Christopher, an intense 21-month-old with spotless white sneakers and a mop of curly brown hair, charges full-speed past a therapist and into a playroom at the Early Childhood Center of Albert Einstein College of Medicine in the Bronx. Christopher’s mother, Tamara Noboa, trails behind. She looks tired, wearily pushing a double stroller that holds baby Elijah, Christopher’s 7-month-old brother. Christopher bolts across the room to a toddler-sized table. He grabs a soft book, runs back to the stroller and shakes the book aggressively in his brother’s face.
“Oh, Christopher!” exclaims Denise Giammanco, the therapist who has been seeing this family for three weeks. “Nice sharing! Good job!” Christopher’s face flickers with only faint recognition of her praise. Within seconds he’s back across the room digging through toys. Giammanco turns to Noboa. “You see how I’m making it very high energy, so that he shares with the baby?” Noboa says Christopher is often jealous of his baby brother; Giammanco wants to encourage positive moments between them.
Therapy has officially begun.
Several months ago, Christopher was saying “Mommy” and “Daddy.” His parents waited for more words to come, but they haven’t. Now, Christopher doesn't say much of anything and rarely responds when spoken to. It’s hard to tell how much he understands. He has also started falling a lot. He cries loudly and frequently in the night, waking the baby. And although he didn't use a pacifier before, he’s begun putting the baby’s pacifier in his mouth. He is easily frustrated, throwing things and hitting. Just this week, he whacked the baby across the face.
Noboa’s teenage daughter also had behavior issues at Christopher’s age. Then she attended a therapeutic day program. It helped a lot. Now she’s on the honor roll. Today, Noboa hints that this is the kind of help she might like for Christopher too.
But the Early Childhood Center, which works primarily with low-income families like Noboa’s, provides a different kind of help, engaging not only the child but the parent as well. Most social work interventions for struggling and poor families view the social worker as the sole therapeutic agent. They strive to change the behavior of either a child or a parent, but not both. In the relationship-based therapy that the Early Childhood Center provides—known as dyadic therapy—the therapist works simultaneously with parent and child, engaging the parent as a partner in the child’s therapy, because in the early years, children are almost entirely dependent on parents to create their world for them.
“There’s very little you can do with a very young child with-out changing the tenor and context in which they live, and young children live in the context of their relationships,” says Susan Chinitz, director of the Early Childhood Center. “Any work that is not relational is probably not going to buy much change.”
“If the therapist spends an hour a week with the child, that’s one thing,” says Fred Wulczyn of Chapin Hall, a policy research center at the University of Chicago. “But if you improve the parenting and then the parent knows how to better manage the child, then you get all that exposure to better parenting instead of trying to get the child to be a better child.Caregivers spend so much more time with the child. Delivering the intervention through the parent means you get much higher dose levels.”
In New York City, however, only a handful of programs and clinics provide dyadic therapy for young children and their caregivers, making families like Christopher’s among the very few to stumble across it. What may eventually pass for a movement is beginning to emerge in agencies across the city, rooted in increasingly robust research—and the experiences of therapists like Denise Giammanco and her colleagues.
Giammanco knows that many of Christopher’s changes started around the time his brother was born and his world turned upside down. He went from being the baby of the family to the big brother, no longer the main focus of his mother’s affections.
Not long after Elijah’s birth, both boys and their mother moved into the home of Christopher and Elijah’s father. (Noboa also has a teenage daughter who sometimes lives there, other times with her father.) Christopher’s mother says she, too, is reeling from all the changes—a new relationship, a new home, two children under the age of 2. Some days she wants to close her bedroom door and block out the world. “He makes me crazy sometimes,” she says about Christopher. “I need help for him. Help for me. I don’t want to scold him all the time.”
Christopher will soon receive a full diagnostic evaluation by a pediatrician who will assess his speech development and how well he understands language, among other things. But Giammanco will also consider murkier factors that could be contributing to Christopher’s behavior and delays.
