The Newsletter of
Infant Mental Health
Promotion (IMHP)
Volume 63
Winter 2014/15
this issue
4 - Preventative Interventions Based in
Attachment Theory: A Meta-Analysis of
Efficacy
11 - Attachment Security and Disorganization
in Maltreating Families and Orphanages
Information for
Members
14 - Exploring the use of the (ASQ: SE) with
Vulnerable Populations
17 - Supporting Ontario’s Youngest Minds:
Investing in the mental health of children
21 - The Declaration of the Infant’s Rights as a
Developmental Milestone In the History of
WAIMH
Letter from the Director
p.28
SPOTLIGHT ON
RESOURCES
Child Discipline - Ontario
Parents’ Knowledge,
Beliefs and Behaviours
p.25
Welcome to Parenting
- for Young Parents
p.26
A Simple Gift:
Now available as a
three-disc set
p.27
Infant Mental Health
Community Training
Institute
p.29
Expanding Horizons for
the Early Years: Looking
Back to Transform the
Future - 2015 National
Institute on Infant
Mental Health
p.30
IMHP Membership Info
p.31
UNDERSTANDING ATTACHMENT PATTERNS OF
CARE-GETTING THROUGH PROXIMITY SEEKING AND
EXPLORATORY SUPPORT
Mary Rella, Manager Clinical Services, Yorktown Child & Family Services
The attachment relationship which develops from
the caregiver’s response to the infant’s distress
successfully guides the infant through important
development domains, (i.e.) cognitive, emotional,
and social. The infant is expert at being dependent,
hence relies on the caregiving relationship
for optimal social, emotional, and cognitive
development. As a result, early promotion of
adaptive mental health in this relationship is key to
the development of the infant’s felt security in the
relationship, and his/her learned capacity to trust
the relationship to identify and modify positive
and negative experiences. Later challenges in the
relationship can often be linked to the infant’s
learned method of miscuing his/her needs to the
caregiver and the caregiver’s responses to such
cues.
Attachment contributes to brain development.
As we know, the brain is built over time, as one
thing builds onto another. Cognitive (thinking) and
emotional (feeling) skills advance together as
other competencies develop. The joint maturation
process of these skills is highly dependent on the
infant’s developed sense of security as a relational
interaction with the caregiver which provides
refuge from stress. Refuge from stress offers
more opportunity to learn. Interaction between
the infant and the caregiver builds and shapes
brain circuitry. This is primarily done through the
serve and return interactions between the infant
and the caregiver, wherein the parent understands
the baby and provides what the baby needs (i.e.)
the parent is mindful of and responsive to the
infant’s cues. As a result, the infant develops
expectations of the caregiver through repeated
experiences, thereby mapping relationship
expectations through shared attention, two way
intentional communications, and serve and return
interactions.
HOW DOES ATTACHMENT DEVELOP?
In many cultures the caregiver fills a variety
of different roles with different significance
and priorities. The caregiver can be a teacher,
companion, playmate, food source, and so on.
Attachment concerns the caregiver’s role as
a protector and the child’s confidence in their
caregiver as a protective figure. These two
components determine the quality of attachment.
The attachment relationship is built through
emotional and relational experiences as the
caregiver buffers sensory stimulation, negative
affect, and physiological states of sleep and hunger.
It is for this very important reason that isolation is toxic to the infant.
A parent lacking attunement to distress, or a parent who is present
but indifferent to an infant’s cues for proximity, is unavailable to
interpret cues to meet needs and provide comfort. This lack of
comforting, responsive interaction is detrimental to the developing
infant’s expectation of care-getting relationship as well as his/her
developing emotion regulation system. Hence, neglect can be seen
as what does NOT happen in the infant and caregiver relationship.
The caregiving relationship has much to do with the caregiver’s
learned understanding of the behaviours they address and buffer
when the infant is in distress. Caregiving behaviours that are
sensitive, responsive, available, and reparative to the distress,
offer felt security for the infant. Caregiving behaviours that are
harsh, punitive, unavailable, frightening, or present as frightened
of the infant’s needs or negative feelings, produce confusion for
the infant’s security. These caregiving behaviours begin to shape
how the infant actively seeks proximity to the caregiver at times
of distress (when the infant is sick, scared, or hurt), as well as
how the infant comes to see their caregiver as helpful to them in
exploring their environment at times when they are not in distress.
Eventually, such joint exploratory behaviours are essential in order
for the infant to develop an understanding of their parent as helpful
when a shared plan is needed. This process begins in the second
year and comes to full development in the fourth year.
The attachment relationship is therefore a pattern which the
infant and caregiver establish together. What the caregiver does
to acknowledge, attend, and relieve the distress of the infant
influences how the infant learns to cue their need for comfort.
Hence, attachment is always developed relationally and does not
belong solely to the infant.
The infant is biologically driven to cue the caregiver to attend to
their need for comfort at a time when their attachment system is
activated (proximity seeking behaviours) by pain, fear and illness.
The infant also looks to their caregiver to help them explore in their
environment and to help them learn from events in the environment
(exploratory seeking behaviours). The proximity seeking and
exploratory systems are understood to operate inversely in order
for the infant to maintain security with the caregiver. In distress,
the infant cues the need for proximity with the caregiver to relieve
the distress. Initially the infant cries, and then with development
the infant learns to reach, then crawl for the parent, eventually
making the cues for care more sophisticated and personalized.
When effective the caregiver’s response deactivates the proximity
seeking behavior and reactivates the infant’s exploratory behavior
based on their ability to accurately interpret cues and respond
effectively. The caregiving behaviours (how the caregiver greets
and relieves the distress) determine the quality of attachment.
The infant sends a signal of distress, “I need you,” the caregiver
identifies the signal and responds with, “I know you need me.” The
caregiver modifies and/or mitigates the distress and the infant
can once again engage from a learning position and with a secure
state of mind knowing that if the caregiver is needed again, she/
he will be available in a reasonable and predictable pattern. The
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Volume 63, Winter 2014/ 15 caregiver’s presence, attachment, and ability to resonate with
the infant’s need, promotes the feeling of trust and security in the
relationship. What the caregiver does teaches the infant about
how to participate in the care getting relationship with the parent.
The relationship is therefore mapped in a pattern of give and take.
The learned caregiving and care getting patterns are classified
as attachment classifications: secure attachment, insecure
avoidant attachment, insecure resistant attachment, or insecure
disorganized attachment. The classifications are not diagnostic
and are meant to highlight protective and risk factors in the infant
and caregiver relationship.
In the secure classification, the infant learns “I always know how to
need you. You are consistent, predictable, and you know my needs
and so I can cue that I need you so I can count on you to bring me
back to a place where I can learn from my environment”.
In the insecure avoidant classification, the infant learns, “I
don’t know how to need you. You are dismissive of my needs for
comfort, you are rejecting of my cries, and needing you makes me
anxious. Therefore I don’t cue you and often will deactivate my own
attachment need. So I learn instead to control my environment and
sometimes you as my caregiver”.
In the insecure resistant classification the infant learns, “I need
you always. You are not consistent and many times appear
preoccupied with your own needs. I can’t risk being away from you
so I cue you often even when I don’t need you very much. I cannot
afford to wait until my attachment system is activated so I cue
you when I may just need your help a little. So I look anxious and
very needy of you and it’s so hard for me to separate from you with
confidence”.
In the insecure disorganized classification, the infant learns “I’m
scared to need you. You frighten me or look frightened of me. You
are present but not available to me and I don’t know if cuing you
will make me feel better or feel worse. Sometimes you cause my
distress so I haven’t learned how to cue you at all. I have learned to
avoid you and be very anxious with you and it is very hard to learn
how to deactivate my attachment needs so I stay distressed for
long periods of time. I have learned to be aggressive with you and
myself as my distress gets in the way of solving many problems.
I sometimes shut down entirely and do not want to deal with any
feelings”.
Each classification becomes a pattern in the relationship and with
maturation establishes how the individual learns to experience
oneself and how they learn to experience others.
By age four, a child’s developmental capacity allows them to
think about the parent’s point of view as well as their own point
of view. As they develop understanding of the other’s perspective,
they learn that what they want, and what the parent wants,
is sometimes different and as a result can cause conflicts.
Therefore, developing “shared plans” becomes significant in
the attachment system. While proximity remains important
,
IMPRINT: The Newsletter of Infant Mental Health Promotion
negotiating in the exploratory system and seeing the parent as
helpful to reach goals of autonomy elaborates the child’s security
and quality of attachment to their caregiver. Autonomy when met
as a need to be buffered and as a scaffolding process promotes
security for the toddler and child.
SUMMARY
Research supports that attachment classifications are associated
with the degree to which an infant’s cues are being interpreted
accurately and then responded to appropriately and contingently
by the parent. Consistently sensitive and responsive parents can
expect to develop security in their relationship with their infant,
while insensitive responses tend to develop insecure attachment
relationships. The attachment relationship is the external regulation
for the infant as the caregiver offers continuous regulation of the
infant’s shifting arousal levels both positive and negative. As a
result, the attachment relationship offers significant contributions
to the child’s developing emotional and cognitive maturation as
well as the maturation of social development.
Hence caregivers and other significant care providers in all settings,
are influential in the promotion of secure environments.
Parents and other caregivers should be aware of how their
“caregiving style” in all settings impacts development for the
purpose of promoting developmental competencies, with
emphasis on how attuned they are to the needs of their infants
and toddlers during times of distress, and how equally important
they are in the development of positive affect and learning.
RECOMMENDED READING
Handbook of Attachment:
Theory, Research and Clinical Applications, 2nd Edition,
Edited by Jude Cassidy and Phillip R. Shaver, 2008
Understanding Early Childhood Mental Health:
A Practical Guide for Professionals,
Susan Janko Summers & Rachel Chazan-Cohen, editors, 2012
Emotion Regulation and Developmental Health:
Infancy and Early Childhood,
Edited by; Barry S. Zuckerman, MD, Alicia F. Lieberman, PhD
and Nathan A. Fox, PhD, 2002
Attachment and Loss, Volume 1: Attachment,
John Bowlby, 1969
Effects of a Secure Attachment Relationship on Right Brain
Development,Affect Regulation and Infant Mental Health,
Allan N. Schore, Infant Mental Health Journal, Vol.22, 2001
REFERENCES
This paper was written on a background of readings from many
sources and owes a debt of gratitude to many scientists and
authors. The following resources can help take readers to more
information about particular findings referred to here.
Ainsworth MDS (1968), Object relations, dependency, and attachment: A
theoretical review of the infant mother relationship. Child Development, 40,
969-1025.
Ainsworth MDS, Blehar MC, Waters E & Wall S (1978). Patterns of attachment: A
psychological study of the Strange Situation. Hillsdale, NJ: Erlbaum.
Bowlby J (1958). The nature of the child’s tie to his mother. International Journal
of Psycho-Analysis, XXXIX, 1-23.
Bowlby J (1969). Attachment and loss, Vol.1: Attachment. New York: Basic Books.
Bowlby J (1988). A secure base: Parent-child attachment and healthy human
development. New York: Basic Books.
Bronfenbrenner U (1979). The ecology of human development. Cambridge, MA:
Harvard University Press.
Crittenden P (1999). Danger and Development: The organisation of self-protective
strategies. Atypical Attachment in Infancy and Early Childhood Among Children
at Developmental Risk. ed. Joan I. Vondra & Douglas Barnett, Oxford: Blackwell
pp. 145-171.
Erikson F (1950). Childhood and society. New York: Norton.
Grossmann KE, Waters E (2005). Attachment from infancy to adulthood: The
major longitudinal studies. New York: Guilford Press.
Lieberman AF & Pawl JH (1988). Clinical applications of attachment theory. In J.
Belsky & T. Nezworski (Eds.), Clinical applications of attachment (pp. 327-351).
Hilldale, NJ: Erlbaum.
Lyons-Ruth K & Block D (1996). The disturbed caregiving system: Relations among
childhood trauma, maternal caregiving, and infant affect and attachment. Infant
Mental Health Journal, 17, 257–275.
Lyons-Ruth K, Bronfman E & Parsons E (1999). Maternal frightened, frightening,
or atypical behavior and disorganized infant attachment patterns. Monographs
of the Society for Research in Child Development, 64, 67–96.
Main M & Solomon J (1990). Procedures for Identifying Infants as Disorganized/
Disoriented during the Ainsworth Strange Situation. In Greenberg, Mark T;
Cicchetti, D; Cummings, EM. Attachment in the Preschool Years: Theory,
Research, and Intervention. Chicago: University of Chicago Press. pp. 121–60.
Marvin BS & Stewart BB (1990). A family system framework for the study of
attachment. In M Greenberg, D Cicchetti, & M Cummings (Eds.), Attachment
beyond the preschool years (pp. 51 -86), Chicago: University of Chicago Press.
Morris P (1982). Attachment and society. In CM Parkes & J Stevenson-Hinde (Eds.),
The place of attachment in human behavior (pp. 185-201). New York: Basic
Books.
Prior V & Glaser D (2006) Understanding Attachment and Attachment Disorders,
London: JKP, p.17
Siegel DJ (1999). The developing mind: Toward a neurobiology of interpersonal
experience. NewYork: Guilford.
Siegel DJ (2012). The developing mind, second edition: How relationships and the
brain interact to shape who we are. New York: Guilford Press.
Sroufe LA (1985). Attachment classification from the perspective of infant
caregiver relationships and infant temperament. Child Development, 56, 1—14.
