PIP and NM-IT Assessment Tools, Forms/Instruments

State of New Mexico Children, Youth and Families Department

Developed by: Jane Clarke, PhD, IMH-E®IV and Deborah Harris, LISW, IMH-E®IV PIP and NM-IT Assessment Tools, Forms/Instruments

PARENT INFANT PSYCHOTHERAPY AND NEW MEXICO-INFANT TEAM FORMS AND INSTRUMENTS

The Parent-Infant Psychotherapy and New Mexico-Infant Team’s program use specific forms and instruments for intake, assessment, tracking progress and quarterly reports.

2 Contents

1. Service Definitions and Assessment Guidelines 4 CYFD-003 5-9 CYFD-004 10-14 Forms, Assessment Tools and Instruments 15 Data Input Flow Chart 16 Assessment Periodicity 17

2. Intake and CPP Trained PIP Clinicians 18 Psychosocial Assessment 19-28 Adverse Childhood Experiences Scoring Sheet (ACES) 29 Life Stressor Checklist – Revised (LSC-R) 30-36 Traumatic Events Screening Inventory –Parent Report 37-39

3. Infant Mental Health Assessments 40 Working Model of the Child Interview 41-48 Modified Working Model of the Child Interview 49-51 Caregiver-Child Structured Interaction (Crowell) 52-61 Baby Crowell Procedure (Modified) 62-64 Post Crowell Procedure Questions from the COSI 65

4. Developmental Information 66 Developmental Milestones and Competency (DC:0-5) 67-94 Competency Domain Summary Table (DC:0-5) 95 Facilitating Developmental Progress (DIAPER) 96-100

5. Tracking Treatment Progress and Program Evaluation 101 Progress in Treatment Assessment (PITA) 102-104 Dimensions of Caregiving/Relational Range (DC:0-5) 105-107 D.A.P. Note (Example) 108

6. Report Forms 109 Quarterly Report Form 110-112

7. Examples of Goals and Objectives 113 Examples from the DC:0-5 and PITA 114-117

8. Example of Discharge Summary 118 Example of Discharge Summary 119

3 Service Definitions and Assessment Guidelines

4 Parent Infant Psychotherapy Severe Emotional Disturbance Birth to three (3) years old CYFD-003

Effective date: July 1st, 2017

Service Description: Parent Infant Psychotherapy (PIP) treatment services target the dyadic relationship between the infant/young child and the parent/caregiver. They are grounded in attachment theory and the science of brain development; they are relationship-based, developmentally appropriate, and trauma-informed. PIP treatment services are an array of therapeutic and developmental services designed to reduce both the acute and chronic behavioral, social and emotional disorders and disruptions in the relationship between an infant/ young child and their parent/caregiver, as a result of toxic stress and major trauma.

Source of Funding: CYFD

Admission/Service Criteria: Infants and young children, and their parent/caregiver, who are: • Birth to three (3) years; • Diagnosed with a Severe Emotional Disturbance (SED);and • Experiencing disruptions in the relationship due to infant/young child and parent/caregiver vulnerabilities.

Target Population: Infants and young children birth to three (3) years who: 1. Have had a Comprehensive Assessment by an independently licensed clinician, who is endorsed by the New Mexico’s Association for Infant Mental Health (NMAIMH)as an Infant Mental Health Specialist Level III (Level III) or an Infant Mental Health Mentor Level IV (Level IV), identifying the need for this service, utilizing at a minimum: A. DC: 0-5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-5); B. Crowell Procedure; C. Working Model of the Child; D. Adverse Childhood Experiences (ACE); And, 2. Once enrolled in PIP treatment services, the following also apply: • Infants/young children who are enrolled before three (3) years old, remain eligible to receive services up to their fifth (5th) birthday, with an extension approved by the Infant/Early Childhood Mental Health (IECMH) Program Director; • Services shall be provided regardless of Medicaid eligibility, and; • Infants/young children who have previously been assessed with the DC: 0-3 R Axis II Parent-Infant Relationship Global Assessment Scale (PIR: GAS), should continue to be assessed with the PIR: GAS until discharged.

Program Requirements:

5 1. Before engaging in PIP treatment services, the infant/young child must receive: A. A Diagnostic Evaluation that has resulted in a diagnosis, and; B. An individualized Treatment Plan that includes PIP treatment as an intervention; 2. When possible, safe, and clinically appropriate 25% of PIP services should be provided in the home or other settings natural to the infant/young child and parent/caregiver; 3. PIP treatment services must be provided by a NMAIMH Level III or Level IV endorsed infant mental health specialist; A. See Minimum Staff Qualifications for a detailed definition; 4. Service delivery is focused on infant/young child and parent/caregiver interactions and the relationship needs of the infant/young child – on the dyadic relationship between the infant/young child and the parent/caregiver. The initial assessment identifies recommendations for service strategies; 5. Each PIP provider must address, at minimum: A. Increasing the parent’s(s’)/caregiver’s (s)’ ability to consistently and appropriately provide for the infant’s/young child’s basic emotional needs for comfort, stimulation, affection, and safety; B. Increasing the infant’s/young child’s ability to initiate and respond to most social interactions in a developmentally appropriate way; C. Increasing the infant’s/young child’s ability to socially discriminate and be selective in choice of attachment figures; D. Providing the parent/caregiver and infant/young child interaction in order to encourage language and play, interpretation of an infant’s/young child’s behavior and reinforcement of a parent’s/ caregiver’s appropriate actions and interactions; 6. Progress towards treatment goals will be assessed quarterly from date of intake and documented, including evidence of developmental goals. Some possible developmental goals include: A. For Infants/Young Children: Level 1: Regulation and Shared Attention 0-3 months; Level 2: Mutual Engagement 2-5 month; Level 3: Intentional 2-Way Purposeful Communication 4-10 month; Level 4: Complex Problem–Solving, Sense of Self 10-18 month; Level 5: Symbolic Thinking/Language/Emotions 18-30 month; Level 6: Building Bridges/Abstract Thinking 30-42 month; Level 7: Multi-causal and Triangular thinking; B. For Parents: Level 8: Comparative and Gray Area Thinking; Level 9: Reflective Thinking/Growing Sense of self/Stable Internal Standard; (See PIP Manual glossary for description of levels) 7. Provider must also provide crisis intervention services as appropriate. See - Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: (DC: 0-5) for related therapeutic issues.

6 young child’s safety, social and emotional needs, and developmental progress; 2. Increase parent’s/caregiver’s ability to meet basic emotional needs for comfort, stimulation, affection, and safety of the infant/young child; 3. Increase infant’s/young child’s ability to initiate and respond to most social interactions in a developmentally appropriate way, and; 4. Increase developmentally appropriate and sensitive parent/caregiver and infant/young child interaction in order to encourage language and play, interpretation of an infant’s/young child’s behavior and reinforcement of a parent’s/caregiver’s appropriate actions and interactions.

Provider Requirements: Services must be provided by a provider organization or independent licensed practitioner, meeting standards established by the Children, Youth and Families Department. Providers must be a legally recognized entity in the United States or a Sovereign Tribal Nation, qualified to do business in New Mexico or in a Sovereign Tribal Nation located within the state boundaries of New Mexico.

Staffing Requirements: Anyone providing this direct service must do so in accordance with applicable NM licensing board standards for their level and type of credentialing.

Minimum Staff Qualifications: 1. Independently Licensed Master’s Level Clinician (LPCC, LMFT, LISW) or Licensed Clinical Psychologist, CNS or RN with a Master’s or Certification in psychiatric nursing, or a Licensed or Board Eligible psychiatrist in good standing, and; 2. Endorsed as a Level III or a Level IV by the NMAIMH; A. If not endorsed, obtain provisional endorsement waiver from IECMH Program Director and complete the full process to achieve Level III or Level IV endorsement within 29 months of receiving the provisional endorsement waiver.

Minimum Staff Experience: Two (2) years supervised work experience providing relationship-based infant mental health services.

7 endorsement within 29 months of receiving the provisional endorsement waiver.

Service Exclusions: This service may not be billed in conjunction with: 1. Multi-systemic Therapy; 2. Accredited Residential Treatment; 3. Residential Treatment Services; 4. Group Home services; 5. Inpatient Hospitalization; 6. Partial Hospitalization; 7. Recreational outings; 8. Travel time, report writing; 9. T1027, and; 10. CYFD-004.

Continuing Service Criteria: Treatment goals and objectives are being met but symptoms are still present and there is still progress to be made. Once enrolled, children remain eligible for PIP treatment services until their fifth (5th) birthday, with an approval from the IECMH Program Director. The request for continuing services shall be made four (4) months prior to the infant’s third (3rd) birthday.

Discharge Criteria: 1. Parent(s)/caregiver(s) completes treatment plan; 2. Parent(s)/caregiver(s) ends services; 3. Parent(s)/caregiver(s) moves out of provider coverage area; 4. No progress is achieved, a referral is indicated for further assessment regarding treatment, and; 5. Service Authorization Period Expires.

Benefit Limits: Exhaust when the infant/young child reaches three (3) years, or their fifth (5th) birthday with an approved extension from the IECMH Program Director. 1. See Continuing Service Criteria for additional information.

Documentation Requirements for the IMH Database: The Infant Mental database is supported by: The University of New Mexico Continuing Education Early Childhood Services Center

Providers shall ensure that all documentation requirements are met and entered into the IMH database on a timely basis for each client file. Some examples of documentation required to be entered into the database are: 1. Diagnostic Evaluation, including diagnosis; 2. Individualized Treatment Plan; 3. P-PITA;

8 4. Progress Notes (DAP) that reflect the evidence of the treatment progress, and; 5. Discharge or transition plan that documents the need for any continuation or support services.

Parent Infant Psychotherapy Manual: More inclusive and extensive programmatic information is provided in the Parent Infant Psychotherapy Manual (Manual). The Manual will be revised and updated as needed. https://cyfd.org/docs/Children,_Youth_and_Families_Parent_Infant_Psychotherapy_Manual.pdf

Rate: • CYFD-003- PIP Services for SED infants and young children, birth to three (3) years, with a possible service extension to their fifth (5th) birthday, the billable amount is: A. For services provided but not paid, all or in part, by Medicaid, other state funding source, private insurance, or grant during the contract period at a rate of $34.00 per 15-minute unit, inclusive of all collateral activities. When possible, safe and clinically appropriate 25% of services should be provided in the home or other settings natural to the infant/young child and parent/ caregiver.

9 Parent Infant Psychotherapy At Risk for a Severe Emotional Disturbance Birth to three (3) years old CYFD-004

Effective date: July 1st, 2017

Service Description: Parent Infant Psychotherapy (PIP) treatment services target the dyadic relationship between the infant/young child and the parent/caregiver. They are grounded in attachment theory and the science of brain development; they are relationship-based, developmentally appropriate, and trauma-informed. PIP treatment services are an array of therapeutic and developmental services designed to reduce both the acute and chronic behavioral, social and emotional disorders and disruptions in the relationship between an infant/young child and their parent/caregiver, as a result of toxic stress and major trauma.

Source of Funding: CYFD

Admission/Service Criteria: Infants and young children, and their parent/caregiver, who are: • Birth to three (3) years; • Determined to be at risk of a Severe Emotional Disturbance (SED), and; • Experiencing disruptions in the relationship due to infant/young child and parent/caregiver vulnerabilities.

Target Population: Infants and young children birth to three (3) years, who: 1. Have had a Comprehensive Assessment by an independently licensed clinician, who is endorsed by the New Mexico’s Association for Infant Mental Health (NMAIMH) as an Infant Mental Health Specialist Level III (Level III) or an Infant Mental Health Mentor Level IV (Level IV), identifying the need for this service utilizing at a minimum: A. DC: 0-5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-5); B. Crowell Procedure; C. Working Model of the Child; D. Adverse Childhood Experiences (ACE); And, 2. Once enrolled in PIP treatment services, the following also apply: • Infants/young children who are enrolled before three (3) years, remain eligible to receive services up to their fifth (5th) birthday, with an extension approved by the Infant/Early Childhood Mental Health (IECMH) Program Director. • Services shall be provided regardless of Medicaid eligibility, and; • Infants/young children who have previously been assessed with the DC: 0-3 R Axis II Parent-Infant Relationship Global Assessment Scale (PIR: GAS), should continue to be assessed with the PIR: GAS until discharged.

Program Requirements: 1. Before engaging in a treatment services, the infant/young child must receive: A. A Diagnostic Evaluation that has resulted10 in a diagnosis, and; B. An individualized Treatment Plan that includes PIP treatment as an intervention; 2. When possible, safe, and clinically appropriate 25% of PIP services should be provided in the home or other settings natural to the infant/young child and parent/caregiver; 3. PIP treatment services must be provided by a NMAIMH Level III or Level IV endorsed infant mental health specialist; A. See Minimum Staff Qualifications for a detailed definition; 4. Service delivery is focused on infant/young child and parent/caregiver interactions and the relationship needs of the infant/young child – on the dyadic relationship between the infant/young child and the parent/caregiver. The initial assessment identifies recommendations for service strategies; 5. Each PIP provider must address, at minimum: A. Increasing the parent’s(s’)/caregiver’s (s)’ ability to consistently and appropriately provide for the infant’s/young child’s basic emotional needs for comfort, stimulation, affection, and safety; B. Increasing the infant’s/young child’s ability to initiate and respond to most social interactions in a developmentally appropriate way; C. Increasing the infant’s/young child’s ability to socially discriminate and be selective in choice of attachment figures; D. Providing the parent/caregiver and infant/young child interaction in order to encourage language and play, interpretation of an infant’s/young child’s behavior and reinforcement of a parent’s/ caregiver’s appropriate actions and interactions; 6. Progress towards treatment goals will be assessed quarterly from date of intake and documented, including evidence of developmental goals. Some possible developmental goals include: A. For Infants/Young Children: Level 1: Regulation and Shared Attention 0-3 months; Level 2: Mutual Engagement 2-5 month; Level 3: Intentional 2-Way Purposeful Communication 4-10 month; Level 4: Complex Problem–Solving, Sense of Self 10-18 month; Level 5: Symbolic Thinking/Language/Emotions 18-30 month; Level 6: Building Bridges/Abstract Thinking 30-42 month; Level 7: Multi-causal and Triangular thinking; B. For Parents: Level 8: Comparative and Gray Area Thinking; Level 9: Reflective Thinking/Growing Sense of self/Stable Internal Standard; (See PIP Manual glossary for description of levels) • Infants/young children who are enrolled before three (3) years, remain eligible to receive services up to their fifth (5th) birthday, with an extension approved by the Infant/Early Childhood Mental Health (IECMH) Program Director. • Services shall be provided regardless of Medicaid eligibility, and; • Infants/young children who have previously been assessed with the DC: 0-3 R Axis II Parent-Infant Relationship Global Assessment Scale (PIR: GAS), should continue to be assessed with the PIR: GAS until discharged.

Program Requirements: 1. Before engaging in a treatment services, the infant/young child must receive: A. A Diagnostic Evaluation that has resulted in a diagnosis, and; B. An individualized Treatment Plan that includes PIP treatment as an intervention; 2. When possible, safe, and clinically appropriate 25% of PIP services should be provided in the home or other settings natural to the infant/young child and parent/caregiver; 3. PIP treatment services must be provided by a NMAIMH Level III or Level IV endorsed infant mental health specialist; A. See Minimum Staff Qualifications for a detailed definition; 4. Service delivery is focused on infant/young child and parent/caregiver interactions and the relationship needs of the infant/young child – on the dyadic relationship between the infant/young child and the parent/caregiver. The initial assessment identifies recommendations for service strategies; 5. Each PIP provider must address, at minimum: A. Increasing the parent’s(s’)/caregiver’s (s)’ ability to consistently and appropriately provide for the infant’s/young child’s basic emotional needs for comfort, stimulation, affection, and safety; B. Increasing the infant’s/young child’s ability to initiate and respond to most social interactions in a developmentally appropriate way; C. Increasing the infant’s/young child’s ability to socially discriminate and be selective in choice of attachment figures; D. Providing the parent/caregiver and infant/young child interaction in order to encourage language and play, interpretation of an infant’s/young child’s behavior and reinforcement of a parent’s/ caregiver’s appropriate actions and interactions; 6. Progress towards treatment goals will be assessed quarterly from date of intake and documented, including evidence of developmental goals. Some possible developmental goals include: A. For Infants/Young Children: Level 1: Regulation and Shared Attention 0-3 months; Level 2: Mutual Engagement 2-5 month; Level 3: Intentional 2-Way Purposeful Communication 4-10 month; Level 4: Complex Problem–Solving, Sense of Self 10-18 month; Level 5: Symbolic Thinking/Language/Emotions 18-30 month; Level 6: Building Bridges/Abstract Thinking 30-42 month; Level 7: Multi-causal and Triangular thinking; B. For Parents: Level 8: Comparative and Gray Area Thinking; Level 9: Reflective Thinking/Growing Sense of self/Stable Internal Standard; (See PIP Manual glossary for description of levels) 7. Provider must also provide crisis intervention services as appropriate. See - Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: (DC: 0-5) for related therapeutic issues.

Performance Outcomes: The following outcomes shall be measured before, during and after the provision of services, by using the following tools: the PIR: GAS for the infants/young children presently being served and the DC: 0-5 for infants/young children enrolling in treatment on or after July 1, 2017, the Crowell, the Working Model of the Child, Circle of Security, ACE, Progress in Treatment Assessment (P-PITA), and Child Parent Psychotherapy (CPP) clinical intervention to: 1. Increase parent’s/caregiver’s ability to11 consistently and appropriately provide for the infant’s/ young child’s safety, social and emotional needs, and developmental progress; 2. Increase parent’s/caregiver’s ability to meet basic emotional needs for comfort, stimulation, affection, and safety of the infant/young child; 3. Increase infant’s/young child’s ability to initiate and respond to most social interactions in a developmentally appropriate way, and; 4. Increase developmentally appropriate and sensitive parent/caregiver and infant/young child interaction in order to encourage language and play, interpretation of an infant’s/young child’s behavior and reinforcement of a parent’s/caregiver’s appropriate actions and interactions.

Staffing Requirements: Anyone providing this direct service must do so in accordance with applicable NM licensing board standards for their level and type of credentialing.