In her hour-long weekly sessions, Giammanco coaches both of Christopher’s parents on how to provide what’s some-times referred to in the small world of infant mental health as “supportive” or “responsive” parenting—a reflectie, child-centered approach to parenting that encourages sensitivity and warmth. Research suggests this kind of parenting is a key to buffering what neurobiologists have documented to be the sometimes brutal and long-term effects of trauma, poverty, and stress in early childhood. (See “The Science of Trauma, page 17.)
A series of studies of 1,200 infants funded by the National Institutes of Health suggests that elements common to poverty, like overcrowding and family turmoil, caused babies’ stress levels to spike precipitously—but only when a baby’s mother was not responsive to her child’s signals. “When mothers scored high on measures of responsiveness, the impact of those environmental factors on their children seemed almost to disappear,” journalist Paul Tough explains in his recent book, How Children Succeed.
Today, in the Early Childhood Center playroom, Giammanco models the supportive parenting approach, interjecting enthusiastic “vroom, vrooms,” as Christopher rolls a truck across the table, and cooing empathetic frustration when he struggles to master a difficult puzzle toy. Eventually, Giammanco will have Christopher play less with her and more with his mother and father as she provides guidance, cheering them on in their parenting in much the same way she cheers Christopher in his play.
For the first 13 ears that Martha Alvarez worked in a high school-based nursery for the babies of teen moms, she had never seen the research around supportive parenting nor heard of dyadic therapy.
Each morning, young mothers dropped off their babies in the school nursery before classes began. Nursery teachers took care of the babies while Alvarez and the other social workers counseled the young mothers, encouraging them to stay in school, speaking with them about college. “It was very academic minded,” Alvarez remembers. “It did touch on issues with their moms and relationships with their babies’ dads, but there was very little to do with the baby.”
Alvarez knew well that many of the young women she worked with were struggling with motherhood. At an age when most young people want nothing more than to forge identities separate from their own families, becoming a parent had tied them inextricably to a very small child—and to their parents and caregivers on whom they depended for support and guidance. While many dressed their infants immaculately in the latest brandname clothing, they often had trouble seeing their babies as separate from themselves, as little people with their own likes, dislikes, wants and needs.
Young mothers would routinely arrive at school upset, says Alvarez. “She had a fight with her mom or she had a fighwith her boyfriend, or her kid threw up on the way.” Typically, staff would take the baby to the nursery and Alvarez would take the mom to her office. “ut I realized that this baby was upset too. This baby would be crying.”
One day it became glaringly obvious she needed to try a different approach. A young mom showed up at school with her 2-year-old son, who proudly showed Alvarez a colorful leaf he’d found. He had picked up the leaf near his home and had made it all the way to the nursery with it intact, in his hand.
“I said, ‘Oh my, this is such a great leaf, what beautiful colors!’” Alvarez remembers. “But the mother had been oblivious to the leaf the whole time, not minding what this little boy was doing for the whole ride to the nursery. She was not attuned to him. I knew there was a disconnect.”
When Alvarez pointed out the leaf to her, the mother said, “Oh, yeah,” and threw it away.
Alvarez remembers the moment as an awakening. “I thought, ‘This kid isn’t getting what he needs.’ I knew that there had to be a way to bring the baby and mother together and work on her parenting skills…. I knew there was something to be done with the moms and babies, but I never had that role explained to me.”
A few years later, through an arrangement with the city’s Department of Education, two social workers arrived at the nursery. Drawing from multiple strategies and interventions developed by researchers and mental health specialists to assist vulnerable parents and their infants, Elizabeth Buckner and Hillary Mayers had created a program called Chances for Children, which gave young mothers a combination of parent education and therapy while working with them and their babies together. The program shifted the focus of Alvarez’s work to helping young mothers take on the vast role of caring for their new families—a role that included pursuing their academic studies, but also a great deal more.
Alvarez’s training was intense. Buckner and Mayers schooled Alvarez and other social workers at the nursery in the research behind the interventions they used. They taught them about attachment theory, which holds that the quality of the attachment an infant has with his caregiver at life’s beginning has lifelong consequences. One University of Minnesota study in the 1970s found that the degree to which young children were securely attached to an adult could predict with high accuracy whether or not they would graduate from high school.