Sroufe LA & Waters B (1977). Attachment as an organizational construct. Child
Development, 49, 1184-1199.
Van Ijzendoorn MH & Kroonenherg PM (1988). Cross-cultural Patterns of
Attachment: A meta-analysis of the Strange Situation. Child Development, 59,
147-156.
Winnicott DW (1965). The maturational process and the facilitating environment.
New York: International Universities Press.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 63, Winter 2014/ 15 3
PREVENTATIVE INTERVENTIONS BASED IN ATTACHMENT THEORY:
A META-ANALYSIS OF EFFICACY
Kylee Hurl, Janelle Boram Lee & Jennifer Theule, University of Manitoba
Research supported by the Canadian Institute of Health Research and the Manitoba Health Research Council
Due to the prevalence of the psychological and behavioural
problems associated with insecure and disorganized attachment
it is important for clinicians to understand and evaluate the
efficacy of attachment-based prevention interventions. Insecure
and disorganized attachment styles are associated with negative
consequences throughout the lifespan. Insecure and disorganized
patterns of attachment are associated with internalizing behaviour
problems, externalizing behaviour problems, impaired language
development, and psychopathology (Belsky & Fearon, 2002;
Fearon, Bakermans-Kranenburg, van IJzendoorn, Lapsley, &
Roisman, 2010; Jinyao et al., 2012).
ABOUT ATTACHMENT
Attachment refers to the emotional relationship between a
child and their caregiver. Based on John Bowlby’s (1958, 1969,
1973) ethological-evolutionary attachment theory, infants are
evolutionarily predisposed to become attached to a principal
caregiver for safety, security, and care. Mary Ainsworth and
colleagues (1979) later proposed the assessment procedure
called the Strange Situation to classify attachment patterns.
In a sequence of episodes, the infant’s primary caregiver and
a stranger come and go from the playroom. Ainsworth and her
colleagues closely observed the infants’ reactions to separations
and reunions and into identified three patterns of reactions:
secure pattern, insecure-avoidant pattern, and insecure-resistant/
ambivalent pattern.
Secure infants play happily with their caregivers in the playroom.
The main characteristics of these infants are that they use their
primary caregivers as a secure base from which to explore their
environment with confidence and comfort. When the caregiver
leaves the room, these babies pause and show some distress
and as their caregiver returns, they welcome them warmly, seek
comfort from them, and quickly return to play.
Insecure-avoidant infants tend to avoid connecting with their
caregivers by continuing to play and not exhibiting signs of distress
when their caregivers leave the playroom. When their caregivers
return, the infants avoid them.
Insecure-resistant/ambivalent infants are preoccupied with
their caregivers in the playroom and they usually respond with
great distress when their caregivers leave the room. When their
caregivers return, the resistant infants behave in a discordant
manner. Sometimes they desire contact and at other times they
resist contact with their caregivers.
4
Volume 63, Winter 2014/ 15 Later, Main and Solomon (1986) defined a fourth type of
attachment pattern, which they called disorganized attachment. In
the Strange Situation, the infants with a disorganized attachment
pattern are cautious in the playroom with their caregivers present
and they may stare, yell, or look scared and confused when their
caregivers leave. When their caregivers return, the infants often
appear dazed or confused and may exhibit odd behaviours, such
as hitting themselves, throwing things, screaming, and clinging.
THE IMPLICATIONS OF ATTACHMENT
Interventions based in attachment theory are important because
past research suggests the stability of attachment styles. For
example, there is a significant relationship between children’s
attachment classifications at 1 and 6 years of age (GlogerTippelt, Gomille, Koenig, & Vetter, 2002). As well, infants with a
disorganized pattern of attachment are more likely to have an
insecure or unresolved attachment classification in early adulthood
(Weinfield, Whaley, & Egeland, 2004). Furthermore, there is
evidence that there is some level of transmission of attachment
across generations. For instance, Gloger-Tipplet et al. (2002)
found a significant correspondence between maternal security
representations and the child’s attachment quality (as much as
75% for secure mother-infant dyads and 95% for insecure motherinfant dyads). In a meta-analysis of several studies, the overall
correspondence between the parental attachment classification
from the Adult Attachment Interview and the child’s attachment
classification from the Strange Situation Paradigm was75% (van
Ijzendoorn, 1995). Likewise, the correspondence of attachment
classification for sets of grandmother, mother, and infant triads
was calculated to be 47% (Hautamaki, Hautamaki, Neuvonen, &
Maliniemi-Piispanen, 2010).
Insecure and disorganized attachment patterns during early
childhood have been linked to a variety of problems throughout
the lifespan. Infants with a disorganized pattern of attachment
are more likely to suffer psychological or behavioural problems
in late adolescence than their securely attached peers (Weinfield,
Whaley, & Egeland, 2004). Additionally, young adults’ retrospective
self-report of insecure attachments have been found to be
associated with negative romantic relationships in adulthood.
Adults with insecure attachment histories tend to suffer from
an extreme need for dependence on partners or mistrust and
avoidance of their partner (Feeney & Noller, 1990).
Studies have identified a range of risk factors associated with the
development of insecure and disorganized attachment patterns
(Edwards, Eiden, & Leonard, 2004; Udry-Jorgensen et al., 2011;
IMPRINT: The Newsletter of Infant Mental Health Promotion
van Ijzendoorn, Schuengel, & Bakermans-Kranenburg, 1999; Cyr,
Euser, Bakermans-Kranenburg, & van Ijzendoorn, 2010). Parental
characteristics are a major predictor of insecure patterns of
attachment. For example, negative parenting with low sensitivity,
addictions, and parental psychopathology are associated with
insecure and disorganized patterns of attachment (Edwards
et al., 2004). In addition, higher rates of insecure attachment
were observed in premature infants in low socioeconomic
status families, especially those with high-risk perinatal medical
problems (Udry-Jorgensen et al., 2011).
There is evidence that disorganized attachment is also related to
childhood maltreatment. Maltreating parents are considered to be
a source of fear for infants who are subsequently likely to suffer
from disorganized attachment relationships with their caregivers
(van Ijzendoorn et al., 1999). This effect is similar for children
whether the maltreatment is from physical abuse or from neglect.
Other risk factors include low income, single motherhood, low
education, ethnic minority, and adolescent motherhood. Although
child maltreatment is a significant risk factor for disorganized
attachment, infants living in high-risk households are more likely
to develop insecure and disorganized patterns of attachment,
whether they are maltreated or not (Cyr et al., 2010).
EXAMPLES OF COMMON PREVENTION INTERVENTIONS
One common preventative intervention based in attachment
theory is Infant-Parent Psychotherapy. This intervention has
been shown to be effective in developing secure attachment in
high-risk families, such as low income and immigrant families
(Cicchetti, Rogosch, & Toth, 2006). Infant-Parent Psychotherapy
assumes that insecure parent-child relationships do not develop
from a lack of parenting knowledge alone, but also result from
a maltreating mother’s insecure internal representational model
that is developed from her childhood interpersonal relationships
(Cicchetti et al., 2006). The intervention consists of weekly home
visits for the duration of one year. The therapist engages in joint
observation of the infant with the mother. In this intervention,
the therapist’s empathy, responsiveness, and respect of the
participating mother’s childhood experiences fosters the
therapeutic alliance. The therapeutic relationship that develops
forms a positive interpersonal relationship model for the mothers
themselves and their relationship with their infant.
Another attachment-based preventative intervention that is
behaviourally-based is the Video-feedback Intervention to Promote
Positive Parenting (VIPP) program. (Velderman et al., 2006). VIPP
is a short-term, strength-based, home visiting intervention that
focuses on increasing maternal sensitivity. It is usually introduced
in the infant’s first year to prevent the development of insecure
attachment patterns. VIPP utilizes video feedback immediately
after video observation of mother-infant dyads in the home to
demonstrate infant signals and caregiver response. Although more
research is needed on this video feedback intervention, the clinical
field is viewing the intervention as promising for the prevention of
behavioural problems associated with insecure and disorganized
patterns of attachment (Velderman et al., 2006).
A third attachment-based intervention that has been used for
preventative efforts is the Circle of Security (Hoffman, Marvin,
Cooper, & Powell, 2006). The Circle of Security starts with an
introduction to attachment theory, in which caregivers learn
what attachment is and why it is important their child develops
a secure attachment. Parents are also given a handout of a
Circle of Security graphic to assist in their understanding of the
caregiver role. The graphic is used throughout the program to
assist caregivers as they review videos of themselves interacting
with their child. Caregivers are also asked to reflect on their own
experiences with their parents when they were a child and relate
these experiences to their own caregiving practices. Through this
intervention caregivers gain a greater awareness of their strengths
and weaknesses as a caregiver and how to respond sensitively to
the cues their child gives (Hoffman et al., 2006).
THE STUDY
The purpose of the present study was to examine the effectiveness
of prevention interventions based in attachment theory. The study
addressed the following research questions:
(a) Are prevention interventions based in attachment theory
effective?
(b) Are prevention interventions based in attachment theory
effective at follow-up?
(c) What bibliographic variables (date of publication,
publication type, and country the study was conducted in)
affect the effect size of interventions based in attachment
theory?
(d) What methodological characteristics (intervention
manualization, the measure used, and treatment fidelity
checks) affect the effect size?
(e) What sample characteristics (risk factors, caregiver
education, caregiver income, sample attrition, proportion
of female and male children and caregivers, age of children
and caregivers, and rate of maternal psychopathology)
affect the effect size?
(f) What characteristics of the intervention (the focus of the
intervention, number of weeks, number of sessions, and
total number of hours the intervention lasted, whether or
not video feedback was used, and if the intervention was
behaviourally-based) affect the effect size?
METHODS
The research design used was a meta-analysis using the random
effects model, with effectiveness of attachment-based prevention
interventions as the main outcome of the study. Meta-analysis is
a method of quantitative review that selects relevant studies from
the literature and then extracts information about mean change
and variability of change in each study (Linden & Hewitt, 2012).
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 63, Winter 2014/ 15 5
The main objective of a meta-analysis is to average the results
of all the research studies on a particular topic (Sánchez-Meca &
Marín-Martínez, 1998). The goal is to understand any study in the
literature in the context of the other studies on the same research
topic. Meta-analytic reviews also focus on quantifying the factors
that possibly affect the overall efficacy of a certain intervention
(Borenstein, Hedges, Higgins, & Rothstein, 2009).
The present meta-analysis began with a systematic literature review.
The first author conducted the initial search to find all potential
articles that have examined attachment-based preventative
interventions. The following databases were searched: PsycINFO,
Medline, ERIC, Google Scholar, Scopus, and Dissertation Abstracts
International. Articles were collected that appeared potentially
relevant based on their title and abstract. The first and second
authors then examined the full text of each potentially relevant
article based on the following seven eligibility criteria.
Studies were considered eligible for the meta-analysis if they
were 1) a randomized control trial and 2) had a quantitative
comparison. That is, participants of the studies reviewed were
randomly assigned to the intervention or control group and
there was a quantitative comparison of these two groups
post-intervention. The studies were also considered eligible
for the meta-analysis if they 3) included a psychotherapeutic
intervention that was based in attachment theory and
4) the intervention was preventative. Preventative was
defined as aiming to prevent the development of insecure
or disorganized attachment or problems associated with
insecure and disorganized attachment before they occur. In
other words, the sample could not be recruited because they
were already displaying clinically significant problems (e.g.,
disorganized attachment, psychopathology, or behaviour
problems). Moreover, to be eligible, the study had to 5)
have a measure of either attachment, behaviour problems,
language abilities, or psychopathology, and 6) have a
sample of children 12 years of age or younger. Lastly, 7) the
meta-analysis only included studies in English.
children; mean age of children and caregivers; sample attrition;
maternal psychopathology; if the caregivers were single parents;
if the sample includes ethnic minorities; and if the caregivers
were adolescents. Finally, the intervention characteristics were
coded for the focus of the intervention, the duration of the
intervention, the location of the intervention, and whether or not
video feedback was used. The data was entered and analyzed
using the Comprehensive Meta-Analysis Version 3 program (CMA;
Borenstein, Hedges, Higgins, & Rothstein, 2007). The results of all
the studies were combined to obtain an overall mean effect size
using Cohen’s d. - an effect size used to indicate the standardised
difference between two means. Meta-regression was used to
determine which variables affected the effect size.
RESULTS AND DISCUSSION
The results of the meta-analysis indicated that attachment-based
prevention interventions produce a reliable small to moderate
change compared to the control group (d = .37, p <.001). Measures
that were taken between 1 to 6 months post-intervention
demonstrated a reliable moderate change compared to the
control group (d = .48, p <.001) Measures that were taken between
Only when the researchers agreed that a study met all seven
criteria, was a study considered eligible for the meta-analysis.
Any disagreements were resolved by discussion between
the two researchers. See Figure 1 for a full summary of the
systematic search.
The next step was to extract the data from the studies
that were eligible for the meta-analysis. A coding manual
was used for this process. Data of the eligible outcome
measures were extracted from the studies. Bibliographic
characteristics were coded (e.g., the type of publication, the
year of publication, and the country the study was conducted
in), followed by the methodological characteristics (e.g.,
intervention manualization, the measurement used,
whether the manual included treatment fidelity, and the
length of follow-up). Sample characteristics were then
coded, such as: caregiver education; caregiver annual
income; proportion of male and female caregivers and
6
Volume 63, Winter 2014/ 15 IMPRINT: The Newsletter of Infant Mental Health Promotion
7 to 12 months post-intervention had a small to moderate change
compared to the control group (d = .40, p =.265). This finding was
not significant. The effect sizes were fairly similar across these
three analyses. They were all within the range .37 to .48. This
may indicate that attachment-based preventative interventions
maintain their effect throughout the first year post-intervention.
