Helping the Baby ‘Walk In’

Including

Infant and Caregiver Mental Health

in our Walk-In Settings

Mary Rella, Dip. C.S.Director, Community and Counselling Services

Skylark Children, Youth and Families

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Are we ready to provide effective support to babies and their caregivers?

✓Accessible

✓ Supportive

✓ Timely problem-solving

✓Reaching young people

✓Over 5,000 visits in the past year

✓Other positives?

What does birth to 18 mean in our settings?

“4th Trimester” Verbiest et al 2017

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The Reality • Risk for postnatal depression

o Impaired maternal sensitivity + compromised attachment with infant

o Immigrant women are at much greater risk

• Maternal depression influences onset of paternal depressiono Fathers are 50% more at risk

• High prevalence of abuse and neglect in the first year

“4th Trimester” Verbiest et al 2017

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The Opportunity

• High motivation to change

Meschino & Martinovic 2017

Importance of Relationships

“Human beings of all ages are happiest and able to deploy their talents when they experience trusted others as standing behind them.”

“Successful parenting is a principal key to the mental health of the next generation.”

John Bowlby, MD

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https://developingchild.harvard.edu/resources/inbrief-resilience-series/

Acknowledgements

• Perinatal Mental Health Program, Mount Sinai Hospital

• Simcoe Local Health Integration Network

• Public Health

• Infant Mental Health Promotion Colleagues

• Women’s Mental Health, Women’s College Hospital

• Simcoe Muskoka District Health Unit

• Crying Clinic, Aisling

• Walk-In Collaborators

• Staff who teach me something new everyday

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AGENDA1. Why include babies and caregivers?

2. What are caregivers dealing with?

3. What do babies need?

4. Walk-In – Ready for Babies and Caregivers

We help develop:

✓ Parent skills and knowledge

✓ Stable supportive relationships

✓ Secure relationships

✓ Safe, supportive environments

✓ Appropriate housing

✓ Appropriate nutrition

✓ Community supports

preconception … pre-natal … infancy and childhood … youth … adulthood

What do infants need?

We see complicated relational challenges

Trauma

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Crying

The first 1,000 days

are key

Toxic Stress

Attachment Relationship

Ongoing Brain Development

Toxic Stress

Interactive

Relationship

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Relationship Factors

✓ Attachment behavioural system (J. Bowlby)

✓ Development of security

✓ Sensitivity and responsivity (M. Ainsworth)

✓ Emotional availability and connectedness (R. Clarke)

✓ Presence, attunement, resonate, trust (D. Siegal)

✓ Right brain affect dysregulation and relational trauma (A. Schore)

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“Neuroscientific, biological, genetic, and social science research is unequivocal…”

• First 1,000 days (3 years) are foundational in terms of brain development Tox 2012, Shore 2010

• Central to ongoing social, emotional, and cognitive development Sameroff 2010

• Increasing evidence that investment in the early years substantially improves adult health Campbell et al 2014

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Social Justice | No Judgement | Hope

Foundational Framework

Security-Formation and Relational Trauma

• Collaborative Problem-Solving

• Cognitive-Behavioural

• Dialectical-Behavioural

• Narrative

• Solution-Based

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Tracking Trauma

History

Society

Parent

Child

“Ghosts in the Society” Suchman 2012

Infants and toddlers are experts at being dependent

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Infants and toddlers must be understood in the context

of the sustaining caregiving

environment

Security & Regulation Formulation

DEVELOPED STRESS RESPONSE SYSTEM

SOCIO-EMOTIONAL DEVELOPMENT

INFANT

CAREGIVING BEHAVIOURS

ATTACHMENT RELATIONSHIP

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Maternal and Paternal Risk Factors

