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The Newsletter of
Infant Mental Health
Promotion (IMHP)
Volume 64
Summer 2015
this issue
4. Infant Mental Health and Family Law
Initiative (FLI)
14. Niagara Initiatives – Evaluating
the Effects of Screening and
Developmental Support Planning
Information
for Members
SPECIAL
ISSUE
ON IMHP
ACTIVITIES
Letter from the
Director
(p. 27)
UPCOMING
EVENTS
18. A Collaborative Approach to
Embedding the Science of Infant
Mental Health and Enhancing Infant
Mental Health Services
What is the Future of Infant Mental Health in
Canada?
Remarks from Dr. Robin Williams
Expanding Horizons for the Early Years: Looking Back to Transform the
Future Special Policy and Advocacy Dinner Tuesday April 21, 2015
I hope here to pull a number of threads and themes
together, and talk about what we can do here in
Ontario for our very youngest children.
3rd Annual
Infant Mental Health:
(IMH-101) The Basics
Sept. 28, 2015
I am the incoming president of the Canadian
Paediatric Society, and from that point of view have
an active interest in watching and hearing what the
rest of the world and Canada are doing for infant
mental health promotion.
(p. 28)
So much of our public discourse is about the wrong
things in my opinion. Who cares that some celebrity
is apologizing for a rude Instagram he sent. Good
grief. Today’s screaming news is that our Canadian
kids, when compared to 29 other developed (rich)
countries, are not doing as well as they should.
We are either in the middle or below on so many
parameters. Pick immunization coverage levels,
or teenagers’ self-reported happiness, or teen
suicides, or infant mortality. It’s a long list.
Refective family
Play - A Whole Family
Treatment Model for
Infants and Younger
Children
Nov. 5 & 6, 2015
(p. 29)
Infant Mental Health
Community Training
- beginning January
2016
(p. 30)
But today you have a chance to go back to the
earliest moments of children’s lives, from the time
of conception through birth and the first year of life,
and talk about what we’ve learned in the past 20
years, and as a result what we need to do about it.
I was a member of the workgroup that Jean Clinton
chaired, where we spent most of a year formulat-
ing what we need to do in Ontario with respect to
infant mental health promotion. That resulted in
the paper that was released last year, Supporting
Ontario’s Youngest Minds: Investing in the minds
of children under 6 (2014). The conference
organizers asked that I make a few comments
from that perspective.
Defining Infant Mental Health
So let’s start with “what is infant mental health”
or, what is the main JOB of infancy and early
childhood?
The main “job” for our youngest is their “social and
emotional development”.
What’s that? It is the developing capacity of the
child from birth to five years of age to do 4 things:
• to form close and secure adult and peer
relationships,
• experience, manage and express a full range
of emotions,
• explore the environment, and
• learn.
All in the context of family, community and culture.
The 5 point Elevator speech
2. Genes and the environment interact.
When I was a practicing pediatrician in the 80’s and 90’s I still,
like all clinicians, was very focused on the physical parameters
of “health”: height and weight (usually concerned about underweight), the motor milestones (i.e., rolling over, sitting, first steps),
and some speech and language (first words, two word sentences).
The interactive influences of genes and experience (the environment) shape the developing brain- the nature/nurture debate- it is
both, with genes being turned off and on by environmental influences (epigenetics). Genes provide the blueprint for the formation
of brain circuits, and these circuits are reinforced by repeated use.
A major ingredient in this developmental process is the serve and
return interaction between children and their parents and other
caregivers in the family or community. In the absence of responsive
caregiving (or if caregiving responses are unreliable or inappropriate) the brain’s architecture does not form as expected, which can
lead to disparities in learning and behavior. Ultimately, genes and
experiences work together to construct brain architecture.
But the new neuroscience emphasizes for us 5 concepts excerpted
here from the Centre on the Developing Child at Harvard University
(2007, 2015) Key Concepts: Brain Architecture. This is the 5 point
elevator speech we all need to be spouting:
1. Brains are built over time, from the bottom up.
Infants are born with the ability to control their heart rate, respiration, blood pressure, temperature - the simpler neuronal
connections that are formed. In the first few years of life, 700 to
1,000 new neural connections form every second. After this period
of rapid proliferation, connections are reduced through a process
called pruning, which allows brain circuits to become more
efficient, and the templates for how we respond to our emotions
(happiness, fear, anxiety) are set during these critical time periods.
This process goes on until late adolescence (frontal lobe connecting and pruning).
2
Volume 64, Summer 2015 3. The brain’s capacity for change decreases with age.
It’s never too late, but earlier is better.
The first years of life are a very busy and crucial time for the
development of brain circuits. The brain has the most plasticity,
or capacity for change, during this time, which means that it is a
period of both great opportunity and vulnerability. The impact of
experiences on brain development is greatest during these years
— for better or for worse. It is easier and less costly to form strong
brain circuits during the early years than it is to intervene or “fix”
them later. Brains never stop developing (it is never too late to
build new neural circuits) but in establishing a strong foundation
for brain architecture, earlier is better.
IMPRINT: The Newsletter of Infant Mental Health Promotion
4. Cognitive, emotional, and social capacities are
inextricably intertwined throughout the life course.
The brain is a highly integrated organ and its multiple functions
operate in coordination with one another. Emotional well-being
and social competence provide a strong foundation for emerging
cognitive abilities, and together they are the bricks and mortar of
brain architecture. The emotional and physical health, social skills,
and cognitive-linguistic capacities that emerge in the early years
are all important for success in school, the workplace, and in the
larger community.
5. Toxic stress weakens the architecture of the
developing brain, which can lead to lifelong problems
in learning, behavior, and physical and mental health.
Mothers/ fathers need to feel loved, safe and secure, have
adequate incomes and housing, and BE STRESS FREE ENOUGH to
do the most important job of life.
The Mental Illness Burden
The burden of mental un-wellness, for youth and adults is pretty
impressive. The number of years of healthy life lost due to depression, fear and anxiety disorders, panic disorders, alcoholism, social
phobias, is very high. The burden, unlike cancer or heart disease,
isn’t related to early death but because of the early age of onset,
prolonged exposure to the burden, and low mortality rates, it is a
different kind of “awful”.
Using conservative estimates, the prevalence of mental health
disorders for kids (4-17 years) is 14% (1 in 7) with the commonest
Experiencing stress is an important part of healthy develop- being depression, anxiety, ADHD, oppositional defiant disorder,
ment. Activation of the stress response produces a wide range of and aggression (Waddell, 2007; Waddell, Shepherd, Schwartz, &
physiological reactions that prepare the body to deal with threat. Barican, 2014).
However, when these responses remain activated at high levels for
significant periods of time, without supportive relationships to help Infant Mental Illness - disorder
calm them, toxic stress results. This can impair the development of
neural connections, especially in the areas of the brain dedicated There is little data on 0-6 but what evidence there is, is in the
same 14-18% rangeand it is consistent internationally (Denmark,
to higher-order skills.
Norway, Germany) (Braddick, Carral, Jenkins & Jané-Llopis,
2009).
The “Job” of Infancy
So what is today’s job of childhood? No longer are we focusing so
singularly on the physical parameters, but increasingly we understand for children to be the best that they can be, we need to focus
on strong social and emotional beginnings. This is the “platform”
on which child development scaffolds physical, mental and social
well being.
When you ask youth their onsets they often reflect back to early
childhood. Kids can start along normal trajectories of growth and
development but these can be impacted by a range of factors and
can lead to the emergence of mental health difficulties. Parent
loss through death or mental health, divorce, and illness are not
deterministic, and research shows there are protective factors that
can mitigate the negative impact of early adversity.
Children develop best on a base of secure attachment, a lap for
every baby and at least one adult that adores every child. For many,
secure attachment is most easily enabled through breast feeding,
not so much because of the nutritional part, but rather the associated touch, warmth, singing/ bantering/ rocking, face-to-face
to-and-fro serve and return interactions that go along with it.
So we hear lots about “putting kids first”, and we are such a
fortunate country with so many resources and with such deep
knowledge and understanding of what matters in early life. Why
can’t we do better?
All children need rich, secure and loving environments, ones
with positive parenting styles. Children live in the context of their
families, and are reared with their parents front and centre. Parents
(and their education/ jobs and incomes) are embedded in communities, and they are also reared in cultures, in social networks, and
in provinces.
If we get off to a good start, prenatally (even pre-conceptually)
there are a whole series of protective factors that enhance how well
our kids will do, and some that “drive down the curve” (negatives:
poverty, lack of heath services, family discord; positives: parent
education, reading to child, appropriate discipline, preschool).
Young children’s experiences in the early years set the foundation
for lifelong mental health and wellbeing. Young children are raised
and set on their paths for life as you can see, in the context of their
mothers /parents, their families and their communities (Ontario
Centre of Excellence for Child and Youth Mental Health, 2014).
Conclusion
There certainly is an increasing understanding and respect within
governments for infant mental health promotion and the work
of all of us in the room. As Ministry of Health and public health
practitioners and folks that work with and for parents across this
province, we have a professional and personal responsibility to add
our voices and shine a light everywhere we can on this incredibility
important time in life. Just because we don’t have “word memories”
of our infancies, doesn’t mean we have not been deeply affected
by the experience of our own infancies- emotionally, socially and
architecturally.
There are opportunities prenatally, postpartum, breastfeeding
programs, home visiting, enhanced 18 month visits, as we work
with individual parents and infants, where we need to pause and
think deeply about what we are really trying to do.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 64, Summer 2015 3
• We need to program more here and less there, but also
maintain some programming for everyone. All families have
some form of struggles (proportionate universality).
Center on the Developing Child at Harvard University (2007). A Science-Based
Framework for Early Childhood Policy: Using Evidence to Improve Outcomes in
Learning, Behavior, and Health for Vulnerable Children. http://www.developingchild.harvard.edu
• We need to keep parents front and centre and advocate and
support their needs (jobs, housing, fair pay, mental health
support) as they lead this work.
Center on the Developing Child at Harvard University (2010). The Foundations of
Lifelong Health Are Built in Early Childhood. http://www.developingchild.harvard.
edu
• We need to advocate and add our voices to every policy table
we join with the 5 key point elevator speech, and with our
understanding of the “job” of childhood.
• We need to remember that across Canada kids are over
represented in our poverty statistics, and our youngest
children are the poorest.
• We need to continue to try and evaluate new things/
approaches/programs, with a many “microprojects”
approach to look for success and scalability.
• We need watch what others are doing.
• We need to lead the learning about infant mental health
promotion in our own communities, every chance we get.
References
Center on the Developing Child at Harvard University (2015). Key Concepts:Brain
Architecture (webpage) http://www.developingchild.harvard.edu/key_concepts/
brain_architecture/
Wadell C. (2007). Improving the mental health of young children. A Discussion
Paper Prepared for the British Columbia Healthy Child Development Alliance.
Waddell C, Shepherd CA, Schwartz C, Barican J. (2014) Child and youth mental
disorders: Prevalence and Evidence - Based interventions. Vancouver, BC:
Children’s Health Policy Centre, Simon Fraser University.
Centers for Disease Control and Prevention (2013). Mental Health Surveillance
Among Children — United States, 2005–2011. Morbidity and Mortality Weekly
Report. 2013;62(Suppl 2). U.S. Department of Health and Human Services.
Braddick F, Carral V, Jenkins R & Jané-Llopis E. (2009). Child and Adolescent
Mental Health in Europe: Infrastructures, Policy and Programmes. Luxembourg:
European Communities. http://ec.europa.eu/health/ph_determinants/life_
style/mental/docs/camhee_infrastructures.pdf
WHO (2005). Mental health: facing the challenges, building solutions. Copenhagen,
WHO, 2005.
Center on the Developing Child at Harvard University (2007). The Science
of Early Childhood Development (InBrief). Retrieved from (http://www.
developingchild.harvard.edu/index.php/resources/briefs/inbrief_series/
inbrief_the_science_of_ecd/)
Ontario Ministry of Education (2014) How Does Learning Happen? Ontario’s
Pedagogy for the Early Years: A resource about learning through relationships
for those who work with young children and their families. http://www.edu.gov.
on.ca/childcare/HowLearningHappens.pdf
Clinton J, Kays-Burden A, Carter C, Bhasin K, Cairney J, Carrey C, Janus M, Kulkarni
C, & Williams R (2014) Supporting Ontario’s youngest minds: Investing in the
mental health of children under 6, Ontario Centre of Excellence for Child and
Youth Mental Health, http://www.excellenceforchildandyouth.ca/sites/default/
files/policy_early_years.pdf
4
Volume 64, Summer 2015 IMPRINT: The Newsletter of Infant Mental Health Promotion
Infant Mental Health and Family Law Initiative (FLI)
Chaya Kulkarni, Director, Infant Mental Health Promotion (IMHP), Brenda Packard, Co-Chair,
Infant Mental Health Family Law Initiative (FLI), Supervisor Children’s Aid Society of Toronto,
Carmela Paolozza, Project Support, and Donna Hill, Administrator, IMHP
Family courts face monumental challenges in balancing the
competing needs of children and their parents. Decisions about
custody, visitation, and access must often be made quickly and
on the basis of limited information. Courts are mandated to act
in the “best interests” of the child. However, because infants and
toddlers literally have “no voice”, their needs can be invisible to the
courts. Sensitivity regarding the “best interests” of children in the
first three years of life requires knowledge of: children’s cognitive,
social and emotional development; the impact of the environment
on brain development; the impact of substance abuse, domestic
violence, and mental illness on children and families; and the risks
of compromised infant-caregiver attachment on infants’ physical
and mental health, as well as ways to enhance the caregiver-child
relationship. It is incumbent on judges, lawyers, and child welfare
personnel to be educated in these areas in order to act in the best
interests of society’s youngest members.
Three features of infant mental health have important implications
for child protection:
1. Infant mental health and development are intertwined –
Infants who are not doing well emotionally tend to lag behind
their peers in achieving developmental milestones (Sroufe,
Egeland, Carlson & Collins, 2005). Each stage of development lays the foundation for the next; therefore, children
who do not have a good start in life are more vulnerable to
setbacks later on. The Canadian Paediatric Society reports
that more than three quarters of children in care have special
health, developmental, or mental health needs that are
often chronic, under-recognized, and neglected. (Canadian
Paediatric Society, Community Paediatrics Committee,
2008).
impacted all areas of their development and health. There is
a greater likelihood that such children have not experienced
the kinds of relationships that support and strengthen synaptic
production. There may have been periods of inconsistent and
unresponsive caregiving that result in toxic levels of stress leading
to the greater expression of some genetic risks. Collectively, these
experiences are likely to cause a toxic stress response which will
ultimately threaten brain architecture. The impact of these experiences cannot always be reversed, and the impact can set a child
on a life course that is less than optimal.
