10/16/2018 MY BACKGROUND OBJECTIVES ASSESSMENT OF INFANTS & TODDLERS GENETT TOMKO MSW, LCSW, IMH-E (III) Private practice in Awahtukee -8 years

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1 OF INFANTS & TODDLERS GENETT TOMKO MSW, LCSW, IMH-E (III) MY BACKGROUND Clinical Supervisor and Child Therapist at the Good Fit Counseling Center at SWHD - 13 years Private practice in Awahtukee -8 years Board of Directors for ITMHCA Chair of Training & Education Committee Endorsed as an Infant Mental Health Specialist IMH-E (III) in 2009 OBJECTIVES Principals of appropriate assessments of Infants and toddlers & practices to avoid Assessment tools and resources DSM V diagnosis appropriate for Infants & Toddlers (DC 0-5) 1

2 ASSESSING INFANTS AND TODDLERS How is assessing infants and toddlers different than assessing preschool and older children? ASSESSING INFANTS AND TODDLER Limited expressive language skills Assessment process is more focused on the parent/child relationship. (Attachment Theory- John Bowlby) Young children are changing at an incredible rate. Each area of development is influenced by every other area of development and it is difficult to tease apart where a problem may occur. Developmental problems in young children can be subtle. It requires experience and knowledge of infant development to build acute observations and interpretation skills. LIMITATIONS OF CURRENT APPROACHES The process is often rushed. May have only one piece of the picture. (children can look different with other caregivers and settings) Infants/toddlers may be stressed by the assessment process or expected to perform on notice. Assessment tests and measurements can be misleading May overlook some of the child s abilities such as social skills. 2

3 9 OF INFANTS & TODDLERS New Visions for the Developmental Assessment of Infants and Young Children Editors- Samuel Meisels and Emily Fenichel Published by Zero to Three: National Centers for Infants, Toddlers, and Families )Assessment must be based on an integrated developmental model. It must take into account the full complexity of the child s development, including Core Functional Areas: Emotional & Social capacities Cognitive capacities Language (expressive & receptive) Motor Sensory functioning 1) MUST BE BASED ON AN INTEGRATED DEVELOPMENTAL MODEL Factors that influence those Core Areas of functioning include: Constitutional & Maturation variations Caregiver s responses Family Community Cultural patterns 3

4 2) Assessment Involves Multiple Sources of Information and Multiple Components. Parent s description of the child Parent s concerns and questions about child Direct observation of child and caregiver Discussion about ways they have found to help support the child Developmental history & evaluations Medical history & records Other caregivers GATHER INFORMATION ABOUT THE FAMILY S SOCIAL HISTORY Mother s experiences during pregnancy Relationship dynamics in family Significant events/changes such as; moves new baby loss of family member change in child care providers divorce/ tension in parents relationship child s schedule (transitions between homes) domestic violence homelessness parent illness, mental illness, or addiction 3) An Assessment should follow a certain sequence Over multiple visits with the child and his/her family a) Establish an alliance with the caregiver& family b) Learn about the child s development, social history & medical history (including prenatal) c) Observethe child in unstructured play with their caregiver multiple times. d) Interactwith the child or observer other professional e) Use a specific assessment tool f) Integrate information collected and discuss it with parents. Always utilize a strength based approach. 4

5 4) The child s relationship and interactions with his or her most trusted caregivers should form the cornerstone of an assessment. This is where the child is probably most comfortable and likely to perform at their optimal level. 5) An understanding of sequences and time tables in typical development is essential as a framework for the interpretation of developmental differences among infants and toddlers. There may be considerable variation in both the characteristic of a particular skill and the timetable for the emergence of the skill. Therefore, there is a considerable range in what can be regarded as normal or typical development. 6) Assessment should emphasize attention to the child s functional capacities, which represent an integration of emotional and cognitive abilities. The child s functional capacities include: Sleep patterns Eating Elimination Paying attention Relating and Engaging Reciprocal Interactions Organizing and Exhibiting patterns of Purposeful Behavior Symbolic Representation Language Problem Solving 5

