Over the past two years, I have had the opportunity to consult with staff in Head Start and Early Head Start programs who were worried about their ability to provide meaningful child and family development services to parents who are struggling with emotional difficulties. The dilemmas I heard them describe reminded me of my own experiences as a home visitor in a prevention-based infant mental health program for pregnant women and families with infants and toddlers. The story of Jean, which follows, brings to light a multitude of challenges that staff in Early Head Start and most other prevention-based early intervention programs must be prepared to address if we are to be successful in providing services to children in these families. This essay will also describe ways in which infant/family programs can prepare and support staff in responding to mental health issues.

Jean Jackson was a woman in her mid-twenties who was referred to our home visiting program after she had given birth to her fourth child, Patricia. Patty had been born 3 months preterm and spent her first two months in the hospital. According to the hospital social worker, Jean had not "bonded" well with Patty during the period of hospitalization, and the social worker was concerned that Jean would not be able to manage this medically fragile baby upon her release from the hospital.

My relationship with Jean and her family began several weeks before Patty's scheduled discharge from the hospital. My primary role as a home visitor was to foster the healthy social; emotional, physical, and cognitive development of Jean's newest addition to the family. During my first home visit, I discovered that Jean had three other children under the age of five in the home. In the two years that followed, I learned that helping Jean and Eric, her husband, support Patty's healthy development involved responding to many different kinds of challenges involving the children in the household, the adults, and their relationships with each other.

For example, Henry, the Jacksons' third child, was two years old when I began my work with the family. To me, he seemed noticeably delayed in both language and motor development. Over the course of several visits, Jean and Eric made comments that suggested they suspected problems with Henry but felt ashamed that his development was not progressing typically. Since my role in the home was to focus on Patty's development, I hesitated to suggest an evaluation for Henry. But as the relationship between me and the family deepened, it was easier to bring Henry's development into our conversations during home visits. These discussions paved the way for my discussing both parents' feelings and the importance of considering early intervention services for Henry who was subsequently diagnosed with cerebral palsy. The Jacksons did not have an easy time accepting this diagnosis, but the strength of our relationship allowed me to offer them considerable support during the assessment process and as they made an enduring connection with the community Early Intervention system.

During the course of our weekly home visits in the months after Patty's discharge from the hospital, Jean slowly realized that her difficulties developing a "relationship" with Patty were grounded in her feeling rejected by this baby, who was experienced by Jean as difficult to engage. To Jean, this rekindled feelings of being "rejected" and "unloved" herself. Jean had endured many years of sexual abuse at the hands of her stepfather from approximately age 5 to l3 and had a hard time establishing trusting relationships with adults. To Jean, her children_especially during early infancy_had come to represent the primary source of love and acceptance. Indeed, as each child moved beyond babyhood and became more independent, Jean found herself yearning to compensate for this "loss" by having another child, even though the closely spaced pregnancies placed her own physical health at risk. Domestic violence was also a recurring problem in the Jackson household, although Jean would always "downplay" the seriousness of the occasional physical altercations between her and Eric.

My efforts to help Jean develop a relationship with an infant who had been diagnosed as having inorganic failure to thrive were affected by the competing demands on this young mother to care for a toddler with significant special needs, deal with episodes of domestic abuse, and confront her memories of childhood sexual abuse. If her relationship with Patty was to get back on track, I, as a home visitor, had to embrace the complexity of Jean's experiences. I had to find a way to respond to Jean that would help her manage her own internal and external realities while at the same time responding to Patty's urgent need for a meaningful, nurturing relationship with their mother.

Jean and her family were not enrolled in an Early Head Start program. But my many conversations with EHS staff suggest the Jacksons' circumstances were no more complex than those of many families with infants and toddlers who are participating in Early Head Start. And while it is possible to use mental health terminology to describe the Jacksons and my work with them, it is not necessary to do so. What is important is that staff of Early Head Start and other comprehensive, community-based programs be willing and able to address the mental health needs of young children and adults, and strengthen positive relationships within the family.

"But mental health support is not my responsibility..."

