child welfare watch: baby steps

8/11/2019 Child Welfare Watch: Baby Steps

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VOL.

23

FALL

2013

Child Welfare WatchBABY STEPS: Poverty, chronic stress,and New Yorks youngest children

centernyc.orgcontinued on page 2

Recommendations and Solutions 3

Baby Watchers 5

Pockets of help for children livingwith traumatic stress

How to Reach the Citys Youngest 8

Experts weigh in

A Call for Help 10

Seeking services fora traumatized toddler

What Works 12

Effective programs for youngchildren and their caregivers

Seen and Heard 16

A video-feedback parentingprogram for my son and me

The Science of Trauma 17

Science is reshaping our understandingof early childhood trauma

Babies in Foster Care 23

Are they getting the help they need?

Learning How Babies 24

Brains Grow

Special Programs for Babies 25

in Foster Care

Further Reading 26

Watching the Numbers 27

OVER THE PASTdecade and a half, scientific research has firmly established thatearly childhood experiences can have a tremendous impact on our lifelong well-being.Giving babies the care and attention they need provides a strong foundation for futuredevelopment, affecting their ability to process information, regulate their emotions,interact with others and understand their worlds. When infants are exposed to constantstress or trauma, the effect can be toxic, stunting brain growth and changing the trajec-

tories of their lives.Thankfully, a growing body of evidence points to supportive caregiving as a means

to buffer the impact of poverty, trauma and other stressors on young children. Sup-portive caregiving is a reflective, child-centered approach to parenting that emphasizessensitivity, warmth and responsiveness. Adult caregivers promote a babys developmentby responding to her cues and needs, and by being generally nurturing. A childs emo-tional well-being is inextricably tied to the parenting she receives.

Of course, a nurturing approach to parenting can be extremely difficult to practicewhile, say, living in a domestic violence shelter or clocking a 60-hour work week forminimum wage. So helping infants means many things, including investing in strategies

CONTENTS


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CHILD WELFARE WATCH2

to make the citys most distressed neighborhoods places wherechildren and families can thrive and supporting policiessuchas accessible, high-quality child careto help families bettercope with their day-to-day pressures. But helping young chil-dren can also involve providing clinical support to their families.

Over the past two decades, professionals devoted to theemotional and social health of babies and toddlers have devel-

oped interventions that work with young children and theircaretakers. These dyadic therapies foster responsive, nurtur-ing parenting and recognize that babies develop in the contextof close, consistent relationships. As these interventions seek to curb social and develop-mental issues before they become severe, they can be tremen-dously cost-effective. The Nobel prize-winning economist

James Heckman showed that early interventions yield a hugecost savings of about $8 for every $1 invested. Waiting to actcan be expensive: Heckman found that the potential economicreturns decline steeply as early as a childs third year of life.

In New York City, this newfound knowledge regardingdevelopmental strategies for securing a childs earliest years hasonly begun to shape the fields of mental health and childrensservices. Just a handful of centers and clinicians are trained andable to offer dyadic therapies for very young children and theirparents. Parents needing help for traumatized toddlers have fewplaces to turn, and the dearth of city services and governmentfunding earmarked for young childrens social and emotional

well-being only exacerbates the problem. The federal- andstate-funded Early Intervention program reaches many of thecitys most vulnerable babies and toddlers, but its services focusprimarily on developmental delays rather than on the effects oftrauma and chronic stress.

There are new programs emerging, however, and a fewproven ones are winning more attention. Small programs inthe Bronx, Brooklyn and Queens are giving parents valuable,hands-on guidance and practice in responsive, playful supportfor their children. The citys Administration for Childrens Ser-vices is steering federal dollars to nascent interventions for vic-tims of trauma and their small children.

In this issue, we survey the evidence from research intochronic stress and the interventions that buffer the toxic ef-fects of trauma on babies and toddlers. We look at the citylandscape, profiling programs that work with the families ofyoung children living with poverty and other forms of stress.

We highlight the need for more expertise, awareness, trainingand services in a growing field that is increasingly described asinfant mental health.

Researchers have developed a vast store of knowledge re-garding what babies require to flourish. The gap between thatknowledge and the enduring realities of social policy has per-sisted so stubbornly, and for so long, that many who work inthis field are stumped. Triage typically trumps prevention, theysay. A violent teenager is more likely to win policymakers atten-tion than a toddler who has trouble sleeping after witnessing hisfathers murder. A mother struggling to care for her small childin an overcrowded apartment is more likely to be the subject ofan investigation by governments child protective services thanto experience dyadic therapy at a neighborhood clinic. Promoting small childrens mental well-being goes far be-yond play therapy. It means finding ways to connect early withparents of young children, help them to lower their stress, andencourage them to provide their families with the love, supportand attention they need to flourish. e

Studies indicate thatchronic stress, trauma orneglect in early life canliterally change the waya childs brain develops,leading to impairmentsthat can be permanent.There is also evidence that

responsive, nurturing care

can prevent or reverse the

damage caused by stress.

(See The Science ofTrauma, page 17.)

National studies have foundthat 20 to 60 percentof foster children underage 5 have significantdevelopmental delays,and that 25 to 40 percentdisplay serious behavioral

problems.Foster careagencies do not regularly

screen for mental health

impairments in very young

children. (See Babies in

Foster Care, page 23.)

In New York City, only ahandful of programs andclinics engage the parentas a partner in a small

childs therapy.(See BabyWatchers, page 5.)

Putting mental healthprofessionals whereparents already aremakes services easierfor families to use.(SeeHow to Reach the Citys

Youngest, page 8.)

Studies have shownthat elements commonto poverty, such asovercrowding and familyturmoil, can causebabies stress levels tospike precipitouslybut only when a babysmother is not responsive

to her childs signals.(SeeBaby Watchers, page 5.)

IssueHighlights:Facts andFigures


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Child Welfare Watc

RECOMMENDATIONS AND SOLUTIONS

THE NEW YORK STATE OFFICE OFMENTAL HEALTH (OMH) AND THECITYS DEPARTMENT OF HEALTH ANDMENTAL HYGIENE SHOULD PROVIDECONSISTENT, ADEQUATE FUNDINGFOR EARLY CHILDHOOD MENTALHEALTH TREATMENT, AND FORPROFESSIONAL TRAINING.

Providing early help to infants andtoddlers who need it can prevent morecostly, intensive and potentially invasiveinterventions later in life. Nobel prize-winning economist James Heckman has

demonstrated that investing in effectiveearly childhood interventions can yieldhuge cost savingsand that there is a steepdecline in the value of these savings as earlyas the end of a childs third year of life.

However, state and city governmentfunding for treatment is very limited andfew professionals are trained to providetreatment to this age group. A 2012 analysisby the Citizens Committee for Childrenestimated that state-licensed mental healthclinics had treatment spots for only 1percent of children age 0 to 4 who neededthem in three of New York Citys boroughs.Slots were most scarce in communitydistricts considered high risk due to factorssuch as economic poverty and safety.Government and society are missing theopportunity to provide young children withappropriate treatment before their needs andsymptoms compound.

Some clinics and organizationsproviding early mental health treatmentare reimbursed a small amount throughMedicaid or, in some cases, by theirreferring foster care agencies. Many

families are not eligible for these funds,or are served outside of clinics. Today, theCity Council is one of the few sources ofgovernment funding for community-basedearly mental health treatment, but itssupport is not solely for treatment or fortraining clinicians to work with infantsand toddlers; it must also cover the cost ofscreenings and evaluations. Whats more,this modest support of $1.25 million is notbaselined into the mayors budget and istherefore at risk of elimination each year.We urge the city and state to recognize

the need for more treatment optionsincluding intensive, dyadic therapy, whichis most lackingfor this vulnerable groupof New Yorkers. There is also a great needto build a viable workforce able to workwith children under 5 and their parents.

THE CITY, STATE, AND NONPROFITORGANIZATIONS SHOULD CO-LOCATEINFANT AND TODDLER MENTAL HEALTHSERVICES IN THE PLACES WHEREYOUNG CHILDREN AND THEIR PARENTSALREADY GO: PEDIATRIC CLINICS,

FOSTER CARE AND PREVENTIVEAGENCIES, FAMILY COURT, HOMES,COMMUNITY CENTERS AND CHILDCARE PROGRAMS.

Parenting young children while living inpoverty or with other sources of chronicstress is taxing. Parents and young childrenwho could benefit from treatment will be farmore likely to find help if it is located in theplaces where parents already go. This makesservices easier to access, reduces the stigmafrequently associated with mental healthtreatment and allows infant mental health

specialists to educate other professionals whowork with babiessuch as child care workers,

judges, pediatricians, home visiting nursesand preventive workersabout the social andemotional development of young children.