Alvarez and the other nursery social workers also learned about the toxic effects of chronic stress on young children. They read psychoanalyst Selma Fraiberg’s “Ghosts in the Nursery,” a seminal 1975 essay that describes how unresolved issues from a parent’s upbringing can haunt their parenting if left unexplored. And they read about more recent neurological research. Through all their training, they experienced a kind of supervision that Buckner describes as “layers of mothering,” where she and Mayers mothered and supported the nursery staff in their work so that they, in turn, could mother the young moms and help them do the same for their babies.
“It took a while for my thinking to change from just the mom to the dyad,” remembers Alvarez. “It was a cognitive shift of working from one to working with both. But it was rich, rich, rich. You look at the mom, you look at the baby.”
The Chances for Children model begins by videotaping mothers as they play with their babies for 10 minutes. The therapist asks the mom to play with her child just as she might at home. Then the two of them watch the video together, with the practitioner building the mother’s trust by focusing on positive moments.
Alvarez remembers how much the young moms loved this strength-based approach, which could also be described as the “oh, wow” method, where the therapist marvels at all the positive things the mother does. “Nobody had told them, ‘Oh, wow, that was so nice what you did. The baby was stumbling and you picked him up. That’s nice,’” she remembers. “They enjoyed the fact that I was paying attention to them and their babies. Many teen moms don’t get that recognition.”
Over time, the therapist moves toward helping the mother experiment with new ways of thinking about and interacting with the child. She asks questions such as, “What do you think the baby is thinking?” or “How about you don’t pick up that toy right now and see what happens?”
Alvarez remembers one young mother who perpetually teased her 18monthold daughter. She’d take away whatever toy the baby chose and proclaim it to be “Mommy’s toy.” She’d shake objects in front of her and then yank them away when the baby tried to grab them. When this mother picked her daughter up after class, she would try to make her jealous by pretending not to notice her daughter as she warmly greeted all the other children in the nursery. The little girl would often respond by shutting down, Alvarez remembers. This, in turn, caused the mother to comment that her daughter didn’t like her and did not want to play with her. She would tease the girl even more. It was a vicious cycle.
Alvarez asked the mom to play with her daughter while teasing her for one minute, as Alvarez videotaped. During the taping, the baby turned away from her mother. “See, she doesn’t want to play with me. She likes to play alone,” the mother said.
Then Alvarez told the mother to play with her daughter for another minute while she videotaped. But this time, Alvarez asked the teen to try out a form of supportive parenting, where the parent responds to the baby rather than directs her. Alvarez asked the young mother to follow her daughter’s lead, allowing her baby to show interest in a toy first, and then follow by showing an interest herself in whatever the baby did. “Do what she does. Talk about what she’s doing,” Alvarez instructed.
An amazing thing happened, remembers Alvarez. As the mother responded to her daughter’s lead, her baby slowly turned to her. Then she lifted a block up to show her. The mother, carefully matching her daughter’s movement, held up another block. Slowly, the daughter touched the mother’s block with her block. The mother turned to the camera, face alit, grinning, amazed that her daughter was playing with her. With the touching of those two blocks, Alvarez recalls, “it was almost like the Sistine Chapel.”
“Do you see what she did?” the mother asked, incredulous.
“Yes, I saw what she did,” Alvarez remembers saying. “You saw what you did? You opened the world to her.”
Alvarez and the young mom would watch that videotape many times. Eventually, they began to explore the mother’s own upbringing. The teen’s mother had teased her throughout her childhood. Remembering this, the young woman began to recall how confusing that had felt. Alvarez believes that the combination of reflecting on her wn childhood while experimenting with new ways of parenting paved a new way for her to relate with her daughter. “We made a new story for her, that she was not her mom, and her story with her daughter was totally different and didn’t have to repeat the past.”
Chances for Children has since moved out of the high schools, where they trained social workers in 13 school nurseries, and into community centers and a clinic in the Bronx. Alvarez and Chances for Children’s three other therapists now work with caregivers of all ages in three neighborhoods. The organization has also trained six clinicians at Riverdale Mental Health Association. Along with the Early Childhood Center at Albert Einstein College of Medicine, they are among a very small number of programs in the city using relationship-based therapy with young children and their families.