Minimum Staff Qualifications: 1. Independently Licensed Master’s Level Clinician (LPCC, LMFT, LISW) or Licensed Clinical Psychologist, CNS or RN with a Master’s or Certification in psychiatric nursing, or a Licensed or Board Eligible psychiatrist in good standing, and; 2. Endorsed as an Infant Mental Health Specialist Level III or an Infant Mental Health Mentor Level IV by the New Mexico’s Association for Infant Mental Health (NMAIMH); A. If not endorsed, obtain provisional endorsement waiver from IECMH Program Director and complete the full process to achieve Level III or Level IV endorsement within 29 months of receiving the provisional endorsement waiver.

Minimum Staff Experience: Two (2) years supervised work experience providing relationship-based infant mental health services.

Minimum Supervision Requirements: 1. Provide clinical, administrative and reflective supervision; 7. Provider must also provide crisis intervention services as appropriate. See - Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: (DC: 0-5) for related therapeutic issues.

Performance Outcomes: The following outcomes shall be measured before, during and after the provision of services, by using the following tools: the PIR: GAS for the infants/young children presently being served and the DC: 0-5 for infants/young children enrolling in treatment on or after July 1, 2017, the Crowell, the Working Model of the Child, Circle of Security, ACE, Progress in Treatment Assessment (P-PITA), and Child Parent Psychotherapy (CPP) clinical intervention to: 1. Increase parent’s/caregiver’s ability to consistently and appropriately provide for the infant’s/ young child’s safety, social and emotional needs, and developmental progress; 2. Increase parent’s/caregiver’s ability to meet basic emotional needs for comfort, stimulation, affection, and safety of the infant/young child; 3. Increase infant’s/young child’s ability to initiate and respond to most social interactions in a developmentally appropriate way, and; 4. Increase developmentally appropriate and sensitive parent/caregiver and infant/young child interaction in order to encourage language and play, interpretation of an infant’s/young child’s behavior and reinforcement of a parent’s/caregiver’s appropriate actions and interactions.

Staffing Requirements: Anyone providing this direct service must do so in accordance with applicable NM licensing board standards for their level and type of credentialing.

Minimum Staff Qualifications: 1. Independently Licensed Master’s Level Clinician (LPCC, LMFT, LISW) or Licensed Clinical Psychologist, CNS or RN with a Master’s or Certification in psychiatric nursing, or a Licensed or Board Eligible psychiatrist in good standing, and; 2. Endorsed as an Infant Mental Health Specialist Level III or an Infant Mental Health Mentor Level IV by the New Mexico’s Association for Infant Mental Health (NMAIMH); A. If not endorsed, obtain provisional endorsement waiver from IECMH Program Director and complete the full process to achieve Level III or Level IV endorsement within 29 months of receiving the provisional endorsement waiver.

Minimum Staff Experience: Two (2) years supervised work experience providing relationship-based infant mental health services.

Minimum Supervision Requirements: 1. Provide clinical, administrative and reflective supervision; 2. Document monthly clinical individual and/or group supervision/consultation, and; 3. Document monthly client records reviewed for: A. Clinical supervision; B. Data entry completeness (Administrative Supervision), and; C. Reflective supervision. 12 Minimum Supervisor Qualifications: 1. Independently Licensed Master’s Level Clinician (LPCC, LMFT, LISW) or Licensed Clinical Psychologist, CNS or RN with a Master’s or Certification in psychiatric nursing, or a Licensed or Board Eligible psychiatrist in good standing, and; 2. Endorsed as an Infant Mental Health Specialist Level III or an Infant Mental Health Mentor Level IV by NMAIMH; A. If not endorsed, obtain provisional endorsement waiver from IECMH Program Director and complete the full process to achieve Level III or Level IV endorsement within 29 months of receiving the provisional endorsement waiver. Service Exclusions: This service may not be billed in conjunction with: 1. Multi-systemic Therapy; 2. Accredited Residential Treatment; 3. Residential Treatment Services; 4. Group Home services; 5. Inpatient Hospitalization; 6. Partial Hospitalization; 7. Recreational outings; 8. Travel time, report writing; 9. T1027, and; 10. CYFD-003.

Continuing Service Criteria: Treatment goals and objectives are being met but symptoms are still present and there is still progress to be th made. Once enrolled, children remain eligible for PIP treatment services until their fifth (5 ) birthday, with an approval from the IECMH Program Director. The request for continuing services shall be made four (4) months prior to the infant’s third (3rd) birthday.

Benefit Limits: Exhaust when the infant/young child reaches three (3) years old, or their fifth (5th) birthday with an approved extension from the IECMH Program Director. 1. See Continuing Service Criteria for additional information.

Documentation Requirements for the IMH Database: The Infant Mental database is supported by: 2. Document monthly clinical individual and/or group supervision/consultation, and; 3. Document monthly client records reviewed for: A. Clinical supervision; B. Data entry completeness (Administrative Supervision), and; C. Reflective supervision.

Minimum Supervisor Qualifications: 1. Independently Licensed Master’s Level Clinician (LPCC, LMFT, LISW) or Licensed Clinical Psychologist, CNS or RN with a Master’s or Certification in psychiatric nursing, or a Licensed or Board Eligible psychiatrist in good standing, and; 2. Endorsed as an Infant Mental Health Specialist Level III or an Infant Mental Health Mentor Level IV by NMAIMH; A. If not endorsed, obtain provisional endorsement waiver from IECMH Program Director and complete the full process to achieve Level III or Level IV endorsement within 29 months of receiving the provisional endorsement waiver. Service Exclusions: This service may not be billed in conjunction with: 1. Multi-systemic Therapy; 2. Accredited Residential Treatment; 3. Residential Treatment Services; 4. Group Home services; 5. Inpatient Hospitalization; 6. Partial Hospitalization; 7. Recreational outings; 8. Travel time, report writing; 9. T1027, and; 10. CYFD-003.

Continuing Service Criteria: Treatment goals and objectives are being met but symptoms are still present and there is still progress to be th made. Once enrolled, children remain eligible for PIP treatment services until their fifth (5 ) birthday, with an approval from the IECMH Program Director. The request for continuing services shall be made four (4) rd months prior to the infant’s third (3 ) birthday.

Documentation Requirements for the IMH Database: The Infant Mental database is supported by:

13 The University of New Mexico Continuing Education Early Childhood Services Center

Provider shall ensure that all documentation requirements are met and entered into the IMH database on a timely basis for each client file. Some examples of documentation required to be entered into the database are: 1. Diagnostic Evaluation, including diagnosis; 2. Individualized Treatment Plan; 3. P-PITA; 4. Progress Notes (DAP) that reflect the evidence of the treatment progress, and 5. Discharge or transition plan that documents the need for any continuation or support services.

Rate: CYFD-004-PIP Services for At-Risk SED infants and young children, birth to three (3) years old, with a possible service extension to their fifth (5th) birthday, the billable amount is: A. For services provided but not paid, all or in part, by Medicaid, other state funding source, private insurance or grant during the contract period at a rate of $31.73 per 15-minute unit inclusive of all collateral activities. When possible, safe, and clinically appropriate 25% of services should be provided in the home or other settings natural to the infant/young child and parent/ caregiver.

14 FORMS, ASSESSMENT TOOLS AND INSTRUMENTS

1. INTAKE • Psychosocial Intake Assessment • Adverse Childhood Experiences Scoring (ACES) – for caregiver(s) and child.

For Child-Parent Psychotherapy Trained PIP Clinicians • Life Stressor Checklist –Revised • Traumatic Events Screening Inventory – Parent Report Revised (TESI)

2. INFANT MENTAL HEALTH ASSESSMENT • Working Model of the Child Interview (WMCI) - full or modified versions • Caregiver-Child Structured Interaction Procedure (Crowell) – full, modified or baby versions. * At the end of Crowell administration, three questions from the Circle of Security Interview (COSI) are asked of parent/ caregiver.

3. DEVELOPMENTAL INFORMATION • DC:0-5: Developmental Milestones and Competency Ratings (Axis V) - not required. • DC:0-5: Infant’s/Child’s Contributions to the Relationship (Axis II) – not required. • Developmentally Informed Assessment Per Each Relationship (DIAPER) – administered quarterly.

4. TRACKING TREATMENT PROGRESS AND PROGRAM EVALUATION • Progress in Treatment Assessment (PITA) – administered quarterly • DC:0-5: Dimensions of Caregiving and Relational Range of Functioning – Axis II Relational Context) – administered quarterly • Developmentally Informed Assessment Per Each Relationship (DIAPER) – administered quarterly • D.A.P. (Data, Assessment and Plan) Progress Note

6. QUARTERLY REPORTS • PIP Quarterly Report Form

* All forms, assessment tools and instruments are available in a Stand Alone file for PIP providers.

15 Data Input Flow Chart

Register Infant Services & Activities Register New Case Infant/Child Name Start – End Time Facts Person # Provider (self INTAKE Name Psycho- Facts # for Case DoB populate) DoB Sex Clinician Social Sex Ethnicity Activity/Service Ethnicity Fund Address/zip/county Staff Present Phone # Notes Primary Language Register Affidavit: Y/N Assessments Lead Clinician Family Constellation ACES IMHT or PIP Name Working Model (Y/N) Referral Source DoB (bio parents) DAP Notes Sex Crowell Plus (Y/N) DAP Ethnicity (bio parents) PITA Relation to infant DIAPER Role in Case DC 03 0-5 Note: every activity needs date Notes Review of Axis (Y/N) Quarterly DAP Updates CPP: TESSI CPP: LSC-R Other Inputs DISCHARGE Notes For Staff Case Determination (IT) Training IMH Recommendation GOAL: Relational Adaptive Endorsement Permanency Hearing Behavior Waiver Notes Objectives ---OR— DAP Notes Reasons (PIP) Data -. Assessment. -Plan Notes Strategies as evidenced by Progress

16 Assessments

CYFD Required Periodicity Subjects++ TYPE OF INPUT ACES Once Bio parents & infants Data Working Model * Once Bio parents Yes/No Crowell ** Plus Once Bio parents Yes/No DIAPER Quarterly Dyads with bio parents Data PITA Quarterly Dyads with bio parents Data DC 03 [0–5] *** Quarterly Dyads with bio parents Data Review of Axes 1, 2, 3 As Clinically Appropriate Bio Parents Yes/No ** CROWELL. DAP summary notes *** DC03 will be replaced and overlap with DC 0-5 (Axis II) ++ If >1 child, on each relationship

CPP Required Periodicity Subjects Data Input TESSI Once On bio parents Yes/No LSC–R Once On bio parents Yes/No

17 Intake and CPP Trained PIP Clinicians INSERT YOUR OWN LOGO

NM Infant Team – Parent-Infant Psychotherapy Services PSYCHOSOCIAL ASSESSMENT

Child’s Name DOB Record # Source(s) of information Information recorded by Interview Date(s)

Reporter Relationship to Child______DOB______

Social Environment

With whom and where is child currently living?

Are there other family members and friends currently living in your home (names, ages, relationships)?

Are there other adults who have important relationships with your child (e.g., daycare providers, relatives, etc,, list names and relationship to child)?

Do you have any worries about the other people who take care of your child? (alcohol/drug use, neglect/abuse, etc.)

Does your child have a regular opportunity to play with other children (describe, if in daycare ask name, number of children, child schedule)?

Prenatal and Perinatal Events, Developmental History, Significant early childhood events

If your child was adopted, what is the history of the adoption? If no, go on to next questions.

Was the pregnancy planned?  Yes  No

Center for Development and Disability at the University of New Mexico

rev. March 2013

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When was your child’s last physical exam?

Are your child’s immunizations up to date?

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Center for Development and Disability at the University of New Mexico 2

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Do you have any other concerns about your child’s health? If yes, please describe.

oes your child tae any medications reularly?

oes your child hae any onoin medical needs or any past serious medical illnesses inuries or accidents? lease note approximate aesdates and where treated

as your child eer een hospitalized since irth?

Do you have any concerns about your child’s development? If yes, please descrie

ae you eer een concerned or worried aout the way your child expresses hisher eelins? r the ways in which your child interacts with others?

s your child oerly sensitie to sounds touch or to the enironment in eneral?

escrie your child’s sleep schedule (bedtime, naps, etc.)

Describe your child’s feeding routines.

Center for Development and Disability at the University of New Mexico 3

Does your child have any special problems or developmental disabilities? Describe

as your child had a developmental evaluation? (ote hat and by hom, obtain release of information).

Does your child have an Individual amily ervice lan (I) ith an early intervention program andor an Individual ducation lan (I) from a school district?

Children may experience stressful events that may affect their health and well-being. Please help us understand you and your child’s experience by answering the following questions to the best of your knowledge.

o your noledge, has your child ever been directly threatened ith physical harm?  es  o If yes, please describe

as anyone ever physically assaulted your child? (itting, pushing, choing, shaing, biting, or burning)  es  o If yes, please describe

as anyone ever punished your child and caused physical inury or bruises?  es  o If yes, please describe

as anyone ever touched your child in a seual ay?  es  o If yes, please describe

Center for Development and Disability at the University of New Mexico 4

o your noledge, has your child ever seen, heard, or heard about, people in your family or surrounds physically fighting, hitting, slapping, icing, or pushing each other?  es  o If yes, please describe

as your child seen that you or a family member as arrested, ailed, or taen aay by the police?  es  o If yes, do you no hat your child as told about the situation?

Do you no hat your child as told about the situation?

as your child ever been yelled at in a scary ay?  es  o If yes, please describe

as your child ever had someone threatened to leave or send him her aay?  es  o If yes, please describe

as your child ever gone through a period of time hen shehe laced appropriate care (e.g., not having enough to eat or drin, not having shelter, being left alone hen too young to care for himherself)?  es  o If yes, please describe

of Child’s Parents

here ere you born? II

Center for Development and Disability at the University of New Mexico 5

Do you have any other children? If yes, provide names and ages

Describe family of origin (include significant relationships, hat as it lie groing up in your home, etc.)

Describe your family’s traditions (languages spoken, religious/spiritual practices or identification, community support, etc.)

Describe the ays in hich these things impact your parenting.

amily history of developmental delays, emotional or social challenges, medical conditions?

arent drugalcohol use

istory of family violence or trauma or other stressors

involvement (include history of foster home placement)?

egal Issues (Probe: court cases, arrests, convictions, incarcerations, gangs, involvement, DI, involvement (past investigations, current involvement, inhome services, custody, termination of parental rights, etc)

Center for Development and Disability at the University of New Mexico 6

dation

ere did you go to scool

at is te igest grade your ae completed

at ere your difficulties in scool (pecial ducation, learning disabilities, etc

loent

Describe your istory of employment

at is your current ob

at is te source of income

Do you feel like you struggle proiding basic needs to your cild

Phsial ealth

Describe your pysical ealt (medical diagnosis, serious or contagious illness, ospitaliation, maor surgery, etc

ental ealth

ae you eer receied counseling or terapy before

ae you eer been gien a mental ealt diagnosis

ae you eer been ospitalied due to mental ealt issues

Center for Development and Disability at the University of New Mexico 7

ae you eer engaged in selfarming beaior

ae you eer struggled it suicidal feelings or attempted suicide

stane se

Describe te use of substances in your family

Probe: Drugs, alcool, age of first use, types of substances, freuency, blackouts, istory of treatment

nterersonal iolene

ae you eperienced iolence in te family of origin, in romantic relationsips, perpetrator, ictim, anger issues, erbal/pysical/seual abuse

as your cild present or as e/se itnessed iolence

tside esoresorts

at outside supports do/can you rely on te most/are most supportie (family, friends, curc

ter agencies/serice proiders (past present please note name, agency, pone address include child’s pediatrician any cild care

ParentChild elationshi

i oer these estions if alread oered in C or arent eretion interie

o ould you describe your cild

Center for Development and Disability at the University of New Mexico 8

26 h e his he senhs

escie n seins h he ccued eeen u nd u child lenh ie eec n en eec n child h his s elined child cuen ic n elinshi ec

h d u ind s diicul u u child

h d u s en u u child

des u child hndle nsiins

des u child hndle seins nd eunins

e u u il hd n les sesss in he s e le ic n il en child enchild elinshi

h e se cuen diiculies h e icin u elinshi ih u child

Parentin elfssessent

It is helpful to spend some time thinking about your relationship to your child and how you are as a parent to this particular child. Please help us to better understand you and your child by answering the following questions.

uld u es descie usel s en

Center for Development and Disability at the University of New Mexico 9

h e u senhs s en

h is chllenin u s en

uld u descie u elinshi ih u child n u chse ne d es descie u elinshi lese ie n ele

e u din s en nd n he s h e in u

u he cncens u u n helh u ein le ce ne u child

s hee n he inin u hin is in us n u u u child

Center for Development and Disability at the University of New Mexico 10

PARENT INFANT PSYCHOTHERAPY PROGRAM

ADVERSE CHILDHOOD EXPERIENCES SCORING SHEET (ACES) CLIENT# CHILD 1: D.O.B. CHILD 2: D.O.B. CHILD 3: D.O.B. CHILD 4: D.O.B. Parent/Guardian 1: D.O.B. Parent/Guardian 2: D.O.B.

Score 1 for Yes, 0 for No While you were growing up, during your first 18 years of life: Child/ren Parents/Gs 1. Recurrent Emotional Abuse C1 C2 C3 C4 P1 P2 Recurrent Emotional Abuse Did a parent or other adult in the household often or very often: Swear at you, insult you, put you down, or humiliate you? Or, act in a way that made you afraid that you might be physically hurt? 2. Recurrent Physical Abuse C1 C2 C3 C4 P1 P2 Did a parent or other adult in the household often or very often…Push, grab, slap or throw something at you? Or, ever hit you so hard that you had marks or were injured? 3. Contact Sexual Abuse C1 C2 C3 C4 P1 P2 Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? Or, attempt or actually have oral, anal, or vaginal intercourse with you? 4. Emotional Neglect C1 C2 C3 C4 P1 P2 Did you often or very often feel that … No one in your family loved you or thought you were important or special? Or, your family didn’t look out for each other, feel close to each other, or support each other? 5. Physical Neglect C1 C2 C3 C4 P1 P2 Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or, your parents were too drunk or high to take care of you or take you to the doctor if you needed it? 6. One or No Parent C1 C2 C3 C4 P1 P2 Were your parents ever separated or divorced? 7. Mother is Treated Violently C1 C2 C3 C4 P1 P2 Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or, sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or, ever repeatedly hit at least a few minutes or threatened with a gun or knife? 8. An Alcoholic and/or Drug Abuser in the Household C1 C2 C3 C4 P1 P2 Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? 9. Someone who is Chronically Depressed. Mentally III. Institutionalized, or Suicidal C1 C2 C3 C4 P1 P2 Was a household member depressed or mentally ill, or did a household member attempt suicide? 10. An Incarcerated Household Member C1 C2 C3 C4 P1 P2 Did a household member go to prison?

