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A mentalization-based primary prevention program for stress prevention during the transition from family care to day care
Mental Health & Prevention 4 (2016) 49–55
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Mental Health & Prevention journal homepage: www.elsevier.com/locate/mhp
A mentalization-based primary prevention program for stress prevention during the transition from family care to day care Christine Bark n, Ilka Baukhage, Manfred Cierpka Institute for Psychosomatic Cooperation Research and Family Therapy, Heidelberg University Hospital, Bergheimerstr. 54, 69115 Heidelberg, Germany
art ic l e i nf o
a b s t r a c t
Article history: Received 10 November 2015 Accepted 29 December 2015 Available online 31 December 2015
A mentalization-based early prevention program for daycares will be presented. The program aims at supporting families during the transition to day care. Transitional phases are significant threshold situations in which vulnerabilities can become activated. Therefore, prevention at this point, especially for children from psychosocial burdened families is of great importance. Theoretical background of the program is the concept of mentalization. In the context of stress and intensive emotional arousal mentalization is likely to fail. The goal of the program is to prevent stress, to strengthen the mentalization ability to support the parent–child relationship and to promote the child's development. & 2016 Elsevier GmbH. All rights reserved.
Keywords: Early prevention program Mentalization Early daycare Transition process Families at risk
1. Introduction Since the introduction of new child-promotive legislation in 20131 in Germany, every child from the age of one to three years has the right to external childcare. The introduction of this law included and led to an increasing construction of day care facilities, and it will most likely be leading to an increased enrollment of children in external childcare. Although day care at this young age is discussed controversially and always contains a social, political, economic and ideological dimension, several study results point towards positive effects of external childcare in regard of children from socially disadvantaged families (Borge, Rutter, Côté, & Tremblay, 2004; Bertelsmann Stiftung, 2008; Côté, Borge, Geoffroy, Rutter, & Tremblay, 2008; Loeb, Bridges, Bassok, Fuller, & Rumberger, 2007; Love et al., 2003). This is mainly explained by compensatory effects that day care can provide in respect to children from psycho-socially burdened families. In a qualitative survey which was conducted with the heads of 21 daycare facilities in the federal state of Saarland it was reported that all of the facilities were working with children at risk or have done so in the past. However the grand majority of the daycare n
Corresponding author. E-mail address: [email protected] (C. Bark). 1 Since August 1st, 2013; The “Kinderfördergesetz” (law of child promotion) came into effect on December 16th, 2008. It entails the appropriation of funds towards the extension of the available childcare facilities (phase 1) and enacts a legal claim to external childcare for children from one to three years of age (phase 2). http://dx.doi.org/10.1016/j.mhp.2015.12.002 2212-6570/& 2016 Elsevier GmbH. All rights reserved.
teachers are not trained in the handling of psycho-socially burdened children and report difficulties in doing so (e.g. displays of behavioral problems on the part of the children, lack of reliability on the part of the parents). Yet the interviewed institutions stated a high willingness in receiving a qualification in this area (Baukhage, Bark, Sidor, & Cierpka, 2014). The quality of early day care generally plays a prominent role concerning the impact on the development of the child (e.g. Bäuerlein, Linkert, Stumpf, & Schneider, 2013; Anders, 2013) and has increasingly become a subject of interest in research. Particularly, high process quality, i.e. developmentally appropriate and needs-oriented interaction processes between child and caregiver, seems to have a positive impact on the key areas of development (Bäuerlein et al., 2013). However the process quality in Germany has been classified only as average and worthy to improve (Tietze et al., 2012). Thus, in this article an early prevention program for daycares to reduce stress during the transition process will be introduced. The overall goal of the program is on the one hand to improve the quality of daycares by training the daycare teachers. On the other hand the program aims at strengthening the parent–child relationship and at promoting the socio-emotional development of the child. The program especially offers opportunities for children from psycho-socially burdened families. 1.1. Importance of early prevention programs Prevention programs in early childhood have shown great effects on the socio-emotional, cognitive and verbal development of
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children (Egeland, Weinfield, Bosquet, & Cheng, 2000). They are posited to have a long-term effect on the child's conditions of maturation of neuronal structures because of the brain's neuroplasticity in this vulnerable time frame (Strüber & Roth, 2012). Following Hertzman and Wiens (1996) the effectiveness of prevention programs is based on two principles: i.e. “the earlier the better”, which refers to the period from birth to pre-school age, and “again and again”, which means to stimulate development continuously, even in later stages of life. Cierpka, Franz, and Egle (2011) also recommend an early investment as it pays off in the long-term because interventions at a later date are more complex in many respects. According to the “latency model”, periods of understimulation, of traumatization and of resulting developmental delay lead to a neurobiological embedded latent vulnerability, which can become activated in significant life events, especially during transitional phases (Hertzman and Wiens, 1996) such as changing from parental to external care. Because children from psychosocial burdened families are often affected by multiple risk factors, this is why the program particularly focuses on these children. 1.2. Previous findings and support for psychosocial burdened families Experiences early in life have a great influence on a child's physical and mental development. Although causal connections are known to be complex, Egle and Hardt (2009) summarized some of the risk factors in early childhood which are associated with a higher probability in developing a physical or mental illness later in life: chronic familial disharmony, alcohol/drug problems of the parents, mental or physical illness of the parents, financial problems, low socio-economic status, maltreatment and neglectjust to be naming a few of them. Families facing the burdens named above have been the target for early intervention programs throughout the last decades. The project “Keiner fällt durchs Netz” (“Nobody slips through the Net”) was one of the pilot projects of early intervention programs implemented in Germany (Cierpka, 2009). In this sensitivity-oriented program trained family midwifes are administering home visits in high-risk families, i.e. families facing multiple psychosocial burdens. Children in families that received the intervention showed an improved level of social development. In addition, mothers in the intervention group judged their 1-year-old children to be less “difficult” compared to the comparison group. Due to the intervention, a more functional mother-child interaction was achieved (Sidor, Kunz, Eickhorst, & Cierpka 2013). The results of the 1-year and 2-year follow-up obtained long-term effects in the areas of maternal assessment of the child's “difficulty” and their parenting behavior. Thus, mothers from the previous intervention group used less negative behavioral strategies when dealing with difficult limit-testing behaviors of their children (Sidor, Fischer, & Cierpka, 2015). Especially high-risk constellations in families are accompanied by limitations on the abilities of mentalization (Fonagy, Gergely, Jurist, & Target, 2002) as well as on parental sensitivity (Ainsworth, 1977). Mentalization inhibiting interactions in families and lacking parental sensitivity are believed to cause behavioral problems in children such as aggressive behavior, emotional problems and interactional problems (Fearon et al., 2006). Fraiberg, Adelson, and Shapiro (1975) describe how unresolved difficult experiences of the parents in their own childhood affect their perception of the relationship with their children. Such interaction problems between parents and children often go along with insecure attachment patterns (overview see Dornes, 1999; Grossmann, 2000). While a secure attachment has been shown to be a protective factor for a healthy mental development in children, in insecure attachment patterns (i.e. anxious-resistant insecure, anxiousavoidant insecure, disorganized attachment) the parents are not or
