Early Intervention with Multi-Risk Families: An Integrative Approach

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9781557666918: Early Intervention with Multi-Risk Families: An Integrative Approach

Helping families who live in environments with multiple risk factors—including poverty, domestic violence, teen parenthood, mental illness, and substance abuse—requires that professionals and paraprofessionals work together to provide the best possible interventions. This much-needed book shows service providers how to help these multi-risk families by using an integrative model that brings together the most effective intervention techniques from a variety of theoretical approaches, parenting strategies, and innovative programs. Professionals will learn how to effectively engage parents if they are resistant to intervention, and they'll discover specific, practical ways to help parents

  • become more self reflective about their parenting and empathetic toward their children
  • examine and gain control over their defenses and ways of dealing with stress that are negatively influencing their parenting
  • strengthen their sense of competence and social support
  • develop positive perceptions of their children
  • deal with unresolved loss and trauma
  • enhance their interactions with their children
  • regulate their own emotions and those of their children
  • develop good planning and problem-solving skills

Extended case studies vividly illustrate key points and techniques and present an integrated model of intervention, making this an ideal professional development resource for psychologists, social workers, early childhood educators, home visitors, and other service providers. To help program administrators ensure high-quality early intervention, the book also demonstrates how to plan and set up service delivery systems within and across individual programs, structure and train effective teams, develop sound organizational policies, and understand and address the effects of burnout and vicarious trauma on staff members. The book is also an excellent resource for university and colleges that train early intervention practitioners who work with families in multi-risk environments.

"synopsis" may belong to another edition of this title.

About the Author:


Dr. Landy is a developmental and specialist clinical psychologist at Family Pathways, Princess Margaret Hospital for Children, Perth, Western Australia. She is also an assistant professor in the department of psychiatry at the University of Toronto and an adjunct professor at York University in Toronto.

Dr. Landy has worked for more than 20 years in the field of early intervention. Among her many published works, she has written several articles and contributed to books on various topics related to the assessment and treatment of infants, young children, and their families, including "Parenting Infants from Birth to Two Years," in Parenting in America (ARC Clio, 2000) with Rosanne Menna; "Assessment and Evaluation in Community Settings," in the World Handbook of Infant Mental Health (John Wiley ©2000); and "Difficult Behaviours: When Your Child Seems Out of Control," from The New Baby and Child Care Encyclopedia (Family Communications, Inc., 1995).

Dr. Landy has been involved in a variety of aspects of early intervention, including program development, program management as director and clinical director, research, consultation, teaching and training, and clinical practice. The programs she has initiated and developed include a tracking system for infants and young children in which mothers and children were assessed for any risks during the children's first 5 years and provided with interventions when necessary. She has also been instrumental in creating developmental services and community-based services for families at psychosocial risk.

Dr. Landy's current interests and activities include assessment and treatment of young children with severe developmental, behavioral, and emotional and social problems of various kinds; intervention with high-risk families with young children; program development; and training. Dr. Landy has long been an advocate for programs that can reach and be relevant for the most at-risk families.



Rosanne Menna, Ph.D., is Associate Professor in the Department of Psychology at the University of Windsor in Ontario, Canada. She is a clinical psychologist and is active in the supervision and training of clinicians. She became involved in the area of early intervention and treatment of high-risk families while she was a postdoctoral fellow in developmental psychopathology at the Hincks-Dellcrest Institute.

She has published articles and contributed to books on topics concerned with child development, parenting, developmental psychopathology, and the assessment and treatment of children and their families. Her research focuses on the development of competence and coping in children and adolescents and the risk for developmental psychopathology. In her private practice she works with children, adolescents, and families; supervises clinicians; and offers consultation to mental health agencies and child care centers.


Excerpt. Reprinted by permission. All rights reserved.:

Excerpted from Chapter 7 Enhancing Parents' Self-Reflectivity and Empathy for the Child in Early Intervention with Multi-Risk Families: An Integrative Approach
By Sarah Landy, Ph.D., & Rosanne Menna, Ph.D.
Copyright © 2006 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.


Self-reflectivity has been defined as "thinking about thinking" (Main, 1991) or about one's own and other people's minds and motivations for behavior. Several other terms have been used to describe this capacity, including psychological mindedness, mentalization, insight, introspection, self-awareness, metacognition, and the capacity for self-observation (McCallum & Piper, 1997). Self-reflectivity contributes to a number of areas of functioning, including staying in therapy and having a successful outcome from it, sustaining relationships, and containing intense emotions in one's self and helping one's children to contain them. Self-reflectivity has also been linked to the ability to provide sensitive parenting, which in turn contributes to the development of a secure attachment in a child and influences a number of developmental capacities. Slade described self-reflectivity in parents as "the capacity to keep the baby in mind" (2002, p. 10). It allows a parent to interpret the intentions and feelings that underlie her child's behavior and to act appropriately in response.