ACE SCORES: CHILD1 CHILD2 CHILD3 CHILD4 P1 P2 CLINICIAN:______DATE OF SCORING:______

29 Life Stressor Checklist - Revised

Admit ID Number Please fill in today's date: / /

READ THIS FIRST: Now we are going to ask you some questions about events in your life that are frightening, upsetting, or stressful to most people. Please think back over your whole life when you answer these questions. Some of these questions may be about upsetting events you don't usually talk about. Your answers are important, but you do not have to answer any questions that you do not want to. Thank you.

1. Have you ever been in a serious disaster (for example, an earthquake, hurricane, Yes No large fire, explosion)?

a. How old were you when this happened? c. At the time of the event did you believe that you or someone else could be killed or Yes No seriously harmed? d. At the time of the event did you experience feelings of intense helplessness, fear, or horror? Yes No e. How much is this affected your life in the past year? 1 2 3 4 5 not at all some extremely

2. Have you ever seen a serious accident (for example, a bad car wreck or an on-the-job Yes No accident)?

3. Have you ever had a very serious accident or accident-related injury (for example, a Yes No bad car wreck or an on-the-job accident)? ? a. How old were you when this happened? c. At the time of the event did you believe that you or someone else could be killed or Yes No seriously harmed? d. At the time of the event did you experience feelings of intense helplessness, fear, or horror? Yes No e. How much is this affected your life in the past year? 1 2 3 4 5 not at all some extremely

4. Was a close family member ever sent to jail? Yes No

a. How old were you when this happened? b. When it ended? c. At the time of the event did you believe that you or someone else could be killed or Yes No seriously harmed? d. At the time of the event did you experience feelings of intense helplessness, fear, or horror? Yes No e. How much is this affected your life in the past year? 1 2 3 4 5 not at all some extremely

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30 5. Have you ever been sent to jail? Yes No

6. Were you ever put in foster care or put up for adoption? Yes No

7. Did your parents ever separate or divorce while you were living with them? Yes No

8. Have you ever been separated or divorced? Yes No

9. Have you ever had serious money problems (for example, not enough money for food Yes No or place to live)? ? a. How old were you when this happened? b. When it ended? c. At the time of the event did you believe that you or someone else could be killed or Yes No seriously harmed? d. At the time of the event did you experience feelings of intense helplessness, fear, or horror? Yes No e. How much is this affected your life in the past year? 1 2 3 4 5 not at all some extremely Office Use Only 50462 - 2 -

31 10. Have you ever had a very serious physical or mental illness (for example, cancer, heart Yes No attack, serious operation, felt like killing yourself, hospitalized because of nerve problems)?

11. Have you ever been emotionally abused or neglected (for example, being frequently Yes No shamed, embarrassed, ignored, or repeatedly told that you were "no good")?

12. Have you ever been physically neglected (for example, not fed, not properly clothed, or Yes No left to take care of yourself when you were too young or ill)?

13. WOMEN ONLY: Have you ever had an abortion or miscarriage (lost your baby)? Yes No

14. Have you ever been separated from your child against your will (for example, the loss Yes No of custody or visitation or kidnapping? ? a. How old were you when this happened? b. When it ended? c. At the time of the event did you believe that you or someone else could be killed or Yes No seriously harmed? d. At the time of the event did you experience feelings of intense helplessness, fear, or horror? Yes No e. How much is this affected your life in the past year? 1 2 3 4 5 not at all some extremely Office Use Only 50462 - 3 -

32 15. Has a baby or child of yours ever had a severe physical or mental handicap (for example, Yes No mentally retarded, birth defects, can't hear, see, walk)?

16. Have you ever been responsible for taking care of someone close to you (not your Yes No child) who had a severe physical or mental handicap (for example, cancer, stroke, AIDS, nerve problems, can't hear, see, walk) ? a. How old were you when this happened? b. When it ended? c. At the time of the event did you believe that you or someone else could be killed or Yes No seriously harmed? d. At the time of the event did you experience feelings of intense helplessness, fear, or horror? Yes No e. How much is this affected your life in the past year? 1 2 3 4 5 not at all some extremely

17. Has someone close to you died suddenly or unexpectedly (for example, sudden heart Yes No attack, murder or suicide)?

18. Has someone close to you died (do NOT include those who died suddenly or Yes No unexpectedly)?

19. When you were young (before age 16). did you ever see violence between family Yes No members (for example, hitting, kicking, slapping, punching)? ? a. How old were you when this happened? c. At the time of the event did you believe that you or someone else could be killed or Yes No seriously harmed? d. At the time of the event did you experience feelings of intense helplessness, fear, or horror? Yes No e. How much is this affected your life in the past year? 1 2 3 4 5 not at all some extremely Office Use Only 50462 - 4 -

33 20. Have you ever seen a robbery, mugging, or attack taking place? Yes No

21. Have you ever been robbed, mugged, or physically attacked (not sexually) by someone Yes No you did not know?

22. Before age 16, were you ever abused or physically attacked (not sexually) by someone Yes No you knew (for example, a parent, boyfriend, or husband, hit, slapped, choked, burned, or beat you up?

23. After age 16, were you ever abused or physically attacked (not sexually) by someone Yes No you knew (for example, a parent, boyfriend, or husband hit, slapped, choked, burned, or beat you up) ? a. How old were you when this happened? b. When it ended? c. At the time of the event did you believe that you or someone else could be killed or Yes No seriously harmed? d. At the time of the event did you experience feelings of intense helplessness, fear, or horror? Yes No e. How much is this affected your life in the past year? 1 2 3 4 5 not at all some extremely

24. Have you ever been bothered or harassed by sexual remarks, jokes, or demands for Yes No sexual favors by someone at work or school (for example, a coworker, a boss, a customer, another student, a teacher)? ? a. How old were you when this happened? b. When it ended? c. At the time of the event did you believe that you or someone else could be killed or Yes No seriously harmed? d. At the time of the event did you experience feelings of intense helplessness, fear, or horror? Yes No e. How much is this affected your life in the past year? 1 2 3 4 5 not at all some extremely Office Use Only 50462 - 5 -

34 25. Before age 16, were you ever touched or made to touch someone else in a sexual way Yes No because he/she forced you in some way or threatened to harm you if you didn't?

26. After age 16, were you ever touched or made to touch someone else in a sexual way Yes No because he/she forced you in some way or threatened to harm you if you didn't?

27. Before age 16, did you ever have sex (oral, anal, genital) when you didn't want to because Yes No someone forced you in some way or threatened to hurt you if you didn't?

28. After age 16, did you ever have sex (oral, anal, genital) when you didn't want to because Yes No someone forced you in some way or threatened to harm you if you didn't?

29. Are there any events we did not include that you would like to mention? Yes No

What was the event? a. How old were you when this happened? b. When it ended? c. At the time of the event did you believe that you or someone else could be killed or Yes No seriously harmed? d. At the time of the event did you experience feelings of intense helplessness, fear, or horror? Yes No e. How much is this affected your life in the past year? 1 2 3 4 5 not at all some extremely Office Use Only 50462 - 6 -

35 30. Have any of the events mentioned above ever happened to someone close to you so that Yes No even though you didn't see it yourself, you were seriously upset by it?

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36 Page 1 of 5 OFFICE ONLY ID:______Respondent: ______Times @ Clinic______Date:______Time Period: ______Assessor:______Vscale______VP1:  Y N VP2:  Y  N VP3: Y  N Admin: interview questionnaire mixed

TRAUMATIC EVENTS SCREENING INVENTORY- PARENT REPORT REVISED

Children may experience stressful events, which may affect their health and well-being. Please indicate if your child has experienced any of these potentially stressful events by answering the shaded questions. If the answer is yes, please answer the follow-up questions. If it’s no, please go to the next shaded question.

If you have any questions or comments about any of the questions, we would be happy to talk to you about them.

SAMPLE ITEM (instructions are in italics) A. Has your child ever had a doctor’s visit? (Mark your answer in the next column. If yes answer the questions below.) Yes If YES  How old was your child?  No The first time:______The last time:______The most stressful:______ Unsure

Your child’s age the first time s/he saw a doctor Your child’s age during his/her most Your child’s age during the most (even if s/he would not have remembered it). recent doctor’s visit. stressful visit for your child (in your opinion).

Was your child strongly affected by one or more of these experiences?  yes  no  unsure (By strongly affected we mean: did your child seem: a) to be extremely frightened; b) to be very confused or helpless; c) to be very shocked or horrified, d) to have difficulty getting back to her or his normal way of behaving or feeling when it was over, OR e) to behave differently in important ways after it was over.)

1.1 Has your child ever been in a serious accident where someone could have been (or actually was) severely injured or died? (like a serious car or Yes bicycle accident, a fall, a fire, an incident where s/he was burned, an actual or near drowning, or a severe sports injury)  No  If YES Identify the type of accident(s):______ Unsure Victim’s relationship to your child:______Did anyone die?  yes  no  unsure How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 1.2 Has your child ever seen a serious accident where someone could have been (or actually was) severely injured or died? (like a serious car or Yes bicycle accident, a fall, a fire, an incident where someone was burned, an actual or near drowning, or a severe sports injury)  No  If YES Identify the type of accident(s) ______ Unsure Victim’s relationship to your child:______Did anyone die?  yes  no unsure

How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences? yes no unsure

Page 2 of 5

1.3 Has your child ever been in a serious natural disaster where someone could have been (or actually was) severely injured or died? (like a Yes tornado, hurricane, fire, or earthquake)  No If YES  Type of disaster:______Did anyone die?  yes no  unsure  Unsure Did people your child knows (family, friends, neighbors) lose their homes or move because their homes were not livable?  yes  no  unsure How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 1.4a Has your child ever experienced the severe illness or injury of someone close to him/her? Yes IF YES  What was this person’s relationship to your child?______ No  Unsure How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 1.4b Has your child ever experienced the death of someone close to him/her? Yes  IF YES  What was this person’s relationship to your child?______No  Unsure How old was your child? The first time:______The last time:______The most stressful:______Was the death(s) due to: (check all that apply)  natural causes  illness  accident  violence  unknown Was your child strongly affected by one or more of these experiences?  yes  no  unsure 1.5 Has your child ever undergone any serious medical procedures or had a life threatening illness? Or been treated by a paramedic, seen in an Yes emergency room, or hospitalized overnight for a medical procedure?  No IF YES Describe ______ Unsure How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 1.6 Has your child ever been separated from you or another person who your child depends on for love or security for more than a few days OR Yes under very stressful circumstances? For example due to foster care, immigration, war, major illness, or hospitalization.  No IF YES Who was your child separated from: ______ Unsure How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 1.7 Has someone close to your child ever attempted suicide or harmed him or herself? Yes  IF YES  What was this person’s relationship to your child?______No  Unsure How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure

37 Page 3 of 5 2.1 Has someone ever physically assaulted your child, like hitting, pushing, choking, shaking, biting, or burning? Or punished your child and Yes caused physical injury or bruises. Or attacked your child with a gun, knife, or other weapon? (This could be done by someone in the family or  No by someone not in your child’s family).  Unsure IF YES What was this person’s relationship to your child? ______

Was a weapon used?  unsure  no  yes (type)______How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 2.2 Has someone ever directly threatened your child with serious physical harm? Yes  IF YES What was this person’s relationship to your child? ______No  Unsure Did they threatened to use a weapon? unsure  no  yes (type)______

How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 2.3 Has someone ever mugged or tried to steal from your child? Or has your child been present when a family member, other caregiver, or friend Yes was mugged?  No IF YES Who was mugged? (If not your child indicate the person’s relationship to your child.) ______ Unsure

Was a weapon used?  unsure  no  yes (type)______How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 2.4 Has anyone ever kidnapped your child? (including a parent or relative) Or has anyone ever kidnapped someone close to your child? Yes  No IF YES Who was kidnapped? (If not your child indicate the person’s relationship to your child.) ______ Unsure What was the kidnapper’s relationship to your child? ______

How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 2.5 Has your child ever been attacked by a dog or other animal? Yes IF YES How old was your child? The first time:______The last time:______The most stressful:______ No  Unsure Was your child seriously physically hurt as a result of the attack? yes  no  unsure Was your child strongly affected by one or more of these experiences?  yes  no  unsure

Page 4 of 5

3.1 Has your child ever seen, heard, or heard about people in your family physically fighting, hitting, slapping, kicking, or pushing each other. Or Yes shooting with a gun or stabbing, or using any other kind of dangerous weapon?  No IF YES What were these people’s relationships to your child? ______ Unsure Was a weapon used? unsure  no  yes (type)______How old was your child? The first time:______The last time:______The most stressful:______

Did your child see what happened?  yes  no  unsure Was your child strongly affected by one or more of these experiences?  yes  no  unsure 3.2 Has your child ever seen or heard people in your family threaten to seriously harm each other? Yes IF YES What were these people’s relationships to your child? ______ No  Unsure Did they threatened to use a weapon?  yes  no  unsure (type)______How old was your child? The first time:______The last time:______The most stressful:______

Was your child present when the threat was made?  yes  no  unsure Was your child strongly affected by one or more of these experiences?  yes  no  unsure 3.3 Has your child ever known or seen that a family member was arrested, jailed, imprisoned, or taken away (like by police, soldiers, or other Yes authorities)?  No  What was this person’s relationship to your child?______IF YES ______ Unsure How old was your child? The first time:______The last time:______The most stressful:______Was your child there when the police came?  yes  no  unsure Was your child strongly affected by one or more of these experiences?  yes  no  unsure 4.1 Has your child ever seen or heard people outside your family fighting, hitting, pushing, or attacking each other? Or seen or heard about Yes violence such as beatings, shootings, or muggings that occurred in settings that are important to your child, such as school, your neighborhood,  No or the neighborhood of someone important to your child?  Unsure IF YES What were these people’s relationship to your child? ______

Was a weapon used?  yes  no  unsure (type)______Where did this happen? ______How old was your child? The first time:______The last time:______The most stressful:______Did your child see what happened?  yes  no  unsure Was your child strongly affected by one or more of these experiences?  yes  no  unsure 4.2 Has your child ever been directly exposed to war, armed conflict, or terrorism? Yes  IF YES How old was your child? The first time:______The last time:______The most stressful:______No  Unsure Was your child strongly affected by one or more of these experiences?  yes  no  unsure 38 Page 5 of 5

4.3 Has your child ever seen or heard acts of war or terrorism on the television or radio? Yes  IF YES How old was your child? The first time:______The last time:______The most stressful:______No  Unsure Was your child strongly affected by one or more of these experiences?  yes  no  unsure 5.1 Has someone ever made your child see or do something sexual (like touching in a sexual way, exposing self or masturbating in front of the Yes child, engaging in sexual intercourse)?  No IF YES What was this person’s relationship to your child? ______ Unsure

Was physical violence used?  unsure  no  yes Was a weapon used?  unsure  no  yes (type)______How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 5.2 Has your child ever been present when someone was being forced to engage in any sort of sexual activity? Yes  IF YES What were these people’s relationship to your child? Victim:______Aggressor:______No  Unsure Was physical violence used?  unsure  no  yes Was a weapon used?  unsure  no  yes (type)______

How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 6.1 Has your child ever repeatedly been told s/he was no good, yelled at in a scary way, or had someone threaten to abandon, leave or send Yes him/her away?  No IF YES What was this person’s relationship to your child?______ Unsure How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure 6.2 Has your child ever gone through a period when s/he lacked appropriate care (like not having enough to eat or drink, lacking shelter, being left Yes alone when s/he was too young to care for herself/himself, or being left with a caregiver who was abusing drugs)?  No IF YES How old was your child? The first time:______The last time:______The most stressful:______ Unsure Was your child strongly affected by one or more of these experiences?  yes  no  unsure 7.1 Have there been other stressful things that have happened to your child? Yes  IF YES Briefly describe these things:______No  Unsure ______

How old was your child? The first time:______The last time:______The most stressful:______Was your child strongly affected by one or more of these experiences?  yes  no  unsure

39 Infant Mental Health Assessments

40 WORKING MODEL OF THE CHILD INTERVIEW

Charles H. Zeanah, M.D. Division of Child & Adolescent Psychiatry Tulane University School of Medicine New Orleans, Louisiana, USA

Diane Benoit, M. D. Department of Psychiatry Hospital for Sick Children Toronto, Ontario, CANADA

Marianne Barton, Ph.D. Department of Psychology University of Connecticut Storrs, Connecticut, USA

Correspondence: Charles H. Zeanah, M.D. Tulane University School of Medicine Department of Psychiatry & Neurology Division of Child & Adolescent Psychiatry 1430 Tulane Avenue, #8055 New Orleans, Louisiana 70112-2715 Ph.: (504) 988-5402 FAX: (504) 988-4264 email: [email protected]

41 (a) What about when he/she becomes emotionally upset? Can you recall a specific example? Indicate that you want an example by providing a reasonably long time to think of one. What did you do when that happened?

What did you feel like doing? What did you feel like? If the subject becomes extremely anxious and cannot recall an example, then proceed to part (b).

(b) What about when he/she has been physically hurt a little bit? Can you give an example and describe what happened? Be sure to find out what the subject felt like and did.

(c) Has your child been sick at all? Give me an example. Again, ask what this experience was like for the parent and how the parent responded to the child affectively and behaviorally.

(10) Tell a favorite story about your child, perhaps one you've told to family or friends. I'll give you a minute to think about this one. If the subject is struggling, you may tell them that this doesn't have to be the favorite story, only a favorite. What do you like about this story?

(11) Are there any experiences which your child has had which you feel may have been a setback for him/her?

Why do you think so? Indirectly, we're trying to determine whether the parent feels responsible in any way for the setbacks. Therefore, be sure to give time to respond before moving on to the more direct questions which follow. Knowing what you know now, if you started all over again with your child, what would you do differently?

Give some time to respond.

The Working Model of the Child Interview is a structured interview to assess parents' internal representations or working models of their relationship to a particular child. The setting of the interview should be comfortable enough to allow for attention to the questions posed and a relaxed atmosphere that permits the opportunity for reflection.

The introductory section on developmental history is optional, depending upon the setting and purposes for which the interview is used. Otherwise, the interviewer should follow the outline. The interview allows for some follow-up probes, particularly those that encourage the individual to elaborate on responses.

