AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
PAULA ZEANAH: The stranger is leaving. Okay. You can just leave the lights off, because I'm going to show three more here in just a second. Okay. What do y'all think? How many do you think secure? How many of you think something other than secure? Okay. If you think not, why not?
UNKNOWN SPEAKER: After the child engaged with its mother, then it turned its head.
PAULA ZEANAH: Okay.
UNKNOWN SPEAKER: It didn't seem to be paying any attention to her, and then got up and walked away.
PAULA ZEANAH: Walked away. Okay. Okay. Those of you who thought the baby was secure, why would you think that would be okay?
UNKNOWN SPEAKER: Because the baby perceived being secure. It wasn't afraid (inaudible). It was not reinforced, secure attachment and then was (inaudible).
PAULA ZEANAH: And then was able to go on out. Okay. We would call this secure. And again, if you look ‑‑ and I understand what you're saying, but this baby was distressed a little bit without its mother. When the mother came back in, he gives a very, what we would call, a full approach. Directly towards the mom, reaches up, she picks him up, she comforts him. He does get settled down. Now he's not rambunctious in his activity and so forth, but he's able to calm down, sit with her for a few minutes and then get back down and go back to whatever he was doing. So that would be considered a version of secure. Okay.
And again, keep in mind, now, again, these are real, live people. They have given permission, I do want to say that, for us to show these videotapes. But imagine ‑‑ there's a lot you can see in just a few seconds of interaction.
Okay. Let's try another one. Same scenario, basically. You can't see the stranger. She's on the side. You'll see her walk out in a minute. This is the mother coming back in.
Okay. You have to take our word for it that these interactions are representative of the quality and relationship of these families and they are, but it's just one small snippet. But what do y'all think of this one?
UNKNOWN SPEAKER: Avoidance.
PAULA ZEANAH: Avoidance? Anybody disagree? Okay. You're two for two, good. That's a good example of avoidance. Just not much happening there. That child looks at the mom and then walks away. There's very little affect. The mother doesn't look particularly happy to see the baby. And the baby is just kind of like, okay, you're back. Big deal, you know, and moving on. So that's a good example of avoidance.
Sorry about the quality of this. The mother has just obviously just come back in. Okay.
UNKNOWN SPEAKER: Insecure. Resistant.
PAULA ZEANAH: Insecure. Resistant. Anything different?
UNKNOWN SPEAKER: Disorganized.
PAULA ZEANAH: Disorganized. Okay. Anybody else? Resistant is the answer. This is a child that we didn't see before the baby ‑‑ before the mother came back in the room. But obviously, the mother was not able to sooth that baby, and had to kind of continue to be upset and distressed.
I want you to just think for a second or two about what it must feel like to be that baby's mom, and think about her subject of experience of being with this baby. But also think about what it feels like to be this baby, and what it would feel like to have a mom who really doesn't ‑‑ at least she was making a few attempts, but affectively she wasn't very engaged with this baby. She really didn't seem to know how to comfort the baby. And imagine what it must feel like for that infant, if this is your main caregiver, to have this kind of thing going on in a regular way. So I want you to just kind of think about these kids.
These are the kids, again, who a lot of times you'll see their behavior escalate. They'll get more and more out of control, because parents sometimes don't know what to do with them or they just ignore them or they hope it will go away and their behavior will escalate, escalate into sometimes even dangerous behavior.
Okay. Want to try another one? Now, this is the stranger here, I believe. Now, the stranger is leaving. So this is the baby's behavior without the mother being present. This is mom coming in. You got your pants coming down on you. She said, stop doing that. I hate it when she does that. So this is not the first time this type of behavior has occurred between these two. This is a familiar pattern. What did y'all think about this one?
UNKNOWN SPEAKER: (Inaudible.)
PAULA ZEANAH: What's left is disorganized. You're right. You can see there's no approach. There's no nothing. I mean, at first it kind of looks funny. But she's throwing herself backward in a way that could actually be harmful to herself. No way to ‑‑ she looks at the mother every once in a while, but she doesn't really do anything to allow herself to be comforted by the caregiver. And the caregiver has just like had it with this mom, because this is what the baby always does. So again, if you put yourself in each of their places, imagine ‑‑ I mean, you can see behaviorally, this is not ‑‑ you know, it's not like our first one that we saw. But imagine too, what it feels like for both of them to be involved in that. In this particular case, this caregiver was the only caregiver that this baby had. There was nobody else around in this child's life. So this is her experience of when she's distressed what she has to do and how she's going to be responded to. You can turn the lights back on.
Okay. So I just want to take few more minutes. Any questions about any of those? I think they're interesting, because they, you know, again in a few seconds you can see ‑‑ you get a lot of information. But again, as a clinician, I would not tell you to use a minute of an observation to count as your assessment.
UNKNOWN SPEAKER: (Inaudible) pediatricians may not have that.
PAULA ZEANAH: And they may not have that. I wish we had time to talk about all of that. There has been a little bit of work looking at some of these behaviors in pediatric settings. But, obviously, you can see, you know, a lot. Especially you can see a lot over time.
So we want to talk about the implications of all of this. So the discreet behaviors are not necessarily stable. So that baby who's thrashing around and throwing her head back down, she's probably not going to be doing that when she's five or 12, but she may have some other kind of behavior where she pushes the mother away or she runs away or she does other kinds of things in the need of distress that are consistent with her experience of this caregiver when she needs help, right? Does that make sense?
