Case Report

A
family-centered approach has been promoted for
several years in the practice arena of early interven-
Occupational Therapy in tion and occupational therapy (Anderson & Hin-
ojosa, 1984; Day, 1982; Friedman, 1982). Lawlor and
Early Intervention: Mattingly (1998) recently discussed various problems
embedded in family-centered care, such as defining the
Applying Concepts From client, the professional role, and the nature of work within
a family-centered approach. Problems involving collabora-
Infant Mental Health tion, trust, and equality of decision making can occur when
the therapist shifts from an intervention that focuses on the
child to one that incorporates the family. Lawlor and
Mattingly also presented concerns regarding cultural con-
flicts and service fragmentation. Hence, the occupational
Winifred Schultz-Krohn, Elizabeth Cara
therapist working within early intervention is required to
shift focus on many levels: intrapersonal, interpersonal, cul-
Key Words: child rearing (parenting) tural, and theoretical.
developmental therapy motherchild This article focuses on the challenges of shifting to a
family-centered approach. Current problems in early inter-
relations vention from an occupational therapy perspective are dis-
cussed. The field of infant mental health has much to offer
early intervention occupational therapy. A therapeutic
approach that incorporates concepts from infant mental
health practice into early intervention occupational thera-
py is proposed (Emde, 1987; Lieberman & Pawl, 1993;
Zeanah, 1993). A description of infant mental health prac-
tice that illustrates how ideas from this approach can be
blended into early intervention occupational therapy prac-
tice is provided. Finally, a case study is presented to demon-
strate the application of this blended approach in practice.
Current Occupational Therapy Practice in
Early Intervention
Occupational therapists in pediatric practice demonstrate
a wide but disparate range of family-centered care prac-
tices (Brown, Humphry, & Taylor, 1997; Humphry,
Gonzales, & Taylor, 1993). Brown et al. (1997) identified
a seven-level hierarchy of familytherapist involvement.
These levels represent a progressive shift in therapeutic
intervention from defining the client as an individual to
defining the client as a member of a family. At the same
time, the levels also shift from the clinician acting as the
director of the intervention plan to the family serving as
the coordinator of the intervention plan. Although this
hierarchy identifies a means to engage the family as an
Winifred Schultz-Krohn, MA, OTR, BCP, FAOTA, is Assistant active member of the intervention plan, the focus of occu-
Professor, Occupational Therapy, San Jose State University, One pational therapy service continues to be on the individual
Washington Square, San Jose, California 95192-0059;
client rather than on the family.
winifred@email.sjsu.edu.
Overall, the delivery of family-centered practice with-
Elizabeth Cara, MA, OTR, MFCC, is Assistant Professor, in the field of occupational therapy lacks coherence
Occupational Therapy, San Jose State University, San Jose, (Lawlor & Mattingly, 1998). Even when occupational
California. therapy literature embraces the concepts of family-cen-
tered intervention, the presumed outcome is still identi-
This article was accepted for publication September 24, 1999.
fied in terms of the individual child and not in terms of
550 September/October 2000, Volume 54, Number 5
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 the family function (Brown et al., 1997; Humphry et al.,
1993). This is in contrast to a family systems approach
that identifies the recipient of service as the family in total
(DeMuth, 1994; Dunst, Trivette, & Thompson, 1994).
The family systems approach focuses on the changing
roles of the family as an evolving entity (Bronfenbrenner,
1986). Several authors have suggested the need to adopt a
family systems approach in pediatric occupational therapy
intervention (Crowe, VanLeit, Berghmans, & Mann,
1997; Humphry, 1989). Humphry (1989) called for pedi-
atric occupational therapists to consider not only the
childs developmental skills, but also the parentchild rela-
tionship as part of the intervention plan. Contemporary
infant mental health practice provides a framework for
occupational therapy to incorporate a family systems
model into an intervention plan (Emde, 1987).
Infant Mental Health Practice Concepts
Infant mental health is a field composed of various profes-
sionals, such as developmental psychologists, psychiatrists,
social workers, and early intervention educators
(Bretherton, 1992; Emde, 1987; Zeanah, 1993). The goal
of infant mental health practice is to assist an infant under
3 years of age to achieve the necessary socioemotional skills
and psychological development to function in his or her
immediate environment (Lieberman & Pawl, 1993).
Historically, infant mental health intervention was directed
toward an infant when the parents had a mental illness.
Currently, infant mental health practice focuses on the
dynamic relationship between the child and parents or
caregivers, who may or may not have a mental illness.
