In October 2012, New York City launched EarlyLearnNYC, a plan that would upend its system for providing subsidized child care to working class and low-income families. The goal was to take the city’s sprawling assortment of child care programs—ranging from subsidized babysitting services to nationally accredited preschools—and blend them into a unified, holistic spectrum of early education services for children from 6 weeks through 4 years old.Read More
Here’s a roundup of this week’s news on low-income children, youth and their families:
Today, the U.S. Department of Housing and Urban Development (HUD) released it’s annual assessment of homelessness in the U.S. The report found that since 2010 homelessness among individuals declined nearly 4.9 percent, homelessness among family households declined by 8.2 percent, and Veteran homelessness declined by 24.2 percent. Despite the overall decrease, New York City experienced one of the largest one-year increases in homelessness between 2012 and 2013. Read the full report, including state-specific information, here.
This week, The American Prospect highlighted an innovative program in New York that is helping low-income families put money aside to pay down debts and cover unexpected expenses.
- November 21 - Education Funders Research Initiative will release its third white paper “Building Blocks for Better Schools: How the next mayor can prepare New York’s students for college and careers.” Watch the live stream discussion of priorities for the next mayor and chancellor.
- November 25 - The New York City Council will hold an oversight hearing on Hunger in NYC. The Hearing is a joint effort of the Committee on General Welfare, the Committee on Women’s Issues and the Committee on Health.
- December 4 - Choosing Leaders for a New Era. Join the Center for New York City Affairs for a post-election roundtable discussion including behind-the-scenes stories direct from the campaign teams and analysts. This forum will examine the mayoral, comptroller and public advocate races. RSVP here.
Scientific research has firmly established that early childhood experiences can have a tremendous impact on our lifelong well-being. When infants are exposed to chronic stress or trauma, the effect can be toxic, stunting brain growth and changing the trajectories of their lives.Read More
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.”
Together, behavioral psychology and neuroscience are reshaping our understanding of the damage caused by trauma in early childhood—and how good parenting heals the wounds. Fifteen years ago, a clinical psychologist named Philip Fisher and his wife applied to the State of Oregon to adopt a 2-year-old boy. Fisher had been working with older kids for many years, mostly in psychiatric treatment programs for youth whose behavior problems had gotten them into serious trouble. Fisher believed in his work—he’d seen that, in the right environment, kids could begin to exorcise demons that had plagued them, in some cases, since before their conscious memories began. But he was disturbed by the feeling that more could have been done if the children had been treated at a younger age. “There aren't many late starters in juvenile delinquency,” he says. “Parents always said things would have been different if they had gotten help early.”
As he waded through the bureaucracy of his own son’s adoption, Fisher’s professional concerns collided with his personal life. The proceedings dragged on for nine months— a developmental lifetime compared to the speed at which a toddler grows and learns, adapting to the turbulence that is inherently part of foster care. Fisher worried that he was missing a crucial window of opportunity to impact the course of his child’s life.
As it turned out, the nature of that developmental window (how it works, why it matters, how to influence it for the best) was the central concern of a newly burgeoning field of science—one that was, back in the late 1990s, just beginning to unriddle one of the fundamental mysteries of childhood: how the things we experience when we’re very young—even when we’re too young to remember—affect who we become later in life.
Child psychologists (along with most of the rest of us) have long understood that there’s a connection between traumatic childhood experiences and poor life outcomes. “There’s been a recognition for at least a century that children who are neglected or abandoned are at risk of problems,” says Jack P. Shonkoff, M.D., director of the Center on the Developing Child at Harvard University. By the time Fisher filed his adoption request, studies had documented enduring links between stress and trauma in childhood and a long list of problems later in life, ranging from mental illness to obesity to cancer.
Until recently, however, scientists had little insight into how those links worked—or how early in life they can form. “The predominant belief,” Shonkoff says, “was that if really bad things happen when children are very young, if you can get them out of those situations early, either they won’t really know what’s going on or they won’t remember. There was a general belief that things that happen to very young children can’t affect them years later.”
Over the past decade and a half, Shonkoff, Fisher and a scattered constellation of researchers across the country have proven that belief wrong, engendering a very new understanding of what children need and how they grow. They have begun to look under the hood at the mechanics of development, revealing how early experiences—especially those involving trauma and chaos—get built not just into children’s minds but their brains and bodies. It’s a relatively young line of inquiry, but its breakthroughs have come about, in large part, through the crossbreeding of two long-established strains of thought: that of behavioral psychology—a field that accumulates its knowledge mainly through observation and self-reporting—with the bloodier science of animal brain development.
For several decades, neurobiologists have subjected animals like rats and rhesus monkeys—mammals whose brains grow in patterns remarkably similar to our own—to experiments designed to trace the impacts of psychological trauma early in life. One frequently repeated experiment has been to traumatize baby rats by separating them from their mothers and siblings for significant periods each day. After weaning, the rats are not only likely to be cognitively impaired— less able to learn, remember and solve problems than other rats—but they exhibit behaviors that mirror mental illness in humans, like anxiety, depression and an unhealthy penchant for ethanol.