only partly available for their children as a “safe base” during a felt threat or during explorative behavior (Marvin, Cooper, Hoffmann, & Powell, 2003). Taking this into account experiences of separation like the transition from parental to external care represent a significant struggle for the child. With described irritations, the child cannot make any or only limited use of the opportunities in the daycare facility, showing limitation in his or her explorative behavior. 1.3. Acclimatization processes in daycares The separation process between parents and child from family care in the home environment to daycare is a transitional phase which puts parents and their child under specific stress, and is a challenge for all participants: the child, the parents and the daycare teacher. Questions such as “Will my child like the teacher more than me?” asked by the mother, “Will my mother leave me alone in this unfamiliar place?” asked by the child, and “Will the parents accept me as an attachment figure for their child?” asked by the daycare teacher, etc. arise and necessitate taking the different perspectives into account. Supporting stressed families in this phase is of great importance for the development of the child and the parents. An investigation by Laewen (1989) found that children, who had to manage the transition to daycare without the support of their parents, exhibited a higher rate of absence because of illness and showed more anxious and less explorative behavior within the first 7 months after transition. Together with the introduction of Bowlby's attachment theory (Bowlby, 1973) those national and international findings led to a different awareness of the transition phase in Germany in the mid-1980s, underlining the importance of an acclimatization period in the presence of one parent. Acclimatization models were developed, in which the adaption of the child to the new childcare setting follows a specific procedure with the parents being present. One of most common and field-tested acclimatization models in Germany is the “Berliner Eingewöhnungsmodell” (Berlin's acclimatization model) which was developed by Laewen, Andres, and Hédervári (2009) and is based on the attachment theory, meaning that the child's basic need for an emotional attachment takes a center stage. The main principle of the model is the development of an attachment of the child to a specific daycare teacher. With the support of the parent as a “safe base” the child can slowly get used to the new surroundings and people. Once the daycare teacher is established as an attachment figure, he or she can serve as a “safe base” for the child during the day. According to the model the acclimatization process may last from one to three weeks, depending on the attachment style of the child with securely attached children needing a longer time. The model consists of an initial phase of 3 days. On the 4th day the first separation between parent and child takes place, after which the time needed for the acclimatization period will be decided, depending on the amount of protest a child shows during the separation. The process is continued by a stabilization phase, where the separation time is slowly expanded and the finalization phase where the parent is not present anymore, but still available if needed. The stabilization phase may vary in duration. A study by Datler, Ahnert, Fürstaller et al. from 2007 to 2012 investigated the transition process from family care to daycare of 104 children at the age of 1 ½ and 2 ½ years, using different methods, e.g. cortisol measurements, analyzing video recordings and psychoanalytic infant observation. One of the main results of the study was that the transition process of children to daycare was very distinct for each child. Therefore, the authors questioned the notion of a unified model, categorizing the children according to similarities in the acclimatization process. The period of time
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children needed in their acclimatization process varied and in some cases lasted for several months, especially if the daycares were not working with a standardized model. Another important finding of the study was that children, who suffered “silently”, i.e. not expressed their distress to the outside through crying, for example, thus showed more internalized behavior, were often overlooked in the current models such as the “Berliner Eingewöhnungsmodell”. Accordingly, daycare professionals who do not recognize the sadness or the suffering of the child would be probable to mistake children's internalizing symptoms for a welladapted behavior. Hence, the stress put on the child would likely go undetected resulting in a lower level of support by the professionals. Considering this, it is crucial to detect the right time span, which each individual child needs in his or her transition to daycare. On the professionals' side, determining the appropriate time span depends on the sensitivity and ability of the teacher to put him- or herself into the position of the child and read the signals of the child correctly. These competencies of pedagogical professionals are the foundation for the newly developed relationship. 1.4. Goals of the prevention program The mentalization-based prevention program is supposed to complement the “Berliner Eingewöhnungsmodell”, adding a more individualized transition process according to the child's need. The overall goal of the program is stress prevention and the strengthening of the mentalization ability of child, parent and daycare teacher. More specifically the program aims at reducing parental stress and improving the parental competencies and emotional availability in the parent–child interaction. On the child's side the program aims at reducing the child's stress and promoting the socio-emotional development of the child. Through the program, the relationship between parents and their children is supposed to be strengthened. In sum, the objective of the program can also be stated as improving the quality of the daycare by training the daycare teachers in an appropriate and needs-oriented interaction process with the children at daycare. Training the daycare teachers in mentalization and helping them to attain a mentalization-based attitude tries to achieve that they get a better understanding of the internal processes of a child. Accordingly, it aims to improve the sensitivity of the teachers in reading the signals of the child. In this way, fewer of the children who are not expressing their burden externalized should be overlooked. Through an individualized process, the mentalization-based program provides the possibility to support children specifically to their needs. This especially allows an intensive treatment for children from high-risk families. In the following, we would like to introduce a mentalizationbased primary prevention program. Firstly, the theory behind the program will be amplified, followed by an introduction of the program, illuminating all of its components (training, supervision, self-awareness course) and finally the program will be discussed and an outlook will be given.
