anne heintzelman, ms, ccc-slpp1cdn4static.sharpschool.com/userfiles/servers/server_20536521/f… ·...
TRANSCRIPT
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 [email protected]