The evaluation process in infant mental health requires
the clinician to use observational skills and introspection
(Lieberman & Pawl, 1993). Information on the
parentinfant relationship is gathered by observing how the
parent and child interact, how the child functions develop-
mentally and emotionally, and how the parent experiences
the child. At the same time, the infant mental health thera-
pist must assess his or her own threshold for forming an
alliance with parents who may have a mental illness or have
been rejected by a bureaucratic system. Families seen in an
infant mental health program often have a history of dys-
function and frequently are disadvantaged economically and
socially. Parents may have had prior negative experiences
with health services, and these experiences may be trans-
ferred to the therapist, clouding perceptions of the current
treatment program.
Infant mental health practice consists of three core
interventions operating simultaneously: infantparent psy-
chotherapy or psychoanalytic intervention, nondidactic
developmental guidance, and direct support and advocacy
(Fraiberg, 1980, 1982; Fraiberg, Adelson, & Shapiro,
1975; Lieberman & Pawl, 1993; Seligman, 1994). These
interventions integrate psychoanalysis, developmental psy-
chology, and social work.
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Psychoanalytic intervention consists of two strategies
for intervention (Lieberman & Pawl, 1993; Seligman,
1994). First, the therapist provides comments that help
parents become aware of how they may be reenacting their
own traumatic childhood experiences with their infants.
Questions posed to a parent such as Why is it important
for the infant to eat an entire bowl of cereal? may reveal a
traumatic experience that a parent had regarding eating.
Explicitly identifying these experiences allows the parents
to examine the childs behavior in a new light. Second, a
therapeutic relationship is established between the therapist
and parent to disrupt the negative influence the parents
prior relationships has on current parentchild interaction.
The therapist mirrors positive aspects of parentchild inter-
action back to the parent in the form of comments. For
example, a therapist will remark that a childs glances at the
parent are signals of love.
Nondidactic developmental guidance is a method of
providing developmental information that assumes par-
ents are best able to use information about their children
when the relational aspects and affective dynamics are con-
sidered (Lieberman & Pawl, 1993; Seligman, 1994).
Instead of giving advice, a therapist might ask the parent
what he or she thinks or observes about a childs experi-
ence. The therapist encourages the parent to view the
infants behavior from alternate perspectives, thus inter-
rupting the current view of the behavior that stems from
the parents own prior negative experiences. This approach
supports parental self-exploration and a change in behav-
ior. A change in parental behavior may produce a change
in the infant and, consequently, in the parentchild inter-
action. An example may be an infant who has eaten
enough but has also dropped food on the floor around the
high chair. The parent is convinced that the infant rejects
the food and does not eat enough. The therapist might ask
the parent how much food a 16-month-old infant needs
or might remark on the ability of the child to distinguish
what he wants to eat while learning to use utensils. The
reframing of parental observations does not negate the
original observations but provides an alternate explanation
for the parent to consider.
Direct support and advocacy includes any activity that
directly bolsters the caregiving relationship (Lieberman &
Pawl, 1993; Seligman, 1994). Direct support provides a
model of a caring relationship that can be translated into a
caring parentchild dyad. It can include referrals to public
housing agencies, social services, or practical assistance with
everyday tasks such as shopping or laundry. Often, these
concrete interventions provide needed relief and supply
some measure of hope to the family.
Providing these core interventions simultaneously in
the home can be a challenge for the therapist because the
usual professional boundaries of a clinical environment are
nonexistent. However, providing family-centered care
requires working on these complex levels.
551
 Early Intervention Occupational Therapy and
Infant Mental Health
Infant mental health practice has core intervention strate-
gies that can be adapted for use in pediatric occupational
therapy (Fraiberg, 1980, 1982; Fraiberg et al., 1975; Lieb-
erman & Pawl, 1993; Seligman, 1994). By adapting these
intervention strategies, many of the recently acknowledged
challenges to providing family-centered occupational ther-
apy may be resolved (Lawlor & Mattingly, 1998).
Additionally, a new model of pediatric occupational thera-
py can be formed that will clarify the role and the delivery
of occupational therapy service using a family-centered
approach.
The goal of pediatric occupational therapy, like the goal
of infant mental health practice, is to assist the client to
achieve satisfactory function socially, emotionally, and psy-
chologically in a natural environment (Lieberman & Pawl,
1993). However, infant mental health practice is focused on
the infants impact on the parent and their relationship; the
client is identified as the parent and child and their rela-
tionship. Although pediatric occupational therapists do not
typically address the issue of transference, they use clinical
reasoning skills to observe and actively search for ways to
enter into alliances or develop rapport (Fleming, 1991;
Mattingly, 1991; Neistadt, 1996; Rogers, 1982).