Some of these programs work individually with parents and their babies; others bring caregivers together for guided playgroups. Some send therapists to work in families’ homes, while most work only in clinics or community settings. Some follow models developed at universities and demonstrated to be effective through research. Others, like Chances for Children, are homegrown programs, picking and choosing among already established best practices while tailoring interventions for individual families. All aim to reach the city’s most vulnerable babies and their caretakers: Teen moms with their babies living in foster homes; families living in homeless shelters; toddlers whose behavior their parents just can’t manage. Almost all of these families teeter on the brink of poverty or are already there. “Poverty just deprives people of the supports that make it easier to cope with the enormous demands of very young children,” Chinitz explains.
All of the programs are strength-based, dedicated to building relationships with caregivers by pointing out the positive aspects of their parenting. “We cheer on the parent as they cheer on the child,” says Lindsey DeMichael, a therapist at the Attachment and Biobehavioral CatchUp program for young children and their caregivers at Forestdale Inc., a Queens foster care agency. She and her colleagues visit with young children and their caregivers in their homes, following a highlystructured 10-week model developed by psychologists at the University of Delaware.
Each of these models aims to help children feel more safe and secure with their parents by increasing their positive interactions in clear and concrete ways. Therapists may try to reduce a parent’s stress by finding legal help for a family onthe verge of eviction, or sending a depressed mom to a psychiatrist. They arm parents with the kind of fundamental information about child development that helped one mother understand that her 3-month-old baby could not actually be flipping her off when he lifted his middle finger, as she believed. Another mom who had been sexually abused needed help to understand that when her baby touched her breast while nursing, it was not a sexual gesture.
The bulk of the work in many of these programs involves helping parents become what Buckner of Chances for Children calls “baby watchers,” parents who have a curiosity about their child and their child’s world, and who respond to their babies in a way that recognizes them as separate from themselves.
Take a situation where a father picks up his toddler son from child care and brings him to a grocery store, where the boy throws a tantrum as they wait in line. A parent who is not attuned to his child, or who is already stretched to the breaking point, might start screaming at the child. Or he might take the advice of others on the line who tell him he needs to take control and smack the child. This would likely exacerbate the situation, causing dad and child to feed off each other’s anger and unhappiness. “It’s a circle where everybody is bringing out the worst in each other,” says Chinitz.
But a parent who reflects before reacting might try to understand why the toddler is so frustrated and even help him understand his own experience by saying something like, “I know you’re very tired. We've been out all day.” Relationship-based therapy tries to nudge parents to this point.
“Most kids who come to our attention at a very young age needing infant mental health care are responding to something in their care-giving circumstances, so there’s very little useful work you can do with that child themselves without changing what’s distressing with the care-giving situation,” explains Chinitz. “We’re really trying to shape the way parents respond to their children.”
Championing reflective, supportive parenting, however, could be considered a mere personal or cultural preference. After all, parenting styles can differ radically among different cultures, generations, even spouses. Who has the authority to say what’s the right way to parent? Complicating matters, the women running the centers and clinics that practice relationship-based therapy are overwhelmingly white, with advanced degrees, while the parents they work with are largely poor women of color. Parents in treatment sometimes find that when they bring new parenting skills back home, neighbors and family members disagree with the approach. The parents themselves frequently raise the question of whether the methods advocated by therapists are really right for their own families—families struggling to raise children with limited supports and resources, often in neighborhoods riddled with violence, addiction, unemployment and failing schools. For instance, many of the moms who come to the Early Childhood Center like to engage their children in educational activities, such as learning the alphabet. The therapists, on the other hand, prefer play for young children. Who’s to say which is better?
Those in the field insist they take great efforts to stay open to these differences and remain mindful that plenty of children whose parents never get down on the play mat with them still grow up with ample love and stimulation. They say they make an effort to not be didactic, but to instead encourage parents to reflection what worked and what didn't in the way they themselves were raised, and to experiment with new parenting techniques, like following a child’s lead instead of teasing. This way parents can come to their own ideas of what will work for them and their families. “We’re really not prescribing a particular way of parenting, but trying to get parents to think about their parenting and not do things automatically, just because that’s the way they were done in their families,” says Chinitz. “We’re not really telling them what to do so much as to get them to think about things through their kids’ eyes.”