THE STATE DEPARTMENT OF HEALTHSHOULD PROVIDE PROFESSIONALS INTHE EARLY INTERVENTION PROGRAMWITH COMPREHENSIVE TRAININGIN THE SOCIAL AND EMOTIONALDEVELOPMENT OF YOUNG CHILDREN.

Early Intervention is the citys largest, mostcomprehensive program for treating kidsunder 3. In theory, Early Intervention canwork with children under 3 whose onlyissues are social-emotional. In practice,the program largely focuses on addressingdevelopmental delays and disabilities,making it a missed opportunity to help thefamilies of babies who are struggling withthe effects of trauma or chronic stress.To help nudge Early Intervention closer tobecoming a system able to address earlychildhood mental health, Early Interventionprofessionals should receive comprehensive

training around the mental health needsof young children, with a focus on how toaddress and recognize the effects of traumain this age group.

THE STATE OMH SHOULD TRACK THENUMBER OF STATE-LICENSED MENTALHEALTH CLINICSALSO KNOWN AS ARTICLE31 CLINICSTHAT HAVE THE CAPACITY TOTREAT INFANTS AND TODDLERS.

Few clinics have the capacity to providemental health treatment to infants and

This issue of the Watchfocuses on the citys youngest residents: babies andtoddlers.We explore the impact of chronic stress on young childrens brain

development and present national research around interventions aimed to buffer thateffect and to better support the parents of young children. More than 6 percentor

518,000of New York Citys 8.1 million residents are under 5 years of age. A handful of

local programs work with the families of young children who are affected by poverty,

chronic stress and trauma, including some innovative programs for the child welfare-

involved parents of young children. We highlight the need for more of this type of

expertise and illuminate the dearth of government funding and services targeted for

caregivers seeking help for young children. Following are recommendations andsolutions proposed by the Child Welfare Watchadvisory board:


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toddlers. No government agency tracks thenumber that do serve very young childrenand their families. This makes it extremelydifficult to address the citywide gap betweentreatment need and capacity.

THE STATE OMH AND THE CITYSHUMAN RESOURCES ADMINISTRATIONAND DEPARTMENT OF HEALTHAND MENTAL HYGIENE SHOULDCOLLABORATE WITH PARENTS ANDCOMMUNITY ORGANIZATIONS TOCREATE AN ADVERTISING CAMPAIGNTHAT PROMOTES POSITIVE, SUPPORTIVEPARENTING OF YOUNG CHILDREN.

A growing body of research suggeststhat supportive parentinga reflective,child-centered approach to parenting

that stresses sensitivity, warmth, andresponsivenessis a key to bufferingthe potentially lifelong toxic effects ofa childhood marred by stress, violenceand trauma. New York should mounta campaign dedicated to educatingparents about the benefits of supportiveparenting and provide powerful examplesof what it means to be responsive tothe developmental needs of infants andtoddlers.

THE ADMINISTRATION FOR CHILDRENS

SERVICES (ACS) SHOULD REQUIREFOSTER CARE AGENCIES TO ENSURETHAT BABIES AND TODDLERS INFOSTER CARE ARE SCREENED FORMENTAL HEALTH IMPAIRMENTS,IN ADDITION TO STANDARDDEVELOPMENTAL EVALUATIONS.

Last year, there were more than 3,050children under age 5 in New York Cityfoster care. Young children often comeinto care with tumultuous historiesthat put them at high risk of medical,emotional and developmental problems.

Once in the system, many of themcontinue to experience turbulence, movingfrom caregiver to caregiver while beingseparated from their families. When foster care is necessary, it shouldbe maximized as an opportunity to nurturechildrens developmental health. In thepast decade, ACS has made great progressin the effort to ensure that children receivedevelopmental screenings when they entercare. These screenings focus primarily oncognitive and physical delays, rather than

on the more subtle impacts of disruptedrelationships and stressful experiencesthat threaten babies emotional wellbeing.Unfortunately, mental health assessmentsoften dont happen until children are

older and demonstrate obvious behavioralsymptoms of emotional distress. Some agencies have developmentalspecialists on staff to ensure thatdevelopmental screenings take place, andto follow kids who demonstrate specialneeds. This systematic approach shouldbe instituted at all agencies, with a similarlevel of attention paid to mental healthscreenings for children of all ages.

ACS AND THE STATE OFFICE OF COURTADMINISTRATION (OCA) SHOULD

ROUTINELY TRAIN FRONTLINE STAFFAND CONTRACT EMPLOYEES ON THEDEVELOPMENTAL NEEDS OF INFANTSAND VERY YOUNG CHILDREN.

Removing babies and toddlers from theirhomes disrupts their attachments tocaregivers and can have lifelong negativeconsequences. Frontline workers at fostercare agencies, as well as child protectivespecialists and key Family Court staff,attorneys and judges, should be regularlytrained in the particular developmental,emotional and mental health needs of

infants and very young childrenincludingthe damage that can be caused byrepeated disruptions in care. In the past, a privately funded courtcommission ran an initiative that educatedcourt staff about infant development, whilealso providing guidelines and checklists tohelp judges and attorneys make sure thatbabies received appropriate care. In theabsence of outside funding, ACS and thecourts should continue these practices. OCAshould consider designating social workers tofollow infants cases in court, ensuring that

they receive developmentally appropriateservices. Along with frontline case workers,Family Court judges should considerconducting analyses of babies existingattachments before making placementdecisions. OCA should also consider thefeasibility of creating specialized court partsfor babies and very young children, staffedby judges with particular training in earlychildhood mental health, and who are fullyinformed of resources in the community forinfants and their parents.

ACS AND NONPROFIT FAMILYSUPPORT ORGANIZATIONSSHOULD ENSURE THAT PARENTINGCLASSES ENGAGE IN ACTIVE SKILL-BUILDING, SUPPORTING PARENTSTO UNDERSTAND AND NURTURETHEIR CHILDRENS DEVELOPMENT.

Too often, parenting classes are didacticexercises in compliance, instructingparents in basic skills they may alreadyknow. These classesin conjunctionwith family visitsshould be used asan opportunity to support parentsmeaningful interaction with their children,building skills that encourage nurturanceand childrens secure attachments.

With the recent introduction of itsChildSuccessNYC initiative, ACS hastaken steps toward incorporating afocus on childrens developmental andemotional needs, and on the positive,crucially important role a parent playsin her childs development. Under theinitiative, parents participate in facilitatedgroups that promote both instruction anddiscussion, including concrete informationabout strategies to support infant braindevelopment and mitigate the potentialharm caused by trauma or neglect. The implementation of ChildSuccessNYCshould not preclude parents and fostercare agencies from pursuing alternative

approaches, however. Specifically, thereought to be more opportunities for parentsto learn about child development inenvironments where they can interact withtheir children, supported by facilitatorswho help them build understanding ofreal-life issues in real time. The Mommyand Me program at SCO Family of Servicesis one example of this kind of program.Parents and their children participate in astructured playgroup, in which facilitatorsdiscuss elements of development,demonstrate strategies to support

that development, and then provideopportunities for parents to interact one-on-one with their children. Support groups and instruction areboth valuable, but they should be closelyconnected to visitation experiencesfor parents and their children in fostercareand parents themselves should haveboth the information they need and thefreedom to choose the most appropriateprograms.


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CHILD WELFARE WATCH

THE CONTEXT:

Trauma and chronic

stress can harm a babys

developing brain, butstudies suggest that

nurturing, responsive

parenting can prevent

long-term injury.

THE ISSUE:

With fast-growing

knowledge about

how to protect babiesand toddlers, should

government support

a systematic mental

health response?

Baby

WatchersA small but growing movement inmental health therapy is providingpockets of help for the citysyoungest children.

BY KENDRA HURLEY

Christopher, an intense 21-month-old with spotless white

sneakers and a mop of curly brown hair, charges full-speedpast a therapist and into a playroom at the Early ChildhoodCenter of Albert Einstein College of Medicine in the Bronx.Christophers mother, Tamara Noboa, trails behind. Shelooks tired, wearily pushing a double stroller that holds babyElijah, Christophers 7-month-old brother. Christopher boltsacross the room to a toddler-sized table. He grabs a soft book,runs back to the stroller and shakes the book aggressively inhis brothers face. Oh, Christopher! exclaims Denise Giammanco, thetherapist who has been seeing this family for three weeks.Nice sharing! Good job! Christophers face flickers with

only faint recognition of her praise. Within seconds hes backacross the room digging through toys.

Giammanco turns to Noboa. You see how Im making itvery high energy, so that he shares with the baby? Noboa saysChristopher is often jealous of his baby brother; Giammanco

wants to encourage positive moments between them. Therapy has officially begun.