Infants and toddlers who require the service of child welfare
agencies are immediately considered to be a child at risk. The
question is, at risk for what? Historically, this risk was about
physical status. Is this child going to starve or be physically or
sexually abused? However, the research shows us that the evaluation of risk needs to focus not just on the physical, but also on the
mental health status of the child. One can certainly make the case
that infants and toddlers involved with child welfare are one of
Canada’s most vulnerable populations, yet there is no differential
response from the majority of child welfare agencies when infants
and toddlers come into care.
While Infant Mental Health Promotion has always recognized
infants and toddlers involved with child welfare as a high risk
population, our understanding of current practices and polices
within such agencies has increased substantially through engaging
with child welfare workers. We found ourselves inquiring about
how this population is supported and about the training workers
receive specifically on infant mental health and development.
We learned very quickly that the majority of agencies have no
protocols specific to the unique needs of this group. Furthermore,
2. Infants are exquisitely sensitive to stress - The confluence of it appeared that many workers do not have any formal training
research from attachment theory, psychobiology, and neuro- in child development and even fewer have training in infant and
biology has provided new insights into the impact of stress toddler development including mental health. For most, infant
on the developing brain and the importance of the infant- mental health was a new concept.
caregiver relationship in helping babies regulate stress
The response to infants and toddlers in child welfare systems
(Glaser, 2000).
still largely focuses on the physical aspects of development, and
3. The risk factors that impede normal social and emotional
even that is largely what is obvious – weight, height, immunization
development accumulate rapidly and exacerbate one another
and immediate physical safety. Few agencies, at the start of an
- Most mental health and emotional problems are developinvestigation, use any tool to understand possible risks beyond the
mental outcomes (Sroufe, Egeland, Carlson & Collins, 2005).
“obvious”.
Severe emotional and behavioural problems are seldom
the result of an inherent deficit or a single adverse experi- The Challenges
ence; they are usually the culmination of a series of adverse
events and vulnerabilities, typically beginning early in life and Family law professionals (including judges, lawyers, advocates,
continuing through different stages of development.
family mediators, and child welfare officials), along with infant
mental health professionals face three particular obstacles as
For young children involved with child welfare, there is a high probathey attempt to address the needs of these high risk infants:
bility that they have experienced adversity that has negatively
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 64, Summer 2015 5
• Infants cannot express their wishes the way older children
can and many professionals including many healthcare
professionals do not recognize symptoms of distress or
psychological disorder in this age group. Although there is
a burgeoning interest in infant mental health in the scientific
community, there are few experts available to help the courts
consider the mental health needs of infants and recognize
misinformation that is sometimes presented.
(Sedlak et al., 2010). Researchers have also found that families in
the lower socio-economic group have often experienced significant
adversity and trauma at a disproportionally higher level compared
to other income groups (Wadsworth & Santiago, 2008). For infants
and toddlers, such adversity when experienced early in life can lead
to a cascade of long-term negative effects on behavior and health
(Boivin & Hertzman, eds., 2012). For example, when examining
the difference between “non poor and poor children in kindergarten,
72% of non poor children are proficient at recognizing words
• The rapid pace of development in infancy adds an element of
compared
to only 19% of poor children” (Duncan- Magnuson,
urgency to court deliberations concerning this population.
2001, p. 22-27). Such early exposure to adversity influences brain
• Parents or caregivers who are caught up in the judicial architecture and gene expression. Poor early development prior to
system are less likely to be capable advocates and protec- school entry, can jeopardize learning outcomes throughout school
tors for their infants and young children. They are more likely and ultimately increase the risk for poor physical and mental
to be stressed and to lack resources for themselves and health outcomes (Boivin & Hertzman, eds., 2012).
their children. They are more likely to distrust community
agencies and other potential supports for themselves and Children in care, particularly infants, toddlers and preschoolers,
their children.
are especially vulnerable to maladaptive outcomes and are at a
heightened risk for developmental delays. Research shows that
For child protection workers - There are many challenges for child
30 to 35% of 0 to 3 year olds investigated for maltreatment have
protection workers attempting to evaluate the condition and needs
developmental scores which may qualify them for early intervenof very young, maltreated children and plan for their care: 1) access
tion services, but only 13% of these children receive services within
to infant mental health and child development specialists varies
12 months of their referral (McCrae, Cahalane, and Fusco, 2011).
throughout the country, especially in rural regions; 2) the symptoms
Reports of the prevalence of developmental delays among children
of emotional maltreatment and mental health problems in infancy
in out-of-home care vary from less than 5% to over 80% and are
are difficult to assess and require close collaboration between
dependent on the sample and the screening or diagnostic measure
mental health, child development, and child protection services
used (Leslie et al., 2005). Risk factors related to developmental
and; 3) infants with serious emotional problems often come with
delay in young children in care include traumatic experiences
parents who have serious emotional problems but the two service
before foster care such as child abuse and neglect, exposure to
systems rarely overlap.
substances, domestic violence, and impaired parenting.
For family lawyers - There are some particular challenges for family
law professionals assigned to protect the rights of a maltreated
infant: 1) preverbal children cannot give instructions to counsel; 2)
at the present time, there are few practice guidelines specifically
regarding the representation of infant clients and; 3) emotional
neglect and abuse in infancy are difficult to define from a legal
point of view and the damage may not be apparent for years to
come. Family lawyers who specialize in child welfare cases do not
necessarily receive specialized training in infant mental health or
development.
For judges - Research suggests that judges are often influenced by
the expressed views and wishes of children and by the testimony
of expert witnesses. Infants cannot express their wishes and infant
mental health expertise is not always accessible; therefore, judges
may be compelled to rely on testimony from witnesses with little
background or experience in recognizing serious mental health
problems in the infant population.
Infants and toddlers served by child welfare agencies are brought
to the attention of such agencies largely due to neglect. The
Ontario Incidence Study (Trocme and Fallon et al, 2008) found that
children under the age of one are the most likely to be investigated
at a rate of 70.25 investigations per 1000 children. As the age
of children increases, the number of child welfare investigations
per thousand decreases. Children served by child welfare often
come from families facing financial hardship (but not exclusively)
6
Volume 64, Summer 2015 For a population already deemed to be at risk, excessive wait times
can lead to further developmental delays. Research has shown
that 30 to 35% of zero to three year olds investigated for maltreatment have developmental scores which may qualify them for early
intervention services, but only 13% of them receive services within
12 months of their referral (McCrae, Cahalane and Fusco, 2011).
Despite the reported high prevalence of developmental delays, too
few children in foster care are systematically screened for developmental and mental health concerns (Dunn and MacLafferty, 2009).
Also, the American Academy of Paediatrics (AAP) recommends a
routine developmental screening for all young children; however,
the majority of providers, including those within the child-welfare
sector do not currently screen children in a systematic fashion in
Ontario (Jee et al., 2010).
Moreover, there is also a lack of consistent strategy within the
child-welfare system to identify, monitor and address developmental delay in young children in care. With the lack of early
identification of developmental delays and intervention, it often
translates into limited or no interventions and support for these
vulnerable children, at a time when their brains are undergoing the
most profound development it will experience in their lives (Center
on the Developing Child at Harvard University, 2011).
These trends are concerning, particularly since research shows
that if we are to change a young child’s developmental trajectory,
we must conduct developmental screens (including mental health)
IMPRINT: The Newsletter of Infant Mental Health Promotion
and intervene prior to the age of two (Zero to Three Task Force
on Infant Mental Health, 2002; Center on the Developing Child at
Harvard University, 2007). This is the time when brain development is most profound and plastic. While change is still possible
after two, it is far more difficult and costly. The notion that all can
be fixed upon school entry is misguided and misinformed.
Resource 1: A Developmental Screen and Support Plan
The proposed approach involves the implementation of a developmental screen and personalized support plan for each child
to be shared with the child’s parents and support services. The
expectation would be that the plan be embedded into all services
and supports the family receives, including access visits, in order
While referrals are made, these often take several months if not to provide a set of common goals and strategies to address any
even a year. As children and families wait, there is opportunity for developmental concerns. This screening cycle would be repeated
practitioners to positively affect the child’s developmental trajec- every 4 to 5 months and the support plan revised each time. This
tory and support the rapid brain development occurring during this process will ensure:
period.
• Any delays are picked up early in a child’s life.
The Infant Mental Health & Family Law
Initiative (FLI)
• Any referrals are made to ensure access to services at the
earliest possible time.
• That while children wait for services, caregivers have a plan
FLI is a collaboration initiated by Infant Mental Health Promotion
that provides developmentally appropriate goals and strate(The Hospital for Sick Children) in 2006 among professionals
gies that can be used daily as well as during access visits.
concerned about the health, mental health and development of
• All caregivers are working on similar goals for the child.
Canada’s abused or neglected children under the age of three.
Partners have included Alberta Health Services, the Provincial
• Those supporting both biological and foster families will use
Centre of Excellence for Child and Youth Mental Health at the
the plan as part of the support process.
Children’s Hospital of Eastern Ontario (CHEO), and the Alberta
Centre for Child, Family & Community Research, and most promi- Resource 2: Family Service and Support Coordinator
nantly the Children’s Aid Society of Toronto. Our goal is to bring
the science of early childhood development into child welfare and This role would require familiarity with the child welfare system,
the family court process and the network of services and supports
family law practice through education and advocacy.
available both within and external to the child welfare system. This
Our first aim is to increase awareness of the unique developmental individual would navigate the social services and health systems
needs of infants and toddlers and educate professionals about the to match parents with the services and supports they need to
impact of maltreatment during this sensitive period. Our second meet the needs of their child. S/he would have extensive reach
aim is to provide child welfare professionals, family court judges, into the community to build relationships with those services that
and family law practitioners with the resources they need to make offer the supports and interventions parents require. S/he would
clinically informed decisions about maltreated young children. negotiate priority referrals for parents and/ or enroll them into
Finally, we aim to promote collaboration among care providers programs that could be helpful, and provide interim supports for
example, ensuring the parent is provided with the support needed
who touch the lives of these children.
to participate in meaningful access visitations with their infant.
In 2008 IMHP undertook a community needs survey including This person would liaise with all parties involved with the case to
speaking to key informants from the judicial and legal professions, outline a proposed support plan and timeframe for implementagathering data on the scope of the problem, surveying the litera- tion of the plan. The support plan would be shared with the Court,
ture on therapeutic jurisprudence, and investigating innovative updates provided via e-mail on a weekly basis unless an alternative
models for specialized family courts. This approach would be used schedule were agreed to by all parties. Ideally, the Family Service
with families to ensure that they have the opportunity to:
and Support Coordinator would have an independent office within
a community law firm.
• Strengthen the learning capacity for the parent(s) and provide
all forms of environmental and relational safety for the infant It is envisioned that the introduction of a Family Service and
or toddler;
Support Coordinator, along with implementation of developmen• Ensure a process whereby helping caregivers understand
both the emotional and developmental needs of the child
and parent risk factors, and learn to increase their potential
for protective actions.
To facilitate this approach, we proposed two additional resources
for infants and toddlers:
• A court-based Family Service and Support Coordinator; and
• Implementation of a process for developmental screening
and support planning for children.
tal screening and support planning into access visits and other
interventions, will facilitate the new approach. These additional
resources will help to ensure that caregivers and permanency
plans are able provide relationships and environments in the best
interest of the child to protect physical, emotional, and developmental safety.
A proposal for a pilot project to be launched in Brampton was
submitted however IMHP was unable to secure funding to proceed,
given the scope and magnitude of the endeavour at the time.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 64, Summer 2015 7
In 2010 IMHP received a significant anonymous donation to
further the FLI Project which allowed us to launch a partnership
with Children’s Aid Society of Toronto (CAST) with the goals to
support the early development of children involved in child welfare
through the 1) creation of infant mental health learning modules
for child welfare practitioners, 2) provision of training opportunities to increase practitioner capacity, and 3) implementation of
screening and developmental support planning. Together with
CAST, practices and resources have been developed that will
enable those working with young children (from birth to age 4) in
care to:
1. To provide the necessary training and support to enable child
welfare staff to further understand infant mental health and
early development, and perform developmental screening
and observation.
2. Establish formal developmental plans for each child in care or
service that will address vulnerability in all areas of development including physical and mental health and will be used
to support the child, the caregivers and other professionals
involved with the child.
3. Improve mental health and physical health outcomes for
young children involved with child welfare agencies.
2011/ 12 Environmental Scan of Child
Welfare Agencies Concerning Infants and
Toddlers
IMHP undertook a survey of Child Welfare agencies across Canada
to better understand the services offered to infants and toddlers
within the child welfare system. The survey was circulated to
directors of child welfare in each province/territory (13 total). IMHP
received responses from only 4 of 13 directors, in Nova Scotia,
Alberta, New Brunswick, and Ontario. After further requests were
circulated to Ontario child protection agencies, IMHP received
responses from an additional 13 Ontario agencies, providing us
with a total of 17 respondents.
It appears that the information required to complete the survey
(e.g., the intake number of young children) was not readily
available to the respondents. Only 5 of 17 respondents were able
to provide the number of infants and toddlers under 3, however
their responses indicate that an average of 31% of cases involve
infants and toddlers under 3.
Which of the following trainings do you offer to staff?
• Infant and toddler development and parenting practices
(6 no, 11 yes)
• Atypical child development (8 no, 9 yes)
• Supports needed by young children with special needs &
their families (10 no, 7 yes)
• Recognition and reporting of child maltreatment (6 no, 11
yes)
• Parent mental health including unresolved loss and trauma
(9 no, 8 yes)
• Evidence-based screening for infants, toddlers and their
families (10 no, 7 yes)
• Evidence-based assessment for infants, toddlers and their
families (9 no, 8 yes)
• Evidence-based intervention approaches for infants, toddlers
and their families (11 no, 6 yes)
• Cultural competence when working with families (8 no, 9 yes)
• Recognition of signs and symptoms and management of
vicarious trauma (9 no, 8 yes)
• Self care to deal with stress and maintain mental, physical,
spiritual and emotional well-being in self and clients (6 no,
11 yes)
• None other than extraordinary special needs (2)
Some further findings of interest are noted below.
What type of assessment information does your agency gather
to share with judges when a cases involving an infant or toddler
comes before the court?
• Observation of parent-child interactions (12 of 17)
• Standardized screening tools (14 of 17)
• Parenting capacity (14 of 17)
• Non-standardized progress monitoring tools (7 of 17)
8
Volume 64, Summer 2015 IMPRINT: The Newsletter of Infant Mental Health Promotion
What barriers does your agency face when establishing
permanent placements for infants and toddlers?
to turn to out-of-province resources to fill needs. This too
results in financial stresses as well as significant challenges
in maintaining family connections.
• Lack of assessment supports (7 cited)
• Many parents involved with child protection services could
benefit from a home visiting program to assist them with
their parenting and care of infants and toddlers.
• Waiting list for court (7 cited)
• Funding challenges (6 cited)
• High caseloads (5 cited)
• All direct service staff could potentially work with children
0-3 years of age.