An infant mental health approach offers a framework
for identifying the strengths and vulnerabilities of the parents
and infants and provides a focus for treatment (Lieberman &
Pawl, 1993). The treatment observations, along with the
desires and needs of the parents, dictate the structure and
place of treatment or who is present for the sessions (Cara,
1997). Clearly, pediatric occupational therapy contributes
special skills regarding child evaluation, but the parent does
not always direct how those skills will be used. Therefore, by
adapting the infant mental health framework and respond-
ing to the wishes of the parent about structure, direction, and
place of treatment, the issue of treatment collaboration is
addressed (Lawlor & Mattingly, 1998). This framework also
addresses the interacting cultural worlds of the practitioner
and family. The occupational therapist is quickly able to
learn about the everyday life of the familytheir habits, rou-
tines, values, idiosyncrasies, or unique rituals embedded in
daily encounters.
Recognizing that both child and caregiver are recipi-
ents of service expands the concept of what constitutes
early intervention occupational therapy service. Applying
intervention strategies from the field of infant mental
health practice equips occupational therapists with the
tools to meet the demands of this expanded practice.
Nondidactic developmental guidance supports a self-right-
ing tendency of the parentchild system (Seligman, 1994).
This strategy supports the idea that the caregiver and child
have strengths and attributes that can be used for positive
change along with the special expertise of the therapist. Use
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of direct support and advocacy strategies enables the thera-
pist to address multiple dimensions of therapy (Lawlor &
Mattingly, 1998). This aspect of service includes activities
that directly bolster the parentchild relationship and,
therefore, the services provided for the child. These con-
crete interventions often provide needed relief so that par-
ents will be able to devote other time and emotional suste-
nance toward the child.
In summary, adapting the interventions of infant men-
tal health to early intervention occupational therapy offers
practical strategies that address the challenges of using a
family-centered approach (Lawlor & Mattingly, 1998). The
use of interventions based on clinical reasoning, nondidac-
tic guidance, and concrete support may ameliorate the
problems faced by the occupational therapist providing
family-centered intervention.
Case Illustration
The following case illustrates the use of infant mental
health care approaches in home-based early intervention
occupational therapy. The occupational therapist, one of
the authors, is and speaks limited Spanish.
The family consisted of a 19-year-old mother, whom
we will refer to as Maria, a 2 1/2-year-old daughter and a
16-month-old son. Maria, originally from a Caribbean
island but now living in Connecticut, spoke Spanish and
English. Marias family had returned to the place of birth
but she chose to remain in Connecticut with her children.
Although an aunt lived in Connecticut, Maria had limited
contact with her. Maria was unemployed, living in a subsi-
dized housing project, and unable to attend school because
of her childrens needs.
Both children had been identified as eligible for early
intervention services under the Individuals With
Disabilities Education Act of 1990 (Public Law 101476).
Her daughter had developmental delays in the area of lan-
guage and received home-based services from an early
intervention educator weekly. The interventionist who pro-
vided services for the daughter said that Maria would often
leave the room during the weekly visits and did not appear
interested in completing the suggested home exercises.
Marias son had cerebral palsy and a seizure disorder. He
had been evaluated by an early intervention identification
team and referred for weekly occupational therapy and
physical therapy services.
At the time that occupational therapy services were ini-
tiated, Maria had a limited understanding of the role of
occupational therapy services for her son. The therapist
reviewed the focus of occupational therapy with Maria and
asked her to help develop the treatment plan for her son.
Maria responded by indicating that the therapist was the
expert and should develop the care plan. Maria appeared
both intimidated by the therapist and resistant to partici-
pating in the development of an intervention plan. When
asked how other medical professionals interacted with her,
September/October 2000, Volume 54, Number 5
 Maria reported that the physicians gave her pills for her son
and the nurse told her how to feed him. Her past experi-
ences with medical professionals gave her the impression
that they were authorities, and she believed that they acted
disrespectfully toward her. This teenage mother seemed
angry that the medical professionals did not approach her
as an adult. She appeared to transfer that anger toward the
therapist and assumed that the therapist would act in a sim-
ilarly disrespectful manner.
Although the son was the identified client, a family
systems approach was used to engage Maria in the decision-
making process for her sons care. The focus of the occupa-
tional therapy services was to foster developmental gains in
the boy through the endorsement of Marias role as an
authority in the care of her children. This represents a shift
from defining the client as the child to defining the client
as the family.