The primary goal of Early Head Start is to enhance the infant and toddler's overall social, emotional, physical, cognitive, and linguistic development. The revised Head Start Performance Standards, which will become effective in January, 1998, require all Head Start programs to accomplish this goal by establishing strong partnerships with parents, as the child's first and most important teachers and caregivers. Staff may confront several barriers to effective partnership, however:

• Lack of training in work with families: While most EHS program staff understand intellectually the importance of working through the parents in providing services to very young children, many practitioners have been trained to provide interventions that are primarily aimed directly at the child. Although most training programs in fields related to early childhood development acknowledge the importance of establishing "rapport" with families as the first step in building a relationship, too few give students a chance to learn or practice the specific skills they will need to work as partners with parents on behalf of their child. Consequently, professionals hired to serve as teachers, health specialists, or child development specialists in EHS programs are likely to be intellectually cognizant of the importance of establishing effective relationships with parents, but trained to interact and relate most effectively with children.
  
  
• Lack of training or experience in working with families facing multiple challenges: When confronted with the realities -- including mental health problems -- that parents in EHS and other community-based programs sometimes experience, staff often feel overwhelmed. This may be especially true of staff who are working with families on an ongoing basis in their homes.
• Values in apparent conflict: For some EHS staff, acknowledging that participating families are struggling with mental health issues seems inconsistent with a "strengths-based" perspective. This reluctance is understandable, given the tendency of some to "pathologize" low-income families and the stigma still attached to mental illness and substance abuse. But if programs like Early Head Start make discussion of mental health problems taboo don't we undermine the strength that families show when they acknowledge the challenges they are facing and seek needed support and treatment?

Within an ongoing, trusting relationship, it is possible, although not always easy, to listen to parents talk about whatever concerns them. It is possible to make observations respectfully and discuss with families how challenges affect the developing relationship between the parents and infant or toddler. If the goal of working through the parents as the child's first and most important teachers is to be achieved, program staff must be prepared both to recognize and support parents' psychological strengths and to address their psychological needs.

How can programs prepare and support staff in responding to mental health issues?

Helping center-based professionals and home visitors in infant/family programs become both skilled and comfortable in their relationships with families when mental health problems are present is a process of staff development that requires attention, time and resources. This is true even for those staff who have been trained to provide mental health services. Key steps in this process include:

• integrating a reflective supervisory process into the overall program design;
• securing access to a regular mental health consultant who has been trained in infant development and who understands the importance of relationships
• in shaping overall infant development; and
• providing staff with appropriate ongoing training and support to increase their awareness, knowledge, and skill concerning mental health issues affecting
• pregnant women and families with infants and toddlers.

Reflective supervision

Reflective supervision (Fenichel, 1992; Norman-Murch, 1996) offers staff a safe environment and a relationship in which they can learn to meet the emotional and intellectual demands of infant/family work. Such a relationship involves three key elements: reflection, collaboration and regularity.

Reflection requires that we "slow down" and "step back" to consider how we, in our efforts to partner with families to accomplish healthy outcomes for their children are being effective in that process or are having trouble. When I worked with Jean, group supervision with other program staff and an outside consultant helped me to understand why the change process was seemingly stalled at times or how my own values might have colored the manner in which I responded to situations I observed during my visits. The opportunity to share observations with staff and the supervisor provided me with alternative lenses through which I was able to interpret the meaning of my observations in working with Jean and her family. This form of support also reduced my sense of feeling overwhelmed and burned out by the challenges that the family had to face during the two-year period of our work together.

In the context of reflective supervision, collaboration means that the front-line worker and the individual providing supervision share responsibility for figuring out together how the worker can increase his or her ability to support families effectively, and facilitate change amid growth. In the context of a collaborative relationship, power is mutually held. Not only does the supervisor see himself or herself as someone who is able to serve as a guide to the supervisee, but the supervisor expects and openly seeks out the knowledge and skill that the supervisee brings to the supervisory relationship.

Reflective supervision requires regularity -- a commitment by program management to a regularly scheduled opportunity for staff to thoughtfully discuss their work with children and families. Although administrators may argue that budget constraints or program mandates do not permit them to reduce the time that staff have available to provide direct services to families, I believe in order for staff to serve families effectively, managers must nurture and provide staff with this form of support.

