Network Projects
Healthy Babies/Healthy Children

One of the major projects of the Early Childhood Mental Health Network was the creation and implementation of the Healthy Babies/Healthy Children program. It represented a collaboration of the Network with PathWays of the Upper Valley, West Central Behaviorsl Health, and the Community Care Center of Alice Peck Day Hospital. Spearheading this project by writing most of the grant to the Endowment for Health and facilitating the implementation of the project was Kathy Marshall, Coordinator of Early Supports and Services of PathWays. Following are two documents that detail this important and valuable program. They are from the grant application to the NH Endowment for Health.

Statement of Need: In the fall of 2000:
Early Childhood Mental Health Network of the Upper Valley Network) members and Network parent members in a separate session underwent an exercise to identify the key barriers to services for families with young children who may be experiencing problems that are not strictly physical. Two barriers were identified. The Network with funding from the Endowment addressed the more manageable barrier of lack of respite care, the result being a wonderful new program administered by the Upper Valley Support Group. The Network then formed the Infant Mental Health Taskforce (Taskforce) to address the more elusive problem, which is that the system of care for young children is fragmented and difficult to navigate for providers and parents. The persistent stigma around mental health is a central reason that the emotional wellbeing of young children is often ignored in primary care settings. This is particularly detrimental for young children, for whom there is no clear distinction between physical and mental health. This stigma results in problems not being identified in a timely manner and children/families not receiving interventions as early as possible when they can be most effective and save money in the end. (Early childhood risk factors that are often not addressed include problems with eating or sleeping, difficult temperament, irritable, constitutionally fragile, inconsolable, unresponsive, listless, depressed, or insecure attachment to caregiver. Toddlers may have developmental delays, disorders, or sensory processing difficulties. Parents may experience depression, substance abuse, social isolation, anxiety, have unrealistic expectations about their children.)

We constructed flow charts for five components of the system of care: public awareness, education and support, screening, assessment and moderate intervention, and assessment and intensive intervention. We also developed flow charts for major providers, such as DHMC, VNA, and WCBH. We identified community assets, decision points, alternative actions, and barriers to care. The following 5 barriers glaringly rose to the forefront:

Stigma and ambivalence:
Parents are ambivalent about seeking help, feel stigmatized for doing so, and thus often do not raise the concerns they have. Professionals are reluctant to place labels on children, and are often uncomfortable with social/emotional issues. Parents are often told to wait a while, and everything will be fine. We believe that stigma is the major contributing factor to the other barriers listed below. According to the Surgeon General’s Report on Mental Health, the stigma “deters the public from seeking, and wanting to pay for, care,” and “Explanations for stigma stem, in part, from the misguided split between mind and body first exposed by Descartes. Another source of stigma lies in the 19th century separation of the mental health system in the United States from the mainstream of health.”

The system is made up of several different systems, each with its own culture, language, funding streams, technology, etc., but none set up for the sole purpose of attending to the social/emotional needs of young children and their families. Only the most persistent of families and professionals can figure it out or locate a successful point of entry. Even then dead ends are often the result. There is no way to identify what each private therapist’s specialties are or what payer he/she accepts. There is no infrastructure which brings people/providers together.