These patterns of attachment are pretty stable. So if you look at them at age one and again at age two, at least in the middle class samples, you will see consistency, what they're rated at age one and age two. But if you look at poverty samples, their ratings are more likely to change because their circumstances change. So there is some variability in this. And certainly there's a lot of factors that can go into how the mother's able to respond. So if the mother's very, very depressed, for example, and she just doesn't have the energy to respond to baby and she gets treated, maybe those interactions are going to look different. We're going to talk about predicting classifications, as much as you can at age 10.
So if you look at secure babies at age one, and then you look at them again between ages three and five, you are going to see these children having better social skills. They know how to get along with people. They're more confident and they're happier kids to get along with. They are more empathic. And little kids, little babies can be pretty empathic early on. They can be tuned in to the distress of other children and responsive to other children. They do more pretend play, which says that they are cognitive, life is flourishing and their ability to imagine for themselves is flourishing.
They're better in terms of communication, saying what they need and getting what they need and letting people know what they need, and they feel better about themselves. You know, if you feel like people are going to respond to you in a positive way, you can feel pretty good about yourself. You know, and these kids do. And they can also show, without fear of reprisals, a wide range of emotions.
If you look on down the line at age 10, these are the kids who are more likely to have good friendships. There is some data that suggests that secure infants have lightly higher IQs? And it makes a certain amount of sense if they're able to be not worried about their caregiver, in whatever way they're worried about them and able to go out and explore and learn, then they're going to be able to learn better. They're more complex in problem solving. They're willing to take more risks. More curious. More creative and they're more confident that they can do well so they will set higher standards for themselves.
These are the times when I started getting nervous, because as a parent, I'm like, oh, my gosh, did I do the right thing for my child? So far so good. I think this stuff is important information for all of us to know.
For the insecure and avoiding babies. As I mentioned before, they're often overly friendly to strangers, but they are less responsive with caregivers. They tend to be more angry more aggressive and more noncompliant. They don't often seek assistance and they're less direct in what they want. So they've learned that the best way to get what you need is to not let people know what you want, right? You have to act like everything's okay. If you act like everything is okay, then you're more likely to get what you need, even if you're distressed. So they're not very direct in letting people know what they want. They have fewer peers. They're more disliked their peers. They tend to pretend like others that don't like them, doesn't bother them at all. They tend to, you know, say, well, if somebody says, well, so and so doesn't like you. Well, that's their problem. I don't care about that, that kind of attitude.
More frustration tolerance or less frustration tolerance. More negative affect. These kids are not liked by a lot of people. The teachers don't like them very much, because they can't read them. They can't tell what they need. So they tend not to reach out to these kids and to try to help them. The same thing with peers. So they get kind of pushed off into a corner.
Sometimes they bring this on ‑‑ again, like I said earlier, they're expecting other people to treat them the way they expect, the way they've been treated. So they draw that out in people. Let's see, did I skip somebody? I hope I didn't skip somebody.
Disorganized. I don't know if you know what role reversal is, but these are situations where the child takes on the emotional responsibility for the relationship. Now, we want our children to become responsible and people who contribute to our family and our communities, right? We want that. But we don't want kids taking on the emotional responsibility of relationships. And even sometimes take on the responsibilities of the household. So sometimes you will see three and four‑year‑olds saying, "Mommy, I think you need to eat some breakfast this morning because you didn't eat last night." Or, "Mommy, you need to go to the grocery store." And, "How are you feeling today, mom? Are you sad today?" Those kinds of things when they're very young. I mean, a little bit of that is okay, but when they're the ones who are responsible for looking out for the maternal, the parent's well‑being, making sure she's okay. That's what we call role reversal. These are kids who also tend to have significant behavioral problems, both of the internalizing kind and the externalizing kind.
I think I lost ‑‑ in all of our cutting and pasting, I think I lost the resistant kids. Those kids are also have more trouble socially than the secure kids do, but they are liked better than the avoiding kids, because they at least are out there. I mean, they may be distressed. So usually when a child is distressed, somebody is going to try to respond to them and take care of them. But they are not ‑‑ they're not a skilled social. They don't really know how to modulate their affect. And like I said, they may be the ones who escalate ‑‑ if they don't get what they want, they're going to keep escalating until somebody pays attention to them. Sometimes taking on fairly significant risk to themselves and so forth. Do y'all want to add anything on these? Questions about any of this?
UNKNOWN SPEAKER: I have a question.
PAULA ZEANAH: Yes.
UNKNOWN SPEAKER: Have there been any research or do you have any comments about how these children then translate into day care centers? Seems to me these are the kids (inaudible).
PAULA ZEANAH: Yes. Again, again, keep in mind; we're not even talking about psychopathology here.
UNKNOWN SPEAKER: No. We're just talking about behavior.
PAULA ZEANAH: Behavior, yes. Some of the studies that have been done on these kids have been done in school and day care settings. So, you know, if you're seeing children with these kinds of behaviors, be thinking relationship with caregiver, what's going on? That's one reason why we're really saying; you have to really think about what's going on, not just with the child but in terms of his relationship. And you will see, probably from working in a day care center, you may see in the child interact differently with the day care provider than they do with the parent. They may act very different, because the demands are different and expectations are different and so forth, and that will give you some clues about what's going on, but certainly that would be something I would think about. Yes?
UNKNOWN SPEAKER: Let me add one thing. Every now and then, you will see, we have had these kids come into our clinic, a kid, we do have a lot of very poor quality child care in the United States, unfortunately. Sometimes you can place a kid who looks okay with his parent in an absolutely abysmal child care center and the kid will get kicked out, but it was because of the center, in general, that that happened. Okay?
PAULA ZEANAH: Yeah. It's important keep all of the context in mind.
UNKNOWN SPEAKER: (Inaudible). (Inaudible).
