6/10/14 HOW TO EVALUATE THE YOUNGEST ABUSED AND/OR NEGLECTED CHILDREN AND THEIR CAREGIVERS: DO S INFANTS IN THE CHILD WELFARE SYSTEM

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1 HOW TO EVALUATE THE YOUNGEST ABUSED AND/OR NEGLECTED CHILDREN AND THEIR CAREGIVERS: DO S AND DON T S Stacy Kurtz, M.A. Amy Dickson, Psy.D. Christina Danko, M.A. Michele Many, MSW, LCSW, BACS Louisiana State University Health Sciences Center New Orleans, LA INFANTS IN THE CHILD WELFARE SYSTEM Infants under the age of one year are the largest cohort in the child welfare system In FY 2012, about 16% of children entering care were under age one About 47% of children entering care were five years of age or younger Infants and young children are most likely to be abused and neglected 79% of child fatalities occur in children under age 4 Young children typically remain in placements twice as long as older children 25-40% of young children in foster care are diagnosed with significant behavior problems INFANT MENTAL HEALTH: WHAT IS IT? The developing capacity of the child, birth to 3 years old, to experience, regulate, and express emotions The ability to form close and secure relationships The ability to explore the environment and to learn Occurs in the context of family, community, and cultural expectations for young children Focus is on health social and emotional development, rather than psychopathology 1

2 ATTACHMENT Is relationship specific Deep and enduring connection between child and caregiver Reciprocal interactions (dance) Psyche of child develops in relation to a real, influential parent Lays the pathways in the brain for future development and future relationships EFFECTS OF ABUSE AND NEGLECT Infants Can result in a loss of routine, predictability, and stability interfering with the baby s development of self-regulation Chronic stressors can cause changes in the brain and nervous system which may result in hyperarousal, persistent fear response, or dissociation Toddlers Can result in a loss of capacity for normative exploration Can lead to the loss of the caregiver as a secure base (not having encouragement and protective presence to permit toddler to explore the world) LSU INFANT TEAM Began in 1998 working in Orleans Parish Receive referrals from Department of Children and Family Services (DCFS) caseworkers for children entering foster care between birth and 5 years Currently includes: Director/Licensed Clinical Psychologist Child Psychiatrist Licensed Clinical Social Worker Two Pre-Doctoral Clinical Psychology Interns 2

3 LSUHSC INFANT TEAM SERVICES Complete evaluations with all caregivers Biological parents All foster parents Any potential relative placements Individual and/or dyadic work with family Individual therapy with biological parent Dyadic therapy with biological parent and child (child-parent psychotherapy) Focus on treating the relationship between the biological parent and child Offer dyadic therapy services for foster parent and child if needed LSU INFANT TEAM EVALUATIONS Typical evaluation with caregivers involves: Consent and HIPPA form Initial Interview Caregiver Perception of the Child Interview Caregiver-Child Interaction Observation Genogram Standardized Measures Parenting Stress- biological and foster parents Depression- biological parent Developmental screener- caregiver rating of child Trauma screener- caregiver rating of child (3+ years old) CAREGIVER PERCEPTION OF THE CHILD INTERVIEW Working Model Interview of the Child (WMCI) Adapted in 1996 from the Adult Attachment Interview (AAI) by Mary Main (Benoit, Zeanah, Parker, Nicholson, & Coolbear, 1997) Semi-structured interview to assess caregivers internal representations of their relationship to a child and about that child Follow outline and necessary probes Do not follow-up with therapeutic or information gathering questions 3

4 CAREGIVER PERCEPTION OF THE CHILD INTERVIEW WMCI (con t) Considerations: Should be set in a comfortable place Good to let interviewee talk freely Questions should be asked in a relaxed, non-clinical fashion Important to listen to entire interview before making judgments about internal representations CAREGIVER PERCEPTION OF THE CHILD INTERVIEW WMCI Qualitative Factors to Observe: Richness of detail Openness to change Intensity Coherence Caregiving sensitivity Acceptance CAREGIVER PERCEPTION OF THE CHILD INTERVIEW WMCI Overall Representations: Balanced Full Restricted Strained Disengaged Impoverished Suppressed Distorted Distracted Confused Role Reversal Self-Involved 4