There is an enormous need for training. There are VERY few psychotherapists with the ability to serve children under 6 and even fewer (perhaps only one) able to serve children under 3. Most others serving young children (child care providers, home visitors, etc.) do not have access to mental health consultation and the opportunity to seek guidance, training or support from professionals knowledgeable about early childhood social and emotional development and relationship-based intervention. Screening: Pediatricians and PCP’s do very little screening for social/emotional issues or caregiver/child relationship issues. There is no clearly-recognized standardized screening tool. Lack of time spent with each child, lack of available services, and difficulties in navigating the system are factors that discourage screening. The limited screening that is done usually does not consider the whole family and the relationship between the child and family. Funding/gaps: It is often impossible to diagnose a child under 3, especially when the difficulty has not yet been internalized by the child, but resides instead in the parent-child relationship. Frequently, diagnosing remains difficult in children under six; thus this population is sometimes denied services funded by third party payers. Because of the gaps and lack of flexibility of funding, services to families are often not flexible. When families are served by two or more systems each with its own agenda and focus, there is duplication of service, conflicts between providers, confusion for the families, and ultimately fragmentation of service and lack of focus on the whole family. The Taskforce then conducted seven focus groups with a total of 53 individuals: 1) people who conduct home visits to families with young children; 2) parents of children with social/emotional issues; 3) child care providers; 4) pediatricians and psychiatrists; 5) psychotherapists; 6) pediatricians; and 7) parents of children who attend the Children’s Center of the Upper Valley. The purpose of the focus groups was to brainstorm strategies to overcome the previously identified barriers to the current early childhood mental health system of care, to stimulate changes in other systems, to stimulate awareness, and to build partnerships between among systems. Notes from every focus group were emailed to every participant. This exercise alone stimulated change in the way people do their work. For example, child care providers developed a system of better communicating concerns to parents and pediatricians. In analyzing the findings of the focus groups, it quickly became apparent that early childhood mental health is all about relationships – the relationship between a parent and child; between the parent and the child’s physician, child care provider; between providers. The power of the relationship between a family and its community also became apparent. A matrix of the major suggestions for a workable early childhood system of care of all focus groups was compiled and is a one page attachment. Suggestions were multiple, across systems, and complex. The Taskforce realized that there would be no simple fix and that a completely new out-of-the-box and system-changing approach was required.

We reviewed the literature and programs across the country. It is now clear from early brain research that early experiences of children from conception on have a profound impact upon emotional health, physical well-being, the immune system, and school readiness. The mind-body connection and the impact of stress on the immune system are well documented. The attachment to caregivers is of primary importance. Primary care physicians play a key role in supporting early childhood mental health and identifying concerns, but time-constraints and lack of training can interfere. In a study of 68 pediatric practices where screenings for social/emotional issues took place, 13% of preschoolers had an emotional/social disorder. Healthy New Hampshire 2010 identifies as an objective: “Increase the number of persons who receive mental health screening and assessment in a primary health care setting.” Interventions to improve early childhood mental health do work.

Economic analyses document the cost effectiveness of intervening early:
Program participants reap a chain of benefits into adulthood, including better school achievement, less special education, increased college attendance and employment, and decreased rates of crime and delinquency. Given the sizeable evidence that early relationships can improve through intervention, we expect that early childhood mental health services will save society money. The cultural stigmatization of mental/relationship problems is an excuse for inaction and discrimination and should no longer be tolerated. Attached is a 2 page summary of the literature and a bibliography.

Review of local demographics and need for service:
There are approximately 2,330 children 0-6 in our service area. If 13% of these have an emotional/behavioral disorder (as the earlier cited study indicated), that would mean approximately 302 children in need of some type of intervention. The Lebanon area SAU is referred about 35 three to six year olds per year; the pre-school coordinator estimates that 14 of these are expected to have social/emotional/relationship needs. The Dresden SAU, which receives 5 to 15 referrals per year, would expect 3 to 6 to have social/emotional/relationship needs. The director of Lebanon’s child care center, the Children’s Center of the Upper Valley, indicated that she would refer 10 of the current 93 families to the new program. Child care centers often know children the best and are de facto in the position of handling mental health issues. UDS currently serves 32 developmentally delayed children birth to three. Of these, 20% are in need of direct mental health services; 50% are in need of mental health consultative services. After many attempts, we have been unable to find out how many children 0-6 are in families being served or investigated by DCYF. In 2004 only 25 children under 4 came to West Central Behavioral Health for an initial appointment, most were 3, a few were 2. However, West Central needs training and support in order to serve very young children and their families. Creative funding also needs to be explored. We know of only one therapist in the area, Dr. Mirian Voran, with the training and expertise to provide therapy to families with very young children.