6 SOCIAL/EMOTIONAL FUNCTIONAL CAPACITIES Crying and behavior is a form of communication for young children Challenging behaviors are often symptoms of stress the child is experiencing *Join with the caregiver in this perspective and together work towards identifying the child s underlying needs *Help parents understand the meaning of the behavior SOCIAL/EMOTIONAL FUNCTIONAL CAPACITIES Rather than focusing on changing the behavior, identify ways to support the parent/child relationship & family to reduce stressors and demands Until a young child s needs are met they will not have the capacity to change their behavior. They cannot be rewarded, bribed or punished into behaving appropriately BEHAVIOR IS A FORM OF COMMUNICATION How is this child feeling? How are her parents feeling? What do you think her day or week has been like? 6

7 7) The assessment process should identify the child s current competencies and strengths, as well as the competencies which will constitute developmental progression in a continuous growth model of development. Strengths Based Determine if development is on track and where it is headed Identify any possible barriers to development such as; hearing impairment, failure to thrive, speech delay, or relationship disturbances with caregiver. 8) Assessment is a collaborative process. Everyone who is involved with the child should be included in the assessment such as; Primary caregiver(s) Teachers/day care Extended family AZEIP/DDD DCS or Tribal social worker Doctors 9) The process of assessmentshould always be viewed as the first step in a potential intervention process. Begin building a relationship with the family Discuss family s visions and goals Hopes 7

8 10) Reassessmentof a child s developmental status should occur in the context of a day to day family and/or early intervention activities. New development should be identified and documented to promote a sense of accomplishment and growthfor the child and family Assessors should conduct home and school observations where the child and family are in their natural environment PRACTICES TO AVOID IN 1) Young children should not be separated from their parents or familiar caregiver for the assessment Young children may seem aloof and aimless in the presence of relative strangers in new settings. PRACTICES TO AVOID 2) Young children should not be assessed by a strange examiner Assessment by an unfamiliar examiner with the parent restricted to the role of passive observer may prohibit the child from demonstrating their highest level of functioning. 8

9 PRACTICES TO AVOID 3) Assessments that are limited to areas that are easily measureable, such as certain motor or cognitive skills, should not be considered complete Such assessments cannot be considered adequate since they do not provide an integrated understanding of the child s development PRACTICES TO AVOID IN 4) Formal tests or tools should not be the cornerstone of the assessment of an infant or young child. Assessment needs to also look at the child s relationship with primary caregiver, observations of spontaneous play, and consider environmental and biological factors. THE PARENT S EXPERIENCE Parents may already be feeling worried and anxious about their child may need emotional support. *Possible grief Be mindful of word choice when talking to parents about their child be strength based Refer child for appropriate evaluations by AZEIP/DDD School Districts Occupational Therapist Speech Therapist Developmental Pediatricians Psychologists Help parent s concerns be heard participate in assessment w/ other professionals send letter describing area of clinical concern Child and Family Team meetings 9

10 RESOURCES FOR DEVELOPMENTAL EVALUATIONS OF INFANTS AND TODDLERS Arizona Early Intervention Program (AZEIP) Division of Developmental Disability (DDD) Early Head Start Family s Local School District-Screening for their Developmental Preschool Program. Child Developmental Center at Southwest Human Development OTHER AREAS TO CONSIDER WHEN ASSESSING INFANTS AND TODDLERS Exposure to Violence or Trauma Handout The Impact of Violence on Young Children (Lieberman& Zeanah1995) OTHER CONCERNS TO WATCH FOR Aspiration Reflux Stiff or loose muscle tone Using one side of the body more than the other or unable to turn their head both ways Periods of spacing out or Seizures Sleep problems/ Sleep apnea Allergies Dental/ oral health problems Hearing loss/ ear infections Sensory processing challenges 10