It is important to note that reflective supervision differs from traditional "administrative" supervision, which is designed to monitor the extent to which staff are performing their responsibilities as expected or according to their job descriptions. This form of administrative supervision is typically tied to performance evaluations. The revised Head Start Performance Standards require that programs conduct performance evaluations. These can be accomplished within a reflective supervision model: a supervisor and supervisee who have been meeting regularly, thinking collaboratively about how best to develop the supervisee's knowledge and skill, and reflecting on the supervisee's effectiveness in his or her role should be able at appropriate intervals to provide a thoughtful, balanced evaluation of the supervisee's performance.

Head Start has enjoyed a long history of promoting better outcomes for children while at the same time providing opportunities for families to benefit economically through employment opportunities within the program. We are doing families and staff who have been hired from the community a tremendous disservice if we fail to provide the support they need to be successful in work with families and that will foster their professional development as members of the staff in our programs.

Mental health consultation

Given the recognition that mental health issues are becoming increasingly evident among families served by Head Start services, programs are being pushed to consider creative ways of addressing mental health concerns from a preventive and treatment perspective (Yoshikawa & Knitzer, 1997). In addition to reflective supervision, mental health consultation should be an integral part of such an effort, and therefore of the overall design of Early Head Start programs. Historically mental health professionals were called upon by Head Start programs on an as-needed basis to respond to reports of problems in the classroom or observations from home visitors. The revised performance standards, however, require that programs not only have access to well-trained mental health consultants, but that they create a regular schedule whereby these consultants are available to program staff.

Early Head Start programs may find it no simple matter to identify mental health consultants who are trained in both infant and family development. Because much of what children learn during the early years of life depends on the quality of their relationships with caregivers, consultants who understand how relationships shape development are essential to the process of helping staff to help families, using resources both within and outside program.

Staff training

Ongoing training to increase staff members' awareness and knowledge of mental health issues among pregnant women, families with infants and toddlers, and very young children themselves is a third way of supporting staff. For example, much has been written from a clinical and research perspective on the impact of maternal depression on the developing relationship between babies and their mothers. Helping staff to recognize the features of both post-partum and clinical depression could be one focus of ongoing training. Similarly, training could offer staff opportunities to learn the principles of infant mental health. This might begin with the basic, but powerful insight that behavior -- even in the youngest infant -- has meaning, and deserves to be understood and responded to sensitively.

Again, Head Start Performance Standards require that all programs develop a systematic approach to provide training opportunities for staff. In our work with Early Head Start Programs during the past two years, EHS National Resource Center staff and regionally funded Infant/Toddler Specialists have stressed the importance of developing on-going, multi-session training sequences, so that staff have opportunities to learn new content, apply it to their daily work with children and families, and revisit content in the light of their experiences.

Concluding comments

The more programs that serve families with infants and toddlers are able to provide staff with reflective supervision, mental health consultation that is an integral part of the program, and rich training opportunities, the better prepared staff will feel to manage their work with families when mental health issues surface.

I do not believe that Early Head Start should become "infant mental health" programs or that all staff of EHS and other comprehensive infant/family programs should become mental health professionals. My point, rather, is that knowledge of and sensitivity to the mental health of young children and adults, and skill in building and maintaining positive relationships are important tools for staff who are expected to work successfully in partnerships with parents to promote healthy infant and toddler development.

Working intensely with families with infants and toddlers is difficult, whether the work takes place in homes, in centers, in health care sites, or throughout a community. Many observers have noted that people tend to come to such work with training and experiences that make them more attuned either to the needs of babies and toddlers or to the needs of parents and other adults. In an initiative like Early Head Start, where the primary reason for working with a family is to support parents in enhancing overall infant and toddler development, striking a balance is essential. Providing services in partnership with parents, directed toward the infant and toddler, and responding, when appropriate, to the mental-health needs of families is an ongoing challenge for Early Head Start and other birth-to-three programs. It is a challenge that we must meet if we are to make a positive difference in the development of the children we are serving.

References

Fenichel, E. (Ed.).(1992). Learning through supervision and mentorship to support the development of infants, toddlers, and their families. Arlington, VA: ZERO TO THREE.

Yoshikawa, H. & Knitzer J. (1997). Lessons from the field: Head Start Mental health strategies to meet challenging needs. New York: National Center for Children in Poverty and the American Orthopsychiatric Association Task-Force on Head Start and Mental Health.

Norman-Murch, T. (1996). Reflective supervision as a vehicle for individual and organizational development. Zero to Three, 17(2), 16-20.