HOME - BASED EARLY HEAD START

“Kitchen Therapy”
By Brenda Jones Harden

Lanita’s commitment to her two daughters is readily apparent to Janice, an Early Head Start (EHS) home visitor, but Janice has also noted several issues. The older daughter has the expressive language skills of a much younger child. She tends to be very oppositional and ignores her mother’s directives or attempts to engage her. Lanita’s younger daughter has a very sad manner, is hesitant to join in play with her sister, does not reach for her mother when she hurts herself in play, and cries inconsolably whenever Janice attempts to leave. Lanita is also extremely sad, lethargic, and unable to focus on even small tasks. Lanita’s boyfriend supports her and her children, but she does not seem interested in maintaining this relationship. She does not find joy in anything she does nor does she have anticipation for the future. In her discussions with Lanita, Janice has learned that Lanita’s grandmother, who raised her, died two years ago and that Lanita has an older child who was placed in foster care at birth.

When families such as Lanita’s are referred to Early Head Start programs, the programs are often at a loss as to how to address their psychological needs. Although Early Head Start is not a mental health program, it has an established goal of promoting the development of the whole child, including the child’s emotional development. For infants and toddlers, the major strategy for addressing their emotional needs is enhancing the parent/child relationship. In fact, the development of the young child across domains is exceedingly difficult to achieve without the support and well-being of the parent, even if the child participates in the highest quality intervention.
Infant mental health services are designed to enhance the emotional well-being of young children through their relationships with their caregivers. Selma Fraiberg (1980), a pioneer in the infant mental health field, referred to these services as “kitchen therapy,” an allusion to the home setting in which she felt these services were best provided.

Providing infant mental health services in the context of the home has several advantages—

• Intervention that is conducted on the family’s turf allows for increased comfort, openness, and trust on the part of the family.
  
  
• Observation of parent/child behavior is possible in familiar surroundings and where the larger family system is present (e.g., grandmothers).
  
  
• Services can be more flexible in terms of time, space, and focus of work.
  
  
• Intervention can incorporate the family’s resources and address the family’s needs in a concrete manner.
  
  
• Intervention can capitalize on natural parent/child interactions in the home, such as feeding, bathing, grooming, and putting the child to bed.
  

Home Visitors’ Role
Alicia Leiberman (1999), an expert in the field of infant mental health, has stated that you do not have to be a therapist to be therapeutic. In other words, there are specific services that can be delivered by EHS staff with appropriate training. Staff members should be consistently supervised. They should discuss families and what needs to be accomplished in the home visits. They should have access to regular mental health consultation to learn more about particular mental health issues and specific strategies to employ with families. Finally, if possible, programs should develop collaborations with local mental health services where parents can obtain treatments for any mental health difficulties.

With an overarching goal of enhancing the parent/child relationship, infant mental health services should focus on meeting the psychological needs of the parent, supporting the parent to attend to the child’s cues, enhancing parent/ child interaction, and fostering the child’s sense of security within the parenting relationship. The following are strategies to meet these objectives in the context of EHS home-visiting programs.

Psychological Needs of the Parent
Jeree Pawl (1998), who has spoken and written on the provision of infant mental health services, coined a “platinum” rule: Do unto others as you would have others do unto others, meaning home visitors should nurture parents in the manner that parents should nurture children. Parents should have the opportunity for an emotionally corrective experience with the home visitor, in which they receive unconditional acceptance throughout the duration of their relationship with the program. Home visitors must provide consistent and empathic care to families, even when parents display “resistance”—such as not being home for appointed visits or expressing anger at the home visitor. In addition, home visitors can do initial screenings regarding the psychological health of the parent. Many programs screen parents for depression using a questionnaire. Parents who report clinical symptoms can be referred for individual psychotherapeutic intervention.

Attending to the Child’s Cues
Pre-verbal children have to rely on the insight of their caregivers regarding their needs. They need adults who understand the message behind their cries, facial expressions, and body movements. Home visitors can help parents pick up these cues by talking about the child’s need for the parents, pointing out specific child behaviors and potential reasons for the behaviors, and mimicking the child’s voice and asking for certain parental responses. Parents can be coached to understand their infants’ temperaments and preferences, and to anticipate their moods and needs. Emphasis should be placed on parental responsiveness during times of distress. For example, when an infant is most vulnerable (e.g. hungry, tired, frustrated, fearful), parents can be coached to remember the behaviors their infants display and the strategies that are effective in consoling them. Coaching the parent during the home visit to use the consoling strategies at the time these behaviors are displayed can be beneficial.