During the initial visit to the home, two of Marias
friends were present and were overheard asking her for
advice regarding boyfriends, family issues, and pregnancy.
This mother apparently had a position of authority in her
peer group because of her life experiences and her demon-
strated ability to care for two children with special needs.
There was an apparent discrepancy in her occupational
roles: a voice of authority with her friends and a passive
recipient of authority with early interventionists.
An attempt was made to engage Maria in developing
the care plan for her son by acknowledging her as the
expert regarding what activities her son could and could
not perform. Maria was then asked to prioritize which
activities were most important within the context of her
family life. The occupational therapist elicited Marias per-
ceptions of her sons strengths and challenges, engaging her
through the process of interactive and narrative clinical rea-
soning (Mattingly, 1991). Essentially, the therapist asked
Maria to tell her own story about her son and did not rely
solely on previous medical evaluations. The treatment plan
was developed by asking Maria to evaluate her sons func-
tion and role within the family system rather than using a
standardized instrument that would compare her sons
skills with typical development. The therapist chose not to
ask Maria what parenting tasks were difficult for her, a
question that would have placed her in a position of admit-
ting lacking parenting skills instead of developing her role
as an authority regarding her children. Maria identified dif-
ficulties her son had in eating and moving his arms. He was
only able to eat pureed foods because of poor oral-motor
control. Marias unique knowledge of her son was used to
develop the care plan, and her concerns dictated the course
of therapy.
Toward the end of the first home visit, specific feeding
techniques were presented in a framework similar to home
exercises but with a distinct difference. The techniques
were not prescribed; instead, nondidactic developmental
guidance was used in first providing suggested feeding
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methods and then asking the mother to evaluate the effec-
tiveness of these methods.
At the second appointment, Maria reported how suc-
cessful the suggested techniques had been to promote feed-
ing skills with her son. Maria then asked the therapist to
watch how well her son was eating. Maria said that she
wanted to introduce textured foods to her son and asked for
additional techniques that were then provided by the occu-
pational therapist. These new techniques represented direct
support toward Marias goal of improving her sons feeding
skills. Maria was developing her role as the director of the
care plan for her son. She, herself, had identified additional
needs for her son instead of relying on the therapist.
During subsequent home appointments, Maria was
very engaged in activities with her son and appeared eager
to learn new techniques to help him develop functional
skills. Activities were designed to meet Marias needs in car-
ing for her children and the childrens need to interact with
each other. These needs, addressed through support and
advocacy, were identified by Maria as a priority for family
function. Specific support was provided by informing her
of parenting groups held without cost, connecting her with
parental support groups in the area, and discussing respite
care as an option. The therapist did not make the arrange-
ments for these services but encouraged Maria to use them.
In this role, the therapist facilitated Marias directive role
within the family. The other early interventionists com-
mented that she had begun to take a more active role with
her son and daughter. Services were continued for an addi-
tional 8 weeks and then Maria decided to move back to her
birthplace to be with her family.
Discussion
Occupational therapy services were provided to foster
developmental abilities in the son using a family-centered
approach that recognized both child and caregiver as recip-
ients of therapy. Instead of the occupational therapist serv-
ing as the expert, the strengths of the mother were facilitat-
ed. It was evident that this mother had begun to establish
a position of expertise with her peers regarding child care;
those already established skills were incorporated into the
intervention plan. The occupational therapist demonstrat-
ed an ability to enter the cultural world of this family.
Instead of delegating the mother to a role of helping in the
occupational therapy program, she directed the program.
The focus of occupational therapy intervention was on
strengthening family roles. The mothers developing role as
an expert in the care for her children was recognized and
fostered within the intervention plan. The family system,
particularly the motherinfant relationship and the moth-
ers role in the family, appeared to be strengthened by this
approach, which then facilitated changes in the son.
The goal of occupational therapy intervention was to
improve the sons developmental skills and was achieved
through the use of a family-as-client approach. In this case
553
 report, we attempted to illustrate the effectiveness of a
family-as-client approach even though an individual fam-
ily member was the designated client. Strategies adapted
from infant mental health practice were demonstrated.
Knowledge of bureaucratic transference enabled the ther-
apist to view this mothers initial resistant response to early
interventionists from an alternate perspective and to re-
frame the interaction between the mother and therapist.
Use of nondidactic developmental guidance promoted the
directive role this young mother was beginning to develop
within the family system. Finally, direct support was pro-
vided to assist this family with daily function. This article
suggests a useful theory and practice model from which
occupational therapists may address problems encoun-
tered in early intervention and expand intervention tech-
niques in their roles with pediatric clients and their fami-
lies. s
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