There is little data on the effect of these interventions over one
year post-intervention.
The majority of the moderator variables were not significant.
Moderator variables related to study quality, including treatment
manualization, if the study monitored treatment fidelity, the
percent of attrition, if the comparison group received services or
nothing, and the use of observational measures (as opposed to
self-report measures) were not related to effect size. This indicates
that variables related to study quality were not biasing the efficacy
of these interventions. The country the study was conducted in was
also not significant, which indicates that this is unlikely biasing
these intervention studies. Furthermore, the two moderator
variables that examined the percentage of female children and the
mean age of children in the sample were not significant. Therefore,
these interventions do not seem to be more effective for either
female or male children. In addition, there does not seem to be a
significant impact of when the intervention is implemented within
the range of prenatally to preschool.
The total number of sessions and proportion of single caregivers
in the sample were associated with a larger effect. However, for
the total number of sessions there were two outliers. Most of the
studies ranged from 3 to 21 sessions, but Heinickie, Fineman,
Ponce, & Guthrie (2001) had an average of 71 sessions and
Cicchetti, Rogosch, & Toth (2000) had an average of 45.6 sessions.
The moderator analysis was rerun without these two studies. When
these two studies were removed, the association was no longer
statistically significant.
There were three moderator analyses that approached significance.
Caregiver mean age had an inverse relationship with effect size,
and using video feedback was associated with a lower effect size.
Measures of attachment were associated with a larger effect than
proxy measures (i.e., measures of behaviour problems, language
development, and emotional regulation), but this relationship was
not significant.
al.’s (2012) sample was maltreated children and the majority was
ethnic minorities, Franz et al.’s (2011) intervention targeted single
mothers, Moran, Pederson, and Krupka’s (2005) sample was of
adolescent mothers, the majority single, and the majority had a
low income, and Velderman et al.’s (2006) sample was of mothers
with insecure attachment classifications. This is a tremendous
strength of the body of research on attachment-based preventative
interventions, that they have been able to effectively apply these
interventions to a variety of populations. This diversity of sample
risk factors did however limit the number of risk factors that had a
sufficient number of studies to analyze as a moderator variable. As
well, some risk factors did not have enough variability to analyze,
such as the proportion of adolescent mothers, which only had
studies where the whole sample was adolescent mothers and
studies where the authors did not report if there were adolescent
mothers in the sample. The effect of different sample risk factors
is an important issue to address meta-analytically as this body of
research grows larger.
PRACTICAL IMPLICATIONS
The present meta-analysis has several practical implications.
First, video feedback is commonly used by clinicians and in
research studies in this area. Of the 20 interventions included in
the meta-analysis, 10 used video feedback. However, the analysis
did not indicate any benefit to using this approach compared to
other approaches.
In addition, it appears that attachment-based preventative
interventions may be more effective for at-risk groups, such as low
income or young mothers. In other words, it appears that these
preventative efforts likely have more of an impact at the level of
selective prevention as opposed to universal prevention. As well,
it seems that the duration of the intervention is not an important
predictor of its effectiveness. That is, even in circumstances where
there is limited funding available, a few sessions may be enough to
make substantial changes. Finally, the effect of these interventions
is small to medium. This indicates that these interventions should
continue to be refined and improved upon.
There is still a need for future research. There were only two
studies in the meta-analysis that had followed up longer than 12
months after the intervention. Thus, there is a lack of research on
the long-term impact of these interventions. As well, despite the
A limitation of the moderator analyses is that they are associations. growing role that fathers have in their children’s lives, they have
Further research is therefore required to experimentally validate been neglected in many of these intervention studies. Future
the findings of the moderator analyses. Another limitation of the research should explore how including both mothers and fathers
present meta-analysis is that not all studies provided data on every in these interventions impacts the efficacy of these interventions
moderator variable analyzed. This may have affected some of the and also look at the efficacy of these interventions for fathers who
moderator analyses because some of the variables may have are the primary caregiver of their child.
lacked sufficient power or it could have biased the results.
In conclusion, prevention interventions based in attachment theory
A third limitation of the current study was that there were a variety for children appear to be effective. However, there is still a need
of at-risk groups across the studies included in the meta-analysis for further research to improve these interventions and to explore
and many studies had multi-risk samples. For example, Bernard et aspects of these interventions that lack research.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 63, Winter 2014/ 15 7
TABLE 1 - CHARACTERISTICS OF STUDIES INCLUDED IN THE META-ANALYSIS
Study
Child Age
at Start of
Study
Measure(s)
Ammaniti et
al. (2006)
Prenatal
Scales of Mother-Infant
interactional systems
Bernard et al.
(2012)
10
Strange Situation
Birth
Strange Situation
Brisch et al.
(2003)
Cassidy et al.
(2011)
7
Strange Situation
Cheng et al.
(2007)
5
Child Behavior Checklist
Cicchetti et al.
(2000)
20
WPPSI-R
Cicchetti et
al. (2006)
& Stronach
(2012)
Intervention
Home visiting intervention that aimed at enhancing maternal sensitivity to
her child’s cues, increasing maternal-child interaction, and to support marital
interaction.
Home visiting intervention that used video feedback to enhance parental
sensitivity and responsiveness. Also focused on helping parents to override
issues from their past that may hinder their ability to respond sensitively to
their child.
Intervention consisted of a parent group, parent psychotherapy, sensitivity
training, and a home visit. Intervention focused on enhancing parental
sensitivity, parental coping, and helping parents to be able to reflect on their
past attachment relationships.
Home visiting intervention that used video feedback to enhance maternal
sensitivity and responsiveness. Also focused on helping mothers become
aware of psychological processes that may affect their ability to respond
sensitively.
Home visiting intervention that focused on enhancing maternal sensitivity
and feelings of competence.
The intervention focused on how maternal representations affect their
interactions and feelings towards their child. The intervention aimed at
helping mothers to form or maintain positive attachment representations of
their child and to foster maternal sensitivity and responsiveness.
Strange Situation
Home visiting intervention that focused on how mothers’ representations affect
their interactions and feelings towards their child. The intervention aimed at
helping mothers to form or maintain positive attachment representations of
their child and to foster maternal sensitivity and responsiveness.
Prenatal
Strange Situation
Intervention included a home visiting and group component, which focused
on promoting maternal sensitivity. Intervention also targeted factors that may
interfere with mothers’ ability to respond sensitively, such as a lack of social
support, their past attachment experiences, and lack of empowerment.
Fisher & Kim
(2007)
53
Parent Attachment
Diary
Franz et al.
(2011)
54
Strengths and
Difficulties
Questionnaire
Egeland &
Erickson
(1993)
Heinicke et al.
(2001)
Juffer et al.
(1997)
Kalinauskiene
et al. (2009)
8
13
Prenatal
Child Expectation of
Being Cared For scale
Child Response to
Separation scale
6
Strange Situation
6
Attachment Q-Sort
Intervention included parent training, consultation from clinician, parent
support group meetings, and child playgroups. Focus of intervention was on
enhancing parental responsiveness and helping the parent create a consistent
environment.
Group-based intervention that focused on reducing maternal depression
and increasing maternal sensitivity and responsiveness to child’s emotions.
Intervention also focused on mother’s perceptions and helped to teach
mothers to manage stress and conflict.
Intervention included home visiting and an infant-mother group. Focus of
intervention was to use the therapeutic relationship as a way for the mother to
experience a stable trusting relationship and to improve maternal sensitivity
and responsiveness.
Home visiting, video feedback intervention that aimed at enhancing maternal
sensitivity and responsiveness.
Home visiting, video feedback intervention that aimed at enhancing maternal
sensitivity and responsiveness.
Volume 63, Winter 2014/ 15 IMPRINT: The Newsletter of Infant Mental Health Promotion
Study
Krupka (1996)
Moran et al.
(2005)
Moss et al.
(2011)
Spieker et al.
(2012)
Van Den Boom
(1994 & 1995)
Van Doesum
et al. (2010)
Velderman et
al. (2006)
Child Age
6
6
40
18
6
5
7
Measure(s)
Attachment Q-Sort
Strange Situation
Intervention
Home visiting intervention that aimed at building a strong therapeutic
relationship and used video feedback to promote maternal sensitivity.
Home visiting intervention that aimed at building a strong therapeutic
relationship and used video feedback to promote maternal sensitivity.
Home visiting, video feedback intervention that aimed at enhancing parental
Child Behavior Checklist
sensitivity.
Child Behavior Checklist
Home visiting, video feedback intervention that aimed at enhancing maternal
sensitivity and responsiveness.
Bayley-III Screening Test
Home visiting intervention that focused on enhancing maternal sensitivity
Strange Situation
and responsiveness.
Infant Toddler Social and Home visiting intervention that primarily used video feedback to enhance
Emotional Assessment maternal sensitivity.
Home visiting, video feedback intervention that aimed at enhancing maternal
Child Behavior Checklist
sensitivity and responsiveness.
Strange Situation
Note. Child age is given in months. WPPSI-R = Wechsler Preschool and Primary Scale of Intelligence-Revised.
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Volume 63, Winter 2014/ 15 IMPRINT: The Newsletter of Infant Mental Health Promotion
ATTACHMENT SECURITY AND DISORGANIZATION IN MALTREATING
FAMILIES AND ORPHANAGES
Marinus H. van IJzendoorn, PhD, Marian J. Bakermans-Kranenburg, PhD, Centre for Child and Family
Studies, Leiden University, Netherlands,
Encyclopedia on Early Childhood Development © November 2009 (Reprinted with permission)
Extremely insensitive and maltreating caregiving behaviors may be
among the most important precursors involved in the development
of attachment insecurity and disorganization. Egeland and Sroufe
(1981) pointed out the dramatically negative impact of neglecting
or abusive maternal behavior for attachment and personality
development, for which they accumulated unique prospective
evidence in later phases of the Minnesota study (Sroufe, Egeland,
Carlson & Collins, 2005).
What do we know about the association between child maltreatment
and attachment, what are the mechanisms linking maltreatment
with attachment insecurity and disorganization, and what type of
attachment-based interventions might be most effective?
SUBJECT
Following Cicchetti and Valentino (2006), we include in our definition
of child maltreatment sexual abuse, physical abuse, neglect and
emotional maltreatment. Besides these “family-context” types of
maltreatment, we also draw attention to structural neglect from
which, world-wide, millions of orphans and abandoned children
suffer.
Structural neglect points to the inherent features of institutional
care that preclude continuous, stable and sensitive caregiving for
individual children: caregiver shifts, high staff-turnover rates, large
groups, strict regimes, and sometimes physical and social chaos
(Bakermans-Kranenburg, Van IJzendoorn & Juffer, 2008).
Attachment disorganization has been suggested to be caused
by frightening and extremely insensitive or neglectful caregiving
(Hesse & Main, 2006).
Studies on non-maltreated samples have demonstrated that
anomalous parenting, involving (often only brief episodes of)
parental dissociative behavior, rough handling, or withdrawn
behavior, is related to the development of attachment
disorganization (see Madigan, Bakermans-Kranenburg et al., 2006
for a meta-analytic review). Parental maltreatment is probably
one of the most frightening behaviors a child may be exposed to.
Abusive mothers show aversive, intrusive and controlling behavior
toward their child, in contrast to neglecting mothers who may
display inconsistent care. Maltreating insensitive parents do not
regulate or buffer their child’s experience of distress, but they
also activate their child’s fear and attachment systems at the
same time. The resulting experience of fright without solution is
characteristic of maltreated children. According to Hesse and Main
(2006), disorganized children are caught in an unsolvable paradox:
their attachment figure is a potential source of comfort and at the
same time a source of unpredictable fright.
PROBLEMS
We speculate that multiple pathways to attachment disorganization
exist involving either child maltreatment by abusive parents or
neglect in chaotic multiple-risk families or institutions.
The pathway of abuse is based on the idea of (physically or sexually)
maltreating parents creating fright without solution for the child
who cannot handle the paradox of a potentially protective and,
at the same time, abusive attachment figure, and thus becomes
disorganized.
A second pathway is associated with the chaotic environment
of multiple-risk families or institutional care leading to neglect
of the attachment needs of the children. Caregivers’ withdrawal
from interacting with the children because of urgent problems
and hassles in other domains of functioning (securing an income,
housing problems, too many children to care for) creates a chronic
hyper-aroused attachment system in a child who does not know
to whom to turn for consolation in times of stress. This may in the
end lead to a breakdown of organized attachment strategies or
impede children’s capacity to even develop an organized insecure
attachment strategy.
Third, marital discord and domestic violence may lead to elevated
levels of disorganization as the child is witnessing an attachment
figure unable to protect herself in her struggle with a partner.
Zeanah et al. (1999) documented a dose-response relation between
mothers’ exposure to partner violence and infant disorganization.
Witnessing parental violence may elicit fear in a young child about
the mother’s well-being and her ability to protect herself and the
child against violence.