Vital to scoring is that the interviewer not make interpretive comments, since we are interested in the degree to which individuals make these links on their own. Requests for clarification about contradictions may be made, but only for purposes of ascertaining whether the individual maintains contradictory views of the infant and only after allowing the individual an opportunity to recognize, acknowledge, and resolve the contradictions on his/her own. Essentially, the purpose of the interview is to have individuals reveal as much as possible in a narrative account of their perceptions, feelings, motives, and interpretations of a particular child and their relationship to that child.

42 WORKING MODEL OF THE CHILD INTERVIEW

We are interested in how parents think and feel about their young children. This interview is a way for us to ask you about child's name and your relationship to him/her. The interview will take us about an hour to complete.

1. I'd like you to begin by telling me about your child's development.

(a) Let's start with your pregnancy. I'm interested in things like whether it was planned or unplanned, how you felt physically and emotionally, and what you were doing during the pregnancy (working, etc.). In a follow-up probe, find out how much the baby was wanted or not wanted. Had you ever been pregnant before? When did the pregnancy seem real to you? What were your impressions about the baby during pregnancy? What did you sense the baby might be like? The idea is to put the subject at ease and to begin to obtain a chronological history of the pregnancy. Additional probes may be necessary to make sure that the individual is given a reasonable opportunity to convey the history of their reactions to and feelings about the pregnancy and the baby (which may or may not be the same).

(b) Tell me about labor and delivery. Give some time to respond before proceeding. How did you feel and react at that time? What was your first reaction when you saw the baby? What was your reaction to having a boy/girl? How did your family react? Be sure to include husband/partner, other siblings.

(c) Did the baby have any problems in the first few days after birth? How soon was the baby discharged from the hospital? Did you decide to breast-feed or bottle-feed? Why?

(d) How would you describe the first few weeks at home: feeding, sleeping, crying, etc. This is often a very important time because it may set the "emotional tone" of the baby's entrance into the family, particularly if the delivery and perinatal period were routine.

43 (e) Tell me about your baby's developmental milestones such as sitting up, crawling, walking, smiling, and talking. Be sure to get a sense of the ways in which the baby was thought to be different, ahead, or behind in motor, social and language development. Did you have any sense of your baby's intelligence early on? What did you think?

(f) Did your baby seem to have a regular routine? What happened if you didn't stay in the routine?

(g) How has the baby reacted to separations from you? Try to get a sense of the baby's reactions at various ages. Were there any separations of more than a day in the first or second year? How did the baby react? How was it for you? How did you feel? What did you do?

(2a) Describe your impression of your child's personality now. Give the subject enough time to respond to this before proceeding to specific descriptors below.

(2b) Pick five words (adjectives) to describe your child's personality. After you have told me what they are, I will ask you about each one. For each one, what is it about him/her that makes you say that?, Then, tell me one specific incident which illustrates what you mean by each word that you chose. You may tell the subject that it is fine to use any of the descriptors they used in response to the general probe above, but do not remind them what they said before you have given them time to recall themselves. Some subjects will have a hard time coming up with five descriptors. If you feel that the subject cannot come up with five, then move on. The numbers are less important than the descriptions.

44 (3a) At this point, whom does your child remind you of? In what ways? When did you first notice similarity? If only one parent is mentioned, ask, in what ways does the child remind you of (the other parent)? The following questions should be asked whether or not the parents have been mentioned. Which of his/her parents is your child most like now? In what ways is your child's personality like or unlike each of his/her parents?

(3b) Are there any family characteristics on your side you see in your child's personality? What about (other parent's) side?

(3c) How did you decide on your child's name? Find out about family names, etc. How well does the name seem to fit?

(4) What do you feel is unique, different, or special about your child compared to what you know of other children?

(5) What about your child's behavior now is the most difficult for you to handle? Give a typical example.

(a) How often does this occur? What do you feel like doing when your child reacts this way? How do you feel when your child reacts this way? What do you actually do?

(b) Does he/she know you don't like it? Why do you think he/she does it?

45 (6a) How would you describe your relationship to your child now? Give time to respond.

(6b) Pick five words (adjectives) to describe your relationship. For each word, describe an incident or memory that illustrates what you mean.

(7a) What pleases you most about your relationship with your baby? What do you wish you could change about it?

(7b) How do you feel your relationship with your child has affected your child's personality? Give ample time for subject to respond to this.

(7c) Has your relationship to your child changed at all over time? In what ways? What's your own feeling about the change?

(8) Which parent is your child closest to now? How can you tell? Has it always been that way? Do you expect that to change (as the child gets older, for instance)? How do you expect it to change?

(9) Does your baby get upset often? Give subject some time to respond before proceeding to specific queries.

What do you do at these times? What do you feel like doing when this happens? What do you feel like at these times?

46 (a) What about when he/she becomes emotionally upset? Can you recall a specific example? Indicate that you want an example by providing a reasonably long time to think of one. What did you do when that happened?

What did you feel like doing? What did you feel like? If the subject becomes extremely anxious and cannot recall an example, then proceed to part (b).

(b) What about when he/she has been physically hurt a little bit? Can you give an example and describe what happened? Be sure to find out what the subject felt like and did.

(c) Has your child been sick at all? Give me an example. Again, ask what this experience was like for the parent and how the parent responded to the child affectively and behaviorally.

(11) Are there any experiences which your child has had which you feel may have been a setback for him/her?

Give some time to respond.

47 (12) Do you ever worry about your child? What do you worry about?

(13) If your child were to be one particular age, what age would you choose? Why?

(14) As you look ahead, what will be the most difficult time in your child's development? Why do you think so?

(15) What do you expect your child to be like as an adolescent? What makes you feel this way? What do you expect to be good about this period in your child's life? What do you expect to be not so good about this period in your child's life?

(16) Think for a moment of your child as an adult. What hopes do you have about that time? What fears do you have about that time?

In a follow-up probe, you may ask what the interview was like for the subject.

48 MODIFIED WORKING MODEL OF THE CHILD INTERVIEW

1a) Describe your impression of the child’s personality now. Give the person enough time to respond to this before proceeding to the specific descriptors below. If parent is confused by the question, you can add something like – “Just describe his/her typical ‘ways’ or how s/he is in a nutshell.”

1b) Pick five words or adjectives to describe your child’s personality. After you have told me what they are, I will ask you about each one. For each one, what is it about him/her that makes you say that? I will ask you to tell one specific incident which illustrates (shows) what you mean by each word that you chose. If the interviewee asks, you may say that it’s fine to use any of the descriptors s/he used in response to the general personality question above, but do not remind them about what those descriptors were. Phrases instead of words are fine (but do not make that part of the instructions). It is important not to rephrase what the interviewee says, but to use the words or phrases they stated. Some people have a hard time coming up with five words. Give them a “few more minutes” to think. If you feel they cannot come up with five, then move on. The numbers are less important than the descriptors. It does not matter if the words are synonyms. If the person cannot give five, you can say “That’s fine, if you think of another, we can come back to it.”

Write down the five words or phrases they give you, and when the interviewee is done, go back and get the specific example for each word or phrase.

(Probe each word for a specific incident/memory: 1. “The first (second, etc.) word (phrase) that you used to describe (your child’s) personality was ______. Tell me about a specific incident or memory that shows why you picked ______to describe him/her.” 2. If the interviewee gives a non-specific example (e.g., “She always does that, or when we go to the park,” then say, “Tell me about one specific time that shows why you picked _____to describe him/her; that stands out when child was ______).” 3. If you still don’t get a specific event, then ask, “When was the last time your child was______.…Tell me about that time. If after those 3 requests you don’t get a specific example, move on to the next word. You must use judgment about whether to do this for all 5 adjectives. If someone has only given generic examples rather than specific examples for the first 3 adjectives and is irritated about the probing, you may have to move on.

2a) At this point, who does your child remind you of? -In what ways? -When did you notice the first similarity? If only one, or neither parent is mentioned, ask: -In what ways does the child remind you of (the other parent)? The following questions should be asked whether or not the parents have been mentioned. -Which of his/her parents is your child most like now?

49 -In what ways is your child’s personality like yours? Not like yours? In what ways is his/her personality like his/her other parent’s (e.g., dad’s)? Not like his/her other parent’s personality?

2b) Are there any family characteristics on your side you see in your child’s personality? -What about (other parent’s) side? If the interview says s/he doesn’t know, move on. If s/he only mentions physical characteristics, probe again for personality.

2c) How did you decide on your child’s name? Find out about family names, etc. How well does the name seem to fit?

3) What do you feel is unique, different, or special about your child compared to what you know of other children? Give ample opportunities for the interview to respond—this is a question to linger on rather than move through quickly. So, if there is a very brief response (or no response) consider saying things like, “That’s ok, take your time,” or “Do you want to add anything else?”

4) What about your child’s behavior now is the most difficult for you to handle? Pause before moving to the next probe. Give a typical example. If the interviewee says “Nothing,” say, “Well, for most parents there’s at least one thing that’s challenging to deal with…what about for you?’ If still nothing, try, “Ok, tell me something that’s just not as easy for you to handle.” If you still get no example of behavior, skip the following probes and go to question 5a).

a) How often does this occur? -What do you feel like doing when your child reacts this way? -How do you feel on the inside when your child reacts this way? -What do you actually do?

b) Does he/she know you don’t like it when she…? -Why do you think he/she does it?

a) What do you imagine will happen to this behavior as your child grows older? -Why do you think so?

5a) How would you describe your relationship to your child now?

Give adequate time to respond before moving to the next probe.

5b) Pick five words (adjectives) to describe your relationship. Just like we did with personality, I’ll go back and ask you for a specific incident or memory for each word that illustrates what you mean. Again, accept whatever they say, then go through each word or phrase and use the same 3-probe approach used for the personality words as needed to get a specific memory.

6a) What pleases you most about your relationship with your baby? -What do you wish you could change about it? Some general probes that you can ask for either question include, “Tell me more.” “How so?” If interviewee says, “Nothing,” to the second question, probe “Is there anything that you wish were a little bit different? Only probe once here.

6b) How do you feel your relationship with your child has affected your child’s personality? Be sure to give ample time to respond to this question. If the parent/caregiver says “Nothing,” probe [only] once “Are you sure?”

6c) Has your relationship to your child changed at all over time? If the parent/caregiver says “No,” you can follow up with, “Not at all?” If the parent does not think the relationship has changed at all, move on to question 7. -In what ways? -What’s your feeling about the change?

7) Which parent/parent figure is your child closest to now? -How can you tell? -Has it always been that way? -Do you expect that to change (as the child gets older, for instance)? -How do you expect it to change?

8) Tell a favorite story about your child, perhaps one that you’ve told to family or friends. I’ll give you a minute to think about this one. If the person is struggling, you may tell them that this doesn’t have to be the favorite story, only a favorite, just one they really like. You want an answer! -What do you like about this story?

9) Think for a moment about your child as an adult. What hopes and fears do you have about that time?

CAREGIVER-CHILD STRUCTURED INTERACTION PROCEDURE (CROWELL) Clinical Administration and Coding

Sherryl Scott Heller, PhD Institute of Infant and Early Childhood Mental Health Tulane University Health Sciences Center

www.infantinstitute.org

52 CAREGIVER-CHILD STRUCTURED INTERACTION PROCEDURE (CROWELL) Sherryl Scott Heller, PhD Institute of Infant and Early Childhood Mental Health Tulane University Health Sciences Center

TABLE OF CONTENTS

Administration and Setup pages 3 - 7 List of freeplay toys page 3 Room description page 4 General reminders page 4 General instructions page 5 Episode sequence and instructions page 5 Developmentally ordered task list pages 6 – 7

Scoring and Interpretation Clinical scoring pages 8 – 10

53 CAREGIVER-CHILD STRUCTURED INTERACTION PROCEDURE (CROWELL) Sherryl Scott Heller, PhD Institute of Infant and Early Childhood Mental Health Tulane University Health Sciences Center

I. Administration and Set-up

A. List of freeplay toys 1. Include toys which support pretend play.

2. a. Currently I include the following toys:  Doll and bottle  Some puppets (human)  Doctor’s kit  Two phones  Plates and food

b. If the child is under 18 months of age include:  stuffed animal  farm house set or toy farm animals  some large trucks or vehicles

c. If the child is 40 months or older include:  Small dolls (doll house type dolls)  Tool kit

3. Do NOT include toys: a. which lend themselves to teaching type interactions, as this will happen during the task portion of the Crowell b. that make loud noises as this makes scoring difficult. c. Large toys (e.g., doll house, kitchen sets) because this interferes with clean-up and if left in the room tends to act as a distracter. Large toys also interfere with video-taping as often times the toys block the view of the child and/or caregiver.

54 CAREGIVER-CHILD STRUCTURED INTERACTION PROCEDURE (CROWELL) Sherryl Scott Heller, PhD Institute of Infant and Early Childhood Mental Health Tulane University Health Sciences Center

B. Room Description 1. It is best if the room is minimally furnished. At our clinic the room never has more than two adult chairs, the toy task cabinet, and a few “educubes” (small child size chairs). Tables are not put in the room as they tend to obscure the view of the child and parent. 2. The Crowell tasks are stored in a cabinet which can be locked. The key is given to the parent during the instruction phase of the procedure. 3. The freeplay toys are kept in a large toy bucket and removed from the room after clean-up. If left in the room they tend to distract the child and parent from the tasks. 4. We have 3 “educubes” in the room. These are large plastic blocks, each block can be used as a table or as a child size chair when turned on it’s side (these are available through J.L. Hammet, Lakeshore, or Beckley Cardy catalogs). 5. There is a telephone in the room which allows the clinician or researcher to call into the room and give instructions during the procedure. The procedure tends to run more smoothly when complete instructions are given before the Crowell starts and then again at each transition.

C. General Reminders

1) Parents are given basic instructions prior to the session and each task is demonstrated (see video tape for specific task instructions). During the session the clinician calls into the room on a telephone to give specific instructions between each transition. 2) Task 1 and 2 should be somewhat below the child's developmental level, ideally the child should be able to do the task with little or no assistance. Tasks 3 and 4 should be above the child's level so that they need the parent's assistance to complete the task. 3) The length of time allowed for each task varies. If the child finishes the task quickly allow time for the task to be done 1 or 2 more times. If time is up and: a) the dyad is close to completing the task allow time for task completion and joy sharing. b) the child is getting frustrated than end the task. c) the task is far from complete than end the task. 4) If the child becomes highly distressed during the separation than the separation is ended early. The parent returns to the room as instructed in section E below. The separation is never shorter than 20 seconds and never longer than 3 minutes.

55 CAREGIVER-CHILD STRUCTURED INTERACTION PROCEDURE (CROWELL) Sherryl Scott Heller, PhD Institute of Infant and Early Childhood Mental Health Tulane University Health Sciences Center

D. General Instructions

Instructions given to the parent at the start of the session: "I will call you between each task and remind you what to do, however I will review everything with you now so you will have an idea of what is going to happen. First I want you to play with (child's name) and the toys here (indicate freeplay toys), then I will call you and ask you to have him/her clean up all of the toys. You can help him/her if you think he/she needs it, but see how much he/she can do on his/her own. I will then call and ask you to do each of the following tasks with him/her. Some of these tasks will be easy for him/her and some will be more difficult, you may help him/her if you think he/she needs it (review the bubbles and 4 tasks). After the fourth task I will call and ask you to leave the room. After leaving the room you may come back into the monitoring room and watch him/her. After a few minutes I will ask you to return to the room and the two of you will play for a few more minutes. If (child's name) becomes to upset we will end the separation early".

E. Episode Sequence and Instructions

Individual episodes: Instruction given over the phone during transitions: Freeplay - 10 minutes Play with the child as you would at home Cleanup - no more than 5 minutes Have the child cleanup, helping him/her if you feel the child needs help. Bubbles I would like you to blow the bubbles and to have (child's name) pop them. Task 1 - 2 to 4 minutes Specific tasks instructions (see videotape). Task 2 - 2 to 4 minutes Specific tasks instructions (see videotape). Task 3 - 3 to 5 minutes Specific tasks instructions (see videotape). Task 4 - 3 to 5 minutes Specific tasks instructions (see videotape). Separation - no more than 3 minutes Open the cabinet doors, so that the child can see the task toys and than leave the room as you would at home. Reunion - 3 minutes Knock on the door, call the child's name, and step all the way into the room.

56 CAREGIVER-CHILD STRUCTURED INTERACTION PROCEDURE (CROWELL) Sherryl Scott Heller, PhD Institute of Infant and Early Childhood Mental Health Tulane University Health Sciences Center

F. Developmentally ordered tasks. See videotape for examples of tasks and the specific instructions given for each task. Please note that this list was developed for a high-risk sample. A low risk sample most likely will be able to do the tasks at a younger age than is listed in column 1.

12 months 1 – Ball 2 – Sorter (6 blocks without lid) 3 – Tower (3 blocks) 4 – Farmer and tractor 5 – Nesting task (2 step) 6 – Nesting task (3 step) 7 – Jack in the box 19 months 8 – Balloon puzzle 9 – Ring Sorter 10 – Blocks inside blocks 11 – 4 part stacking clown 12 – Farm pop-up 22 months 13 – People on bus 14 – Tower (6 blocks) 15 – Sesame Street pop-up 16 – School house 17 – Nesting task (5 step) 31 months 18 - Sorter (6 shape blocks with lid) 19 - Shape puzzle (with knobs/handles) 20 - Teddy bear puzzle 21 – Rainbow board 22 – Colored balls & pegs 37 months 23 – Colored peg board 24 – Duplo police station 25 – Colored necklace 26 – Red push/pull car (duplo) 27 – Puzzles with handles  Dinosaur puzzle  Pond animal puzzle  Farm animal puzzle 28 – Sorting task – 1 category  Animals  Fruits  Transportation vehicles 29 – Shape peg board 30 – Teddy bear shape peg board 31 - Transportation puzzle

57 CAREGIVER-CHILD STRUCTURED INTERACTION PROCEDURE (CROWELL) Sherryl Scott Heller, PhD Institute of Infant and Early Childhood Mental Health Tulane University Health Sciences Center

32 – Egg shape task 43 months 33 – Barrel-o-monkeys 34 – Sorting task – 2 categories

Task list (cont.)  Animals  Fruit  Transporation vehicles  Dinosaurs 35 – Fish puzzle 36 – Blue lego car 37 - Oval train track 38 – Large school bus puzzle 39 – Wooden shapes 40 – Puzzles  Goofy  Noah’s Ark 41 – Duplo pagoda 42 – Memory game 43 – 8 shaped train track

58 CAREGIVER-CHILD STRUCTURED INTERACTION PROCEDURE (CROWELL) Sherryl Scott Heller, PhD Institute of Infant and Early Childhood Mental Health Tulane University Health Sciences Center

II. Scoring and Interpretation There are 2 methods used to score or interpret the Crowell procedure. One is for clinical purposes and the other is for research purposes. Below the behaviors looked for from a clinical perspective are listed. The coding scheme used for research follows.