2. Theoretical framework of the prevention program The concept of mentalization forms the basis of the prevention program presented here. It has derived in the last decades from the research on the theory of mind and was mainly characterized and developed by Fonagy et al. (2002). The understanding of the internal stages of development in early childhood is given through an introduction to the development of the sense of self according to Daniel Stern (2011).
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2.1. Mentalization and the development of the mentalizing capacity Mentalization includes two aspects: the ability to understand the mental state of others (e.g. needs, desires, feelings, beliefs, goals, purpose and reason), that underlies overt behavior, and it is the ability to reflect about oneself, which circumstances and experiences in the past and present have led to own intentions, desires, thoughts and beliefs. Mentalizing is the imaginative mental activity that enables us to perceive and interpret human behavior in terms of intentional mental states (Fonagy, Bateman, & Luyten, 2012). Mentalization not only demands a reflecting process of one's own internal reality and the internal world of others (first-order understanding), but it also means to be able to reflect the modality of how we and others do this (second-order understanding, metacognition) (Bolm, 2009). The ability to mentalize develops in a sensitive process with the caregiver in early childhood. It is shaped in and by an affective relationship with the caregiver (Schmeets, 2008). The development process is thus highly dependent on the affective-interactional quality of the primary relationships. The development of the mentalizing ability proceeds within interpersonal relationships in a mostly implicit process. Intuitive competencies in the interaction with others form the basis of the implicit mentalizing abilities. Absolutely essential for the child is the experience to be mirrored in his or her emotional state by an attachment relationship (Dornes, 2004). The ability of parents to view their infants as thinking and sentient beings is known to have a positive influence on the development and the attachment security of children. In the interaction between parent and infant the following dimensions play a defining role: the parental responsiveness to change in child's direction of gaze and to child's object-directed action, (vocal) imitation, encouragement of autonomy and appropriate mind-related comments (Meins, Firnyhough, Fredley, & Tuckey, 2001; Meins et al., 2002). These dimensions will be particularly addressed during the current prevention program. Their influence on attachment security of children has been demonstrated on several occasions (Dornes, 2004). The attachment security is crucial for the further development of the child. The significant time frame for developing attachment security lies within the first three years of age. Whereas parental comments on mental processes of their child predict security of attachment (Meins et al., 2001). The process of mentalization, which is normally implicit, has to be regarded critically when mentalization is in an impaired or distorted form, or when interaction partners fall back into prementalistic modes of reality. In those cases the goal of the preventive program is to stimulate an explicit, reflective mentalization process. Observing these prementalistic modes of reality in certain age segments in development can help the adult to discover situations, in which he or she tends to fall back into prementalisitc modes, and can help him or her to understand how experiencing a particular mode affects one's own interaction with others. The consequence of inhibited mentalization is the reemergence of prementalistic representation of internal states. Whereas the psychic equivalence mode is characterized by concreteness of thought, what is thought is experienced as real and true. In the teleological, outcomes-oriented, mode the physical and observable dominates. “Experience is thought to be valid only when its consequences are apparent to all.” (Fonagy et al., 2012). 2.2. The five interrelated senses of self in early childhood In the prevention program all stages of acquiring mentalization in early childhood that enroll in interaction with caregivers will be introduced. The contents will be practiced in intervention units. Introducing daycare professionals and parents to the stages of
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acquiring mentalization in early childhood will support the daycare teachers and the parents in empathizing and thinking about the emotional state and behavior of the child with a mentalizing attitude. One focus strengthening the cognitive process lies on the child's development of the sense of self according to Stern (2011). The sense of self is the main organizational principle, from which the child experiences oneself and the world. The sense of self in infants and toddlers develops in an interactive and sensitive process with the primary caregivers. Stern distinguishes five interrelated senses of self, which develop during sensitive periods in the first years of life:
relationship between child and parent and intervention to promote the development of the child. The prevention program consists of four steps: 1) First, the daycare teachers receive a training, 2) then, in the intervention phase, the program will be implemented in the daycare, 3) the daycare teacher will receive a regular supervision during the intervention phase, and 4) the program is complemented with a self-awareness course for daycare teachers. In the following, the components of the program will be described separately, supplemented with empirical and theoretical justifications. 3.1. Preliminary work
1) the sense of an “emergent self”, which forms from birth to age two months 2) the sense of a “core self”, which forms between the ages of two and six months 3) the sense of a “subjective self”, which forms between seven and twelve months 4) the sense of a “verbal self”, which forms from eighteen months and is never finished 5) the sense of a “narrative self“, which forms between three and four years The stages of development become visible in the child's direction of gaze and in his or her object-directed action. This can be observed during the play of the child. The play of the child is understood to be the child's handling of the world. The sensitivity and responsiveness of the caregivers for these aspects and an open curiosity for the child's intentionality are crucial for a healthy development of the child (Meins et al., 2001, 2002). During the creative process of playing basic physical (gross and fine motor skills), cognitive and emotional aspects of development can be observed. In the process of playing, the autonomy of the child according to his or her individual developmental state can be fostered, which is another goal of the prevention program. 2.3. Supporting the evolving sense of self with a mentalization-based attitude Biographical aspects of the parents that may influence the interaction and the way the parents mentalize, as well as how the parents experience the interaction with the child will be reflected. From this, (vocal) imitations of expressions of the child and appropriate mind-related comments are being derived.