Emotional and

physical abuse

21ACE STUDY

Recurrent

physical abuse

Chronic

depression or

mental illness

Violence

between

adults

in the family

Recurrent

emotional abuse

Sexual

abuse

Incarceration

Neglect/alcohol/

drug abuse in

the family

ACEs CHART

ABUSE HOUSEHOLD CHALLENGES NEGLECT

EMOTIONAL“VIOLENCE BETWEEN

PARENTS” PHYSICAL

PHYSICAL SUBSTANCE ABUSE

EMOTIONALSEXUAL

SEPARATION/DIVORCE(LOSS OF PARENT)

22Vince Felitti, Centers for Disease Control and Prevention

ACE Study Adverse Childhood Experiences

(Luby et al., 2017)

Early ACEs in

children aged

3-6 years old

Decreased volume

in subregions of

prefrontal cortex at

children aged 7-12

years

Increased risk for

poor mental and

physical health

outcomes at 9-15

years

A longitudinal, prospective neuroimaging study…

(Luby et al., 2017)

Why talk about adverse events?

• Need an adult to help protect infant from associated stress

• If no adult buffers the experience, toxic stress results

• Poses potential difficulties in the dyad and early days of relationship building

• Leads to chronic health conditions

• Developmental trauma occurs

– in the context of caregiving

– in the caregiving relationship

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“Developmental trauma occurs when emotional pain cannot find a relational home where it can be held.”

Stolorow 2007

Developmental Trauma:

• Domestic abuse• Neglect• Physical abuse• Sexual abuse• Removed from home• Separation• Witnessing abuse• Witnessing the arrest of a parent

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stress onset

stress activation

stress recovery and engagement

Sarah Watamura 2016

• Fight

• Flight

• Freeze

Watson 2017

LeDoux 2011, 2013, 2016

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FAST Pathways to Recovery

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stress onset

stress activation

• Fight• Flight• Freeze

Amygdala

Moreexperiences

FAST pathways become more sensitized

• Making sense

• Making meaning

• Reflection

• Problem analysis

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SLOWER Pathways to Recovery

All less able to develop

Watson 2017 LeDoux 2011, 2013, 2016

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stress onset

stress activation

• Making sense• Making meaning• Reflection• Problem analysis

Amygdala

Less able to develop

Watson 2017

LeDoux 2011, 2013, 2016

What does this have to do with babies?

• Exposed to stress in caregiving relationship

⇢Demonstrated stress response to angry voices, even when sleeping Graham, Fister 2013

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• Exposed to fighting parents

⇢Experienced more stress response when picked up by mom; not easily soothed Davis et al 2010

What does this have to do with children?

Greater adversity

Cognitive and social domains are affectedoAttention and focuso Integration and sensoryoEmotion modulation Watson 2017; Stolorow 2017

Learning is hardero Getting along with peers, teacher, is harder

Watamura 2016

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⇢ struggle more during the day

What does this have to do with caregivers?

Difficulties modulating emotion

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⇢ Increased risk for difficulty co-regulating with infant

⇢ Increased risk for depression Watson 2017

⇢Dyad is at increased risk for attachment difficulties –mis-attunement

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Attunement

Mis-Attunement

Caregivers

• with difficulties

modulating

emotion

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• with adverse

events and

experiences

(ACEs)

Infants

• with

developmental

trauma

Toxic Stress transmission

Mental health problem

Public health problem

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We need to recognize

• High incidence of ACEs in adult population

• Maternal ACEs increase opportunity for Infant ACEs

• High prevalence of abuse and neglect in infant’s first year

• Caregiver mental health = dyad mental health = infant mental health

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What needs to happen?

• Caregiver ACEs need attention

• Need to decrease stressful circumstances

– Strengthen families

– Develop community supports

– Reduce poverty

• Need to increase caregiver buffering abilities– Reduce/end violence in families– Increase parental supports

• Address social determinants of health

Caregiving System

Caregivers gain pleasure from recognizing their behaviours decrease the distress of the infant

Suchman, Decoste 2016

When caregiving system is activated to address baby’s distress, mother’s efforts to relieve the distress release dopamine and mother feels pleasure when it works

Caregiving System

For mothers with own adverse events related to how they were cared for

Suchman, Decoste 2016

Circuit is high jacked

Infant’s distress causes pain, fear, uncertainty, resentment

• Substance-using mothers are exposed to elevated amounts of dopamine as a result of substance use