When scientists examine the rats through adolescence and adulthood, they find that the psychological problems are matched by an array of physiological abnormalities, the sum of which converge on a rather astonishing finding: The rats’ experience of trauma early in life literally changes the way their brains develop, altering hormone function and stunting growth in areas that are essential, in humans, to thinking, remembering and controlling emotions.
Scientists at Shonkoff ’s research center explain the phenomenon through the metaphor of architecture: Infant brains (whether they belong to rats, monkeys or people) are genetically programmed to grow and make connections in response to experience. When babies’ environments are healthy, their neural connections grow sturdy and effective, providing a strong foundation for future learning and development. When they are exposed to repeated stress, the effect is toxic, weakening brain growth in ways that can do permanent damage.
The ongoing challenge for child development researchers is to decipher the blueprints—to find out which experiences matter and trace the pathways by which they do harm. It’s a project with tantalizing prospects—a kind of neurological treasure hunt that promises clues not just to further our understanding of brain development but, in its furthest extrapolation, to decode the enigmatic connection between biology and character. If we could better understand the physiological legacies of our experiences, might it be possible to map our personalities—even, to some extent, our destines—onto a network of chemical pathways and neural wiring? How does adversity change who we are? How do our environments mark and define us? To what extent are we trapped by our pasts, and how do we understand the potential to overcome?
It’s a body of questions with profound implications for our approach to early childhood. In the longstanding debate over nature versus nurture, says Jack Shonkoff, “the ‘versus’ is scientifically dead.” In its place, he argues, these investigations charge us with a renewed imperative to fulfill one of the basic obligations of a social contract: improving the conditions in which children and their families live. “You put up a brain scan and people get excited,” Shonkoff says. “‘Oh my god, this is real!’”
Human babies are born with approximately 100 billion neurons, each connected to thousands of others through an immensely intricate network of chemical pathways called synapses. Each experience a baby is exposed to—everything she sees, every song she’s sung, every time she’s held or fed or smiled at—sends a series of electrical impulses shooting through the developing circuits of her brain, strengthening pathways and inciting new synapses to grow. During the first few years of life, that growth happens exponentially. At its peak, the cerebral cortex region of an infant’s brain can produce two million new synapses every second—a warp-speed neural spider web that sets the parameters of a person’s capacity to think, learn and process emotion. Connections that are stimulated consistently over time will grow stronger. Others will weaken and die.
The raw materials of brain development are predetermined, encoded in the 23,000 genes we inherit from our parents. But the way those genes behave—whether they live up to their potential—is determined in large part by the inputs we get during the first few years of life.
Since the 1970s, psychologists have posited that the key ingredient to a child’s development is her emotional attachment to her caregivers. As babies, the idea goes, we depend on adults not just to make sure we’re fed and clothed, but to respond to our cries, our facial expressions, our inquiries about the world and our attempts to connect. Behavioral researchers are fond of quoting the psychologist Urie Bronfenbrenner, famous for founding the Head Start program for low-income preschoolers. “In order to develop normally,” Bronfenbrenner wrote, a child needs to interact with “one or more adults who have an irrational emotional relationship with the child. Somebody’s got to be crazy about that kid.”
Attachment theory has reigned as the dominant philosophy of child wellbeing for close to half a century. The trouble with hypotheses about behavioral psychology, however, is that they are difficult to test. In order to isolate the impacts of nurturing parenting, researchers needed the chance to study a control group—in other words, a large group of kids who never got to be nurtured. That opportunity arose with the fall of the Socialist Republic of Romania, when Western scientists discovered Romanian orphans.
In the mid-1960s, Nicolai Ceausescu, the Stalinist leader of Romania, invoked a series of laws designed to increase his country’s human capital by forcing up its birthrate. He outlawed contraception and abortion, subjected women to compulsory fertility tests and taxed families that produced fewer than five children. Childbirth shot up, as did poverty. The state was obligated to create hundreds of institutional orphanages to care for babies whose parents didn’t want or couldn’t care for them.
When Ceausescu was deposed in the 1989 Romanian Revolution, nearly 170,000 children were living in state institutions that Western reporters, newly allowed into the country, described as being more like warehouses than orphanages. Babies and toddlers spent day and night in rows of cribs, removed only to sit on pots they used as toilets. They were rarely held and had almost no one-on-one interaction. The buildings were mostly silent.
Thousands of Romanian orphans were taken into homes in the United States, where adoptive parents discovered that, despite the drastic change in their circumstances, many suffered from severe and persistent problems. A significant number had stunted growth or abnormally small heads. Many were cognitively impaired or had behavior disorders and extreme difficulty engaging in relationships. For some kids, some of the problems dissipated over time; others proved more stubborn.
In 2000, a team of American neuroscientists traveled to Romania’s capital, Bucharest, to study children in its orphanages, which remained the country’s default form of care for orphans and unwanted kids. Starting with a group of 136 children, aged 5 months to 2.5 years, the scientists ran tests to measure cognitive and emotional development, then compared the results to a group of same-aged Romanian children who lived at home.
In every domain, the researchers found evidence that institutionalization had done tremendous damage. Kids in the orphanages showed diminished electrical activity in their brains, slower neural reactions and weaker connections between areas of the brain that integrate information. Their cognitive scores were at a level associated with mental retardation. They demonstrated almost no attachment to their caregivers and, when researchers tried to engage them with activities like peek-a-boo or puppet shows, no ability to experience amusement or joy.