3. Mentalization-based prevention program for day care The mentalization-based primary prevention program is a program supporting infants and toddlers from 0–3 years and their parents during the transition from family care to day care. It is a program offering prevention and early intervention to all children who are attending daycare, with a special focus on children from high-risk families. The prevention program is conceptualized in terms of a “train the trainers” curriculum, meaning that in the first step the daycare teachers will be trained, and in the second step the daycare teachers carry out the program as trainers with the children and their parents. The manualizied program takes place during the familiarization phase of the child to the daycare. The procedure of the familiarization process is based on the “Berliner Eingewöhnungsmodell”, and is complemented with interventions held by the daycare teachers with child–parent dyads in the context of a mentalizationbased attitude. The interventions, which will be described further in point 3.3., are divided into interventions to strengthen the
The program was developed at the Institute for Psychosomatic Cooperation Research and Family Therapy, Heidelberg University Hospital. It integrated the experiences from many years in the field of early prevention and prevention research with high-risk families (e.g. “Nobody slips through the Net”) of the Institute, as well as experiences from the specialist outpatient clinic for parents, infants and toddlers (Thiel-Bonney & Cierpka, 2012). Experiences from the mentalization-based group therapy for parents as a secondary preventive intervention offered in the outpatient clinic, especially aimed at psycho-social burdened families and single parents (Bark, 2013), were also involved. 3.2. Training for daycare teachers 3.2.1. Procedure and content The training for daycare teachers will be held on 2 days in small groups by two qualified trainers. Daycares can either be trained individually in their locality or together with other daycare facilities. One main goal of the training is to convey a mentalizationbased attitude to the daycare teachers. To understand what mentalization is about and to acquire a mentalization-based attitude is an essential part of the training. The training thus includes an introduction on the theoretical background, the concept of mentalization and relevant contents of developmental stages in early childhood. The interventions of the program will be introduced during the training and an instruction on how to conduct them with child and parent will be given. With regard to content the manual is offering techniques to improve the parental sensitivity during the play of the child. With the help of video clips which are shown during the training the mentalization-based attitude in consideration of different perspectives can be practiced, as well as developing a slight for the development stages of the sense of self. During the analysis of videos attachment-strengthening factors according to Meins, as well as the criteria of emotional availability will be demonstrated and practiced. For further practice every participant receives a DVD on which the exercises for the interventions are being demonstrated. 3.2.2. Importance Qualifying the daycare teacher on regards of their attitude and in their way to understand and address children has the major goal to improve the quality of the daycare facilities. The project “WiKo” by Fürstaller, Funder, and Datler (2012) developed concepts for acclimatization processes in daycares and kindergartens and found that only discussing the pedagogical know-how theoretically does not lead to a higher pedagogical quality in practice. Next to a well-organized framework, so-called ‘psychological structures’ are needed to achieve an improvement in pedagogical quality. These ‘psychological structures’ will be addressed in the prevention program with help of the mentalization concept.
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The qualification of daycare teachers is also important, because like the parents, early daycare teachers are involved in the development process of the children's mentalizing ability (Bolm, 2009). The objective of the mentalization-based program is to change the attitude of every member of the team, as well as the attitude of the whole team. According to the findings of the “WiKo” project, it is particularly important that the whole team will be trained. It is not sufficient to compensate for deficits of single staff members. 3.3. Intervention phase During the intervention phase the daycare teachers implement the program in the daycare. All new children will be supported in their transition to the daycare according to the prevention program. The daycare teacher will pass the learned content of the training and the mentalization-based attitude to the parent by means of supervised parent–child–activities. The interventions of the program are divided into interventions that focus on strengthening the relationship between parent and child, and interventions that focus on promoting the development of the child. Depending on the individual need of the child and parent 10– 15 intervention units will be held. The amount and the type of applied interventions will be decided individually for each child. The intervention that supports the exploration of the child in the presence of the parent at the beginning of the acclimatization phase can be held when the child is brought to daycare. This intervention can also be used as a diagnostic of the parent–child interaction. The other interventions can be best held when the child is picked up from the daycare by the parent. Time arrangements should be discussed directly with the parents. The interventions last approximately one hour. Every intervention unit is composed of: 1) a theoretical development psychological part and a deepening of the theory with video examples, 2) exercises that will first be demonstrated from the daycare teacher and 3) then be performed by the parent, and 4) a transfer for practicing at home with further instruction for accompanying the child's play and specific developmental exercises. During the exercise part, the daycare teachers promote the development of the child through supporting an age-appropriate play of the child. Through the play a common shift of attention will be strengthened and a secure attachment to the parent as well as generally parental competencies will be fostered. The age-appropriate play is the key aspect of the program in regard of an important learning context. The creativity of children can be unfolded during the child's play-during the child playing by him- or herself, in a playful dialog and during playing together. From the play the emotional and cognitive development of the child can be seen. To assure quality of the prevention program it is recommended that every trained person videotapes one of his or her intervention units with the parent and child. 3.4. Supervision A core element of the prevention program is the supervision. It is conducted by qualified supervisors who are experienced with the mentalization-based early prevention program. The supervision takes places regularly during the intervention phase, approximately every 6 weeks or as necessary. Developing a mentalization-based attitude is not a simple process of learning. A long-term practice is necessary to perceive mental process of oneself and of others, to put them into words and to reflect them in consideration of different perspectives. To allow this process to happen, resources have to be activated and
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structures have to be formed (Fürstaller et al., 2012). During the prevention program, this will be fulfilled through regular supervision. Therefore, the supervisors need to be experts on the field of mentalization-based therapy, and generally should a psychotherapeutic qualification. The supervision provides the opportunity to ask questions and discuss difficulties. It particularly offers room for discussing burdened parent–child constellations where the mentalizing ability is limited because of present risk factors within the family. During supervision empathy and mentalization of the mental processes of the child, of the parent, and of the daycare teacher are being strengthened and reflected. If available, this can be done with the help of videotapes from a child–parent interaction. In addition, the team and the supervisors decide during the supervision which intervention unit will be helpful for the individual child. Part of the prevention program is not only a regular supervision, but also a self-awareness course for the daycare teachers. Both guarantee that the implementation and the experiences with the program are being reflected continuously and are based on the concepts. 3.5. Self-awareness course The self-awareness course provides the opportunity to view the work with the children as a chance and a challenge for a reflection about oneself, and as an opportunity for own development. The self-awareness course takes place on three different days and is held in mixed groups with daycare teachers from different facilities. To be able to support children and their parents during the transition process to early daycare it is helpful and essential for early daycare teachers to know about their own way of handling transitional situations and separations. A main question in the course is: how do I deal with transitional situations and with separation? Funder, Fürstaller, and Hover-Reisner (2013) describe that daycare teacher who had painful experiences with separation in their past showed resistances towards imagining and emphasizing burdens of separations within the children. As consequence the unconscious desire to avoid reliving own separation experiences lowers the ability of the daycare teacher to be sensitive with the children and parents on their daily separation process (Datler, Datler, Fürstaller, & Funder, 2011). The behavior of children can activate unconscious affective reaction in daycare teachers (Grossmann & Grossmann, 1998). To not be overwhelmed by difficult feelings at once or to avoid impulsive behavior, it is essential that feelings about oneself become conscious and are being reflected (Funder et al., 2013). Taking this into account, it is particularly important that daycare teachers reflect their own history. Another objective of the self-awareness course is to demonstrate the importance of self-reflection processes for the quality of daycare, as well as for the mentalizing ability of daycare teachers. Reflecting about emotional processes of the children is an essential part of the prevention program and will be promoted by the selfawareness course through self-reflection. The first step in opening ourselves for alternative ways is to understand how things work in ourselves. Learning more about oneself will enable daycare teachers to be more open for alternative ways, e.g. for the individual acclimatization processes of every child and his or her parents. The content of the self-awareness course will be transferred by illustrating three basic needs of children, and of every person: 1) the need for relationship, love, care and attachment, 2) the need for knowledge, orientation and safety, and 3) the need for autonomy, differentiation and self-assertion. Due to didactical reasons
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the three days of the course are divided into the three basic needs with every need being in focus on one day.