PAULA ZEANAH: Right. I mean, one thing I do want to point out is that, you know, we are looking at relationships. And I just want to emphasize, emphasize, emphasize that, although we do hold the caregiver accountable more than we do the child, the child still brings something to the relationship.
And you will see, I mean, when you work with abused and neglected kids, there's families where one child gets abused and the rest of them are fine. Well, maybe not fine, but they're not getting abused. I mean, there are differences in relationships. Or a child who is in a neglecting or abusive relationship will have a disorganized relationship, as Brian was saying earlier, with one parent, but the other one is a secure relationship.
So we know that, you know, if you can load the dice and the child can have, you know, the more secure relationships, the better, but a secure relationship is protected for that child, even if there are other relationships that aren't or other circumstances that aren't so great for them. Yes?
UNKNOWN SPEAKER: Just a comment. As you stated, we're just looking at a slice of the child's life ‑‑
PAULA ZEANAH: Right.
UNKNOWN SPEAKER: ‑‑ in a day care situation. Lots of kids during the day, when parents come (inaudible).
PAULA ZEANAH: Yes.
UNKNOWN SPEAKER: And it's a very different response, at least for a period of time (inaudible).
PAULA ZEANAH: Absolutely. That's a good point. The point was that sometimes these kids come home at the end of the day and they're tired, they're exhausted, you know, and it may take them a little bit of time to reconnect. And obviously, in day care it's important to let parents know that and to prepare them that that may be their experience that they have. Thank you for saying that. Yes?
UNKNOWN SPEAKER: If it's (inaudible) from zero‑to‑three ‑‑
PAULA ZEANAH: Uh‑huh. Right. Right.
UNKNOWN SPEAKER: ‑‑ um, what can you do? In my situation, I got a three‑year‑old that's disorganized.
PAULA ZEANAH: Uh‑huh.
UNKNOWN SPEAKER: And she has been kicked out of two day care centers so far. And does the whole, it just escalates to head banging, biting the kids, kicking of the teachers, and I'm just wondering, you know ‑‑
PAULA ZEANAH: How do you deal with that? I think, and I'm sure my other two colleagues will be happy to kick in. I mean, like the Neurons to Neighborhood book says, looking at zero‑to‑three starts too late, because there's prenatal things that go on. Certainly the mother's experience, the parents' experience and their own care giving experience is going to impact their phase of the pregnancy and the baby. And ending at three is too soon. Because we know that we can have, you know, all of us, hopefully, you know, it's not that all of our experiences is laid down by age three, would be kind of hopeless, right? It would be kind of sad for some people.
So I think that, you know, I think recognizing it, first of all, is important. You know, recognizing that there's a pattern, there's a problem. Because I think that one of the things that we're able to do now, that we haven't done before, is say, you know, it's something that can ‑‑ it's not necessarily something that they're going to outgrow. It's something that we can perhaps work with and try to make better for them. And that over time through therapy and treatment and other kinds of intervention, that we can help this child, you know, learn to trust the parent more or help with that interaction better. So that they can ‑‑ they can learn that there are other ways to interact in a relationship. Does that make sense?
UNKNOWN SPEAKER: Yeah. And keep in mind too that because attachment relationships are relationship specific, you can ‑‑ you can see some improvement. Especially if you know the factors of the baby's history and what they may or may not have experienced and you factor in the best guess what the temperament might be.
Because, believe me, by three, a lot of things could have happened to change that child from who they were born to be. But it's like Paula says, you don't have to stop here. But it does require a great deal of, um, support and effort and informed parenting with those children.
PAULA ZEANAH: Right.
UNKNOWN SPEAKER: I would like to adjust two things along those lines. I think part of it is there's been a shift when thinking about zero‑to‑three's critical period. We're thinking it's sensitive period. And the reason for that is we see (inaudible) change is going on as well. Why it's a sensitive area is because it's happening in the brain, the brain is primed with the baby's synapses. The synapses are connections between all the neurons in the brain. So a lot of these behavioral patterns were being laid down early in the first three years of life.
What happens about age three is you begin to permeate that, so that these neurons that are connected together and get fired off in every relationship, those things that are connected together begin to wire together. And then the other ones that are other potential types of behaviors in relationships, those begin to (inaudible). So it makes it much harder (inaudible).
PAULA ZEANAH: That's a good point.
UNKNOWN SPEAKER: (Inaudible).
PAULA ZEANAH: Good. I hope that's helpful. What I want to do now is just add, just do a little bit of summary here and then we'll take a break, because I know we've been sitting here for an hour and a half here and then we'll move on into services.
Just in terms of thinking about, we're going to switch into from this kind of clinical, theoretical background kind of thing and think, what does this mean for services? And just to sort of briefly set the stage, that we believe there's a lot of implications for services, really, at every single level. Educating families and communities about their role in social and emotional development. This is something that, again, I think about my nursing history and how little we got when I was in nursing school about ‑‑ oh, I won't say how long ago it was, it was a while ago. A lot has changed. I wish I'd known what I know how when I had my children, who are now in their early '20s. So just general information about what to expect out of a baby and what parents can do. I look at parenting magazines every once in a while and think there's more work in those kinds of (inaudible) that we need to do more about.
Obviously, education. Providing support in early child care and educational settings. I mean, there's a lot of it. We will be talking some more about that. Some of you all are coming from those settings, so we want to hear from you as well.
So we also need, you know, really good assessment. We really need services. We need to have, how do we do prevention and how do we do intervention for these children whose relationship situations where there's already some serious situations going on and we need to get them in there and try to move them on to a different path.