A. Clinical Scoring 1. Free play a. Level of comfort with one another Does the dyad seem comfortable with each other or does one or both partners seem tense or uncomfortable with this type of interaction? Remember to take into account that the caregiver may be somewhat apprehensive about being observed and videotaped. b. Familiarity with play and fun together Does this type of interaction seem familiar to the dyad, is this the way they behave outside the clinic? c. Task oriented versus child- or fun-oriented Does the dyad, especially the caregiver, seemed focused on what they perceive to be the task at hand or is the dyad more focused on enjoying each others company and having a good time? d. Partnership versus solidarity. Does the dyad spend most of its time interacting with each other or playing together. Or does the dyad spend most of its time playing separately with little or no interaction?

2. Clean-up a. Compliance Does the child comply with the request of the caregiver. If the child does not how is this handled? Are the caregiver’s expectations of the child developmentally appropriate? Non-compliance is not necessarily bad – as long as the caregiver is able to manage it appropriately and it is clear that the caregiver is in charge of the interaction.

b. Cooperation Do the two work together to clean-up or is the child expected to do it all on his/her own? How do the two function as a team?

c. Transitions How does the child handle transitions? If the child has difficulty with them is the parent able to help the child re-focus on the next task? Is the parent able to anticipate that the child is going to have difficulty with the transition and assist him/her with future transitions?

59 CAREGIVER-CHILD STRUCTURED INTERACTION PROCEDURE (CROWELL) Sherryl Scott Heller, PhD Institute of Infant and Early Childhood Mental Health Tulane University Health Sciences Center

3. Bubbles a. Positive and shared affect You are interested in whether or not the child references the adult during the task and shares his/her excitement with the caregiver. You also are interested in whether or not the parent matches or supports the child’s expression of joy.

b. Enjoyment and enthusiasm This task pulls for joy and excitement from the child. It is concerning if the child does not exhibit joy and/or enthusiasm in regards to this task.

4. Four structured tasks a. Increasing difficulty The tasks are ordered so that they increase in difficulty. The last two tasks are intentionally above the child’s developmentally level. How does the dyad manage this increase in difficulty? Does the parent increase his/her support of the child? Is the child able to use the parent’s help?

b. Reliance for help Does the child turn to the caregiver for assistance when he/she needs it or is the child unable to rely upon the parent for assistance?

c. Staying focused Does the child stay on task? Does the parent help to keep the child on task? Is the parent able to do this in a supportive and developmentally appropriate manner?

c. Maintaining balance (anticipating frustration) Does the child get frustrated? Is the parent able to diffuse or anticipate this frustration?

5. Separation

a. Stress This is designed to be a stressful situation for the child. Does the caregiver simply leave the room or does the caregiver prepare the child for this separation? How does the child respond to the separation?

b. Activate attachment system

60 CAREGIVER-CHILD STRUCTURED INTERACTION PROCEDURE (CROWELL) Sherryl Scott Heller, PhD Institute of Infant and Early Childhood Mental Health Tulane University Health Sciences Center

This episode is designed to activate the attachment system so that when the parent returns the child’s response to the parent should be to seek proximity and comfort.

c. Self-soothing/coping behavior Is the child able to manage his/her level of distress or does the child become so distressed that the separation must be ended early.

6. Reunion a. How does the dyad reunite Does the child seek out the caregiver – either physically or verbally (greeting or inviting the mother to play)? Does the child ignore or respond minimally to the caregiver’s return? Does the child seek out the parent and than respond to the parent in an angry or rejecting manner?

b. Response to distress How does the caregiver respond to the child’s distress – does the caregiver minimize the child’s distress? Does the caregiver acknowledge and respond to the child’s distress? Does the caregiver’s response match the child’s level of distress?

c. Congruence between separation and reunion Does the child’s response in the reunion match his/her level of distress during the separation? Is the child able to be comforted by the caregiver?

c. Resumption of play/exploration Is the child able to return to play by the end of the reunion? Does the child’s level of play match that of his/her play pre-separation or is the level of play muted? Does the child remain near the parent and/or refuse to return to play?

61 BABY CROWELL PROCEDURE (Modified) January 2017

Tulane University

Instructions to give caregivers are noted in bold font.

Baby Crowells take place on a mat or a blanket – not in a high chair or infant seat. Baby must be able to sit up independently to accomplish a Baby Crowell (age range is generally 6 – 12 months—should not be used if child can walk independently).

The first episode is Free Play; toys for Free Play are listed below.

“Once you are in the room, please just make yourself and your baby comfortable. You can spend time with your child as you normally would.”

1) 5 minutes: Free play with caregiver/parent and baby (“Play as you normally would”) 2) Clean-up: Caregiver is told to “place the toys in the bucket and push the bucket to the door. Child can “help” as appropriate.” 3) Parent puts the toys in the bucket and pushes the bucket to the door. Team member removes bucket from room. On the phone: Ask caregiver/parent to “take out the bubbles and blow them for the baby.”

4) 2 minutes: caregiver/parent blows bubbles for the baby

On the phone: Ask caregiver to “get out 1st task and teach the baby the task.” (See list of teaching tasks, below)

5) 3 minutes: first teaching task

On the phone: Ask caregiver to “get out 2nd task and teach the baby the task.” (See list of teaching tasks)

6) 3 minutes: second teaching task

On the phone: “Please do whatever you feel is necessary to make your baby comfortable and then come out of the room. The baby will stay in the room for a couple of minutes.”

7) 2 minutes: separation (caregiver/parent leaves) (No more than 20 seconds if the child is very distressed)

In the monitoring room: When time has elapsed (or if baby is distressed), walk caregiver/parent to the door. Instructions: “Please knock on the door, call the baby’s name, and then step all the way into the room. We would like you to spend some time with your baby doing what comes naturally. You will have several minutes alone with your baby.”

8) 3 minutes: reunion (caregiver/parent returns)

FREE PLAY TOYS FOR BABY CROWELL

 Dolls and bottles (various ethnicities, both genders)  Stuffed animal  Activity Boards (but not with many bells and whistles, which make hearing interaction difficult)  Farm house set or farm animals  Large trucks or vehicles

Toy are placed in big bucket with rope handles

TEACHING TASKS FOR BABY CROWELL

1) Balls in the bowl – you will need a clear plastic bowl and several plastic balls (see toysrus.com “Pound a Ball” by Castle Toys for the type of balls needed). Have the parent remove the balls from the bowl and then teach the baby to put the balls back in the bowl.

2) Tower of 2 – you will need 4 basic blocks. Have parent build a tower of two and then teach the baby how to build his/her own tower. You can put the blocks in a plastic container.

3) Blocks in the Bucket – remove the lid from the sorter and have the parent teach the baby to put 6 shapes (e.g., 2 squares, 2 triangles, and 2 circles) into the bucket (see toysrus.com for “Baby’s First Blocks” by Fisher Price). You can also use basic blocks in a clear plastic container for this task.

4) Ball – have the parent roll the ball to the baby and teach the baby to roll it back. Use a regular rubber playground ball that is not too large for the baby to handle (about 8” - 9”). Balls that are developmentally-oriented and involve using all the senses can be found at Discovery Toys.

5) Tower of 3 – same as Tower of 2; use 6 blocks instead of 4.

63 6) Nesting Task – place the smallest object in the toy inside 2 - 3 “layers” and ask the parent to have the baby locate it. See store.babycenter.com for either the “Discover Sounds Stackin’ Pans” by Little Tikes or the “Three Little Pigs Playset” by Lizzybee.

Choose tasks based on baby’s age (and developmental level). Higher numbers = harder tasks. Choose two tasks for each Baby Crowell. Vary the chosen tasks. For example, don’t ask baby to put balls in the bowl and then balls in the bucket or Tower of 2 and then Tower of 3.

64 Post Crowell Procedure Questions from the COSI (Hoffman, Cooper and Powell)

“I’m now going to ask you several questions about the experience that you and (name of child) just had together in the room (upstairs, downstairs, down the hall, in the next room, etc)”.

1. What was it like for you to participate in the experience you just completed with him/her?

2. You were asked to leave (name of child) in the room (one or two) time(s). What do you think that was like for him/her (each time?) (It is acceptable for parent to give a general description of both separations or be specific for each.) What was that like for you (each time?).

3. Most parents have never had a chance to see their child from behind a one-way mirror. a) While you stood there watching (name of child) was there anything that stood out for you? b) What do you think he/she needed during the time that you were watching him/her? 4. 5. You came back into the room (two times): a)What do you think that was like for (name of child) each time? [Note: It is acceptable for parent to give a general description of both reunions or be specific for each.] b)What was the reunion like for you (each time?) [Note: Same rules apply as above.] 1) In either of the reunions, did (name of child) show you that she/he needed comfort from you? 2) Decision tree: a) [If he/she showed a need for comfort:] 1) What did you do? 2) How did it feel when he needed comfort from you? 3) Is this the way he/she usually shows you he/she needs comfort? Or: b) [If he/she didn’t seem to require comfort:] 1) How does (name of child) show you when he/she need’s comfort from you? 2) What is it like for you when she/he shows you that he needs comfort from you?

6. When you asked (name of child) to pick up the toys, could you describe what happened? a) What do you think that was that like for her/him? b) What was it like for you?

THANK YOU

65 Developmental Information

66 Developmental Milestones and Competency Ratings Developmental Milestones and Competency Ratings By 3 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Emotional Briefly calms self (e.g., sucks on hand).

Exhibits interest in the outside world when in an alert state (e.g., gazes at objects, people, or light; localizes to sound; adjusts breathing in response to sound of voices). Is comforted by proximity to caregiver and soothing motion.

Remains in a calm, focused state for at least 2 minutes.

Makes smooth state transitions (e.g., sleep to drowsy to awake).

Expresses contentment or discomfort.

Social-Relational Smiles responsively (i.e., social smile).

Looks at caregiver’s face.

Coos responsively.

Localizes to familiar voices and sounds.

Shows interest in facial expressions.

67 Developmental Milestones and Competency Ratings

By 3 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Language- Follows sounds (e.g., turn- Social ing head in response to Communication sound).

Coos and gurgles.

Imitates simple facial expressions (e.g., smiling, sticking tongue out).

Cognitive Follows people and objects with eyes.

Loses interest or protests if activity does not change.

Movement and Pushes up trunk when Physical lying on stomach.

Holds head up without support.

Hands are often open (i.e., not in fists).

68 Developmental Milestones and Competency Ratings

By 6 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Emotional Responds to affection with smiling, cooing, or settling.

Demonstrates a range of emotions that includes happiness, excitement, sadness, fear, distress, dis- gust, anger, joy, interest, and surprise. Expresses anger, frustration, or protest with distinct cries and facial expressions. Recovers from distress when comforted by caregiver.

Social-Relational Imitates some movements and facial expressions (e.g., smiling or frowning). Engages in socially reciprocal interactions (e.g., playing simple back- and-forth games). Seeks social engagement with vocalizations, emotional expressions, or physical contact. Watches faces closely.

Language- Copies sounds. Social Communication

Babbles with p, b, and m sounds.

Vocalizes excitement and displeasure (e.g., laughs and coos).

Produces distinct cries to show hunger, pain, or being tired.

69 Developmental Milestones and Competency Ratings

By 6 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Cognitive Tracks moving objects with eyes from side to side.

Experiments with cause and effect (e.g., bangs spoon on table).

Smiles and vocalizes in response to own face in mirror image.

Recognizes familiar people and things at a distance.

Demonstrates anticipation of certain routine activities (e.g., shows excitement in anticipation of being fed). Movement and Swats at dangling Physical objects.

Pushes down on legs when feet are on a hard surface.

Sits without support.

Rolls over from tummy to back.

Holds and shakes an object.

Bangs two objects together.

Brings hands to midline.

Reaches for object with one hand.

70 Developmental Milestones and Competency Ratings

By 9 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Emotional Has strategies for self-soothing.

Demonstrates preference for caregivers.

Intentionally communi- cates feelings to others.

Social-Relational Distinguishes between familiar and unfamiliar voices.

Shows some stranger wariness.

Protests separation from caregiver.

Enjoys extended play with others, especially caregivers.

Engages in back- and-forth, two-way communication using vocalizations and eye contact. Mimics other’s simple gestures.

Follows other’s gaze and pointing.

71 Developmental Milestones and Competency Ratings

By 9 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Language- Responds to sounds by Social making sounds or mov- Communication ing body.

Imitates speech sounds when prompted

Begins to use noncrying sounds (speech sounds) to get and keep attention

String vowels together when babbling (ah, eh, oh).

Makes sounds to show joy or displeasure

Begins to use gestures to communicate wants and needs (e.g., reaches to be picked up). Follows some routine commands when paired with gestures

Shows understanding of commonly used words.

Cognitive Mouths or bangs objects.

Tries to get objects that are out of reach.

Looks for things he or she sees others hide (e.g., toy under blanket).

72 Developmental Milestones and Competency Ratings

By 9 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Movement and Rolls over in both direc- Physical tions (front to back, back to front).

Brings self to sitting position independently.

Stands with support.

Moves independently from one place to another (e.g., crawling, scooting). Turns pages of a book.

Reaches for and grasps objects.

Passes objects from one hand to the other.

73 Developmental Milestones and Competency Ratings

By 12 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Emotional Looks to caregiver for information about new situations and environments. Looks to caregiver to share emotional experiences.

Responds to other people’s emotions (e.g., displays sober, serious face in response to sadness in parent; smiles when parent laughs). Uses gestures to communicate feelings (e.g., clapping when excited). Social-Relational Offers object to initiate interaction (e.g., hands caregiver a book to hear a story). Plays interactive games (e.g., “peek-a-boo” and “pat-a-cake”).

Looks at familiar people when they are named.

Gives object to seek help (e.g., hands shoe to parent).

Extends arm or leg to assist with dressing.

Language- Understands “no.” Social Communication

Responds to own name.

Looks in response to “where” questions (e.g., “Where is the doggie?”).

74 Developmental Milestones and Competency Ratings

By 12 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Language- Makes different con- Social sonant sounds such as Communication mamamam and babababa. (continued) Points to nearby objects.

Imitates conventional gestures (e.g., waving bye- bye, clapping).

Responds to simple di- rectives accompanied by gestures such as “come here.” Has a few words (e.g., “mama,” “dada,” “hi,” “bye-bye,” or “dog”).

Cognitive Watches the path of something as it falls.

Has favorite objects (e.g., toys, blanket).

Explores objects and how they work in multiple ways (e.g., mouthing, touching, dropping). Fills and dumps containers.

Plays with two objects at the same time.

75 Developmental Milestones and Competency Ratings

By 12 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Movement and Takes a few steps without Physical holding on.

Walks holding onto furniture (i.e., cruises).

Moves from sitting to standing position.

Stands alone.

Picks up things between thumb and index finger (e.g., cereal).

Crawls forward on belly, pulling with arms and pushing with legs.

Turns around while crawling.

Crawls while holding an object.

76 Developmental Milestones and Competency Ratings

By 15 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Emotional Shows affection with kisses (without pursed lips).

Demonstrates cautious or fearful behavior such as clinging to or hiding behind caregiver. Social-Relational Seeks and enjoys attention from others, especially caregivers.

Engages in parallel play with peers.

Presents a book or toy when he or she wants to hear a story or to play.

Repeats sounds or actions to get attention.

Enjoys looking at picture books with caregiver.

Engages in parallel play with peers.

Language- Uses simple gestures such Social as shaking head “no” or Communication waving “bye-bye.”

Responds to the gestures of others.

Enjoys looking at picture books with caregivers.

Makes sounds with changes in tone (sounds more like speech).

77 Developmental Milestones and Competency Ratings

By 15 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Language- Uses complex com- Social munication skills Communication integrating gestures, (continued) vocalizations, and eye contact (e.g., looking to parent while taking his or her hand to bring him or her to a desired toy). Identifies correct picture or object when it is named.

Follows simple requests (e.g., “pick up the toy”; “roll the ball”).

Cognitive Imitates complex gestures (e.g., signing).

Initiates joint attention (e.g., points to show others something inter- esting or to get others’ attention). Finds hidden objects easily.

Uses objects for their intended purpose (e.g., drinks from a cup, smooths hair with brush). Movement and Explores physical Physical environment.

Pushes objects (e.g., boxes, toy trucks, push toys).

Walks independently.

78 Developmental Milestones and Competency Ratings

By 18 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Emotional Demonstrates self- comforting strategies.

Shares humor with peers or adults (e.g., laughs at and makes funny faces or nonsense rhymes). Social-Relational Likes to hand things to others during play.

Engages in reciprocal displays of affection (e.g., hugs or kisses with a pucker). Asserts autonomy (e.g., “me do”).

Reacts with concern when someone appears hurt.

Leaves caregiver’s side to explore nearby objects or setting.

Engages in teasing behavior such as looking at parent and caregiver and doing something “forbidden.” Language- Uses at least 20 words Social or word approximations Communication such as baba for ball.

Shows consistent increas- es in vocabulary each month.

Says and shakes head “no.”

Can follow one-step verbal commands without any gestures (e.g., sits when you say “sit down”).

79 Developmental Milestones and Competency Ratings

By 18 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Language- When pointing, looks Social back to caregiver to con- Communication firm joint attention. (continued) Combines words, gestures, and eye contact to communicate feelings and requests. Cognitive Enacts play sequences with objects according to their intended use (e.g., pushing a toy dump truck and emptying its cargo). Shows interest in a doll or stuffed animal by giving a hug.

Points to at least one body part.

Points to self when asked.

Plays simple pretend games (e.g., feeding a doll).

Scribbles with crayon, marker, and so forth.

Turns pages of book.

Recognizes self in mirror.

Movement and Stacks two blocks. Physical

Walks up steps with help.

80 Developmental Milestones and Competency Ratings

By 18 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Movement and Pulls toys while walking. Physical (continued) Helps undress him- or herself (e.g., pulls off hat, socks, mittens).

Eats with a spoon.

Drinks from open cup.

81 Developmental Milestones and Competency Ratings

By 24 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Emotional Exhibits embarrassment and pride.

Exhibits shame and guilt.

Exhibits empathy (e.g., offers comfort when someone is hurt).

Attempts to exert independence frequently.

Names or understands words for basic emotions.

Social-Relational Imitates others’ complex actions, especially adults and older children (e.g., putting plates on the table, posture, gestures). Enjoys being with other young children.