4. Conclusion The prevention program presented in this article has the goal to support children and their parents successfully and without stress during the transition process from family care to day care. This is tried to be achieved through strengthening a mentalization-based attitude of the involved parents and daycare teachers. The close cooperation with the parents as well as the consideration of the real life context of the child, i.e. the daycare, meet the quality principles for child day care of the Karl Kübel foundation and Vodafone foundation (Kobelt Neuhaus, 2014). In addition, it complies with the requirements of the Prevention Act passed in 2015 in Germany, which places an emphasis on preventive intervention that take place within the real life context of children. In sum, the mentalization-based prevention program has several advantages. In comparison to current models such as the “Berliner Eingewöhnungsmodell” it provides the opportunity of a more individualized acclimatization process in daycares. The concept of mentalization and the acquiring of a mentalizationbased attitude are supposed to help daycare teachers to understand better what each individual child needs and what goes on in each child emotionally during his or her transition to daycare. This ensures for example a closer look for children who suffer “silently” and who are so far often overlooked in the currents models according to the findings of the study by Datler et al. (2011). These children do not call attention “loudly” or through crying and therefore their internalizing symptoms are often mistaken for a well-adapted behavior. A principle of the program is to strengthen the early attachment and the “safe base”, from where and through which the child can dissolve to gain autonomy and to explore the surrounding. As stated, this is not only important for children, whose difficulties are overt in their behavior, but also for children who suffer “silently”. The qualification of daycare teachers as well as a process of regular supervision and self-awareness guarantee for a long-term practice needed in developing a mentalization-based attitude and understanding the internal process of a child. Furthermore, it enables the addressing of so-called ‘psychological structures’ as demanded by Fürstaller et al. (2012) to improve the quality of daycares. The mentalizing ability of pedagogical professionals in the field of early childhood is an essential quality feature of daycares. However, so far there does not exist any empirical research on this matter (compare Fürstaller & Studener-Kuras, 2013), leaving the question open, of how good the mentalizing ability of professionals in early childhood is. The mentalization-based prevention program is offering primary prevention as it is a program for all children attending daycare. But it also provides secondary prevention as it has a special focus for children at risk. Through an individualized acclimatization process children from psychosocial burdened families become a more intensive and individual care according to their needs. The intervention units can be chosen individually regarding their necessities. Another advantage of the program is that because it is mainly based on acquiring an attitude and a concept of how to understand and address children, it is also useful for other professionals in the field of early childhood. The manual of the program is not specific to daycare teachers it can be used by other professionals working with parents and young children such as childminders, midwifes or pediatric nurses. In the context of the current refugee crisis more children from
refugee families will make up the group of high-risk families in Germany. Integration starts already when these children step into the door of daycares. An early integration has a great chance to be successful. The acclimatization of these children requires concepts and methods which do not depend on a high knowledge of language. The mentalization-based prevention program provides the opportunity to conduct interventions non-verbally through imitation. Hence, the program is particularly suitable for refugee families and can be adapted to them.
5. Outlook In the context of early intervention, a term used in Germany that refers to coordinated local support systems for families with children from pregnancy until the age of three, a well-established network and cooperation between the institutions and programs offered in this field is inevitable to guarantee for a good quality of the support system. Especially for children at risk it is essential that the programs and institutions in the field of early intervention are linked together to create so-called “chains of prevention and support”. Concerning the mentalization-based prevention program, our plan is to establish a network between daycares and special trained family midwifes and family nurses who support psychosocial burdened families and their newborn child during the first year of age. For all those children at risk for whom early daycare is thought to be appropriate or inevitable because of occupational necessity of the parents, it is important that the way to daycare is going to be paved for them and that the transition is well prepared. Therefore, trainings for family midwifes and family nurses in the mentalization-based program will be provided. With the family midwifes being involved in the transition process and with the consent of the parent they can not only pass useful information about the child to the daycare, but also prepare the transition to daycare together with the parents already from at home. With a mentalization-based attitude they can support the parents at home in taking the necessary steps in regard to the needs of each family in their transition process. For example introducing a transitional object (e.g. blanket or stuffed animal) will help the child in his or her emotional regulation during the separation from the parents. As a part of the on-going project “Frühe Hilfen Plus” (“Early intervention Plus”) funded by the Ministry of Social Affairs, Health, Women and Family of Saarland the mentalization-based prevention program is currently being executed and process evaluated in six pilot daycares in the federal state of Saarland. Perspectively, our goal is to expand the implementation of the program and to conduct an efficacy study.