Remembering it's the relationship that counts. And that whenever you think about treatment or whenever you think about assessment, um, you need to think about the relationship, not just the parent or not just the baby. And this, to me, is a paradigm shift. Because most of us, if we're in pediatric settings, we think, this is the baby or this is the mom. We tend to want to blame parents. This is not a blame a parent type of thing, because there's too many things that can impact how that parent is functioning. And certainly, again, as I say, the baby brings something into it too. So it's pretty complex. It's truly a paradigm shift. And if you attend to only the child or the parental needs, you might miss the boat in terms of your assessment and treatment. Yes?
UNKNOWN SPEAKER: Implications for service (inaudible), what you're showing there or just now immediately is like in the realm of education?
PAULA ZEANAH: Yes.
UNKNOWN SPEAKER: But back further, you were implying that the mother, under stress, finds it very hard to respond to the needs of the child.
PAULA ZEANAH: Right.
UNKNOWN SPEAKER: And I'm dealing with an issue in program development in which there's some controversy among the participants of the difference between parenting education and family support, primarily, case management.
PAULA ZEANAH: Right.
UNKNOWN SPEAKER: And it seems to be a great dilution focused on the need for support of the mother and the family as in the case of social casework.
PAULA ZEANAH: Right.
UNKNOWN SPEAKER: And so that that's just not so terribly important at times. And that by educating the parent in the development of the child, that that's ‑‑
PAULA ZEANAH: I think we are ‑‑ you know, I mean, the exciting thing is, is that this is kind of new. There's a lot of impetus. People are excited, interested in this. But we're all ‑‑ many of us of are still working in the ways that we've always worked. So I think it's sometimes hard to shift into something, and how do you tease out education from support from all these different things? And I think that when we start talking about various services, again, we're going to use Louisiana as an example. But I think that, in my opinion, we need a range of services. It can't be either/or. These families need a lot, and the system needs to be able to provide a lot, because just education alone, that may be important for the vast majority of people. I mean, there are many people if I just, you know, if I just knew, they can take that information and they can apply it to themselves and they know what to do and they can read a little article and they're fine. But for a lot of people, that is just not enough. And for those for whom there is psychopathology or severe relationship problem or whatever, you have to have treatment and case management or education isn't enough. And so we need to have a range of services that are out there that will be able to capture, you know, all of these things.
UNKNOWN SPEAKER: If it's not psychopathology, you can have (inaudible) ‑‑
PAULA ZEANAH: Right.
UNKNOWN SPEAKER: ‑‑ through economic effects ‑‑
PAULA ZEANAH: Right.
UNKNOWN SPEAKER: And in which case they would need a case worker.
PAULA ZEANAH: Right. And you might need both. And we'll be talking about a program that we have in Louisiana that tries to address family issues cross the ranges of things that can impact their parenting. Because it's not necessarily the relationship that can be the problem, you know, it could be these other things ‑‑ these other things are impacting that.
UNKNOWN SPEAKER: Let me just say that we're going to talk a lot about this after the break. But on our way out the door, let us just say that case work, as it is reimbursed and conceptualized right now, is not, in my professional opinion, social case work, number one. Okay? It's not part of the (inaudible), that may not be part of the knowledge base. And number two; you have some very wonderful parent education programs. However, parent education programs tend to vary wildly in their quality and they also are only now starting to incorporate the attachment information. Okay? Which is very important.
Now, here's one of our tricks in mental health where we get caught up. Sometimes, depending upon one's own caregiving experience, one will view certain parent‑child relationship behaviors as not problematic or more problematic simply because you don't have a good knowledge base. Things get to be very tricky. Is that clear? Do people understand what I'm saying about that?
So for us to just go and just toss out attachment stuff ‑‑ let me just end this by saying this, whenever I am teaching clinical information and (inaudible), everybody by the break or by the end of the two hours, is totally panicked that they totally screwed up their kids.
PAULA ZEANAH: Right. Right.
UNKNOWN SPEAKER: This is a complex and a thought‑provoking and (inaudible) workshop in one‑day thing, which will lead to all of our comments about workforce capacity and other system issues. But you bring up some very valuable points and we will address those further right after the break.
PAULA ZEANAH: Let's take about a five ‑‑ I'm going to say five minutes. It will probably actually be 10. There are a lot of issues, I wish we had the time to spend a lot more time on all this. Maybe another AMCHP, maybe we'll have more time to do this. I don't know.
But obviously, there are just a huge number of issues that are in store for us personally, as well as professionally, because it sounds like most of you have worked with families where you've seen issues that have come about. We're glad we're provoking your thoughts, but we know there's a lot more to learn. And it's usually with families where you've seen issues that have come about.
Switch gears for purposes of the rest of this presentation today and talk about services. I'm going to start with this little, I don't know, I guess chart or graph or whatever that we came up with in thinking about, partly this comes out of how we've been doing stuff in Louisiana. Part of it comes out of the ECCS, Early Childhood Comprehensive Systems Programs that are going on around the country and people trying to develop early childhood systems for their communities.
And this is our version of what we think needs to take place. Um, with universal and preventative services kind of being sort of a gateway into other types of services. Although, um, we feel like people can ‑‑ there's this whole issue of entry into services, and how do people get into one system and from one system to the next system and so forth?
But certainly, universal preventative services are those that are good for all of us. Obviously, things like health and developmental screening and assessment, typical well‑child care, all those kinds of things are important to insure that the child is physically developing and healthy and so forth. Case management, we mentioned to have that widely available. Parenting education. Health promotion. Referrals to other kinds of services all of those would fall under universal or preventative services.
I guess if you thought about it in a step‑wise, well, you think a child would come into a universal situation, either in a child care center, a health center or whatever. And then they would get referred to focused services or to tertiary services. But sometimes they come in through the tertiary services door, or sometimes they come in through the focus services door and then need to go to other places so the systems need to be open. I know I'm talking to people that believe all this, so I'm not going to belabor all that.