5 CAREGIVER PERCEPTION OF THE CHILD INTERVIEW WMCI Highlights: How did you feel when you discovered you were pregnant? First reaction to child Personality and relationship characteristics Who do they remind you of? What is unique about your child? Difficult behavior Favorite story Setbacks Teen/Adult projections CAREGIVER PERCEPTION OF THE CHILD INTERVIEW: WORKING MODEL OF THE CHILD INTERVIEW VIDEO EXAMPLES OBSERVATION Decide best observation based on age/ developmental level of the child Still Face Interaction Children under 7-8 months of age or children that cannot sit independently Can be used for handicapped or delayed children Modified-Crowell Observation Beginning when child can sit independently 5

6 OBSERVATION: STILL FACE Developed by Tronick called the Mutual Self- Regulation Model Can be used in a variety of ways Directions: Interaction Still Face Interaction Situate chair close to the child Do not touch the baby No pacifiers or other soothers No distractions in the room OBSERVATION: STILL FACE What to observe: Affect attunement Aversion Bids for interaction with caregiver Caregiver s ability to read cues Indicators of child distress OBSERVATION: STILL FACE VIDEO EXAMPLES 6

7 Developed by Judith Crowell to assess models of attachment Crowell Procedure: 10 minute free play Clean-up Bubble play 4 graduated structured tasks Separation Reunion Administration: Have child wait outside room while clinician explains instructions to caregiver Communicate with parent to let them know to start the next task (i.e., knock on wall) Need to have appropriate free play toys and toys for structured tasks that are developmentally appropriate Do not have toy items or soothing objects in the room What To Look For: Child variables: Depression/withdrawal from interaction Irritability/anger Non-compliance Aggression Enthusiasm Persistence with tasks Caregiver variables: Behavioral and emotional responsiveness Positive affect Withdrawn/depressed behavior Irritability/anger/aggression Discipline Tone of interaction 7

8 What To Look For: Free play: Sharing the lead in the play Eye contact Conversation Physical contact Affect and affection Level of control Clean-up: Compliance What To Look For: Bubbles: This is to help calm the child who may have had a stressful clean-up Level of control Affect Enjoyment Tasks: Developmental data Helpfulness/scaffolding Cooperation Praise Affect Anticipate frustration and manage it Focus How to handle extra time What To Look For: Separation: Does the parent prepare the child? How anxious is the parent? What does the parent do while watching the child? How does the child respond to the parent leaving? Reunion: Recognition of child s experience Contact- physical and emotional When does the child calm? Behavior of the child towards the caregiver 8

9 OBSERVATION: MODIFIED CROWELL VIDEO EXAMPLES ADDITIONAL ASSESSMENT TOOLS Genogram Standardized Self-Report Measures Parent Stress Index- Short Form (PSI/SF) Biological Parents, Foster Parents, Relative Caregivers Beck Depression Inventory (BDI-II) Biological Parents Ages and Stages Questionnaire (ASQ-III) Caregiver report of child 0-5 years Ages and Stages Questionnaire: Social Emotional (ASQ-SE) Caregiver report of child 0-5 years Devereux Early Childhood Assessment (DECA) Caregiver report of child 2-5 years Trauma Symptoms Checklist for Young Children (TSCYC) Caregiver report of child 3-12 years LSUHSC INFANT TEAM EVALUATION: SUMMARY Entire LSUHSC Infant Team evaluation process helps inform treatment for the family Indentify strengths and areas of concern in each relationship Identify parent/caregiver relationship to the child(ren) Identify child s relationship to each caregiver Identify how the individuals relate as a dyad Evaluation will inform whether a parent/caregiver has a psychiatric history, substance abuse history, and trauma history that may impact treatment Evaluation guides what will need to be addressed in treatment 9