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SEVERAL MONTHS AGO, Christopher was say-ing Mommy and Daddy. His parents waited for more

words to come, but they havent. Now, Christopher doesntsay much of anything and rarely responds when spoken to.Its hard to tell how much he understands. He has also startedfalling a lot. He cries loudly and frequently in the night, wak-

ing the baby. And although he didnt use a pacifier before,hes begun putting the babys pacifier in his mouth. He is eas-ily frustrated, throwing things and hitting. Just this week, he

whacked the baby across the face. Noboas teenage daughter also had behavior issues atChristophers age. Then she attended a therapeutic day pro-gram. It helped a lot. Now shes on the honor roll. Today,Noboa hints that this is the kind of help she might like forChristopher too.

But the Early Childhood Center, which works primar-ily with low-income families like Noboas, provides a differ-ent kind of help, engaging not only the child but the parent

as well. Most social work interventions for struggling andpoor families view the social worker as the sole therapeutic

agent. They strive to change the behavior of either a childor a parent, but not both. In the relationship-based therapythat the Early Childhood Center providesknown as dyadic

therapythe therapist works simultaneously with parent andchild, engaging the parent as a partner in the childs therapy,because in the early years, children are almost entirely depen-dent on parents to create their world for them. Theres very little you can do with a very young child with-out changing the tenor and context in which they live, and youngchildren live in the context of their relationships, says Susan Chi-nitz, director of the Early Childhood Center. Any work that isnot relational is probably not going to buy much change.

If the therapist spends an hour a week with the child,thats one thing, says Fred Wulczyn of Chapin Hall, a policy

research center at the University of Chicago. But if you im-prove the parenting and then the parent knows how to bettermanage the child, then you get all that exposure to better par-enting instead of trying to get the child to be a better child.Caregivers spend so much more time with the child. Deliver-ing the intervention through the parent means you get much

higher dose levels. In New York City, however, only a handful of programsand clinics provide dyadic therapy for young children andtheir caregivers, making families like Christophers among thevery few to stumble across it. What may eventually pass for amovement is beginning to emerge in agencies across the city,rooted in increasingly robust researchand the experiencesof therapists like Denise Giammanco and her colleagues. Giammanco knows that many of Christophers changesstarted around the time his brother was born and his worldturned upside down. He went from being the baby of thefamily to the big brother, no longer the main focus of his

mothers affections. Not long after Elijahs birth, both boys and their moth-er moved into the home of Christopher and Elijahs father.(Noboa also has a teenage daughter who sometimes livesthere, other times with her father.) Christophers mother saysshe, too, is reeling from all the changesa new relationship,a new home, two children under the age of 2. Some days she

wants to close her bedroom door and block out the world.He makes me crazy sometimes, she says about Christopher.I need help for him. Help for me. I dont want to scold himall the time.

Christopher will soon receive a full diagnostic evaluation

by a pediatrician who will assess his speech development andhow well he understands language, among other things. ButGiammanco will also consider murkier factors that could becontributing to Christophers behavior and delays. In her hour-long weekly sessions, Giammanco coachesboth of Christophers parents on how to provide whats some-times referred to in the small world of infant mental healthas supportive or responsive parentinga reflective, child-centered approach to parenting that encourages sensitivityand warmth. Research suggests this kind of parenting is a keyto buffering what neurobiologists have documented to be thesometimes brutal and long-term effects of trauma, poverty,

and stress in early childhood. (See The Science of Trauma,page 17.) A series of studies of 1,200 infants funded by the Na-tional Institutes of Health suggests that elements common topoverty, like overcrowding and family turmoil, caused babiesstress levels to spike precipitouslybut only when a babysmother was not responsive to her childs signals. Whenmothers scored high on measures of responsiveness, the im-pact of those environmental factors on their children seemedalmost to disappear, journalist Paul Tough explains in hisrecent book, How Children Succeed.

Young children livein the context oftheir relationships.Any work that is notrelational is probablynot going to buymuch change.


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CHILD WELFARE WATCH

Today, in the Early Childhood Center playroom, Giam-manco models the supportive parenting approach, interject-ing enthusiastic vroom, vrooms, as Christopher rolls a truckacross the table, and cooing empathetic frustration when hestruggles to master a difficult puzzle toy. Eventually, Giam-manco will have Christopher play less with her and more

with his mother and father as she provides guidance, cheeringthem on in their parenting in much the same way she cheersChristopher in his play.

A Therapeutic Approach that TreatsParent and Baby, Together

For the first 13 years that Martha Alvarez worked in a highschool-based nursery for the babies of teen moms, she hadnever seen the research around supportive parenting norheard of dyadic therapy.

Each morning, young mothers dropped off their babies

in the school nursery before classes began. Nursery teach-ers took care of the babies while Alvarez and the other social

workers counseled the young mothers, encouraging themto stay in school, speaking with them about college. It wasvery academic minded, Alvarez remembers. It did touch onissues with their moms and relationships with their babiesdads, but there was very little to do with the baby.

Alvarez knew well that many of the young womenshe worked with were struggling with motherhood. At anage when most young people want nothing more than toforge identities separate from their own families, becom-ing a parent had tied them inextricably to a very small

childand to their parents and caregivers on whom theydepended for support and guidance. While many dressedtheir infants immaculately in the latest brand-name cloth-ing, they often had trouble seeing their babies as separatefrom themselves, as little people with their own likes, dis-likes, wants and needs.

Young mothers would routinely arrive at school upset,says Alvarez. She had a fight with her mom or she had a fight

with her boyfriend, or her kid threw up on the way. Typi-cally, staff would take the baby to the nursery and Alvarez

would take the mom to her office. But I realized that thisbaby was upset too. This baby would be crying.

One day it became glaringly obvious she needed to try adifferent approach. A young mom showed up at school withher 2-year-old son, who proudly showed Alvarez a colorful leafhed found. He had picked up the leaf near his home and hadmade it all the way to the nursery with it intact, in his hand.

I said, Oh my, this is such a great leaf, what beauti-ful colors! Alvarez remembers. But the mother had beenoblivious to the leaf the whole time, not minding what thislittle boy was doing for the whole ride to the nursery. She wasnot attuned to him. I knew there was a disconnect. When Alvarez pointed out the leaf to her, the mother

said, Oh, yeah, and threw it away.Alvarez remembers the moment as an awakening. I

thought, This kid isnt getting what he needs. I knew thatthere had to be a way to bring the baby and mother togetherand work on her parenting skills. I knew there was some-thing to be done with the moms and babies, but I never had

that role explained to me. A few years later, through an arrangement with the citysDepartment of Education, two social workers arrived at thenursery. Drawing from multiple strategies and interventionsdeveloped by researchers and mental health specialists to as-sist vulnerable parents and their infants, Elizabeth Bucknerand Hillary Mayers had created a program called Chances forChildren, which gave young mothers a combination of par-ent education and therapy while working with them and theirbabies together. The program shifted the focus of Alvarezs

work to helping young mothers take on the vast role of caringfor their new familiesa role that included pursuing their

academic studies, but also a great deal more. Alvarezs training was intense. Buckner and Mayersschooled Alvarez and other social workers at the nursery in theresearch behind the interventions they used. They taught themabout attachment theory, which holds that the quality of theattachment an infant has with his caregiver at lifes beginninghas lifelong consequences. One University of Minnesota studyin the 1970s found that the degree to which young children

were securely attached to an adult could predict with high ac-curacy whether or not they would graduate from high school. Alvarez and the other nursery social workers also learnedabout the toxic effects of chronic stress on young children.

They read psychoanalyst Selma Fraibergs Ghosts in theNursery, a seminal 1975 essay that describes how unresolvedissues from a parents upbringing can haunt their parenting ifleft unexplored. And they read about more recent neurologi-cal research. Through all their training, they experienced akind of supervision that Buckner describes as layers of moth-ering, where she and Mayers mothered and supported thenursery staff in their work so that they, in turn, could motherthe young moms and help them do the same for their babies.

It took a while for my thinking to change from just themom to the dyad, remembers Alvarez. It was a cognitiveshift of working from one to working with both. But it was

rich, rich, rich. You look at the mom, you look at the baby. The Chances for Children model begins by videotap-ing mothers as they play with their babies for 10 minutes.The therapist asks the mom to play with her child just asshe might at home. Then the two of them watch the videotogether, with the practitioner building the mothers trust byfocusing on positive moments.

Alvarez remembers how much the young moms lovedthis strength-based approach, which could also be describedas the oh, wow method, where the therapist marvels at allthe positive things the mother does. Nobody had told them,


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INFANT MENTAL HEALTH experts warn that the best way to address the citys stark shortage in mental health services for youngchildren is not simply to create more treatment slots. Rather, attention has to be paid to placing these programs where familiescan find and use them. We believe in a co-location model, where you put what we do in other systems, explains Joaniko Kohchi,child development specialist at the Early Childhood Center of the Albert Einstein College of Medicine in the Bronx.

Kohchi and her colleagues would like to see infant mental health services in places where parents with young children alreadygo: pediatric clinics, child care centers, high school-based nurseries, Family Court, foster care agencies, even in home-visiting pro-grams. If a parent is already stressed, the chances of you getting to a clinic once every week is not realistic, says Susan Chinitz,director of the Early Childhood Center.