The researchers assigned half the children to specially trained Romanian foster parents, leaving the other half in institutions. Over the next several years, they ran developmental tests aimed at finding out if, when and how the children’s trajectories diverged. What would change when terribly neglected babies began receiving individualized care? Could the damage be undone?
The answer turned out to be both yes and no. At 30 months, the children who had been moved into foster homes showed a capacity to express positive emotions that was indistinguishable from children who had never been institutionalized. After a year of foster care, they matched the expressive and receptive language skills of children in the community control group, though their grammatical abilities remained low. By 54 months, their average IQ score had risen by about seven points—still much lower than that of kids who had never been in orphanages, but an improvement over children who had remained there. The latter group’s average score dropped by one.
There was one area, however, in which foster care made almost no difference. All of the institutionalized kids— those who had been moved into homes as well as those who remained—were diagnosed with drastically higher rates of depression, anxiety, ADHD and conduct disorders than children in the community control group. At 54 months old, more than half were found to have a diagnosable psychiatric illness.
In a 2009 paper on their findings, the Bucharest Study researchers noted that the children’s impairments—and improvements— were not evenly distributed: Kids who had been moved into families before the age of two made significantly more progress than those who moved when they were older. “Our results,” the researchers wrote, “strongly support intervention at earlier ages.”
The lesson of the Bucharest study was rare in its lack of ambiguity: The absence of parenting is disastrous to babies’ development.
But it’s also a finding that begs to be turned upside down. For people who work with traumatized children and their families—especially in the child welfare system, with its mandate to decide the slippery question of when caregivers are good enough—the most relevant question is the degree to which good parenting can help. To what extent can the presence of an involved caregiver protect a child’s brain from the harm caused by early stress and trauma? Which practices help children develop, and which don’t?
An important clue seems to be hidden in the function of a stress-related steroid hormone called cortisol. When human beings encounter a threat, our brains launch an intricately choreographed, nearly instantaneous response designed to muster our metabolic resources to fight or to flee. Jolts of electricity shoot from the sensory organs, through the limbic system to the hypothalamus, a cluster of neurons nestled near the root of the brain stem. The hypothalamus triggers the pituitary and adrenal glands, which deluge the bloodstream with chemical signals that incite our hearts to pump faster, our airways to open and our glucose levels to rise. Cortisol is both the end product and the regulatory agent of the stress-response cascade, instructing the body either to relax or remain vigilant to danger.
Cortisol is indispensible, should you find yourself facing a stranger in a dark alley or the more abstract menace of a looming deadline at work. But it is markedly less useful for coping with the grinding, long-term stress that results, for example, when a child’s family falls apart. “These systems were designed by evolution to deal with much more immediate situations,” says Philip Fisher, the University of Oregon psychologist. “We’re not well adapted for the kind of chronic, persistent stress that can happen when parents are drug abusing or mentally ill. In evolutionary terms, there wasn't a lot of survival… somebody takes over the parenting or the infant dies.”
In studies of children’s stress-response systems, cortisol is often used as a marker of things gone awry. Under normal circumstances, both children and adults have regular, predictable patterns of cortisol production: We wake up in the morning with high levels, which decrease steadily throughout the day. When we encounter a stressful situation, our cortisol levels spike, then—if our systems are healthy—quickly return to baseline. When children’s brains are exposed to cortisol too often and for too long—either because of traumatic experiences like neglect and abuse or simply because they absorb the atmospheric stress that so often tailgates intractable poverty—it can alter the structure of the genes that control hormone production, disrupting the stress-response system in one of two ways: Either children’s cortisol production becomes hypersensitive (quick to turn on and stubbornly resistant to being shut down), or it becomes chronically dampened, producing abnormally low levels of cortisol to start the day.
In a particularly damaging corollary, prolonged stress seems to stunt growth in parts of the brain that have large numbers of cortisol receptors. This includes the prefrontal cortex—a region most closely associated with a set of skills known collectively as ‘executive function.’
Executive function is not the same as intelligence, but it encompasses abilities that are crucial to learning, such as the power to control impulses, to shift attention from task to task, and to manipulate information in the short-term. Children living in poverty regularly score lower on tests of executive function than wealthier kids. Many scientists think the cause is exposure to ambient stress.
In 2002, a team of researchers in Pennsylvania and North Carolina launched a study designed to untangle the relationship between poverty, stress and brain function. Starting with a cohort of nearly 1,300 babies, they ran periodic tests until the children were 3 years old. First, they measured stressful conditions such as family crowding and the noise level and safety of babies’ homes and neighborhoods. Then they subjected the babies to briefly stressful situations, such as taking away a toy or repeating the child’s name while wearing a strange mask. Before and after each experience, the researchers took saliva samples to measure the babies’ production of cortisol.
As with previous studies, the researchers found that kids who lived amid greater levels of poverty and chaos were likely to have disrupted cortisol patterns, and that these kids did worse than other kids on measures of executive function. But the study also tested a potential mitigating factor: the relationships between babies and their mothers.