Meins and colleagues considered the importance of what they described as maternal mind-mindedness (MM), or the ability to treat "one's infant as an individual with a mind" and its contribution to the child's security of attachment and later theory of mind (2003, p. 1199). Some behaviors considered to be associated with MM include responsiveness to changes in the infant's gaze and to the infant's play objects, imitation, and mind-related comments (e.g., "You're really interested in that block. I guess you'd like to hold it"). The practice of suggesting how the child is feeling is also associated with MM (e.g., "I'll bet you're feeling bored and lonely and would like to be held"). The method for assessment of MM is described briefly in Chapter 2.

Self-reflectivity allows parents to ascribe more realistic and positive attributions and less negative and blaming intentions to their children and, consequently, to respond in a more nurturing and sensitive way. For example, a mother with very low self-reflectivity may respond to a crying baby by becoming angry and blaming the baby for being bad because she perceives the baby as intentionally difficult. As a result, she may fail to respond sensitively to the baby and instead, may put the baby to bed, where he continues his crying. Conversely, a parent with high self-reflectivity is likely to respond to the crying baby by trying to understand what he may be feeling or thinking about. The parent may decide that, because the baby has just been fed and changed, he is probably feeling lonely or overwhelmed. The self-reflective parent would be likely to pick the baby up and quietly talk to him and calm him down so that he can fall asleep. This kind of experience will allow the baby to feel secure and to begin to believe that he can make things happen and that his caregiver can be counted on to respond to him. These very different responses, repeated multiple times, can have a significant influence on how the baby thinks and feels about himself and other people in his world and can encourage a sense of self-agency or self-efficacy and self-acceptance.


SELF-REFLECTIVITY IN EARLY INTERVENTION

Mary Main (1991) was one of the first attachment theorists to emphasize the importance of self-reflectivity. She called it metacognitive monitoring, or as mentioned earlier, the ability to "think about one's thinking." A parent may be practicing self-reflectivity when she is thinking about her own parenting and why she acts the way she does; she may also be remembering how her mother and father parented her and how her own parenting style may be related to theirs.


Self-Reflectivity and Attachment

Main and Goldwyn (1994) developed the Adult Attachment Interview (AAI) to help assess various types of attachment. On the AAI, providing two or more examples of metacognitive thinking is seen as strongly related to autonomous (or secure) attachment. These researchers also designated a coherence of the interview scale on the AAI, not only as a measure of the person's coherence of mind, but also as indicative of the degree of self-reflectivity. A person would be demonstrating coherence of mind, for example, when she is able to use an adjective to describe her relationship with a parent and come up with an example that would fit the descriptor (e.g., "Distant. . . . My father never touched or hugged me or talked to me about how I felt").

The concept of reflectivity was expanded by several researchers to include not only the intersubjective (i.e., thinking about oneself in relation to others) but also interpersonal relating (i.e., thinking about one's behavior and how it affects others) (Fonagy, Gergely, Jurist, & Target, 2002; Fonagy, Leigh, et al., 1995; Fonagy, Steele, Steele, Higgitt, & Target, 1994; Fonagy, Steele, Steele, Moran, & Higgitt, 1991; Fonagy & Target, 1997, 1998; Grienenberger, Kelly, & Slade, 2001; Slade, 2002; Slade, Belsky, Aber, & Phelps, 1999; Slade & Cohen, 1996; Slade, Grienenberger, Bernbach, Levy, & Locker, 2001). Reflectivity or mentalization defined in this way refers to an adult's capacity to understand his own or another's behavior in terms of the underlying emotions and mental states that contribute to it. Thus, high reflectivity refers to the ability to understand behavior and personality in terms of the changing, and sometimes confusing, aspects of emotional experience in oneself and in others. These researchers believe that this knowledge is central for understanding and containing otherwise overwhelming emotions. When emotions are understood, even when they are complex and confusing, they are no longer experienced as frightening or overwhelming, and this ability to mentalize emotions is as important in managing them as it is in expressing them (Fonagy, Gergely, et al., 2002). The capacity for understanding the thoughts and feelings of oneself and others also enables the differentiation of self from other people.