RESEARCH CONTEXT
Collecting data on maltreatment samples is difficult. Maltreated
children are often victims of multiple forms of abuse, making it
difficult to compare the different types of maltreatment. Conjoint
work with the child welfare system may raise legal and ethical
issues involving sharing information with clinical workers or being
asked to provide a statement in court.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 63, Winter 2014/ 15 11
Remarkable and rigorous but scarce work has been conducted by
research groups pioneering this challenging area. Seven studies
on attachment security/disorganization and child maltreatment
in families have been reported, and six studies on attachment in
institution-reared children using the (modified) Strange Situation
procedure to assess attachment (Ainsworth, Blehar, Waters &
Wall, 1978). In order to examine the impact of child maltreatment
on attachment we compare the studies’ combined distribution
of attachment patterns to the normative low-risk distribution
of attachment (N=2104, derived from the meta-analysis of
Van IJzendoorn, Schuengel, & Bakermans-Kranenburg, 1999):
insecure-avoidant (A): 15%, secure (B): 62%, insecure-resistant (C):
9%, and disorganized (D): 15%.
RESEARCH GAPS
How do some institution-reared and maltreated children develop
secure attachment, and what characterizes these children? Does
attachment security constitute a protective factor in high-risk
contexts? Does it interact with other protective factors such as
the child’s biological constitution or the caregivers’ psychosocial
resources? Little is known about the differential effects of the
various types of abuse and neglect – co-morbidity may hamper a
clear distinction of differential effects. Lastly, long-term effects of
child maltreatment should be studied more closely.
IMPLICATIONS FOR PARENTS, SERVICES AND POLICY
Several randomized control trials have started to provide data on
the effectiveness of attachment-based interventions with high-risk
Three issues are central: first, does child maltreatment lead to populations (see Bakermans-Kranenburg, Van IJzendoorn, & Juffer,
more insecure-organized (avoidant and resistant) attachments? 2003; Juffer, Bakermans-Kranenburg, Van Ijzendoorn, 2008 and
Second, is maltreatment related to attachment disorganization? Berlin, Ziv, Amaya-Jackson, & Greenberg, 2005 for reviews).
Third, what are effective (preventive) interventions for child
However, very few of these intervention studies were conducted
maltreatment?
with maltreated children and their parents, or with children in
orphanages.
RECENT RESEARCH RESULTS
KEY RESEARCH QUESTIONS
The lack of evidence-based interventions for maltreatment may
have led some clinicians to rely on so-called holding therapies,
in which children are forced to make physical contact with their
caregiver although they strongly resist these attempts. Holding
therapy has not been proven to be effective (O’Connor & Zeanah,
This distribution differs strongly from the normative distribution, 2003; Sroufe, Erickson & Friedrich, 2002), and in some cases has
in particular in terms of disorganization (Barnett, Ganiban & been harmful for children to the level of casualties (Chaffin et al.,
Cicchetti, 1999; Crittenden, 1988; Egeland & Sroufe 1981; 2006). Holding therapy is not implied at all by attachment theory.
Lamb, Gaensbauer, Malkin & Schultz, 1985; Lyons-Ruth,
Connell, Grunebaum & Botein, 1990; Valenzuela,1990; for a
meta-analysis see Cyr, Euser, Bakermans-Kranenburg, & Van
Figure 1:
Ijzendoorn, 2010).
Attachment Distributions (Proportions) in
Studies of children maltreated in families show very few securelyattached children (14%), a majority of disorganized children (51%),
and some insecure-avoidant (23%) and insecure-resistant (12%)
attachments.
Six recent studies addressed the effects of institutional care
on attachment (The St. Petersburg – USA Orphanage Research
Team, 2008; Vorria, et al., 2003; Zeanah, Smyke, Koga &
Carlson, 2005; Steele, Steele, Jin, Archer & Herreros, 2009;
Herreros, 2009; Dobrova-Krol, Bakermans-Kranenburg, van
Ijzendoorn & Juffer, 2009).
Maltreatment Samples, Institutions and Typical
Families
Overall, the distribution of institution-reared children was
strongly deviating from the norm distribution, with 17% secure,
5% avoidant, 5% resistant, and 73% disorganized attachments
to the favorite caregiver.
The percentage of secure attachments is similar in maltreated
children and institution-reared children, but the percentage
of disorganized attachments in institution-reared children is
considerably larger (see Figure 1: Attachment Distributions
(Proportions) in Maltreatment Samples, Institutions and Typical
Families).
12
Volume 63, Winter 2014/ 15 IMPRINT: The Newsletter of Infant Mental Health Promotion
In fact, therapists force the caregiver to be extremely insensitive
and to ignore clear child signals. A major randomized control
study by Cicchetti, Rogosch, and Toth (2006) has demonstrated
the effectiveness of an attachment-based intervention for
maltreating families with child-parent psychotherapy, enhancing
maternal sensitivity through reinterpretation of past attachment
experiences. The intervention resulted in a substantial reduction
in infant disorganized attachment, and an increase in attachment
security.
Maltreatment prevalence data show a large impact of risk factors
associated with a very low education and unemployment of
parents (e.g., Euser et al., 2010). A practical implication of this
observation is the recommendation to pursue a socio-economic
policy with a strong emphasis on education and employment.
Since unemployed and school dropped-out parents are the most
frequent perpetrators of child maltreatment, policies enhancing
education and employment rates are expected to effectively
decrease child maltreatment rates.
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IMPRINT: The Newsletter of Infant Mental Health Promotion www.excellence-earlychildhood.ca
Volume 63, Winter 2014/ 15 13
EXPLORING THE USE OF THE AGES AND STAGES QUESTIONNAIRE: SOCIAL
EMOTIONAL (ASQ: SE) WITH VULNERABLE POPULATIONS
Caitlyn Passera RECE, BCD, Masters of Teaching candidate , Ontario Institute for Studies in Education of
the University of Toronto, Olga Gintsburg RECE, BCD, Sahel Naserinasab RECE, BCD, BEd candidate, York
University, Bahara Ayubi BCD candidate & Nicole Glen BCD Candidate
BACKGROUND
This applied research study was completed in conformity with
the requirements of the Bachelor of Child Development Degree
of Seneca College of Applied Arts and Technology, to explore
the current use of the Ages and Stages Questionnaire: Social
Emotional (ASQ: SE) (Squires, Bricker & Twombly, 2003) by child
development professionals with vulnerable populations of children
in Ontario. This article highlights the professionals’ perceptions of
the screening and assessment tools which they make use of in the
field, and the reasons why these are their tools of choice.
An online survey was sent out to eligible members in the field of
early care and education who come into contact with vulnerable
populations. Participants were asked about their knowledge,
opinions, and usage of common tools, specifically the Ages and
Stages Questionnaire: Social Emotional (ASQ:SE), to further
examine usage of screening tools in the field. Participants were
also asked what they believe makes the various reported tools
adequate, and what makes them inadequate, so that the ASQ: SE
could be compared to this. The goal of this study is to inform future
research into usage of the ASQ: SE as an adequate tool which
meets the reported criteria desired by professionals working with
vulnerable populations.
The Ages and Stages Questionnaire: Social Emotional (ASQ: SE)
is a screening tool that helps to identify children who may be at
risk for social emotional developmental delays. Research has
shown that the ASQ: SE is indeed a valid tool when looking at the
social emotional development of young children (Wiggins, 2010).
The tool is easily adaptable for many languages and cultures
(Heo & Squires, 2012; Kucuker et al., 2011) and ensures that the
primary caregivers are the main support in administering a child’s
developmental support plan (Harris-Solomon, 2001).
The number of children who enter the child welfare system with
mental health needs greatly exceeds the number of those children
whose concerns are addressed (McCrae, Cahalane, & Fusco,
2011). When mental health concerns are left untreated, this often
leads to later disorders or diagnoses (Feeney-Kettler, Kratochwill,
Kaiser, Hemmeter, & Kettler, 2010). A longitudinal research study
conducted in the United States by the Department of Health and
Human Services was undertaken from 1997-2013. This study,
called the National Survey of Child and Adolescent Well-Being
(NSCAW), surveyed families that were part of the child welfare
system and concluded that children of this population often had
both mental and physical developmental delays (Administration
14
Volume 63, Winter 2014/ 15 for Children and Families, Office of Planning, Research and
Evaluation, 2013).
Attachment theorist, John Bowlby (1907-1990), observed
maladjusted children’s relationships with their families to identify
how “children’s actual experiences form the basis of their notions
about themselves, others and relationships” (Goldberg, 2007,
p.5). Bowlby’s observations of these maladjusted children and
their compromised family lives led him to infer that family life is
important to social emotional development and should be included
in intervention practices (Goldberg, 2007). Early interactions and
experiences have a strong influence in determining the child’s overall
developmental outcomes; the quality of children’s interactions
and experiences determine their emotional, social and intellectual
development (Wiggins, 2010). It is imperative, therefore, to foster
strong relationships between the child and primary caregivers
early in life. Additionally, children who receive early intervention
services at a younger age have a higher chance of attaining a more
optimal developmental outcome compared to those who do not
receive services, or who receive intervention later in life (Including
all Children and Families Expanding Partnerships Project , 2010).
In order to identify needs and implement appropriate services,
however, a suitable and efficient early screening and assessment
is necessary.
Research regarding the use of the ASQ: SE with vulnerable
populations is limited and further investigation is warranted.
Current research does not define the extent to which the ASQ: SE
is being used in the child protection field; therefore this research
study is intended to bring perceptions and usage of the tool to light.
THE AGES AND STAGES QUESTIONNAIRE: SOCIAL
EMOTIONAL (ASQ: SE)
The first three years of life are a critical time for brain development.
In order to increase the chances for healthy brain development,
young children need good pre- and post-natal care, secure
attachment and positive stimulation during this most sensitive
period from birth to 5 years of age (Wiggins, 2010). It is also
important to intervene before this time has passed for optimal
intervention success. Thus, the young child’s rapidly developing
brain is a key impetus for the use of the ASQ: SE.
Children who have had inconsistent stability in their lives, as
is often the case for children involved in the foster care system,
are at risk of suffering from social emotional health issues (Jee,
Conn, Szilagyi, Blumkin, Baldwin, & Szilagyi, 2010). Despite a
IMPRINT: The Newsletter of Infant Mental Health Promotion
lack of screening tools which address mental health issues, the
ASQ: SE has been rated most favourably over other commonly
used measures, such as the Behavioral and Emotional Screening
System (BASC-2 BESS), the Early Screening Project (ESP), and
Preschool Behavior Screening System (PBSS) (Feeney-Kettler et
al., 2010). The ASQ: SE is lauded for its inclusion of the family
in the screening and intervention process (Harris-Solomon,
2001). Parents or the primary caregivers fill out the ASQ: SE. The
caregiver is thus involved as a main source of information in the
identification of any possible developmental delay. Once the ASQ:
SE is administered, intervention and/ or referrals can be planned
and an interim developmental support plan can be created with the
family’s lifestyle and routine in mind. This approach acknowledges
the family as the main source of support for the child’s growth
and allows intervention to focus on creating strong bonds and
relationships.
The ASQ: SE has been successfully adapted for use in different
countries. For example, Kucuker, Kapci & Uslu (2011) evaluated
the Turkish version of the ASQ: SE for accuracy in the identification
of social emotional problems in Turkish children, and it scored
within the 85th percentile. This same study further determined that
the ASQ: SE is an excellent tool to screen children in other cultures
from 3- 63 months for social emotional delays who could benefit
from some form of intervention. Likewise, the North American
version of the ASQ: SE was successfully adapted to reflect different
traditions within the Korean culture and is now recognized in Korea
as a culturally appropriate tool (Heo & Squires, 2012).
RESEARCH STUDY
This applied research survey explored the current prevalence of
the use of the ASQ: SE by child development professionals working
with vulnerable populations of young children in the Greater
Toronto Area. The study also examined professionals’ perspectives
on the type of screening and assessment tools they used, and the
rationale for their selections.
(ABLLS-R), 1 used social service assessments1 and 2 participants
stated they used the Ages and Stages Questionnaire: Social
Emotional (ASQ: SE). advantage of the ASQ: SE as it is a tool that
is easily adaptable to a variety of cultures and languages (Heo &
Squires, 2012; Kucuker et al., 2011).
When participants were asked about the adequacy of the tools
they currently used within their practice, the BRIGANCE, the NDDS
and the ASQ: SE each had two participants state that they were
adequate tools for use in the field. The ABLLS-R and social service
assessments each had one participant state that they were
adequate.
When asked to go into more detail regarding the use of the
tools, participants provided specific reasons for their selection
of screening and assessment tools identified. Some reasons
included:
• how quickly they could be administered;
• the tool’s applicability to a wide age range;
• the ease with which it can be conducted in a familiar place
for the child;
• how the tool can be used to educate parents;
• the tool’s ability to assess current development and monitor
the child’s development;
• and that the tool covers all development domains.
The reasons participants gave for not using screening tools were
that further evaluation might be required and the lack of detail
provided by the tools - that it may be too simplistic to give a
detailed report.
The study outlined here used a qualitative and quantitative
methodology to survey the use of the ASQ: SE. Eligible participants
self-identified as working with vulnerable populations. A total of
11 eligible participants responded to the survey. The participants
included 3 Early Childhood Educators (ECE), 3 Registered Early
Childhood Educators (RECE), 1 Junior Autism Therapist, 1 Mediator/
Respite, 1 Site Supervisor, one Program Manager at a Children’s
Mental Health Centre, and 1 volunteer at the Children’s Aid Society
(CAS) of York Region. All respondents were involved in programs
located in the Greater Toronto (GTA) and York Region area.
