MORE THAN A quarter-century ago, Selma Fraiberg, one of the founding Board members of ZERO TO THREE, and her colleagues in Ann Arbor, Michigan crafted an extraordinary approach to strengthening the development and well-being of infants and young children within secure and stable parent-child relationships. Fraiberg called the practice Infant Mental Health. “Infant” referred to children under three years of age. “Mental” included social, emotional, and cognitive domains. “Health” referred to the well-being of young children and families.
Under Fraiberg's careful direction, social workers, psychologists, nurses, and psychiatrists—seasoned practitioners and student interns—worked together at the Child Development Project in Ann Arbor, Michigan to translate new knowledge into practice through the Infant Mental Health (IMH) approach. Parent and infant were seen together, most frequently in their own homes, for early identification of risk and treatment to reduce the likelihood of serious developmental failure and relationship disturbance. Sitting beside the parent and infant at the kitchen table or on the floor or on a sofa, the Infant Mental Health practitioner watched and listened carefully in an effort to understand the capacities of the child and family, the risks they faced, and the ways in which the practitioner might be helpful to the infant or toddler and family.
Infant Mental Health represented a dramatic shift in focus in clinical practice as it existed at the time. Attention to the baby, the parent, and the early developing parent-child relationship required a comprehensive and intensive approach. Services included concrete assistance, emotional support, developmental guidance, early relationship assessment and support, infant-parent psychotherapy, and advocacy. These dimensions of service continue to define Infant Mental Health practice in many settings.
The early Infant Mental Health practitioners were social workers, psychologists, nurses, and psychiatrists. In recent years, attention to infancy, early relationship development, and parental mental health has become part of the training of practitioners in other disciplines—for example, early childhood education, occupational therapy, and physical therapy. Consequently, it may be most helpful to define the Infant Mental Health (IMH) specialist not as a member of a particular discipline, but rather as someone with a distinct set of core beliefs, skills, training experiences, and clinical strategies who incorporates a comprehensive, intensive, and relationship-based approach to working with young children and families.
In its Guidelines for Infant Mental Health Practice, 1 the Michigan Association for Infant Mental Health recently listed the following basic beliefs that support and sustain IMH specialists as they work with infants and families:
- Optimal growth and development occur within nurturing relationships.
- The birth and care of a baby offer a family the possibility of new relationships, growth and change.
- What happens in the early years affects the course of development across the life span.
- Early developing attachment relationships may be distorted or disturbed by parental histories of unresolved losses and traumatic life events. 2
- The therapeutic presence of an IMH specialist may reduce the risk of relationship failure and offer the hopefulness of warm and nurturing parental responses.
Numerous case studies and interviews with experienced IMH consultants, supervisors, and practitioners in Michigan suggest a list of skills and strategies that together constitute competent and reflective Infant Mental Health practice. 3 These skills and strategies include:
- Building relationships and using them as instruments of change;
- Meeting with the infant and parent together throughout the period of intervention;
- Sharing in the observation of the infant's growth and development;
- Offering anticipatory guidance to the parent that is specific to the infant;
- Alerting the parent to the infant's individual accomplishments and needs;
- Helping the parent to find pleasure in the relationship with the infant;
- Creating opportunities for interaction and exchange between parent(s) and infant or parent(s) and practitioner;
- Allowing the parent to take the lead in interacting with the infant or determining the “agenda” or “topic for discussion”
- Identifying and enhancing the capacities that each parent brings to the care of the infant;
- Wondering about the parent's thoughts and feelings related to the presence and care of the infant and the changing responsibilities of parenthood;
- Wondering about the infant's experiences and feelings in interaction with and relationship to the caregiving parent;
- Listening for the past as it is expressed in the present, inquiring and talking;
- Allowing core relational conflicts and emotions to be expressed by the parent; holding, containing and talking about them as the parent is able;
- Attending and responding to parental histories of abandonment, separation, and unresolved loss as they affect the care of the infant, the infant's development, the parent's emotional health, and the early developing relationship;
- Attending and responding to the infant's history of early care within the developing parent-infant relationship;
- Identifying, treating and/or collaborating with others if needed, in the treatment of disorders of infancy, delays and disabilities, parental mental illness, and family dysfunction;
- Remaining open, curious, and reflective.