Takes pride and pleasure in independent accomplishments.

Primarily plays in proximity to other young children but notices and imitates other young children’s play more frequently. Responds to being cor- rected or praised.

Language- Enjoys being read to. Social Communication

Names actions.

82 Developmental Milestones and Competency Ratings

By 24 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Language- Knows names of familiar Social people and many body Communication parts. (continued) Uses two words together (e.g., “more cookie”; “Dada, bye-bye?”).

Repeats words overheard in conversation.

Names objects in picture books (e.g., cat, bird, ball, or dog).

Imitates animal sounds such as “meow,” “woof,” “baa,” and “moo.”

Uses some self-referen- tial pronouns such as “mine.”

Cognitive Finds things even when hidden under two or three covers or when hidden in one place and moved to a second place (i.e., does not give up when the hidden object is not in the first location). Begins to sort shapes and colors.

Completes sentences and rhymes from familiar books, stories, or songs.

Plays simple make-believe games (e.g., pretend meal).

Builds towers of four or more blocks.

Follows two-step instructions (e.g., “Pick up your shoes and put them in the closet”).

83 Developmental Milestones and Competency Ratings

By 24 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Movement and Participates in dressing Physical (e.g., putting arms into sleeves, pulling pants up or down, putting on hat). Stands on tiptoes.

Kicks a ball.

Runs.

Climbs onto and down from furniture without help.

Walks up and down stairs holding on.

Draws lines.

Drinks using a straw.

Opens cabinets, drawers, and boxes.

84 Developmental Milestones and Competency Ratings

By 36 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Emotional Expresses full range of emotions, including pride, shame, guilt, and empathy. Expresses distress or anger with words.

Shows pride in new learning and new experiences.

Expresses affection open- ly and verbally.

Expresses feelings through pretend play and drama.

Social-Relational Shows affection to peers without prompting.

Shares without prompts.

Can wait turn in playing games.

Shows concern for crying peer by taking action.

Engages in associative play with peers (i.e., infants/young children participate in similar activities without formal organization but with some interaction). Shares accomplishments with others.

Helps with simple household tasks.

85 Developmental Milestones and Competency Ratings

By 36 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Language- Clearly uses k, g, f, t, d, Social and n sounds. Communication

Builds logical bridges between ideas using words such as “but” and “because.” Asks questions using words such as “why?” or “how?”

Says first name when asked.

Names most familiar objects.

Understands words such as “in,” “on,” and “under.”

Knows own identifying information (e.g., name, age, gender).

Identifies peers by name.

Uses some plurals (e.g., “cars,” “dogs,” “cats”).

Uses labels “mine,” “I,” “you,” “me,” “their,” “his,” or “hers” accurately. Speaks well enough for familiar listeners to understand most of the time. Carries on a conversation using two or three sentences.

Uses sentences that are at least three to four words.

86 Developmental Milestones and Competency Ratings

By 36 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Cognitive Labels some colors correctly.

Plays thematic make-believe with objects, animals, and people.

Answers simple “why” questions (e.g., “Why do we need a coat when it’s cold outside?”). Shows awareness of skill limitations.

Understands “bigger” and “smaller.”

Understands concept of “two.”

Enacts complex behavioral routines observed in daily life of caregivers, siblings, or peers. Solves simple problems (e.g., obtains a desired object by opening a container). Attends to a story for 5 minutes.

Plays independently for 5 minutes.

Movement and Manipulates some but- Physical tons, levers, and moving parts.

Climbs on high and low structures.

Runs fluidly.

87 Developmental Milestones and Competency Ratings

By 36 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Movement and Copies a circle. Physical (continued) Builds tower of more than six blocks.

Pedals a tricycle (three- wheel bicycle).

Catches and kicks big ball.

Walks up and down steps, alternating feet.

88 Developmental Milestones and Competency Ratings

By 48 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Emotional Expresses distress or anger with words.

Conveys emotional experiences in pretend play.

Complies with basic cul- tural rules for emotional expression.

Social-Relational Pretends to play “Mom” and “Dad” (or other relevant caregivers).

Asks about or talks about parent and caregiver when separated (i.e., holds the other in mind). Engages in cooperative play with other infants/ young children.

Has a preferred friend.

Expresses interests, likes, and dislikes.

Language- Relates experiences from Social school or outside home. Communication

Describes events or things using four or more sentences at a time.

Identifies rhyming words such as “cat–hat” or “ping–ring.”

Recognizes and understands basic rules of grammar (e.g., plurals, tense). Sings a song or says a poem from memory (e.g., “Itsy Bitsy Spider” or the “Wheels on the Bus”).

89 Developmental Milestones and Competency Ratings

By 48 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Language- Tells stories. Social Communication (continued) Says first and last name when asked.

Uses words or adjectives to describe or talk about him- or herself.

Understands, uses, and responds to questions of “how” or “when.”

Uses words that talk about time.

Speech is generally understood by nonfamily members.

Cognitive Names several colors and some numbers.

Counts to five.

Has rudimentary understanding of time.

Shares past experiences.

Remembers parts of a story.

Engages in make-believe play with capacity to build and elaborate on play themes. Connects actions and emotions.

90 Developmental Milestones and Competency Ratings

By 48 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Cognitive Responds to questions (continued) that require understanding the idea of “same” and “different.” Draws a person with two to four body parts.

Understands that actions can influence others’ emotions (e.g., tries to make others laugh by telling simple jokes). Waits for turn in simple games.

Elaborates on thematic make-believe play.

Plays board or card games with simple rules.

Describes what is going to happen next in a book.

Talks about right and wrong.

Movement and Skips, hops, and stands Physical on one foot for up to 2 seconds.

Catches a large, bounced ball most of the time.

Copies “plus” sign.

Uses toilet during the day with few accidents.

Pours from one container to another, cuts with supervision, and mashes own food.

91 Developmental Milestones and Competency Ratings

By 60 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Emotional Expresses two or more emotions at the same time.

Shows awareness of and interest in personal success.

Shows increased confi- dence associated with greater independence and autonomy. Social-Relational Wants to please friends.

Emulates role models, real or imaginary.

Values rules in social interactions.

Participates in group activities that require as- suming roles (e.g., Follow the Leader). Modulates or mod- ifies voice correctly depending on situation or listener (e.g., outside voice, to adult, other infant/young child, or younger child). Language- Makes all speech sounds. Social May make mistakes on Communication more difficult sounds such as ch, sh, th, l, v, and z (linguistically variable). Understands words denoting order such as “first,” “second,” “third,” “next,” and “last.” Uses “today,” “yester- day,” “tomorrow,” “last week,” and “before” correctly. Discriminates rhyming and nonrhyming words.

92 Developmental Milestones and Competency Ratings

By 60 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Language- Recognizes words with Social same beginning sound. Communication (continued) Identifies individual sounds within words (e.g., “dog”: d–o–g).

Tells a simple story using full sentences.

Uses future tense (e.g., “Grandma will be here”).

Says full name and address.

Cognitive Counts 10 or more things.

Tells stories with beginning, middle, and conclusion.

Draws a person with at least six body parts.

Acknowledges own mistakes or misbehaviors and can apologize.

Distinguishes fantasy from reality most of the time.

Names four colors correctly.

Follows rules in simple games.

Knows function of ev- eryday household objects (e.g., money, cooking utensils, appliances).

93 Developmental Milestones and Competency Ratings

By 60 months old Rating key: 1 = Fully present; 2 = Inconsistently present or emerging; 3 = Absent.

Competency Milestone Milestone Comments Competency Domain Rating Domain Rating Cognitive Attends to group activity (continued) for 15 minutes (e.g., circle time, storytelling).

Movement and Stands on one foot for 10 Physical seconds or longer.

Copies a triangle and other geometric shapes.

Copies some letters or numbers.

Hops on one foot.

Uses utensils to eat.

Uses the toilet independently (wipes, flushes, and washes hands).

Swings independently on a swing.

94 COMPETENCY DOMAIN RATING SUMMARY TABLE

On the basis of the review of this infant’s/young child’s developmental capacities, complete the table below to indicate the category that best describes the infant’s/young child’s functioning in each of the domains that comprise Axis V: To be completed for all infants/young children. Indicate competency domain rating scores by placing an “X” in the box for the appropriate score for each developmental domain.

Competency Emotional Social- Language- Cognitive Movement and Domain Rating Relational Social Physical Communication Exceeds developmental expectations

Functions at age-appropriate level

Competencies are inconsistently present or emerging

Not meeting developmental expectations (delay or deviance)

Overall impression. Provide Axis V formulation as an overall impression on the basis of the ratings above. Indicate any unevenness of developmental competencies highlighting relative strengths and concerns. Also note whether there have been any recent changes in competencies in any developmental domain.

FACILITATING DEVELOPMENTAL PROGRESS Developmentally Informed Assessment Per Each Relationship (DIAPER)

Developed By: Jane Clarke, PhD

Check or circle the number next to each statement that best describes the caregiver’s capacities to support his/her infant’s/child’s development according to the scoring criteria. Safety 1. 1. Caregiver creates a physical sense of safety that allows for infant’s/child’s 1 2 3 4 developmental progress and emotional repair. Regularity and Stability 2. Caregiver maintains regularity and consistency of visits and/or treatment 1 2 3 4 sessions, which provides opportunity to support developmental interactions with infant/child. Responsivity 3. Caregiver responds to infant/young child in a contingent way, reading 1 2 3 4 infant’s/child’s cues accurately, and responding promptly to cues. 4. Caregiver follows the infant’s/child’s lead by focusing on what he/she is 1 2 3 4 looking at, asking for, playing with, or trying to do. 5. Caregiver stimulates infant/child at pace, rhythm and timing that allows 1 2 3 4 infant/child to respond. Co-Regulation Strategies 6. Caregiver is able to anticipate and modulate the infant/child’s state of arousal 1 2 3 4 reactivity (e.g., from hyperarousal, hypoarousal or state lability to an organized state; not under-focused or hypervigilant) to support his/her development. 7. Caregiver attunes to the infant’s/child’s emotions and affect during 1 2 3 4 developmental activities and interventions. 8. Caregiver comforts infant/child when distressed (e.g., hugging, kissing, 1 2 3 4 picking up child, rocking, sing-song voice, soothing language). Caregiver uses effective coping strategies to regulate his/her own stress in 1 2 3 4 9. interactions with infant/child. Non-Verbal and Verbal Interactions 10. Caregiver physically positions his/her body to be available for eye contact and 1 2 3 4 face to face interactions with infant/child to allow for circles of communication and development. 11. Caregiver uses infant/child-directed speech (e.g., simplified grammar, 1 2 3 4 exaggerated speech melody, diminutive forms of words such as doggie, and a highly repetitive style) to support interactions with infant/child. 12. Caregiver responds to infant’s/child’s vocalizations and verbalizations through 1 2 3 4 imitation, repetition and expansion, to allow for turn-taking and back-and- forth chains of communication.

1 96

Motor and Play 13. Caregiver engages in and scaffolds play with infant/child appropriate to his/her 1 2 3 4 developmental level.

14. Caregiver encourages motor activities and movement at infant’s/child’s 1 2 3 4 developmental level to allow for social engagement and cognitive development.

Scoring Criteria

Safety 1. Caregiver creates a physical sense of safety that allows for infant’s/child’s developmental progress and emotional repair. 1 = None - Caregiver is not engaged in treatment or visits and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low – Caregiver is not aware of the physical safety needs of infant/child that allows for developmental progress and emotional repair. 3 = Medium – Caregiver is working on creating a physical sense of safety that allows for infant’s/child’s developmental progress and emotional repair. 4 = High – Caregiver creates a physical sense of safety that allows for infant’s/child’s developmental progress and emotional repair.

Regularity and Stability 2. Caregiver maintains regularity and consistency of visits and/or treatment sessions, which provides opportunity to support developmental interactions with infant/child. 1 = None - Caregiver is not engaged in treatment or visits and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low – Caregiver is inconsistent with visits and/or treatment sessions and attends no more than 40% of visits. 3 = Medium – Caregiver attends visits and/or treatment sessions at least 41% of time. 4 = High – Caregiver attends visits and/or treatment sessions at least 75% or more of time.

Responsivity 3. Caregiver responds to infant/young child in a contingent way, reading infant’s/child’s cues accurately, and responding promptly to cues. 1 = None - Caregiver is not engaged in treatment and/or visits and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low – Caregiver reads and accurately responds to infant’s/child’s cues in a contingent manner no more than 40% of the time. 3 = Medium – Caregiver reads and accurately responds to infant’s/child’s cues in a contingent manner at least 41% of the time. 4 = High - Caregiver reads and accurately responds to infant’s/child’s cues in a contingent manner with consistency at least 75% of the time or more of the time.

4. Caregiver follows the infant’s/child’s lead by focusing on what he/she is looking at, asking for, playing with, or trying to do.

97 1 = None - Caregiver is not engaged in treatment and/or visits and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low - Caregiver follows infant’s/child’s lead by focusing on what he/she is looking at, asking for, playing with, or trying to do, no more than 40% of the time. 3 = Medium - Caregiver follows infant’s/child’s lead by focusing on what he/she is looking at, asking for, playing with, or trying to do, at least 41% of the time. 4 = High – Caregiver consistently follows the infant’s/child’s lead by focusing on what he/she is looking at, asking for, playing with, or trying to do at least 75% or more of the time.

5. Caregiver stimulates infant/child at pace, rhythm and timing that allows infant/child to respond. 1= None -Caregiver is not engaged in treatment and/or visits is not involved in infant’s/child’s developmental progress or interventions. 2 = Low - Caregiver stimulates infant/child at pace, rhythm and timing that allows infant/child to respond no more than 40% of the time. 3 = Medium - Caregiver stimulates infant/child at pace, rhythm and timing that allows infant/child to respond at least 41% of the time. 4 = High - Caregiver stimulates infant/child at pace, rhythm and timing that allows infant/child to respond at least 75% of the time or more.

Co-Regulation Strategies 6. Caregiver is able to anticipate and modulate the infant/child’s state of arousal reactivity (e.g., from hyperarousal, hypoarousal or state lability to an organized state; not under-focused or hypervigilant) to support his/her development. 1 = None - Caregiver is not engaged in treatment and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low - Caregiver anticipates and modulates the infant’s/child’s state of arousal reactivity to support his/her development no more than 40% or less of time. 3 =Medium - Caregiver anticipates and modulates the infant’s/child’s state of arousal reactivity to support his/her development at least 41% of the time. 4 = High - Caregiver anticipates and modulates the infant’s/child’s state of arousal reactivity to support his/her development at least 75% of the time or more.

7. Caregiver attunes to the infant’s/child’s emotions and affect during developmental activities and interventions. 1 = None - Caregiver is not engaged in treatment and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low - Caregiver attunes to the infant’s/child’s emotions and affect during developmental activities and interventions no more than 40% of the time. 3 = Medium - Caregiver attunes to infant’s/child’s emotions and affect during developmental activities and interventions at least 41% of the time. 4 = High – Caregiver attunes to the infant’s/child’s emotions and affect during developmental activities and interventions at least 75% of the time or more.

8. Caregiver comforts infant/child when distressed (e.g., hugging, kissing, picking up child, rocking, sing-song voice, soothing language). 1 = None - Caregiver is not engaged in treatment and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low - Caregiver does no comfort infant/child when distressed at least 40% of the time.

98 3 = Medium - Caregiver comforts the infant/child when distressed at least 41% of the time. 4 = High - Caregiver comforts the infant/child when distressed at least 75% of the time or more.

9. Caregiver uses effective coping strategies to regulate his/her own stress in interactions with infant/child. 1 = None - Caregiver is not engaged in treatment and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low - Caregiver uses effective coping strategies to regulate his/her own stress in interactions with infant/child no more than 40% of the time 3 = Medium - Caregiver uses effective coping strategies to regulate his/her own stress in interactions with infant/child for at least 41% of the time 4 = High – Caregiver uses effective coping strategies to regulate his/her own stress in interactions with infant/child at least 75% of the time or more.

Non-Verbal and Verbal Interactions 10. Caregiver physically positions his/her body to be available for eye contact and face-to-face interactions with infant/child to allow for circles of communication. 1 = None - Caregiver is not engaged in treatment and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low - Caregiver physically positions his/her body to be available for eye contact and face-to-face interactions with infant/child to allow for circles of communication no more than 40% of the time. 3 = Medium –Caregiver physically positions his/her body to be available for eye contact and face-to- face interactions with infant/child to allow for circles of communication for at least 41% of the time. 4 = High – Caregiver physically positions his/her body to maximize eye contact and face-to-face interactions with infant/child to allow for circles of communication for at least 75% of the time or more.

11. Caregiver uses infant/child-directed speech (e.g., simplified grammar, exaggerated speech melody, diminutive forms of words such as doggie, and a highly repetitive style) to support interactions with infant/child. 1 = None - Caregiver is not engaged in treatment and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low - Caregiver uses infant/child-directed speech to support interactions with infant/child no more than 40% of the time. 3 = Medium - Caregiver uses infant/child-directed speech to support interactions with infant/child for at least 41% of the time. 4 = High - Caregiver uses Infant/child-directed speech to support interactions with infant/child for at least 75% of the time or more.

12. Caregiver responds to infant’s/child’s vocalizations and verbalizations through imitation, repetition and expansion, to allow for turn-taking and back-and-forth chains of communication. 1 = None - Caregiver is not engaged in treatment and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low - Caregiver responds to infant’s/child’s vocalizations and verbalizations through imitation, repetition and expansion to allow for turn-taking and back-and-forth chains of communication no more than 40% of the time.

99 3 = Medium –Caregiver responds to infant’s/child’s vocalizations and verbalizations through imitation, repetition and expansion to allow for turn-taking and back-and-forth chains of communication at least 41% of the time. 4 = High - Caregiver responds consistently to infant’s/child’s vocalizations and verbalizations through imitation, repetition and expansion to allow for turn-taking and back-and-forth chains of communication at least 75% of the time or more.

Motor and Play 13. Caregiver engages in and scaffolds play with infant/child appropriate to his/her developmental level. 1 = None - Caregiver is not engaged in treatment and is not involved in infant’s/child’s developmental progress or interventions. 2 = Low - Caregiver engages in and scaffolds play with infant/child appropriate to his/her developmental level no more than 40% of the time. 3 = Medium - Caregiver engages in and scaffolds play with infant/child appropriate to his/her developmental level at least 41% of the time. 4 = High - Caregiver consistently engages in and scaffolds play with infant/child appropriate to his/her developmental level at least 75% of the time or more.