Project & Grant Description:
The goal of the Healthy Babies/Healthy Children Program is to improve the access to a full range of health care for children in Upper Valley, New Hampshire families from pregnancy until the child’s 6th year by normalizing the inclusion of mental health supports in primary care settings. These early years have become widely recognized as the most vulnerable and most developmentally critical. The program will work to increase the community’s and parents’ awareness that a child’s earliest years play a critical and lasting role in intellectual, social, and emotional development, and that parents are their child’s first and most important teachers. The provision of health care will require changes in the mental health, developmental, and primary care systems. The success of the project will depend upon the recognition that a child can not be evaluated or helped as an entity separate from his/her family and environment, that the nature vs. nurture debate is no longer relevant for services to young children, and that for young children there is no clear distinction between physical and mental health. This recognition (by parents, pediatricians, other providers, community members, and those across the state who are in policymaking positions told of this program) will begin to reduce the stigma of mental health issues.

Our Network is currently providing leadership to other areas of the state. Although systems of care are by their very nature fluid and vary according to the assets of any community, we hope to provide a blue print to others. The program will expand the existing services of UDS’s Early Intervention. A developmental specialist, most likely a social worker, trained in early childhood mental health will be hired the first year; a second specialist will be hired the second year. Miriam Voran will provide clinical training and supervision. The specialists will provide services in primary care settings, in families’ homes or other natural settings, and consultation to other programs serving young children.

The outcomes expected for the program are outlined in detail on the accompanying Workplan.

The Taskforce is aware that this is a difficult time to secure continuing funding for new programs. However, we believe the following sustainability plan is workable:

Organizational Capacity:
United Developmental Services has been providing quality services to people with or at risk of developing developmental disabilities since 1970. Within the state they have a proven track record of providing leadership in the area of disabilities. Within the Upper Valley they have a proven track record of collaboration with school, hospitals, and other providers. They have the respect and trust of the families they serve. UDS is committed to removing the barriers, especially stigma, which have prevented families from receiving the supports and services they need. It now appears that the proposed forced merger/dissolution of UDS is unlikely. In the unlikely event that a merger takes place in FY07, all contracts will be honored and services would not be interrupted.

Collaborating organizations/people and their roles are as follows: UDS has agreed to assume the role of lead agency. They will hire the developmental specialists, formalize agreements with collaborators, and act as the lead in exploring continued funding. As indicated on the front page of the proposal the key contact people are Bruce Pacht, Executive Director, and Kathy Marshall, Program Coordinator of UDS Early Intervention. (See letter in attachments.) Community Care Center of Alice Peck Day Memorial Hospital will be the first pilot screening site. Doug Williamson, MD, the Medical Director of the Center is the contact person and may be reached at 448-3122. (See letter in attachments.)

Dartmouth Hitchcock Medical Center Mascoma site has agreed to be the second pilot screening site. They will also include the screening protocol in teaching pediatric residents at the site. William Boyle, MD and Mardee Laumann, ARNP are the contact people and may be reached at 523-4382 (See letter in attachments.) This will serve as a door into the more complex DHMC Lebanon site. West Central Behavioral Health has agreed to explore what services they can best provide, seek training and supervision in these areas, and provide therapeutic interventions were as needed. (See letter in attachments.) Miriam Voran, Ph.D. psychologist and widely recognized expert in the area of early childhood mental health has agreed to provide training and clinical supervision to UDS and West Central staff. This could later be broadened as necessary. She may be reached at 448-5912. (See letter in attachments.) Early Childhood Mental Health Network has agreed to act as advisors to the program and to assist with marketing of the program. Cindy Swart, the main writer of this grant and the Network Coordinator may be reached at 795-2243. It is anticipated that more formal collaboration will develop with Network members as the program matures.