Acknowledgment The project has been friendly supported and is founded by the Helmut Mader Stiftung, Frankfurt, the Heidehof Stiftung GmbH, Stuttgart and the Ministry of Science, Research and the Arts of the State of Baden Württemberg.
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A mentalization-based primary prevention program for stress prevention during the transition from family care to day care Christine Bark n, Ilka Baukhage, Manfred Cierpka Institute for Psychosomatic Cooperation Research and Family Therapy, Heidelberg University Hospital, Bergheimerstr. 54, 69115 Heidelberg, Germany
art ic l e i nf o
a b s t r a c t
Article history: Received 10 November 2015 Accepted 29 December 2015 Available online 31 December 2015
A mentalization-based early prevention program for daycares will be presented. The program aims at supporting families during the transition to day care. Transitional phases are significant threshold situations in which vulnerabilities can become activated. Therefore, prevention at this point, especially for children from psychosocial burdened families is of great importance. Theoretical background of the program is the concept of mentalization. In the context of stress and intensive emotional arousal mentalization is likely to fail. The goal of the program is to prevent stress, to strengthen the mentalization ability to support the parent–child relationship and to promote the child's development. & 2016 Elsevier GmbH. All rights reserved.
Keywords: Early prevention program Mentalization Early daycare Transition process Families at risk
1. Introduction Since the introduction of new child-promotive legislation in 20131 in Germany, every child from the age of one to three years has the right to external childcare. The introduction of this law included and led to an increasing construction of day care facilities, and it will most likely be leading to an increased enrollment of children in external childcare. Although day care at this young age is discussed controversially and always contains a social, political, economic and ideological dimension, several study results point towards positive effects of external childcare in regard of children from socially disadvantaged families (Borge, Rutter, Côté, & Tremblay, 2004; Bertelsmann Stiftung, 2008; Côté, Borge, Geoffroy, Rutter, & Tremblay, 2008; Loeb, Bridges, Bassok, Fuller, & Rumberger, 2007; Love et al., 2003). This is mainly explained by compensatory effects that day care can provide in respect to children from psycho-socially burdened families. In a qualitative survey which was conducted with the heads of 21 daycare facilities in the federal state of Saarland it was reported that all of the facilities were working with children at risk or have done so in the past. However the grand majority of the daycare n
Corresponding author. E-mail address: [email protected] (C. Bark). 1 Since August 1st, 2013; The “Kinderfördergesetz” (law of child promotion) came into effect on December 16th, 2008. It entails the appropriation of funds towards the extension of the available childcare facilities (phase 1) and enacts a legal claim to external childcare for children from one to three years of age (phase 2). http://dx.doi.org/10.1016/j.mhp.2015.12.002 2212-6570/& 2016 Elsevier GmbH. All rights reserved.
teachers are not trained in the handling of psycho-socially burdened children and report difficulties in doing so (e.g. displays of behavioral problems on the part of the children, lack of reliability on the part of the parents). Yet the interviewed institutions stated a high willingness in receiving a qualification in this area (Baukhage, Bark, Sidor, & Cierpka, 2014). The quality of early day care generally plays a prominent role concerning the impact on the development of the child (e.g. Bäuerlein, Linkert, Stumpf, & Schneider, 2013; Anders, 2013) and has increasingly become a subject of interest in research. Particularly, high process quality, i.e. developmentally appropriate and needs-oriented interaction processes between child and caregiver, seems to have a positive impact on the key areas of development (Bäuerlein et al., 2013). However the process quality in Germany has been classified only as average and worthy to improve (Tietze et al., 2012). Thus, in this article an early prevention program for daycares to reduce stress during the transition process will be introduced. The overall goal of the program is on the one hand to improve the quality of daycares by training the daycare teachers. On the other hand the program aims at strengthening the parent–child relationship and at promoting the socio-emotional development of the child. The program especially offers opportunities for children from psycho-socially burdened families. 1.1. Importance of early prevention programs Prevention programs in early childhood have shown great effects on the socio-emotional, cognitive and verbal development of
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children (Egeland, Weinfield, Bosquet, & Cheng, 2000). They are posited to have a long-term effect on the child's conditions of maturation of neuronal structures because of the brain's neuroplasticity in this vulnerable time frame (Strüber & Roth, 2012). Following Hertzman and Wiens (1996) the effectiveness of prevention programs is based on two principles: i.e. “the earlier the better”, which refers to the period from birth to pre-school age, and “again and again”, which means to stimulate development continuously, even in later stages of life. Cierpka, Franz, and Egle (2011) also recommend an early investment as it pays off in the long-term because interventions at a later date are more complex in many respects. According to the “latency model”, periods of understimulation, of traumatization and of resulting developmental delay lead to a neurobiological embedded latent vulnerability, which can become activated in significant life events, especially during transitional phases (Hertzman and Wiens, 1996) such as changing from parental to external care. Because children from psychosocial burdened families are often affected by multiple risk factors, this is why the program particularly focuses on these children. 1.2. Previous findings and support for psychosocial burdened families Experiences early in life have a great influence on a child's physical and mental development. Although causal connections are known to be complex, Egle and Hardt (2009) summarized some of the risk factors in early childhood which are associated with a higher probability in developing a physical or mental illness later in life: chronic familial disharmony, alcohol/drug problems of the parents, mental or physical illness of the parents, financial problems, low socio-economic status, maltreatment and neglectjust to be naming a few of them. Families facing the burdens named above have been the target for early intervention programs throughout the last decades. The project “Keiner fällt durchs Netz” (“Nobody slips through the Net”) was one of the pilot projects of early intervention programs implemented in Germany (Cierpka, 2009). In this sensitivity-oriented program trained family midwifes are administering home visits in high-risk families, i.e. families facing multiple psychosocial burdens. Children in families that received the intervention showed an improved level of social development. In addition, mothers in the intervention group judged their 1-year-old children to be less “difficult” compared to the comparison group. Due to the intervention, a more functional mother-child interaction was achieved (Sidor, Kunz, Eickhorst, & Cierpka 2013). The results of the 1-year and 2-year follow-up obtained long-term effects in the areas of maternal assessment of the child's “difficulty” and their parenting behavior. Thus, mothers from the previous intervention group used less negative behavioral strategies when dealing with difficult limit-testing behaviors of their children (Sidor, Fischer, & Cierpka, 2015). Especially high-risk constellations in families are accompanied by limitations on the abilities of mentalization (Fonagy, Gergely, Jurist, & Target, 2002) as well as on parental sensitivity (Ainsworth, 1977). Mentalization inhibiting interactions in families and lacking parental sensitivity are believed to cause behavioral problems in children such as aggressive behavior, emotional problems and interactional problems (Fearon et al., 2006). Fraiberg, Adelson, and Shapiro (1975) describe how unresolved difficult experiences of the parents in their own childhood affect their perception of the relationship with their children. Such interaction problems between parents and children often go along with insecure attachment patterns (overview see Dornes, 1999; Grossmann, 2000). While a secure attachment has been shown to be a protective factor for a healthy mental development in children, in insecure attachment patterns (i.e. anxious-resistant insecure, anxiousavoidant insecure, disorganized attachment) the parents are not or