The skills and strategies described in points 1–9 and 17 are not unique to the IMH specialist. Relationship building, informal and formal observation of a young child's development, guided interaction and parental support, and reflection are skills that all infant/family practitioners who work from a relationship perspective use and value. However, points 10–16 are more clearly specific to the IMH specialist and may help to distinguish IMH practice from other forms of infant and family services. These seven strategies attend to the emotional health and development of both parent and child. They focus clearly on relationships, past and present, and the complexities that many parents encounter when nurturing, protecting, and responding to the emotional needs of young children. Finally, these strategies require the creation of a safe and nurturing context in which a parent and specialist may think deeply about the care of the infant, the emotional health of the parent, the multiple challenges of early parenthood, and possibilities for growth and change.
These seven strategies characterize the work of IMH specialists across disciplines and at multiple service levels, from prevention and early identification of risks to intensive assessment and treatment of serious emotional disturbances or jeopardized relationships. The IMH specialist uses these clinical strategies as she works with infants, toddlers, and families who come to her attention because of concerns about the child's development or behavior, parental factors, situational stress, or multiple risks to child and family.
The following excerpt from one of the 12 detailed case studies in Case Studies in Infant Mental Health: Risk, Resiliency and Relationships4 illustrates the application of Infant Mental Health principles and strategies within the context of early intervention practice. The IMH specialist (Julie Ribaudo) and the occupational therapist (Sandra Glovak) describe their initial contacts with Jacob and his family in some detail in order to illustrate their emphasis on building a strong relationship with the family; attending to thoughts and feelings in the present and from the past; and reflecting on their own experience as intervention proceeds.
JACOB AND HIS FAMILY
Jacob, a healthy, handsome, 22-month-old boy, was referred by his pediatrician to Early On, Michigan's early intervention system, due to difficulties with self-regulation. He had been a much-anticipated addition to the Williams family, which included four-year-old Liam and his parents, Rebecca and Jonathon Williams. Liam had been an easy baby, but from the beginning, everything about Jacob was different. Jacob demanded to be held constantly, and everyone had to be quiet when he napped. Jacob could not fall asleep unless rocked at length, woke repeatedly during the night, and needed his parents' help to fall back to sleep. When Jacob was 18 months old, the pediatrician made some suggestions about how to help Jacob learn to regulate his sleep patterns and to settle himself at night. Although the parents attempted to follow the pediatrician's suggestions, they did not work and led to Jacob's increased clinginess during the day. As he grew, Jacob was unable to handle textured foods and began to have temper tantrums.
Although the pediatrician was not concerned about Jacob's growth and development, he recognized that Jacob had difficulty with self-regulation. He suggested that Mrs. Williams call Early On, Michigan's early intervention system, to help her deal with Jacob's problems. When Mrs. Williams called Early On, the parent specialist who took the call heard the concern in the mother's voice and listened quietly, letting Mrs. Williams know that her worries would be heard and addressed. When the parent specialist told Mrs. Williams that she had talked to other parents with similar problems, she could hear relief in Mrs. Williams' voice. The parent specialist offered to have an IMH specialist call Mrs. Williams to schedule an appointment to discuss her child's behavior. Although Mrs. Williams was initially hesitant, the parent specialist assured her that the home visitor would be able to help Mrs. Williams with Jacob.
Beginning the Relationship: The Infant Mental Health Specialist's Perspective
When I (Julie Ribaudo) called Mrs. Williams to set up an appointment, I initially had difficulty hearing her over Jacob's screams and Liam's pleas for attention. She was clearly having a difficult moment, so I offered to call back at another time. She broke into tears saying, “That would be better,” but stayed on the telephone. After a moment, when Mrs. Williams calmed down, she said she wanted to set a date for an appointment as soon as possible. Jacob quieted and I could hear Mrs. Williams gathering her children for an instant to talk to them in a soft voice. She went on to say that it was becoming increasingly hard to find foods that Jacob would eat, and although her husband understood that Jacob was sensitive, her in-laws accused them of spoiling Jacob. Mrs. Williams choked up again, admitting that all of this made it hard to feel close to Jacob.