As reported in a 2000 report of the Surgeon Generals Conference on Childrens Mental Health, one study found that onlyabout 41 percent of children referred by a pediatric provider for outside mental health services actually made it to intake. Puttingmental health professionals where parents already are makes services easier for families to use while reducing the stigma oftenassociated with mental health treatment, says Bonnie Cohen, director of University Settlements Butterflies Program. This also al-lows infant mental health specialists to educate other types of professionals, like child care workers, about the often overlookedsocial-emotional side of infant and toddler development. A 2012 Citizens Committee for Children analysis found that in the Bronx, Staten Island, and Brooklyn, mental health treat-ment slots exist for only about 1 percent of the children ages 0-to-4 who need them. Once a child turns 5, however, options forreceiving help increase. Many more clinics accept children 5 and older, and with kids entering kindergarten at this age, it is far

easier for professionals to identify who needs support and to provide help at school. Mental health specialists say that waiting untilage 5 wastes valuable time as well as a key opportunity to help children at an age when their brains are developing most rapidly.(See The Science of Trauma, page 17.)

In some ways, its discriminatory to only start services at school age, says Chinitz. Why wouldnt there be services forevery age? Kendra Hurley

A few New York City initiatives are already structured this way

How to Reach the Citys Youngest: Experts Weigh In

Therapists in the Butterflies Program at UniversitySettlementwork with the children, teachers, and familiesenrolled in University Settlements EarlyLearn program.One full-time therapist and one part-time therapist screennearly 350 children under age 5 each year for social and

emotional issues, support and train EarlyLearn staff, andprovide therapy for children and families who need moreintensive help. Many of the children they work with areChinese-American and have recently been reunited withtheir parents in New York after spending earlier yearswith grandparents in China. Butterflies therapists helpthem reconnect with their parents and adjust to their newhomes and country.

The foster care agency Forestdales Attachment andBiobehavioral Catch-Up programworks with babiesbetween 6 and 24 months and their caregivers right intheir homes. The highly-structured, 10-week program aimsto increase attachment between children and caregivers.Forestdales version of the model typically works withbabies in foster care and their foster parents, as wellas with parents and children who have recently begunliving together again after involvement in foster care.These mothers have been brought to the attention ofchild welfare and feel like theyve done something terribleand that they arent a good mother, says Anstiss Agnew,Forestdales executive director. The model is meant toreassure and teach at the same time.

Recognizing that pediatricians are the only professionalsto regularly see most babies, the Childrens Hospital at

Montefiorein the Bronx pairs an infant mental healthclinician with pediatricians. At the hospitals childrensclinic, this psychologist or licensed social workerwhohas the more parent-friendly, less stigmatizing titleHealthy Steps Specialistworks alongside pediatricians

to help ensure that young patients and their parentsget appropriate mental health screening, referrals andtreatment along with their physical checkups and vaccines.The infant and toddler specialist also trains pediatriciansand medical students, helping to make them morecomfortable in talking with patients about issues like post-partum depression, trauma and substance abuse.

The Family Court in the Bronxhas partnered with earlychildhood specialists at the Early Childhood Center, whoprovide treatment to parents of young children involvedin Family Court while sharing their expertise with judgesand other court officials. The Jewish Board of Family andChildrens Services Institute for Infants, Children & Familiesis planning a similar program for Manhattan Family Court,which will be funded by the states Office of Children andFamily Services.

The Riverdale Mental Health Association(RMHA) providesmental health treatment along with services like workreadiness training and job placement. Chances for Children,which works to strengthen relationships and attachmentbetween parents and their young children, is based atRMHA and trains the associations clinicians on how to workwith the families of young children who have experiencedtrauma, stress and attachment difficulties.


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CHILD WELFARE WATCH

Oh, wow, that was so nice what you did. The baby was stum-bling and you picked him up. Thats nice, she remembers.They enjoyed the fact that I was paying attention to themand their babies. Many teen moms dont get that recognition.

Over time, the therapist moves toward helping the moth-er experiment with new ways of thinking about and interact-ing with the child. She asks questions such as, What do youthink the baby is thinking? or How about you dont pick upthat toy right now and see what happens?

Alvarez remembers one young mother who perpetuallyteased her 18-month-old daughter. Shed take away whatevertoy the baby chose and proclaim it to be Mommys toy.Shed shake objects in front of her and then yank them away

when the baby tried to grab them. When this mother pickedher daughter up after class, she would try to make her jealousby pretending not to notice her daughter as she warmly greet-ed all the other children in the nursery. The little girl wouldoften respond by shutting down, Alvarez remembers. This, inturn, caused the mother to comment that her daughter didntlike her and did not want to play with her. She would teasethe girl even more. It was a vicious cycle.

Alvarez asked the mom to play with her daughter whileteasing her for one minute, as Alvarez videotaped. During thetaping, the baby turned away from her mother. See, she doesnt

want to play with me. She likes to play alone, the mother said.Then Alvarez told the mother to play with her daughter

for another minute while she videotaped. But this time, Alvarezasked the teen to try out a form of supportive parenting, wherethe parent responds to the baby rather than directs her. Alvarezasked the young mother to follow her daughters lead, allow-ing her baby to show interest in a toy first, and then follow byshowing an interest herself in whatever the baby did. Do whatshe does. Talk about what shes doing, Alvarez instructed.

An amazing thing happened, remembers Alvarez. As themother responded to her daughters lead, her baby slowlyturned to her. Then she lifted a block up to show her. Themother, carefully matching her daughters movement, heldup another block. Slowly, the daughter touched the mothersblock with her block. The mother turned to the camera, facealit, grinning, amazed that her daughter was playing with her.

With the touching of those two blocks, Alvarez recalls, it wasalmost like the Sistine Chapel.

Do you see what she did? the mother asked, incredulous.Yes, I saw what she did, Alvarez remembers saying.

You saw what you did? You opened the world to her. Alvarez and the young mom would watch that videotapemany times. Eventually, they began to explore the mothersown upbringing. The teens mother had teased her through-out her childhood. Remembering this, the young woman be-gan to recall how confusing that had felt. Alvarez believes thatthe combination of reflecting on her own childhood whileexperimenting with new ways of parenting paved a new wayfor her to relate with her daughter. We made a new story forher, that she was not her mom, and her story with her daugh-ter was totally different and didnt have to repeat the past.

New York Citys Pockets of Help forInfants and Their Caretakers

Chances for Children has since moved out of the high schools,where they trained social workers in 13 school nurseries, andinto community centers and a clinic in the Bronx. Alvarezand Chances for Childrens three other therapists now work

with caregivers of all ages in three neighborhoods. The orga-nization has also trained six clinicians at Riverdale Mental

Health Association. Along with the Early Childhood Cen-ter at Albert Einstein College of Medicine, they are among avery small number of programs in the city using relationship-based therapy with young children and their families.

Some of these programs work individually with parentsand their babies; others bring caregivers together for guidedplaygroups. Some send therapists to work in families homes,

while most work only in clinics or community settings. Somefollow models developed at universities and demonstrated tobe effective through research. Others, like Chances for Chil-dren, are homegrown programs, picking and choosing amongalready established best practices while tailoring interventions

for individual families. All aim to reach the citys most vulner-able babies and their caretakers: Teen moms with their babiesliving in foster homes; families living in homeless shelters;toddlers whose behavior their parents just cant manage. Al-most all of these families teeter on the brink of poverty or arealready there. Poverty just deprives people of the supportsthat make it easier to cope with the enormous demands ofvery young children, Chinitz explains.

All of the programs are strength-based, dedicated tobuilding relationships with caregivers by pointing out thepositive aspects of their parenting. We cheer on the parent

Were not really telling parents what to doso much as to get them to think about thingsthrough their kids eyes.


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CHILD WELFARE WATCHhas heard from many parents and ad-vocates that New Yorkers seeking emotional and behavioralhelp for very young children are hard-pressed to find it. To seefirsthand if this were true, I called New York Citys hotline formental health referrals to seek services for a 2-year-old.

I called 1-800-LifeNet and explained that a 2-year-old girlwho had witnessed a violent event was having trouble sleeping,in addition to behavioral problems like tantrums and hitting.The operator sounded sympathetic. She said she thought thetoddler probably needed play therapy. But its kind of difficultbecause a lot of agencies start at age 5, she explained. Therearent a lot of services for this age.

She told me to give her my zip code and shed see whatshe could find. Two locations in Brooklyn, where I live, poppedup. Neither were anywhere near my home, but both workedwith children under age 5. One, Kings County Hospital, did notlist a minimum age requirement, but when I called they said

they couldnt take children younger than 3. They suggested I tryEarly Intervention.