11 SCREENING TOOLS ASQSE: Ages and Stages Questionnaire Social/Emotional Infant/Toddler Sensory Profile Traumatic Events Screening Inventory Post Traumatic Stress Response in Infancy & Early Childhood Interview (P.I.E.) INFANT & TODDLER MENTAL STATUS EXAM ANNE. L BENHAM, M.D. I. Appearance II. Reaction to situation: to transitions, exploration III. Self Regulation: frustration tolerance, activity level, attention span IV. Motor V. Speech and language VI. Thought: fears, nightmares, dissociative state VII. Affect and Mood: range, intensity, duration of emotion VIII. Play:Sensorimotor, functional, symbolic, content of play IX. Cognition X. Relatedness: to parent, to examiner, attachment behaviors & disturbances in attachment behaviors; over compliance, indiscriminate ASSESSING THE CHILD/PARENT RELATIONSHIP Strange Situation - Mary Ainsworth 1978 * Assessing patterns of Attachment Crowell Procedure Domains of Parent-Child Relationship (Emde, 1989, Zeanahet al., 1997; Larrieu & Bellow, 2004) 11

12 CAREGIVER TOOLS Working Model of the Child Interview Angels in the Nursery Interview Life Stressor Check List Adult Attachment Interview PTSD Symptom Scale Interview (PSSI) DIAGNOSING Who can Diagnose Infants and Toddlers? Psychologist Psychiatrist Developmental Pediatrician Licensed Clinical Social Worker (LCSW) Licensed Professional Counselor (LPC) Licensed Marriage & Family Therapist (LMFT) other mental health professional being directly supervised by one of the above professionals (diagnosing in collaboration with supervisor) All professionals should have specialized training in Infant Mental Health and development of young children 0-3. DIAGNOSIS OF INFANTS & TODDLERS DSM V or ICD-10 (required for billing Medicaid and insurance companies ) DC 0-5: Diagnostic Classification 0-5 years (Zero to Three 2016) * link to DSM V & ICD-10 * developmental milestone chart 12

13 R/O TRAUMA FIRST If there is a clear stress condition and is associated with disordered behavior or emotions, consider Post Traumatic Stress Disorder as a primary diagnosis. Abuse Domestic Violence Loss of caregiver/sibling Multiple placements Intrusive medical procedures Repeated hospitalization DSM V DIAGNOSIS APPROPRIATE FOR INFANTS & TODDLERS Diagnosis DSM-V code pg# ICD-10 code Posttraumatic Stress Disorder P 271 F43.10 Disinhibited Social Engagement Disorder P 268 F94.2 Other Specified Trauma and Stressor Related Disorders *Prolonged Bereavement/Grief Reaction p 289 F43.8 DSM V DIAGNOSIS APPROPRIATE FOR INFANTS & TODDLERS Diagnosis DSM-V code pg# ICD-10 code Other Specified Mental Disorder due to another Medical Condition - Language Delay p. 707 F06.8 Generalized Anxiety Disorder P 222 F41.1 Separation Anxiety P 190 F93.0 Adjustment Disorder Unspecified (6 months only) P 286 F

14 DSM V DIAGNOSIS APPROPRIATE FOR INFANTS & TODDLERS Diagnosis DSM-V code pg# ICD-10 code Other Specified Neuro Developmental Disorder -Methamphetamine - Alcohol P 86 F88 Child Neglect P 718 Confirmed T74.02X Initial T74.02XD Subsequent Child Sexual Abuse P 717 Suspected Initial T76.22XA Subsequent T76.22XD Confirmed Initial T74.22XA Subsequent T74.22XD Child Physical Abuse P 715 Confirmed Initial T74.12XA Subsequent T74.12XD DSM V DIAGNOSIS APPROPRIATE FOR INFANTS & TODDLERS Diagnosis DSM-V code pg# ICD-10 code Other Specified Mental Disorder P 708 F99 V CODES: secondary diagnosis only Parent Child Relationship V61.20 Child affected by parental relationship distress V61.29 Disruption of family by separation or divorce V61.03 Unspecific housing or economic problem V60.9 Sibling relational problems V61.8 AUTISM SPECTRUM DISORDER Limited or atypical social-emotional responsivity, or sustained social attention Deficits in nonverbal social-communication behaviors Peer interaction difficulties Repetitive or restrictive behaviors Evaluation and Diagnosis Psychologist, Psychiatrist, Developmental Pediatrician 18 months In the US: 1 in 42 boys, 1 in 189 girls (DC: ) 14