Jacob's sleep problems were very frustrating. “I can't get anything done around the house. As soon as I start to cook or clean, Jacob wakes up. He sleeps so lightly I can't check on him because the sound of the clasp clicking in the door wakes him.” She felt trapped in the house because Jacob loses control even more easily at restaurants, stores, or social gatherings at church. Mrs. Williams was grateful to have someone to talk to who didn't think that her problems with Jacob were unimportant. We decided on a late afternoon appointment so that Mr. Williams could join us after work. I told Mrs. Williams that I looked forward to our visit.
As I drove to the first appointment, I wondered if I would be able to understand the difficulties of this little boy and his family. It would take time to tease out the many strands that had led to this moment. I knew I had to be careful not to make too many suggestions or comments but, instead, to listen and watch carefully.
Mrs. Williams answered the door, smiling shyly. Liam came running up and greeted me with an exuberant, “I'm Liam!” I greeted each member of the family, “Hi, I'm Julie Ribaudo,” allowing them to choose how they wanted to address me. I asked Mrs. Williams what she would like to be called, and she said, “Rebecca is fine.” Jacob hid behind his mother's leg, holding tight to her pants. He looked at me warily and then reached up for his mother, saying “Up.” We all settled in the family room, and Rebecca put Jacob down. He immediately fussed, saying, “No! Me up, me up!” and climbed back in her lap. Rebecca sighed, saying, “You're not ready yet, eh?” She explained that it took Jacob a long time to warm up to new people and new situations. “I was shy when I was little. I was hoping my children wouldn't be that way.” She got a faraway look and mumbled that it had been hard to be shy, but stopped short, as if to say, “That's not why you are here.”
Wanting her to know that her thoughts, feelings, and memories would be important to me, I replied, “It's hard when we see our children face some of the same struggles we did. You want to protect him from that.” Rebecca agreed, saying how she was relieved that Liam is so outgoing. Liam, playing with a puzzle, looked up at his mother before going back to his work.
Jacob sat in Rebecca's lap, with his hand on her chin, rubbing it gently. I said to Jacob, “You look so comfy on your mommy's lap,” and then asked Rebecca, “Is that one of the ways he soothes himself?” Rebecca nodded, looking chagrined. They had tried very hard to find a blanket or other item that he would use, but he never seemed to find them soothing. Rebecca thought that the fact that Jacob was a nursing toddler might have something to do with it, but added that Liam had nursed and also had a favorite blanket that he still slept with now. I replied, “Liam and Jacob have been so different from each other. That isn't quite what you had expected, is it?” Rebecca shook her head, half-laughing, but in a pained way. I asked if there were other things that had been different than expected. Rebecca teared up and explained how even the pregnancy was different. Liam had been delivered at full term after a happy, healthy pregnancy. With Jacob, she felt fine for the first two trimesters, but was suddenly confined to bed rest at 28 weeks to keep her from early delivery. I reflected how scary and hard that must have been. Rebecca agreed, stroking Jacob's hair. He looked at her, smiled a little, and climbed off her lap, then pulled a pillow off the floor to lie on. He lay there for a while, twirling his hair as I wondered when, and if, he would begin to play with some toys. I asked Rebecca what Jacob liked to play with. She replied that he really didn't focus much on toys unless someone was playing with him. He liked games like peek-a-boo but seemed uninterested in toys themselves. She had tried various ways to gain his interest, but it was hard to figure out what he enjoyed. He didn't like having dirty hands; anything that was slimy or sticky upset him. Rebecca felt guilty because she was so tired during the day that she often didn't feel like playing with him. Still, she enjoyed the interest he was taking in the world. He liked listening to stories and having her name things around the house. I acknowledged how enjoyable the “labeling” phase could be, yet also reflected to Rebecca how hard all of this had been, how tired she spoke of being, and how hard they were working to understand Jacob.