Early Intervention is by far the states most comprehen-sive program for treating kids under 3, serving more than75,000 infants and toddlers a year. The program, managed bythe state and city health departments, works with toddlerssuspected of having developmental delays or disabilities, or athigh risk of developing delays because of a diagnosed physi-cal or mental condition. In theory, the program can work with kids whose issuesare behavioral and potentially rooted in trauma, like the child Icalled about. However, New York Citys Early Childhood MentalHealth Strategic Work Groupan advisory group of practitio-

ners, researchers and others in the fieldnotes that in practicethis is rarely the case. It is the view of the committee, thegroup wrote in a 2011 report, that it is infrequent that childrenare found eligible for services where social-emotional difficul-ties are the sole or primary basis of delay. The chair of the workgroup explained to me that Early Intervention professionals arenot routinely trained to recognize and address trauma.

When I called Early Intervention, the receptionist con-firmed that their focus was on disabilities and delays in thingslike talking or walking, but she suggested I go ahead and

schedule an evaluation. If the toddler did turn out to havea delay along with the behavior issues, she would likely beeligible for services. In the absence of a delay, it was not clearthey could help.

The second Brooklyn referral I got from LifeNet was for thePark Slope Center for Mental Health, but the operator didnt soundtoo hopefulit was listed as only serving kids 3 and older.

The childhood intake coordinator said they would work withchildren younger than 3, as long as the families agreed to bringthe child in for weekly therapy. After the parent completes aninitial intake with the center, she said, they are put on a wait list,which typically means another six-to-eight weeks before treat-ment begins. This is a long time in a young childs life, not tomention a new parents.

LifeNets final referral was for a center in Manhattan. Theoperator sounded apologetic about thatshe knew schleppinganywhere with a tantrum-prone toddler was difficult, and some-

thing that many clinics discourage. But this was the only place onthe list that specified that it served very young children.

The program, Butterflies at the University Settlement So-ciety of New York, was a name I already knew. They are one ofthe citys pockets of capacity for infant mental health thatclinicians had told me aboutthe programs that are often over-whelmed with referrals since there are so few of them. They areone of a handful of organizations to receive city funding for thetreatment of very young children. But when I spoke with Butterflies director and identifiedmyself as a reporter, I learned they would not have been able towork with the 2-year-old I described to LifeNet. Due to severefunding cuts, the program has downsized since its start in 2006.

They now have just one full-time and one part-time therapist.Both spend nearly all of their time working with the childrenand teachers in University Settlements Early Learn child careprogram, and accept very few outside clients. When they do,they prioritize local families with volatile situations, like onesreferred from foster care.

Despite being booked to capacity, Butterflies funding isnot baselined in the city budget. Rather, it is on the choppingblock year after year, always dependent on its funding beingrenewed by the City Council. Kendra Hurley

A Call for Help: Seeking Services for a Traumatized Tot

as they cheer on the child, says Lindsey DeMichael, a thera-pist at the Attachment and Biobehavioral Catch-Up programfor young children and their caregivers at Forestdale Inc., aQueens foster care agency. She and her colleagues visit withyoung children and their caregivers in their homes, followinga highly-structured 10-week model developed by psycholo-gists at the University of Delaware. Each of these models aims to help children feel more safeand secure with their parents by increasing their positive in-teractions in clear and concrete ways. Therapists may try toreduce a parents stress by finding legal help for a family on

the verge of eviction, or sending a depressed mom to a psy-chiatrist. They arm parents with the kind of fundamental in-formation about child development that helped one motherunderstand that her 3-month-old baby could not actually beflipping her off when he lifted his middle finger, as she be-lieved. Another mom who had been sexually abused neededhelp to understand that when her baby touched her breast

while nursing, it was not a sexual gesture.The bulk of the work in many of these programs involves

helping parents become what Buckner of Chances for Childrencalls baby watchers, parents who have a curiosity about their


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CHILD WELFARE WATCH

child and their childs world, and who respond to their babiesin a way that recognizes them as separate from themselves.

Take a situation where a father picks up his toddler sonfrom child care and brings him to a grocery store, where theboy throws a tantrum as they wait in line. A parent who is notattuned to his child, or who is already stretched to the break-

ing point, might start screaming at the child. Or he mighttake the advice of others on the line who tell him he needsto take control and smack the child. This would likely exac-erbate the situation, causing dad and child to feed off eachothers anger and unhappiness. Its a circle where everybodyis bringing out the worst in each other, says Chinitz. But a parent who reflects before reacting might try to un-derstand why the toddler is so frustrated and even help himunderstand his own experience by saying something like, Iknow youre very tired. Weve been out all day. Relationship-based therapy tries to nudge parents to this point.

Most kids who come to our attention at a very young

age needing infant mental health care are responding to some-thing in their caregiving circumstances, so theres very littleuseful work you can do with that child themselves withoutchanging whats distressing with the caregiving situation, ex-plains Chinitz. Were really trying to shape the way parentsrespond to their children.

Championing reflective, supportive parenting, however,could be considered a mere personal or cultural preference.

After all, parenting styles can differ radically among differentcultures, generations, even spouses. Who has the authorityto say whats the right way to parent? Complicating matters,the women running the centers and clinics that practice re-

lationship-based therapy are overwhelmingly white, with ad-vanced degrees, while the parents they work with are largelypoor women of color. Parents in treatment sometimes find that

when they bring new parenting skills back home, neighborsand family members disagree with the approach. The parentsthemselves frequently raise the question of whether the meth-ods advocated by therapists are really right for their own fami-liesfamilies struggling to raise children with limited supportsand resources, often in neighborhoods riddled with violence,addiction, unemployment and failing schools. For instance,many of the moms who come to the Early Childhood Centerlike to engage their children in educational activities, such as

learning the alphabet. The therapists, on the other hand, preferplay for young children. Whos to say which is better? Those in the field insist they take great efforts to stay opento these differences and remain mindful that plenty of children

whose parents never get down on the play mat with them stillgrow up with ample love and stimulation. They say they makean effort to not be didactic, but to instead encourage parents toreflect on what worked and what didnt in the way they them-selves were raised, and to experiment with new parenting tech-niques, like following a childs lead instead of teasing. This wayparents can come to their own ideas of what will work for them

and their families. Were really not prescribing a particularway of parenting, but trying to get parents to think about theirparenting and not do things automatically, just because thatsthe way they were done in their families, says Chinitz. Werenot really telling them what to do so much as to get them tothink about things through their kids eyes.

Research suggests these interventions are having a positiveimpact. Studies have found that young children who receivedthe Attachment and Biobehavioral Catch-Up intervention be-ing used at Forestdale, for instance, experienced less stress and

were more frequently securely attached to their caregivers thanchildren who received a different intervention. In a peer-re-viewed, control group study, Chances for Children found that

infants who had received its intervention showed an increasein interest in their mothers and responded more positively tophysical contact, compared to another group of infants whodid not participate in its program.

Another model, known as Child-Parent Psychotherapy,has been demonstrated to be effective and replicable through

high-quality evaluation research and is thus widely recognizedas an evidence-based program. It is one of the most influ-ential models and is used in many clinics nationwide that dorelationship-based work with young children. In New York, itis used at the Jewish Board of Family and Childrens Services(JBFCS) Institute for Infants, Children & Families, and isslated to soon be used by the Association to Benefit Chil-dren in Manhattan and the Jewish Child Care Association inBrooklyn to help families stay out of the foster care system.

Among the findings: Children aged 5 and younger who hadwitnessed domestic violence and received this intervention

Trauma in earlychildhood doesnt looklike trauma to peoplewho dont know whattheyre looking at. Itcan look like a behaviorproblem. It can look like

bad parenting. It canlook like neglect.


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Franchesca Davis and herdaughter took part in a dyadic

therapy program for familiesinvolved in Family Court.


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CHILD WELFARE WATCH

HOW CAN A PRACTITIONER tell which programs are most likely tomake a positive difference in the lives of children and their families?

In Beyond Common Sense: Child Welfare, Child Well-Being,and the Evidence for Policy Reform, five researchers attempt toanswer the question. They examined programs that have beendemonstrated through research to be effective and identifiedthe characteristics commonly found among those programs.Programs that work for young children, they discovered, fre-quently have these characteristics: They are active and experiential rather than didactic;

caregivers learn through doing and experimenting ratherthan simply through instruction.

They are relationship-based, focusing not just on the child orcaregiver, but the relationship between them.

They address mental health issues and are led by skilled,

professional staff. They are long-term, preferably lasting six months or more,

and are delivered on a weekly or bi-weekly basis.

They are often evidence-based, meaning theyve beendemonstrated to be effective through rigorous evaluation.

They target a specific type of parent, such as one strugglingwith addiction or mental health issues, but tailor services tomeet each individual familys needs.

