified prenatally

Referred at newborn hearing screening Bilateral ANSD identified at 2 months

Bilateral hearing aids fit at 4 months of age (inconsistent use)

Birth to 3 services at 4 months • weekly visits from an early educator/SLP • Feeding consultation (inconsistent)

What would you like to know?

Rossetti Infant Toddler Language Scale • Solid skills in the 3-6 month range with scatter 6-

9 months Speech production

• consonants (d, m, b, g, w), vowels (ah, uh, ae, oo) Emerging awareness of sounds

• Awareness of voices, but response varies • 4/6 Ling sounds • 30% response to name

Parent Child Early Relationship Assessment (Clark, 2010)

Video recording of parent and child • 15 minutes of play • A Challenge Task • Snack or feeding

Parent (29 variables) Child (28 variables) Dyad (8 variables)

Ratings

• Area of Strength (4-5) • Some Concern (3) • Area of Concern (1-2)

What is the felt experience of this mother?

What is the felt experience of this child? What are you feeling?

What is the port of entry?

Parent Strengths Some concern

Parent’s characteristic mood: not hostile, but borderline moments

Tone of voice

Structures and mediates environment

Expressed attitude toward the child

Amount of visual contact with the child

Flexibility/Rigidity

Quality and amount of physical contact

Creativity/Resourcefulness

Consistency/Predictability

Enjoyment/pleasure

Parent Areas of Concern

Mood and Expressed Affect Quality of Verbalizations Social Initiative

Child Strengths Some concern

Mood Affect Responsiveness

Alert and interested Visual Contact with Mom

Initiates Communicative Competence

Attention span Motor skills

Self regulation Quality of exploratory play

Readability

Consolability/soothability

Child Challenges

Strengths Some concern

Goodness of fit? Affective quality: flat, constricted, borderline hostility

Joint attention

Challenges

Enjoyment Reciprocity

17 Communicative Attempts • 8 vocalizations (request, comment, protest) • 4 Eye gaze • 3 Combination (eye gaze and vocalization, body

language) • 1 gesture • 1 body language (rocking)

9 vocalizations were ambiguous No responses to Mom’s requests for

behavior Did not follow Mom’s point

43 Verbalizations Mean Length of Utterance 3.77 2/17 non-verbal responses to child’s

initiations Content of her utterances

• Comments 9 • Questions 8 • Commands Behavior 16 • Corrects 6 • Positive Reinforcement 1 • Play 3

New information to share with the parent • Shapes parent’s perception of the child • Contributes to parent’s view of own competence

Enhances ability to focus on relationship—foundation for communication development

Identify a Port of Entry

Strengths • Information to share; to build on • New positive information to offer to the parents that

may influence image and connection Areas of some concern

• New techniques to offer: Watch-Wait-Wonder, mirroring

• Parent’s ability to mentalize baby, Speak for the baby, emotion coaching

• Focus on fun/play and reciprocity, closed loops of play and communication

What coaching goals and strategies can we use that will enhance the relationship between Mom and J • Reinforce and increase Mom’s playful language

and behavior • Increase Mom’s skills; ability to observe J’s

communication behavior, make meaning, and respond to it

Lead to improved communicative outcomes for J?

Continue giving space for autonomous exploration and to initiate with you.

Continue with your creativity. J has so much fun playing with you when you are silly. Make him giggle!

Continue using warm supportive physical contact with her in activities

Continue moving your face into his visual field

Encourage/model animated voice and facial expressions, bright eyes and warm smiles

Wonder with Mom: I wonder what he is trying to tell us? I wonder what would happen if you….

Sentence Length: 1-3 words Pair words and intonation with gestures Say words that you think he might be

thinking or doing, e.g., “yummy block”, “bumpy”, “goooo”

Video Replay • Help parent identify existing knowledge and

practices • Help parents develop new skills • Promote continuous self-assessment and learning

Speak for the Baby Watch-Wait Wonder

• What did you see? What do you think he might be trying to do? How did you feel when he did that?

Language input • Follow-in comments • Linguistic mapping

17-month-old child and her mother. Referred at newborn hearing screening. Moderate-severe, bilateral hearing loss

identified at 3 months of age. No other handicapping conditions. Bilateral hearing aids fit at 4 months of

age. Enrolled in Birth to 3 at 4 months of age

with weekly visits from an early educator/SLP.

MacArthur Bates Communication Development Inventory at 14 months of age was approximately age-level for expressive and receptive vocabulary

Parent Strengths Some concern

Tone of voice Expressed positive affect

Parent’s mood Expressed negative affect

Quality of verbalizations Enthusiasm/enjoyment/pleasure

Structures and mediates environment Amount of Visual Contact with Child

Creativity Contingent responsivity to Child

Mirroring

Parent Challenges

Amount of Positive Physical Contact Amount of Verbalizations

Child Strengths Some concern

Alertness/interest Responsiveness

Compliance Visual Contact with Mom

Good motor skills Communicative Competence

Attention span

Self regulation

Visual contact

Readability

Child Challenges

Strengths Some concern

Organized/well-regulated Reciprocity

Joint attention Enjoyment/enthusiasm

Goodness of fit

Challenges

23 Communicative Attempts • 13 verbal attempts • 7 vocalizations + gesture • 3 non-verbal (gestures) • Communicative acts: calling attention,

requesting action, requesting objects, commenting, labeling, reject

• Initiated 10 times • Responded to Mom’s initiations/questions 5X • Utterance length range 1-3 words, MLU 1. 4

22 Verbalizations Mean Length of Utterance 5.6 Very few verbal responses to child’s

vocalizations (6/23) Quality of her utterances

• Typically following the child’s lead • Comments and questions relate to what the child

is experiencing • Emphasizes key words

Strengths • What strengths would you want to share with Mom?