As I listened to Rebecca, I instinctively wanted to focus on understanding what Jacob brought to the relationship instead of focusing solely on the present difficulties between them. I knew it would take time to understand how his parents' interpretations of his behavior had affected their relationships, but I also felt that Jacob was telling us something about the way the world felt to him.
I decided to pursue questioning that would help me understand how Jacob was taking in and responding to the world. When asked if she had noticed other things that upset Jacob, she rattled off a long list: loud noises, being in the car, being swung or moved too fast, diaper changes, getting his face washed, the sun in his eyes, big group gatherings, even the breeze of the church fan. “Should I keep going?” she asked; I nodded. She described how certain clothes seemed to bother Jacob. He was getting fussier about what she could dress him in, and mornings were becoming a nightmare. He often tried to take off his socks.
As she talked, Mr. Williams came in. After greeting the boys, who eagerly called out and went to him, he sat down to join the discussion. Jacob climbed in his lap and sat contentedly. When asked to add to the list of things that upset Jacob, Mr. Williams (who asked to be called Jonathon) added that one of the things he missed was being able to roughhouse with Jacob, who seemed to hate to be swung in the air or tossed, something Liam had enjoyed.
“What is that like that for you?” I asked, wondering for a split second if I had asked too much too soon. I wanted to know a bit about what Jacob's behavior meant to his parents. Did they feel rejected by him? Did they think he was being intentionally oppositional? Jonathon noted that he had not been much of a roughhouse kind of kid either, but that he had enjoyed that type of play with Liam. Trying to figure out what Jacob liked was more of a challenge. At that point, Liam came by his father, bumping up against Jacob, who struck out at Liam yelling, “No!” Rebecca offered to look at what Liam wanted to show his dad, but he wanted to show it to him. As Jonathon tried to look at a Lego tower Liam had built, Jacob quickly escalated. I noticed that he kept trying to push Liam away as if he suddenly felt crowded, in addition to not wanting to share his dad's attention.
I stayed quiet, wanting to see how the parents intervened and how they normally helped Jacob and Liam negotiate. Jonathon gently asked Liam to come to his other side, all the while rubbing Jacob's back. I noticed how carefully Jonathon tried to meet the needs of both children. As the situation calmed down, I asked, “How does Jacob usually react when other children come close to him?” They paused a moment, as if they hadn't ever really thought about it; then Jonathon said, “When we take Jacob to playgrounds, he often hangs back. By the time he is ready to play, it's time to go.” I asked, “What have you said to yourself about that? What do you make of it?” Both parents thought he was just shy and had difficulty warming up. Rebecca noted that she had noticed that there were times when he might get warmed up, but when other kids came around, he would have a “meltdown.” She figured he was just worried about sharing. Jonathon added that Jacob really seemed to have tantrums when it was time to leave places, even if he had been upset by the place initially.
Knowing that our first visit would be ending soon, I asked the Williams to tell me more about the sleep and eating problems they had described in the first call. I wanted to make sure that I addressed their presenting concerns, not just where my own curiosity took me. As they talked about their experience with Liam and Jacob, I began to see that these parents were able to respond to the differing needs of their children. I offered reflections on what I thought I had heard. Jacob seemed to be easily overstimulated and overwhelmed. Sounds, lights, movement, and touch all seemed to cause varying degrees of difficulty for him. Jonathon and Rebecca nodded and Jonathon added, “I never really thought about all of those things being connected.” Rebecca asked, “What causes that and what can we do?”
I suggested that we meet again to watch more carefully how Jacob played and how he took in the world. I offered to help them look at several areas of Jacob's development, so that we would be sure we weren't missing other factors that might be making things difficult for him. I explained and showed them a copy of the Infant Toddler Developmental Assessment (IDA), 5 a tool used to gain an idea of a child's overall development. I assured them that Jacob was developing well and using a lot of language—I had heard various words such as up, truck, no, Mama, Liam, me, and “Daddy home” during this visit. I also explained that sometimes, the difficulties with being overwhelmed affected other areas of a child's development in subtle ways, even in things like how they played with toys. We would want to have a clear idea of what challenged Jacob and where he was doing well to best know how to help him.