They take advantage of the window of opportunity justbefore and after a babys birth when parents are especiallyreceptive to help. Rahil Briggs and Andrew D. Racineexplained the clinical significance of this moment in InfantMental Health Journal: Even in the most at-risk families,with previous histories of neglect or abuse, each new babyappears to present a brief opportunity to do it right this

time around. There is often a sense of hopefulness, ratherthan the hopelessness which sets in all too soon in our most

stressed and underprepared families.The California Clearinghouse for Evidence-Based

Practices for Child Welfare is a good place to learn aboutspecific therapies that work with caretakers and youngchildren together, and that have been demonstrated throughresearch to work well for families. These include:

Child-Parent Psychotherapy, which has been found in peer-reviewed research to strengthen the attachment betweeninfants and mothers, and to reduce symptoms of traumaticstress disorder and behavior problems in young childrenexposed to violence.

The 10-week Attachment and Biobehavioral Catch-upprogram, which has been demonstrated to help young

children experience less stress and become more securelyattached to their caregivers than children who received adifferent intervention.

Interaction Guidance, which uses videotaped interactionsbetween children and caretakers to reinforce positiveinteractions and help caregivers learn about infant behaviorand development. It has been found to improve mother-child interactions.

To learn more about programming that works, visit theCalifornia Clearinghouse for Evidence-Based Practices forChild Welfare (http://www.cebc4cw.org) and see BeyondCommon Sense: Child Welfare, Child Well-Being, and the

Evidence for Policy Reformby Fred Wulczyn, Richard P. Barth,

Ying-Ying T. Yuan, Brenda Jones Harden and John Landsverk,published in 2005 by Aldine Transaction.

What Works: Characteristics of Effective

Programs for Infants, Toddlers, and their Caregivers

had a greater reduction in behavior problems and traumaticstress syndromes than those in a control group.

A Dearth of Government Supportfor the Citys Youngest

In the 1990s, the philanthropist Irving Harris, who helped

JBFCS create a training program around infant mentalhealth, made a prediction: In 20 years, the country wouldrecognize the urgency of addressing infants social and emo-tional needs, but there would not be a trained workforce ofleaders able to rise to that challenge.

To many in the field, Harris prediction has come toseem prophetic. Brain scan technology has turned the ab-stract notion that early childhood experience has immenseinfluence into something concrete: We can now see that anabused childs brain can look and behave differently fromthe brains of other children. But despite the growing aware-

ness of the developmental importance of early childhood,New York City has yet to develop a systematic response tothe emotional and social needs of babies and toddlers. Thecity and state health departments manage the Early Inter-vention Program, which funds services for children underage 3 who are at risk for or who have developmental delays.In theory, the program can work with small children on so-

cial and emotional issues, but in practice, it is not designedto address the impact of trauma.

The city has a handful of centers and clinics that somein the field describe as little pockets of capacity to work

with young children, but few provide the kind of long-termdyadic therapy that the Early Childhood Center or Chancesfor Children provides. There are really not treatment slotsfor young children, particularly children who are the mostvulnerable, kids who need intensive services, says EvelynBlanck, associate executive director of New York Center forChild Development and chair of the New York City Early


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Childhood Mental Health Strategic Work Group.Last year, an analysis by the Citizens Committee for Chil-dren estimated that nearly 47,500 New York City childrenages 4 and under have a behavior problem as defined by the

American Psychiatric Association, which includes diagnosessuch as hyperactivity or oppositional defiance disorder. But atthe state-licensed mental health clinics in Brooklyn, the Bronxand Staten Island, there were treatment slots for only 270, or 1percent, of those children. (They couldnt identify the unmetneed citywide, due to the lack of data for Queens and Manhat-tan.) The analysis found treatment slots to be especially lacking

in the community districts needing them most.Those in the field say that a large part of the problem isthat the level of state and city funding has been inadequate fora long time and isnt getting any better. Relatively few publicdollars are targeted to mental health services for New Yorksyoungest children, the Early Childhood Mental Health Stra-tegic Work Group wrote in 2011.

Ten years ago, Chinitz set out to change this. The EarlyChildhood Center was inundated with referrals for strugglingyoung children. The citys children who had been born at theheight of the crack epidemic were rapidly becoming parents

FY 2012-13:

Source of Funding Funding Amount Early Childhood Services Agency/Program

City Council $200,000 Social emotional screening and trauma screening; Parentaldepression screening; Mental health consultation to staff;Mental health treatment, where indicated, to families

Safe Space

City Council $200, 000 Social emotional screening; Parental depression screening;Mental health consultation; Social emotional training tostaff; Mental health treatment (dyadic therapy)

University Settlement

City Council $75,000 Mental health consultation and training; Family workshops JBFCS

City Council $100,000 Social emotional screening; Maternal depressionscreening; Mental health treatment (psycho-education andsupportive counseling )

OHEL Childrens Home andFamily Services

City Council $100,000 Social emotional screening; Maternal depressionscreening; Social emotional training to staff (homevisiting); Parent training (Parent Corps)

Child Center of New York

City Council $60,000 Mental health consultation to staff; Mental healthtreatment

Staten Island MentalHealth Society

City Council $400,000 Social emotional screening; Maternal depressionscreening; Mental health treatment (dyadic therapy);Parental visit coaching (child welfare); Mental healthconsultation (family court; early care and education)

Albert Einstein Collegeof Medicines Early ChildhoodCenter

City Council $100,000 Trauma screening; Training on trauma Safe HorizonCounseling Center

NYS OMH /

NYC DOHMH

$400,000 Social emotional screening; Mental health consultation New York Center for Child

Development (NYCCD)

NEW, KNOWN FUNDING FOR FY 2014:

OCFS $131,500 Mental health consultation (Manhattan family court);Mental health treatment (dyadic therapy for court-involved families); Intensive reunification and placementplanning (child welfare)

Association to Benefit Children inManhattan and Jewish Child CareAssociation

ACS n/a Mental health treatment (dyadic therapy) University Settlement

ACS n/a Low intensity treatment CAMBA

NEW YORK STATE AND CITY FUNDING FOR EARLY CHILDHOOD MENTAL HEALTH

Following is a list of all city and state funding for early childhood mental health services that Child Welfare Watch

was able to identify. This does not include federal funding, such as Medicaid, or three federal grants that have been

awarded to ACS, the Child Study Center at NYU Langone Medical Center, and Bellevue Hospital to support programs

assisting NYC children with mental health needs, including some mothers who have experienced trauma and who

are parenting children 5 years old and under. Nor does this chart include the city and state-run Early Intervention

Program for children with disabilities and developmental delays.


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CHILD WELFARE WATCH

themselves, and many had been abandoned by their familiesand grown up in foster care with few models for how to parent.

Five of the infants that the Early Childhood Centerworked with at the time had each witnessed their mothersmurder. A number of the toddlers and young preschool chil-dren had been sexually abused. Many young children in their

clinic had bounced from one foster home to another or hadbeen kicked out of child care centers and preschools becausetheir behavior was so difficult to manage. Then there werethe referrals the center could not accept, because they simplydid not have the resources. Chinitz believed that waiting untilthese children were 5 or 6an age for which there are farmore services availablewas wasting valuable time.

So she began leaving the clinic each day to knock on thedoors of power, making impassioned pleas for governmentofficials and policymakers to invest in the field. She spokeabout the aggressive and hyper-vigilant toddlers who had wit-nessed street shootings or seen their mothers beaten by their

fathers or their mothers boyfriends. She spoke about youngchildren in foster care who had not had an opportunity toform an attachment with a trusted adult. She talked about theimpulsive and irritable children, whose stressed, sometimesdepressed mothers struggled to manage.

Sometimes she referenced the Nobel prize-winning econo-mist James Heckman, who has demonstrated how investing ineffective early childhood interventions can yield huge cost sav-ings for society. According to Heckman, there is a steep declinein these savings even by the end of a childs third year of life.The longer society waits to intervene in the life cycle of a disad-vantaged child, the more costly it is to remediate disadvantage,

Heckman wrote. Gaps in development open up early and areextremely difficult and expensive to close.In 2004, then-City Councilmember Margarita Lopez

took heed. She organized a hearing and pressed for fundingfor a handful of early childhood programs. This led to animportant recognition among the citys child-serving mentalhealth clinics. Previously, most everyone assumed these clin-ics could not serve children under age 5. But Lopez helpedclarify that this was not the case, and made these clinics awarethat they could amend their licenses to treat children of allages if they were not already authorized. Nonetheless, thelarger problem still lingered, as Harris had predicted: Most

clinics lacked the expertise to do dyadic work with youngchildren and their caretakers.Today, nearly 10 years after Councilmember Lopez re-

sponded to Chinitzs pleas, not a lot has changed. Few clinicscan work with babies, though how many no one knows for surebecause the states Office of Mental Health does not keep track.

