History of ECMHN

Overview
Beginnings
Community Education
Projects Network Meetings
Study and Network Growth: The Recent Past
Overview
Mental health of babies
All they do is eat and sleep.
They don’t talk, and barely have minds, so how could you ever do psychotherapy with them?

These reactions--stunned, and sometimes even contemptuous--greeted the newborn Network almost 20 years ago. Since then, we have worked to weed out ignorance and prejudice and to create fertile ground for nurturing early childhood mental health. As a group, we have sown many seeds. Some seeds—like community lectures—have generated new ideas for helping young children and their families. Some seeds have grown into ambitious projects: the Respite Child Care Project; and Healthy Babies/Healthy Children, which integrated mental health services into primary medical care. Of these projects, some flourished, and survive to this day. Others withered, not because they weren’t good ideas, but because the cultural soil was too thin. In either event, our work has enriched community understanding of infants and young children.

Two decades have convinced us that infant mental health is all about relationships. Babies need dependable and sensitive caregivers. Likewise, parents need sustaining relationships to support them in their parenthood. And, the community that supports young children and their families needs professional collaboration. The Network has forged these essential relationships. We, the members of the Network, have formed a nexus of diverse perspectives, energies, talents, strengths and limitations through respectful dialogue about young children’s mental health. Making and sustaining creative connections is the story of our work.

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Beginnings
In a 1994 survey, New Hampshire’s early interventionists—physical, occupational, and speech/language therapists; social workers; and educators working with infants and toddlers who had disabilities or developmental delays—asked to learn more about infant mental health. In response, the state Family Centered Early

Supports and Services (ESS) organized New Hampshire’s first infant mental health conference. In June 1995, Daniel Stern—psychoanalyst, author, and interpreter of infant research—introduced the North Conway audience to the richness of early mental development. Babies’ minds, said Stern, are shaped by attachment interactions with their caregivers. These interactions, in turn, are reciprocally influenced by both baby and parents, often by thoughts and feelings of which parents are unaware. And, these relationships can be enriched by infant-parent psychotherapy. This new view of the infant, of the power of the infant-parent relationship, of the power of relationship-focused interventions, and of the power of the unconscious mind, inspired the audience.

To fix these ideas in the community’s memory, and to sustain the conversation, the state funded regional infant mental health teams. They gathered representatives from early intervention, preschool special education, community mental health, child protection, child care, maternal and child health, and pediatrics. The state allowed each region to choose their team activities.

Here in the Upper Valley, Kathy Marshall, ESS director at United Developmental Services, convened the first Network meeting in 1995. Around the table sat Susan Lloyd from Dartmouth College’s Child Care Project, Pat Martin from the VNA parent-aide program and Good Beginnings, Carol Little and Carol Andrews from Dartmouth-Hitchcock Medical Center, Judy Ford from the Family Place, Miriam Voran from West Central, and Stephanie Schell from Developmental Services of Sullivan County. This core group generated plans and shared their dreams for the Network.

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Community Education
The Network’s first priority was education. In 1995, we brought Susan Partridge, a psychologist from Maine, to lead a day-long training. Susan had developed the AIMS curriculum—promoting Attachment, Initiative and Mastery in infants and toddlers. Her work sounded the same themes that Stern had introduced at the state conference, but gave practical form to his ideas. The AIMS curriculum was being used in doctor’s offices, mental health clinics, and homes throughout Maine, and had apparently helped Maine become a leader in infant mental health. This well-attended training established community education as a successful Network activity. The Partridge/Stern interface reflected a fundamental tension, the tension between our need to respect and accommodate the complexity and depth of the mind, on the one hand, and our need for “doable” programs, on the other. This tension would become the principle challenge for the Network.

Four years later, the Network sponsored a second training—this time a two-day workshop on a parenting curriculum for teenage mothers. The curriculum, Partners in Parenting Education (PIPE), promoted actual interactions between parents and their infants. Using exercises that showed how babies communicated and self-soothed, PIPE helped parents and babies have fun together. Following the training,

PIPE was used at Hannah House, the Family Place, and parent groups co-led by the VNA and West Central.

In addition to these two trainings for early childhood professionals, the Network has sponsored lectures for the community. We have hosted talks by Network members and brought prominent speakers to the Upper Valley, each event building awareness and showcasing different approaches to early childhood mental health. The Child Care Project helped organize and publicize the talks, and eventually incorporated mental health topics into its ongoing trainings for childcare providers. Key Network talks have included:

Theresa Bollick on “What Does It Mean?” advocating careful observation and description of behavior.