Reflecting on the First Visit
As I drove off, I thought about what I had seen and heard. I was hopeful; I didn't have the ache I sometimes feel when I leave a family where no one feels nurtured or cared about. Although some of Jacob's behaviors certainly could come as a result of an insecure or disorganized attachment, I didn't think the relationship between Jacob and his parents was seriously disturbed. They were exhausted, perplexed, and overwhelmed, yet they were responsive to Jacob, not openly hostile to him, and able to talk about him affectionately. I had also noted that Jacob responded positively to the subtle ways his parents had adapted to his needs. His mom's ability to label his feelings when he was anxious and not ready to leave her lap, to his father's ability to reposition Liam and Jacob while they negotiated attention, showed me some of the many capacities they had. I realized that Mr. and Mrs. Williams had confronted a challenge that many families face in welcoming a second child into the family. Ambivalence would not be uncommon as they adapted to the needs of two young children and to the loss of the singular relationship with the first child. Although they had seemingly negotiated the integration of Liam with ease, the unexpected differences that Jacob brought were presenting a challenge. Understanding those differences would be a priority.
Finally, I sorted out my own conflicting thoughts. Early in my career I had been taught that a baby's cries most often reflected the unheard cries of the primary caregiver, usually the mother. “Ghosts in the Nursery” had been the most often and well-accepted explanation for difficult babies. 2 What soothing did the mother need? Who was there to hear and hold her cries? Those were often the first questions considered when seeing fussy babies in the past. Yet, I had come to understand, as the field was also coming to understand, that the baby brings something to the relationship as well. 6 In this instance, it seemed like Jacob came into the world wired in a different way. Although the parental anxiety was high at this point, I wondered if that was in response to some of the difficulties Jacob experienced. This baby seemed very different from what Rebecca had expected.
Learning from the IDA
From medical records and the IDA assessment (in which Rebecca functioned as primary examiner and which we videotaped, so that Jonathon could see it and all of us could review it as needed), we saw that Jacob had strong cognitive, fine motor, communication, problem-solving, and spatial-relation skills. The areas that gave Jacob more difficulty were gross motor, emotions and feelings, and coping. The IDA also revealed that Jacob demonstrated significant fear and anxiety in new or highly stimulating environments. As I reviewed these patterns with Rebecca, I talked to her about sensory integration difficulties and offered three ideas to consider: (1) meeting with the Williams regularly to provide support for them as they grew to understand the particular challenges that Jacob presented, and then how best to help him be more comfortable in the world; (2) getting a full sensory integration evaluation from an occupational therapist (OT); and (3) writing an Individualized Family Service Plan together to develop a clear plan of action. Getting an OT evaluation to more fully understand Jacob was the Williams' top priority. I offered to assist in arranging the OT evaluation and to accompany them if they liked. Our relationship, as well as information, was a powerful part of the treatment. Rebecca seemed relieved by that offer.
UNDERSTANDING JACOB'S PHYSIOLOGICAL SYSTEM: AN OCCUPATIONAL THERAPIST'S PERSPECTIVE
As an OT, I (Sandra Glovak) take in information from the moment a child enters my office and at times even watch to see how they leave the car. As I prepared for the evaluation, I listened down the hallway to Jacob's reactions to an unfamiliar place. His mother, father, and the referring infant mental health specialist, Julie, accompanied him. He was a little apprehensive, and Rebecca reassured him several times that this was not a doctor's office, and that he was going to play and have fun. Julie had explained what the evaluation would be like, but, of course, the family was still anxious. I entered the quiet waiting room and crouched to Jacob's eye level, saying, “Hi, my name is Sandy. You're Jacob, right?” Jacob looked at me, nodded, and smiled. I let Jacob know immediately, “We're going to have fun playing today, and guess what? We'll even have your mom and dad come along.” I introduced myself to his parents, and invited them to follow me. Jacob had difficulty leaving the waiting room; he fussed and refused to go. Rebecca had to playfully interact with him to persuade him to follow us into the therapy room, which was set up for Jacob's visit. On the way to the room, Jacob sometimes walked on his toes; the IMH specialist indicated he occasionally did so at home, also.