Statement of Need:
Healthy Babies/Healthy Children was conceived by the Early Childhood Mental Health Network of the Upper Valley (Network) based on local planning and focus groups initiated in the fall of 2000. (See attached matrix of focus group specific concerns by groups of stakeholders). As noted in our recent Letter of Inquiry, information indicated that the current system of care for young children to support their overall health, including mental health, was fragmented and difficult to navigate for both the family and providers. Common threads of concern included these needs: more trained therapists for young children, education for community providers and physicians to recognize red flags and have a system for follow-up, home based services and therapeutic childcare, more resources for families and providers, identification of a screening tool for social/emotional concerns, care managers in pediatric offices or the community mental health office, and services for all exclusive of funding or diagnosis.

Through combined funding sources, the Network began to address some of the concerns noted by the stakeholders at the focus groups and at Network monthly meetings. The choice of using the primary care setting as the natural site for supporting families with young children was supported by nationwide initiatives, such as North Carolina Assuring Better Child Health and Development Project (ABCD). Literature from their project offered many “pearls”, two of which were “identify a physician champion to lead project activity” and “direct activity from a local level rather than at the state level”. Douglas Williamson, MD, was identified as an interested pediatrician and his practice as the initial site.

Our early experiences highlighted the mental health needs of the youngest children and documented the effectiveness of early identification and treatment.

A new mother, who had psychiatric hospitalization and ECT during pregnancy, was overwhelmed, isolated, and fearful about parenting her infant. The Healthy Babies counselor engaged this mistrustful mother in the ESS program and provided home-based infant-parent psychotherapy. This high-risk infant-mother pair now has a network of support and her baby is developing close to what is expected for his age. Supports are continuing through PathWays.

Parents overwhelmed by their toddler's activity level, aggression, and defiance received consultation in the pediatrician's office. They now feel more effective in teaching their child self-control. A relationship that had been headed towards escalating power struggles is now on a positive, cooperative path.

Our continued research supported the wisdom of moving forward with addressing the needs of our Upper Valley community. Review of literature indicated relevant information that could be applicable for the local communities: “About 16% of children have disabilities including speech and language delays, mental retardation, learning disabilities and emotional/behavioral problems; however, only 30% with disabilities are detected before school entrance”

“Maternal depression, alone, or in combination with other risks, can pose serious but typically unrecognized barriers to healthy early development and school readiness, particularly for low-income young children”. “Even for typically developing children, families benefit by increased awareness of appropriate developmental and behavioral expectations”. “The pediatric office is recognized as a universally accessed, non-stigmatized setting, ideal for the assessment and treatment of early childhood mental health problems. However barriers to this type of care are considerable, including time limitation on the part of pediatricians, inadequate reimbursement structures, inadequate training of pediatricians, and insufficient connections between physical and mental health providers”.

Given knowledge of the local community and nationwide issues concerning the social/emotional wellness of young children, the Network reframed its Healthy Babies/Healthy Children initiative for moving forward in program development. The combined practices of Drs. Feyrer and Williamson serve 1000 children from newborn to age 6. With the current level of support, the office is only able to screen 10% of its patients. Of that 10%, only 3-5% receive additional supports for concerns regarding social/emotional wellness. DHMC-Mascoma is a smaller practice and serves 150 children from age six months to six years. Screening is similarly low at about 20%. Intervention is at approximately 10%.

Project and Grant Description:
The vision of Healthy Babies/Healthy Children is for children to be healthy, happy and successful in their families and communities. The goal of the program is to improve the access to a full range of health care for children in Upper Valley, New Hampshire families from pregnancy through the child’s fifth year by normalizing the inclusion of social/emotional wellness supports in primary care settings. These early years have become widely recognized as the most vulnerable and most developmentally critical. The program will work to increase awareness that a child’s earliest years play a critical and lasting role in intellectual, social, and emotional development, and that families are the primary supports for young children. The provision of health care will require changes in the mental health, developmental, and primary care systems. Communities will need to provide accessible and appropriate services for families with young children when there is a mental health concern. The success of the project will depend upon the recognition that a child can not be evaluated or helped as an entity separate from his/her family and environment, that for young children there is no clear distinction between physical and mental health and that the community offers a wide array of services to support families.