• Therefore do not get accurate feedback on caregiving efforts

• ‘Flatter’ – don’t receive pleasure feedback on activities, especially parenting

• Little to no chemical reward

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stress onset

stress activation

stress recovery and engagement

Sarah Watamura 2016

New Goal

• Gain pleasure from recognizing that caregiving behaviours promote security because they decrease distress and enhance delight

• Use mentalization because it increases sensitivity, increasing opportunity for reparative care, leading to getting better at regulating child

• Practice, practice, practice

Maladaptive Caregiving Behaviours

RejectingFrightened

Inconsistent

Rolereversal Frightening

Intrusive

Suggest one Withdrawn

Dissociative

PunitiveOver promoting attachment cues

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GOAL: Self-Regulation

problem solving

PROCESS: Co-Regulation

organizing stress to solve problems45

The Infant in the Dyad

What Infants Need

#1 Attachment relationship

is key to the infant's optimal social, emotional and cognitive development

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• Sensitivity

• Responsivity

• Availability

• Reparative

• Harsh

• Punitive

• Unavailable

• Frightening/ frightened

CAREGIVING RELATIONSHIP

• Seek proximity

• Seek autonomy

• Develop shared plans

• Secure

• Insecure

• Disorganized

DEVELOPED ATTACHMENT RELATIONSHIP

Simple circuits and skills provide scaffolding for more advanced circuits and skills

Brains are built from the bottom up, over time

#2

• Synaptic growth in the first year is massive: 1 billion synaptic connections per second

• There is an overproduction of synapses

• At about 8 months underused synaptic connections start being pruned

• Synaptic pruning and synaptic reinforcing are influenced by baby’s emotional interactions with caregiver

#3 Interactive relationship

• shape the infant's developing brain

• influence interactions between genes and expression of genes, increasing and/or decreasing protective and risk factors

Back and forth interactions between infant and caregiver…

“s e r ve a n d re t u r n ” 52

The caregiver offers continuous regulation of the infant’s shifting arousal levels –

Schore 2000; Siegal 2003, 2012

up-regulating down-regulatingand

#4 Toxic stress and the development of self regulation

• is associated with persistent negative effects on the nervous system, damaging early brain architecture

• negatively influences self-regulation development, resulting in lifelong problems in learning, behaviour, physical health, mental health

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Co-regulation(with caregiver)

• Self-soothe

Co-dysregulation(with caregiver)

• Escalate

DEVELOPED STRESS RESPONSE SYSTEM

Baby sends signal

Mother receives signal

Identify signal

Response to signal

Modifies stress

Repeated experience

Mindful parent

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Dan Siegel

PRESENCE there, available

ATTUNEMENT focus on other

RESONATE change internal state to care for infant

TRUST knowing

Complex Trauma

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• The experience of multiple or chronic and prolonged developmental adverse traumatic events

• Exposure in the infant’s caregiving system

• Includes emotional neglect

• Is not a singular event; it is cumulative

• Permeates the infant’s experience

• How? When the caregiver does not provide interactive repair, the infant’s negative state lasts a long time

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Attachment/Relational Trauma

• Cannot soothe the baby

When caregiver is unable to cope with own state, baby’s distress is more than she/he can bear

• Cannot connect from a reflective place

• Cannot understand or relate to baby’s experience

Whole interaction is traumatic for the baby

• Needs are in competition with baby’s needs

• Stress overload shuts down the system that enables us to experience cognitive empathy

Stuart Shankar, 2015

• Being affected takes precedence over what someone else feels

• Social systems shut down and ancient systems run the show

• Aggression and/or withdrawal is the behaviour

Interpersonal development

Intrapersonal development

Cognition

Communication and social behaviours

Self-efficacy and esteem

Sense of self

SOCIO-EMOTIONAL DEVELOPMENT

• Parent stays organized as she/he organizes, buffers, eliminates stress for infant and provides…