When participants were asked what screening or assessment tools
they preferred to use if they were concerned about a child’s social
emotional development, six of the participants stated that they
would use the ASQ: SE. Nine of the eleven participants had heard
of the ASQ: SE, and believed that it would be a useful screening
tool. Only one of the nine participants who mentioned the ASQ: SE,
however, had used it in the field. Although two of the participants
indicated that they had not used the tool, they were familiar with
the concept of developmental support planning using results
from the ASQ: SE. Five participants mentioned that they had only
used the ASQ: SE for school purposes, while the remaining four
participants had not come in contact with any aspect of the tool.
When asked about the screening tools they used or came into
contact with in their practice, 6 of the 11 participants mentioned
using one or more tools. Of the 6 participants who said they used
screening tools, 3 used the BRIGANCE© Early Childhood Screens,
3 used the Nipissing District Developmental Screen (NDDS),1 used
the Assessment of Basic Language and Learning Skills-Revised
Most (from the 11) participants agreed that although they had not
used it in the field personally, they believed that the ASQ: SE would
be a useful tool because it was easy to understand, and would
enable them to monitor a child’s development based on everyday
activities. For example, one participant stated that, “The ASQ:
SE provides a screen that is most accurate to the child’s age and
1 - the raw data shows this response as only “social service assessment”. There was no clarification as to what this entailed, as they filled out the survey online)
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 63, Winter 2014/ 15 15
allows for results to further assess and monitor for any delays”
(participant 08).
Another participant contended that, “Questions help break the
ice with the family and begin to develop a relationship. We use it
with children where we are unable to complete the developmental
screen for a variety of reasons. This is a vehicle to open up
discussion.” (participant 10) Most respondents had a positive
stance in regards to the ASQ: SE being a useful tool.
STUDY LIMITATIONS
The sample size of those who responded was a major barrier in the
applied research study as only 11 responses total were collected.
It is very difficult to generalize such a large population of child
development professionals working with vulnerable populations
from a sample size of only 11. The fact that an anonymous survey
was created also meant that we could not go back to the same
participants for future research. It would have been beneficial to
have contact information for the participants so that gathering
further information would be possible.
IMPLICATIONS OF THE STUDY
This study indicates that, although the majority of study
participants know about the ASQ: SE and identify it as useful
when working with children in vulnerable populations, the majority
of these professionals still do not use this method of screening.
The findings of this study indicate that this may be due to lack
of access to the instrument. The gap between the knowledge of
and the use of the ASQ: SE suggests that the participants in the
study may not be in a position of authority to introduce this type of
screening tool, and it may be the administrators who decide what
screening or assessment tools are used.
It is recommended that further research be conducted to determine
the reasons the ASQ: SE, while familiar to and viewed favourably
by many professionals working with vulnerable populations, is not
commonly used in the workplace. The research survey conducted
here did not look into whether cultural adaptability played a
role in how or why professionals utilized the ASQ: SE. It would
be of interest to investigate whether professionals working with
vulnerable populations are taking advantage of the ASQ: SE as it is
a tool that is easily adaptable to a variety of cultures and languages
(Heo & Squires, 2012; Kucuker et al., 2011).
16
Volume 63, Winter 2014/ 15 REFERENCES
Administration for Children and Families, Office of Planning, Research and
Evaluation (2013). National Survey of Child and Adolescent Well-Being
(NASCAW). U.S. Department of Health and Human Services. Retrieved April
20, 2014, from http://www.acf.hhs.gov/programs/opre/research/project/
national-survey-of-child-and-adolescent-well-being-nscaw
Curriculum Associates LLC (2015). Brigance early childhood screens
III. North Billerica, MA. Retrieved January 18, 2015, from http://www.
curriculumassociates.com/products/detail.aspx?title=BrigEC-Screens3
Feeney-Kettler KA, Kratochwill TR, Kaiser AP, Hemmeter ML, & Kettler RJ
(2010). Screening young children’s risk for mental health problems: A review
of four measures. Assessment for Effective Intervention, 35(4), 218-230. doi:
10.1177/1534508410380557
Goldberg S (2007). Attachment and Development. New York, NY: Routledge.
Harris-Solomon A (2001). Identifying social-emotional problems in young children:
perspectives of a program coordinator. Early Childhood Research Quaterly,
16(4), 427-429.
Heo K, & Squires J (2012). Cultural adaptation of a parent completed social
emotional screening instrument for young children: Ages and stages
questionnaire-social emotional. (Unpublished doctoral dissertation), Available
from Seneca Libraries.
Including all Children and Families Expanding Partnerships Project
(2010). Early Childhood Intervention: Module One – Typical and
Atypical Development - Importance and necessity of early intervention.
University of British Columbia (UBC) Faculty of Education. Retrieved
April 05, 2014 from http://blogs.ubc.ca/earlychildhoodintervention1/
category/1-2-what-is-ei-importance-and-necessity-of-early-intervention
Jee S, Marie Conn A, Szilagyi P, Blumkin A, Baldwin D & Szilagyi M (2010).
Identification of social-emotional problems among young children in foster care.
Children and Youth Services Review,51(12), 1351-1358.
Kenner C & Lubbe W (2009). Neonatal brain development. (Vol. 15, pp. 137-139).
Kucuker S, Kapci EG & Uslu RI (2011). Evaluation of the turkish version of the
“ages and stages questionnaires: Social-emotional” in identifying children
with social-emotional problems. Infants & Young Children, 24(2), 207-220. doi:
10.1097/IYC.0b013e31820eae26
Mccrae J, Cahalane H & Fusco R (2011). Directions for developmental screening in
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Screen Intellectual Property Association. North Bay: ndds. Retrieved January 18,
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Partington Behavior Analysts (2015).The assessment of basic language and
learning skills – revised (ABLLS-R). Retrieved January 18, 2015, from http://
www.partingtonbehavioranalysts.com/page/ablls-r-25.html
Squires J, Bricker D & Twombly E (2003). Ages and stages questionnaires: Socialemotional. Baltimore, MD: Paul H. Brookes Publishing
Wiggins P (2010). Infant brain development. Making the Program Work for Early
Childhood Programs, 1-6. doi: Texas Child Care
IMPRINT: The Newsletter of Infant Mental Health Promotion
SUPPORTING ONTARIO’S YOUNGEST MINDS: INVESTING IN THE MENTAL
HEALTH OF CHILDREN UNDER 6 - EXECUTIVE SUMMARY
Ontario Centre for Excellence in Child and Youth Mental Health, November 2014
Full Paper http://www.excellenceforchildandyouth.ca/sites/default/files/policy_early_years.pdf
Ontario is focusing unprecedented attention on mental health,
including large-scale changes to how the provincial child and
youth mental health system is organized. Given the impact of early
childhood experience on lifelong mental health and well-being
(Boivin & Hertzman, 2012), this is an opportune time to take a
life course approach to mental health and focus on the specific
needs of infants and young children (ages 0-6 years), as well
as their families. An ideal system for Ontario should build on
existing resources and engage families and caregivers, service
professionals working with infants and young children and whole
communities in decision-making about systemic and policy
initiatives.
strengthen infant and early childhood mental health services
in our province. While the content of this paper is relevant to a
number of stakeholder groups (e.g. families, youth, community
partners), the primary audience for this paper includes policy
makers from various government ministries, community leaders
and organizational decision-makers. The paper is meant to
establish a shared understanding of infant and early childhood
mental health, summarize current evidence on effective policy
and practice, provide a snapshot of the current system from a
service provider perspective and make specific recommendations
to ensure accessible mental health services during the early years
of children’s lives.
Research has consistently demonstrated that the first six years of
a child’s life are crucially important (Centre on the Developing Child
at Harvard, 2010). The brain grows and changes significantly, and
is influenced considerably by the child’s environment (Center on
the Developing Child at Harvard, 2010; National Scientific Council
on the Developing Child, 2004). Mental health is correlated with
a number of social determinants, including income and income
distribution, education, employment, food security, gender,
race, ability, Aboriginal status, housing and early childhood
development. Of the many determinants that influence early
childhood development, a secure attachment between a baby and
a caring adult is essential to healthy development (Schweinhart,
2003). The role of caregivers1 in children’s lives is critical, and the
nature of these relationships is important in shaping development.
Effective policy supports parents and caregivers and recognizes
the significance of the relationship between child and caring
adults. It should seek to create environments that promote secure
attachment, prevent issues that disrupt these relationships and
support appropriate intervention as soon as issues emerge.
As Ontario’s child and youth mental health sector transitions to a
new system of integrated services2, MCYS is working closely with
other ministries3 in a shared attempt to prioritize mental health
and repurpose resources for maximum impact. This presents an
ideal opportunity to consider the needs of infants and children and
the parents/caregivers who support them. Jurisdictions in Canada
and other countries are developing policies based on a growing
body of evidence that young children’s experiences in the early
years set the foundation for lifelong mental and physical health
and well-being. These jurisdictions are also placing a greater
emphasis on creating broader environments for young children
that promote and support optimal mental health and skills that
enhance resilience for all children, youth and families.
Ontario’s Ministry of Children and Youth Services (MCYS) identified
infant and early childhood mental health as an issue that needs
policy development to ensure the availability and accessibility
of optimal and consistent services across the province. At the
Ministry’s request, this policy paper was initiated by the Ontario
Centre of Excellence for Child and Youth Mental Health (the
Centre), and written by a multi-disciplinary team with clinical and
research expertise in infant and early childhood mental health,
led by Dr Jean Clinton. The paper draws on the latest research
evidence and information from environmental and jurisdictional
scans to advance evidence-informed policy recommendations to
Studies of prevalence of mental disorder in children 0-6 years are
not as common as those that look at children starting at age 4
years. Even when using conservative estimates, the prevalence
of any mental health disorder for children between ages 4-17
years is 14% (Waddell, 2007). Serious mental health issues can
occur in very young children and may manifest as serious social,
emotional or behavioural problems (Zeanah et al., 2008) including
aggression, hyperactivity, anxiety and depression (Egger & Angold,
2006). Egger & Angold (2006) reviewed four studies in younger
children and prevalence of any disorder ranged from 14% to 26%.
There is common belief that young children may outgrow early
mental health problems, but longitudinal studies show that this is
not the case (Breslau et al., 2014). In fact, the long-term social and
economic impact of mental health problems among infants and
young children is significant, making infant and early childhood
mental health an issue of critical importance for government and
communities.
1 - Throughout this paper, the term “caregivers” includes child care providers and other caring adults who play a critical role in child development.
2 - http://www.children.gov.on.ca/htdocs/English/topics/specialneeds/mentalhealth/momh.aspx
3 - Ministry of Health and Long-Term Care, the Ministry of Children and Youth Services, and the Ministry of Education
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 63, Winter 2014/ 15 17
According to a family member we consulted in writing this paper:
Many of us with children who have diagnoses of mental
health disorders or mental illnesses noticed concerns before
the age of 6 years, but were unable to get the supports and
services needed to effectively intervene and minimize the
impact of these diagnoses for our children, our families and
our communities.
The evidence is clear that prevention is better than cure, and
earlier is usually better and more economical than waiting until
the later years. Nobel Prize winning economist Dr. James Heckman
conducted a cost-benefit analysis of targeted early years programs
and found that investing in early childhood yielded a 7-10% annual
rate of return (Heckman, 2012). He concluded that “(investing in)
early childhood education is an efficient and effective investment
for economic and workforce development. The earlier the
investment, the greater the return” (Heckman, 2012, pp. 49-58).
Effective infant and early childhood mental health policy
encompasses the full continuum of promotion, prevention and
early intervention, with strategies targeted appropriately to the
unique needs of families, schools and communities.
The elements of an effective framework include:
• universal promotion to reduce risk factors and promote
protective factors
• early identification and intervention
• evidence-informed mental health programs and practices
• seeing caregivers and families as key in developing a
system of care that meets their children’s mental health
needs (Miles et al., 2010)
While most of Ontario’s communities provide a variety of valuable
services, our environmental scan found that efforts vary across
regions in Ontario and that there are gaps and inconsistencies in
the provincial system of infant and early childhood mental health
care. In an effort to advance a common understanding of infant
and early childhood mental health that conveys the importance
of a child’s social and emotional development, the U.S. Zero to
Three Infant Mental Health Task Force4 developed the following
definition, and later modified it to include all children under 6 years:
Infant and early childhood mental health, sometimes referred to
as social and emotional development, is the developing capacity
of the child from birth to five years of age to form close and secure
adult and peer relationships, experience, manage and express
a full range of emotions, and explore the environment and learn
– all in the context of family, community, and culture (Cohen,
Oser & Quigley, 2012, pg. 1). International jurisdictions including
Australia, Scotland, New Zealand, Norway and the United Kingdom
have used this definition to develop child and youth mental health
policy. It is this definition that is most often used by those working
in the field of infant and early childhood mental health in Ontario
and Canada, and the authors recommend that it be adopted for
use by government to guide policy development in this province.
The following recommendations offer opportunities for immediate
policy development while establishing the foundation for longerterm system change. They have been crafted to build on existing
government investments and leverage mental health policies and
strategies currently underway. Based on the literature, leading
policy in other jurisdictions and the results of an environmental
scan, the authors propose the following recommendations:
1. Engage families and caregivers together with service
providers in developing and implementing infant and early
childhood mental health policy and system planning. This includes
working together to conceptualize information and resource
systems that contribute to promotion; develop care pathways,
and collaborate to develop and provide training and education for
service providers.