At each visit, researchers videotaped mothers interacting with their children. They then coded the videotape, rating mothers on qualities such as sensitivity, animation and the positive regard they expressed for their babies. What they found was that when mothers were rated as being particularly responsive and nurturing, their babies’ cortisol patterns were much more likely to be normal, regardless of whether they lived in poverty or chaos. Even in the cases where babies’ cortisol patterns were irregular, those with responsive mothers were likely to score higher on tests of executive function. In other words, having a nurturing mother almost completely mitigated the developmental damage that, in other children, correlated with stress.
In a 2011 journal article, the study’s authors posed a series of questions about their findings. “It is not clear,” they wrote, whether particularly responsive mothers were affecting their babies “through a tactile and kinesthetic nurturing process” or through more contextual practices “such as structuring of opportunities and appropriate levels of stimulation.” It’s even possible, they suggested, that the behaviors they measured simply coincided with other markers of involved parenting, like exposing children to new situations.
Whatever the operative mechanism, the study was among a growing number that point to the good-news flip-side of this research on trauma and development: Stressful environments are damaging to children’s growth, but committed caregivers have the power to protect them. Damage, in other words, is not a foregone conclusion.
The question, for Philip Fisher, is how to make that good news relevant to kids whose relationships with their parents have already been disrupted.
Once his toddler’s adoption finally went through, Fisher found himself in the disorienting position of a service provider who has become in need of services. “Although the placement process was difficult,” he says, “the adoption went really well initially and we were very happy.” As his son approached adolescence, however, he started to struggle. Fisher realized that his family fell into a kind of social services hinterland. Few of the people traditionally designated to help troubled kids and families (grateful though he was for their support) understood the needs of children who had experienced the displacement of foster care or adoption. On the other hand, people who worked with families in the child welfare system—those in the best position to impact foster children’s developmental health—largely reserved their attention for older kids.
Working with researchers at the Oregon Social Learning Center, a think tank that develops service programs for kids and families, Fisher set out to create a new model for providing foster care to preschool-aged children—one that would protect them, at least in part, from the long-term damage caused by trauma and stress. The goal was to isolate what scientists had learned about the benefits of responsive parenting— those practices that had proved most likely to protect children from developmental harm—and inject them into relationships that are, by definition, temporary.
Under Fisher’s program, which goes by the unwieldy name of Multidimensional Treatment Foster Care for Preschoolers, or MTFC-P, foster parents undertook a training program that emphasized a preschooler’s need for structure, consistency and nurturing. They learned strategies to address negative behaviors, but were instructed to mete out approval much more frequently than punishment, and to respond readily to children’s attempts to connect. The program also provided a great deal more assistance than is typically available to foster parents, including weekly support groups and home visits from a child development consultant. Kids in the program attended weekly therapeutic playgroups and worked one-on-one with a therapist if they showed evidence of developmental delays. Program staff were available 24 hours a day to troubleshoot any problems.
Fisher and his team tested the model with a group of 117 foster children in rural Oregon. Half were placed in standard foster homes; half went to foster parents who had been trained in Fisher’s program. The researchers compared their outcomes to a community control group of low-income, preschool- aged kids who lived with their parents.
Over time, as might be expected in a program with so many supports, kids in the MTFC-P homes did better than kids in regular foster care by all the standard measures of child welfare success. They moved between foster placements less frequently. When they went home to their parents, they were less likely to come back into the system. And when they were adopted, the adoptions were more likely to last.
Far more revelatory was what happened when researchers measured the children’s stress-response systems. At the beginning of the study (and like foster kids in previous experiments), children in care were much more likely than other kids to have abnormal cortisol production. Nearly one-third came into the study with what Fisher describes as a ‘blunted’ pattern, starting off with low cortisol in the morning and experiencing a much smaller than normal decrease through the day.
As the study progressed, cortisol production among the children in traditional foster homes became even more abnormal. Their mean level of morning cortisol dropped by close to 30 percent, so the pattern became significantly more blunted over time. Meanwhile, morning cortisol levels among the children in the MTFC-P homes rose. By the end of the study, their cortisol production was indistinguishable from children in the community control group.
Fisher explains that much of what happened during the study remains mysterious. Scientists don’t fully understand how or why cortisol patterns change, or even precisely what the changes mean for a child’s long-term development. What was clear, however, was that something about the MTFC-P foster homes allowed very young children to reverse damage that had been caused by turmoil in their lives. Given the right training and support, caregivers were able to nurture children who then regained a measure of health. “It shows that plasticity works both ways,” Fisher says. “It’s not just that we say, ‘bad things produce bad outcomes.’ If we can maintain the right circumstances, things can get back on track.”
In that sense, the premise of the model reflects that of the science that informs it. It rests on the hope that the better we understand how children grow, the more possible it will become to sever the link between traumatic childhoods and chaotic adulthoods. For the most part, chronically stressed children don’t grow in isolation. They develop in the context of overtaxed families and of communities made unstable by poverty, violence, illness and incarceration. The science of infant development promises hope that we can wipe the slate a little bit cleaner—that if we are willing to build the skills of children’s caregivers and to ease some of the burdens that limit their ability to provide responsive, nurturing care, it might be possible to loosen the grip of the past on the future. Fortunes can be reversed; children freed to reach their potential.
