PA-AIMH breakfast 12-04-15

The December 2015 infant mental health breakfast featured a lively resource fair with presentations and materials from five organizations, followed by much discussion and commentary.
Karen Krivit from Elwyn SEEDS showed a remarkable autism education video, made by herself, and directed toward assuring parents that they are not alone in dealing with autistic children. Karen has created videos for a range of languages and cultural backgrounds. The one she showed us was in Spanish and English, with the innovative feature of alternating languages for spoken words and subtitles--  sometimes English with a Spanish subtitle, sometimes the other way around.  The audience was fascinated and impressed, and we could easily have spent the whole meeting discussing the video and how it was made and is used.

Brenda Golden and Marilyn Edmond of ChildLink discussed the provision of early intervention services to children 3 years old and under, and brought materials about infant-toddler and preschool intervention. They brought up an issue that became a general theme of this breakfast: how do we communicate with families in need of services? What happens if the family moves to a different area of the city? What happens if they become homeless? And what happens if one child problem is successfully addressed, but a different one emerges with age? These questions can be particularly important for issues like hearing impairment, where problems change or appear to be “solved” as development progresses. The presenters also pointed out that a stumbling block for provision of services is difficulty in recognizing early signs of trouble; another problem is keeping a positive approach so parents are not scared.

Sharon McClafferty of Southeast Regional Key sent information about Keystone STARS, and infant-toddler specialists Sarita Brown and Lizbeth Ramos presented. STARS is a statewide program of the Pennsylvania Office of Child Development and Early Learning which supports childcare programs, with an emphasis on staffing.  Programs approved by STARS at the Star 1 level have a parent handbook, an annual plan to continue professional development, and a practice of meeting with parents when a child enrolls. In Star 2 programs, at least half of the group supervisors have associate’s degrees in early childhood education, parents get daily updates on classroom activities, and teachers observe children’s development when they enroll. In Star 3 programs, group supervisors have at least associate’s degrees in early childhood education, there are at least two teacher conferences each year, and there are independent evaluations of classroom arrangements and learning activities. At the Star 4 level, at least half of the group supervisors have bachelor’s degrees in early childhood education and programs have strategic plans to ensure continuing quality improvement. Infant-toddler specialists, child care health consultants,  and early childhood mental health consultants  are available for needed assistance.

Elaine Frank and Denise Rowe of Parenting Services for Families described their organization’s services for both adoptive and non-adoptive families. These include assessment of family relationships, child behavior, and parenting concerns and parent-child counseling and therapy. Adoptive families may also need help with children’s adjustment to the new family, developmental delays, attachment problems, or the consequences of coming to the family from other countries, orphanages, or foster care. Parent-child counseling and therapy are available for children under three as well as for older ones. Parent coaching and developmental guidance is another service offered.

Icylee Basketbill of Health Federation of Philadelphia discussed home visitation and a recruitment program, and mentioned the importance of working with both fathers and mothers. In addition, Icylee was mentioned as one of the “stars” of one of Karen Krivit’s autism education programs!

The group discussion was enlivened by the presence of Stephanie Bey, program analyst for early intervention for the city of Philadelphia, who joined with the rest of us in the discussion of issues of collaboration and communication.    