In the last few years, the Office of Mental Health has be-gun funding nine agencies in New York City to screen for ear-ly childhood mental illness. This screening does not providemoney for treating the children or training people to providethe interventions. We are going to identify all these people

who need services, but with no money to train, where willthey get served? asks Dorothy Henderson, director of earlychildhood trauma services and associate director of trainingat JBFCS Institute for Infants, Children & Families. Theresnot a lot of people who can work with babies.

During the recession, JBFCS had to close the training

program Irving Harris had helped start, which had producedmany of the citys infant mental health leaders. Meanwhile, theCity Council has remained one of the only sources of govern-ment funding for early mental health treatment. That fund-ing, which also covers services like screening and evaluating,has decreased from its height of over $1.6 million about fiveyears ago to the $1.25 million to be distributed among eightorganizations in fiscal year 2014, and the money is at risk ofdisappearing each year. Meanwhile, most mental health initia-tives serving children under 5 rely on private funding and ne-gotiating creative ways to get Medicaid to pay for dyadic work. Some in the field say a large part of the funding chal-

lenge is the misperception that little children are immune totheir surroundings, including stress and trauma. Traumain early childhood doesnt look like trauma to people whodont know what theyre looking at. It can look like a be-havior problem. It can look like bad parenting. It can looklike neglect, says Bonnie Cohen, director of the Univer-sity Settlements Butterflies Program, which provides earlychildhood mental health services.

But Joaniko Kohchi, a child development specialist at theEarly Childhood Center, believes infants get routinely over-looked because they cant do harm. Mental health, in general,people dont want to talk about unless they have to, and they

only have to when someone is dangerous, says Koachi. Littlebabies dont scare people. They dont need to be incarcerated. Franchesca Davis counts her daughter Haylee amongone of the lucky ones to have benefited from the advocacyefforts. About a year after Davis lost custody of 9-month-oldHaylee, the two began receiving therapy tailored for familiesinvolved in Family Court. Just 19 years old, Davis had alwaysknown she didnt want to punish Haylee by hitting her, the

way she herself was raised, but she didnt have a clear idea ofhow she did want to parent.

Relationship-based therapy has helped her figure it out.Today Davis shares custody of Haylee, now 4, with the girls

father, and Haylee lives in Davis apartment three days eachweek. Davis still remembers how strange it felt the first timeshe sat down to play with her daughter at the Early Child-hood Center. It was just the two of them, with nothing inbetween them. At home, the baby usually stayed in the crib,

with the TV on. Now, when Davis watches that first video ofthem playing before they received dyadic therapy, she shud-dersyou can tell she and Haylee have a bond, she says, butshe seems so cold with her daughter, so bossy. Yet in the finalvideo ECC made of the pair, Were like kids in a candy store.

We were together in unison. e


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Seen and

HeardA video-feedback parentingprogram helped my son and me.

BY PIAZADORA FOOTMAN

MOST PARENTS WHOSE children enter fostercare have to take parenting classes in order to get their chil-dren back. I went to two parenting classes that didnt helpbefore I found a program that worked for me.

The ones that didnt help were the ones where the in-structor read to us from a big parenting skills book or playedold videos of moms trying to get their kids to listen. Then theinstructor would say, Ok, what did you learn? or just, Hey,use the skills you saw today in this video.

Id sit there thinking that the strategies didnt apply tomy son. The book would say to put your kid in a time out ifhe acted out, but when I tried time out with my son, it onlymade him angrier. When I told the instructor that, she justsaid, Keep trying. I felt defeated, like a failure.

At the time, my 5-year-old son was living with mygrandmother because Id been arrested and then placed in amental health facility for 18 months. By the time I moved

back home, Id overcome an addiction and was managingmy bipolar disorder. Xavier was about to come back homeand I felt overwhelmed because we still didnt have thatmother-son respect level. I wanted it to be that I spoke tomy son once and he would listen, period, end of story. But

Xavier was not listening the first, second or third time I toldhim to do something. I had to understand that thats notquite how kids are. Eventually the court sent me to a different kind of par-enting program, a video training at a program in the Bronxcalled Chances for Children. Each week, they took video ofme playing with my son and then the therapist discussed it

with me. At first I felt like, Ugh, I dont want to be here. Itlljust be a repeat of the last two classes. But it was different.With the video, I got to see the problems between my son andme from a different point of view.

During our video sessions, Ms. Martha would haveXavier and me play on the carpet with different toys. In themiddle of the session, shed stop the tape to show me what shenoticed. She said that it was good that I even wanted to play

with my son, and that she could tell that we normally playwith one another. She also noticed that when we were color-ing, Xavier longed for my approval of his picture. Ms. Martha

told me this meant Xavier cared about what I thought, whichis a sign of a mother-child bond.

Ms. Martha also showed me how I was frustrating Xavierby moving too fast from toy to toy. I kept changing the toysbecause I was bored with them instead of waiting for him tofinish. This would make Xavier upset. He would try to get the

same toy again. I thought Xavier was too young to understandplaying. I wanted to teach him how to follow instructions sohe could play with his toys how they were meant to be played

with. I didnt understand his way of playing, that it didnt mat-ter if he followed the instructions if he was enjoying himself. It was hard to watch the first days video. When I saw my-self pressure Xavier into playing with a new toy because I wastired of playing with the old one, I felt like I was being a bully,not a mom. But after that session, I felt amazed. Ms. Marthahad already helped me understand why my son got frustrated

when we played together; he was unable to finish tasks that hestarted. Martha told me it was OK if Xavier stayed on tasks a

little longer than I preferred.At first, when I tried to follow Ms. Marthas advice at

home, it was a disaster. Xavier took so much time to play thathe didnt want to stop to eat or take a bath or do anything thathe wasnt ready to do! At our next session, I told Ms. Marthathat I could not just simply let him play as long as he wanted.

We had things to do besides play!She told me about the egg timer approach. I would set

the egg timer to go off 10 minutes before I wanted Xavier todo a different task. The countdown helped Xavier understandthat playtime was almost over. At home, the egg timer ap-proach didnt work immediately, but eventually it worked so

well that I just gave Xavier early warnings and we gave the eggtimer a rest.From our video parenting sessions, I learned that Xavier

needed me to be more patient with him and to hear him out.I also felt like he began to understand that when I gave him

warnings that it was time to stop playing, he had to listen. The biggest change was in my thinking. When mygrandmother raised me, she acted like children should haveno say-so, no thoughts, no feelings and, point blank, novoice. When Xavier was young, I found myself inhabited bymy grandmothers ghost. I treated Xavier the same way. The video parenting helped me realize that kids have their

own minds and have real feelings too. Now that Ive acknowl-edged that children are human just like me, I can talk withthem instead of demanding. When I first went to the videoparenting, I just wanted to get Xavier to listen to me. From ourexperience, I learned that I needed to listen to him, too. e

Piazadora Footman is 28 years old with three children, ages 12, 8and 4. She is a graduate of Child Welfare Organizing Projects ParentLeadership/Advocate curriculum and the editorial assistant at Rise, amagazine written by and for parents in the child welfare system, wherea version of this article first appeared. The latest issue of Risefocuses onthe impact of trauma on parenting.


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CHILD WELFARE WATCH

The Science

of TraumaTogether, behavioral psychologyand neuroscience are reshapingour understanding of thedamage caused by trauma inearly childhoodand how goodparenting heals the wounds.

BY ABIGAIL KRAMER

Fifteen years ago, a clinical psychologist named Philip Fish-er and his wife applied to the State of Oregon to adopt a2-year-old boy. Fisher had been working with older kids formany years, mostly in psychiatric treatment programs foryouth whose behavior problems had gotten them into serioustrouble. Fisher believed in his workhed seen that, in theright environment, kids could begin to exorcise demons thathad plagued them, in some cases, since before their consciousmemories began. But he was disturbed by the feeling thatmore could have been done if the children had been treated

at a younger age. There arent many late starters in juveniledelinquency, he says. Parents always said things would havebeen different if they had gotten help early.

THE CONTEXT:

In recent years, scientists

have begun to understand

how childrens earliest

experiences shape the way

their brains grow.

THE ISSUE:

Can science help us

preventand recover

fromthe damage caused

by stress and trauma in

childhood?


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AS HE WADEDthrough the bureaucracy of his own sonsadoption, Fishers professional concerns collided with his per-sonal life. The proceedings dragged on for nine monthsa developmental lifetime compared to the speed at which atoddler grows and learns, adapting to the turbulence that isinherently part of foster care. Fisher worried that he was miss-

ing a crucial window of opportunity to impact the course ofhis childs life.