2. Adopt and promote the Zero to Three definition of infant
and early childhood mental health across all sectors
including health, mental health, child development, education,
youth justice and child welfare. This definition states that “infant
and early childhood mental health, sometimes referred to as social
and emotional development, is the developing capacity of the child
from birth to five years of age to form close and secure adult and
peer relationships, experience, manage and express a full range
of emotions, and explore the environment and learn – all in the
context of family, community, and culture (Cohen, Oser & Quigley,
2012, pg. 1).
3. Ensure the provision of infant and early childhood
mental health promotion, prevention and intervention in all
provincial service areas. The system of care in each service area
should include access to information and resources to support the
mental health of infants and young children. The system should
make use of existing resources to enhance prevention and leverage
natural connections between families and the system to address
infant and early childhood mental health in one place. The system
of care should also provide targeted support for populations that
are identified as at-risk, include evidence-informed interventions
and provide clear pathways to care. The system should see the
client as the child and family/caregiver, working together within an
inter-generational treatment model.
4. Invest in training the infant and early childhood mental
health workforce, recognizing the many roles and sectors with a
direct stake in infant and early childhood mental health. This can
be accomplished through building on existing in-service training
to develop coordinated workforce training so that all those who
work with infants and children are able to recognize risk factors
4 - Zero to Three is a national non-profit organization in the United States that informs trains and supports professionals, policy makers and parents in their efforts to
improve the lives of infants and toddlers. More information can be found at: www.zerotothree.org
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Volume 63, Winter 2014/ 15 IMPRINT: The Newsletter of Infant Mental Health Promotion
and children who are experiencing challenges and refer families to
appropriate support. Professionals can be trained depending on
the degree of specialization needed: awareness for all (including
knowledge about how best to engage families), literacy for some,
and expertise for a few. Concrete strategies include on-site
coaches at the local level, agency practice leads and infant and
early childhood mental health communities of practice. This should
include education of medical students and other professionals.
The meaningful engagement of families and caregivers that
represent the diversity of Ontario’s population (including but not
limited to Francophone, First Nations, Inuit, Métis, newcomers,
differently-abled and LGBTTQ) will be essential in moving these
recommendations forward.
There are opportunities to leverage existing strategies by scaling
up, building on or integrating interventions within the natural
settings where children spend most of their time and have the
most significant relationships (Zeanah, 2009). By promoting and
encouraging local development of integrated care systems within
service areas and across ministries, existing public investment
can be used more efficiently, improving collaboration and reducing
duplication.
5. Strengthen data collection, monitoring and research
on infant and early childhood mental health and improve
communication among ministries. The infant and early
childhood mental health field in Ontario would benefit from a
provincial initiative to enhance data linkage, sharing and expansion
of surveillance systems and data sets.
Early identification systems for infants
using evidence-informed tools should
TOWARDS A MORE INTEGRATED SYSTEM OF CARE AND INTERVENTION
feed into data collection and reporting
systems to better monitor population
There are currently a variety of provincial programs that support infant and early childhood
health. The government’s role in
mental health promotion, prevention and intervention, but as yet there is no system of
developing effective policy should be
care or communication between and among the services.
evaluated.
6. Adopt a government-wide
approach to infant and early
childhood mental health and
designate
one
ministry
to
coordinate these efforts. This
should begin with a provincial, multisector, multi-disciplinary advisory
group that meaningfully engages
families and caregivers along with
service providers as partners to advise
on and evaluate progress on infant and
early childhood mental health policy
development and implementation.
As child and youth mental health
system transition progresses and
care pathways are developed, the
ministries must identify clear roles
and responsibilities required within
the system of care that support
infants, young children, their families/
caregivers and communities.
While the recommendations in this
paper stem directly from clinical and
research evidence and practitioners
involved in infant and early childhood
mental health promotion, prevention
and intervention, acting on these
recommendations
will
require
meaningful engagement with families
and caregivers along with service
providers to verify the nature and
scope of these priorities and plan for
implementation.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 63, Winter 2014/ 15 19
In an ideal system, comprehensive infant and early childhood
mental health policy creates universal access to conditions that
support early child development, and works at all levels – for
families and caregivers, service providers, communities and the
province (Boivin & Hertzman, 2012).
A prosperous and vibrant future for Ontario depends on the health
and well-being of its youngest members and their families. By
working across sectors and embracing a life-course approach
to mental health that includes attention to the specific needs of
infants, young children and their families, Ontario can work with
families and professionals to reduce costs, avoid duplicating
services, leverage existing effective services and ultimately
improve mental health outcomes across the lifespan.
ACKNOWLEDGEMENTS
This paper was initiated by the Ontario Centre of Excellence for
Child and Youth Mental Health. It was developed in collaboration
by a multi-disciplinary team with expertise in infant and child
mental health to provide a link between the research evidence and
a policy landscape that demands the efficient delivery of effective
services.
PREPARED BY
Dr. Jean Clinton, MD, FRCP (C), Associate Clinical Professor,
Department of Psychiatry and Behavioural Neuroscience,
McMaster University
Angela Kays-Burden, MSW, RSW, Former Director of Innovative
Practice, Reach Out Centre for Kids
Charles Carter, MPPM, Knowledge Broker, Ontario Centre of
Excellence for Child and Youth Mental Health
Komal Bhasin, MSW, MHSc, Mental Health Consultant
Dr. John Cairney, Ph.D., McMaster Family Medicine Professor
of Child Health Research Director of INCH (Infant and Child
Health Research Lab) Department of Family Medicine
Professor, Departments of Psychiatry and Behavioural
Neurosciences & Kinesiology McMaster University
Dr. Normand Carrey, MD, Associate Professor, Department of
Psychiatry, Dalhousie University and IWK Health Center
Dr. Magdalena Janus, PhD, Associate Professor, Psychiatry
& Behavioural Neuroscience, McMaster University, Offord
Centre for Child Studies, McMaster University
Dr. Chaya Kulkarni, D.Ed., Director of Infant Mental Health
Promotion, Hospital for Sick Children
Dr. Robin Williams, MD Clinical Professor, Department of
Pediatrics, McMaster University, President-elect, Canadian
Pediatric Society
20
Volume 63, Winter 2014/ 15 REFERENCES
Boivin M & Hertzman C (Eds.). (2012). Early Childhood Development: adverse
experiences and developmental health. Royal Society of Canada - Canadian
Academy of Health Sciences Expert Panel (with Ronald Barr, Thomas Boyce,
Alison Fleming, Harriet MacMillan, Candice Odgers, Marla Sokolowski, & Nico
Trocmé). Ottawa, ON: Royal Society of Canada. Available from: https://rsc-src.
ca/sites/default/files/pdf/ECD%20Report_0.pdf
Breslau N, Koenen KC, Luo Z, Agnew-Blais J, Swanson S, Houts RM, & Moffitt TE
(2014). Childhood maltreatment, juvenile disorders and adult post-traumatic
stress disorder: a prospective investigation. Psychological medicine, 44(09),
1937-1945.
Center on the Developing Child at Harvard University (2010). The Foundations of
Lifelong Health Are Built in Early Childhood. http://www.developingchild.harvard.
edu
Cohen J, Oser C & Quigley K (2012). Making it happen: Overcoming barriers to
providing infant-early childhood mental health. Zero To Three. Available at
http://www.zerotothree.org/public-policy/federal-policy/early-child-mentalhealth-final-singles.pdf
Egger HL & Angold A (2006). The Preschool Age Psychiatric Assessment (PAPA):
A structured parent interview for diagnosing psychiatric disorders in preschool
children. In R. Delcarmen-Wiggens and A Carter (Eds.). A Handbook of Infant and
Toddler Mental Health Assessment. New York, NY: Oxford University Press
Heckman JJ, & Kautz T (2012). Hard evidence on soft skills. Labour economics,
19(4), 451-464.
Miles J, Espiritu RC, Horen N, Sebian J & Waetzig E (2010). A Public Health
Approach to Children’s Mental Health: A Conceptual Framework. Washington,
DC: Georgetown University Center for Child and Human Development, National
Technical Assistance Center for Children’s Mental Health.
National Scientific Council on the Developing Child (2004). Young children develop
in an environment of relationships. Working Paper No. 1. Available at http://
www.developingchild.net
Schweinhart LJ (2003). Benefits, Costs, and Explanation of the High/Scope Perry
Preschool Program.
Wadell C (2007). Improving the mental health of young children. A Discussion
Paper Prepared for the British Columbia Healthy Child Development Alliance.
Zeanah CH (Ed.). (2009). Handbook of infant mental health. Guilford Press.
Zeanah PD, Gleason MM & Zeanah CH (2008). Infant mental health. In M. M. Haith
& J. B. Benson (Eds.), Encyclopedia of infant and early childhood development
(pp. 301–311). NewYork: Elsevier.
What do you see as next steps following this
policy brief?
Join us April 21 at Expanding Horizons for the Early Years:
Looking Back to Transform the Future
IMHP 2015 National Institute, for a Special Policy and
Advocacy Dinner Presentation and Strategic Visioning Forum
What is the Future of
Infant Mental Health in Canada?
with moderators Jean Clinton and Robin Williams
Registration and details at:
http://www.imhpromotion.ca/Events/
ExpandingHorizonsfortheEarlyYears2015.aspx
IMPRINT: The Newsletter of Infant Mental Health Promotion
THE DECLARATION OF THE INFANT’S RIGHTS AS A DEVELOPMENTAL
MILESTONE IN THE HISTORY OF THE WORLD ASSOCIATION FOR INFANT
MENTAL HEALTH
Perspectives in Infant Mental Health, Vol. 22 No. 2-3 | Summer 2014
(Reprinted with Permission)
Miri Keren, MD ,WAIMH President, Presented at the Presidential Symposium, 14TH WAIMH World
Congress, Edinburgh 2014
I will start by reminding us all, for the young ones among us
especially, about the pioneering investigators who showed the
crucial importance of infancy, a period in our development that
we, as adults, remember only implicitly.
1972, Selma Fraiberg received grant support from federal and
foundation sources to start a therapeutic model of intervention
for mother-infant dyads (The Child Development Project), followed
by a small clinical training program at the University of Michigan.
Fraiberg’s integration of scientific studies of child development
Let me begin with Darwin who, in 1877, published the Baby with her well-grounded psychoanalytical training led her to the
Biographies and the emergent psychoanalytic theory that led to core concept of interdisciplinary study and intervention in the first
the general idea that infancy may be an important period. Still, we years of life with the mother and infant together.
had to wait until the 1940s, with observations by Godfarb, Anna
Freud and Rene Spitz who came to the same conclusion: Without Fraiberg’s next step was the professionalization of Infant
“mothering”, infants die (Anaclitic Depression).
Mental Health in 1977, when Fraiberg’s 12 trainees decided to
organize a two-day conference on clinical issues of infancy and
Infancy became the object of scientific study in 1952 when John early parenthood and the dissemination of knowledge about
Bowlby published Maternal Care and Mental Health. In 1964, this important period of time and approach to service to other
Donald Winnicott enlarged the scope of study with his publication, professionals. The creation of the Michigan Association for
The Child, the Family and the Outside World. This new knowledge Infant Mental Health (MIAIMH) was triggered by the necessity
could have remained in the university libraries, beside much of to have a sponsor for the conference! MI-AIMH initiated the first
the scientific research. However, thanks to Margaret Ribble’s interdisciplinary gathering of research and clinical colleague in
direct observation of 600 infants in three maternity wards in New 1979 and created the Infant Mental Health Journal (IMHJ) with Jack
York City in 1943, the general public was made aware of the link Stack, MD, MI-AIMH Board Member, the first editor-in-chief. The
between the infant’s physiological development and the maternal first issue of the IMHJ came out in 1980. Leaders from MI-AIMH
caregiving environment, with emphasis on the vulnerability of the later created the International Association for Infant Mental Health
developing brain.
(IAIMH) and, along with MI-AIMH, the IMHJ became of the official
world publication for the field of infant mental health.
Ribble’s work resulted in a call for infant’s rights which was
summarized in simple and clear words, accessible to all: Mothering Next, comes a difficult question: to which family does this “baby
increases breathing which at birth is still shallow. Deep breathing is profession” belong? To the interdisciplinary field of Infant Mental
important for the brain development. Sucking increases breathing Health or the disciplinary specific field of Infant Psychiatry? Renee
and also satisfies a deep inner need… therefore if the infant cannot Spitz, MD was the first to use the term, “Infant Psychiatry”, in 1950
suck spontaneously, it should be taught. Baby needs physical thus introducing the idea that infant psychiatry is a specialized
contact (“stimulus hunger”) as the precursor of real longing to the subfield of psychiatry.
love object. Lack or sudden interruption of stimulus hunger, and
throw a baby back to a much lower level of physical functioning In 1974, Justin Call, MD, became the Chair of the American
and emotional withdrawal (Ribble, 1943).
Academy of Child & Adolescent Psychiatry’s Committee on Infant
Psychiatry. As we all know, splitting is a severe risk for dysfunction!