PA-AIMH 11/6/15
A large and enthusiastic audience welcomed the infant mental health breakfast seminar presentation by Dr. Nathan Blum on Nov. 6, 2015. Dr. Blum is Chief of the Division of Developmental and Behavioral Pediatrics at Children’s Hospital of Philadelphia. He spoke on behavioral management of children’s oppositional behavior.
A basic theme of Dr. Blum’s presentation was that oppositional behavior has generally been learned in the course of a child’s interactions with parents, and if the nature of the interactions is changed, more compliant behavior can be learned and can take the place of opposition. To accomplish this, parents need to understand the role of reward/reinforcement of desirable behavior and the withholding of rewards for unwanted oppositional behavior (for example, by the use of time-outs).
Children who become oppositional may lack flexibility and adaptability to begin with, but a problematic social environment operates to bring about consistent noncompliance. Dr. Blum mentioned as features of this environment the following: unclear rules; inappropriate expectations about behavior; lack of parental attention for desirable behavior; parental failure to recognize a child’s efforts when they do not have a perfect outcome; the child’s experience of escaping from demands by inappropriate behavior; “bribing” by allowing the child a reward following undesirable behavior; and the existence of excessive environmental stressors.
As children become more oppositional, parent-child interactions move toward a more coercive pattern, said Dr. Blum. The child learns not to listen; the parent learns to repeat commands; the parent learns that only the statement of a threat will bring compliance; and the child learns that it is not necessary to listen until the threat appears. Parents who have learned to use threats begin to threaten or yell at the slightest problem event, and the child learns to engage the parents’ attention in this way.
Dr. Blum mentioned a number of evidence-based treatments (EBTs) designed to correct oppositional behavior. These all share certain components that are taught to parents: the use of praise, time-outs that withhold attention and rewards following unwanted behavior, the use of tangible rewards, the use of clear commands, problem-solving to eliminate obstacles like stress, and the use of differential reinforcement with high contrast between reinforcing and non-reinforcing conditions. Dr. Blum also recommended the “1, 2, 3, magic” approach, in which clear, brief, and precise commands – statements, not questions—are not followed by parent commentary or discussion; the parent counts to 3 instead of continuing to talk.
Dr. Blum suggested that when a new behavior is to be learned, its difficulty should be managed so that the child can be successful and be reinforced on 7 or 8 occasions out of every 10 attempts. When the behavior has become well established, reinforcement can become intermittent, but frequent reinforcement is needed early on. If this reward system does not seem to be working, there may be one or more of several problems that need to be corrected. The behavior being demanded may be too difficult for the child at this point in development. The reward chosen may be wrong--  not of interest or value to the child. (Parental attention is often the most valuable reward.) Or, high levels of stress in the environment and the parent-child relationship may interfere with the child’s ability to comply.
Some problems with which parents may need help are inconsistency and the wish to try to change too many behaviors at the same time. Rules and commands need to be limited. Parents need to be counseled to ignore behaviors that are simply mildly to moderately annoying, and to select 2 or 3 positive behaviors that can be worked on consistently and attentively; once these are established, 2 or 3 more may be chosen. Dangerous behaviors should always be punished by methods like time-out.  In answer to an audience question, Dr. Blum suggested that parents who are unduly concerned with “defiance” and triggered emotionally by child opposition may need more basic work before they are able to use behavior management methods.

PA-AIMH breakfast 9/11/2015
The PA-IMH breakfast seminar on Sept. 11, 2015, featured Dr. Wanjiku Njoroge presenting on the topic “What are young children watching? Exploring the cultural determinants of early childhood viewing practices”. The presentation included Dr. Njoroge’s own research as well as a review of much other work on the subject of young children’s use of television and DVDs.

Dr. Njoroge began with a critical point: yes, television is educational; the question is, what does it teach? From this, she continued to the basic question of her research: how do cultural attitudes influence the television experiences that parents mediate for their young children? What are the beliefs and goals that lead parents of color to permit or encourage more use of television for their young children than is the case for non-Hispanic white parents? Given that television and other screen experiences are not going to go away, how can we shape children’s use of television in a beneficial way while working within the parameters established by parents’ beliefs and wishes?

The American Academy of Pediatrics in 1999 and again in 2011 advised against television viewing for children under the age of two, and minimal viewing for preschool children. But, Dr. Njoroge, asked, how did that advice work in the context of parents’ beliefs and goals for their children? There is no question that there are risks connected with extensive television use in early childhood; these risks include compromised executive functioning, increased aggression and disruptive behavior, and delayed language and reading skills. But are there also benefits that parents are seeking? Yes, there is evidence of early learning and the development of prosocial behaviors as modeled in appropriate television programming. When parents mediate by watching with children and interacting with them about what they see, developmentally-appropriate, educational, prosocially-oriented programs can lead to those benefits. It’s the type of program and the context that makes the difference, not just the amount of viewing time. Guidance to parents needs to stress these issues, not just to prohibit television use for young children.

Many Hispanic parents are reported to see television and other communication technology as beneficial for their preschool children’s reading skills. Lower-income families in general are more likely than high SES parents to turn to television as a way to enrich and supplement their children’s early learning, with a view to helping them prepare for school success.
Research done in Seattle suggests that in fact family income is a more significant factor in determining young children’s television use than race is. Children in the Seattle study  watched more educational television when their parents believed there were positive effects of watching. African-American and Asian-American parents were more likely than non-Hispanic whites to think that television can encourage prosocial behavior in preschool children.
Recommending that parents co-view television with their children, and intervening to help parents learn to interact with the children over material viewed, seem to be ways to help reduce the risks and increase the benefits associated with television-watching by young children. These approaches may be more effective than attempting to get all parents to minimize television use, when we know that the parents may believe that television benefits their children. In addition, parents may be helped to identify good television for children by groups such as the Fred Rogers Institute and commonsensemedia.org.