I: Foundations

Chapter I

Conceptualizing Infant Play Therapy in the Context of Infant Mental Health

Janet A. Courtney

The field of infant mental health is growing exponentially, and many practitioners from a range of professional disciplines are desiring to grow their expertise to work with young children. Among these, many play therapists and child counselors who utilize the therapeutic powers of play (Schaefer & Drewes, 2014) as a central intervention are choosing to bring their skill set to this younger population. However, working with young children from birth to three years old requires specialized knowledge and training that is often not included in most child counseling, play therapy, or even graduate school curriculums. This chapter seeks to provide a brief overview of work with infants to include a discussion related to infant trauma, and an introduction to infant mental health and the importance of early intervention. It then puts infant play therapy into context in relationship to infant mental health, as well as highlighting a selection of prominent “shapers” of the field in infant mental health.

The Need for Infant Mental Health: Infants and Trauma

Infants do experience trauma. Unfortunately, as noted by Osofsky, Stepka, & King (2017), many perceive that infants are unaffected by traumatic experiences because they do not retain a conscious memory of the trauma. This societal myth of infancy has caused much harm as we have overlooked the crucial needs of this population. We now understand that those trauma experiences are part of the implicit memory (Cozolino, 2014; Osofsky & Lieberman, 2011; Schore, 2012, 2019; Siegel, 2012). Fortunately, the old myths that humans in utero and as infants do not experience the effects of early life trauma are now being challenged and dispelled. This is particularly credited to the neuroscience revelations of the 1990s, to the rise of the infant mental health field, and to rigorous research studies such as the Adverse Childhood Experiences carried out at Kaiser Permanente or what is commonly known as the ACE study (Felitti et al., 1998). This study included 18,000 participants and was instrumental in providing evidence that early life trauma can have a detrimental effect throughout childhood and into adulthood. In brief, the

ACE study revealed strong correlations between the number of risk factors an infant was exposed to in relationship to later life stress and dysfunction within families. The United States Centers for Disease Control and Prevention website listed the following child maltreatment reports (note: this is only for the United States and does not represent numbers globally—refer to the World Health Organization, https://www.who.int/):

  • • There were 676,000 victims of child abuse and neglect reported to child protective services (CPS) in 2016.
  • • It is estimated that 1 in 4 children experience some form of child abuse or neglect in their lifetimes and 1 in 7 children have experienced abuse or neglect in the last year.
  • • About 1,750 children died from abuse or neglect in 2016.
  • (Source: https://www.cdc.gov/violenceprevention/ childabuseandneglect/index.html)

Infants are our most vulnerable population, and unlike children, adolescents, adults, or the elderly, if someone is harming an infant, they have no ability to run or move away, or block a slap or punch, and they certainly are not able to tell someone else if they have been harmed (Courtney, Velasquez, & Bakai Toth, 2017). Child (infant) maltreatment is recognized as any risk of physical or emotional harm including physical and emotional abuse, sexual abuse, neglect, and exposure to domestic violence. We also recognize the detrimental effects that those traumas have on young children (Gil, 2017). In Terr’s landmark book, Too Scared to Cry (1990), she discussed observing withdrawn infant personalities due to abuse and neglect. In the following heartbreaking account, she described how she tried to help an abused infant in a hospital setting:

One eight-month-old Cleveland girl, whom I tried to help at the university hospital there, had been ignored and occasionally beaten by her severely depressed mother. In her hospital crib, the infant lay on her back with her little hands clutched at midline. It was difficult to pry apart those tiny, fixed fingers. The baby ignored a brightly colored mobile that had been placed over her crib to keep her busy. She paid scant attention to Hospital procedures that would have brought shouts of protest from any ordinary child provoked hardly a complaint from this one. There was no brain damage. The damage resided only in the baby’s still rudimentary, but benumbed, personality style.

(Terr, 1990, p. 85)

Trauma is a whole body sensory-based experience and infants attune to what they see, hear, taste, touch, see, and smell. Their immature nervous systems are highly sensitive and can often be triggered into states of hyperarousal or hypoarousal, leaving infants vulnerable to a range of emotional states of fear, confusion, depression, withdrawal, and anger. Neuroscience literature overwhelmingly concludes that infant and childhood developmental trauma alters the brain and results in enduring problems related to executive functioning skills and emotional, behavioral, cognitive, social, and physical challenges (Badenoch, 2018; Cozolino, 2014; Hudspeth, 2016a; Humphreys Sc Zeanah, 2015; Perry, 2006; Porges, 2018; Schore, 1994, 2019; Siegel, 2012). Van der Kolk (2014) advised, “whatever happens to a baby contributes to the emotional and perceptual map of the world that its developing brain creates” (p. 56). This emotional map, or internal working model, as Bowlby (1988) described it, originates at the implicit level beginning in pregnancy. It is the responsibility of the caregivers to be the external regulators to stabilize arousal states, reduce suffering and ensure optimal emotional and physical safety and health.

Early Intervention—the Key to Healing Early Trauma Experiences

Play therapy pioneer, Virginia Axline (1969) saw the vital importance of healthy beginnings, from a Humanistic standpoint, in the following statement: “There seems to be a powerful force within each individual which strives continuously for complete self-realization. It goes on relentlessly to achieve consummation, but it needs good ‘growing ground’ [italics added] to develop a well-balanced structure” (p. 10). The key words here are “growing ground” as Axline recognized that if given an optimal emotional and psychological foundation, then we (human beings) will naturally tap into our innate drive to reach our highest potential.