But certainly it requires a lot of work at the local level, because that's where things happen is right there within a community. But a lot of times those things can't happen unless there's support at the higher levels, at the State level or regional levels or whatever. So there's a huge amount and we could go on. We could spend a whole afternoon talking about the issues related to collaboration and coordination and all that sort of stuff.
But certainly, all those kinds of things need to take place, both at the State level and at the local level. And each of those else levels need to address these various types of services and so forth. And we believe, and what we've done a lot of in Louisiana, is sort of begun to load up a little bit on the issue of consultation to various programs, and I'm going to talk more about that in a minute. Any questions about this little scheme? Yes?
UNKNOWN SPEAKER: How do you define at‑risk children (inaudible)?
PAULA ZEANAH: Oh, good question. Well, that can be defined in a million differently ways. Um, so I'm going to give you a couple of examples, but it could be teenage moms. It could be poor moms. It could be depressed moms. It could be low‑income families. It could be substance‑abusing people. It could be ‑‑ you choose the risk and apply a service to it. That's what I would call in this focus.
So you're looking at a group for whom you believe or that it is evident that the people in that group are more likely to have poor outcomes. And you develop some kind of service that will hopefully, you know, prevent the poor outcomes from happening or make them less ‑‑ less difficult.
UNKNOWN SPEAKER: Where that comes in relationship to attachment?
PAULA ZEANAH: It could be in a relationship ‑‑ here we're specifically talking about attachment, social, emotional development, behavioral development. Those kinds of things. You might choose to look, and I'm glad you're asking this question, because it's important to recognize that, when you have a service, you need to think about what are you trying to make a difference of? You got this group of at‑risk people, what do you want to do? What would a good outcome be? What are you trying to do? And then obviously, tailor your services. And in the outcome evaluations, you have to assess in fact what did to make a difference on your outcomes. As Jean was saying, there's a million programs out there that are addressing a lot of focused services that are out there that may or may not have any evidence for them or that may not match up to what the actual, you know, the actual service itself isn't related to what the outcome is hoped to be and so forth.
So it gets complicated very quickly. We weren't really planning on spending a whole lot of time talking about those issues, but they are really important issues on how you set up the services so they make a difference for these families.
UNKNOWN SPEAKER: Now, let me just say, theoretically, here's a rule of thumb. If you can intervene to prevent or you can help with strengthening the attachment relationship early on, it almost always translates into global better child outcomes, i.e., better success in school.
You will remember that most of the kids in kindergarten and in first outcomes, i.e., better success are higher than their peers who are moving on in their behavioral issues that are holding them back.
With that affiliative stuff that Paula was talking about earlier, that's where we come up with all kinds of problems related to this, but these child outcomes, if we're not just talking strictly about things like immunizations or physical health things, which really, the United States has done a pretty good job, I think, in the big picture. When we're talking about child outcomes, we almost always come down to academic in through and inability to formulate relationships and work and pay taxes, amen.
PAULA ZEANAH: Freud said, ability to love and work was good mental health, in a little nutshell. So focus would be identifying a population that's considered to be at risk for whatever the poor outcome is you want to look at and doing something to prevent or to improve those outcomes.
Tertiary services are when a problem is identified and you got to provide some kind of intervention. So, in our scenario here, you might have a child for who has been, um, who has been exposed to some kind of trauma and is experiencing posttraumatic stress disorder, which we don't have time to talk about, but you can see this in very, very young children. So you're treating the disorder. There are already disorders there.
Now, in some cases tertiary and focus overlap with each other, and we're going to mention a program that kind of all of us got our starts in, in a way, that was aimed at assessing and treating, if necessary, children who had validated abuse and neglect under the age of four. They weren't necessarily in because they had some disorder or psychopathology, but they were in court‑ordered evaluations for the team to say, what are you going to do? What's going on? What needs to happen?
And in that situation, there was treatment ‑‑ there is treatment of psychopathology, treatment of disorder relationships and so forth. But what they found is that it also prevents abuse and so forth from happening down the road. So it functions, you know, sometimes tertiary can also function in a preventive way.
And meanwhile, those children who have abuse and neglect also have general health care needs. They need primary care. They may need other kinds of support services and education, all those kind of universal things that we want everybody to get and so forth. So that's sort of ‑‑ this is sort of our framework for how we think about service development and so forth.
And again, you know, there's an overlap in systems. We talk about (inaudible). I actually love the concept of (inaudible). It is so true. Because I see, you know, in our state, our health system, our mental health system, our social service system all developing very parallel services sometimes. You know, talking about, you know, (inaudible). And yet, we aren't necessarily talking with each other. We're all seeing the same kids, just different slices of their life and all running into very similar problems.
So we have a lot of overlapping needs with these kids and these kids are not, obviously, partitioned into health beings or social beings or educational beings or whatever. So we need to keep that in mind, that these kids need comprehensive approaches and their families as well.
I'm going to briefly talk about some universal, very briefly talk about this, and then we're going to move into some of our more focused approaches. But universal and preventive services really are aimed, in general, improving child development; in general, parenting knowledge; as a result, infant mental health. And it's services that are applied sort of widely.
Like Jean was talking about, we give immunizations to everybody or almost everybody, because it's good for you. You know, it keeps us from getting these bad diseases. So everybody gets immunizations. And so we're trying to prevent these illnesses. And similarly, we're talking about things that are good for everybody. The approaches are generally health promotion, screening, assessment, education, guidance and referral is sort of the first line of approach, if you will.