As it turned out, the nature of that developmental win-dow (how it works, why it matters, how to influence it for thebest) was the central concern of a newly burgeoning field ofscienceone that was, back in the late 1990s, just beginningto unriddle one of the fundamental mysteries of childhood:how the things we experience when were very youngeven

when were too young to rememberaffect who we becomelater in life. Child psychologists (along with most of the rest of us)have long understood that theres a connection between trau-

matic childhood experiences and poor life outcomes. Theresbeen a recognition for at least a century that children who areneglected or abandoned are at risk of problems, says JackP. Shonkoff, M.D., director of the Center on the Develop-ing Child at Harvard University. By the time Fisher filed hisadoption request, studies had documented enduring linksbetween stress and trauma in childhood and a long list ofproblems later in life, ranging from mental illness to obesityto cancer. Until recently, however, scientists had little insight intohow those links workedor how early in life they can form.The predominant belief, Shonkoff says, was that if really

bad things happen when children are very young, if you canget them out of those situations early, either they wont reallyknow whats going on or they wont remember. There was ageneral belief that things that happen to very young childrencant affect them years later. Over the past decade and a half, Shonkoff, Fisher anda scattered constellation of researchers across the countryhave proven that belief wrong, engendering a very new un-derstanding of what children need and how they grow. Theyhave begun to look under the hood at the mechanics of de-velopment, revealing how early experiencesespecially thoseinvolving trauma and chaosget built not just into childrens

minds but their brains and bodies. Its a relatively youngline of inquiry, but its breakthroughs have come about, inlarge part, through the crossbreeding of two long-establishedstrains of thought: that of behavioral psychologya field thataccumulates its knowledge mainly through observation andself-reportingwith the bloodier science of animal brain de-velopment.

For several decades, neurobiologists have subjected ani-mals like rats and rhesus monkeysmammals whose brainsgrow in patterns remarkably similar to our ownto experi-ments designed to trace the impacts of psychological trauma

early in life. One frequently repeated experiment has beento traumatize baby rats by separating them from their moth-ers and siblings for significant periods each day. After wean-ing, the rats are not only likely to be cognitively impairedless able to learn, remember and solve problems than otherratsbut they exhibit behaviors that mirror mental illness

in humans, like anxiety, depression and an unhealthy pen-chant for ethanol. When scientists examine the rats through adolescenceand adulthood, they find that the psychological problems arematched by an array of physiological abnormalities, the sumof which converge on a rather astonishing finding: The ratsexperience of trauma early in life literally changes the waytheir brains develop, altering hormone function and stuntinggrowth in areas that are essential, in humans, to thinking,remembering and controlling emotions.

Scientists at Shonkoffs research center explain thephenomenon through the metaphor of architecture: Infant

brains (whether they belong to rats, monkeys or people)are genetically programmed to grow and make connectionsin response to experience. When babies environments arehealthy, their neural connections grow sturdy and effective,providing a strong foundation for future learning and de-velopment. When they are exposed to repeated stress, theeffect is toxic, weakening brain growth in ways that can dopermanent damage.

The ongoing challenge for child development researchersis to decipher the blueprintsto find out which experiencesmatter and trace the pathways by which they do harm. Itsa project with tantalizing prospectsa kind of neurological

treasure hunt that promises clues not just to further our un-derstanding of brain development but, in its furthest extrapo-lation, to decode the enigmatic connection between biologyand character. If we could better understand the physiologi-cal legacies of our experiences, might it be possible to mapour personalitieseven, to some extent, our destinesontoa network of chemical pathways and neural wiring? Howdoes adversity change who we are? How do our environmentsmark and define us? To what extent are we trapped by ourpasts, and how do we understand the potential to overcome? Its a body of questions with profound implications forour approach to early childhood. In the longstanding debate

over nature versus nurture, says Jack Shonkoff, the versusis scientifically dead. In its place, he argues, these investiga-tions charge us with a renewed imperative to fulfill one of thebasic obligations of a social contract: improving the condi-tions in which children and their families live. You put up abrain scan and people get excited, Shonkoff says. Oh mygod, this is real!

Human babies are born with approximately 100 billionneurons, each connected to thousands of others through an


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CHILD WELFARE WATCH

immensely intricate network of chemical pathways calledsynapses. Each experience a baby is exposed toeverythingshe sees, every song shes sung, every time shes held or fedor smiled atsends a series of electrical impulses shooting

through the developing circuits of her brain, strengtheningpathways and inciting new synapses to grow. During the firstfew years of life, that growth happens exponentially. At itspeak, the cerebral cortex region of an infants brain can pro-duce two million new synapses every seconda warp-speedneural spider web that sets the parameters of a persons capac-ity to think, learn and process emotion. Connections that arestimulated consistently over time will grow stronger. Others

will weaken and die. The raw materials of brain development are predeter-mined, encoded in the 23,000 genes we inherit from our par-ents. But the way those genes behavewhether they live up

to their potentialis determined in large part by the inputswe get during the first few years of life.Since the 1970s, psychologists have posited that the key

ingredient to a childs development is her emotional attach-ment to her caregivers. As babies, the idea goes, we depend onadults not just to make sure were fed and clothed, but to re-spond to our cries, our facial expressions, our inquiries aboutthe world and our attempts to connect. Behavioral researchersare fond of quoting the psychologist Urie Bronfenbrenner,famous for founding the Head Start program for low-incomepreschoolers. In order to develop normally, Bronfenbrenner

wrote, a child needs to interact with one or more adults who

have an irrational emotional relationship with the child.Somebodys got to be crazy about that kid. Attachment theory has reigned as the dominant philoso-phy of child wellbeing for close to half a century. The trouble

with hypotheses about behavioral psychology, however, is thatthey are difficult to test. In order to isolate the impacts ofnurturing parenting, researchers needed the chance to studya control groupin other words, a large group of kids whonever got to be nurtured. That opportunity arose with the fallof the Socialist Republic of Romania, when Western scientistsdiscovered Romanian orphans.

In the mid-1960s, Nicolai Ceausescu, the Stalinist lead-er of Romania, invoked a series of laws designed to increasehis countrys human capital by forcing up its birthrate. Heoutlawed contraception and abortion, subjected women to

compulsory fertility tests and taxed families that producedfewer than five children. Childbirth shot up, as did poverty.The state was obligated to create hundreds of institutionalorphanages to care for babies whose parents didnt want orcouldnt care for them.

When Ceausescu was deposed in the 1989 RomanianRevolution, nearly 170,000 children were living in state insti-tutions that Western reporters, newly allowed into the coun-try, described as being more like warehouses than orphan-ages. Babies and toddlers spent day and night in rows of cribs,removed only to sit on pots they used as toilets. They wererarely held and had almost no one-on-one interaction. The

buildings were mostly silent. Thousands of Romanian orphans were taken into homesin the United States, where adoptive parents discovered that,despite the drastic change in their circumstances, many suf-fered from severe and persistent problems. A significant num-ber had stunted growth or abnormally small heads. Many

were cognitively impaired or had behavior disorders andextreme difficulty engaging in relationships. For some kids,some of the problems dissipated over time; others provedmore stubborn. In 2000, a team of American neuroscientists traveled toRomanias capital, Bucharest, to study children in its orphan-

ages, which remained the countrys default form of care fororphans and unwanted kids. Starting with a group of 136children, aged 5 months to 2.5 years, the scientists ran teststo measure cognitive and emotional development, then com-pared the results to a group of same-aged Romanian children

who lived at home.In every domain, the researchers found evidence that

institutionalization had done tremendous damage. Kids inthe orphanages showed diminished electrical activity in theirbrains, slower neural reactions and weaker connections be-tween areas of the brain that integrate information. Their

Each experience a baby is exposed toeverything she sees, every song shes sung,

every time shes held or fed or smiled atsends a series of electrical impulses shootingthrough the developing circuits of her brain.


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cognitive scores were at a level associated with mental retar-dation. They demonstrated almost no attachment to theircaregivers and, when researchers tried to engage them withactivities like peek-a-boo or puppet shows, no ability to expe-rience amusement or joy. The researchers assigned half the children to specially

trained Romanian foster parents, leaving the other half in in-stitutions. Over the next several years, they ran developmen-tal tests aimed at finding out if, when and how the childrens

trajectories diverged. What would change when terribly ne-glected babies began receiving individualized care? Could the

damage be undone?The answer turned out to be both yes and no. At 30months, the children who had been moved into foster homesshowed a capacity to express positive emotions that was indis-tinguishable from children who had never been institutional-ized. After a year of foster care, they matched the expressiveand receptive language skills of children in the communitycontrol group, though their grammatical abilities remainedlow. By 54 months, their average IQ score had risen by aboutseven pointsstill much lower than that of kids who hadnever been in orphanages, but an improvement over children

who had remained there. The latter groups average scoredropped by one.

There was one area, however, in which foster care madealmost no difference. All of the institutionalized kidsthose who had been moved into homes as well as those whoremainedwere diagnosed with drastically higher rates ofdepression, anxiety, ADHD and conduct disorders thanchildren in the community control group. At 54 monthsold, more than half were found to have a diagnosable psy-chiatric illness. In a 2009 paper on their findings, the Bucharest Studyresearchers noted that the childrens impairmentsand im-

provementswere not evenly distribu

child welfare watch: baby steps

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