• Change in legal counsel (4)
• High Risk Infant team has smaller caseloads than traditional
Family Service Workers, however, this team has not received
any formalized training in infant mental health, just what is
received from OACAS and their social work training.
• Delays with respect to processing through Family Court (4)
• Lack of culturally appropriate placement (1)
• Waiting forensic evidence of neglect (1)
• Time needed for assessment of parenting capacity (2)
• There could always be more specific training in regards to the
mental health needs of infant and toddlers.
Survey Results in General
• Information on the prevalence of infants and toddlers in child
welfare is not readily available.
• Specialized intake procedures are NOT consistently in place
to serve the unique needs of this population.
• The workers serving this population DO NOT have adequate
training to provide the court system with the necessary
observations.
• Though training is cited as being provided, funds are not
necessarily designated to this area.
• Child welfare agencies rely heavily on external mental health
services for expertise.
Additional Comments and Concerns from Respondents
• Physicians and medical professionals are resistant to
providing medical assessment and services to children
involved with CAS. Many professionals do not want to be
involved in court processes and may not have expertise
assessing and treating children that have suffered
maltreatment and have complex resulting needs. Medical
professionals will often verbally site neglect concerns as
impacting child development and health but will not commit
to this assessment in writing as court evidence.
• High-risk infant nurses are a valuable resource for infants
but there are not enough resources in this area to provide
assessment and support to the volume of infants served.
• It was difficult to respond to some of the questions as child
intervention staff do not have caseloads dedicated to infants
and toddlers.
• There are additional challenges with regard to training for
both front-line workers and resource parents. Travel costs
(in terms of dollars and travel time) often limit ability to send
people to training.
• [Agencies] are also often faced with limitations in accessing
specialized assessment/treatment options and have had
• Those providing direct intervention are ill equipped and lack
training specific to infant mental health.
Through these interviews it became apparent that the first place
to begin the process of change was within the child welfare sector.
This is the sector in which service providers have the opportunities to observe the child, obtain relevant information and advocate
on the infant’s behalf so that they may present solid scientificallyvalidated evidence to support recommendations for access and
permanency in a meaningful way.
Addressing Identified Needs - Infant
Wellness in Child Welfare Pilot Study
We began asking more questions of workers and supervisors
from many agencies. We realized that for children served by
child welfare there was no specific process that monitors their
overall development. Physician visits are largely focused on
medical concerns, weight, height and immunization. It also
became apparent, that plans of care were quite limited and largely
addressed physical issues (i.e., late walker). Shortly after our interviews began, a worker at CAST asked how she could learn more
about a child’s development. We introduced the Ages & Stages
Questionnaires®, Third Edition (ASQ-3™) A Parent-Completed
Child Monitoring System (Squires & Bricker, 2009). and the Ages
& Stages Questionnaires®: Social-Emotional (ASQ:SE™) A Parent-
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 64, Summer 2015 9
Completed Child Monitoring System for Social-Emotional Behaviors
(Squires, Bricker & Twombly, 2002) as developmental screening
tools. This provided her with a better understanding of whether
the child’s development was at risk. Upon using it with a child
who did present as developmentally at risk, the worker was unsure
about next steps. We discussed referral options most of which
were submitted by the worker immediately, but also presented
long wait times. Again, we discussed with the worker how such
lengthy wait times might be used to promote development and
perhaps reduce risk.
This round of questions led us to consider the creation of an interim
developmental support plan (DSP) that could be used by the
worker, the foster family, and the biological family during access
visits. The plans would be informed by the developmental screen,
observations of the child by the worker and others, and interviews
with all caregivers. The plans would identity developmental goals
for each domain and provide caregivers with specific strategies/
activities to support the child to reach the goal.
This first case had some immediate benefits, so much so, that as
the worker shared her story with other workers, our phones started
to ring. More and more workers were asking to be trained on using
the developmental screen and creating developmental support
plans. Within a 6-month period we individually trained 15 workers
who completed developmental screens and support plans for over
60 children. The interest continued to rise and we made a decision
to offer a formal training to workers at CAST. In the 12 months
that followed, our office trained over 200 child welfare workers in
a wide range of roles that included child service workers, family
service workers, resource workers, intake workers, foster parent
support workers and supervisors. We also prepared a formal
proposal for the agency and received ethics approval for a pilot.
There were four main components to the Infant Wellness Program.
1. Knowledge, capacity building and mentoring of staff.
2. Implementation of ASQ-3 and ASQ:SE for children under the
age of four at the Toronto Branch, Children’s Aid Society of
Toronto.
3. Creation of individualized developmental support plans
(DSPs) that will facilitate best mental and physical health
outcomes in young children in care.
4. Implementation and integration of DSPs into work with
children, foster families, biological families and other professionals working with the child.
Implementation of the ASQ-3 and ASQ:SE
This model of early identification and intervention applies well
researched tools, the Ages and Stages Questionnaires (both
ASQ-3 which monitors overall physical and social development
and ASQ:SE which focuses on mental health). This non-diagnostic,
caregiver completed tool can be administered by child-welfare
practitioners and caregivers. The ASQ is a first-level screen used to
identify infants or young children (5 years and under) who require
further evaluation for possible developmental delays. In addition,
the ASQ:SE screens for potential difficulties with socio-emotional
functioning.
Once equipped with the knowledge and skill needed to administer the ASQ tools, child welfare workers begin regular use with
children under the age of four who are involved with the agency.
Both tools are used along with observations and interviews with
caregivers and practitioners involved with the child to collect as
much information as needed about the child’s developmental
status – physical and mental – to inform the creation of a developmental plan.
Creation of Individualized Developmental Support Plans
What we know today is that mental health has a direct relationship to physical health (Felitti et al, 1998). Developmental support
plans include goals and strategies to support both mental and
physical health for each child through a strength-based, holistic
approach. Even in situations when development is not an identified concern, the plans could still be created to include goals and
strategies based on the next developmental milestones the child
may be expected to achieve. The developmental plans are shared
by the worker with the foster family and/or the biological family.
The aim is for all caregivers to work on the same goals with consistent strategies which are more likely to lead to developmental
success for the child. Individualized care plans have been found
to be associated with significant positive findings in children from
the community, particularly in the area of cognitive and motor
development (Wallin & Eriksson, 2009). It is anticipated that the
implementation of individualized care plans will have a similar
effects on children receiving out-of-home care.
Lastly, family empowerment is also a central tenant of this
component. It is hypothesized that as foster and biological
caregivers receive support in tailoring their parenting strategies
to complement the specific needs of their child, their feelings of
competency as a parent will increase.
Training: Knowledge, Capacity Building and Mentoring
Infant Wellness Pilot Study Results
To build capacity amongst front-line, child-welfare practitioners to
monitor and promote normal growth and development, the Infant
Mental Health Promotion team developed and delivered training to
child welfare staff and foster families and any allied professionals
working with the agency. This 5-day training provided an overview
of how infant mental health develops, the risk factors associated
with mental health, and ways to support a child’s development
when development is compromised or seen to be at risk.
This pilot was an initial effort to understand specific aspects of the
child welfare system as experienced by infants and toddlers within
Canada’s largest child welfare agency, Children’s Aid Society of
Toronto. The objectives of the study were to:
10
Volume 64, Summer 2015 • Increase the knowledge and understanding of child welfare
workers about research on early mental health and those
risk factors that can derail early development;
IMPRINT: The Newsletter of Infant Mental Health Promotion
• Train workers in the interpretation of screening results
and how to use these results to create a plan of care that
responds to the identified needs of the child;
• Examine mental health and physical health outcomes for
young children involved with a child welfare agency using a
developmental screen alone;
• Examine mental health and physical health outcomes for
young children involved with a child welfare agency using a
developmental screen in conjunction with a developmental
support plan;
Some of the key findings from the CAST Infant Wellness Pilot Study
are as follows:
1) Training and the implementation of developmental support
plans (DSP) helped to increase child welfare practitioners’
knowledge of early childhood development and awareness
of the importance of early identification and intervention.
• Standardized screening tools assisted in identifying issues
with young children’s development.
• The DSP included tangible and helpful recommendations
for enhancing socio-emotional and physical development
concerns.
The pilot findings are encouraging however they are inconclusive, as there are numerous limitations that are common in pilot
studies, such as small sample size, and participant drop out.
Moving forward, IMHP is currently expanding upon the preliminary findings from the Infant Wellness Pilot Study conducted with
CAST, through additional studies with a variety of community
based partnerships, to examine the efficacy of the developmental
support planning model.
1)Niagara Region Initiatives – Evaluating the Effects of
Screening and Developmental Support Planning, further
outlined in this issue of IMPRINT.
2) When considering the “problem range” of the ASQ-3 and
ASQ:SE before DSP, that is, the established cut-off points
that indicate concerns that warrant a referral for further
assessment:
2)Helping Early Adjustment and Relationships to Thrive: Natural
Experiment in Ontario and Alberta, with primary investigator
Nicole Letourneau, University of Calgary.
3)Fetal Alcohol Spectrum Disorder (FASD) Research Program:
Early life adversity, outcomes, and secondary intervention
and prevention, with primary investigator James Reynolds,
NuroDev Net, Queen’s University.
• 56% (19 of 34) of children scored in the problem range of
at least one developmental area.
• 38% (13 of 34) of children scored in the problem range of
socio-emotional concerns.
• 68% (23 of 34) of children scored in the problem range of
either a developmental or socio-emotional concern.
3) When considering the “monitoring zone” (scores that suggest
that a child’s development should be monitored over time)
for the ASQ-3 before DSP, in addition to the “problem range”
scores for the ASQ-3 and the ASQ:SE:
• 85% (29 of 34) of children scored in the problem range
AND monitoring zone of at least one developmental area.
• 88% (30 of 34) of children scored in the problem range
AND monitoring zone of a developmental concern or the
problem range of socio-emotional concerns.
4) There was a statistically significant (albeit borderline),
decrease (p<.05), from before to after DSP for mean socioemotional scores for 19 children in the intervention group.
5) For children under 24 months (8 of 19), there were no significant differences in socio-emotional scores (p>.05). This may
be due to a small sample size; however, this area requires
further inquiry.
6) 50% (13/26) of children screened with the comparison
measure, the Child Behaviour Check List (CBCL), scored in a
clinically concerning range (i.e., Total Problem Score). There
was no significant change in scores for this group between
the first and second screening..
7) Common themes emerged across both focus groups
conducted with child welfare workers (n=4) and foster
parents (n=3):
Next Steps - Judicial Education
The notion of infants experiencing mental health problems can be
troubling. Many, including those within the child welfare system
(workers, lawyers and judges) believe that very small children will
quickly forget traumatic events that have occurred in their lives
and that children are resilient. While it is true that infants can and
do recover from early setbacks, recent findings on brain development suggest that infants and toddlers are more vulnerable to the
consequences of neglect and abuse, not less (De Bellis, 2005).
Infant maltreatment is a significant issue in Canada. According
to the Canadian Incidence Study of Child Abuse and Neglect, the
number of substantiated cases of abuse or neglect of children
aged three and under in 2008 was around 21,000, or about 16
for every 1000 (Public Health Agency of Canada, 2010). This is
significantly more than the 13,000 reported for 1998 (Trocmé, et
al, 2001). Many of these cases are processed through the family
courts across Canada. The judiciary is a key participant in influencing outcomes for this vulnerable group.
Over the past three years Infant Mental Health Promotion (IMHP)
has worked to create educational materials for the child welfare
sector that focus on infant mental health and trauma. These
materials, now in the final stages of review, are designed for front
line staff within the child welfare system and will be available
online.
IMPRINT: The Newsletter of Infant Mental Health Promotion • Infant Mental Health
• Infant Trauma
Volume 64, Summer 2015 11
• Nurturing Parent-Infant Relationships
• Service Planning and Coordination
• A Push Towards Permanency
Leveraging the work that has happened thus far, IMHP is now
working towards adapting these materials to meet the learning
needs of the judiciary across Canada. In partnership with The
National Judicial Institute (NJI) the body for training judges across
Canada, and the Office of the Chief Justice, IMHP is in the process
of creating three online modules for judges presiding over family
court. Through the generous support of an RBC knowledge translation grant, IMHP has completed three videos titled “Infant Mental
Health from the Bench” which will be further incorporated into an
online learning platform. The NJI has agreed to promote and host
these modules in their online learning centre which is currently
being developed. Access to the modules will be provided to judges
from across Canada.
Our consultations with the NJI indicate that judges prefer online
resources that they can access through the NJI learning portal.
In keeping with this preference, IMHP is developing the following
three online learning modules:
Online Module 1: Understanding Attachment
• What is attachment? How does it happen? How does it
“unhappen”? What is the difference between a positive
attachment and a negative or traumatic attachment? What
are the signs?
• How settled and consistent (among experts) is the science
on attachment? How can a judge tell if the expert in front of
them really understands the issues?
• How might the research on attachment influence decisions
about access visits (frequency, duration, who should be given
access visits with a child, etc.)
• What is the impact on an infant’s development when secure
attachment does not happen?
Online Module 2: Understanding Infant Mental Health and Trauma
• What is infant mental health? When does it begin, what
promotes good mental health and what leads to poor mental
health?
• Can poor mental health in infants and toddlers be recognized? What behaviours should be considered indicators of
poor mental health in an infant or toddler?
• What are the short-term and long-term implications of poor
mental health?
• What is the connection of poor early mental health to brain
development as well as to physical health?
• What is the connection between parental mental health and
infant mental health?
12
Volume 64, Summer 2015 Online Module 3: Understanding Intervention from the Bench
• What reliable intervention programs should be used with
infants and toddlers who have experienced trauma?
• How does parental mental health connect to an infant’s
mental health in terms of interventions that should be
required?
• What types of reports and assessments should be included
in a review of a very young child’s case?
There have been significant advances in science in the areas of
brain development, epigenetics, the impact of toxic stress – all
specific to the negative effect on early development that can
subsequently impact lifelong outcomes. Ensuring judges and
those involved in family courts have this information within the
context of their role will increase the likelihood that they are
making informed decisions in the best interest of the child.
To date, through the Family Law Initiative IMHP has developed
many resources to be shared through the IMHPromotion website
and members’ portal. We are proud that the work undertaken to
date has already positioned Infant Mental Health Promotion at The
Hospital for Sick Children as a leading expert in the area of infant
mental health within Canada, and we are looking forward to much
more collaboration in the future.
References
Boivin M, Hertzman C, (eds.) (2012) Early Childhood Development: Adverse
Experiences and Developmental Health. The Royal Society of Canada and the
Canadian Academy of Health Sciences Expert Panel (with Barr R, Boyce WT,
Fleming A, MacMillan H, Odgers C, Sokolowski M, Trocmé N). Ottawa: Royal
Society of Canada, 2012. <https://rsc-src.ca/sites/default/files/pdf/ECD%20
Report_0.pdf> (Accessed on December 10, 2012)
Canadian Paediatric Society, Community Paediatrics Committee (2008). Special
considerations for the health supervision of children and youth in foster care.