Here are some examples, and we're not will beginning to be exhausted by any means. I just wanted to hit a few high points. The first thing is that the ECCS, Early Childhood Comprehensive System, is one of the pieces that they're really focusing on is establishing medical homes for children. One of the reasons for that, aside from being able to keep better track of children and make sure that they're getting, you know, they're getting continuity of care and all that, is the importance of that relationship of that parent or that family with the health care provider. If you go into someone different every single time, that person isn't going to know you, you're not going to feel as comfortable in letting them know what's going on and so on and so forth. So we're back to that whole relationship thing.
I think Bright Futures ‑‑ how many of ya'll have used Bright Futures or are familiar with Bright Futures? Some of you are. It's ‑‑ I'm not going to spend a lot of time talking about this, but it's an approach actually developed out of Maternal Child Health Bureau a few years ago for well‑child care. There's a lot of problems because people think it takes too long and all that, but I happen to love it because it's very, very social, emotional relationship focused, family focused and so forth. And it spends a lot of time talking about how to think that way in the course of a well‑child visit, and so I think its very useful framework to be thinking about.
And in our State, we've used it ‑‑ a few years ago we did training around the entire state in our health departments to try to use that as a part of their well‑child visits. Well, shortly after that, we quit doing well‑child visits in our health departments so we kind of quit doing it. But I still use it for educational purposes and for reference purposes, and for a program that I'm going to talk about in a minute, because I think it's very useful in terms of how to think about child health.
Some places use developmental specialists in primary settings. It could be in a health setting, like Healthy Steps or the Touch Points that Barry Bradlington does, the child care infant specialist. There are a lot of ways that people are getting social, emotional concepts and development and so forth into settings where the children are, and those are usually health settings and child care settings. So that's where a lot of this kind of stuff is going.
In terms of screening and assessment, usually you're talking about some kind of screening. Usually it has to be something quick. We're not talking about a long evaluation process in primary care health or child care settings.
The things that are getting the most attention these days, I call them the big three, in terms of what puts families at risk, are maternal depression, partner violence, and substance abuse. Those are the three things that repeatedly come up as major impediments to good, healthy parenting and so forth.
And then there can be a myriad of other things that go into family stress which can also affect them. I'm going to show y'all a brief example of what we're doing in Louisiana about this.
In terms of screening for assessing social and emotional development, my personal opinion, there's not a lot of good measures out there because they focus only on the child. They don't focus on the relationship. There's not a lot of quick and dirty checklists where you look at relationships. I do think the age and stage of social and emotional versions are pretty good, if used like every six months. It does get at some relationship issues. It is a parent report, so you do have that bias. It doesn't relate, you know, necessarily rely on observations and so forth. But anyway, at least it's a start, and a lot of people are using Ages and Stages and especially social and emotional.
There's a myriad of other kinds of behavioral screens and assessments. And again, most of them are oriented towards the parent, the prenatal depression, postpartum depression, or substance abuse or partner violence or whatever. Very few are really relationship focused, but you can still use those for other things.
And then again, observations are just key. So these little, brief observations, how do we learn to look at what we're seeing right in front of our face? I've heard so many people say, "I knew something was wrong, but I just didn't know what it was." We've probably all felt like that. So learning how to use observations are really, really important, because we all have a rich, rich opportunity right in front of us.
I actually think Bright Futures in their mental health tool kit; they have a nice little one page or two-page thing about observing the parent‑infant relationship in like the first year. I think it's really great. It's not even a checklist. You don't have to add anything. You can just kind of look at it, what would you be looking at with a two‑month‑old or a six‑month‑old or a nine‑month‑old? It's really, really very good.
We have developed our own version of a risk assessment. This is just part of what we're doing. This has been in the works for a really long time, and we're finally beginning to use it. We don't have copies to give out. It's not validated yet, but we are starting to use it. We hope that we will eventually get, you know some good, validated information about it.
One‑page checklist knowing that there are all these issues out there, knowing that there's things like depression and partner violence and substance abuse are going to impact health outcomes, as well as behavioral, emotional and mental illnesses outcomes, we wanted to do something. Because these families were coming into the health clinics and they're all there. I mean, when I first started working at the health department, 60 percent of the babies in Louisiana went to the health units to get immunizations or well‑child ‑‑ I mean, what a gold mine. They're all right there, you know, just needing to be recognized and whatever they're going to do with them.
So we have a one‑page, self‑report checklist that includes some key information about medical home and other key health risk of child and mother. We have a prenatal version, and then we have an infant version. We look at the kinds of things that are always, you know, always in the pot of things that are predictors like maternal age, level of education. We know that, for example, that low‑education moms, their babies have poor outcomes, in terms of social and emotional outcomes and so forth. Housing, residents, all that kind of stuff that goes into stresses.
Then we also have items that look at maternal depression, substance abuse and domestic violence. We also have a few items that look at the baby's behaviors and what the mother thinks about that baby. And what does she think about that baby's personality and how difficult this baby is? Because again, how does a mother perceive that baby's behavior is really important as to how and what her experience is like. So we do ask that. This information is reviewed by a social worker or nurse and then they're referred to a number of our programs that we have. We have established a way we can begin to track some of these ‑‑ these programs ‑‑ these moms. And so we can sort of see how they're doing and so forth.
I have to say that referral is a challenge. A lot of times, um, even if you have the services, I'm not even going to talk about the fact that you don't have the services for these problems, but if you have these services available and they're wonderful, a lot of people don't want to go. So my own feeling about them (inaudible) and somebody brought this up at the break, do you ask about stuff if you're not going to be able to treat it? Do you ask about this if you can't provide services?