Miriam Voran, PhD, in her review of relevant literature, shares the following best practices for the youngest children:

Interventions will draw on promising clinical practices that have fostered secure attachment in high-risk dyads and resolved regulatory and behavior problems in clinic-referred infants and toddlers . These psychodynamic treatments use in-vivo infant-parent interactions to help parents 1) understand the baby’s individuality and developmental needs, and 2) reflect on the baby’s mind. The parents’ ability to think about mental states (their child’s and their own) and to see how behaviors are meaningful linked to an inner life of thoughts, feelings, and wishes is called reflective function. Thru reflective function, parents promote secure attachment and teach their children to think about and regulate emotions. Thus, helping parents understand their children’s minds and needs is an overarching goal of Healthy Babies interventions. Both the short-term interventions offered through the primary care setting and the more intensive treatments provided by community therapists will draw on lessons learned from developmental psychopathology and clinical research about ways to foster the parental reflective function and secure attachments that promote a child’s mental health.

The program has identified several outcomes which are described in depth on the Workplan. Essentially the outcomes are divided between expansion of the Healthy Babies/Healthy Children pilot program initiated with combined funding, including Endowment Technical Assistance funding, and the addition of new outcomes which add opportunities for the inclusion of new community partners. It is anticipated that two Healthy Babies/Healthy Children specialists will be needed to address the many facets of the program.

A. Enhancement and Expansion of Pilot Project:
Healthy Babies intends to build upon successes and make needed refinements to services that began with the pediatric practices of Douglas Williamson, MD and Sheila Feyrer, MD. Within the practices, universal screenings for social/emotional concerns will be included, as well as family supports for those children and families for whom a mild level of intervention (resource and referral, home visit, consultation) are needed. For those families and children needing a greater level of service, services in the pediatric site become a bridge to more intensive interventions. More focused screenings; e.g., suspected autism, will help to make the decision for further referrals.

With the interest generated within the medical community, a second site has been chosen. This site, Dartmouth Hitchcock Medical Center-Mascoma, (Ann Laumann, NP, Kimberly Gifford, MD, David Cunis, MD) serves a more rural population. Approximately 150 patients from 6 months to 6 years are served in the practice. Mental health supports for children and families in this practice generally address concerns related to environmental risks associated with poverty /low income and lack of availability of community supports (e.g., transportation, multi-agency presence).

Expansion also includes the role of the Healthy Babies specialist within PathWays as the area agency for developmental disabilities. Provision is made for direct service delivery for infants and toddlers who meet the eligibility criteria of Family Centered Early Supports and Services and consultation delivery for preschoolers within the system. Provision is also made for consultation to include staff providing services within Sullivan County.

B. Addition of Community Partners:
Through the Healthy Babies pilot, the consulting psychologist contacted Dr. Diane Kittredge about using the model at Dartmouth-Hitchcock Medical Center. Dr. Kittredge, who is the Associate Program Director for the residency and the Director of Ambulatory Education, became excited about opportunities for resident training. She wanted to strengthen the residents’ competencies to conduct developmental surveillance and screening, promote healthy development (including mental health), and make appropriate referrals. Thus, Dr. Kittredge and Dr. Carol Little (pediatric faculty in Child Development) partnered with the psychologist to develop a training curriculum.