• Stress Management Relationship Model

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Attachment is…

• Recovery

The Attachment System

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Attachment SecurityAttachment = Two Inverse Systems

SECURE

Exploratory Behaviours

away from caregiver

Attachment-Based Behaviours

towards caregiver

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Attachment SecurityAttachment = Two Inverse Systems

SECURE

Exploratory Behaviours

away from caregiver

Attachment-Based Behaviours

towards caregiver

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Secure Attachment

Exploratory Behaviours

away from caregiver

Attachment-Based Behaviours

towards caregiver

CAREGIVING

• Gentle

• Accepting

• Contingent Affective state

• Containment

I know how to

need you…

when I’m

scared, hurt,

sick

SECURE

• Available

• Sensitive

• Responsive

• Interactive Repair

Attachment Security

• Parent resonates with baby

• Parent changes when baby changes

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Attachment Resistant

Exploratory Behaviours

away from caregiver

Attachment-Based Behaviours

towards caregiver

I need you

always…

when I’m scared,

hurt, sick

CAREGIVING

• Inconsistent

• Role reversal

• Focus on parent

• Ability to provide comfort contingent on child

SECURE

I don’t know

how to need

you…

when I’m

scared, hurt,

sick

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Attachment Avoidant

Exploratory Behaviours

away from caregiver

Attachment-Based Behaviours

towards caregiver

CAREGIVING

• Rejecting

• Dismissive

• Unresponsive

• Emotionally unavailable

SECURE

SECURE

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Attachment Disorganized

Exploratory Behaviours

away from caregiver

Attachment-Based Behaviours

towards caregiver

CAREGIVING

• Hesitant

• Aggressive

• Intrusive

• Dissociative

• Frightened

• Frightening

Caregiving Behaviours

• Gentle• Sensitive• Autonomy from

a secure base• Scaffolding

opportunities• Delights

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Attachment Patterns

Behaviour Problems

Experience Problems

Infant’s secure attachment-based

behaviour cues

SecureAttachment

Goal?

As infant’s secure attachment-based

behaviour cues

RECEIVED

Attuned Responsive Reparative

Walk-Infor Babies

and Caregivers

Walk-Outto Babies

and Caregivers

Purpose

Post-natal depression/violence screening and intervention

How

Inviting families to walk in for service

Baby Walk-In

BCEs - Benevolent Childhood Experiences

1. At least one safe caregiver

2. At least one good friend

3. Personal beliefs that bring comfort

4. School enjoyment

5. At least one teacher who cared

6. Good neighbours

7. Supportive adult (non-caregiver)

8. Opportunities for fun

9. Positive self-image

10. Predictable home routine

Narayan, Rivera, Gosh, Lie

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Health Promotion Conceptual Framework

• Mobilizing social supports

• Realizing self-efficacy

• Creating coping strategies

• Having realistic expectations

Services need to be convenient, easily accessible

Services need to focus on:• Sleep issues• Education• Listen, listen…

Verbiest, Tully, Stuebe 2016

Possible partners

Public Health

Child Welfare

Children’s Mental Health

Early Years Centres

ATTEND - The Baby “Walk-Out” ProjectBaby Walk-In

Baby Walk-In Model

VISIT #1Support

Screening/Intervention

EXIT/REFERRALInvitation to come

back to Walk-In

VISIT #2Support

Screening/Intervention

VISIT #3Support

Screening/Intervention

EXIT/REFERRALInvitation to come

back to Walk-In

EXIT/REFERRALto BRIEF?

Screening

SCREENS • PQ-9

• BECK

• Perceived Stress Scale

• Other scales as relevant (e.g. Appreciative Inquiry)

Who can we refer to?

