Introduction
Home Visitors’ Role
Psychological Needs of the Parent
Attending to the Child’s Cues
Fostering Parent/Child Interaction
Enhancing Child’s Sense of Security
Other Services
Selected References
Lanita’s commitment to her two daughters is readily apparent
to Janice, an Early Head Start (EHS) home visitor, but Janice has also
noted several issues. The older daughter has the expressive language skills
of a much younger child. She tends to be very oppositional and ignores
her mother’s directives or attempts to engage her. Lanita’s
younger daughter has a very sad manner, is hesitant to join in play with
her sister, does not reach for her mother when she hurts herself in play,
and cries inconsolably whenever Janice attempts to leave. Lanita is also
extremely sad, lethargic, and unable to focus on even small tasks. Lanita’s
boyfriend supports her and her children, but she does not seem interested
in maintaining this relationship. She does not find joy in anything she
does nor does she have anticipation for the future. In her discussions
with Lanita, Janice has learned that Lanita’s grandmother, who raised
her, died two years ago and that Lanita has an older child who was placed
in foster care at birth.
When families such as Lanita’s are referred to Early Head Start
programs, the programs are often at a loss as to how to address their
psychological needs. Although Early Head Start is not a mental health
program, it has an established goal of promoting the development of the
whole child, including the child’s emotional development. For infants
and toddlers, the major strategy for addressing their emotional needs
is enhancing the parent/child relationship. In fact, the development of
the young child across domains is exceedingly difficult to achieve without
the support and well-being of the parent, even if the child participates
in the highest quality intervention.
Infant mental health services are designed to enhance the emotional well-being
of young children through their relationships with their caregivers. Selma
Fraiberg (1980), a pioneer in the infant mental health field, referred
to these services as "kitchen therapy," an allusion to the
home setting in which she felt these services were best provided.
Providing infant mental health services in the context of the home has
several advantages—
- Intervention that is conducted on the family’s turf allows for
increased comfort, openness, and trust on the part of the family.
- Observation of parent/child behavior is possible in familiar surroundings
and where the larger family system is present (e.g., grandmothers).
- Services can be more flexible in terms of time, space, and focus
of work.
- Intervention can incorporate the family’s resources and address
the family’s needs in a concrete manner.
- Intervention can capitalize on natural parent/child interactions
in the home, such as feeding, bathing, grooming, and putting the child
to bed.
Home Visitors’ Role
Alicia Leiberman (1999), an expert in the field of infant mental health,
has stated that you do not have to be a therapist to be therapeutic. In
other words, there are specific services that can be delivered by EHS
staff with appropriate training. Staff members should be consistently
supervised. They should discuss families and what needs to be accomplished
in the home visits. They should have access to regular mental health consultation
to learn more about particular mental health issues and specific strategies
to employ with families. Finally, if possible, programs should develop
collaborations with local mental health services where parents can obtain
treatments for any mental health difficulties.
With an overarching goal of enhancing the parent/child relationship, infant
mental health services should focus on meeting the psychological needs
of the parent, supporting the parent to attend to the child’s cues,
enhancing parent/ child interaction, and fostering the child’s sense
of security within the parenting relationship. The following are strategies
to meet these objectives in the context of EHS home-visiting programs.
Psychological Needs of the Parent
Jeree Pawl (1998), who has spoken and written on the provision of infant
mental health services, coined a "platinum" rule: Do unto
others as you would have others do unto others, meaning home visitors
should nurture parents in the manner that parents should nurture children.
Parents should have the opportunity for an emotionally corrective experience
with the home visitor, in which they receive unconditional acceptance
throughout the duration of their relationship with the program. Home visitors
must provide consistent and empathic care to families, even when parents
display "resistance"—such as not being home for appointed
visits or expressing anger at the home visitor. In addition, home visitors
can do initial screenings regarding the psychological health of the parent.
Many programs screen parents for depression using a questionnaire. Parents
who report clinical symptoms can be referred for individual psychotherapeutic
intervention.
Attending to the Child’s Cues
Pre-verbal children have to rely on the insight of their caregivers regarding
their needs. They need adults who understand the message behind their
cries, facial expressions, and body movements. Home visitors can help
parents pick up these cues by talking about the child’s need for
the parents, pointing out specific child behaviors and potential reasons
for the behaviors, and mimicking the child’s voice and asking for
certain parental responses. Parents can be coached to understand their
infants’ temperaments and preferences, and to anticipate their moods
and needs. Emphasis should be placed on parental responsiveness during
times of distress. For example, when an infant is most vulnerable (e.g.
hungry, tired, frustrated, fearful), parents can be coached to remember
the behaviors their infants display and the strategies that are effective
in consoling them. Coaching the parent during the home visit to use the
consoling strategies at the time these behaviors are displayed can be
beneficial.