The room contained a large carpeted barrel lying on its side, sturdy foam steps, a foam incline, and a wooden platform suspended from one point with an inner tube inside and a large multicolored foam dome. The attractive equipment was placed on vinyl-covered foam mats. As I reviewed the information on the Symptom Checklist completed by Mr. and Mrs. Williams, I watched Jacob surreptitiously. The responses on the checklist indicated that Jacob wakes more than three times per night, avoids textured foods, becomes excited in busy areas such as supermarkets and restaurants, and is distracted by sounds that most people do not hear or notice. In the area of self-regulation, Rebecca indicated that Jacob goes easily from whimper to intense cry, demands adult attention constantly, and must be prepared several times in advance before change is introduced. Of the several tools available for the evaluation, I would determine which to use based on my observations of Jacob's play skills. These tools included the Peabody Developmental Motor Scales 7 and The Pediatric Evaluation of Disability Inventory. 8 While I talked to Rebecca regarding Jacob's sensitivity, I observed Jacob's approach to the environment. Under the fluorescent lights, Jacob had a tendency to squint, suggesting sensitivity to some types of lighting. He left his mother's side very slowly, and when changing from the carpeted to a 2-inch matted surface, he went to his knees and crawled to avoid walking across changing surfaces. He held his hands in a fisted position when crawling to avoid tactile input from the mats to the palmar surface of the hands. Jacob did not play on the equipment spontaneously but moved about the room without engaging in any goal-directed play. He appeared to become more excited as he moved about the room, so I attempted to engage him in activity. Jacob played peek-a-boo and appeared curious about the barrel. I persuaded him to get into the barrel with minimal physical assistance, but held it so it would not shift. As soon as I released the barrel a bit, and Jacob's weight shifted while he was on his belly, he looked frightened and ran back to his mother. I had to work hard to regain Jacob's trust and did get him to move tentatively up and down the foam incline on hands and knees. I attempted to get him to walk up and down the incline holding his hand, but he did not seem to like me touching his hand and pulled away.
Jacob seemed fearful of unexpected movement, which was apparent both in response to the barrel moving and the way he went to his hands and knees to avoid walking across changing surfaces. I explained the concept of gravitational insecurity. Gravity should be the most consistent input that we receive and if Jacob could not feel stable when moving about, it would certainly affect his emotional security. Rebecca denied seeing much of this behavior at home, but, when asked if Jacob liked to swing, noted, “He sometimes used to throw his hands back, as if startled, each time the baby swing moved backward.” Jonathon reminded his wife that Jacob did not like roughhousing or being swung in the air by his father. I explained that a child could have an adequate sense of balance yet have difficulty with modulation of movement. That was why Jacob seemed to score within the normal range on the IDA. Julie expanded this information by pointing out how this was affecting Jacob emotionally, that is, not letting Rebecca out of his sight. Since he didn't feel fundamentally safe in the world, he used his mother to gain a sense of safety. Although this was initially adaptive, Jacob needed to explore the world, and this was becoming increasingly difficult for him.
Referring to the symptoms that the parents had noted on the checklist, I was able to explain how Jacob's sensitivity to touch affected his walking, eating, sleeping difficulties, and play with others. I also explained that low tone in the muscles of Jacob's inner ear might explain his hyperalertness to ordinary household sounds. To explore Jacob's difficulty with “motor planning” I asked, “In what situations do you see difficulty with adapting to change?” The Williamses responded with many anecdotes. I explained that, like many children with motor planning problems, “Jacob cannot figure out how to change his plan himself. He knows what he wants to do but just cannot figure out how to accomplish the task. When others change it for him, he becomes uncomfortable because he takes longer to get ready for a new plan.” Recognizing that all of this information was a lot for a parent to incorporate, I decided not to administer further testing at this point. I changed my focus to demonstrating techniques that I thought would have more immediate results.