Paediatrics & Child Health, 13(2), 129-32.
Center on the Developing Child at Harvard University (2011). Building the Brain’s
“Air Traffic Control” System: How Early Experiences Shape the Development of
Executive Function: Working Paper No. 11. Retrieved from www.developingchild.
harvard.edu
Center on the Developing Child at Harvard University (2007). A Science-Based
Framework for Early Childhood Policy: Using Evidence to Improve Outcomes in
Learning, Behavior, and Health for Vulnerable Children. http://www.developingchild.harvard.edu
Center for Disease Control (2008). Adverse childhood experiences study.
Publications on major findings by publication year. Retrieved May 27, 2008 from
www.cdc.gov/nccdphp/ace/publications.htm
De Bellis M. (2005). The psychobiology of neglect. Child Maltreatment, 10,
150-172.
Dunn KG, MacLafferty RL. (2009) Foster Care: Health Needs of Many Young
Children Are Unknown and Unmet. Washington, DC: US General Accounting
Office Report;1995; Available at: www.gao.gov/archive/1995/he95114.pdf.
Accessed December 1,2009
Fallon B, Trocmé N, MacLaurin B, Sinha V, Black T, Felstiner C, Schumaker K, Van
Wert M, Herbert A, Petrowski N, Daciuk J, Lee B, DuRoss C & Johnston A.(2010)
Ontario Incidence Study of Reported Child Abuse and Neglect-2008 (OIS2008).
Toronto, ON: Child Welfare Research Portal.
Felitti V, Anda RF, Nordenberg D, Williamson DF, Spitz A, Edwards V, Koss MP,
Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction
to many of the leading causes of death in adults – impact on children. American
Journal of Preventative Medicine, 14, 245-258.
IMPRINT: The Newsletter of Infant Mental Health Promotion
Fallon B, Trocmé N, MacLaurin B, Sinha V, Black T, Felstiner C, Schumaker K, Van
Wert M, Herbert A, Petrowski N, Daciuk J, Lee B, DuRoss C & Johnston A.(2010)
Ontario Incidence Study of Reported Child Abuse and Neglect-2008 (OIS2008).
Toronto, ON: Child Welfare Research Portal.
Felitti V, Anda RF, Nordenberg D, Williamson DF, Spitz A, Edwards V, Koss MP,
Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction
to many of the leading causes of death in adults – impact on children. American
Journal of Preventative Medicine, 14, 245-258.
Squires J, Bricker D, Twombly E. (2002) Ages & Stages Questionnaires®:
Social-Emotional (ASQ:SE™) A Parent-Completed Child Monitoring System for
Social-Emotional Behaviors. Baltimore, MD: Brookes Publishing.
Trocmé N, MacLaurin B, Fallon B, Daciuk J, Billingsley D, Tourigny M, Mayer M,
Wright J, Barter K, Burford G, Hornick J, Sullivan R, McKenzie B. (2001) Canadian
Incidence Study of Reported Child Abuse and Neglect: Final Report.Ottawa,
Ontario: Minister of Public Works and Government Services Canada
Glaser D. (2000). Child abuse and neglect and the brain-a review. Journal of Child
Psychology and Psychiatry, 41, 97-116.
Trocmé N, Fallon B, MacLaurin B, Daciuk J, Felstiner C, Black T, et al. (2005).
Canadian Incidence Study of Reported Child Abuse and Neglect – 2003: Major
findings. Ottawa, ON: Minister of Public Works and Government Services Canada.
Jee S, Szilagyi M, Ovenshire C, Norton A, Conn AM, Blumkin A, and Szilagyi PG.
(2010). Improved detection of developmental delays among young children in
foster care. Paediatrics, 125(2), 282-289.
Wallin L & Eriksson M. (2009). Newborn Individual Development Care and
Assessment Program (NIDCAP): A Systematic Review of the Literature.
Worldviews on Evidence-Based Nursing, 6(2), 54-69.
Leslie LK, Gordon JN, Lambros K, Premki K, Peoples J and Gist K (2005).
Addressing the developmental and mental health needs of children in foster
care. Journal of Developmental Behavioural Paediatrics, 26, 140-151.
Wotherspoon E, O’Neill-Laberge M, Pirie J. (2008). Meeting the emotional needs
of infants and toddlers in foster care: The Collaborative Care experience. Infant
Mental Health Journal, 29(4); 1-21
McCrae J, Cahalane H, and Fusco RA. (2011). Directions for developmental screening in child welfare based on the Ages and Stages Questionnaires. Children and
Youth Services Review, 33, 1412-1418.
Wotherspoon E & Gough P. (2008).Assessing emotional neglect in infants.
CECW Information Sheet #59E. Toronto, ON: University of Toronto, Faculty
of Social Work. Retrieved July 2, 2015 from www.cecw-cepb.ca/DocsEng/
EmotionalNeglectInfants59E.pdf
Public Health Agency of Canada (2010) Canadian Incidence Study of Reported
Child Abuse and Neglect – 2008: Major Findings. Ottawa.
Sroufe A, Egeland B, Carlson E & Collins WA. (2005). The development of the
person: The Minnesota study of risk and adaptation from birth to adulthood. New
York: The Guilford Press.
Squires J & Bricker D (2009). Ages & Stages Questionnaires®, Third Edition (ASQ3™) A Parent -Completed Child Monitoring System. Baltimore, MD: Brookes
Publishing.
Wotherspoon E, Hawkins E & Gough P. (2009). Emotional trauma in infancy. CECW
Information Sheet #75E. Toronto, ON, Canada: University of Toronto FactorInwentash Faculty of Social Work. Retrieved July 2, 2015 from www.cecw-cepb.
ca/DocsEng/InfantTrauma75E.pdf
Wotherspoon E & Petrowski N. (2008). Supporting the emotional development
of infants and toddlers in foster care. CECW Information Sheet #60E. Toronto,
ON, Canada: Centre of Excellence for Child Welfare. Retrieved July 2, 2015 from
www.cecw-cepb.ca/DocsEng/EmoNeedsFoster60E.pdf
Want to know more
about the Developmental
Support Planning Model?
The full
Hand in Hand
Developmental Support
Planning Resource Kit
•Intervention Manual
•Strategies Database
•Sample DSPs and Templates
•Practice Case Study
is FREE for IMHP
members through
www.IMHPromotion.ca
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 64, Summer 2015 13
Niagara Initiatives – Evaluating the Effects of Screening and
Developmental Support Planning
Chaya Kulkarni, Director, IMHP, Adeena Persaud, Project Support, IMHP, and The Niagara Infant
Mental Health Pilot Project Advisory Committee1
Improving child outcomes early in life can have a positive effect on
the child, the family, the community and society in general (Center
on the Developing Child at Harvard University, 2010). But in order
for change to happen, multiple systems and disciplines within a
community need to be involved. To be sustainable, all those within
these systems and disciplines need access to opportunities to
increase their knowledge of infant mental health, become familiar
with tools and resources that are standardized and validated,
and see themselves as early interventionists regardless of their
role. The following are the objectives of the Niagara Infant Mental
Health Promotion Program:
1.To enhance the knowledge of infant mental health of all
practitioners/clinicians working with young children;
2.To create a common approach to early developmental
screening within the community;
3.To agree and use a model for developmental support
providing families with developmental goals and strategies
while they wait for more intensive service; and
4. To improve the developmental outcomes of young children.
Vulnerability for poor mental health outcomes can be recognized
as early as 3 months of age. Such vulnerability, when unidentified
and untreated, can lead to poor outcomes for physical and mental
health outcomes (Felitti et al., 1998). In fact, research conclusively shows that when individuals experience poor mental health
early in life (birth to age 5), they are at an increased risk for chronic
illnesses such as diabetes, obesity and coronary disease.
education outcomes, awareness in communities such as Niagara
has increased. This has led to a strong desire and commitment
to see how community partners can together embed this science
into the programs and services delivered to young children and
their families. The ultimate goal is to see better developmental
outcomes for young children identified as at risk for developmental
delays.
Project Summary
Niagara Infant Mental Health Promotion: Embedding Science into
Practice (NIMHP) aims to improve mental and physical wellbeing
of young children through:
• Knowledge translation and exchange among professionals
working regularly with this population;
• Early identification of risk for developmental delay; and
• Creation and implementation of a developmental support
plan for those children waiting for more intensive service or
assessment.
All staff will be invited to attend training on:
• Infant Mental Health: Understanding and Embedding the
Science
• How to administer and interpret the ASQ tools
• How to create a developmental support plan for those
children at risk of a developmental delay.
Infant Mental Health Promotion, in partnership with Children’s Roles and responsibilities will align as follows:
Aid Society of Toronto, completed a pilot that looked at the use of
• Local agency staff will be completing developmental screens
knowledge translation, developmental screening and implantation
on those children who participate.
of developmental support plans as a way to improve developmen• Local agency staff will be creating developmental support
tal outcomes (outlined in a previous article in this issue, IMHP
plans for those children whose score indicates a risk of delay.
2015). The findings of this pilot suggest that the provision of
developmental support plans improved developmental outcomes
• Local agency staff will collect demographic data of the
(Kulkarni, Cheung Fillipelli, Packard, Paolozza. (2013).
families of the children who will be developmentally screened.
Recent advances in science have reinforced the importance of
early developmental screening and intervention – what we do in the
early years profoundly influences a child’s developmental trajectory over the lifespan. As Infant Mental Health Promotion along
with others such as Dr. Jean Clinton have spoken to communities
about the significance of early mental health on later health and
• Local agency staff will submit the demographic data and
developmental screen scores they collect to Infant Mental
Health Promotion using REDCap .
• IMHP will be responsible for providing training on early
mental health, early development, and how to create a developmental support plan.
1 - The Niagara Infant Mental Health Pilot Project Advisory Committee is comprised of: Strive Niagara (formerly AFSSN), Pathways Academy, A Child’s World, YMCA,
Family and Children’s Services Niagara, Pathstone Mental Health, Early Childhood Community Development Centre, Niagara Region Public Health (Healthy Babies
Healthy Children and Infant and Child Development Services), Speech Services Niagara, Niagara Region Children’s Services, Hannah House, Childcare Sector, District
School Board of Niagara, Bethlehem Projects, Quality Child Care Niagara, Niagara Children’s Centre, CAPC Niagara Brighter Futures, CPNP Healthy from the Start,
Niagara Chapter Native Women, Department of Family Medicine McMaster University, Rosalind Blauer Centre for Child Care, Toronto Children’s Aid Society, and IMHP.
14
Volume 64, Summer 2015 IMPRINT: The Newsletter of Infant Mental Health Promotion
• IMHP will be responsible for collecting all data using REDCap2
and completing any analysis of data.
Program Description
The program will work to build capacity within the health, education
and social services sectors within the Niagara region. Families
will be asked by participating pilot site agencies to volunteer to
participate in the study. Every child engaged in the study will
receive the Ages and Stages Questionnaires: A parent-completed,
child-monitoring system (ASQ-3™) (Squires & Bricker, 2009) and
Ages & Stages Questionnaires®: Social-Emotional (ASQ:SE™) A
Parent-Completed Child Monitoring System for Social-Emotional
Behaviours (Squires, Bricker, Twombly, 2002) screens at 3 intervals
over the course of one year. Ultimately, the hope is that there
will be an improvement in the scores of children with concerning
scores who receive the Developmental Support Plans, allowing us
to determine the effectiveness of this intervention model.
conducted in 2012/13 show a 20% increase in positive response
to the question “I am confident that I can accurately identify an
infant or young child who is at risk for developmental delay”.
Objectives of Component 1
The training and mentoring will be delivered through a combination of face-to-face training, online sessions and technical support
sessions to support staff in feeling confident and equipped to:
• Enhance their knowledge of infant-early mental health and
its relationship to developmental outcomes over the lifespan;
• Administer the developmental screening tools;
• Interpret the results from developmental screens, observations and interviews;
• Use the information gathered to create developmental
program plans that are responsive to the developmental
needs of young children who may be at risk for a developmental delay; and
This collaborative quality improvement initiative will consist of four
different components.
Component 1: Knowledge Translation and Exchange
In order for any system to be effective those within it must have
the knowledge they need to be responsive and also be adaptable
to unique circumstances. In the case of those systems working
closely with very young children this is certainly the case. Every
child is unique with a unique social history, support system and
experiential base. For staff to be and feel effective, their knowledge
of early development is essential to any intervention, curriculum or
other resource introduced in a community.
• Continue monitoring development and revising the developmental plans.
Component 2: Developmental Screening
The ASQ is a first level screen used to identify infants or young
children (5 years and under) who require further evaluation for
possible developmental delays. The ASQ 3 includes 21 age-specific
questionnaires each with 30 items to be completed by parents
or primary caregivers (McCrae et al., 2011). The 30 items cover
5 domains: communication, gross motor, fine motor, problem
solving, and personal-social. Caregivers are asked whether their
child: performs a particular skill (value of 10), sometimes performs
For this reason, this project will create and maintain a strong the skill (value of 5), or is not yet performing the skill (value of
knowledge translation and exchange component. All staff will 0). Children whose score is 2 or more standard deviations below
have access to training on infant mental health, developmental the mean are considered to be in need of further evaluation. In
screening and developmental support plan creation. In addition, addition, the ASQ-SE screens for potential difficulties with socioevery month, staff will have the opportunity to attend technical emotional functioning. This tool can be completed by child-welfare
support meetings to discuss challenges in the implementation of practitioners and caregivers. Both the ASQ 3 and ASQ-SE demonthe developmental screen, the interpretation of results and the strate good psychometric properties. For instance, concurrent
creation of a developmental support plan. These sessions will be validity (comparing the percentage of agreement between the
provided by Infant Mental Health Promotion and will take place in results of ASQ-3 with the results of professionally administered
the Niagara region.
standardized assessments) “ranged from 74% for the 42-month
ASQ-3 questionnaire to 100% for the 2-month and 54-month
Staff will be asked to complete a knowledge survey prior to the start
questionnaires, with 86% overall agreement”. (Squires, Twombly,
of the project. They will be asked to complete the same survey at
Bricker & Potter, 2009). Both the ASQ 3 and ASQ-SE can be used
the one year anniversary of the project. The purpose of this pre and
for children between the ages of 2 to 72 Months.
post knowledge survey is to determine if the activities have collectively led to an increased understanding of early mental health Objectives of Component 2
among staff. To date, pre and post training survey comparisons
consistently demonstrate general improvement in knowledge and Once equipped with the knowledge and skill needed to use the
opinions. For example, results of the pre-post training knowledge ASQ tools, practitioners will:
survey from the Infant Mental Health Community Training Pilot
2 - Study data are collected and managed using REDCap electronic data capture tools hosted at The Hospital for Sick Children, Toronto. REDCap (Research Electronic
Data Capture) is a secure, web-based application designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry; 2)
audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and
4) procedures for importing data from external sources.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 64, Summer 2015 15
• Begin regular use of the ASQ tools with children under the
age of four;
• Use both tools along with observations and interviews
with caregivers and practitioners involved with the child to
collect as much information about the child’s developmental
status – physical and mental – to inform the creation of a
Developmental Support Plan; and;
• Use the results of developmental screens for program and
service planning to inform programs and services.