“Obviously there are going to be limits depending on how severe a child’s experiences were,” says Fisher. “You can’t take a child that’s experienced extreme deprivation and make everything hunky dory for them, but you can improve their trajectory. And for children who've experienced less severe adversity, there’s potential to make things move in a really solid direction.”
In the past two decades, researchers have learned a great deal about how to protect children from the harm caused by early trauma or neglect. That knowledge does little good, however, if it doesn't reach the people caring for the kids who are most at risk. For babies and very young children in New York City’s foster care system, that means not only the foster parents who take them in at times of crisis, but also the birth parents to whom most kids eventually go home.
Two years ago, the city’s child welfare administration hired a researcher named Philip Fisher to develop a program that would help caregivers understand how baby and toddler brains grow. Out of the profoundly complicated and rapidly expanding universe of thought on infant neurobiology (and along with scientists at Harvard University’s Center on the Developing Child) Fisher extracted a single concept that he considers to be the basic unit of infant development.
The idea is simple: It is in babies’ nature—in their basic wiring— to initiate interaction with the adults who take care of them. What determines a baby’s fate is whether she has a caregiver who responds. If she does, and especially if the responses are consistent and nurturing, her brain will make connections between sounds, expressions and objects, stimulating her neural circuitry to grow in the sturdy configurations that buttress future thinking and learning. Her relationship with her caregiver will become stronger, freeing her to explore her world and initiate further interactions—and so the cycle is set up to repeat itself.
“The underlying guiding principle is that healthy development is preprogrammed to occur,” Fisher says. “But it requires the right kinds of input.” When caregivers give that input, they create a kind of developmentally stimulating interaction that Fisher and his collaborators call ‘serve and return.’
In order to teach parents how to recognize babies’ serves and give them appropriate returns, Fisher developed a series of brief video clips, each designed to demonstrate the micro-moments of responsive parenting. In one, a mom picks up her baby. Through a succession of freeze-frames, we watch the baby begin to fuss. When his mother reaches for him, we see him look for her face. His eyes brighten and he kicks with excitement. The mother makes eye contact, speaking in a gentle voice as she takes the baby into her arms.
The interaction lasts less than half a minute. It’s one that any parent in the room—even one who has lost custody of her child—has almost certainly experienced. Which is precisely the point, says Kristen Greenley, who manages Fisher’s video project. A basic principle of the program is that if caregivers understand why their nurturing is so important—if they learn to see themselves as a powerful, positive force in their children’s development—they will nurture more and, as a result, build stronger relationships and raise healthier kids. “We’re showing them: You’re already doing this,” Greenley says. “Pay attention to when you’re doing it. It’s really good for your child.”
The city’s Administration for Children’s Services (ACS) has adopted Fisher’s work as one piece of a larger project to improve and standardize services for families in the child welfare system. Under the broader initiative, which goes by the umbrella name of ChildSuccessNYC, parents attend a series of workshops, which are run as a cross between a parenting class and a support group. Facilitators instruct caregivers on developmental stages (what parents can reasonably expect from their children and when) and on parenting strategies intended to nurture children’s development at each stage. Caregivers are assigned to practice the strategies at home and have regular, individual check-ins with caseworkers about their progress.
The workshops adhere to what are known as “evidence based” models: They were tested in controlled trials involving large cohorts of foster kids, with results that showed better outcomes than those of kids whose caregivers weren't enrolled in the programs. However, the programs were developed for parents with children over age 5—kids whose problems are often more obvious than those of babies and toddlers. In New York City, foster care agencies are using Fisher’s video clips in order to fill the gap.
So far, five of the city’s foster care agencies have been trained to offer the ChildSuccessNYC workshops. More than 400 foster parents and nearly 350 birth parents have completed them. Close to half have children under age 5.
In other versions of Fisher’s program, being implemented elsewhere, facilitators visit parents in their homes and videotape them interacting with their own children. Then they isolate examples of serve and return and play them back to parents in individual sessions, pointing out the connection they see in those moments. Fisher says that individual video screenings are the optimal way to run the program, but that they would have been too costly and time-consuming to meet New York City’s requirements. “We have to be adaptable,” he says. “One of the things we’re waiting to see is, in the context of larger groups designed for older kids, how much will the infant material be infused? How much do the techniques get employed?”
ACS is working with an independent evaluator to assess the impact of the programs. The results will be available sometime next year.
Most parents whose children enter foster care have to take parenting classes in order to get their children back. I went to two parenting classes that didn't help before I found a program that worked for me. The ones that didn't help were the ones where the instructor read to us from a big parenting skills book or played old videos of moms trying to get their kids to listen. Then the instructor would say, “Ok, what did you learn?” or just, “Hey, use the skills you saw today in this video.”
I’d sit there thinking that the strategies didn't apply to my son. The book would say to put your kid in a time out if he acted out, but when I tried time out with my son, it only made him angrier. When I told the instructor that, she just said, “Keep trying.” I felt defeated, like a failure.