14. Caregiver encourages motor activities and movement at infant’s/child’s developmental level to allow for social engagement. 1 = None - Caregiver is not engaged in treatment and is not involved in infant’s/child’s developmental progress or interventions. 2 =Low - Caregiver encourages motor activities and movement at infant’s/child’s developmental level to allow for social engagement and cognitive development no more than 40% of the time. 3 = Medium - Caregiver encourages motor activities and movement at infant’s/child’s developmental level to allow for social engagement and cognitive development at least 41% of the time. 4 =High –Caregiver consistently encourages motor activities and movement at infant’s/child’s developmental level to allow for social engagement and cognitive development at least 75% of the time or more.

• Format of the DIAPER adopted from the Progress in Treatment Assessment (PITA) developed by Dr. Charley Zeanah and Dr. Julie Larrieu from Tulane University. • Support on design and scoring criteria from Dr. Julie Larrieu.

100 Tracking Treatment Progress and Program Evaluation

101 Tulane Infant Team Tulane University School of Medicine New Orleans, Louisiana

Name:______Date:______

Clinician: ______

P - Progress in Treatment Assessment (PITA) 1. Degree of responsibility parent assumes for state of child (the fact that the child 0 1 2 3 has been maltreated and/or has emotional, behavioral and relationship problems)* 2. Sustained awareness demonstrated by parent of the need to change his/her 0 1 2 3 own behavior 3. Evidence that parent can put the needs of their child ahead of their own needs 0 1 2 3 4. Does not blame the child for his/her maltreatment, emotional, behavioral, and 0 1 2 3 relationship problems*

5. Recognition by parent of need to address personal, marital, relationship 0 1 2 3 problems to improve parenting Recognition by parent of need to address substance abuse issues to improve 0 1 2 3 6. parenting Recognition by parent of need to address psychiatric disorder in order to 0 1 2 3 7. improve parenting Willingness and/or capacity to cooperate with involved professionals in process 0 1 2 3 8. of treatment 9. Potential for change, flexibility, and willingness to try different approaches 0 1 2 3 within a time frame appropriate to child 10. Makes use of available community resources needed to assist family 0 1 2 3

*Modification by Jane Clarke, PhD - Soledad Martinez, MSW, of New Mexico Early Childhood Infrastructure Project

1. Degree of responsibility parent assumes for state of child (the fact that the child has been maltreated and/or has emotional, behavioral, and relationship problems) 0 = parent accepts no responsibility for child’s condition e.g., ( does not think neglect/abuse has occurred; does not feel child has been impacted; blames others (i.e., system, reporter, etc) for contact with system) 1= parent accepts limited responsibility for child’s condition (e.g., admits some problems may exist, does not feel child was impacted) 2 = parent es recogniz that child was impacted by behavior and begins to accept personal responsibility 3= parent accepts personal responsibility for child’s abuse/neglect and can provide convincing detail about ways in which child was impacted

2. Sustained awareness demonstrated by parent eed of the n to change his/her own behavior 0=parent demonstrates awareness no of need to change his/her own behavior (e.g., feels unjustly accused, ‘picked on’) 1=parent demonstrates limited awareness of need to change his/her own behavior (e.g., begins to voice awareness of problematic behavior)

2=parent demonstrates some progress in awareness of need to change his/her own behavior and actively works to alter behavior, demonstrates changes in behavior (e.g., can describe problematic behavior and its impact on life)

3=parent demonstrates significant progress in awareness of need to change his/her own behavior, consistently demonstrates change in behavior (e.g., parent reflects on impact of problematic behavior, details efforts made to alter behavior, awareness of impediments to changing problematic behavior)

102 3. Evidence that parent can put s the need f o their child ahead of their own needs 0=no evidence that parent can put needs of child ahead of their own (e.g., shows no ability to identify child’s needs; actively resists suggestion that child’s needs should be priority) 1=limited evidence that parent can put child’s needs ahead of their own needs (e.g., agrees when child’s needs are pointed out; starting to identify child’s needs but may focus on instrumental needs only) 2=increasing evidence that parent can put child’s needs ahead of their own, begins to identify and meet some basic emotional needs of child 3=significant evidence that parent can put needs of child ahead of their own (e.g., parent actively identifies and quickly meets instrumental and emotional needs of child, even if parent’s wishes/needs may be sacrificed; parent values their ability to meet child’s needs)

4. Parent does not blame the child for his/her , maltreatment emotional, behavioral, and/or relationship problems 0=parent actively and consistently blames child for his/her own maltreatment (e.g., cites child’s “bad” behavior; states that child left the house in disarray; blames other children in the home for maltreatment, failure to clean up, etc) 1=parent sometimes or passively blames child for his/her own maltreatment 2=parent rarely blames child for his/her own maltreatment 3=parent does not blame child at all for his/her own maltreatment

5. Recognition by parent of need to address personal, marital, relationship problems to improve parenting 0=parent has no recognition of need to address personal, marital, or relationship problems to improve parenting (e.g., parent does not feel that any changes are necessary to deal with family involvement in child welfare) 1=parent has limited recognition of need to address personal, marital, relationship problems to improve parenting, just beginning to identify relationship issues that impact parenting 2=parent has some recognition of need to address personal, marital, relationship problems to improve parenting, has begun to address problems (e.g., can identify several personal, marital, or relationship issues impacting parenting) 3=parent has clear recognition of need to address personal, marital, relationship problems to improve parenting and continues process of addressing problems (e.g., actively participates with clinician in identification of issues and seeks ways to address issues)

6. Recognition by parent of need to address substance abuse issues to improve parenting 0=parent has no recognition of need to address substance abuse issues (e.g., despite positive drug screens or being ‘high’ in visits, parent denies drug use and/or its impact on parenting “Everyone does it,” “Getting high doesn’t affect my parenting”; multiple excuses for failing to participate in treatment) 1=parent has limited recognition of need to address substance abuse issues to improve parenting (e.g., occasional positive drug screens, may attend occasional meetings, attendance at drug treatment inconsistent) 2=parent has some recognition of need to address substance abuse issues to improve parenting (e.g., more consistent attendance at drug treatment, attends 12t step meetings, obtains a sponsor) 3=parent has significant recognition of need to address substance abuse issues to improve parenting (e.g., parent identifies effects of drug abuse on parenting, actively attends and values treatment, has obtained a sponsor and is actively, honestly working 12t Steps; can identify a ‘home meeting’) or parent does not have substance abuse issue.

7. Recognition by parent of need to address psychiatric disorder in order to improve parenting 0=parent has no recognition of need to address psychiatric disorder to improve parenting (e.g., parent does not feel that their mental state warrants intervention, shows active evidence of illness, e.g., psychosis, marked depression, significant dysregulation)

103 7. continued 1=parent has limited recognition of need to address psychiatric disorder in order to improve parenting (e.g., somewhat able to identify psychological distress, unwilling to receive psychiatric evaluation to address issues) 2=parent has some recognition of need to address psychiatric disorder to improve parenting (e.g., parent has participated in psychiatric evaluation but has not followed up on mended recom intervention) 3=parent has significant recognition of need to address psychiatric disorder to improve parenting (e.g., actively engaged in psychiatric treatment, can identify ways in which psychiatric illness impacts parenting) or parent does not have psychiatric disorder

8. Willingness and/or capacity to cooperate with involved professionals in process of treatment 0=parent shows no willingness and/or capacity to cooperate with involved professionals in process of treatment (e.g., parent cannot be reached to schedule appointments, parent refuses all evaluation/treatment) 1=parent shows limited willingness and/or capacity to cooperate with involved professionals in process of treatment (e.g., parent ‘not shows’ multiple appointments; parent refuses some interventions [eg.,DV, drug treatment], parent seems unable to understand/integrate treatment efforts; parent attends appointments but does not actively engage in treatment process) 2=parent shows some willingness and/or capacity to cooperate with involved professionals in process of treatment (e.g., parent misses occasional appointments, at times, but generally engages actively in treatment; parent appears open to treatment process and shows some overall ability to benefit from process of treatment) 3=parent shows significant willingness and/or capacity to cooperate with involved professionals in process of treatment (e.g., parent rarely misses appointments, thinks about treatment outside of session, actively brings issues to treatment for consideration, has incorporated information from treatment into dayt tot day parenting)

9. Potential for change, flexibility, and willingness to try different approaches within a time frame appropriate to child 0=parent shows no potential for change, flexibility or willingness to try different approaches within time frame appropriate to child (e.g., parent unwilling to think about different approaches to parenting) 1=parent shows limited potential for change, flexibility or willingness to try different approaches within time frame appropriate to child (e.g., parent shows beginning willingness to try different approaches, seems inflexible in approach to parenting child, not open to change) 2=parent shows some potential for change, flexibility or willingness to try different approaches within time frame appropriate to child (e.g., parent demonstrates flexibility, willingness to change in some areas) 3=parent shows significant potential for change, flexibility or willingness to try different approaches within time frame appropriate to child and implements changes (e.g., shows flexibility, demonstrates change in most areas)

10. Makes use of available community resources needed to assist family 0=parent makes no use of available community resources needed to assist family (e.g., parent makes no attempt to follow up on suggestions re: housing, food stamps, other resources to assist family) 1=parent makes limited or inconsistent use of available community resources needed to assist family (e.g., even when parent is directed to community resources, makes little effort to pursue resources for family) 2=parent makes some use of available community resources needed to assist family (e.g., begins to independently seek, and make use of, community resources) 3= parent makes significant use of available community resources needed to assist family (e.g., independently seeks a variety of community resources, collaborates with agencies in meeting needs of family, makes good use of community resources)

104

by:

R -

Treatment

Caregiving Caregiving determined

Dyadic DIAPER #2 DIAPER #1 PITA #3, #9 #3, PITA Crowell Crowell DIAPER #2 DIAPER #3 CPP Fidelity CPP Fidelity TreatmentDyadic TESI, LSC TESI, WMCI CPP Fidelity Safety Assessment/CPS TreatmentDyadic Safety Assessment/CPS Psychosocial Intake #10 PITA TreatmentDyadic WMCI CPP Fidelity Crowell TreatmentDyadic Crowell sion sion

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DC:0 - 5 Manual indicate how the quality of the dimension was determined was dimension the of quality the how indicate

Adapted - Enough Then to Good Good to Well

5 manual. 5 -

Dimensions of Caregiving and Relational Range Functioning

145of the DC:0

3. pages 143 pages Levels of Adaptive Functioning. The Levels of Adaptive Functioning are defined on page 3 of this document and further on further and document this of 3 page on defined are Functioning Adaptive of Levels The Functioning. Adaptive of Levels Caregiving Dimension Caregiving Check the appropriate box that best describes the contribution of the relationship the of contribution the describes best that box appropriate the Check Interviews, Dyadic Therapeutic Sessions Therapeutic Dyadic Interviews, Ensuring Physical Safety Physical Ensuring hygiene, food, (e.g., needs basic for Providing care) health housing, clothing, and commitmentto psychological Conveying child infant/young the in investment emotional Establishingstructureand routines infant’s/young the to responding and Recognizing signals and needs emotional child’s

1. 2. 4. 5. 6. Behaviors(Structured and Unstructured), Perception Observation of Interactive and Developmental Promoting Promoting Developmental and Interactive of Observation

105

DIAPER #4 DIAPER #7 DIAPER #9 DIAPER #12 Crowell #3 PITA Dyadic TreatmentDyadic Crowell TreatmentDyadic CPP Fidelity Crowell CPP Fidelity Dyadic TreatmentDyadic TreatmentDyadic CPP Fidelity CPP Fidelity Crowell DIAPER #12, #13 Crowell Crowell TreatmentDyadic Crowell WMCI TreatmentDyadic WMCI TreatmentDyadic DIAPER #3, #4 TreatmentDyadic WMCI TreatmentDyadic

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and enjoyable activities enjoyable and

ambivalent feelings in the caregiver the in feelings ambivalent

comfortfordistress stimulation social and Teaching play in Engaging child’s infant’s/young the in interest Showing perspectives and experiences Demonstratingcapacityreflectiveregarding the trajectory developmental child’s infant’s/young of point child’s infant’s/young the Incorporating ways appropriate developmentally in view infant/young child relationship child infant/young Providing Providing Socializing Disciplining Tolerating

7. 8. 9. 10. 11. 12. 13. 14. 15.

106 evident evident

caregiver caregiver -

5 manual)5 - DC:0 perturbations perturbations may be noted in

esent. esent. However, there is evidence of a thatis determined to be the 145 of the of 145 -

Comments LEVELS LEVELS appropriate exploration and learning. learning. and exploration appropriate unquestionable unquestionable urgency about the need to intervene to -

velnumber in the box below on. le the15 Caregiving Dimensions

(Read further descriptions on pp. 143 pp. on descriptions further (Read

3 acity acity to engage in adequate protection, emotional availability, and emotion Relationships Relationships convey an Relationships are clearly in the range of clinical concern and require intervention Relationships Relationships show some worrisome patterns of interaction or subjective experience. Ratings Ratings at this level range from adequate to outstanding infant/young child on the basis of appropriateexplorati

Level Level 1: relationships. Ups and downs may be evident, and occasional response to stressors, but the relationship functions adequately or better most of the time. for both partners Level 2: The relationship is conflicted, insufficiently engaged, or inappropriately imbalanced (e.g., role reversed). Some important adaptive qualities are pr struggle within the or relationship concern about the dyad's capacity for healthy expression of and responding to needs for comfort and or protection, support for and to willingness engage age - in Level 3: because of risk to the infant's/young child's problems, safety, persistent or distress, risk for current subsequent serious occasionallybut are too inconsistent or mostly lacking. functional impairment. Adaptive Level qualities 4: may be qualities Not adaptive are only qualities. relationship dangerous and potentially serious address lacking but the relationship pathology is severe and often pervasive, with impairments in the dyad's cap regulation; expressing and responding to needs for comfort and caregiving; as well as support age in engage to willingness and for

Functioning Functioning

Levels of Adaptive Functioning — DC - 0 5 Manual Levels of Adaptive Functioning

Adaptive Adaptive

sindicated. Date CLINICAL ASSESSMENT CLINICAL functioning adequately for for adequately functioning

best fit for the relationship in question, and indicate the

Relationships that are not of clinicalconcern. This level of range broad a covers that those from relationships, are Careful monitoring (at least) us definitely indicated, and i intervention Relationship disturbance is and range, clinical the in clearly required. is intervention Intervention is not only urgently is but required severity the of because needed ofthe relationship impairment. both partners on the the on partners both those to dimensions caregiving exemplary. are that Current Range of of Range Current of

overall

1. 3. 2. 4. Indicate the the Indicate Adapted to Good to Adapted - Relationships Relationships Relationships FUNCTIONING Functioning Level Functioning Enough Relationships Enough Well Strained to Concerning Concerning to Strained RELATIONALRANGEOF Disordered to Dangerous Dangerous to Disordered Compromised to Disturbed Disturbed to Compromised Number of Current Range Current of Number

107 D.A.P. Progress Note Checklist

Check if addressed Data 1. Subjective data about the client—what are the clientʼs observations, thoughts, direct quotes? 2. Objective data about the client—what does the counselor observe during the session (affect, mood, appearance)? 3. What was the general content and process of the session? 4. Was homework reviewed (if any)?

Assessment 5. What is the counselorʼs understanding about the problem? 6. What are the counselorsʼ working hypotheses? 7. What are the results of any testing, screening, assessments? 8. What is the clientʼs current response to the treatment plan?

Plan 9. Based on clientʼs response to the treatment plan, what needs revision? 10. What goals, objectives were addressed this session? 11. What is the counselor going to do next? 12. When is the next session date?

General Checklist 13. Does this note connect to the clientʼs individualized treatment plan? 14. Is this note dated, signed, and legible? 15. Is the client name and identifier included on each page? 16. Has referral information been documented? 17. Are client strengths/limitations in achieving goals noted and considered? 18. Are any abbreviations used standardized and consistent? 19. Would someone not familiar with this case be able to read this note and understand exactly what has occurred in treatment? 20. Are any non-routine calls, missed sessions, or professional consultations regarding this case documented?