Component 3: Developmental Support Plans
whether the worker’s increased knowledge of infant mental health
has led to better developmental outcomes for the infants and
toddlers and the families they serve. Demographics regarding the
family of the screened children will be collected to evaluate how
the process works with different families.
The demographic information that will be collected by the local
agency staff are:
• Postal codes
• Single or 2 parent household
• Level of education of parents
Collectively, the information from developmental screens enables
• Primary language spoken in the home
us to recognize those who may be vulnerable or at risk for a delay.
• Levels of income of both parents
Although referrals are made for further assessment and/or intervention, it often takes several months, if not a year to receive
• Both parents working/school
such services. While children and families wait, those already
• Other family members who are parenting this child, i.e.,
working with a child can create a Developmental Support Plan that
grandparents
provides families with clear developmental goals and strategies
to address specific developmental goals. These plans are then
• Have you been invited to participate by another program?
implemented by all caregivers (early learning and care staff, home
visitors, biological families, foster families and other profession- The process evaluation is a collaborative effort between Infant
als involved with the child). The plans also remind parents how Mental Health Promotion and the community agencies involved
and includes the following tasks:
important they are to their child’s development.
Objectives of Component 3
a) The Developmental Support Plans will identify goals and
strategies to achieve the goals and will also provide caregivers with an understanding of why the goal and strategies
are important for the child. When child welfare workers feel
challenged in the creation of the plan, Infant Mental Health
Promotion will provide guidance and support to ensure all
plans are meeting the global needs of the child. To support
those creating plans, Infant Mental Health Promotion has
created a manual and resource kit, Hand in Hand: Growing
Together Everyday (IMHP, 2014). The resource provides
practitioners with a sample of developmental goals and
strategies to address goals in all developmental domains.
b) Once the plan has been developed, practitioners will confidently and regularly:
• Create and implement Developmental Support Plans for
those children at risk of a developmental delay.
• Review the Developmental Support Plan with the child’s
family/caregivers and any other professionals involved
with the child.
• Ensure that all caregivers and practitioners working with
the child understand the developmental goals and how to
integrate the strategies into daily routines with the child.
• Record when goals are successfully achieved.
Component 4: Process Evaluation
Infant Mental Health Promotion, with the help of all the partnering
agencies would like to evaluate the effectiveness of the process
we have outlined in this proposal. Particularly, we will be examining
16
Volume 64, Summer 2015 • Local agency staff will complete developmental screens on
those children who participate.
• Local agency staff will collect the demographic information
of the families of the children who receive developmental
screens.
• Local agency staff will create Developmental Support Plans
for those children whose score indicates a risk of delay.
• Infant Mental Health Promotion will be responsible for
providing training on early mental health, early development,
and how to create a DSP.
• Infant Mental Health Promotion will be responsible for collecting all data using REDCap and completing any analysis of the
data.
Objectives of Component 4
Through this process evaluation, Infant Mental Health Promotion
and the collaborative agencies hope to:
• Determine if this process is an effective and successful way
for practitioners to respond to the developmental needs of
infants and toddlers identified as at risk for a developmental
delay;
• See how each particular component works and how practitioners execute them throughout the process;
• Determine how the process works with different types of
families based on the demographic information we collect;
• Implement this process in another community that wishes to
address the developmental needs of infants and toddlers in
that community.
IMPRINT: The Newsletter of Infant Mental Health Promotion
Niagara Infant Mental Health Pilot Sites
References
There are 13 programs participating in this evaluation from March
2015 to March 2016.
Center on the Developing Child at Harvard University (2011). Building the Brain’s
“Air Traffic Control” System: How Early Experiences Shape the Development of
Executive Function: Working Paper No. 11. Retrieved from www.developingchild.
harvard.edu
1. Strive Niagara formerly Adolescent’s Family Support Services
Niagara) - 3 sites
2. Niagara Region Home Childcare Children’s Services
3.Niagara Region Public Health (Healthy Babies Healthy
Children)
4. Niagara Regional Childcare (Branscombe Family Centre)
5. Rosalind Blauer Centre for Childcare
6. CAPC Niagara Brighter Futures
7. CPNP Healthy from the Start
8. Hannah House
9. Family and Children’s Services (FACS)
10. Pathways Academy
11. A Child’s World (ACW) Childcare centres-5 sites
12. YMCA of Niagara Childcare-3 sites
13. Bethlehem Housing and Supports
These sites will complete the Ages and Stages Questionnaires with
consenting families from their programs. Following the completion
of the questionnaires, a Developmental Support Plan (DSP) will be
created for each child whose screens demonstrate that they may
be at risk for a developmental delay, along with any appropriate
referrals. The DSP will include strategies caregivers can use during
daily activities to promote development in all areas with a special
focus on any areas where risk is identified. Every three months
families will be asked to complete another questionnaire that will
examine how the child’s development has changed since implementing the DSP strategies, and another DSP will be created.
Center on the Developing Child at Harvard University (2010). The Foundations of
Lifelong Health Are Built in Early Childhood. http://www.developingchild.harvard.
edu
Felitti V, Anda RF, Nordenberg D, Williamson DF, Spitz A, Edwards V, Koss MP,
Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction
to many of the leading causes of death in adults – impact on children. American
Journal of Preventative Medicine, 14, 245-258.
Kulkarni C, Cheung C Fillipelli J, Packard B, Paolozza C. (2013) Infant Wellness and
Child Welfare: Promoting Mental and Physical Welbeing. Poster Presentation
Zero to Three National Institute, Dec. 12 - 14, San Antonio, TX
Infant Mental Health Promotion. (2014) Hand in Hand: Growing Together Everyday
Developmental Support Planning Resource Kit. IMHP, the Hospital for Sick
Children, Toronto. Retrieved from http://www.imhpromotion.ca
Infant Mental Health Promotion. (2015). Infant Mental Health and Family Law
Initiative (FLI) IMPRINT: The Newsletter of Infant Mental Health Promotion, Issue
64, Summer 2015.
McCrae J, Cahalane H, and Fusco RA. (2011). Directions for developmental screening in child welfare based on the Ages and Stages Questionnaires. Children and
Youth Services Review, 33, 1412-1418.
National Scientific Council on the Developing Child. (2008/2012). Establishing
a Level Foundation for Life: Mental Health Begins in Early Childhood: Working
Paper 6. Updated Edition. http://www.developingchild.harvard.edu
Squires J & Bricker D (2009). Ages & Stages Questionnaires®, Third Edition (ASQ3™) A Parent -Completed Child Monitoring System. Baltimore, MD: Brookes
Publishing.
Squires J, Bricker D, Twombly E. (2002) Ages & Stages Questionnaires®:
Social-Emotional (ASQ:SE™) A Parent-Completed Child Monitoring System for
Social-Emotional Behaviors. Baltimore, MD: Brookes Publishing.
Coming soon...
The data collected from the completed questionnaires will be
evaluated to measure the effectiveness of the screening tool and
the accompanying developmental support plan model.
It is our hope that this initiative will bear three fold results:
1) Increased capacity of frontline practitioners to identify early
developmental concerns through screening and observation.
2) Increased communication and family-centred care to create
common goals, and enhance service delivery.
3) Increased capacity of practitioners to provide families with
supportive strategies to promote infant development.
It is our hope that by identifying developmental concerns early and
providing a supportive response, in this case the Developmental
Support Plan, we have a greater likelihood of effectively addressing the concerns for children at risk.
Activity Program
for Parents, Infants,
Toddlers and Preschoolers
Facilitator materials to deliver a brief 6 week
program for parents and their children with a
focus on supporting child development.
Download it for FREE
at www.IMHPromotion.ca
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 64, Summer 2015 17
A Collaborative Approach to Embedding the Science of Infant
Mental Health and Enhancing Infant Mental Health Services
Chaya Kulkarni, Director, and Adeena Persaud, Administrative Assistant, Infant Mental Health
Promotion (IMHP)
The diversity of Canadian communities underscores the need
9. Identify funding needs and resource requirements to support
to work locally with agencies and experts to determine how the
implementation;
science and best practices for infant mental health can be effec10. Implementation of evaluation components to determine
tively embedded into policies, programs and services. The reality
efficacy;
is that on their own, individuals will find it challenging to create
11. A detailed plan for knowledge transfer and embedding of
a shift in practice and policy in response to this knowledge. With
infant mental health into practice.
this in mind, Infant Mental Health Promotion has actively created
a process to engage and mobilize communities in exploring the
rapid application of knowledge and emerging science to practice. Each community actively worked with IMHP to create a Community
Consultation Report to reflect these discussions. Common
In December, 2014, the Public Health Agency of Canada (PHAC) themes emerged across communities about infant mental health
provided funding to Infant Mental Health Promotion at the Hospital practices, policies, services and in relation to the knowledge and
for Sick Children to create a collaborative, community-based competencies of those working with this young population and
process to explore the issues at play for direct service delivery their families.
agencies. Documents such as the Infant Mental Health Best
Practice Guidelines (IMHP, 2002, 2004, rev. 2011) and Supporting
Ontario’s Youngest Minds: Investing in the Mental Health of
Children under 6 (Clinton et al, 2014), were used as reference
documents to guide community discussions.
Through this project, IMHP has consulted with five communities
in Ontario in order to facilitate a greater understanding among all
agencies and sectors concerned with infant mental health as to
the existing gaps or barriers, opportunities for improved service
delivery, and potential solutions for inter-systemic supports. Over
the course of four months IMHP conducted discussions within
each community that explored the following:
1. A shared understanding of the state of knowledge and
practice among all professionals specific to infant mental
health;
2. Identification of short and long term opportunities to
strengthen knowledge and practices among practitioners/
and their agencies specific to infant mental health;
3. Identification of current practices that support infant mental
health promotion and intervention;
4. Identification of local champions within the relevant sectors;
5. Identification of agency policies that are supportive of best
practices specific to infant mental health promotion, prevention and intervention;
6. Identification of short and long opportunities to change
and strengthen policies and practices to further reflect the
science of infant mental health promotion and intervention;
7. Identification of next steps to support the Implementation of
short term opportunities and explore how to act on long term
opportunities within each community;
8.Expressions of support needed from IMHP on an ongoing
basis, such as ongoing teleconference support, etc.;
18
Volume 64, Summer 2015 What was evident across all communities was a passion and
commitment to strengthen infant mental health from all perspectives and in all areas of services – policies, practice, and knowledge
of those delivering service. There was a recognition that training
alone would not be enough to lead to a significant change of
paradigm.
While some aspects of mental health services may be well
designed or under construction in some regions, an inclusive and
coordinated system of infant mental health services , including
a variety of access points, tools, and interventions available to
all families, is in itself in its’ infancy. In an environmental scan
conducted by IMHP which surveyed a sample of Ontario communities (Clinton, 2014 p. 21) it was found that:
• The type of early mental health care available to young
children in direct service settings varies among agencies.
The extent to which these services are accessible also varies.
• Agencies use a variety of screening and assessment instruments to understand family need and develop treatment
plans.
• The level of training among staff delivering services varies,
and there is an inconsistent understanding of what infant
and early childhood mental health means.
• Agencies typically have, or are working on, referral arrangements with other agencies to provide complementary and
mental health specialty services, with varying degrees of
coordination between schools and community partners.
Special Needs Resourcing funding appears to help facilitate
internal agency referrals.
• While internal referrals appear to be relatively fast, average
wait times for external assessments and mental health
services were reported to be four to six months, with wait
times for services ranging from six weeks to a full year.
IMPRINT: The Newsletter of Infant Mental Health Promotion
Methodology
Selection of Communities
Ontario is a vibrant province diverse in its communities ranging
from large urban settings to rural communities that span a great
geographic distance. As a pilot, the goal was to select five communities that represented the diversity of Ontario. The following
criteria were used to guide the selection of communities:
• Presence and leadership of a strong Community Action
Program for Children (CAPC) and Canada Prenatal Nutrition
Program (CPNP) in the community;
• Participation by some community partners in the online
Infant Mental Health Community Training Institute offered by
IMHP during the past three years;
• A willingness among community partners to commit 3 days
toward discussions at a community table;
ensure that those at the community table were in management
positions within their agencies with the hope that this would ensure
a rich source of information gathered and effective communication back to each agency.
Data Collection: Learning About Each
Community, Their Policies, Practices, and
State of Knowledge Specific to Infant
Mental Health
A standard template was created to guide discussions and
specifically examine core prevention and intervention activities,
competencies and organizational policies. The Infant Mental
Health Promotion Best Practice Guidelines (IMHP, 2002, 2004,
rev. 2011) were the framework that guided these discussions. The
information gathered was organized into the categories below.
• Support for infant mental health and the process to identify
strengths and opportunities from:
• Current programs and/or services that the community
considered to be part of their system of infant mental health
services that were available to all families or targeted toward
high risk families.
• the local Medical Officer of Health or Local Health
Integration Networks (LHIN);
• Current strategies for developmental screening and what
aspects of this examined mental health.
• at least one child welfare agency in the community;
• Current prevention and early intervention programs with a
focus on those addressing infant mental health.
• a regional/ municipal child care body;
• a board of education;
• an existing early years or best start table in the community;
• three local champions of infant mental health;
• some practitioners who had participated in the training
provided by IMHP, with attendance from at least one
person in three sectors.
Establishing Community Tables
The following communities were ulitmately selected to represent
a relatively diverse social, economic and environmental sample:
• Simcoe County
• Niagara
• Muskoka and Parry Sound
• Ottawa
• Regent Park
The appendix following this article includes a full list of the
participating agencies in each region selected and the respective
partners who were at the discussion tables.
• The current state of knowledge and skill of practitioners in the
community working with this age group within the following
sectors:
• Education
• Child Protection
• Early Learning and Care
• Children’s Mental Health
• Public Health
• Rehabilitation Services
• Speech and Language Services
• Existing collaboration among agencies
• Short term opportunities to strengthen practices, services,
and policies. These were identified as activities the
community felt could be achieved within one year.
• Long term opportunities to strengthen practices, services and
policies. These were identified as activities the community
felt would require more than one year to achieve.
• Organizational policies and procedures specific to infant
mental health. For instance, were caseloads within agencies
reflective of the intense work often required when an infant’s
mental health is vulnerable; or did staff receive regular
supervision that offered opportunities for reflection and also
provided support to the trauma some staff witnessed?
In all communities a CAPC and/or CPNP site was identified as a
local champion of infant mental health and lead for organizational
purposes, either on their own or in partnership with another agency.