A number of studies have been carried out to verify the importance of the parents' level of self-reflectivity on attachment security and other aspects of development. These studies have used a scale developed by Fonagy (1994). This Self-Reflective Scale assesses the capacity for self-reflectivity on a 7-point scale (see Chapter 2 for a description). As well, in order to evaluate parents' representations of their children and themselves as parents, Aber, Slade, Berger, Bresgi, and Kaplan (1985) developed the Parent Development Interview (PDI) (see Chapter 2 for a description), a 45-item, semi-structured clinical interview that asks parents about their relationship with their children. Fonagy's scale was then adapted for use with the PDI in order to evaluate parents' capacity for self-reflectivity. Many studies have demonstrated that a significant concordance varying from 75% to 80% exists between parents' quality of attachment to their own parents and their children's attachment classifications in relation to them (Benoit & Parker, 1994; Benoit, Parker, & Zeanah, 1997; Fonagy, Steele, & Steele, 1991; Zeanah, Benoit, Hirshberg, Barton, & Regan, 1994). These relationships have also been found across three generations, from grandmother to mother and from mother to child. The major characteristics that were thought to explain this similarity between the attachment classifications were behavioral indices such as the sensitivity and responsiveness of the parent to the child's cues. However, a number of studies have focused on self-reflectivity and related it to the quality of attachment between parents and their children as an important mechanism whereby this intergenerational transmission occurs. In a meta-analysis of studies conducted to evaluate the contribution of various factors to attachment security, De Wolff and van IJzendoorn (1995) found a combined effect size of .24 for a parent's sensitivity to her infant in interactions and concluded that other dimensions of parenting are equally important. In a more recent study using the PDI and Fonagy's Self-Reflective Scale to assess parental self-reflectivity, Slade, Grienenberger, and colleagues (2001) found an effect size of .41 between child attachment security and parents' reflective function.

Fonagy and colleagues also found that mothers who exhibited autonomous or secure attachment had significantly higher reflective functioning scores than those who presented with an insecure attachment or unresolved loss and trauma. These researchers concluded, therefore, that the ability to attribute mental states to self and others may be a critical vehicle in the intergenerational transmission of attachment quality.

In other studies, Fonagy and colleagues have demonstrated that lack of reflectivity was a core deficit underlying a great deal of the symptomatology of borderline pathology (Fonagy, Gergely, et al., 2002; Fonagy, Leigh, et al., 1995). The characteristic of having little capacity for self-reflectivity or mentalization is related particularly to an individual's inability to contain his affect and the extraordinary rage reactions that characterize borderline personality disorder (BPD). Lack of self-reflectivity also affects the types of relationships some people have that are characterized by a lack of empathy for the thoughts and feelings of others, as well as an excruciating sensitivity or alertness to any real or perceived rejection by them.

Just as the capacity for self-reflectivity significantly influences a parent's ability to parent her child, it may also significantly influence her willingness to be involved in interventions. Thus, a parent's level of self-reflectivity is an important consideration in deciding on the type of intervention that can best be provided.


Other Approaches to Understanding Self-Reflectivity

As mentioned in the beginning of this chapter, attachment researchers have had the most to say about the importance of self-reflectivity for parenting interactions and in the transmission of the quality of attachment across generations. A number of other researchers have considered the importance of self-reflectivity for predicting the best type of therapy to be used with people, however, as well as its ultimate success. Psychological mindedness (PM) has been defined by cognitive theorists as the capacity to achieve psychological understanding of the thoughts, feelings, and motives of self and others (Hatcher, Hatcher, Berlin, Okla, & Richards, 1990). McCallum and Piper considered the importance of psychological mindedness in therapy and defined it as the "ability to see relationships among thoughts, feelings, and actions, with the goal of learning the meanings and causes of his experiences and behavior" (1997, p. 36). This ability can provide some insight into the parent's defenses and how emotions are being dealt with (see Chapter 6 for further discussions of this).

McCallum and Piper also described how people with alexithymia, a disorder characterized by limited ability to be aware of different emotions and to create fantasies, have very little capacity for psychological mindedness. As a consequence, they have an emotionless way of relating to others and a tendency to employ action in an effort to relieve unpleasant emotional tension (Sivik, 1993; Taylor, Bagby, & Parker, 1997). They may also show a tendency to somatize, develop eating disorders, abuse substances, and engage in self-mutilation. These tendencies seem to be used primarily to relieve unbearable tension and arousal. McCallum and Piper (1997), using a measure of psychological mindedness (PM) that they developed, found that the measure predicted dropout in group therapy as well as the amount of time an individual spent working on her issues in the group. Only 14% of those with high PM were group therapy dropouts, whereas 53% of those with low PM dropped out. Success and retention in the group was also related to the severity of the psychiatric disturbance of the participant (Piper, McCallum, & Hassan, 1992).

Most cognitive therapists also consider the capacity for and the type of monitoring of clients' own cognitions and how they relate to psychological functioning. Wells (2000) considered the metacognitive knowledge that a person has about his own cognitions as well as the strategies used to monitor and control them. These include executive functions such as attending, monitoring, and planning. As Wells pointed out, not only are negative self-beliefs destructive but also some strategies such as worrying, ruminating, and self-recrimination may be problematic because they do not allow flexibility in shifting between various executive functions (Wells, 2000). These types of thinking, or a heightened level of self-focus, are seen as related to proneness to anxiety and depression, pathological worry, and obsessive-compulsive symptomatology.

The development of self-reflectivity is briefly described next as well as the characteristics of parenting or support needed to develop it. This developmental approach is then used to discuss ways to engage a parent who has very little self-reflectivity and strategies that can be used in sessions to enhance it.

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