10 ONGOING TREATMENT WITH LSU INFANT TEAM: OBSERVATIONS Weekly individual therapy with parents Ongoing observations of parent s perception of child Work on rehabilitating reason that child came into care Help parent accept their role in child coming into care Weekly dyadic work with family (Child-Parent Psychotherapy) Focus on relationship between parent and child Observe child s reactions and responses to parent ad parent s interaction with child Look for positive changes over time EVALUATING YOUNG ABUSED AND/OR NEGLECTED CHILDREN : DO S AND DON T S Need to observe child and caregiver together Cannot base opinions solely on parent/caregiver interview Need to observe child with various caregivers Attachment is relationship specific Allows observers to see child s baseline Child s reaction to the parent gives important information about the relationship, even when they are pre-verbal Cannot give a psychological evaluation (i.e., personality measures) and determine an individual s ability to parent a young child without observation Need for professionals that have a specialty in Infant Mental Health to help guide what is necessary with a young abused/ neglected population Appropriate assessment measures Dyadic treatment recommendations SELECTED REFERENCES Benoit, D., Zeanah, C. H., Parker, K. C. H., Nicholson, E., & Coolbear, J. (1997). Working Model of the Child Interview: Related to clinical status of infants. Infant Mental Health Journal, 18, Crowell, J. A. & Feldman, S. S. (1991). Mothers working models of attachment relationships and mother and child behavior during separation and reunion. Developmental Psychology, 27, Crowell, J. A. & Feldman, S. S. (1989). Assessment of mother s working models of relationships: Some clinical implications. Infant Mental Journal, 10, Crowell, J. A. & Fleischmann, M. A. (1993). Use of structured research procedures in clinical assessments of infants. In C. H. Zeanah (Eds.), Handbook of infant mental health (pp ). New York: Guilford. Erickson, S. & Low, J. (2008). The role of maternal responsiveness in predicting infant affect during the still face paradigm with infants born very low birth weight. Infant Mental Health Journal, 29(2), Harmon, R. J., (1990). Unresolved grief: A two-year-old brings her mother for treatment. Infant Mental Health Journal, 11(2), Hernandez-Reif, M., Diego, M., Feijo, L., Vera, Y., Gill., K., Sanders, C. (2007). Still-face and separation effects of depressed mother-infant interactions. Infant Mental Health Journal, 28(3), Karen, R. (1994). Becoming attached: Unfolding the mystery of the infant-mother bond and its impact on later life. New York: Warner Books, Inc. Lieberman, A., & Van Horn, P. (2008). Psychotherapy with Infants and Young Children: Repairing the effects of stress and trauma on early attachment. New York: Guilford. 10

11 SELECTED REFERENCES (CON T) Osofsky, J. D. (1982). The development of the parent-infant relationship. Psychoanalytic Inquiry, 1(4), Osofsky, J. D., Kronenberg, M., Hammer, J. H., Lederman C. S., Katz, L., Adams, S., Graham, M., & Hogan, A. (2007). The development and evaluation of the intervention model for the Florida infant mental pilot program. Infant Mental Health Journal, 28, Rosenblum, K. L., McDonough, S., Muzik, M., Miller, A., & Sameroff, A. (2002). Maternal representations of the infant: Associations with infant response to the still face. Child Development, 73(4), Sokolowski, M., Hans, S., Bernstein, V. (2007). Mothers representations of their infants and parenting behavior: Associations with personal and social contextual variables in a highrisk sample. Infant Mental Health Journal, 28(3), Tronik, E. Z., Cohn, J., & Shea, E., (1985). The transfer of affect between mothers and infants. In T.B. Brazelton & M. Yogman (Eds.), Affective development in infancy (pp ). Norwood, NJ: Ablex. Tronik, E., Als, H., Adamson, L., Wise, S., & Brazelton, T. B. (1978). The infant s reponse to entrapment between contradictory messages in face-to-face interaction. Journal of the American Academy of Child Psychiatry, 17, Zeanah, C. H. & Benoit, D. (1995). Clinical applications of a parent perception interview. In K. Minde (Eds.) Infant psychiatry: Child psychiatric clinics of North America (pp ). Philadelphia, W.B. Saunders. Zeanah, C. H. & Benoit, D. (1994). Mothers representations of their infants are concordant with infant attachment classifications. Developmental Issues in Psychiatry & Psychology, 1,