Each community champion was asked to assist with scheduling
2.5 days of face to face meetings. The champions were asked to Infant Mental Health Promotion was the lead to record all informareach out to all sectors and to ensure that the community table tion and draft the final reports.
was diverse from a systems perspective. They were also asked to
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 64, Summer 2015 19
As information was gathered and organized it was sent back to
each community for review, edits and suggestions. It was essential
that all community partners agreed with the information that was
documented. The editing phase was primarily conducted through
email and at least one teleconference call with each community.
It is important to note that within each community the level of
honesty and candour was impressive. Speaking about strengths
was easy and enriching to hear, often with moments of clarity
among partners as they gained insight into what others were doing.
Identifying where services could be better, or policies needed to be
refined because of the science, was more challenging. Within each
community table there were members who helped to create a safe
environment in which these conversations could take place. These
more difficult conversations were honest and positive and were
not riddled with blame or judgments from one sector to another.
Instead, these conversations were guided by what the science is
telling us, how this is shaping local efforts to respond to vulnerability more effectively, and ultimately how infant and early childhood
mental health can be better supported.
Opportunities to Enhance Core Prevention
and Intervention
The following is a synopsis of discussion themes which were
brought forth by the five community partners involved in this
project. Some opportunities identified may be considered short
or long term goals depending on the community and individual
agencies. Some agencies may already have many of these
suggestions and initiatives in place or in progress.
Prevention/ Advocacy
• Continue to embed infant mental health where applicable
into programs, services, and treatments. Maintain a strong
focus and commitment to ensuring culturally and linguistically competent services, supports and processes for
families and family--centred care.
• Identify pre-existing campaigns to adapt or create locally
developed key parenting messages on child development
(using a universal language and based on the science) to
promote and advocate the importance of parent-child relationships, accessing developmental screenings, engaging and
empowering parents, healthy development, parental mental
health and the impact of cumulative risk factors on infants
and toddlers.
• Explore and review resources on developmental milestones
that could be promoted online or shared face to face
with families as a consistent resource for parents and
professionals.
• Create and implement the dissemination of a universal brief/
pamhplet for physicians to use during visits that includes key
messages about the importance of infant mental health,
including relationships for babies. Encourage all agencies
in the region to use this document to support a common
language and understanding.
20
Volume 64, Summer 2015 • Develop and/or promote a web-friendly resource for parents
to access to access key information that will include
milestones for different developmental stages. Leverage
existing web resources which could be used as a portal.
Explore how technology can be used to improve information
gateways for families. For example, explore the use of social
media by agencies to promote programs, leverage existing
web resources and promote IMH messaging to families.
• Identify media opportunities and resources in an effort to
reach out to the general public promoting e awareness of
infant mental health e.g., through radio, TV stations, commercials at movie theatres, etc.
• Identify and include programming specifically for fathers and
build on existing efforts (e.g., Dad Central, various coalitions)
to strengthen and create new opportunities for fathers.
• Advocate for the inclusion of a parenting/ family studies
courses in school and high school curricula to teach child
development, families/parenting, and life skills (including
“Roots of Empathy”).
• Engage in advocacy conversations with the Ministry of
Children and Youth Services to seek much needed support
for Healthy Babies Healthy Children programs and resources
for ongoing home visits to young children, including those in
foster homes.
• Implement region-wide strategies to support infant feeding
and general nutrition from birth to five, including the Baby
Friendly Initiative (BFI). Explore the transferability of the
Baby-Friendly Initiative (i.e., creating supportive environments) into other community agencies, and encourage
organizations to become BFI designated.
• Identify potential funders for IMH promotion, prevention, and
intervention initiatives.
• Identify local champions, community tables and networks to
address IMH concerns.
• Broaden and implement opportunities for physicians and
other health professionals to become aware of infant
and parental mental health through education (through
Continuing Medical Education (CME) credits).
• Advocate for government/ agencies to address the impact
that adult/ parental mental health has on infant mental
health.
Support for All Families with a Focus on Those at Risk
• Develop a “Community of Practice” to establish and support
the implementation of early screening, intervention and
assessment practices.
• Develop a “local developmental services pathways”
document for parents/ families and community partners (i.e.
health and social services) as a point of reference outlining
local services available for prenatal to three years of age for
early development, screening, assessment, prevention, intervention and treatment.
IMPRINT: The Newsletter of Infant Mental Health Promotion
• Included in the pathways document should be:
• Explore opportunities to enhance or develop a model that
supports family time through parent education and coaching,
applicable or adaptable to a variety of settings including child
protection, Ontario Early Years or Best Start Child and Family
Centres to address the needs of vulnerable families.
• Agencies and screening tools being used in your region.
• Services that require a formal referral from a physician.
• Services/tools that can be accessed by front-line
practitioners.
• A clear referral process that all community partners are
aware of.
• Increase education opportunities for primary care physicians
working with at-risk young mothers and vulnerable families
to link with community agencies.
• Create a process to build capacity to recognize the risk for
early mental health concerns and respond with appropriate
services.
• Strengthen community awareness on issues such as
Postpartum Mood Disorders and supporting vulnerable
parents and families.
• Broaden mandates of agencies to include prenatal
components.
Early Screening and Assessment Activities
• Ensure families that are waiting for intensive services are
provided with interim resources and strategies they can use
to support their child’s development in the interim.
• Explore further how initiatives can be more inclusive and
reflective of the population (e.g. economic or cultural
diversity) of the region.
• Promote existing and/ or implement more multi-sector
opportunities for staff to be coached on communicating and
sharing information with parents about normal development
and developmental concerns.
• Create key messages to educate practitioners and funders
around difficult to engage families and strategies for effective
non-traditional approaches (such as telephone based peer
support). Identify strategies to build capacity for clients to
become more receptive to services, address the barriers they
face, and assess their readiness. Explore effective outreach
methods for agencies working with vulnerable families in
high risk situations. Explore non-traditional strategies to
engage families in services as families often experience
challenges in physically attending services (e.g., providing
transportation fare may not be enough if public transit is not
accessible).
• Explore ways for families/parents with young children to
better inform practitioners/ professional they are engaged
with, of their needs (e.g., through a checklist document
families fill out, etc.).
• Use the documents parents complete as an opportunity for
open conversation and dialogue to engage and motivate
families to build relationships with staff. For example, the
early learning and child care (ELCC) sector could look to
create an “intake” resource for practitioners to learn more
about a child, facilitate discussion between staff and
families, and support families on a daily basis. This could
include questions regarding the child’s temperament and/ or
the familial/ caregiving structure, for instance.
• Explore opportunities to strengthen co-located models/
services for mental health and addictions for vulnerable
populations.
IMPRINT: The Newsletter of Infant Mental Health Promotion • Explore and identify ways to increase early screening opportunities across sectors (physicians, early learning and care
settings etc.). Explore existing initiatives that could be
adopted or adapted in your community, e.g., implementation of developmental screening clinics. Review admissions
and follow-up forms (which document the child’s history)
and explore if possible how to embed infant mental health/
screening and/ or assessment components.
• Ensure that the tools used are robust and include a strong
social-emotional component. Explore the inclusion of the
ASQ-3 and ASQ-SE tools in in developmental assessments.
Explore how existing tools and resources can include a
stronger focus on infant and early childhood mental health
concerns.
• Look to expand conversations on screening and assessment
for social-emotional development to include parents from
the community at the table. Include in this conversation a
discussion of a referral procedure for the community. How
can the community support families and determine if they
have engaged and accessed the service successfully?
• Develop a local services pathways document that can be
referenced by both professionals and parents. Explore and
identify all current services that provide developmental
screening including infant and early mental health. Identify
and document which agencies are using what screening
tools and the protocol followed by each when there is a developmental concern. Explore the ideal intervals for screening
to occur.
• Look for ongoing opportunities to implement and strengthen
early screening and developmental support planning, particularly in individual, home-based, and clinic-based treatment
plans within early learning and care settings. Explore what
other services or agencies could consider implementing
developmental screening including infant and early mental
health.
• Identify all tools used for early developmental screening and
ensure all agencies working with this age group understand
the purpose and administration of the tools, how to interpret
the score and how to combine information from a screen
with other sources of information about a child in a meaningful way.
Volume 64, Summer 2015 21
• As a community, consider alternate validated screening tools
which could be used in community agencies with children
under five years. Practitioners will have the choice of which
tools they prefer to use. This could be a part of a long term
plan to increase developmental screening across the district.
Early Intervention
• Explore and identify current infant mental health experts
within sectors and share this information at the Best Start
Network table. This may include a discussion about what
criteria would identify any individual as an “infant mental
health” expert.
Treatment
• Explore hosting a city/ region-wide Developmental Support
Planning training for your community.
• Review treatment options, referral pathways and inclusion
criteria.
• Promote and enhance coordinated listings and existing
pathways documents among professionals that address
early mental health. Ensure consistency within pathways
documents and how they are guiding both professionals and
parents. Include details of the extent of programs/services
so agencies are aware of expertise within the community that
is accessible. This will also include common screening and
assessment tools to ensure that professionals and parents
understand the scope and purpose of each.
• Strengthen infant/early mental health services in special
needs and mental health sectors.
• Identify strategies to increase the system capacity for
referrals to be followed up and coordinated for both universal,
early/ indicated intervention and treatment, including but
not limited to the used of a shared records system. Explore
how a shared records system can be used by those currently
not using it to enhance coordinated referrals, early intervention and treatment. Include physicians and midwives in the
process of shared records, and other early identification
initiatives. For example, explore a provision within screening
initiatives that allows relevant practitioners to be prompted
with updated information in an alert message (e.g. text
message update – (child) has begun treatment for (disorder)
at (clinic), no further follow up needed).
• Advocate for and engage with adult mental health counselling
services that will positively impact parent-child relationships
and parenting capacities.
• Develop a form of passport document and/ or shared
electronic record for families for when they visit physicians,
nurses, and other support services. Explore existing models
of developmental passports from other sectors (e.g. health
care) that could be replicated for early mental health services.
• Strengthen cultural sensitivity when administering developmental assessments and intervention.
• Have community tables explore possible strategies to
provide developmental support to families while they are
wait listed for intensive services. Explore what strategies can
be presented to families, including systematic referrals to
supportive services such as HBHC, while they wait for specialized care.
• Strengthen service coordination throughout all systems and
in particular for children transitioning from one system to
another, such as from preschool to school, to ensure continuation and consistency.
• Create and implement an annually updated ‘transition to
school’ plan before children enter kindergarten so all are
aware of any new information from May to September.
• Develop a plan and additional resources for staff to support
and teach self- regulation and problem solving strategies to
children.
22
Volume 64, Summer 2015 • Advocate for treatment services in both official languages.
• Explore further how treatment services can be more accessible, inclusive and reflective of the population of the region.
For example, consider use of internet services, videoconferencing or telephone-based supports to increase accessibility
to services for remote regions.
Collaboration
• Assess and take inventory on what is available in the
community in regards to models of co-located and/ or
overlapping services.
• Initiate community meetings to enrich current initiatives
and tables to ensure cohesiveness. Communicate what is
transpiring at the moment and identify how community
agencies can become involved. Using/ leveraging existing
tables and initiatives, including and not limited to Best Start,
Mental Health Transformation, and Special Needs Table, and
Child and Youth Initiatives, look at coordinated listings and
pathways for accessing developmental and support services,
and identify gaps in service provision.
• Explore how to include parents in the development and
design of the system that meaningfully responds to early
mental health (as the many tables are in the midst of evaluating mental health services). Explore how planning might fit
into existing community tables or whether a new/separate
table is needed.
• Strengthen partnerships with the First Nations, Métis,
Inuit (FNMI) community and explore how to include the
FNMI community, Aboriginal Mental Health Programs and
Aboriginal Healthy Start.
• Expand Prenatal Infant and Early Years Mental Health
Task Groups to include First Nations Metis and Inuit (FNMI)
community, Francophone community, midwives, doctors,
parents, and other professionals to the table. Explore and
work toward the inclusion of parents at local task groups.
Ensure that reports and resources are inclusive and respectful to the specific needs of FNMI and Francophone families in
the region.
IMPRINT: The Newsletter of Infant Mental Health Promotion
• Reach out to the FNMI communities affected by the fee
subsidy restrictions and boundaries to look for a resolution.
• Engage the Local Health Integration Network (LHIN) and
share the final reports created as a community. Engage in
conversation with the LHIN regarding shared or joint training
opportunities, for example, accessing the Infant Mental
Health Community Training archives.
• Encourage local midwives to refer/ introduce families to
other community agencies and the services they offer to
support families following the end of their involvement (6
weeks after birth). One option could be a drop-in or a meet
and greet with community agencies.
• Engage in a community discussion on how to address infants
and toddlers with a positive toxic screening result or identified Fetal Alcohol Spectrum Disorder or Neonatal Abstinence
Syndrome.
• Develop a collaborative approach to parent education
programs and events among agencies across the district.
• Develop a more organized system for volunteers in community
agencies:
• Explore a strategy to engage the public schools in infant
mental health conversations.
• Continue to increase the number of volunteers within
community agencies to assist with identified needs or gaps,
e.g., transportation services for families.
• Communicate to the Mental Health Transformation leads the
need for knowledge exchange amongst services/programs,
sharing what services entail and any resources families may
be using/given. The transition from/ between services needs
to be highlighted as well.
• Explore how to develop the organizational capacity to include
the role of volunteer coordinator. Increase support and
resources for coordination of volunteers.
• Create a package and executive summary for policy, strategy
and service integration bodies to highlight key points and
recommendations.
• Host a meeting with agencies who serve the most vulnerable
to discuss and determine solutions to challenges they face
in service delivery, particularly clients who are difficult to
engage.
• Implement a model of collaborative problem solving (CPS)
approaches with agencies that are interested and may
benefit from such an approach.
Strengthening Data Collection/ Statistical Analysis and
Assessment
• At local teams, determine what could be done to engage all
practitioners and clinicians to create a more robust team and
strengthen and expand inter-agency and peer relationships.
• Identify opportunities to leverage agencies who have established relationships with families when sharing plans for
care.
• Increase the collaboration between agencies, for example
CPNP sites in the community and Community Health Centres,
and agencies and primary care.
• Explore collaboration to support both parents and their
children. Create a collaborative practice with Adult Mental
Health Services (including a FNMI service lead) to strengthen
the bridges between community agencies and adult mental
health services. At existing community meetings initiate a
dialogue about parental mental health, topics of child development, parenting approaches, and how they can contribute
to (or prevent)the developmental vulnerability of infants and
toddlers.
• Include school boards at community tables to leverage and
create more awareness of services.
• Convene a multi-sector group to look at the current data
collected and develop a database to capture information
regarding the prenatal and 0 to 5 age group including components relevant to infant-early mental health. Determine what
type of data is being collected by the LHIN and health units
that could be helpful to community partners. Health units
may look to collect Health Equity Data to help with service
planning.
• Determine who is collecting current research and statistics
specific to your region, for example, prevalence rates of post
partum mood disorder (PPMD) in Northern Ontario. This
data will strengthen the advocacy efforts of the community
partners.