Fostering Parent/Child Interaction
Building a relationship is best carried out in the context of "in-vivo" parent/child interaction. Home visitors can engage parents and infants
in play interactions to provide them with positive joint experiences without
pressure. They can use the toys and materials that are in the home to
increase the likelihood that mothers will repeat these activities when
the home visitor is not there. Similarly, capitalizing on the routine
interactions between the mother and her baby (e.g., grooming, feeding,
putting to bed) allows the caregiver to work on relationship issues with
the infant during frequent or daily activities. Finally, coaching the
parent to use playful, fun types of interaction can enhance the parent/child
relationship.
Enhancing Child’s Sense of Security
Developing an attachment to a primary caregiver is the major social-emotional
milestone of the infancy period. Scholars have emphasized that security
of attachment during the infancy period leads to later positive outcomes
across all domains of child development. Thus, when home visitors work
toward establishing secure attachments between parents and children during
infancy, they are potentially supporting the child’s long-term development.
Home visitors can accomplish this in several ways, including 1) promoting
parents’ constant expression of love and care for their infant;
2) coaching parents to be consistent, gentle, and developmentally appropriate
in their provision of structure and discipline; 3) encouraging parents
to be a secure base for their infants when they are distressed; 4) helping
parents think through how to handle separations from their infants appropriately;
5) facilitating parents’ feeling of joy when they are with their
infants; and 6) meeting the child’s needs as responsively as possible.
Other Services
Deborah Weatherston (1995), who directs one of the few long-standing infant
mental health training programs in the country, has delineated a set of
comprehensive infant mental health services that should be provided to
families at environmental risk. In addition to the relationship-focused
therapeutic intervention that should occur at each home visit, she suggests
including the following intervention modalities—
- Developmental Guidance
Educating the parent about developmental milestones and appropriate
expectations for their children is a major component of the services
that Early Head Start programs provide. This guidance should be provided
in the course of the moment-to-moment interactions that the parents
have with their children. It is less effective to lecture to the parent.
- Emotional Support for the Parent
Because the role of Early Head Start home visitors is not to provide
mental health services to parents, it is essential that programs have
a mental health consultant on staff who can offer such services or have
a cooperative agreement with a local mental health provider. In rural
areas, where it may be difficult to access a mental health provider,
it may be appropriate to arrange mental health supervision by telephone
or Internet for the most qualified person on staff to provide such services.
As discussed in the previous section, home visitors themselves can augment
this type of mental health intervention by directly providing emotional
support to the parent as well.
- Concrete Services for the Family
Families at environmental risk are beset by many stressors that come
from not having adequate resources, such as food, housing, money, and
transportation. For parents to focus on psychological issues, they must
have their basic needs for survival met. Home visitors must address
these issues with parents through joint problem solving as well as direct
referrals. This work can be linked to the goals of infant mental health
intervention by promoting parental self-esteem when parents overcome
one of these barriers, and addressing how the parents’ stress
affects the child’s psychological well-being.
In sum, infant mental health intervention can facilitate the accomplishment
of the overarching goal of Early Head Start—to promote optimal child
development. Many scholars and clinicians advocate for the provision of
preventive infant mental health services in the context of the home. Early
Head Start home visitors have a unique opportunity to support child and
family development through this modality. By receiving infant mental health
services in the home, families like Lanita and her children can move toward
the sense of psychological well-being that is essential for their capacity
to progress toward other developmental goals.
Selected References
Fraiberg, S. 1980. Clinical studies in infant mental health: The first
year of life. New York: Basic Books.
Leiberman, A. & C. Zeanah. 1999. Contributions of attachment theory
to infant-parent psychotherapy and other interventions with infants and
young children. In Handbook of Attachment, eds. J. Cassidy &
P. Shaver, 555-574. New York: Guilford Publications.
Pawl, J. & M. St. John. 1998. How you are is as important as what
you do. Washington, D.C.: ZERO TO THREE/ National Center for Clinical
Infant Programs.
Weatherston, D. 1995. She does love me, doesn’t she? Zero to
Three 15(4): 6-10.
Brenda Jones Harden was a 2000-2001 Society for Research in Child
Development Fellow, CORE, Office of Planning, Research and Evaluation,
ACF, DHHS. She currently serves as Assistant Professor at the University
of Maryland Institute for Child Study. T: 301-405-2580; E: bj34@umail.umd.edu.