At the time, my 5-year-old son was living with my grandmother because I’d been arrested and then placed in a mental health facility for 18 months. By the time I moved back home, I’d overcome an addiction and was managing my bipolar disorder. Xavier was about to come back home and I felt overwhelmed because we still didn't have that mother-son respect level. I wanted it to be that I spoke to my son once and he would listen, period, end of story. But Xavier was not listening the first, second or third time I told him to do something. I had to understand that that’s not quite how kids are.
Eventually the court sent me to a different kind of parenting program, a video training at a program in the Bronx called Chances for Children. Each week, they took video of me playing with my son and then the therapist discussed it with me. At first I felt like, “Ugh, I don’t want to be here. It’ll just be a repeat of the last two classes.” But it was different. With the video, I got to see the problems between my son and me from a different point of view.
During our video sessions, Ms. Martha would have Xavier and me play on the carpet with different toys. In the middle of the session, she’d stop the tape to show me what she noticed. She said that it was good that I even wanted to play with my son, and that she could tell that we normally play with one another. She also noticed that when we were coloring, Xavier longed for my approval of his picture. Ms. Martha told me this meant Xavier cared about what I thought, which is a sign of a mother-child bond.
Ms. Martha also showed me how I was frustrating Xavier by moving too fast from toy to toy. I kept changing the toys because I was bored with them instead of waiting for him to finish. This would make Xavier upset. He would try to get the same toy again. I thought Xavier was too young to understand playing. I wanted to teach him how to follow instructions so he could play with his toys how they were meant to be played with. I didn't understand his way of playing, that it didn't matter if he followed the instructions if he was enjoying himself.
It was hard to watch the first day’s video. When I saw myself pressure Xavier into playing with a new toy because I was tired of playing with the old one, I felt like I was being a bully, not a mom. But after that session, I felt amazed. Ms. Martha had already helped me understand why my son got frustrated when we played together; he was unable to finish tasks that he started. Martha told me it was OK if Xavier stayed on tasks a little longer than I preferred.
At first, when I tried to follow Ms. Martha’s advice at home, it was a disaster. Xavier took so much time to play that he didn't want to stop to eat or take a bath or do anything that he wasn't ready to do! At our next session, I told Ms. Martha that I could not just simply let him play as long as he wanted. We had things to do besides play! She told me about the egg timer approach. I would set the egg timer to go off 10 minutes before I wanted Xavier to do a different task. The countdown helped Xavier understand that playtime was almost over.
At home, the egg timer approach didn't work immediately, but eventually it worked so well that I just gave Xavier early warnings and we gave the egg timer a rest.
From our video parenting sessions, I learned that Xavier needed me to be more patient with him and to hear him out. I also felt like he began to understand that when I gave him warnings that it was time to stop playing, he had to listen.
The biggest change was in my thinking. When my grandmother raised me, she acted like children should have no say-so, no thoughts, no feelings and, point blank, no voice. When Xavier was young, I found myself inhabited by my grandmother’s ghost. I treated Xavier the same way.
The video parenting helped me realize that kids have their own minds and have real feelings too. Now that I've acknowledged that children are human just like me, I can talk with them instead of demanding. When I first went to the video parenting, I just wanted to get Xavier to listen to me. From our experience, I learned that I needed to listen to him, too.
by Piazadora Footman
Piazadora footman is 28 years old with three children, ages 12, 8 and 4. She is a graduate of Child Welfare Organizing Project’s Parent Leadership/Advocate Curriculum and the editorial assistant at Rise, a magazine written by and for parents in the child welfare system, where a version of this article fist appeared. The latest issue of Rise focuses on the impact of trauma on parenting.
INFANT MENTAL HEALTH experts warn that the best way to address the city’s stark shortage in mental health services for young children is not simply to create more treatment slots. rather, attention has to be paid to placing these programs where families can find and use them. “We believe in a co-location model, where you put what we do in other systems,” explains Joaniko Kohchi, child development specialist at the Early Childhood Center of the Albert Einstein College of Medicine in the Bronx. Kohchi and her colleagues would like to see infant mental health services in places where parents with young children already go: pediatric clinics, child care centers, high school-based nurseries, family Court, foster care agencies, even in home-visiting pro-grams. “if a parent is already stressed, the chances of you getting to a clinic once every week is not realistic,” says Susan Chinitz, director of the Early Childhood Center.
As reported in a 2000 report of the Surgeon general’s Conference on Children’s Mental health, one study found that only about 41 percent of children referred by a pediatric provider for outside mental health services actually made it to intake. Putting mental health professionals where parents already are makes services easier for families to use while reducing the stigma often associated with mental health treatment, says Bonnie Cohen, director of university Settlement’s butterflies Program. This also a-lows infant mental health specialists to educate other types of professionals, like child care workers, about the often overlooked social-emotional side of infant and toddler development.
A 2012 Citizens’ Committee for Children analysis found that in the Bronx, Staten island, and Brooklyn, mental health treatment slots exist for only about 1 percent of the children ages 0-to-4 who need them. once a child turns 5, however, options for receiving help increase. Many more clinics accept children 5 and older, and with kids entering kindergarten at this age, it is far easier for professionals to identify who needs support and to provide help at school. Mental health specialists say that waiting until age 5 wastes valuable time as well as a key opportunity to help children at an age when their brains are developing most rapidly. (See “The Science of Trauma.”)