only partly available for their children as a “safe base” during a felt threat or during explorative behavior (Marvin, Cooper, Hoffmann, & Powell, 2003). Taking this into account experiences of separation like the transition from parental to external care represent a significant struggle for the child. With described irritations, the child cannot make any or only limited use of the opportunities in the daycare facility, showing limitation in his or her explorative behavior. 1.3. Acclimatization processes in daycares The separation process between parents and child from family care in the home environment to daycare is a transitional phase which puts parents and their child under specific stress, and is a challenge for all participants: the child, the parents and the daycare teacher. Questions such as “Will my child like the teacher more than me?” asked by the mother, “Will my mother leave me alone in this unfamiliar place?” asked by the child, and “Will the parents accept me as an attachment figure for their child?” asked by the daycare teacher, etc. arise and necessitate taking the different perspectives into account. Supporting stressed families in this phase is of great importance for the development of the child and the parents. An investigation by Laewen (1989) found that children, who had to manage the transition to daycare without the support of their parents, exhibited a higher rate of absence because of illness and showed more anxious and less explorative behavior within the first 7 months after transition. Together with the introduction of Bowlby's attachment theory (Bowlby, 1973) those national and international findings led to a different awareness of the transition phase in Germany in the mid-1980s, underlining the importance of an acclimatization period in the presence of one parent. Acclimatization models were developed, in which the adaption of the child to the new childcare setting follows a specific procedure with the parents being present. One of most common and field-tested acclimatization models in Germany is the “Berliner Eingewöhnungsmodell” (Berlin's acclimatization model) which was developed by Laewen, Andres, and Hédervári (2009) and is based on the attachment theory, meaning that the child's basic need for an emotional attachment takes a center stage. The main principle of the model is the development of an attachment of the child to a specific daycare teacher. With the support of the parent as a “safe base” the child can slowly get used to the new surroundings and people. Once the daycare teacher is established as an attachment figure, he or she can serve as a “safe base” for the child during the day. According to the model the acclimatization process may last from one to three weeks, depending on the attachment style of the child with securely attached children needing a longer time. The model consists of an initial phase of 3 days. On the 4th day the first separation between parent and child takes place, after which the time needed for the acclimatization period will be decided, depending on the amount of protest a child shows during the separation. The process is continued by a stabilization phase, where the separation time is slowly expanded and the finalization phase where the parent is not present anymore, but still available if needed. The stabilization phase may vary in duration. A study by Datler, Ahnert, Fürstaller et al. from 2007 to 2012 investigated the transition process from family care to daycare of 104 children at the age of 1 ½ and 2 ½ years, using different methods, e.g. cortisol measurements, analyzing video recordings and psychoanalytic infant observation. One of the main results of the study was that the transition process of children to daycare was very distinct for each child. Therefore, the authors questioned the notion of a unified model, categorizing the children according to similarities in the acclimatization process. The period of time
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children needed in their acclimatization process varied and in some cases lasted for several months, especially if the daycares were not working with a standardized model. Another important finding of the study was that children, who suffered “silently”, i.e. not expressed their distress to the outside through crying, for example, thus showed more internalized behavior, were often overlooked in the current models such as the “Berliner Eingewöhnungsmodell”. Accordingly, daycare professionals who do not recognize the sadness or the suffering of the child would be probable to mistake children's internalizing symptoms for a welladapted behavior. Hence, the stress put on the child would likely go undetected resulting in a lower level of support by the professionals. Considering this, it is crucial to detect the right time span, which each individual child needs in his or her transition to daycare. On the professionals' side, determining the appropriate time span depends on the sensitivity and ability of the teacher to put him- or herself into the position of the child and read the signals of the child correctly. These competencies of pedagogical professionals are the foundation for the newly developed relationship. 1.4. Goals of the prevention program The mentalization-based prevention program is supposed to complement the “Berliner Eingewöhnungsmodell”, adding a more individualized transition process according to the child's need. The overall goal of the program is stress prevention and the strengthening of the mentalization ability of child, parent and daycare teacher. More specifically the program aims at reducing parental stress and improving the parental competencies and emotional availability in the parent–child interaction. On the child's side the program aims at reducing the child's stress and promoting the socio-emotional development of the child. Through the program, the relationship between parents and their children is supposed to be strengthened. In sum, the objective of the program can also be stated as improving the quality of the daycare by training the daycare teachers in an appropriate and needs-oriented interaction process with the children at daycare. Training the daycare teachers in mentalization and helping them to attain a mentalization-based attitude tries to achieve that they get a better understanding of the internal processes of a child. Accordingly, it aims to improve the sensitivity of the teachers in reading the signals of the child. In this way, fewer of the children who are not expressing their burden externalized should be overlooked. Through an individualized process, the mentalization-based program provides the possibility to support children specifically to their needs. This especially allows an intensive treatment for children from high-risk families. In the following, we would like to introduce a mentalizationbased primary prevention program. Firstly, the theory behind the program will be amplified, followed by an introduction of the program, illuminating all of its components (training, supervision, self-awareness course) and finally the program will be discussed and an outlook will be given.