In 1959, a book for the wider public was written by Selma Fraiberg: Therefore leaders from both “camps” decided to join forces with
The Magic Years, thus bringing public attention to the effects of IAIMH and officially merge the associations and approaches. Parent
environmental influences on the infant’s social and emotional World Association for Infant Psychiatry and Allied Disciplines +
development. Then, in the 1960’s, many publications focused the Parent International Association for Infant Mental Health = Baby
infant’s sensory-motor and social competencies, mother-infant WAIMH! WAIMH is indeed the mix of the healthy development,
communication, and ego development. Thanks to these publications, developmental psychopathology, and psychiatry. Consequently,
increasing awareness about infant mental health encouraged some WAIMH’s identity is about planning for multidisciplinary preventive
to ask - what should society do in those situations where an infant’s as well as therapeutic interventions and treatments: Conducting
mental health or infant mental health is endangered? Indeed, in clinical and basic scientific studies, teaching and training, and
advocating for infant’s needs and rights.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 63, Winter 2014/ 15 21
The idea of having organizations work collaboratively on behalf of
babies has continued. For example, the first two editions of the
Diagnostic Classification for Infants (DC-0-3) were initiated and
supported by ZERO TO THREE (under Emily Fenichel’s special
leadership) with input from WAIMH. Today, a third revision is under
way and supported by ZERO TO THREE under the leadership of
Charlie Zeanah, MD, with participation from the WAIMH leadership,
strengthening the work between the two organizations.
At this first half of the 21st century, many more people are aware
of infants’ needs, but it is now time for all to think about infants’
rights. In 2012, the WAIMH Ethics Committee, led by Bob Emde,
MD and Tuula Tamminen, MD, brought to the Board a preliminary
comprehensive report looking at the need to specify Infant’s rights,
beyond what had already been included in the United Nations
Convention on the Rights of the Child (CRC). The Board’s decision
was to go for it. Committee members composed several drafts
of the Declaration of Infant’s Rights (DIR) and in the beginning of
2014, the WAIMH Central Office sent out a survey to all members
asking the question, “Do we need such a Declaration?”
The majority answered YES, because:
• The CRC does not include contemporary knowledge from
the neuroscience field about the impact of early experience
on brain development.
• The CRC does not focus on what is unique about needs
during the first three years, nor takes into account the
infant’s unique nonverbal ways of expressing their feelings
and their perceptions of their environment.
• The infant’s needs and rights are often overlooked in the
midst of conflicted priorities for rights of older children and
parents (custody disputes).
• In spite of the CRC, many societies around the globe pay
insufficient or no attention to infants, especially in times of
stress and trauma.
Our final goal is to have the Declaration of Infant’s Rights (DIR)
become a Convention for the Rights of Infants (CRI) that will guide
policies to support mothers, fathers and caregivers and give value
to babies in contexts of risk and violence.
The DIR is divided into two parts:
1. The infant’s basic rights, that should be endorsed
everywhere, regardless of society and cultural norms.
2. Social and Health Policy Areas to be informed by the basic
principles expressed in the Declaration of Infant’s Rights,
that are more sociocultural context-dependent and take
into consideration the fact that in non- Western countries,
hunger, diseases, high mortality of mothers and babies,
war, infanticide, abandonment, are still common.
22
Volume 63, Winter 2014/ 15 I. BASIC PRINCIPLES OF INFANT’S RIGHTS
(BIRTH TO THREE YEARS OF AGE)
1. The infant by reason of his/her physical and mental
immaturity and absolute dependence needs special
safeguards and care, including appropriate legal protection.
2. Caregiving relationships that are sensitive and responsive to
infant needs are critical to human development and thereby
constitute a basic right of infancy. The infant therefore
has the right to have his/her most important primary
caregiver relationships recognized and understood, with the
continuity of attachment valued and protectedespecially
in circumstances of parental separation and loss. This
implies giving attention to unique ways that infants express
themselves and educating mothers, fathers, caregivers
and professionals in their recognition of relationship-based
attachment behaviors.
3. The infant is to be considered a vital member of his/
her family, registered as a citizen, and having the right
for identity from the moment of birth. Moreover, the
infant’s status as a person is to include equal value for life
regardless of gender or any individual characteristics such
as those of disability.
4. The infant has the right to be given nurturing that includes
love, physical and emotional safety, adequate nutrition and
sleep, in order to promote normal development.
5. The infant has the right to be protected from neglect,
physical, sexual and emotional abuse, including infant
trafficking.
6. The infant has the right to have access to professional help
whenever exposed directly or indirectly to traumatic events.
7. The infant with life-limiting conditions needs access to
palliative services, based on the same standards that stand
in the society for older children.
II. SOCIAL AND HEALTH POLICY
Areas to be informed by the Basic Principles of Infant’s Rights
Policies that support adequate parental leave so that parents
can provide optimal care for their infants during the crucial
early years of life.
Policies that minimize changes in caregiver during the early
years of development.
Policies that promote the provision of informational support to
parents regarding the developmental needs of their infants
and young children.
Policies that recognize the importance of facilitating emotional
support for mothers, fathers, and caregivers, as an
important component of fostering the optimal development
and wellbeing of the infant.
IMPRINT: The Newsletter of Infant Mental Health Promotion
Policies that promote access to evaluation and treatment
of risks to development by trained professionals who
are culturally sensitive and knowledgeable about early
development and emotional health.
Policies that provide access to palliative services to infants
with life-limiting conditions.
Policies that assure adequate circumstances, including time
for mothers, fathers, caregivers to get to know their infants
and become skilled in providing for their infant’s care
and comfort, throughout the support of their family and
community. The right for parental leave, and its duration,
should be valued by the society, in a way that fits its
contextual reality.
Policies that provide access to relevant early educational and
psychological opportunities and programs that promote
good-enough relationship experiences and thus, enhance
cognitive and socio-emotional development.
Policies that ensure the provision of prompt access to
effective mental health treatment for mothers, fathers,
and caregivers that alleviates infants’ suffering and better
assures optimal development for the child.
Policies that allocate resources for training and supervision for
caregivers in infant institutions, foster care professionals
and foster parents, as well as resources for assessing and
treating foster care infant’s emotional and developmental
status.
4. The child shall enjoy the benefits of social security. He
shall be entitled to grow and develop in health; to this
end, special care and protection shall be provided both to
him and to his mother, including adequate pre-natal and
post-natal care. The child shall have the right to adequate
nutrition, housing, recreation and medical services.
5. The child who is physically, mentally or socially handicapped
shall be given the special treatment, education and care
required by his particular condition.
6. The child, for the full and harmonious development of
his personality, needs love and understanding. He shall,
wherever possible, grow up in the care and under the
responsibility of his parents, and, in any case, in an
atmosphere of affection and of moral and material security;
a child of tender years shall not, save in exceptional
circumstances, be separated from his mother. Society
and the public authorities shall have the duty to extend
particular care to children without a family and to those
without adequate means of support. Payment of State and
other assistance towards the maintenance of children of
large families is desirable.
7. The child is entitled to receive education, which shall be
free and compulsory, at least in the elementary stages. He
shall be given an education which will promote his general
culture and enable him, on a basis of equal opportunity, to
develop his abilities, his individual judgement, and his sense
of moral and social responsibility, and to become a useful
member of society.
The best interests of the child shall be the guiding principle
of those responsible for his education and guidance; that
responsibility lies in the first place with his parents. The
child shall have full opportunity for play and recreation,
which should be directed to the same purposes as
education; society and the public authorities shall endeavor
to promote the enjoyment of this right.
ENDORSEMENT OF THE 10 PRINCIPLES OF THE
UN CONVENTION ON THE RIGHTS OF CHILDREN,
1990 AND 2005 GENERAL COMMENT NO. 7
WAIMH endorses the 10 principles of the UN Convention on the
Rights of Children (as passed by the General Assembly of UN in
1989, and activated in Sept. 1990) that is:
1. The child shall enjoy all the rights set forth in this
Declaration. Every child, without any exception whatsoever,
shall be entitled to these rights, without distinction or
discrimination on account of race, colour, sex, language,
religion, political or other opinion, national or social origin,
property, birth or other status, whether of himself or of his
family.
2. The child shall enjoy special protection, and shall be given
opportunities and facilities, by law and by other means,
to enable him to develop physically, mentally, morally,
spiritually and socially in a healthy and normal manner and
in conditions of freedom and dignity. In the enactment of
laws for this purpose, the best interests of the child shall be
the paramount consideration.
3. The child shall be entitled from his birth to a name and a
nationality.
8. The child shall in all circumstances be among the first to
receive protection and relief.
9. The child shall be protected against all forms of neglect,
cruelty and exploitation. He shall not be the subject of
traffic, in any form. The child shall not be admitted to
employment before an appropriate minimum age; he
shall in no case be caused or permitted to engage in any
occupation or employment which would prejudice his health
or education, or interfere with his physical, mental or moral
development.
10. The child shall be protected from practices which may
foster racial, religious and any other form of discrimination.
He shall be brought up in a spirit of understanding,
tolerance, friendship among peoples, peace and universal
brotherhood, and in full consciousness that his energy and
talents should be devoted to the service of his fellow men.
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 63, Winter 2014/ 15 23
Additionally, WAIMH endorses the points published in 2005 by the
UN Committee on the Rights of the Child as “General Comment
No. 7”, that emphasize the need to include all young children i.e.
at birth throughout infancy, during the preschool years, as well as
during the transition to school. Through this general comment, the
committee made clear that young children are holders of all rights
enshrined in the convention and that early childhood is a critical
period for the realization of these rights, where parents and state
parties play a major role.
Assistance to parents is also mentioned as a right of the young
child. A special section is dedicated to young children in need of
special protection.
ENDORSEMENT OF THE UN MILLENIUM DEVELOPMENT
GOALS
As a background for the Declaration of Infant’s Rights (DIR),
WAIMH also endorses the United Nations Millennium Development
Goals that include:
1. The eradication of extreme poverty and hunger
2. The achievement of universal primary education
3. Gender equality and women’s empowerment
4. The reduction of child mortality
5. Improvement of maternal health
6. Combating HIV/AIDS, malaria and other diseases ensuring
environmental sustainability
7. Ensuring global partnerships for development.
24
Volume 63, Winter 2014/ 15 This draft will go through editing in terms of legal wording, during
the coming autumn 2014.
Key documents underpinning the Declaration of the Rights of the
Child:
Bartlett S (2005). An Alternative Model for Responding to Children in Poverty:
The Work of the Alliance in Mumbai and Other Cities. Children, Youth and
Environments, 15(2),342-355.
Bernard van Leer Foundation (2009). Realising the rights of young children:
progress and challenges. Early Childhood Matters, No 113. Council of Europe:
Commissioner for Human Rights. www.coe.int/t/commissioner
Irwin LG, Siddiqi A & Hertzman C (2007). Early Child Development: A Powerful
Equalizer. Final Report for the WHO’s commission on the Social Determinants
of Health.
MacNaugthon G, Hugues P & Smith K (2007). Young children’s rights and public
policy: Practices and possibilities for citizenship in the early years. Children &
Society, 21(6), 458–469.
NGO Group for the Convention on the Rights of the Child www.childrightsnet.org
Office of the High Commissioner for Human Rights. The Declaration of the Rights
of the Child. (adopted by the General Assembly of the United Nations, 1959).
Ribble M (1943). The Rights of Infants. New York: Columbia University Press.
The Office of the United Nations High Commissioner for Human Rights. (2011).
The rights of vulnerable children under the age of three: Ending their placement
in institutional care The UN Committee on the Rights of the Child. http://www.
europe.ohchr.org/Documents/Publications/Children_under_3__webversion.pdf
The UN Committee on the Rights of the Child’s General Comment on implementing
child rights in early childhood: http://bit.ly/JcMoNX
Perspectives in Infant Mental Health is a quarterly publication of the
World Association for Infant Mental Health. Address correspondence to
Deborah Weatherston ([email protected]). ISSN 2323-4822.
All opinions expressed in Perspectives in Infant Mental Health are those
of the authors, not necessarily those of WAIMH’s. Permission to reprint
materials from Perspectives in Infant Mental Health is granted, provided
appropriate citation for source is noted. Suggested format: Perspectives
in Infant Mental Health 2014, Vol 22, No. 2-3, WAIMH.
IMPRINT: The Newsletter of Infant Mental Health Promotion
SPOTLIGHT ON RESOURCES
CHILD DISCIPLINE - ONTARIO PARENTS’ KNOWLEDGE, BELIEFS AND
BEHAVIOURS
Best Start Resource Centre - Health Nexus
The Best Start Resource Centre is pleased to announce the
availability of a new report titled: Child Discipline - Ontario Parents'
Knowledge, Beliefs and Behaviours. It reviews the results and
makes recommendations for initiatives aiming to reduce the
prevalence of corporal and emotional punishment of children.
SUMMARY
A survey was done in 2013 by the Best Start Resource Centre to
determine parents’ knowledge, beliefs and behaviours towards
child discipline. A total of 500 parents, or main caregivers of
children zero to six years old living in Ontario filled out the survey.*
Here are the main findings:
• Overall, parents with a child aged 6 years or younger were
not very knowledgeable about Canada’s laws regarding
physical punishment for children. Parents’ perception of
Canadian laws was more in line with the Convention on the
Rights of the Child, which prohibits the use of violence on
children.
• The majority of parents reported that, at least once a week,
they got annoyed with their child for doing something he or
she was not supposed to and lost their temper.
• Although one quarter of parents thought that slapping or
spanking a child was an effective method to discipline a
child, and used that approach,
more than half the parents
believed this method taught
children that it is acceptable to hit
others.
• When we asked parents what type of information they were
looking for regarding child discipline, a majority of parents
did not know what they were looking for. This was more
prevalent for fathers.
• Parents were influenced in their parenting by family, friends
and colleagues. Their main information sources in this area
were also Internet and social media, as well as their child’s
teacher or educator and their health care provider. Internet
was particularly influential for parents aged less than 35
years old.
The main recommendations of this report are the following:
• Parents need practical suggestions to help them manage
their reactions to their child’s behaviour in a positive way,
without using punishment.