“In some ways, it’s discriminatory to only start services at school age,” says Chinitz. “Why wouldn't there be services for every age?”
A few New York City initiatives are already structured this way
- Therapists in the Butterflies Program at University Settlement work with the children, teachers, and families enrolled in university Settlement’s EarlyLearn program. One full-time therapist and one part-time therapist screen nearly 350 children under age 5 each year for social and emotional issues, support and train EarlyLearn staff, and provide therapy for children and families who need more intensive help. Many of the children they work with are Chinese-American and have recently been reunited with their parents in New York after spending earlier years with grandparents in China. Butterflies therapists help them reconnect with their parents and adjust to their new homes and country.
- The foster care agency Forestdale’s Attachment and Biobehavioral Catch-Up program works with babies between 6 and 24 months and their caregiver’s right in their homes. The highly-structured, 10-week program aims to increase attachment between children and caregivers. Forestdale’s version of the model typically works with babies in foster care and their foster parents, as well as with parents and children who have recently begun living together again after involvement in foster care. “These mothers have been brought to the attention of child welfare and feel like they’ve done something terrible and that they aren't a good mother,” says Anstiss Agnew, Forestdale’s executive director. “The model is meant to reassure and teach at the same time.”
- Recognizing that pediatricians are the only professionals to regularly see most babies, the Children’s Hospital at Montefior in the Bronx pairs an infant mental health clinician with pediatricians. At the hospital’s children’s clinic, this psychologist or licensed social worker—who has the more parent-friendly, less stigmatizing title healthy Steps Specialist—works alongside pediatricians to help ensure that young patients and their parents get appropriate mental health screening, referrals and treatment along with their physical checkups and vaccines. The infant and toddler specialist also trains pediatricians and medical students, helping to make them more comfortable in talking with patients about issues like post-partum depression, trauma and substance abuse.
- The Family Court in the Bronx has partnered with early childhood specialists at the Early Childhood Center, who provide treatment to parents of young children involved in family Court while sharing their expertise with judges and other court officials. The Jewish board of family and Children’s Services’ institute for infants, Children & families is planning a similar program for Manhattan family Court, which will be funded by the state’s office of Children and family Services.
- The Riverdale Mental Health Association (RMHA) provides mental health treatment along with services like work readiness training and job placement. Chances for Children, which works to strengthen relationships and attachment between parents and their young children, is based at RMHA and trains the association’s clinicians on how to work with the families of young children who have experienced trauma, stress and attachment difficulties.
This issue of the Watch focuses on the city’s youngest residents: babies and toddlers. We explore the impact of chronic stress on young children’s brain development and present national research around interventions aimed to buffer that effect and to better support the parents of young children. More than 6 percent—or 518,000—of New York City’s 8.1 million residents are under 5 years of age. A handful of local programs work with the families of young children who are affected by poverty, chronic stress and trauma, including some innovative programs for the child welfare involved parents of young children. We highlight the need for more of this type of expertise and illuminate the dearth of government funding and services targeted for caregivers seeking help for young children. Following are recommendations and solutions proposed by the Child Welfare Watch advisory board: The New York State Office of Mental Health (OMH) and the city’s Department of Health and Mental Hygiene should provide consistent, adequate funding for early childhood mental health treatment, and for professional training.
Providing early help to infants and toddlers who need it can prevent more costly, intensive and potentially invasive interventions later in life. Nobel prizewinning economist James Heckman has demonstrated that investing in effective early childhood interventions can yield huge cost savings—and that there is a steep decline in the value of these savings as early as the end of a child’s third year of life. However, state and city government funding for treatment is very limited and few professionals are trained to provide treatment to this age group. A 2012 analysis by the Citizens’ Committee for Children estimated that state-licensed mental health clinics had treatment spots for only 1 percent of children age 0 to 4 who needed them in three of New York City’s boroughs. Slots were most scarce in community districts considered high risk due to factors such as economic poverty and safety. Government and society are missing the opportunity to provide young children with appropriate treatment before their needs and symptoms compound. Some clinics and organizations providing early mental health treatment are reimbursed a small amount through Medicaid or, in some cases, by their referring foster care agencies. Many families are not eligible for these funds, or are served outside of clinics. Today, the City Council is one of the few sources of government funding for community-based early mental health treatment, but its support is not solely for treatment or for training clinicians to work with infants and toddlers; it must also cover the cost of screenings and evaluations. What’s more, this modest support of $1.25 million is not “baselined” into the mayor’s budget and is therefore at risk of elimination each year. We urge the city and state to recognize the need for more treatment options—including intensive, dyadic therapy, which is most lacking—for this vulnerable group of New Yorkers. There is also a great need to build a viable workforce able to work with children under 5 and their parents.
The city, state, and nonprofit organizations should co-locate infant and toddler mental health services in the places where young children and their parents already go: pediatric clinics, foster care and preventive agencies, family court, homes, community centers and child care programs.
Parenting young children while living in poverty or with other sources of chronic stress is taxing. Parents and young children who could benefit from treatment will be far more likely to find help if it is located in the places where parents already go. This makes services easier to access, reduces the stigma frequently associated with mental health treatment and allows infant mental health specialists to educate other professionals who work with babies—such as child care workers, judges, pediatricians, home visiting nurses and preventive workers—about the social and emotional development of young children.