This curriculum has two foci. First, residents will learn to use screening tools that are time-efficient in a busy practice, such as Ages and Stages and the M-CHAT. Second, recognizing that residency provides a unique opportunity to deepen clinical skills, each resident will also conduct in-depth developmental surveillance with three young children during the three-year residency. With these training cases, the residents will gain hands-on experience with neurobehavioral assessment in infancy, observation of infant-parent interaction and attachment, and use of the Denver Developmental Screening Test with toddlers and preschoolers. These clinical experiences are designed to strengthen the residents’ understanding of normal development and their ability to detect early signs of concern. The training also shows residents how parents nurture their child’s developing mind and how they as pediatricians can support healthy child-parent relationships. Thus, residents will see the powerful potential of the pediatrician to promote early childhood mental health.

To implement the curriculum, faculty will provide training through the residents’ pre-clinic conferences (5 sessions) and noon conferences (4 sessions). Five continuity clinic preceptors will support and observe the residents’ use of screening tools as the residents provide health supervision to their own panel of families. In addition, one of our child development faculty (CA, CL) will provide as needed one-on-one supervision and the psychologist (MV) will give as-needed mental health consultation. When residents identify mental health concerns, they can refer families to the Healthy Babies specialist and other community resources. Pediatric clinic’s onsite social worker will facilitate referrals as needed.

This project will focus on the interns entering our pediatric residency over the 5 year project [N= 7 interns x 5 years =21]. In addition, other learners, such as senior residents, chief residents, medical students and nursing staff will be exposed to portions of the curricular materials.

Drs. Michelle Parsons and Nancy Nowell, at West Central Behavioral Health, have indicated their interest in building capacity and skills within WCBH by expanding the connection with Healthy Babies/Healthy Children. WCBH desires to serve infants and toddlers and their families with the same expertise and supports that they can offer older children. Typically serving very young children has been a challenge both through clinical expertise and barriers to reimbursement. WCBH participants have the desire to address both limiting factors in their ability to provide services to the community. Participating pediatricians have noted the need for intensive mental health services for some of their youngest patients. Pediatricians note maternal depression, parent-child interaction difficulties, and anxious toddlers as only a few of the presenting concerns within their practices and for which they seek assistance from local mental health professionals.

Community agencies within the Early Childhood Mental Health Network serve a diverse population of families with young children in the Upper Valley. Agency representatives speak of the need for training and consultation within their own staff and within their programs of supporting families. Healthy Babies/Healthy Children will offer community agencies assistance with addressing the social/emotional wellness of the children and families whom they serve through training and consultation.

PathWays, in collaboration with other participating agencies, has developed the following sustainability plan: Each collaborating organization will explore every avenue of billing—private insurance, Medicaid, and fees for service—for the services provided at their site and/or by their staff. Memorandums of understanding and contracts, if needed, will be developed among the agencies. IDEA Part C funds will be maximized within PathWays Early Supports and Services. DHMC will assume the cost of the pediatric resident training program at the end of the grant period if the curriculum is successful (well received, effective, and feasible in DHMC setting). Graduates of the residency program will carry their skills into their future practice, thus reaching a broad population of young families.

Local funders (United Way, Grafton County) and other interested stakeholders will be approached yearly for renewed funding. This funding may be available to several agencies within the program each of whom could apply separately and for different needs. A Sustainability Developer will assist with exploring funding streams.

PathWays recognizes the need for input from a sustainability developer to address an issue that has plagued initiatives such as Healthy Babies/Healthy Children nationwide. Under the Endowment Technical Assistance Grant, research was done and lessons were learned with respect to sustainability. Some of these lessons, particularly regarding local community partnerships/roles have continued to be explored so that more realistic outcomes have been developed for Healthy Babies. Concerns at the state level need to be addressed with the Upper Valley partners taking the responsibility as a group to address barriers for more comprehensive services for young children within the state.

Organizational Capacity PathWays is a non-profit agency that serves people with disabilities in their home communities in Sullivan and Lower Grafton counties. PathWays works with children, adults, and their families to provide ongoing, individualized support. PathWays works with local agencies, programs and businesses to provide individuals with meaningful work, recreation and community life.