• Determine what information is currently being collected
by agencies to help learn where in the region families are
accessing services and where there is less involvement.
• Advocate with existing data collection initiatives e.g., Better
Outcomes Registry & Network (BORN), and/ or electronic
Child Health Network coordinators to include elements of
infant-early mental health and other useful information.
• Inform other regions about effective project collaborations,
for example between child protection and adult mental
health agencies. Explore effective practices conducted in
other jurisdictions.
• Explore how to include evaluation components into programs
that serve infants, toddlers, and families. Create a process
to evaluate programs and initiatives including the efficacy
of screening and assessment tools used. Valid and reliable
instruments/ tools should always be used.
• Disseminate more information about local screening clinics
or services that provide developmental screening, and initiatives among professionals to refer families needing follow-up
(based on funding).
• Measure critical outcomes for children – not just quantitative measurement. For example, does the screening process
capture children who may have been missed otherwise?
Evaluate the number of referrals from one year to the next.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 64, Summer 2015 23
• Connect with local academics, universities and post
secondary institutions regarding conducting evaluation on
the progress of initiatives. Explore the potential to involve
students/ faculty in evaluation efforts.
• Conduct environmental scans of the service availability,
efficacy, and capacity for infant/ preschool development
in the community. Coordinate existing scans between the
Mental Health Transformation Table and public health
agencies to determine overlaps or gaps.
• Ensure that community agencies are included in existing
environmental scans. Working documents should be shared
with the community to ensure the inclusion of services as
they are being mapped. As a community, review the environmental scan and referral pathways together once they are
complete.
• Create a process to gather data on the number of completed
assessments and screenings for children ages 0-5 years.
Child care services may have the capacity to collect data
as well as HBHC and local children’s mental health, primary
care and early years centres.
• Explore a plan that uses a universal tool to capture family/
child, assessment, referral, and screening information.
Opportunities for Building Competencies
• Understanding of infant mental health for staff engaged in
legal proceedings (e.g. lawyers, judges) involving infants and
toddlers.
• Working effectively and compassionately with families who
have experienced oppression and/ or unresolved loss and
trauma.
• Engaging families in conversations on child development and
accessing services.
• Enhancing capacity for staff engagement with families in
a collaborative way across sectors/ agencies/ services/
programs.
• Providing empathetic, culturally and linguistically competent
practices.
• Develop innovative outreach strategies to engage families in
services.
• Develop a common understanding of appropriate referral
sources (i.e. who to refer to and who are the experts).
Opportunities for Knowledge Building for Professionals
• Discuss the opportunity to host region-wide (annual) training
for all sectors on key infant mental health topics, including
influences on child development (risk/protective factors),
and responding to signs of distress in infants and toddlers.
• Communities reported that they would like to strengthen
knowledge, capacity, assessment and intervention skills in
the following areas:
• Determine a structure to disseminate current research for
frontline practitioners on infant-early mental health topics
(e.g., Working groups).
• Influences on child development (risk and protective factors)
specific to children under 3 to make better informed developmental support plans.
• As a part of conversations also include the discussion of
common language among services and sharing information/
resources used by the family and agency.
• Common behavioral concerns and disorders of early
childhood.
• Determine long-term sustainable strategies and opportunities to support practitioners as they apply what they learned
through education and training initiatives. Engage supervisors to be a part of conversations about service integration
around the new knowledge from community training. Gain
support and develop strategies for evidence-based practices/
programs to assist with maintaining manageable caseloads.
• Responding to parental mental health concerns in a timely
way with age-appropriate interventions.
• Responding to signs of distress.
• Observational skills, assessment and case formulation from
an infant mental health lens to monitor families – e.g., there
are limited windows of opportunity when practitioners can do
this, especially if they are only involved in a drop-in program.
• Early intervention strategies - Child-focused intervention
within a coordinated parental mental health context.
• Evidence based practices and programs – ensuring use of
interventions and programs that have been evaluated.
• Supporting parent-child relationships for families experiencing antenatal mood disorders.
• The impact of exposure to domestic violence for children
under 5.
• Trauma-informed practices among more disciplines and
services.
• Supporting First Nation, Métis, Inuit communities.
24
Volume 64, Summer 2015 • Explore how to strengthen coordinated, targeted messaging
around parenting, child development and infant-early mental
health to reach families more effectively in the public. The
location of these messages is essential in reaching the
families who may not otherwise access services or be aware
of services available. There are likely many current resources
and activities in the community which could be leveraged to
do this.
• Explore how we can create infant mental health experts
and champions within agencies and the region. Create a
mechanism so experts from one agency can support and/
or provide some training to other agencies that may want to
strengthen particular areas of expertise.
• Seek out expertise and build the practitioner capacity to
assist families in building skills for developing empathy and
positive relationships between parents and infants/ children.
IMPRINT: The Newsletter of Infant Mental Health Promotion
• Leverage current training initiatives by community agencies
by exploring how they can be opened up to other community
partners. Strengthen the opportunities for cross disciplinary,
collaborative professional development training using the
Best Start Network Tables to share opportunities. Explore
the possibility of opening up the early childhood educator
student conferences to other colleges, etc.
sionals which would include job shadowing, professionaldevelopment events and staff swapping opportunities to
assist in strengthening observational skills specific to infant
mental health. This could enhance skills but also enhance
understanding among disciplines about roles and scope of
practice.
• Enhance the skills of practitioners and clinicians to make
observations of infants, toddlers and their development
within the context of infant mental health with a clear
protocol established.
• Create a portal for training opportunities relevant to infant
mental health practices.
• Explore and identify both strengths and limitations in infant
mental health expertise in your region’s services. Look to
engage children’s mental health services in a collaborative
discussion on building capacity for infant mental health
treatment.
• Engage and begin a conversation with the post-secondary
sector and professional associations to share knowledge of
early mental health and encourage the inclusion of key topics
in curricula across disciplines, for example, working with
parents with unresolved trauma and how it can affect their
parenting capacity. Explore the development and delivery
of an Infant Mental Health Program at your local college/
university.
• Examine how infant mental health is managed within respective areas and various community planning tables/networks
(e.g. PPMD, Adult Mental Health, and At Risk Transition
Committee comprised of participants of CAPC/ CPNP,
Transition to Ontario Early Years Centre ,and/ or High Risk
Family Table),
• Explore potential opportunities to identify how the different
sectors serving children under 5 years can share their experiences, skills, and knowledge with each other.
• Host lunch and learn sessions for primary care and public
health sectors: Provide brief description on IMH and screening
initiatives. This will be a great opportunity to ensure that tools
are being consistently used to help with the circle of care.
• Engage agencies in how to create a continuum of learning
that is accessible and affordable. Quality Child Care Niagara
(QCCN) is a good example of a well established model.
• Acknowledge the need to strengthen the capacity and
resources to provide individual and family counselling.
• Strengthen and support families’s when returning home
after hospital visits. Explore with community agencies how
they can support families when they return home/into the
community, taking more active role with families.
Opportunities to Support Organizational
Policies & Practices
It was discussed at all community tables that there needs to be
more information regarding organizational policies and practices
that support infant mental health in order to identify gaps and
opportunities.
It was determined that the best method to collect this information
would be through a survey of front-line practitioners and staff to
gain a better understanding of staff perceptions and of the organizational policies and practices of agencies working with infants
and toddlers in each community. IMHP will develop the survey
based on the needs identified by the community from IMHP’s 2004
organizational policies and practices document. The outcome of
the survey would be used to highlight the need for the development
of agency policies and procedures, including resource allocation,
that support practitioners and clients. Because of the potential
to bring up sensitive information regarding personal experiences,
interpersonal interactions, salary and compensation etc., it was
recommended that the survey be completed anonymously, with
the exclusion of name, agency, and sector.
• A preface will be very important to outline how the information will be used, to identify recipients of the survey, etc.
• Evaluate the effectiveness of programs in the community
and whether they lead to better outcomes. Utilize existing
researchers and teams in the community.
• There will be a focus on staff capacity and knowledge of
infant-early mental health across the community. Staff will
rank the areas in which they feel they need to increase their
knowledge.
• As a community, create parent education resources for
families on optimal development periods to reach families
before the child enters school (e.g., 2-3 easy to understand
presentations, bulletin boards, or handouts).
• Discussion of which opportunities identified can be achieved
and incorporated into existing policy, and which would require
further organizational structure will be necessary.
Opportunities for Skill Building for Professionals
• The early learning and care sector identified specifically
they would like to strengthen their approaches for engaging
families around concerns about their child’s development/
behaviours.
Identified Opportunities for Organizational Policy and
Practice
• Provide opportunities for mentorship and supervision. Create
a community based mentoring calendar amongst profesIMPRINT: The Newsletter of Infant Mental Health Promotion • Adopt the Zero to Three definition of infant mental health and
identify where it needs to be included across the region.
Volume 64, Summer 2015 25
“Infant mental health” is defined as the healthy social and
emotional development of a child from birth to 3 years;
and a growing field of research and practice devoted
to the:
• promotion of healthy social and emotional development;
• prevention of mental health problems; and
• treatment of the mental health problems of very
young children in the context of their families.
(Zero to Three Infant Mental Health Task Force, 2014)
• Develop protocols/ pathways for dealing with vicarious
trauma, compassion fatigue, and burnout for community
partners to support staff. Identify experts on this topic.
Develop or identify existing resources that support vicarious
trauma in infant mental health settings.
• Adopt a supervision model that is specific to an infant mental
health context.
• Explore opportunities for supervisors to strengthen
their capacity to support and recognize when staff are
overwhelmed or experiencing vicarious trauma/ compassion
fatigue.
• Explore building capacity specific to infant mental health as
new staff are hired.
• Voice and request support at Best Start Network to ensure
compliance with regional Children’s Charter or Rights.
Service Delivery
• Begin to develop a protocol for sharing information and
equipping families through transitioning services.
• Assess if the hours of operation at community agencies are
accommodating for different types of family needs/services.
• Explore ways to create more flexibility within agencies to
accommodate individual family needs.
• Work towards service integration.
MOVING FORWARD
• IMHP will create a resource list with articles of interest, and
web resources on topics around infant mental health.
• IMHP will continue to host annual IMH Basics workshops and
the Infant Mental Health Community Training Institute which
could be incorporated in staff training.
• IMHP intends to also create an Infant Mental Health Basics
for Parents presentation which could be shared with families
in facilitated discussion and will host train the trainer events
for workshop delivery.
• IMHP Family Law Initiative learning modules will be piloted
and shared with agencies to increase understanding of early
mental health.
• IMHP will consult as to what kind of database/information
would be helpful around the services/programs available for
infant/early mental health.
• IMHP will look to connect with provincial organizations such
as the Registered Nurses Association of Ontario to embed
the Best Practices Guidelines within theirs.
• IMHP will explore having pre- and post-training knowledge
tests validated, and to expand evaluative efforts.
• IMHP will work towards the creation of a directory of professional contacts and highlight their expertise in areas relevant
to infant mental health to facilitate connecting community
partners with experts in the field.
We hope that these suggestions and opportunities will spark
communities to mobilize to make the change to current policy and
practice that is needed on behalf of infants and young children and
families in Canada.
References
Community agencies engaged in this initiative will formally share
the reports developed through this initiative with their Executive
Directors and Senior Management to speak to the limitations,
borders and boundaries present to knowledge exchange and
service collaboration among agencies. As a community, these
reports will be shared with the Special Needs Tables and Mental
Health Transformation leads in the community to inform them of
what was discussed through the consultations.
Through the course of this project discussions have informed IMHP
as to future directions as well as to how we can further support the
field of infant mental health in Canada.
• IMHP will continue to collaborate with communities to
increase awareness and knowledge of infant mental health
with families and practitioners.
26
• IMHP will work towards the creation of brief, interactive
online modules and print ready information and advocacy
resources for professionals, advocates and families on key
topics, such as the development of self regulation, early
mental health and development, parental mental health/
PPMD, etc..
Volume 64, Summer 2015 Clinton J, Kays-Burden A, Carter C, Bhasin K, Cairney J. Carrey N, Janus M, Kulkarni
C & Williams R. (2014). Supporting Ontario’s youngest minds: Investing in the
mental health of children under 6. Ontario Centre of Excellence for Child and
Youth Mental Health. Retrieved from http://www.excellenceforchildandyouth.
ca/sites/default/files/policy_early_years.pdf.
Infant Mental Health Promotion. (2002, rev. 2011) Competencies for Practice in
the Field of Infant Mental Health – Best Practice Guidelines. The Hospital for Sick
Children, Toronto. Retrieved from: http://www.imhpromotion.ca
Infant Mental Health Promotion. (2004, rev. 2011). Core Prevention and
Intervention for the Early Years – Best Practice Guidelines. The Hospital for Sick
Children, Toronto. Retrieved from: http://www.imhpromotion.ca
Infant Mental Health Promotion. (2004, rev. 2011). Organizational Policies &
Practices to Support High Quality Infant Mental Health Services – Best Practice
Guidelines. The Hospital for Sick Children, Toronto. Retrieved from: http://www.
imhpromotion.ca
Zero to Three Infant Mental Health Task Force (2014) Early Childhood Mental
Health. (webpage) reririeved July 1, 2015) from (http://main.zerotothree.org/
site/PageServer?pagename=key_mental)
IMPRINT: The Newsletter of Infant Mental Health Promotion
Letter from the DIRECTOR
Chaya Kulkarni, Director, Infant Mental Health Promotion
I have just finished a final read
through of this issue of IMPRINT
and I am struck by the fact that,
in our office at Infant Mental
Health Promotion at The Hospital
for Sick Children we sometimes
become so immersed in our work
or a certain project, the collective whole of our efforts is not clearly seen. This special issue of
IMPRINT shares with all of you the progress on some of our key
projects - and the word some is important. What is in this is issue
presents the highlights of some of our largest projects but it is
not all that we do at IMHP. Each of these projects is built on a
foundation of collaboration with professionals from Canadian
communities. While IMHP was started in Toronto by a group of
infant mental health experts and advocates, today our work and
the relationships that inform or support that work extend across
Canada.
Supporting Ontario’s youngest minds: Investing in the mental health
of children under six (Clinton,Kays-Burden, Carter, Bhasin, Cairney,
Carrey, Janus, Kulkarni, Williams, 2014). While written for Ontario,
our partners across the country suggest that the recommendations which cross service delivery, policy, practice and training of
professionals are relevant to many Canadian communities. The
science that supports the need for infant mental health as priority
has never been clearer (the references for these are cited throughout the project descriptions). As we look to the year ahead, some
of the initiatives that we will be working on include:
• A Call to Action for Maltreated Babies and Toddlers. This
document will capture the research and will provide those
working with maltreated infants and toddlers with an advocacy
tool to present a voice for this vulnerable population.
• NeuroDevNet Study. We will begin work with a remarkable
team at Queens University led by Dr. James Reynolds to
look at how the Developmental Support Plans can be used
to support early development of infants who have confirmed
exposure to alcohol in utero. This will be a multi-site study.