The State Department of Health should provide professionals in the Early Intervention Program with comprehensive training in the social and emotional development of young children.
Early Intervention is the city’s largest, most comprehensive program for treating kids under 3. In theory, Early Intervention can work with children under 3 whose only issues are social-emotional. In practice, the program largely focuses on addressing developmental delays and disabilities, making it a missed opportunity to help the families of babies who are struggling with the effects of trauma or chronic stress. To help nudge Early Intervention closer to becoming a system able to address early childhood mental health, Early Intervention professionals should receive comprehensive training around the mental health needs of young children, with a focus on how to address and recognize the effects of trauma in this age group.
The state OMH should track the number of state-licensed mental health clinics—also known as Article 31 clinics—that have the capacity to treat infants and toddlers.
Few clinics have the capacity to provide mental health treatment to infants and toddlers. No government agency tracks the number that do serve very young children and their families. This makes it extremely difficult to address the citywide gap between treatment need and capacity.
The state OMH and the city’s Human Resources Administration and Department of Health and Mental Hygiene should collaborate with parents and community organizations to create an advertising campaign that promotes positive, supportive parenting of young children.
A growing body of research suggests that “supportive parenting”—a reflective, child-centered approach to parenting that stresses sensitivity, warmth, and responsiveness—is a key to buffering the potentially lifelong toxic effects of a childhood marred by stress, violence and trauma. New York should mount a campaign dedicated to educating parents about the benefits of supportive parenting and provide powerful examples of what it means to be responsive to the developmental needs of infants and toddlers.
The Administration for Children’s Services (ACS) should require foster care agencies to ensure that babies and toddlers in foster care are screened for mental health impairments, in addition to standard developmental evaluations.
Last year, there were more than 3,050 children under age 5 in New York City foster care. Young children often come into care with tumultuous histories that put them at high risk of medical, emotional and developmental problems. Once in the system, many of them continue to experience turbulence, moving from caregiver to caregiver while being separated from their families. When foster care is necessary, it should be maximized as an opportunity to nurture children’s developmental health. In the past decade, ACS has made great progress in the effort to ensure that children receive developmental screenings when they enter care. These screenings focus primarily on cognitive and physical delays, rather than on the more subtle impacts of disrupted relationships and stressful experiences that threaten babies’ emotional wellbeing. Unfortunately, mental health assessments often don’t happen until children are older and demonstrate obvious behavioral symptoms of emotional distress. Some agencies have developmental specialists on staff to ensure that developmental screenings take place, and to follow kids who demonstrate special needs. This systematic approach should be instituted at all agencies, with a similar level of attention paid to mental health screenings for children of all ages.
ACS and the state Office of Court Administration (OCA) should routinely train frontline staff and contract employees on the developmental needs of infants and very young children.
Removing babies and toddlers from their homes disrupts their attachments to caregivers and can have lifelong negative consequences. Frontline workers at foster care agencies, as well as child protective specialists and key Family Court staff, attorneys and judges, should be regularly trained in the particular developmental, emotional and mental health needs of infants and very young children—including the damage that can be caused by repeated disruptions in care. I n the past, a privately funded court commission ran an initiative that educated court staff about infant development, while also providing guidelines and checklists to help judges and attorneys make sure that babies received appropriate care. In the absence of outside funding, ACS and the courts should continue these practices. OCA should consider designating social workers to follow infants’ cases in court, ensuring that they receive developmentally appropriate services. Along with frontline case workers, Family Court judges should consider conducting analyses of babies’ existing attachments before making placement decisions. OCA should also consider the feasibility of creating specialized court parts for babies and very young children, staffed by judges with particular training in early childhood mental health, and who are fully informed of resources in the community for infants and their parents.
ACS and nonprofit family support organizations should ensure that parenting classes engage in active skillbuilding, supporting parents to understand and nurture their children’s development.
Too often, parenting classes are didactic exercises in compliance, instructing parents in basic skills they may already know. These classes—in conjunction with family visits—should be used as an opportunity to support parents’ meaningful interaction with their children, building skills that encourage nurturance and children’s secure attachments. With the recent introduction of its ChildSuccessNYC initiative, ACS has taken steps toward incorporating a focus on children’s developmental and emotional needs, and on the positive, crucially important role a parent plays in her child’s development. Under the initiative, parents participate in facilitated groups that promote both instruction and discussion, including concrete information about strategies to support infant brain development and mitigate the potential harm caused by trauma or neglect. The implementation of ChildSuccessNYC should not preclude parents and foster care agencies from pursuing alternative approaches, however. Specifically, there ought to be more opportunities for parents to learn about child development in environments where they can interact with their children, supported by facilitators who help them build understanding of real-life issues in real time. The ‘Baby & Me’ program at SCO Family of Services is one example of this kind of program. Parents and their children participate in a structured playgroup, in which facilitators discuss elements of development, demonstrate strategies to support that development, and then provide opportunities for parents to interact one-on-one with their children. Support groups and instruction are both valuable, but they should be closely connected to visitation experiences for parents and their children in foster care—and parents themselves should have both the information they need and the freedom to choose the most appropriate programs.