Fostering Parent/Child Interaction
Building a relationship is best carried out in the context of “in-vivo” parent/child interaction. Home visitors can engage parents and infants in play interactions to provide them with positive joint experiences without pressure. They can use the toys and materials that are in the home to increase the likelihood that mothers will repeat these activities when the home visitor is not there. Similarly, capitalizing on the routine interactions between the mother and her baby (e.g., grooming, feeding, putting to bed) allows the caregiver to work on relationship issues with the infant during frequent or daily activities. Finally, coaching the parent to use playful, fun types of interaction can enhance the parent/child relationship.

Enhancing Child’s Sense of Security
Developing an attachment to a primary caregiver is the major social-emotional milestone of the infancy period. Scholars have emphasized that security of attachment during the infancy period leads to later positive outcomes across all domains of child development. Thus, when home visitors work toward establishing secure attachments between parents and children during infancy, they are potentially supporting the child’s long-term development. Home visitors can accomplish this in several ways, including 1) promoting parents’ constant expression of love and care for their infant; 2) coaching parents to be consistent, gentle, and developmentally appropriate in their provision of structure and discipline; 3) encouraging parents to be a secure base for their infants when they are distressed; 4) helping parents think through how to handle separations from their infants appropriately; 5) facilitating parents’ feeling of joy when they are with their infants; and 6) meeting the child’s needs as responsively as possible.

Other Services
Deborah Weatherston (1995), who directs one of the few long-standing infant mental health training programs in the country, has delineated a set of comprehensive infant mental health services that should be provided to families at environmental risk. In addition to the relationship-focused therapeutic intervention that should occur at each home visit, she suggests including the following intervention modalities—

• Developmental Guidance
  Educating the parent about developmental milestones and appropriate expectations for their children is a major component of the services that Early Head Start programs provide. This guidance should be provided in the course of the moment-to-moment interactions that the parents have with their children. It is less effective to lecture to the parent.
  
  
• Emotional Support for the Parent
  Because the role of Early Head Start home visitors is not to provide mental health services to parents, it is essential that programs have a mental health consultant on staff who can offer such services or have a cooperative agreement with a local mental health provider. In rural areas, where it may be difficult to access a mental health provider, it may be appropriate to arrange mental health supervision by telephone or Internet for the most qualified person on staff to provide such services. As discussed in the previous section, home visitors themselves can augment this type of mental health intervention by directly providing emotional support to the parent as well.
  
  
• Concrete Services for the Family
  Families at environmental risk are beset by many stressors that come from not having adequate resources, such as food, housing, money, and transportation. For parents to focus on psychological issues, they must have their basic needs for survival met. Home visitors must address these issues with parents through joint problem solving as well as direct referrals. This work can be linked to the goals of infant mental health intervention by promoting parental self-esteem when parents overcome one of these barriers, and addressing how the parents’ stress affects the child’s psychological well-being.
  

In sum, infant mental health intervention can facilitate the accomplishment of the overarching goal of Early Head Start—to promote optimal child development. Many scholars and clinicians advocate for the provision of preventive infant mental health services in the context of the home. Early Head Start home visitors have a unique opportunity to support child and family development through this modality. By receiving infant mental health services in the home, families like Lanita and her children can move toward the sense of psychological well-being that is essential for their capacity to progress toward other developmental goals.

Selected References

Fraiberg, S. 1980. Clinical studies in infant mental health: The first year of life. New York: Basic Books.

Leiberman, A. & C. Zeanah. 1999. Contributions of attachment theory to infant-parent psychotherapy and other interventions with infants and young children. In Handbook of Attachment, eds. J. Cassidy & P. Shaver, 555-574. New York: Guilford Publications.

Pawl, J. & M. St. John. 1998. How you are is as important as what you do. Washington, D.C.: ZERO TO THREE/ National Center for Clinical Infant Programs.

Weatherston, D. 1995. She does love me, doesn’t she? Zero to Three 15(4): 6-10.

Brenda Jones Harden was a 2000-2001 Society for Research in Child Development Fellow, CORE, Office of Planning, Research and Evaluation, ACF, DHHS. She currently serves as Assistant Professor at the University of Maryland Institute for Child Study. T: 301-405-2580; E: bj34@umail.umd.edu.