REFERRALS• Perinatal Mental

Health Program, Mount Sinai Hospital

• Public Health

• Women’s Mental Health, Women’s College Hospital

• Crying Clinic, Aisling

• And more …

VISIT #1: GET TO KNOW THE CAREGIVER

A. Learn about prenatal health care, parenting risk factors

▪ Social determinants of health – security/insecurity of housing, food, income/employment, education, social support, physical environment, legal issues

▪ Key health behaviours (smoking, diet), safe sleeping

▪ Other children, family/extended family supports/risk

Focus on the stress factors parents face

B. Administer screens to parent(s)

▪ PQ-9

▪ BECK, Perceived Stress Scales, as relevant

C. Be alert to possible intimate partner violence

▪ Do not raise in joint session

▪ Administer violence/risk/stress scale when appropriate

D. Talk with parents about• Emotional/behavioural regulation/dysregulation

• Caregiving behaviours (warm sensitive … intrusive)

• Understanding of parenting skills

• Adverse Childhood Experiences (ACEs)

• Mothers – talk about experience of mothering

• Fathers – talk about experience of fathering, transition to fatherhood, building skills, confidence, competence

• Couples – talk about understanding of each other’s skills, identify areas of co-operation, tension, conflict

E. Refer and/or invite to return to Walk-In

Subsequent Visit(s)Checking in…continued screening to identify parents who might benefit from low key involvement…higher need involvement

A. Review

• Moods – observed sadness, irritability, anger

• Feelings – exhausted, forgetful, disorganized, sad …

• Behaviours – forgetting, sleeping more/less, eating more/less, not able to complete daily activities (e.g. shopping, showering)

• Thoughts – pessimism, worthlessness, difficulty making decisions

B. Screen

• PQ-9

• BECK, Perceived Stress Scale, as relevant

C. Support parents to integrate importance of• Stress management

• Baby in mind

• Security building

• Parenting skills

• Medical attention

Screens and Tools

Screens

BECK’SDEPRESSION INVENTORY

Widely-used scale for monitoring severity of depression

First published in 1961

PQ-9

Patient Health Questionnaire foridentifying/monitoring depression

Pfizer

PERCEIVED STRESS SCALE

Perception of stress; may help to hone in on specific issues (e.g. intimate partner violence)

Cohen, 1994

Beck’s Depression Inventory

21-questionmultiple-choice

self-report inventory

PHQ-9

multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression

Perceived Stress Scale

Measures degree to which situations in one’s life are appraised as stressful

CAUSAL RUBRIC Example: Behaviour Expression Stroud 2012

Is the behaviour the result of developmental delay or constitutional limitation?

Does the behaviour result from a less than optimal relationship dynamic?

And serve as child’s best efforts in this system to get needs met?

• Physiological factors ruled out?• Significant sensory aversions?• On track for motor, language, self-help, social-

emotional?

Is the behaviour the byproduct of intense stress in the system or severe trauma?

Is the behaviour at such a level of disorder/distress that impairment in functioning is evident?

• Does caregiver show sensitive and attuned responses to child’s cues?

• Is caregiver emotionally well-regulated and able to support self-regulation of child?

• What is dyad’s relationship quality as assessed by ??

• What environmental conditions may be contributing to stress in relationship?

• What is caregiver’s capacity to co-regulate child in face of stressful conditions?

• Does family system experience ongoing, unbaiting stress thus reaching the level of trauma?

• In what way do you observe the behaviour as negatively impacting child’s development, overall functioning, and ongoing social-emotional success?

NO

YES

NO

YES

NO

YES

YES

PICCOLOParenting Interactions with

ChildrenChecklist of Observations Linked to Outcomes

Lorri Roggman, Gina Cook, Mark Innocenti, Vonda Jump Norman, Katie Christiansen, Sheila Anderson

PICCOLO

• is a practical observational measure of developmental parenting based on strengths as they relate to outcomes for child

PICCOLO

Why observe parenting strengths?

1. To encourage “Developmental ” parenting

2. To increase support for child development

3. To build upon parents' existing capacities

What does PICCOLO measure?

The research literature shows 4 domains that encourage

child development and enhance attachment:

• Affection

• Responsiveness

• Encouragement

• Teaching

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STRESS

Promotes difficult relational

connectionsAdverse events