15 WHY NOT START WITH THESE DIAGNOSES? ADHD? child should be at least 3 years old before considering this diagnosis *However there can be many different reasons why a child may struggle to focus including; Trauma, Anxiety and Sensory processing challenges Oppositional Defiant Disorder or Disruptive Behavior Disorder? Suggests that the problem resides inherently within the child rather than considering the impact of relationships and environmental factors Reactive Attachment Disorder? Very rare Disorder of no attachmentto any caregiver Most children develop an attachment ATTACHMENT Attachment describes a young child s tendency to seek comfort, support, nurturance and protection selectively from at least one adult caregiver. Human infants are biologically predisposed to form attachments to caregivers. ATTACHMENT RELATIONSHIP An enduring emotional connection between a child and a caregiver characterized by a tendency to seek and maintain proximity to a specific figure (attachment figure), particularly when under stress The emotional bond or attachment is a long-lasting relationship, not a transient enjoyment of another s company or comfort 15

16 ATTACHMENT & BONDING Attachment: The specific affiliative tie of the infant to the caregiver (thought to become established in the 7-9 month period). Bond: *The affiliative tie of the adult caregiver to the infant * Which can be thought of as the caregiver s affectionate, warm, and loving commitment to the infant. (Emde, 1989) Evolutionary Survival Function Internal Goal of Felt Security External goal of balancing exploration and proximity to caregiver Secure Base PATTERNS OF ATTACHMENT Secure Attachment Develops when the parent/caregiver is nurturing, supportive, responsive, consistent, reliable, and safe Child is able to utilize caregiver for comfort and secure base for exploration when not distressed. Confidence and trust in the caregiver. Upon reunion with caregiver, after separation, the infant is able to seek and maintain contact which is soothing for the child Little or no resistance to contact and interaction with caregiver upon reunion 16

17 PATTERNS OF INSECURE ATTACHMENT Types of Insecure Attachments 1. Avoidant 2. Resistant 3. Disorganized *Children can have different types attachments to different caregivers *Attachment can change over time with decreased stress on child & caregiver, increased support & intervention. I N SECURE AVOIDANT Child shows little affective sharing with parent, hostile tone, flat affect during distress, avoids contact, withdraws or ignores parent when distressed. Unlikely to appear distressed. (Bunny) Caregiver demonstrates a hostile and rejecting or dismissive tone; aversion to physical contact, tense and irritable, emotionally unresponsive and psychologically unavailable. Inner Working Model: Caregivers are unavailable and indifferent especially during distress; interactions with others likely to be painful, unrewarding, unsatisfying; expectation of rejection, self as unworthy of care. Child is tense, easily upset; preoccupied with parent s proximity or distance (clingy); difficult to soothe when distressed; actively angry, alternately seeking and resisting contact when upset. Caregiver demonstrates an insensitivity to infant s signals, unpredictable responsiveness; interfering, erratic, inconsistent, and inept, anxious, tense, intrusive. Inner Working Model: Caregivers are unreliable, ineffective and intrusive; interactions with others are frustrating, unrewarding, annoying; the child see self as inept, impotent, and incompetent. The hallmark of this classification is the child seeks contact, then resists contact angrily once it is achieved. Thus there is an obvious ambivalence in many of these relationships. 17

18 Child is fearful, disorganized or undirected; responses to caregivers are conflicted or contradictory, stereotypies, freezing, or stilling. There is an inability to maintain one coherent attachment strategy in the face of distress. Caregiver is frightening or threatening or alarmed by the infant, dissociates, helpless, At once the source and the solution to the child s alarm. (unresolvable fear) Inner working Model: Caregivers are necessary, but potentially dangerous and harmful or terrifyingly absent; disorganized, dysregulated self (Ainsworth et al, 1978; Lyons-Ruth & Jacobvitz, 1999; Main, 2000, Weinfield et al, 1999) The infant-caregiver relationship is a crucial factor affecting social and emotional development. Decades of research have provided compelling evidence that this early relationship has long term consequences for developmental outcomes including relationships with peers and later parenting attitudes and behaviors. QUESTIONS? 18

19 Thank You! Genett Tomko 19