Miriam Voran on distinguishing ADHD from traumatic reactions and attachment problems.

Dan Hughes, on the afternoon of 9/11/2001, describing the emotional power of attachments, before an audience still reeling from the trauma of the terrorist attacks.

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Projects
Encouraged by the enthusiastic response to our early trainings, Network members became eager to pursue projects that would improve services for young children. The first effort grew out of conversations among Network members. Pat Martin, directing a home-visiting program, urged home-based psychotherapy to reach vulnerable families. With funding from the Division of Behavioral Health, West Central began Right from the Start (RFS), an early childhood mental health program with a continuum of services. At West Central, a psychologist (Miriam Voran) provided infant-parent psychotherapy, and--for toddlers and preschoolers—individual treatment with parent consultation. The agency also hired a new therapist to see families in their homes and to meet regularly with the VNA’s staff serving the same families. By fostering collaboration within the community mental health center and across agencies, RFS was an exciting model. It also demonstrated that a community mental health center could be reimbursed for treating young children. However, it was hard to find clinicians experienced in working with young children, a challenge the Network continued to face as it implemented programs. RFS faltered as staff left the agency and ended in 2001.

Despite its short life, this first project helped bring seeds of change to the Network. With extra funding from RFS, we hired Cindy Swart as our facilitator. Skilled in grant-writing, program development, and running meetings; energetic; and well-networked in the community, Cindy helped us tackle big problems with big projects. In the fall of 2000, we conducted a needs assessment and identified the key barriers parents faced in obtaining help for their struggling young children. This list gave us a new focus of “to dos” as we undertook projects that required systemic changes in funding streams and cross-agency cooperation.

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Respite Child Care
First we addressed respite child care. Historically, this critical family support was tied to specific agency programs. A child might receive respite through West Central Behavioral Health because of a mental illness, or through United Developmental Services (now PathWays) because of a developmental disability. However, many children didn’t meet criteria for these programs, yet their parents still needed respite care. Network members, and the parents we interviewed, knew that families were falling through the cracks. Giving parents a break to re-fuel could help them better nurture all their children.

After researching successful models, the Respite Task Force, with 3-year funding from the NH Endowment for Health, created the Respite Child Care Program (RCCP) in 2001. The program has been administered by the Upper Valley Support Group, now called the Special Needs Support Center (SNSC), and continues to this day. It has received funding from a variety of sources, including Grafton County Incentive Funds, Granite United Way, and several foundations. With shrinking funds, RCCP has focused its limited resources on families with special needs children. In fiscal year 2014, money for RCCP has become very limited and SNSC is exploring a number of funding sources for the future. Despite these funding challenges, RCCP has served 10 to 25 families each year since 2001. Respite care remains a major need of all families and an invaluable resource needing continued funding.

For more details about the history of RCCP see the Networks Projects page of our website.

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Healthy Babies/Healthy Children
With a new respite program thriving, the Network then turned to the more elusive problem on our “to do” list—that the system of care for young children was fragmented and difficult to navigate. We formed the Infant Mental Health Task Force and met with parents and six professional groups to understand the problems. The issues were obvious. Persistent stigma inhibited doctors from discussing mental health during well-child visits and left parents ambivalent about getting help; neither parents or professionals could navigate the confusing maze of services, filled with false turns and dead-ends, to find the right help for a child; and there was a shortage of therapists trained to work with young children, especially those under age 3.

To fix this broken system, we needed a completely new and integrated approach. So, in 2006, the Network launched Healthy Babies/Healthy Children, an ambitious project that infused early childhood mental health into primary care, early intervention, and the community mental health center. Kathy Marshall, ESS director at PathWays, administered the new project and Miriam Voran, psychologist, provided consultation. Major funding came from the NH Endowment for Health, with additional support from the Kettering Family Foundation, United Way, and Grafton County Funds.

Healthy Babies began with an 18-month pilot project at Doug Williamson’s pediatric practice at the Community Care Center of Alice Peck Day Hospital. A “developmental specialist” (Connie O’Leary, an experienced nurse and mental health clinician) conducted developmental screenings using the Ages and Stages questionnaires, provided parenting support, and—for high-need families—home-based therapy. Dr. Williamson readily identified struggling families for the program. Over time, he also recognized that “stable” families wanted to see Connie, many of them opening up about unexpected family struggles. With this new awareness of ubiquitous and often hidden emotional challenges, we were on the road to infusing early childhood mental health as a UNIVERSAL support for families.