Our office will provide the training and technical support
while Dr. Reynolds and his team will evaluate the impact.
As you read through these initiatives we invite you to share not
just your thoughts about our work, but how IMHP can support your
efforts to support infant mental health in your community. Our
work with five Ontario communities helped us understand the
diversity of needs and resources specific to infant mental health.
Our role to support local efforts has never been clearer for us at
IMHP. Collaborating with communities to build capacity in terms
of knowledge, practice and policy specific to infant mental health
is a key role for this office. You may ask yourself, or your network,
colleagues or community early years tables the following:
• Helping Early Adjustment Relationships to Thrive (HEART).
This study led by Dr. Nicole Letourneau just received funding
from a donor in Alberta to evaluate the impact of developmental screening and developmental support plans for
infants and toddlers at risk for poor development with a
focus on social and emotional development.
• Launching Comfort, Play and Teach - an Activity Program.
Designed originally by the team at Invest In Kids this resource
provides those in programs serving young children with a
ready to go parent-child program focussing on supporting
early development. There will be three versions, one for
infants, one for toddlers and one for preschoolers, all of
which will be free on our website.
• When we talk about children and youth in our community are
we ensuring that includes infants and toddlers?
• How can we leverage the resources created by IMHP to
strengthen infant mental health in our community?
• Do we have some successes that we should share with IMHP initiatives that have proven to be effective in improving infant
mental health practices, policies and.ior knowledge that may
be useful for other communities?
• A special issue on infants and toddlers involved with child
welfare which will be produced in partnership with Child
Welfare League of Canada.
• Are there resources or materials that IMHP could create to
better support our efforts?
• Is there more that the team at IMHP can do to support our
efforts to strengthen infant mental health practices, policies
and knowledge among our practitioners in our community?
• How can our community be more engaged with IMHP?
• Is there a need for a national voice on infant mental health
and how does our community become part of that voice?
There is no doubt in our minds that we need a system to support
infant mental health in all communities. In Ontario, we had the
opportunity and privilege to work with a group of experts led by
Dr. Jean Clinton to produce a policy brief on infant mental health,
• A survey of practitioners in the five communities we worked
with to better understand organizational policies and
practices from a staff perspective.
Being more engaged with Canadian communities is a priority for
us at IMHP. Please feel free to call or email any member of our
team about how we can better support your efforts to promote
infant mental health in your community. There is such a need and
no one person will be able to manage or sustain this. This is an
opportunity for us all to collaborate and collectively change how we
respond to the needs of infants and toddlers, especially those who
may be vulnerable for delays.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 64, Summer 2015 27
ONE-DAY WORKSHOP
Monday September 28, 2015
3rd Annual
Infant Mental Health:
(IMH-101) The Basics
Chaya Kulkarni (BAA, M.Ed, Ed.D) Director, Infant Mental Health Promotion
and
Mary Rella (BA, Dip.CS) Manager of Clinical Services, Yorktown Child and Family Services
Awareness of early childhood mental health is essential for any professional working with very young children
(ages 0-3). Early learning and care practitioners (ECE’s), home visitors, and child welfare workers in particular
need to understand the impact of a young child’s experiences on their mental health and emerging sense of self.
This one day workshop will highlight the basic principles related to infant mental health and how this information
is applicable to different professional settings and roles involved in caring for and serving this age group.
We will explore key topics including:
o Principles of Core Prevention and Intervention
o Brain development – How relationships build brains
o Attachment and Self Regulation
o Temperament and “Goodness of Fit”
o Responding to Challenging Behaviours– Infant Cues
o Understanding Developmental Milestones and
Screening for concerns
This workshop is
for newcomers to the field of
infant mental health - a first step
in understanding the importance of social,
emotional and cognitive development during
the first three years, and the prevention of
mental health issues later in life.
Practitioners working with infants and children under three are in a unique
position to support and provide optimal responsiveness to a child’s needs during this incredibly sensitive period
of growth and development, and to promote healthy social and emotional outcomes throughout that individual’s
lifespan. The earlier we identify developmental concerns and the earlier we respond with appropriate supports
and services the more likely we are to positively influence a child’s developmental – mental and physical –
outcomes. In order to do this, every professional working with young children needs a strong understanding of
infant mental health – what it is, how it develops, how it is influenced and implications for a child’s development
when mental health is vulnerable in the early years.
IMHP Members
REGISTER TODAY
LOCATION:
The Hospital for Sick Children
555 University Ave. Toronto ON
1st Fl. Auditorium/ Daniels Hollywood Theatre
Save 20%
REGISTRATION OPTIONS & FEES:
In-Person: Members $20, Non-Members $25
WEBCAST (Live and Archived): Members $100, Non-Members $125
ALSO AVAILABLE BY WEBCAST - VIEW AS A GROUP!
For more details or to register visit
28
www.IMHPromotion.ca
Volume 64, Summer 2015 or contact
[email protected]
IMPRINT: The Newsletter of Infant Mental Health Promotion
TWO-DAY WORKSHOP
@ the Hospital for Sick Children, Toronto
November 5 & 6, 2015
Reflective Family Play
A Whole-Family Treatment Model
for Infants and Younger Children
Developed & Presented by
Diane A. Philipp, MD FRCP(C) and Christie Hayos, MSW, RSW
Reflective Family Play (RFP) is a family-based intervention developed to fill a gap in services and move
beyond dyadic treatments (Philipp, 2012; Philipp & Hayos, 2015). This model brings both parents and
any siblings into the treatment setting to participate in a play-based family wide intervention. Viewing
the young family as an emergent system, the hope is to bring about change during this critical period by
providing a venue and containment for family play, observation and reflection.
Some of the benefits of Reflective Family Play:
• Increase cooperative coparenting by providing
an experiential space for parents to work
together
• Increase reflective capacity in parents and
facilitate attunement to their child or children
• Decrease children’s presenting issues by
focusing on family dynamics “in the moment”
From this workshop, participants will be able to:
1) Develop a foundation in the theories informing
Reflective Family Play
2) Learn about the Reflective Family Play model
and its techniques
3) Identify which clients might be suitable for this
approach
4) Begin implementing this approach with clients
Reflective Family Play is a manualized treatment approach for the infant and preschool population. It borrows
techniques from well established dyadic treatments grounded in attachment theory and mentalization-based
intervention, but it also incorporates elements of structural family therapy. Didactic materials and recorded
vignettes of sessions will be used to illustrate concepts, and basic skills in assessment of families for RFP will
be presented. Adaptations for diverse families will be briefly covered as well, including single parents with two
or more children.
IMHP Members
REGISTER TODAY
INTENDED AUDIENCE
This workshop is for psychotherapists working with the 0-6
population. Participants will receive the RFP manual as part
of the workshop registration. Participants will also be eligible
to attend a monthly, year-long supervision group to gain
advanced training in RFP.
For more details or to register visit
Save 20%
REGISTRATION OPTIONS & FEES:
In-Person: IMHP Members $260, Non-Members $325
WEBCAST or OTN Videoconferencing
(Access to Both LIVE and ARCHIVED)
Members $600, Non-Members $750
www.IMHPromotion.ca
IMPRINT: The Newsletter of Infant Mental Health Promotion or contact
[email protected]
Volume 64, Summer 2015 29
Starting again in January 2016
WEB-BASED
LEARNING
This 15 Part Training
Series Includes:
Introduction to IMH & Early Development
Understanding Brain Development in the Early Years
The Importance of Attachment to Development
Temperament
The Development of Regulation in the Early Years
The Impact of Early Trauma on Development
Parental Depression
The Impact of Poor Parental Mental Health on a Child
Domestic Violence – A Trauma Experience for Young
Children
FASD and Impact of Substance Misuse on the
Caregiving Relationship
Common Disorders of Early Childhood
Administering and Interpreting the Ages and Stages
Developmental Screen (ASQ 3)
Administering and Interpreting the Ages and Stages
Questionnaire Social Emotion (ASQ:SE)
Creating Developmental Support Plans
Early Development Index(EDI): What Does the EDI
Tell us About the Children in Our Community?
The science is clear – early experiences in the first three years
impact the architecture of the brain – this impact can be lifelong and profoundly positive or negative depending on the
quality and consistency of the experiences. Poor parenting,
abuse and neglect in the first three years of life have profound
and devastating effects on brain development and emotional
functioning. When there are identified risks and disorders
in young children or in family functioning, well planned
and evidence-informed intervention can promote optimal
outcomes.
This training program aims to increase knowledge about infant
mental health among all staff within community-based agencies
in order to affect a cultural shift among agency staff - to empower
individuals to be agents of change in their roles and to ensure
that every child served by their organization has access to the
best mental health outcomes possible. The inclusion of infant
mental health promotion, prevention, and treatment as a key
focus of practice within community based health and/or social
service organizations will lead to enhanced:
• Understanding of just how critical early mental health is for
a child, a community, and society at large;
• Understanding of risk and protective factors that contribute
to early mental health and development;
• Integration and promotion of practices that focus on the
prevention of infant mental health trauma;
• Embedding of screening practices to identify when a young
child may be experiencing poor mental health; and
• Integration of interventions that can be provided to children
who may be at risk of experiencing poor mental health.
Register today to gain essential knowledge for
supporting infants and families
After initial license purchase by a participating agency/ site, unlimited participants from that agency may register
as a GUEST at no additional cost in order to gain access,s in person, by live Webcast or OTN Videoconferencing or
Archived Webcast recordings to access the training at your own pace, in team meetings or individually.
For more details or to register visit
30
www.IMHPromotion.ca
Volume 64, Summer 2015 or contact
[email protected]
IMPRINT: The Newsletter of Infant Mental Health Promotion
BECOME AN
IMHP MEMBER
Registertoreceive:
• Subscription to IMPRINT – The Newsletter of Infant Mental Health Promotion
• 20% Discount on all IMHP Resources and Workshops
• Access to Exclusive Member resources at www.IMHPromotion.ca including:
- IMPRINT ONLINE
- Member Exclusive Online Learning Resources
presentations, modules & training materials
- IMHP Membership Networking Directory
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Please make donations by cheque payable to
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IMPRINT: The Newsletter of Infant Mental Health Promotion Membership will become active when payment has been received.
Forward form and payment to:
InfantMentalHealthPromotion(IMHP)
The Hospital for Sick Children,
555 University Ave. Toronto ON M5G 1X8
416-813-7654 x 201082 Fax: 416-813-2258
[email protected] www.IMHPromotion.ca
Volume 64, Summer 2015 31
Infant Mental Health Promotion (IMHP) is a coalition of individuals and professional agencies dedicated
to promoting optimal mental health outcomes for infants with a focus on the first three years of life. We are
committed to developing and supporting best practices through education and training, dissemination of current
information, networking and advocacy.
Our goal is to support the field of infant mental health by providing relevant
and reliable content: information about current research, resources and
programs available, as well as practical strategies to assist and inform those
working with families. Through our efforts, we hope to provide valuable information to reduce gaps in knowledge and practice.
IMPRINT enables local and international experts, service providers and
advocates for children to communicate information about their programs and
resources to a large and diverse audience across Canada. IMHP is delighted
to provide IMPRINT as a vehicle for discourse throughout this community
and to encourage networking and collaboration across sectors, disciplines
and the various areas of
expertise in this field.
We would like to hear from YOU!
We are always seeking suggestions and articles for publication in upcoming volumes
of IMPRINT We welcome submissions from professionals and community members
alike, and hope that you will share your experiences, research and insights.
IMPRINT: The Newsletter of Infant Mental Health Promotion STEERING COMMITTEE
Margaret Leslie, Mothercraft, Breaking the Cycle (Co-Chair)
Jean Wittenberg, The Hospital for Sick Children, Infant Psychiatry (Co-Chair)
Cynthia Alutis, Child Development Institute
Mary Rella, Yorktown Child & Famiily Services
Rochelle Fine, Hincks-Dellcrest Centre
Rebecca Pillai-Riddell, York University, OUCH Lab
Chetan Bahri, Aisling Discoveries Child & Family Centre
Beverley Cesar Nova, Toronto Children’s Services
Brenda Clarke, Algoma Family Services
Leona Corniere, Yukon Child Development Centre
Malini Dave, The Hospital for Sick Children, Emergency Medicine
Zaheeda Daya, Toronto Public Health
Susan Dundas, Child Psychiatrist
Lee Hinton, Saskatchewan Prevention Institute
Jane Kenny, Rosalie Hall
Brigitte Lapointe, Association of Early Interventionists, New Brunswick
Wendy McAllister, Health Nexus
Donna McIlroy, Peel Children’s Centre
Brenda Packard, Chidren’s Aid Society of Toronto
Francine Umulisa, Ministry of Children and Youth Services
EDUCATION COMMITTEE
Mary Rella, Yorktown Child & Family Services (Chair)
Anna Baas Anderson, Sheridan College
Heather Bartlett, Daybreak Parent Child Centre
Tina Bobinski, Dilico Anishinabek Child & Family Services
Anju Dhawan, Toronto Public Health
Mia Elfenbaum, Red River College, Early Childhood Education
Rochelle Fine, Hincks-Dellcrest Centre
Lee Ford-Jones, The Hospital for Sick Children, Social Pediatrics
Sharon Lorber, The Hospital for Sick Children, Social Work
Susan Mace, Region of Durham Health Department
Pat Mousmanis, Ontario College of Family Physicians
Erin O’Dacre, Durham Family Resources
Angelina Paolozza, Queens University, Centre for Neurociences
RebeccaPillai-Riddell, York University, OUCH Lab
James Reynolds, Queens University, Centre for Neurociences
LavonneRoloff, Alberta Home Visiting Network Association (AHVNA)
Lisa Saunders, Catholic Children’s Aid Society
Ruth Sischy, Toronto District School Board
Gina Spratt, Infant and Child Development Services-Niagara
Mireille St.Jean, Department of Family Medicine University of Ottawa
Joanne Tuck, Humber College, Early Childhood Education
Marlyn Wall, Ontario Assocations of Children’s Aid Societies (OACAS)
Roxanne Young, Halton Region Public Health
Many thanks
for your
dedication and
support!
Volume 64, Summer 2015 Editorial Board
Susan Berry, Peel Children’s Centre (Retired)
Eileen Keith, Infant and Child Development Services Peel (consultant)
Kathy Moran, Simcoe County Children’s Aid Society
Mary Jean Watson, Simcoe Muskoka District Health Unit
IMHP STAFF
Chaya Kulkarni, Director, (416) 813-6062 e-mail: [email protected]
Donna Hill, Administrator, (416) 813-7654 x 201082
e-mail: [email protected]
Adeena Persaud, Project Support, 416-813-7654 x 228185
email: [email protected]
IMPRINT Editing and Layout: Donna Hill
Infant Mental Health Promotion (IMHP)
c/o The Hospital for Sick Children
555 University Ave.
Toronto ON M5G 1X8
fax: 416-813-2258
[email protected]
www.IMHPromotion.ca