• The strategies offered should be attractive to fathers, who
are more likely to erroneously believe that strict discipline
and punitive techniques are effective. Mothers and the
general public would also benefit from such strategies.
• Social media and Internet are good ways to reach parents of
young children.
• Childcare providers and teachers, as well as health care
providers, are key service providers who
can help disseminate information to
parents on effective discipline methods.
• A large majority of parents believed
that putting a child in time-out was
an effective discipline method and
used that technique.
• Parents who used corporal
punishments belonged to all
socio-economic groups. The
weekly use of corporal punishment
was greater with parents 35 to
44 years old when compared to
younger parents. The weekly use
was lower by parents with a high
school diploma or less education,
than by parents with college, trade
or technical training.
IMPRINT: The Newsletter of Infant Mental Health Promotion This report is part of the background
research done by the Best Start Resource
Centre to guide its upcoming campaign
on Child Discipline (scheduled for fall
2015).
For more information on the campaign,
including highlights of this report, we
encourage you to read the article on
the Best Start campaign published in
the Ontario Health Promotion Bulletin,
August 15 edition.
The full report is available online at:
http://www.beststart.org/resources/
hlthy_chld_dev/BSRC_Child_Discipline_
Report.pdf
Volume 63, Winter 2014/ 15 25
SPOTLIGHT ON RESOURCES
WELCOME TO PARENTING - FOR YOUNG PARENTS
The Phoenix Center for Children and Families, a not for profit
Children’s Mental Health Centre, is announcing the launch of
Welcome to Parenting for Young Parents.
Created by experts in prenatal education, child development
and parenting, and administered by The Phoenix Centre,
www.WelcometoParenting.com is an online series of prenatal
and parenting classes for busy expectant and new parents. The
program takes parents through the prenatal stages of pregnancy
and through the first year of your baby’s life. Parents can obtain
support from an online parent educator, our panel of experts or by
connecting with other parents online!
• Specially created for expectant parents or parents with a
baby from birth to one year
• Structured with parents’ busy schedule in mind
• Easily accessible - all a parent needs is a computer with
internet access
• Relevant, useful and timely
• Based on the latest research on pregnancy, childbirth, child
development and parenting
• Built on Comfort, Play and Teach: A Positive Approach to
Parenting®
This online resource aims to provide young parents with the skills,
knowledge and confidence they need to become a positive and
confident parent and create happy, healthy families. The Phoenix
Centre, with funding from Trillium Foundation and 10 collaborating
agencies has adapted the Welcome to Parenting program
for young parents.
Teen and young parent pregnancies have higher risks for the
parent as well as the child in many different areas, including birth
weight, physical health, preterm labour, mental health and family
life/relationships. Welcome to Parenting for Young Parents was
developed using evidence-based content and covers an array of
topics from prenatal up to 12 months of age. It includes prenatal
26
Volume 63, Winter 2014/ 15 and postnatal care, labour and birth, nutrition, relationships,
attachment, growth and child development to help parents be the
best parents possible. Young parents have access to experts and
an online parent community.
Infant Mental Health Promotion’s award winning DVD series
Executive Director of the Phoenix Center, Greg Lubimiv is one of
the program’s health experts available for users to ask questions.
“The majority of parents, in particular first time parents, are
experiencing unprecedented
stress
in presents
their role
as mothers
and
This video for
parents
well-researched
information
about
the importance
an infant’s
relationship
with caregivers
fathers. Most parents’
view
their roleofas
the most
important
job
in clear, easy-to-understand language with examples of when
they have, but research
tells
us
they
aren’t
feeling
supported,”
says
and how to respond to an infant’s distress in order to promote a
baby’s trust and confidence to explore the world.
Lubimiv.
A SIMPLE GIFT
1998
10 minutes
In a landmark Canadian study called Vital Communities, Vital
Negative Emotions
(anger,
fear, jealousy)
Support (2010), it became
clear that
firstsadness,
time parents
did and
not the
difficult behaviours that may follow (temper tantrums, whining)
feel they were receiving
enough
emotional
practical
support.
are normal
in young
children. and
Not learning
to manage
negative
emotions
the early years
may result
in latertoproblems.
This may be the outcome
of in
a growing
stigma
attached
parentsThis
video shows how parents can help young children understand
needing and asking difficult
for help
andand
training.
Research
shows
that
feelings
express them
in acceptable
ways.
2001knowledge,15
minutes
healthy children begin with parents who have the
skills,
confidence and support
they need to do their most important job
Some caregiver behaviours may be frightening to a young child
– raising a child.
and may contribute to emotional and behavioural problems.
This video will help parents recognize and prevent interactions
that may be harmful, and describes some reasons why parents
to
The Canadian report might
also revealed
that ways.
fifteen
mothers
behave in these
As percent
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and nearly 30 percentinteract
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reportare
insufficient
17 Minutes
parenting (involving praise, encouragement,2005and affection).
In
addition, 25 percent of mothers and 30 percent of fathers indicate
excessive levels of negative parenting (angry/aggressive, punitive,
Each disc
includes:
harsh parenting)
and
notes this is not confined to parents with low
Videos
in
English
and French
income voiced
or education.
and captioned for accessibility
and
Lubimiv Print-Ready
says, “LevelsMaterials
of positive parenting are not high enough. On
Illustrated who
Parent Guides
average, parents
are high users of programs and resources
2 Page Summary Handouts
are 70% more
likely
to exhibit
positive parenting. Welcome to
only)
Professional
Guide (English
Parenting for Young Parents includes the Comfort, Play, Teach
approach
that information
gives parentsvisit
positive parenting techniques. By
For more
developing
the
right
tools
and
removing
the stigma around support
www.IMHPromotion.ca
© 2014, Infant Mental Health Promotion (IMHP),
for parents, increased health and wellbeing
will be the natural
The Hospital for Sick Children, Toronto
result.”
To celebrate the launch of this program, we will offer five free
access codes to agencies or government departments. For more
information visit. http://yp.welcometoparenting.com or email us
at [email protected].
IMPRINT: The Newsletter of Infant Mental Health Promotion
SPOTLIGHT ON RESOURCES
EDUCATIONAL RESOURCES
A Simple Gift, the award winning series of educational videos and guides for families and
professionals presents well-researched information on early mental health, attachment and
emotion regulation in a practical, easy to understand format.
A SIMPLE GIFT
A SIMPLE GIFT
Comforting
Your Baby
NOW AVAILABLE
as a
Complete 3 - Disc Set
updated and improved
to include:
ALL THREE TITLES
in English and French
(voiced and captioned
for accessibility)
Helping Young
Children Cope
with Emotions
PDF Print-Ready
Illustrated Parent Guides
and
2 Page
Summary Handouts
(in English and French)
Ending the
Cycle of Hurt
and
PDF Print-Ready
Professional Guides
(in English only)
This collection is widely used by parenting groups, home visitors, and others to
discuss important ways for parents to support early mental health and promote
positive parent-child interactions, and is a valuable addition to any resource library.
PLACE YOUR ADVANCE ORDER TODAY!
Items will be shipped as soon as they are available (Feb 2015).
Prices and order information on reverse. To order online visit www.IMHPromotion.ca
IMPRINT: The Newsletter of Infant Mental Health Promotion Volume 63, Winter 2014/ 15 27
LETTER FROM THE DIRECTOR
Chaya Kulkarni, Director, Infant Mental Health Promotion
This fall Infant Mental Health
Promotion began a 15 part institute
on infant mental health. Agencies
from across Canada were invited to
purchase a site license that allowed
them to send as many staff as they
wanted. The sessions focused on a
variety of topics directly related to infant mental health such as
infant trauma, parental mental health, early brain development
and many others. Over 1600 individuals from nearly 40 agencies
are currently participating. Individuals are able to join in real time
via the web, telehealth, or attendance at the hospital. Or, they can
view the lecture at their convenience on line. To know that 1600
people are actively engaged in conversations about infant mental
health is very exciting. In some case teams within agencies are
watching the broadcast together at a convenient time and then
engaging in discussion. Others are watching live on their own and
then coming together as a group within an agency to discuss. The
response is very positive as individuals and teams within agencies
enhance their knowledge of infant mental health and the factors
that promote and derail its development.
Both the online training and the first round of “embedding the
science” will both end in the spring at which time IMHP will be
hosting our Bi-Annual Expanding Horizons for the Early Years
National Institute on Infant Mental Health: This year we will offer
two Pre-institute sessions. The first will be for those working with at
risk infants, toddlers and preschoolers who may have experienced
neglect and/or trauma and will be led by Dr. Ed Tronick. At the
same time, we will offer a second pre-institute presented by
Dr. Kristen McLeod who will explore how infant mental health
influences practice in early learning and care settings including
centre based care, home child care, parent literacy programs and
drop in programs such as those offered at Ontario Early Years
Centres. Dr. McLeod will focus on those young children who may
have experienced trauma and the work of the professionals within
these settings.
Collectively, it is one of IMHP’s busiest years but we are inspired
by the willingness of those in communities to enhance their
knowledge and their practice. So, join us as we take the science,
pair it with our will to create opportunities for infants and toddlers
to thrive in their communities.
But in some instances, this is just the beginning! Infant
Mental Health Promotion is now working with a few
communities on embedding the science of infant mental
health into the diverse services offered to young children
and their families. In these communities, community
champions have brought agencies and their staff to a
single table where together we are collaborating about
how this science can be embedded into the practice
of all health, education and social services programs
including early learning and care practitioners,
elementary teachers, home visitors, child welfare staff
and health care providers. In each community we will
be creating an evaluation model that will enable us to
see if and how this effort is improving outcomes for
young children.
What has become key in all of these discussions is that
we have enough science to change a generation. But
the science alone is not enough. The embedding of this
science into practice requires a significant collaborative
effort from local agencies who each come to a table
with the support of their directors and managers.
Furthermore, how the science is embedded may look
slightly different from one community to another
because after all, no two communities are exactly the
same and therefore, programs and services may look
different from one community to another. The science,
however, is the same and will be at the core of this effort.
28
Volume 63, Winter 2014/ 15 IMPRINT: The Newsletter of Infant Mental Health Promotion
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
www.IMHPromotion.ca
IMPRINT: The Newsletter of Infant Mental Health Promotion or contact
[email protected]
Volume 63, Winter 2014/ 15 29
National Institute
on Infant Mental Health
EXPANDING HORIZONS
FOR THE EARLY YEARS
Looking Back to Transform the Future
April 21 & 22, 2015
The Westin Prince Hotel,
Toronto ON
Featuring
over 30 concurrent sessions and
keynote presentations including:
Nathan Fox
Gideon Koren
Gilles Julien
Judy Cameron
Harriet McMillan
Normand Carrey
with Full-Day Pre-Institute Workshops April 20
The Mutual Regulation Model
of Infant-Mother Interaction:
Caregiving Through the
Trauma-Lens:
A framework for understanding
typical and a-typical development
Becoming trauma-informed
to help young children succeed
with Dr. Edward Tronick
with Dr. Kristen McCleod
Also by
WEBCAST
REGISTER TODAY @ www.IMHPromotion.ca
30
Volume 63, Winter 2014/ 15 IMPRINT: The Newsletter of Infant Mental Health Promotion
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Volume 63, Winter 2014/ 15 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 broad
articles for publication in upcoming volumes
field.
We would like to hear from YOU!
We are always seeking suggestions and
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 MANY THANKS FOR
YOUR DEDICATION
AND SUPPORT!
Volume 63, Winter 2014/15 STEERING COMMITTEE
EDITORIAL BOARD
Cynthia Alutis, Child Development Institute (Co-Chair)
Jean Wittenberg, The Hospital for Sick Children, Infant Psychiatry (Co-Chair)
Brenda Clarke, Algoma Family Services
Louise Cohen, Toronto Children’s Services
Malini Dave, The Hospital for Sick Children, Emergency Medicine
Susan Dundas, Child Psychiatrist
Zel Fellegi, Aisling Discoveries Child & Family Centre
Rochelle Fine, Hincks-Dellcrest Centre
Jane Kenny, Rosalie Hall
Brigitte Lapointe, Association of Early Interventionists, New Brunswick
Margaret Leslie, Mothercraft, Breaking the Cycle
Wendy McAllister, Health Nexus
Donna McIlroy, Peel Children’s Centre
Brenda Packard, CAS Toronto
Rebecca Pillai-Riddell, York University
Mary Rella, Yorktown Child & Family Services
Francine Umulisa, Ministry of Community, Family & Children’s Services, Toronto
Nicole Welch, Toronto Public Health
Susan Berry, (Retired) Peel Children’s Centre
Eileen Keith, Infant and Child Development Services Peel
Kathy Moran, Simcoe County Children’s Aid Society
Mary Jean Watson, Simcoe Muskoka District Health Unit
EDUCATION COMMITTEE
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
Mary Rella, Yorktown Child & Family Services (Chair)
Anna Baas-Anderson, Sheridan College, Early Childhood Education
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
Angelina Paolozza, Queens University, Centre for Neurosciences
Rebecca Pillai-Riddell, York University
James Reynolds, Queens University, Centre for Neurosciences
Lavonne Roloff, Alberta Home Visiting Network Association (AHVNA)
Lisa Saunders, Catholic Children’s Aid Society of Toronto
Ruth Sischy, Toronto District School Board
Joanne Tuck, Humber College, Early Childhood Education
Marlyn Wall, Ontario Association of Children’s Aid Societies (OACAS)
Roxanne Young, Halton Region Public Health
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