In 2008, Healthy Babies grew into a 3-year program. Using lessons learned from the pilot, the program now promoted universal screening in pediatric practices, a psychologist for the ESS team, a closer partnership with the community mental health center, and training for pediatric residents. One clinician (Erika Gore Bacon) did screenings and anticipatory guidance at the existing Community Care Center site, and saw families for ongoing therapy through West Central. A second clinician (Caroline Levy, psychologist) worked in the Mascoma Clinic of Dartmouth Hitchcock Medical Center and followed ESS families with social-emotional concerns. Both clinicians had learned Brazelton’s Newborn Behavioral Observations (NBO) system and used this tool to help parents, and even siblings, get acquainted with their newborns. The NBO showed parents how their babies reacted to sights and sounds and regulated intense sensations, and how they as parents could support this regulation. We were showing parents that infants did far more than eat and sleep. And we were highlighting regulation as a cornerstone of the infant’s growing mind.

Of course, it was not always easy to implement Healthy Babies in a busy clinic. With clinicians working part-time, and tight clinic schedules, we didn’t meet our goal of universal screening, nor did we always have relaxed time with a family. But the clinicians were flexible and creative; many families received support and consultation in the clinic; and many families were referred for further help. The Healthy Babies staff found that their relationships with families, rather than any specific screening tool, allowed them to understand concerns and make a difference. Another challenge was the persistent difficulty in billing for the clinicians’ time. Lacking evidence that Healthy Babies could become self-supporting, additional funding was not requested and, in 2011, the program ended.

Although Healthy Babies itself is gone, the program’s ripple effects endure. West Central hired a Healthy Babies therapist, who continues to see referrals from the pediatric practice. In addition, the agency trained many of its clinicians in Child-Parent Psychotherapy (CPP), an evidenced-based manualized treatment for young traumatized children. Recognizing that Healthy Babies would increase the need for early childhood therapists, West Central had sought their own training, partnering with the Psychiatric Research Group who had already trained their staff in evidenced-based treatments. Although this was not the approach that all Network members might have hoped for, CPP has increased the number of therapists for young children and their parents.

Other legacies of Healthy Babies continue around the community. At Dartmouth-Hitchcock Medical Center, the residency training, with a component started through Healthy Babies, gives new pediatricians in-depth experience with assessment of the infant-parent relationship and developmental screening tools. At PathWays, the ESS workers draw on perspectives gained through collaborating with psychologists. With separate grant funding, they and the psychologist learned to use the Autism Diagnostic Observation Schedules (ADOS) to identify toddlers with autism spectrum disorders. And, the professional consultation the consulting psychologist sought in response to Healthy Babies cases has enriched her own practice. The program got many parents and young children early help. In the process, clinicians shared their perspectives and deepened their understanding of young children’s minds.

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Family Resource Center
In 2007, with Healthy Babies launched, the Network explored a third major project—a family resource center. We wanted a single building to house the patchwork of family supports presently scattered across our community. We dreamed that this center could include a toy lending library, play groups, and parenting workshops—in short, a home for normalized supports for all parents. We also dreamt of a therapeutic child care program for emotionally challenged children, a need that Healthy Babies was making conspicuous. Ultimately, the Network, despite careful planning and tending relationships with potential collaborators, decided the time was not right and reluctantly placed this good idea on the back burner.

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Resource Posters
One final Network project has persisted for many years and now has a home on this website—large posters that map the early childhood resources for New Hampshire and Vermont. Hanging in doctors’ offices, child care centers, and stores throughout the Upper Valley, these posters remind parents that child development matters. A second, smaller hand-out lists the developmental and educational systems. Both these resources were produced by Kathy Marshall of Pathways, a volunteer parent (also a graphic designer), and Susan Lloyd of the Child Care Project.

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Network Meetings
One activity has remained constant across our almost 20 years—monthly Network meetings. Here, we bring news about evolving community needs and resources, talk about our own work, challenge each other with different perspectives, germinate new ideas, and—most important--build relationships. “Relationships” is an enduring Network theme. Just as infants depend on their parents to grow, and parents need connections with a coherent system of care, the relationships forged around the Network table help us better meet the needs of young children and their families. These collaborations have enabled us to tackle projects that no one group or individual could undertake alone. They have also enriched our daily work, as it grew easier to pick up the phone and call a network colleague for advice or help.

Network relationships have broadened and deepened our vision of what supports healthy development and successful parenting.