Treatment Planning M.A.T.R.S.: Module 4 – Handout 6 Utilizing the Addiction Severity Index (ASI) to Make Required Data Collection Useful

108 Report Forms

109 INFANT AND EARLY CHILDHOOD MENTAL HEALTH SERVICES Parent Infant Psychotherapy QUARTERLY REPORT FORM

Reporting Period: PIP Provider:

Services Provided • Number of Total Children Served:______• Number Served as CYFD-003______• Number Served as CYFD-004______

CYFD-003 a. Before engaging in an IECMH treatment services, did infant(s) receive:  a diagnostic Evaluation that has resulted in a diagnosis______ an individualized Service Plan that includes IECMH treatment as an intervention______b. Have services been: At least 25% of IECMH services must be provided in vivo at least weekly in the home or other settings natural to the infant and family (or primary caregiver). Please Describe: c. Service delivery is focused on the dyadic relationship between the infant and parent (or primary caregiver) and the relationship needs of the infant or toddler. The initial assessment results in intervention strategies and treatment recommendations for services. Describe recommendations below: d. Each Infant/Early Childhood Mental Health provider must address, at minimum: 1. Increase parent’s(s’)/adult caretaker’s(s’) ability to consistently and appropriately provide for the child’s safety, social and emotional needs, and developmental progress;

110 2. Increase parent’s(s’)/adult caretaker’s(s’) ability to meet basic emotional needs for comfort, stimulation, affection, and safety of the infant 3. Increase child’s ability to initiate and respond to most social interactions in a developmentally appropriate ay 4. Increase developmentally appropriate and sensitive parent/child interaction in order to encourae lanuae and play, interpretation of a child’s behavior and reinforcement of a parent’s (or primary caregiver’s) appropriate actions and interactions Describe Below:

CYFD-004 e. Before enain in an I treatment services, did infant(s) receive  a dianostic valuation that has resulted in a dianosis  an individualied ervice lan that includes I treatment as an intervention f. ave services been t least 25 of I services must be provided in vivo at least eekly in the home or other settins natural to the infant and family (or primary careiver) Please Describe g. ervice delivery is focused on the dyadic relationship beteen the infant and parent (or primary careiver) and the relationship needs of the infant or toddler he initial assessment results in intervention strateies and treatment recommendations for services Describe recommendations below: h. ach Infant/arly hildhood ental ealth provider must address, at minimum 5. Increase parent’s(s’)/adult caretaker’s(s’) ability to consistently and appropriately provide for the child’s safety, social and emotional needs, and developmental proress 6. Increase parent’s(s’)/adult caretaker’s(s’) ability to meet basic emotional needs for comfort, stimulation, affection, and safety of the infant

111 7. Increase child’s ability to initiate and respond to most social interactions in a developmentally appropriate ay 8. Increase developmentally appropriate and sensitive parentchild interaction in order to encorage langage and play interpretation of a child’s behavior and reinforcement of a parent’s (or primary caregiver’s) appropriate actions and interactions Describe Below:

Descriptions of Children Served a mber of bstantiatedrevios eferrals mber in oster are mber ith h of crrent Inome ervices b mber in hild are c mber in ead tart d mber in arly ead tart e mber in ome isiting rogram f mber in re program g ther

Challenges and Successes this Quarter:

112 Examples of Goals and Objectives

113

EXAMPLES OF GOALS AND OBJECTIVES USING THE DC: 0-5 AND THE PITA

GOAL: Relational Adaptive Functioning

CAREGIVING STRATEGIES EVIDENCED BY OBJECTIVES 1. Degree of responsibility CPP or COS described in 0 = parent accepts no responsibility for child’s condition (e.g., does not think parent assumes for state detail in the DAP note neglect/abuse has occurred; of child (the fact that the does not feel child has been impacted; blames others (i.e., system, reporter, etc.) for child contact with system) has been maltreated 1 = parent accepts limited responsibility for child’s condition (e.g., admits some and/or has emotional, problems may exist, does not feel child was impacted) behavioral and 2 = parent recognizes that child was impacted by behavior and begins to accept relationship problems) personal responsibility 3 = parent accepts personal responsibility for child’s abuse/neglect and can provide convincing detail about ways in which child was impacted 2. Sustained awareness CPP or COS described in 0 = parent demonstrates no awareness of need to change his/her own behavior demonstrated by parent detail in DAP note (e.g., feels unjustly accused, ‘picked on’) of the need to change 1 = parent demonstrates limited awareness of need to change his/her own behavior his/her own behavior (e.g., begins to voice awareness of problematic behavior) 2 = parent demonstrates some progress in awareness of need to change his/her own behavior and actively works to alter behavior, demonstrates changes in behavior (e.g., can describe problematic behavior and its impact on life) 3 = parent demonstrates significant progress in awareness of need to change his/her own behavior, consistently demonstrates change in behavior (e.g., parent reflects on impact of problematic behavior, details efforts made to alter behavior, awareness of impediments to changing problematic behavior) 3. Evidence that parent CPP or COS described in 0 = no evidence that parent can put needs of child ahead of their own (e.g., shows can put the needs of their detail in DAP note no ability to identify child’s needs; actively resists suggestion that child’s needs child ahead of their own should be priority) needs 1 = limited evidence that parent can put child’s needs ahead of their own needs (e.g., agrees when child’s needs are pointed out; starting to identify child’s needs but may focus on instrumental1 needs only) 2 = increasing evidence that parent can put child’s needs ahead of their own, begins to identify and meet some basic emotional needs of child 3 = significant evidence that parent can put needs of child ahead of their own (e.g., parent actively identifies and quickly meets instrumental and emotional needs of child, even if parent’s wishes/needs may be sacrificed; parent values their ability to meet child’s needs) 4. Does not blame the CPP or COS described in 0 = parent actively and consistently blames child for his/her own maltreatment child for his/her detail in DAP note (e.g., cites child’s “bad” behavior; states that child left the house in disarray; blames maltreatment, emotional, other children in the home for maltreatment, failure to clean up, etc) behavioral, and/or 1 = parent sometimes or passively blames child for his/her own maltreatment relationship problems 2 = parent rarely blames child for his/her own maltreatment 3 = parent does not blame child at all for his/her own maltreatment 5. Recognition by parent CPP or COS described in 0 = parent has no recognition of need to address personal, marital, or relationship of need to address detail in DAP note problems to improve parenting (e.g., parent does not feel that any changes are personal, marital, necessary to deal with family involvement in child welfare) relationship problems 1 = parent has limited recognition of need to address personal, marital, relationship to improve parenting problems to improve parenting, just beginning to identify relationship issues that impact parenting 2 = parent has some recognition of need to address personal, marital, relationship problems to improve parenting, has begun to address problems (e.g., can identify several personal, marital, or relationship issues impacting parenting) 3 = parent has clear recognition of need to address personal, marital, relationship problems to improve parenting and continues process of addressing problems (e.g., actively participates with clinician in identification of issues and seeks ways to address issues) 6. Recognition by parent CPP or COS described in 0 = parent has no recognition of need to address substance abuse issues (e.g., of need to address detail in DAP note despite positive drug screens or being ‘high’ in visits, parent denies drug use and/or substance abuse issues its impact on parenting “Everyone does it,” “Getting high doesn’t affect my to improve parenting parenting”; multiple excuses for failing to participate in treatment) 1 = parent has limited recognition of need to address substance abuse issues to improve parenting (e.g., occasional positive drug screens, may attend occasional meetings, attendance114 at drug treatment inconsistent)

2 1 = limited evidence that parent can put child’s needs ahead of their own needs (e.g., agrees when child’s needs are pointed out; starting to identify child’s needs but may focus on instrumental needs only) 2 = increasing evidence that parent can put child’s needs ahead of their own, begins to identify and meet some basic emotional needs of child 3 = significant evidence that parent can put needs of child ahead of their own (e.g., parent actively identifies and quickly meets instrumental and emotional needs of child, even if parent’s wishes/needs may be sacrificed; parent values their ability to meet child’s needs) 4. Does not blame the CPP or COS described in 0 = parent actively and consistently blames child for his/her own maltreatment child for his/her detail in DAP note (e.g., cites child’s “bad” behavior; states that child left the house in disarray; blames maltreatment, emotional, other children in the home for maltreatment, failure to clean up, etc) behavioral, and/or 1 = parent sometimes or passively blames child for his/her own maltreatment relationship problems 2 = parent rarely blames child for his/her own maltreatment 3 = parent does not blame child at all for his/her own maltreatment 5. Recognition by parent CPP or COS described in 0 = parent has no recognition of need to address personal, marital, or relationship of need to address detail in DAP note problems to improve parenting (e.g., parent does not feel that any changes are personal, marital, necessary to deal with family involvement in child welfare) relationship problems 1 = parent has limited recognition of need to address personal, marital, relationship to improve parenting problems to improve parenting, just beginning to identify relationship issues that impact parenting 2 = parent has some recognition of need to address personal, marital, relationship problems to improve parenting, has begun to address problems (e.g., can identify several personal, marital, or relationship issues impacting parenting) 3 = parent has clear recognition of need to address personal, marital, relationship problems to improve parenting and continues process of addressing problems (e.g., actively participates with clinician in identification of issues and seeks ways to address issues) 6. Recognition by parent CPP or COS described in 0 = parent has no recognition of need to address substance abuse issues (e.g., of need to address detail in DAP note despite positive drug screens or being ‘high’ in visits, parent denies drug use and/or substance abuse issues its impact on parenting “Everyone does it,” “Getting high doesn’t affect my to improve parenting parenting”; multiple excuses for failing to participate in treatment) 1 = parent has limited recognition of need to address substance abuse issues to improve parenting (e.g., occasional positive drug screens, may attend occasional meetings, attendance at drug treatment inconsistent) 2 = parent has some recognition of need to address substance abuse issues to improve parenting (e.g., more consistent attendance at drug treatment, attends 12 step meetings, obtains a sponsor) 3 = parent has significant2 recognition of need to address substance abuse issues to improve parenting (e.g., parent identifies effects of drug abuse on parenting, actively attends and values treatment, has obtained a sponsor and is actively, honestly working 12 Steps; can identify a ‘home meeting’) or parent does not have substance abuse issue. 7. Recognition by parent CPP or COS described in 0 = parent has no recognition of need to address psychiatric disorder to improve of need to address detail in DAP note parenting (e.g., parent does not feel that their mental state warrants intervention, psychiatric disorder in shows active evidence of illness, e.g., psychosis, marked depression, significant order to improve dysregulation) parenting 1 = parent has limited recognition of need to address psychiatric disorder in order to improve parenting (e.g., somewhat able to identify psychological distress, unwilling to receive psychiatric evaluation to address issues) 2 = parent has some recognition of need to address psychiatric disorder to improve parenting (e.g., parent has participated in psychiatric evaluation but has not followed up on recommended intervention) 3 = parent has significant recognition of need to address psychiatric disorder to improve parenting (e.g., actively engaged in psychiatric treatment, can identify ways in which psychiatric illness impacts parenting) or parent does not have psychiatric disorder 8. Willingness and/or CPP or COS described in 0 = parent shows no willingness and/or capacity to cooperate with involved capacity to cooperate detail in DAP note professionals in process of treatment (e.g., parent cannot be reached to schedule with involved appointments, parent refuses all evaluation/treatment) professionals in process 1 = parent shows limited willingness and/or capacity to cooperate with involved of treatment professionals in process of treatment (e.g., parent ‘not shows’ multiple appointments; parent refuses some interventions [eg., DV, drug treatment], parent seems unable to understand/integrate treatment efforts; parent attends appointments but does not actively engage in treatment process) 2 = parent shows some willingness and/or capacity to cooperate with involved professionals in process of treatment (e.g., parent misses occasional appointments, at times, but generally engages actively in treatment; parent appears open to treatment process and shows some overall ability to benefit from process of treatment) 3 = parent shows significant willingness and/or capacity to cooperate with involved professionals in process of treatment (e.g., parent rarely misses appointments, thinks about treatment outside of session, actively brings issues to treatment for consideration, 3has incorporated information from treatment into day to day parenting 9. Potential for change, CPP or COS described in 0 = parent shows no potential for change, flexibility or willingness to try different flexibility, and willingness detail in DAP note approaches within time frame appropriate to child (e.g., parent unwilling to think to try different about different approaches to parenting) approaches within a time 1 = parent shows limited potential for change, flexibility or willingness to try different frame appropriate to approaches within time frame appropriate to child (e.g., parent shows beginning child willingness to try different approaches, seems inflexible in approach to parenting child, not open to change) 2 = parent shows some potential for change, flexibility or willingness to try different approaches within time frame appropriate to child (e.g., parent demonstrates flexibility, willingness to change in some areas) 3 = parent shows significant potential for change, flexibility or willingness to try different approaches within time frame appropriate to child and implements changes (e.g., shows flexibility, demonstrates change in most areas) 10. Makes use of available CPP or COS described in 0 = parent makes no use of available community resources needed to assist family community resources detail in DAP note (e.g., parent makes no attempt to follow up on suggestions re: housing, food needed to assist family stamps, other resources to assist family) 1 = parent makes limited or inconsistent use of available community resources needed to assist family (e.g., even when parent is directed to community resources, makes little effort to pursue resources for family) 2 = parent makes some use of available community resources needed to assist family (e.g., begins to independently seek, and make use of, community resources) 3 = parent makes significant use of available community resources needed to assist family (e.g., independently seeks a variety of community resources, collaborates with agencies115 in meeting needs of family, makes good use of community resources) EMOTIONAL STRATEGIES EVIDENCED BY FUNCTIONING OBJECTIVES 1. Support the ability of Play, Social and 0 = Never achieved the dyad (caregiver and Emotional Interactions 1 = With persistent and/or predictable support there are brief glimpses of this infant/child) to attend to and Experiences capacity

4 3 = parent shows significant willingness and/or capacity to cooperate with involved professionals in process of treatment (e.g., parent rarely misses appointments, thinks about treatment outside of session, actively brings issues to treatment for consideration, has incorporated information from treatment into day to day parenting 9. Potential for change, CPP or COS described in 0 = parent shows no potential for change, flexibility or willingness to try different flexibility, and willingness detail in DAP note approaches within time frame appropriate to child (e.g., parent unwilling to think to try different about different approaches to parenting) approaches within a time 1 = parent shows limited potential for change, flexibility or willingness to try different frame appropriate to approaches within time frame appropriate to child (e.g., parent shows beginning child willingness to try different approaches, seems inflexible in approach to parenting child, not open to change) 2 = parent shows some potential for change, flexibility or willingness to try different approaches within time frame appropriate to child (e.g., parent demonstrates flexibility, willingness to change in some areas) 3 = parent shows significant potential for change, flexibility or willingness to try different approaches within time frame appropriate to child and implements changes (e.g., shows flexibility, demonstrates change in most areas) 10. Makes use of available CPP or COS described in 0 = parent makes no use of available community resources needed to assist family community resources detail in DAP note (e.g., parent makes no attempt to follow up on suggestions re: housing, food needed to assist family stamps, other resources to assist family) 1 = parent makes limited or inconsistent use of available community resources needed to assist family (e.g., even when parent is directed to community resources, makes little effort to pursue resources for family) 2 = parent makes some use of available community resources needed to assist family (e.g., begins to independently seek, and make use of, community resources) 3 = parent makes significant use of available community resources needed to assist family (e.g., independently seeks a variety of community resources, collaborates with agencies in meeting needs of family, makes good use of community resources) EMOTIONAL STRATEGIES EVIDENCED BY FUNCTIONING OBJECTIVES 1. Support the ability of Play, Social and 0 = Never achieved the dyad (caregiver and Emotional Interactions 1 = With persistent and/or predictable support there are brief glimpses of this infant/child) to attend to and Experiences capacity one another and remain 2 = With structure can demonstrate capacity but vulnerable to stress and/or calm and focused for a constricted range of affects reasonable period of 3 = Age appropriate with full range of affect states time depending upon age 4 of infant/child. 2. Support the ability for Play, Social and 0 = Never achieved mutual emotional Emotional Interactions 1 = With persistent and/or predictable support has brief glimpses of this capacity engagement (joint and Experiences 2 = With structure can demonstrate capacity but vulnerable to stress and/or involvement) seen in constricted range of affects looking, listening to, 3 = Age appropriate with full range of affect states joyful smiling/ laughing, gestures, movements and touch which convey a sense of pleasure and affective engagement. 3. Support the ability for Play, Social and 0 = Never achieved or infant/child younger than 4 months the dyad to interact in a Emotional Interactions 1 = With persistent and/or predictable support has brief glimpses of this capacity purposeful, intentional and Experiences 2 = With structure can demonstrate capacity but vulnerable to stress and/or and reciprocal manner, constricted range of affects both initiating and 3 = Age appropriate with full range of affect states responding to each other’s signals. 4. Support ability of Play, Social and 0 = Never achieved or infant/child younger than 8 months infant/child to engage in Emotional Interactions 1 = With persistent and/or predictable support has brief glimpses of this capacity multiple back and forth and Experiences 2 = With structure can demonstrate capacity but vulnerable to stress and/or communicative circles constricted range of affects through gestures, 3 = Age appropriate with full range of affect states vocalizations and/or words, and for caregiver to reciprocate for continuous flow of interactions. 5. Support ability of child 0 = Never achieved or infant/child younger than 10 months to stay in relationship and 1 = With persistent and/or predictable support has brief glimpses of this capacity engage in problem 2 = With structure can demonstrate capacity but vulnerable to stress and/or solving with caregiver constricted range of affects through facial 3 = Age appropriate with full range of affect states expressions, movement through space, 5 verbalizations, gestures, physical activity, and reciprocal touching. 6. Support ability of child 0 = Never achieved or infant/child younger than 18 months to use language or 1 = With persistent and/or predictable support has brief glimpses of this capacity sequenced pretend play 2 = With structure can demonstrate capacity but vulnerable to stress and/or for communicating constricted range of affects emotional themes and 3 = Age appropriate with full range of affect states ideas with caregiver (at first gestures and language may be concrete and functional, related to daily experiences and routines). 116

6 through facial 3 = Age appropriate with full range of affect states expressions, movement through space, verbalizations, gestures, physical activity, and reciprocal touching. 6. Support ability of child 0 = Never achieved or infant/child younger than 18 months to use language or 1 = With persistent and/or predictable support has brief glimpses of this capacity sequenced pretend play 2 = With structure can demonstrate capacity but vulnerable to stress and/or for communicating constricted range of affects emotional themes and 3 = Age appropriate with full range of affect states ideas with caregiver (at first gestures and language may be concrete and functional, related to daily experiences and routines).

RELATIONAL RANGE CLINICAL LEVELS OF FUNCTIONING ASSESSMENT (Read further descriptions in DC:0-5 manual) Well-Adapted to Good Relationships that are not Level 1: Ratings at this level range from adequate to outstanding infant/young child- Enough Relationships of clinical concern. This caregiver relationships. Ups and downs may be evident, and occasional perturbations level covers a broad may be noted in response to stressors, but the relationship functions adequately or range of relationships, better for both partners most of the time. from those that are functioning adequately for both partners on the caregiving dimensions to those that are exemplary. Strained to Concerning Careful monitoring (at Level 2: Relationships show some worrisome patterns of interaction or subjective Relationships least) us definitely experience. The relationship is conflicted, insufficiently engaged, or inappropriately indicated, and imbalanced (e.g., role reversed). Some important adaptive qualities are present. intervention is indicated. However, there is evidence of a struggle within the relationship or concern about the dyad's capacity for healthy expression of and responding to needs for comfort and protection, or support for and willingness to engage in age-appropriate exploration. Compromised to Relationship Level 3: Relationships are clearly in the range of clinical concern and require Disturbed disturbance is clearly intervention because of risk to the infant's/young child's safety, persistent 6 Relationships in the clinical range, distress, risk for subsequent problems, or current serious functional and intervention is impairment. Adaptive qualities may be evident occasionally but are too required. inconsistent or mostly lacking. Disordered to Intervention is not Level 4: Relationships convey an unquestionable urgency about the need Dangerous only required but is to intervene to address serious and potentially dangerous relationship Relationships urgently needed qualities. Not only are adaptive qualities lacking but the relationship because of the pathology is severe and often pervasive, with impairments in the dyad's severity of the capacity to engage in adequate protection, emotional availability, and relationship emotion regulation; expressing and responding to needs for comfort and impairment. caregiving; as well as support for and willingness to engage in age- appropriate exploration and learning.

117 Example of Discharge Summary

118 First Judicial District Infant Team Las Cumbres Community Services

EXAMPLE OF DISCHARGE REPORT

Name: Date of Birth:

Reason Entered Care: (In this section, be sure to include number of prior referrals)

Current Disposition:

Ongoing Supports and Special Services Needed: For Child

For Parent(s)

Risk of Dismissal:

Best Interest of the Child:

Respectfully Submitted by,

Stephanie Albury, MA, LPCC Co-Director First Judicial District Infant Team

119