Helping the Baby - CMHO Conference... · Helping the Baby ‘Walk In’ ... ATTUNEMENT focus on...
Transcript of Helping the Baby - CMHO Conference... · Helping the Baby ‘Walk In’ ... ATTUNEMENT focus on...
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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?
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“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
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“4th Trimester” Verbiest et al 2017
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The Opportunity
• High motivation to change
Meschino & Martinovic 2017
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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/
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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
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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
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What do infants need?
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We see complicated relational challenges
Trauma
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Crying
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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
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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
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Security & Regulation Formulation
DEVELOPED STRESS RESPONSE SYSTEM
SOCIO-EMOTIONAL DEVELOPMENT
INFANT
CAREGIVING BEHAVIOURS
ATTACHMENT RELATIONSHIP
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Maternal and Paternal Risk Factors
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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
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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
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(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…
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(Luby et al., 2017)
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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
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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
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• 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
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• 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
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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
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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
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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
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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
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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
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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
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• 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
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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
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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
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The Infant in the Dyad
What Infants Need
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#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
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• Seek proximity
• Seek autonomy
• Develop shared plans
• Secure
• Insecure
• Disorganized
DEVELOPED ATTACHMENT RELATIONSHIP
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Simple circuits and skills provide scaffolding for more advanced circuits and skills
Brains are built from the bottom up, over time
#2
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• 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
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#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
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The caregiver offers continuous regulation of the infant’s shifting arousal levels –
Schore 2000; Siegal 2003, 2012
up-regulating down-regulatingand
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#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
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Baby sends signal
Mother receives signal
Identify signal
Response to signal
Modifies stress
Repeated experience
Mindful parent
56
Dan Siegel
PRESENCE there, available
ATTUNEMENT focus on other
RESONATE change internal state to care for infant
TRUST knowing
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Complex Trauma
57
• The experience of multiple or chronic and prolonged developmental adverse traumatic events
• Exposure in the infant’s caregiving system
• Includes emotional neglect
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• 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
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• 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
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• 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
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Interpersonal development
Intrapersonal development
Cognition
Communication and social behaviours
Self-efficacy and esteem
Sense of self
SOCIO-EMOTIONAL DEVELOPMENT
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• Parent stays organized as she/he organizes, buffers, eliminates stress for infant and provides…
• Stress Management Relationship Model
62
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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64
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
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• 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
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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
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SECURE
69
Attachment Disorganized
Exploratory Behaviours
away from caregiver
Attachment-Based Behaviours
towards caregiver
CAREGIVING
• Hesitant
• Aggressive
• Intrusive
• Dissociative
• Frightened
• Frightening
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Caregiving Behaviours
• Gentle• Sensitive• Autonomy from
a secure base• Scaffolding
opportunities• Delights
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Attachment Patterns
Behaviour Problems
Experience Problems
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Infant’s secure attachment-based
behaviour cues
SecureAttachment
Goal?
As infant’s secure attachment-based
behaviour cues
RECEIVED
Attuned Responsive Reparative
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Walk-Infor Babies
and Caregivers
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Walk-Outto Babies
and Caregivers
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Purpose
Post-natal depression/violence screening and intervention
How
Inviting families to walk in for service
Baby Walk-In
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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
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Possible partners
Public Health
Child Welfare
Children’s Mental Health
Early Years Centres
ATTEND - The Baby “Walk-Out” ProjectBaby Walk-In
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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?
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Screening
SCREENS • PQ-9
• BECK
• Perceived Stress Scale
• Other scales as relevant (e.g. Appreciative Inquiry)
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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 …
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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
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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
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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
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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
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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
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Screens and Tools
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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
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Beck’s Depression Inventory
21-questionmultiple-choice
self-report inventory
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PHQ-9
multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression
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Perceived Stress Scale
Measures degree to which situations in one’s life are appraised as stressful
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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
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PICCOLOParenting Interactions with
ChildrenChecklist of Observations Linked to Outcomes
Lorri Roggman, Gina Cook, Mark Innocenti, Vonda Jump Norman, Katie Christiansen, Sheila Anderson
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PICCOLO
• is a practical observational measure of developmental parenting based on strengths as they relate to outcomes for child
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PICCOLO
Why observe parenting strengths?
1. To encourage “Developmental ” parenting
2. To increase support for child development
3. To build upon parents' existing capacities
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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