My personal feeling is, you got to start somewhere. You know, you got to have a reason to argue that you need the services. Asking these questions, even if the parent says, "No, I don't want to go. I don't need problems now." Puts the little seed in their head that maybe I could get help for this. And maybe two months from now or six months from now or a year from now, they will say, "You know what, I think I need to get help for this."
So I think part of what we're doing by these assessments and these screenings is education, actually. Not only educating our clients, but educating the powers that be that have the purse strings that provide the services and so forth. Plus, hopefully it will help guide us into what we will really be spending our money on anyway. Everything.
Okay. Other universal strategies, child care. Brian, you might want to mention this, what this Baby Space is.
MR. STAFFORD: Yeah. That's a now program in Minnesota (inaudible) Minnesota. It's terry Rhodes' program for child care. It's called Baby Space. It's unique day care centers that really infuse mental health and blend mental health services into the day care.
PAULA ZEANAH: So more savvy ‑‑ infant mental health savvy day care services themselves in our state and probably in other states. We're often behind. We're trying to develop a quality rating scale for day care.
Up until now, we've only had ratings that sort of identify if they serve food or not. And very, very basic, you know, kind of health standards types of things. Nothing about the quality of the actual child care itself. So there's a real effort trying to be made in how to address that. Yes?
UNKNOWN SPEAKER: In talking to early childhood professionals, this is really well‑known thing called (inaudible)?
UNKNOWN SPEAKER: Yes. That is part of our system.
UNKNOWN SPEAKER: (Inaudible) may not ‑‑ it may not be able (inaudible) that you're talking about, because it is geared toward education.
PAULA ZEANAH: Right.
UNKNOWN SPEAKER: It is geared toward an environmental screen of the day care side.
PAULA ZEANAH: Jean, do you want to mention that? Because Jean has been involved in this part more than me.
MS. VALLIERE: Yes. We, in effect, the next quality control rating, as you know Louisiana is a poor state. We're even poorer now. We have low levels of education. We have very poor child care provider reimbursement. And then there is an excellent child care to requirement to raise goal standards. The bottom line is that the people out of North Carolina who developed that are very bright. If you're good on that scale, your programming is almost guaranteed to be pretty good.
And it's true that it is not a mental health focused thing, per say, but it does do an excellent job with the environment. It takes into consideration the responsiveness of the teacher to the infant. The ratio, ratio, ratio. That's all I'll say. So, yeah, that's correct.
PAULA ZEANAH: I mean, I'm sure other states are ahead of us, as far as this goes. I know some states, in fact, the whole early childhood system is coming out of work being done in child care.
In our state, we happen to have a lot of expertise in infant mental health. We'll talk a little bit about that more in a minute. So we a lot of impetuses come out of that group. But I know in other states, there's been a lot more attention given, you know, in the child care setting, which is good. We're trying to work on that here, but certainly that would be considered a universal strategy to get child care settings up and running and where they ought to be.
Education and guidance. These are just a few programs. Like I said earlier, there's a million of them. I don't know if ya'll are familiar with Keys to Care Giving. It's one that I love. It came out of the University of Washington, School of Nursing. It is aimed at parents of newborns on how to read their baby's cues and their behaviors.
Now, I love this because, you know, nurses are really good at teaching parents how to change their diapers, make the formula, fix the cord, all that stuff. But that whole other part of taking care of that baby, about crying and what does this behavior mean and all that, that whole other half is essentially, usually not addressed. And that's what Keys to Care Giving is all about. We use it in our programs. We teach the nurses to it. Everybody, everybody loves this program. There's a lot of great videos for it. If you want more information on it, I'm happy to pass it along. It doesn't apply just to brand newborns. It applies really to, it has implications beyond new infancy.
Bright Futures has lots and lots of good education materials, not just for the providers, but to give to parents and to use all kinds of great anticipatory guidance materials, and we use those sometimes as well.
The nurturing program is a program that's out there. It's like a parenting education program a lot of people are using. Some people, but with we have a few people using it in our State that seem to like it. I don't know if y'all have had experience with this. It's just another one of those examples out there that people are using it in our State.
Okay. Moving on quickly to focus services. Again, specifically identified groups. A variety of examples of what people can do, home visiting services, preventive interventions for abused or neglected children. Postpartum depression services.
I'm going to start this with the program that I'm responsible for in Louisiana, and then Jean is going to take over and talk more about what we're doing. These are some of the things that we're doing here. Nurse‑Family Partnership. That's our risk assessment that I mentioned. The ECCS. We have a national toddler child care program that we're going to talk about. We do have a fair amount of programs, a couple programs in our State that do a lot of training for the professionals in the State.
The Nurse‑Family Partnership. How many of ya'll have heard about the Nurse‑Family Partnership? A few of you have. Well, I'm very proud to talk about this, because I'm the director for the program, but I've been involved in it in Louisiana since it started back in about '99. It comes out of the University of Colorado. Dr. David Olds is the person who developed this program many, many years ago.
There's going to be other presentations on this. I'm not going to belabor it, but I just want to talk a little bit about it. It's a program that targets first‑time mothers, meaning, having had babies who have not lived. Okay? They cannot have a child who has lived. They can have previous pregnancies. And their low socioeconomic status. In our State, I say below 133 percent of poverty. That's where we started. We now are Medicaid eligible is how we're capturing that, because we get Medicaid reimbursement in our State for this.
The program goals are improved outcomes of pregnancy, improved child health and development and the mother's own personal life course development. There's three, short, little statements that are huge in terms of what is done in this program.