PathWays is a merged agency that combined Developmental Services of Sullivan County (DSSC) of Claremont, and United Developmental Services (UDS) in Lebanon in 2006. DSSC has provided quality services to individuals since 1973. UDS has a similar rich history of service since 1970. Together, the merged agency is moving forward with its mission of “expanding the opportunities that enrich the lives of people with disabilities”. PathWays staff have worked to serve the needs of its consumers through providing residential services, employment and day services, service coordination, family support, and Family-Centered Early Supports and Services. Staff is supported by strong management and fiscal teams.

Collaborating organizations/ people and their roles:
PathWays is the lead agency for the program. The agency will take the responsibility for hiring the Healthy Babies/Healthy Children specialists, formalize agreements with collaborators, maintain data bases, explore continued funding, and report out to all funders. Key contact people are Mark Mills, CEO, David Hill, CFO and Kathy Marshall, Director of Early Supports and Services. Robert A. Mesropian Community Care Center, through its pediatricians Douglas Williamson, MD, and Sheila Feyrer, MD, will be a primary medical site.

Dartmouth Hitchcock Medical Center-Mascoma, through its staff of David Cunis, MD, Ann Laumann, ARNP, and Kimberly Gifford, MD, will develop its site as a full participant. Dartmouth Hitchcock Medical Center residency program, under the direction of Diane Kittredge, MD, Carol Little, MD, and Carol Andrew, Ed.D., will develop and implement the inclusion of social/emotional wellness in the pediatric training.

Miriam Voran, Ph.D., psychologist, has agreed to provide training and clinical supervision to the Healthy Babies specialists and to collaborate in the resident training program. West Central Behavioral Health has agreed to explore its resources for building capacity to serve very young children and their families. Michelle Parsons, PhD. is the contact. The Early Childhood Mental Health Network has agreed to act in an advisory capacity. Cindy Swart, MSW, is the coordinator of the Network and liaison with statewide Infant Mental Health teams.

 Earls, Marian F. Shackelford, S. Setting the State for Success: Implementation of Developmental and Behavioral Screening and Surveillance in Primary Care Practice—The North Caroling Assuring Better Child Health and Development (ABCD) Project. Pediatrics, 2006; 118: 187

 Glascoe FP, Shapiro HL., Introduction to developmental and behavioral screening. Available at :  Knitzer, J, Theberge, S, Johnson, K, Reducing Maternal Depression and Its Impact on Young Children, National Center for Children in Poverty, Columbia University, January 2008, 1.

 Earls,Marian,; pg. 184.

 Briggs, RD, Racine, AD, Chinitz, S; Preventive Pediatric Mental Health Care: A Co-location Model; Infant Mental Health Journal, Vol 28 (5), 481.

 Lieberman, A.F., Weston, D., & Pawl, J.H. (1991). Preventive intervention and outcome with anxiously attached dyads. Child Development, 62, 199-209.

 Robert-Tissot, C., Cramer, B., Stern, D.N., Serpa-Rusconi, S., Bachmann, J.-P., Palacio-Espasa, F., Knauer, D., De Muralt, M., Berney, C., & Mendiguren, G. (1996). Outcome evaluation in brief mother-infant psychotherapies: Report on 75 cases. Infant Mental Health Journal, 17, 97-114.

 Fonagy, P., Steele, M., Moran, G., Steele, H., & Higgit, A. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 13, 200-216.

 Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005a). Maternal reflective functioning, attachment, and the transmission gap: A preliminary study. Attachment & Human Development, 7, 283-298.

Slade, A., Sadler, L., De Dios-Kenn, C., Webb, D., Currier-Ezepchick, J., & Mayes, L. (2005b). Minding the baby: A reflective parenting program. Psychoanalytic Study of the Child, 60, 74-100.

 PathWays brochure, 2008

 PathWays mission statement


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

Terms of this website prohibit downloading photos and other licensed materials from this website.