During the rest of the evaluation, I demonstrated calming techniques, including deep touch pressure, skin brushing, joint compression, and hand hugs. I demonstrated them on Mr. and Mrs. Williams, and then had them try them on me to assure that they were comfortable and knew how to perform them correctly. Next, they used them on Jacob. He had been running around the room and immediately sat down, holding up his leg so his mother would repeat the stimulus. I pointed out that Jacob's face looked less stressed after this firm input, and instead of crawling up the incline, he walked somewhat hesitantly up and down. I explained that increasing information to the joints of the legs (lower extremities) made him feel a little more secure with movement through space. A final observation was that Jacob did not often interact with the unfamiliar toys, which could be associated with a fearful response to the environment. As the session progressed, he would have likely interacted more with the toys.
As the assessment drew to a close, we discussed a plan of action for OT. The Williamses knew they would need time to digest some of the information they received, and I reassured them that, as they had more questions, they could call me. I suggested twice-weekly treatment to start, combined with a “sensory diet” that I would help them plan. Treatment could be done in the course of their daily routines to help make the treatment hour even more effective for Jacob.
Julie, who did not want to overwhelm the family, wondered how all of this sounded to them. Rebecca laughed, “If it will help us sleep, I'll do anything.” We all discussed how it would be intensive at first, but within a short time, things were likely to improve and, thus, not be so overwhelming. It was also noted that, since so much of what would be done with Jacob at home would be play-based, Liam could also join in, thus reducing the chance that he would feel left out.
FOLLOW-UP WITH THE INFANT MENTAL HEALTH SPECIALIST
After the OT assessment, the Williamses and I (Julie Ribaudo) developed an IFSP (Individualized Family Service Plan) that called for weekly home visits. We used our time together in various ways. Some sessions were spent in play activities designed to engage Jacob in ways that he could tolerate. Other sessions were spent talking about what Rebecca was learning about Jacob and the sadness and guilt she felt about those early months. However, she quickly came to see the gifts he brought to their family, even if they had been a bit hard to discover at first. I listened carefully, pointing out to Rebecca that she had understood Jacob's problem but didn't have words for it in the early months. I was careful not to dismiss Rebecca's feelings of guilt but instead to allow her to express them and understand them. At times I gently reminded her of all the ways they had tried to help Jacob. I made a conscious effort to highlight the parents' strengths and how what they had done allowed Jacob to be as secure as he was.
Once Rebecca let go of her guilt feelings, she was ready to respond to Jacob as he was now. One day, about two months into our work together, Jacob tried to take a toy from Liam, who protested and pulled the toy away. Jacob looked angry. Everyone paused with bated breath, because this would usually lead to a quick meltdown. Rebecca said quietly, “You can have a turn when Liam is done. Do you want this instead?” Jacob hesitated and took the toy that Rebecca offered. Rebecca and I looked at each other, and I asked, “Do you think he could have done that two months ago?” Rebecca laughed and said, “Maybe not even a week ago!” When I asked if it felt good to have some of her hard work pay off, Rebecca talked of feeling much more able to respond quietly and calmly to Jacob, knowing that not every limit set would result in a tantrum. By paying attention to Rebecca's ability to respond to both boys, I tried to support her in her attempts to come to know Jacob as he was. Although Jonathon was not frequently involved in home visits, he enjoyed some of the home program routines that allowed him to roughhouse with Jacob in ways different than he first imagined, but equally rewarding.
Between OT appointments and our home visits, the time invested in treatment was initially a struggle for the Williamses. However, the results soon helped family life improve. Jacob was sleeping better, with less need for parental support. He was still fussy about foods but was eating a wider range and no longer gagging at the sight of textured foods. As he began to feel more secure in his body, he became more independent and began to explore his world more readily. Liam seemed happier that he could play without worrying that he would be told to be quiet because Jacob was sleeping.
Although parent-child treatment alone would have been supportive for this family, without specific treatment for Jacob's hypersensitivities and other sensory integration difficulties, he would not have been able to contribute to the relationship in ways that allowed for more joy and pleasure in the family. An understanding of what the baby brought to the relationship was crucial in developing a treatment plan that effectively alleviated the distress of the child and the family. Just as crucial was a place for these parents, particularly Rebecca, to explore their feelings of sadness and to develop a sense of their own ability to understand and meet their child's needs.