November - SE Regional Breakfast Meeting - Update Blog by Jean Mercer

The PA-IMH breakfast seminar presentation for November, 2014 was given by Judith Silver, Ph.D., of CHOP, and focused on the special needs of children between birth and three years who are involved with the child welfare system. Because Pennsylvania state laws will soon change to lower the bar for investigation of abuse and neglect cases, it will become increasingly important to be able to make an accurate assessment of the needs of vulnerable young children. Infants and toddlers are especially vulnerable to neglect, they are the largest cohort of victims of substantiated abuse and neglect, they make up half of all substantiated medical neglect cases, they account for 70% of all child deaths, and they are often without contact with mandated reporters of abuse and neglect. Unfortunately, few states treat the needs of infants and toddlers as different from the needs of older children, and few have put to work some of the promising approaches for meeting young children’s developmental needs. The Family Advocacy & Support Tool (FAST 0-5 module) offers a way to help caseworkers plan effective interventions and provides a rating system that identifies specific problems as “actionable”. The FAST approach includes items that have to do with risk for death and injury and medical neglect or developmental disabilities. Failure to thrive is one focus, and includes concerns about babies receiving insufficient calories because of inappropriate formula preparation, failed breast feeding, or food insecurity, all possibly associated with parents’ intellectual disability or with medical causes such as lead exposure or HIV. Another serious concern has to do with the development of early vision and hearing problems, which must be resolved in the first year or less in order to prevent long-term effects on language development or blindness.

For most breakfast seminar attendees, an important aspect of FAST was the setting of standards to use in assessing behavioral and emotional concerns such as sleep practices, self-regulation issues like crying and tantrums, and the progress of eye contact and social engagement. Most of the FAST items of this kind are not only focused on birth to age three, but provide information on developmental sub-periods, as sleep practices or concerns with crying are very different for young infants than they are for toddlers. For example, with respect to sleep issues, one item is specifically designed for babies from birth to four months of age, the period when death from SIDS is by far the most likely. During this age period, babies’ sleep situations may be evaluated as having 0 or 1 concerns, in which no changes are needed, or they may be ranked as having moderate or significant concerns, and therefore needing to have this issue included in the individual family plan.

Concerns about crying in young babies and tantrums in toddlers are carefully defined in the FAST approach. If infants aged 1 to 5 months are moderately easily soothed, this concern is a minor one, but there is much more concern if a baby cries for extended periods and does not soothe, especially if the caregiver gets no breaks from responsibility. The concern with tantrums focuses on children from about 12 months to 5 years of age. No problem is indicated if these are brief outbursts that are resolved in 10 minutes or so, and if they are triggered by age-appropriate issues like power struggles or crankiness. There is slight concern if tantrums occur more than 5 times a day and if they resolve in 10 to 15 minutes. Moderately concerning tantrum behavior involves tantrums more than five times a day, lasting more than 20 minutes, or involving aggression or head-banging on soft surfaces. Significant reason for concern exists if tantrums are intense and the child hysterical and inconsolable for long periods, and where there is abrupt head-banging on hard surfaces. In the last case, planning should include investigation of developmental disorders like language delays, or reminders of  past trauma as reasons for significant tantrums.  

The FAST birth-to-five module presents an extremely useful definition/checklist approach that should be of great value to professionals doing individual family plans.