Research suggests these interventions are having a positive impact. Studies have found that young children who received the Attachment and Biobehavioral Catch-Up intervention being used at Forestdale, for instance, experienced less stress and were more frequently securely attached to their caregivers than children who received a different intervention. In a peer-reviewed, control group study, Chances for Children found that infants who had received its intervention showed an increase in interest in their mothers and responded more positively to physical contact, compared to another group of infants who did not participate in its program.
Another model, known as Child-Parent Psychotherapy, has been demonstrated to be effective and replicable through high-quality evaluation research and is thus widely recognized as an “evidence-based” program. It is one of the most influential models and is used in many clinics nationwide that do relationship-based work with young children. In New York, it is used at the Jewish Board of Family and Children’s Services’ (JBFCS) Institute for Infants, Children & Families, and is slated to soon be used by the Association to Benefit Children in Manhattan and the Jewish Child Care Association in Brooklyn to help families stay out of the foster care system. Among the findings: Children aged 5 and younger who had witnessed domestic violence and received this intervention had a greater reduction in behavior problems and traumatic stress syndromes than those in a control group.
In the 1990s, the philanthropist Irving Harris, who helped JBFCS create a training program around infant mental health, made a prediction: In 20 years, the country would recognize the urgency of addressing infants’ social and emotional needs, but there would not be a trained workforce of leaders able to rise to that challenge.
To many in the field, Harris’ prediction has come to seem prophetic. Brain scan technology has turned the abstract notion that early childhood experience has immense influence into something concrete: We can now see that an abused child’s brain can look and behave differently from the brains of other children. But despite the growing awareness of the developmental importance of early childhood, New York City has yet to develop a systematic response to the emotional and social needs of babies and toddlers. The city and state health departments manage the Early Intervention Program, which funds services for children under age 3 who are at risk for or who have developmental delays. In theory, the program can work with small children on social and emotional issues, but in practice, it is not designed to address the impact of trauma.
The city has a handful of centers and clinics that some in the fielddescribe as “little pockets of capacity” to work with young children, but few provide the kind of long-term dyadic therapy that the Early Childhood Center or Chances for Children provides. “There are really not treatment slots for young children, particularly children who are the most vulnerable, kids who need intensive services,” says Evelyn Blanck, associate executive director of New York Center for Child Development and chair of the New York City Early Childhood Mental Health Strategic Work Group.
Last year, an analysis by the Citizens’ Committee for Children estimated that nearly 47,500 New York City children ages 4 and under have a behavior problem as defined y the American Psychiatric Association, which includes diagnoses such as hyperactivity or oppositional defiance disorder. But at the state-licensed mental health clinics in Brooklyn, the Bronx and Staten Island, there were treatment slots for only 270, or 1 percent, of those children. (They couldn't identify the unmet need citywide, due to the lack of data for Queens and Manhattan.) The analysis found treatment slots to be especially lacking in the community districts needing them most.
Those in the field say that a large pat of the problem is that the level of state and city funding has been inadequate for a long time and isn't getting any better. “Relatively few public dollars are targeted to mental health services for New York’s youngest children,” the Early Childhood Mental Health Strategic Work Group wrote in 2011.
Ten years ago, Chinitz set out to change this. The Early Childhood Center was inundated with referrals for struggling young children. The city’s children who had been born at the height of the crack epidemic were rapidly becoming parents themselves, and many had been abandoned by their families and grown up in foster care with few models for how to parent.
Five of the infants that the Early Childhood Center worked with at the time had each witnessed their mother’s murder. A number of the toddlers and young preschool children had been sexually abused. Many young children in their clinic had bounced from one foster home to another or had been kicked out of child care centers and preschools because their behavior was so difficult to manage. Then there were the referrals the center could not accept, because they simply did not have the resources. Chinitz believed that waiting until these children were 5 or 6—an age for which there are far more services available—was wasting valuable time.