It starts during pregnancy, prior to the beginning of the third trimester. Prior to the 20th week of pregnancy. The reason being that there needs to be enough time for the nurse to get in there and talk to the mother about the pregnancy, to make some difference in her health behaviors during pregnancy, to prepare her for labor and delivery and so forth. So a lot of times people say, "She's 30 weeks," and we say, "Too bad." We have to be strong about that.
But, you know, we really want them to get in early. The earlier we can get them in, the better. They are seen every week or every other week, depending on when they come into the program, before the child is born. Then once the child is born, they go, they're seen once a week for the first six weeks and every other week until the baby is 21 months of age, and then once a month until the baby turns two.
So this takes place in the home. It is almost two 1/2 years for those who stay in all the way. It's a pretty intensive program, in terms of the amount of time and energy that's invested.
The very first thing that the nurse has to do with these moms is to establish a relationship with them. Because if she doesn't, first of all, they're not going to stay in the program, which we want them to stay in the program. But if the families don't believe that this nurse has something to offer them, then they're not going to do what she suggests. They're not going to be a working partner with her.
So a lot of time is spent with ‑‑ I have to say I've been real touched at times with the challenges of this, because we have a lot of people out there who don't know how to have a relationship. I will just give you a very, very brief example of one of our cases. This was a teenage mom who was new to the program. The nurse was trying to engage her into the program and felt like she wasn't really getting anywhere. So she sent her a birthday card. I mean, a birthday card we think of ‑‑ we just kind of take for granted. Just a way to reach out and let her know. The girl never said anything, never responded. The nurse felt like she was getting nowhere with her.
Well, she found out a few months later that this girl, 16, had never received a birthday card in her life. Never. And she carried this birthday card around with her all the time and showed it to people. "This is from my nurse." And she told her friend or her cousin or whoever it was, that she would pull that card out when she got upset, because it made her feel good to know that this nurse was there with her.
Now, I wish I could tell you that that was a unique story, but it's not. So we say form a relationship like it's an easy thing to do. But if you've never had someone say happy birthday to you, you know, or acknowledge that, how are you going to do that for your baby? You know, how are you going to do that?
So I say that, and my own personal bias about this, and we have Pat Years here, who is from the national program. But, you know, to me, the relationship the nurse forms with these mothers is the critical ingredient, even though there's a lot of good things that the nurses are doing. And there's a lot of critical (inaudible). Like how long they work with these families, for one thing. It's a long program. And the kind of information that they give and so forth. But that relationship, I believe, is what is oftentimes pivotal for these families.
They follow ‑‑ they do have outlines or guidelines that they use to address these various domains of functioning, but it is individualized so that the mothers are able to decide for themselves. It's really meant to be what do you want? What are your dreams for yourself and for your baby?
And again, unfortunately, a lot of our moms have never had anybody say them to, "What are your dreams?" We had one girl, I'm sure more than one girl, who got pregnant about 14 in this rural place up in northern Louisiana, dropped out of school. So one of the things the nurse was trying to do is get them go back to school. Turns out nobody in her community finished high school, because there were no jobs for anybody to do that required a high school education. I mean, you know, you can't do this in a vacuum. But maybe going back to school wasn't going to be the top priority for her. So the nurse is going to work with her and try and figure out what else ‑‑ what are her dreams for herself, and have them even think about having dreams.
The program has been immensely successful. And it is in many, many states around the country. This is work by David Olds and he did randomized control trials of this program in Altmar, New York, and in Memphis, Tennessee, and in Denver.
And he continues to publish the impact of this program, not only initially but in the long run, many years out. And I'm not going to read through all this, but these were the findings he found initially after the first two years in the program. Significant decreases in very important child health measures, including big increases in how the mother was functioning in her society. And as a result of all of these improvements in injuries and accidents and things that cost money, it's actually a very, very cost‑effective program.
Fifteen years later, which is almost unheard of, I don't really know of too many studies or too many programs that have 15‑year outcomes, and he's getting ready to have longer term outcomes. This is what the children look like fifteen years out, those who were in the program, um, compared to those who were randomly assigned to approaches, had 48 percent less abuse and neglect, less ‑‑ fewer arrests, fewer adjudications. That's people in need of services. That's where kids who are delinquent get sent as a preventive measure. There was a trend in these kids to have fewer convictions, fewer lifetime sex partners and so forth. So this is 15 years out, these kids are looking ‑‑ these kids are looking better.
In the mothers too, they followed up and found that across ‑‑ now these are not, you know, always mothers who are doing well. Many fewer arrests, many fewer convictions and many fewer days in jail. So they're functioning is better.
Now, does it help everybody all the time? Not necessarily. But it's obviously having significant effects, short‑ and long‑term effects. I have to just ‑‑ here's a cost savings. This was done by the ‑‑ who did this? I'm blanking on who did it. I'll think about that in a minute.
UNKNOWN SPEAKER: Rayon Corporation.
PAULA ZEANAH: Rayon Corporation. Thank you. This has been repeated recently by the University of Washington, in Washington State. Who also looked at cost‑effectiveness of various intervention programs for children and found very similar results to this. That the cost savings was significant and much greater than most other programs. It's not a cheap program. In our State, it runs about 33, $3,400 a year per family to run, but if you're saving, you know, $12,000 or $18,000 down the road, then it makes sense to save that money up front.I just want to, before I close my piece, I have to brag a little bit. Because one of our nurses was featured in, um, the New Yorker a few weeks ago in a story called The Swamp Nurse, by a woman named Kate (inaudible) that some of you may have seen it. It's a long article. And so a lot of people said, why don't you read the whole thing? Because it is a long article. It really kind of captures the complex kinds of things that these nurses get involved in when they go into the homes. And this nurse is going to be featured on ABC Nightline, I think Monday night. That's what we're hoping. And so you'll get ‑‑