Understanding and screening for high risk factors can be a first step of early intervention. One glaring impediment to cognitive and language development revealed through extensive research is that children impacted by poverty often lag behind children noted from more affluent systems (Fernald, Marchman, Sc Weisleder, 2013; Hart Sc Risley, 2003; Piccolo Sc Noble, 2019; Votruba- Drzal, Miller, Sc Coley, 2016). Other identified risk factors growing in research and attention is maternal depression, substance abuse in parents of young children, pre-term infants, exposure to violence, and abuse and neglect (Boris, Renk, Lowell, Sc Kolomeyer, 2019; Murray, Halligan, &C Cooper, 2019; Shah, Browne, Sc Poehlmann-Tynan, 2019).

What is clear is that early intervention and prevention with infants and families that are culturally sensitive, strength-based, and resiliency focused have been shown to be effective (Zeanah Sc Zeanah, 2019). Schaefer, Kelly-Zion, McCormick, 8c Ohnogi (2008) in their edited book, Play Therapy for Very Young Children, advocated, “It is never too soon to provide the appropriate play-based intervention to young children to help them adapt successfully to their environment and family” (p. ix). Ideally, each infant and family system needs to be sized up to discern which model of therapy is best suited for that particular family or caregiver system. This “prescriptive” (Schaefer, 2003) or “integrative” (Gil, et al.,

2015) approach recognizes the uniqueness of each family system where practitioners must consider the presenting problem, the relevant research, and multicultural and diversity factors, to then choose the most appropriate treatment modalities that effect the highest potential for positive therapy outcomes.

Infant Play Therapy in Context

What is meant by Infant Play Therapy? The field of play therapy has traditionally been known to work with children ages four and older as the primary population of treatment (Schaefer, et ah, 2008). The focus of most play therapy interventions is to work with children through the healing power of symbolic type play—with carefully planned playrooms to allow for a child’s innate abilities to play out their worries, traumas, anger, and so forth. Some play therapy theoretical approaches work with children at the pre-symbolic level of play, including Developmental Play Therapy (DPT) (Brody, 1997; Courtney &C Gray 2014) and Theraplay (Booth Sc Jernberg, 2010). However, these models, like the symbolic models, again have traditionally trained therapists to work with children primarily three to four years and older.

The concept of infant play therapy has emerged within recent years with the upsurge of demand by play therapists and other practitioners to find successful ways to provide therapy services to infant populations. The problem is that the traditional types of play therapy approaches, where the therapist may see the child for individual play therapy sessions without the parent in the room, becomes a ridiculous (and highly unethical) scenario if we were to imagine, say, seeing a five- month-old infant for therapy while the parent sits out in the office waiting room. Add to that absurd notion a therapist then telling a parent that what was going to happen in the play therapy room between the therapist and infant was “confidential.” The practice wisdom is that all infant mental health interventions are relationally oriented and therefore must include the parents or caregivers within the therapy sessions. Zeanah Sc Zeanah (2019) wrote that the “relational framework of infant mental health distinguishes it from work with older children and adolescents” (p. 6). Therefore, if play therapists are generally seeking to bring their unique skill set to infant populations, then we can 1) adapt current known evidence-based play therapy modalities (e.g. Filial Play Therapy, Theraplay) to infant populations (e.g. Schaefer et ah, 2008), or 2) new infant-based play therapy models can be developed (e.g. FirstPlay® Therapy), or 3) we can learn and receive training in the existing infant mental health models that utilize play principles (e.g. Child Parent Psychotherapy). These three different ways of envisioning infant play therapy within an infant mental health context are included in this book.

“Child mental health” can be envisioned as the overarching umbrella from which hundreds of child-based theories and interventions fall beneath. In like manner, we can imagine “infant mental health” to be an overarching umbrella term from which interventions that best assist infant populations

l.l Infant mental health organizational framework

Figure l.l Infant mental health organizational framework.

fall. With this in mind, we can now think of infant play therapy as a secondary subset heading under which varied play therapy approaches fall (see Figure 1.1). As infant play therapy models are created and adapted, they must also integrate the vast literature and research established within the neuroscience and infant mental health fields. Additionally, new or adapted play therapy interventions must also set forth the rigor of qualitative and quantitative research designs to establish their overall effectiveness.

The question arises: What expertise does the field of play therapy bring to work with young children? The obvious answer is that play therapists’ expertise is grounded in the understanding that play is intrinsically healing. They value that play is a child’s natural language of communication and self- expression (Schaefer Sc Drewes, 2014). Play therapists also consider the latest research, including findings indicated in the field of neuroscience/neurobiol- ogy (Badenoch, 2018; Hudspeth, 2016a; Kestly, 2014). For the purposes of this book, and to offer a “working” definition of what is meant by the term infant play therapy, I offer the following: Infant play therapies are informed by the fields of neuroscience and infant mental health, are culturally sensitive, and utilize the therapeutic powers of play to effect positive change for the infant and parental (or caregiver) relational system and social environment.

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