So she began leaving the clinic each day to knock on the doors of power, making impassioned pleas for government officials and policy makers to invest in the field.She spoke about the aggressive and hyper-vigilant toddlers who had witnessed street shootings or seen their mothers beaten by their fathers or their mother’s boyfriends. She spoke about young children in foster care who had not had an opportunity to form an attachment with a trusted adult. She talked about the impulsive and irritable children, whose stressed, sometimes depressed mothers struggled to manage.
Sometimes she referenced the Nobel prize-winning economist James Heckman, who has demonstrated how investing in effective early childhood interventions can yield huge cost savings for society. According to Heckman, there is a steep decline in these savings even by the end of a child’s third year of life. “The longer society waits to intervene in the life cycle of a disadvantaged child, the more costly it is to remediate disadvantage,” Heckman wrote. “Gaps in development open up early and are extremely difficult and expensive to close.”
In 2004, then-City Council member Margarita Lopez took heed. She organized a hearing and pressed for funding for a handful of early childhood programs. This led to an important recognition among the city’s child-serving mental health clinics. Previously, most everyone assumed these clinics could not serve children under age 5. But Lopez helped clarify that this was not the case, and made these clinics aware that they could amend their licenses to treat children of all ages if they were not already authorized. Nonetheless, the larger problem still lingered, as Harris had predicted: Most clinics lacked the expertise to do dyadic work with young children and their caretakers.
Today, nearly 10 years after Council member Lopez responded to Chinitz’s pleas, not a lot has changed. Few clinics can work with babies, though how many no one knows for sure because the state’s Office of ental Health does not keep track.
In the last few years, the Office of Mental Health has begun funding nine agencies in New York City to screen for early childhood mental illness. This screening does not provide money for treating the children or training people to provide the interventions. “We are going to identify all these people who need services, but with no money to train, where will they get served?” asks Dorothy Henderson, director of early childhood trauma services and associate director of training at JBFCS’ Institute for Infants, Children & Families. “There’s not a lot of people who can work with babies.”
During the recession, JBFCS had to close the training program Irving Harris had helped start, which had produced many of the city’s infant mental health leaders. Meanwhile, the City Council has remained one of the only sources of government funding for early mental health treatment. That funding, which also covers services like screening and evaluating, has decreased from its height of over $1.6 million about five years ago to the $1.25 million to be distributed among eight organizations in fiscal year 2014, and the money is at risk of disappearing each year. Meanwhile, most mental health initiatives serving children under 5 rely on private funding and negotiating creative ways to get Medicaid to pay for dyadic work.
Some in the field say a large part of the funding challenge is the misperception that little children are immune to their surroundings, including stress and trauma. “Trauma in early childhood doesn’t look like trauma to people who don’t know what they’re looking at. It can look like a behavior problem. It can look like bad parenting. It can look like neglect,” says Bonnie Cohen, director of the University Settlement’s ButterfliesProgram, which provides early childhood mental health services.
But Joaniko Kohchi, a child development specialist at the Early Childhood Center, believes infants get routinely overlooked because they can’t do harm. “Mental health, in general, people don’t want to talk about unless they have to, and they only have to when someone is dangerous,” says Koachi. “Little babies don’t scare people. They don’t need to be incarcerated.”
Franchesca Davis counts her daughter Haylee among one of the lucky ones to have benefited from the advocacy efforts. About a year after Davis lost custody of 9-month-old Haylee, the two began receiving therapy tailored for families involved in Family Court. Just 19 years old, Davis had always known she didn’t want to punish Haylee by hitting her, the way she herself was raised, but she didn’t have a clear idea of how she did want to parent.
Relationship-based therapy has helped her figure it out. Today Davis shares custody of Haylee, now 4, with the girl’s father, and Haylee lives in Davis’ apartment three days each week. Davis still remembers how strange it felt the first time she sat down to play with her daughter at the Early Child-hood Center. It was just the two of them, with nothing in between them. At home, the baby usually stayed in the crib, with the TV on. Now, when Davis watches that first video of them playing before they received dyadic therapy, she shudders—you can tell she and Haylee have a bond, she says, but she seems so cold with her daughter, so bossy. Yet in the final video ECC made of the pair, “We’re like kids in a candy store. We were together in unison.”