Over the years, our membership has swelled and dwindled; we have been more and less involved with statewide projects. One time, nearly 20 people sat at the table, racing through updates, Task Force reports on our projects, and, if we were lucky, discussion of an article. Until recently, NH’s Children’s Care Collaborative funded all the regional infant mental health teams. Cindy Swart participated in quarterly meetings of Network facilitators and brought news of conferences and projects around the state. Then, the state decided to tie team funding to participation in it’s new screening program—Watch Me Grow. After much discussion, the Network decided to forgo state funding. Healthy Babies, a Watch Me Grow site, had sent screening data to the state registry. But without Healthy Babies, being unable to cover the unfunded costs of implementing Watch Me Grow, and doubting the value of a screening program that didn’t include the therapeutic supports we’d come to appreciate in Healthy Babies, we declined participation in Watch Me Grow, and focused our energies elsewhere.

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Study and Network Growth: The Recent Past
Another Network change has been the departure of key members, and at times we have struggled to keep our momentum. In 2010, Cindy Swart retired, leaving big shoes we knew couldn’t be filled. Change, as we tell families, creates both loss and opportunity. For the Network, Cindy’s unwanted departure also opened space to rethink our focus and direction, assessing the present landscape of early childhood mental health and which barriers—in systems and in community attitudes—we could realistically address. Without a paid facilitator and with fiscal belt-tightening throughout the state, the climate was inhospitable for launching new projects. Briefly, before her own retirement, Susan Lloyd, long-standing core member, facilitated our group. Then, in 2011, Phil Eller, Director of Special Needs Support Center, agreed to take the helm. Phil has brought expertise in building bridges among diverse groups and his organization’s resources. He has drawn in new members, including Nina Sand-Loud, developmental pediatrician, and Stephen Mott, pediatric neurologist, both from the Children’s Hospital at Dartmouth. Building relationships continues to be a key Network activity, as we learn about the respective systems, each with respective constraints, in which we work to help young children. We have also been educating ourselves about developmental neuroscience and “toxic stress.” These readings give hard science evidence for a core Network theme: the central importance of early relationships in shaping mental and physical health.

Our most recent public activity occurred in October 2011, when Network members, along with the Special Needs Support Center and the Ethics Institute of Dartmouth College, brought Robert Whitaker, award-winning science writer, to the Upper Valley. Whitaker’s newest book, Anatomy of an Epidemic, reviewed the long-term outcomes of psychotropic medication. Over the years, we had watched an alarming sea change in early childhood mental health. In contrast to the initial stunned reactions to mental health for little children, by the late 1990s, preschoolers, and even toddlers, were increasingly receiving psychiatric diagnoses and pills. “Big Pharma,” having gobbled up the adult and school-age market, was reaching for younger and younger children. In the process, a narrow deterministic view of young children’s mental health was taking hold. Where, we wondered, had the more complex developmental perspective gone? Whitaker’s talk raised questions about our ready turn to medication and got the community talking. One pediatrician said that it dramatically changed his practice. And the success of this event has reminded the Network of its power of public education.

Over the last two decades, services for young children and families in the Upper Valley, their needs, and the cultural climate have all changed dramatically. Network activities, along with growing cultural awareness of the importance of early experience, have put early childhood mental health on the map. Gone are the days when such concerns were ridiculed. With an explosion in the diagnosis of autism spectrum disorders and an understanding of the necessity of early detection and treatment, the social-emotional development of infants and young children is now in the spotlight. The American Academy of Pediatrics has declared systematic developmental screening the standard of care and urges pediatricians to add mental health promotion to their clinical responsibilities. Although the implications of health care reform remain largely unknown, the thrust towards cost-containment promises to encourage prevention of serious troubles and the integration of mental health services into primary care. With more struggling infants and young children identified, the question has shifted from “DO the under-fives need mental health treatment?” to “WHAT KINDS of treatment work and for whom?” Pressure for evidenced-based treatment raises questions about what kinds of data will illuminate the treatment of complex minds and the complex relationships (between parents and children, between providers and families) that nurture mental growth. Around the Network table, we bring different views and experience to these questions.

It is easy to forget the endless complexity of the human brain, whose activity, starting long before birth, gives rise to our experience of mind. The brain is the most complex organ in our body. It is perhaps the most complex object in the known universe. Mental processes, in their complexity, far exceed any other biological process; they may influence other biological processes in ways we are just beginning to understand. Nowhere do we have a greater opportunity to shape mental growth than in our work with babies and parents. Our challenge as a Network is to capitalize on these opportunities, even as we struggle against cultural prejudices.

The Network is evolving in response to the needs of our community. If you care about young children’s mental health, we invite you to join us.

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The Early Childhood Mental Health Network of the Upper Valley website address is www.ecmhn.org
Email us at info@ecmhn.org
Or call us at 603-448-6311.

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