Areas of concern Techniques to offer? Parent? Dyad/Play?

What coaching goals and strategies can we use that will …. • enhance the relationship between Mom and S • increase Mom’s skills, ability to self reflect and

confidence • lead to improved communicative outcomes for S

Continue using animated voice and facial expressions, bright eyes and warm smiles, and warm supportive physical contact with her in activities

Move your face into her visual field to engage her eye contact sometimes.

Watch to see how much she checks in with you visually.

Wonder with Mom: if S were more keyed into your face if you would experience more back and forth interaction.

Continue following her lead in play and giving her lots of space for autonomous exploration and to initiate with you.

Continue with your creativity. S has so much fun playing with you when you show her new things and when you are silly.

Sentence Length: 4- to 6 words. Mirroring: • Beautiful job mirroring non-verbally

(facial expressions) • Mirror language that S might be feeling

or experiencing; e.g., “I like that”, “That’s funny”, “Too hard!

Expand on her utterances with one or two words. • S says “I see it”, model and expanded sentence

that is based on her idea, “I see the ball”. • Expand her idea, e.g., “The ball rolled away”/

“It’s under the table.” Use linguistic mapping when S vocalizes

• Model words for her vocalizations that match her intent

Video Replay • Help parent identify existing knowledge and

practices • Help parents develop new skills • Promote continuous self-assessment and learning

Coaching strategies • Mirroring (relationship focused) Mind/Feeling-related comments, facial expressions, body

language, intonation • Quality of verbal input Language techniques Follow-in comments Linguistic mapping

Parent Strengths Some concern

Expressed Affect Tone of voice

Not intrusive Mood: withdrawn, depressed, ?anxious

Contingent responsivity to child Enthusiasm/enjoyment/pleasure

Structures and mediates environment Amount of Visual Contact with Child

Quantity of verbalizations Connectedness

Reads child’s cues and responds sensitively

Mirroring

Quality of verbalizations Parent Challenges

Enjoyment/Pleasure expressed toward child Amount of positive physical contact

Child Strengths Some concern

Alertness/interest Visual Contact with Mom

Compliance

Good motor skills

Attention span

Self regulation

Visual contact

Readability

Child Challenges

Social Responsiveness

Communicative Competence

Strengths Some concern

Organized/well-regulated Reciprocity

Joint attention Enjoyment/enthusiasm

Overall affective Quality of the Interactions

Goodness of Fit

Challenges

Constricted

Vocal Quality and Facial Expressions: animated voice and facial expressions,

bright eyes and warm smiles. Touch in warm supportive way: let her

know you are there Hold her gaze when you can with bright

eyes and smiling to let her know you are happy she is looking at you.

Make it Fun!! Make the most of the moments when you

are really connecting with her. Try to engage her with your facial

expressions. Move your face into her visual field to engage her eye contact in play routines.

Try some play with physical contact and turn taking; e.g., sing and row “row row row your boat”.

Watch her face and gestures; imitate her facial expressions as though she were looking in a mirror.

Try modeling language that matches or mirrors what E might be feeling or experiencing; e.g., “I like that”, “That’s funny”, “Too hard!” Watch her facial expressions and body language to give you clues about what language to model.

Being on the floor and close to her really helps . Try moving so that you are face to face with E.

Communication emerges in infancy in the context of a relationship with a primary caregiver.

The quality of the social bond between a primary caregiver and a young child has an impact on the child’s communication development.

We are most effective in supporting the growth and development of young children if we provide meaningful coaching to support parents in developing a relationship with their children.

Our work is more effective when we have opportunities to reflect on our practice, explore the impact of our own actions, and reflect on our own subjective experience with families.

Witness Open and Curious Wonder Positive Support Model Reflect Hold

Apply something from today to your work next week. • Reflect with a colleague or supervisor about

what it meant to you; what it felt like. Expand your knowledge—be open and

curious—take on learning new techniques!

Establish a reflective practice: regular opportunities to reflect on your role and subjective experience

Families Staff and families at the Center for

Communication Hearing and Deafness, West Allis, WI

University of WI-Madison and Waisman Center, UCEDD

Assessment of Early Intervention Outcomes Project, funded by WI-DHS, Wisconsin Sound Beginnings

Mentors in the Infant, Early Childhood, and Family Mental Health Certificate Program • Roseanne Clark, PhD, Linda Tuchman-Ginsberg, PhD,

Janna Hack, MSSW, Carol Noddings-Eichenger, LFT

Anne Heintzelman, MS., CCC-SLP, IMHE ®-II University of Wisconsin-Madison Clinical Associate Professor, Emerita Senior Clinical Speech Pathologist, Emerita anne.heintzelman@wisc.edu