2. Theoretical framework of the prevention program The concept of mentalization forms the basis of the prevention program presented here. It has derived in the last decades from the research on the theory of mind and was mainly characterized and developed by Fonagy et al. (2002). The understanding of the internal stages of development in early childhood is given through an introduction to the development of the sense of self according to Daniel Stern (2011).
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2.1. Mentalization and the development of the mentalizing capacity Mentalization includes two aspects: the ability to understand the mental state of others (e.g. needs, desires, feelings, beliefs, goals, purpose and reason), that underlies overt behavior, and it is the ability to reflect about oneself, which circumstances and experiences in the past and present have led to own intentions, desires, thoughts and beliefs. Mentalizing is the imaginative mental activity that enables us to perceive and interpret human behavior in terms of intentional mental states (Fonagy, Bateman, & Luyten, 2012). Mentalization not only demands a reflecting process of one's own internal reality and the internal world of others (first-order understanding), but it also means to be able to reflect the modality of how we and others do this (second-order understanding, metacognition) (Bolm, 2009). The ability to mentalize develops in a sensitive process with the caregiver in early childhood. It is shaped in and by an affective relationship with the caregiver (Schmeets, 2008). The development process is thus highly dependent on the affective-interactional quality of the primary relationships. The development of the mentalizing ability proceeds within interpersonal relationships in a mostly implicit process. Intuitive competencies in the interaction with others form the basis of the implicit mentalizing abilities. Absolutely essential for the child is the experience to be mirrored in his or her emotional state by an attachment relationship (Dornes, 2004). The ability of parents to view their infants as thinking and sentient beings is known to have a positive influence on the development and the attachment security of children. In the interaction between parent and infant the following dimensions play a defining role: the parental responsiveness to change in child's direction of gaze and to child's object-directed action, (vocal) imitation, encouragement of autonomy and appropriate mind-related comments (Meins, Firnyhough, Fredley, & Tuckey, 2001; Meins et al., 2002). These dimensions will be particularly addressed during the current prevention program. Their influence on attachment security of children has been demonstrated on several occasions (Dornes, 2004). The attachment security is crucial for the further development of the child. The significant time frame for developing attachment security lies within the first three years of age. Whereas parental comments on mental processes of their child predict security of attachment (Meins et al., 2001). The process of mentalization, which is normally implicit, has to be regarded critically when mentalization is in an impaired or distorted form, or when interaction partners fall back into prementalistic modes of reality. In those cases the goal of the preventive program is to stimulate an explicit, reflective mentalization process. Observing these prementalistic modes of reality in certain age segments in development can help the adult to discover situations, in which he or she tends to fall back into prementalisitc modes, and can help him or her to understand how experiencing a particular mode affects one's own interaction with others. The consequence of inhibited mentalization is the reemergence of prementalistic representation of internal states. Whereas the psychic equivalence mode is characterized by concreteness of thought, what is thought is experienced as real and true. In the teleological, outcomes-oriented, mode the physical and observable dominates. “Experience is thought to be valid only when its consequences are apparent to all.” (Fonagy et al., 2012). 2.2. The five interrelated senses of self in early childhood In the prevention program all stages of acquiring mentalization in early childhood that enroll in interaction with caregivers will be introduced. The contents will be practiced in intervention units. Introducing daycare professionals and parents to the stages of
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acquiring mentalization in early childhood will support the daycare teachers and the parents in empathizing and thinking about the emotional state and behavior of the child with a mentalizing attitude. One focus strengthening the cognitive process lies on the child's development of the sense of self according to Stern (2011). The sense of self is the main organizational principle, from which the child experiences oneself and the world. The sense of self in infants and toddlers develops in an interactive and sensitive process with the primary caregivers. Stern distinguishes five interrelated senses of self, which develop during sensitive periods in the first years of life:
relationship between child and parent and intervention to promote the development of the child. The prevention program consists of four steps: 1) First, the daycare teachers receive a training, 2) then, in the intervention phase, the program will be implemented in the daycare, 3) the daycare teacher will receive a regular supervision during the intervention phase, and 4) the program is complemented with a self-awareness course for daycare teachers. In the following, the components of the program will be described separately, supplemented with empirical and theoretical justifications. 3.1. Preliminary work
1) the sense of an “emergent self”, which forms from birth to age two months 2) the sense of a “core self”, which forms between the ages of two and six months 3) the sense of a “subjective self”, which forms between seven and twelve months 4) the sense of a “verbal self”, which forms from eighteen months and is never finished 5) the sense of a “narrative self“, which forms between three and four years The stages of development become visible in the child's direction of gaze and in his or her object-directed action. This can be observed during the play of the child. The play of the child is understood to be the child's handling of the world. The sensitivity and responsiveness of the caregivers for these aspects and an open curiosity for the child's intentionality are crucial for a healthy development of the child (Meins et al., 2001, 2002). During the creative process of playing basic physical (gross and fine motor skills), cognitive and emotional aspects of development can be observed. In the process of playing, the autonomy of the child according to his or her individual developmental state can be fostered, which is another goal of the prevention program. 2.3. Supporting the evolving sense of self with a mentalization-based attitude Biographical aspects of the parents that may influence the interaction and the way the parents mentalize, as well as how the parents experience the interaction with the child will be reflected. From this, (vocal) imitations of expressions of the child and appropriate mind-related comments are being derived.
3. Mentalization-based prevention program for day care The mentalization-based primary prevention program is a program supporting infants and toddlers from 0–3 years and their parents during the transition from family care to day care. It is a program offering prevention and early intervention to all children who are attending daycare, with a special focus on children from high-risk families. The prevention program is conceptualized in terms of a “train the trainers” curriculum, meaning that in the first step the daycare teachers will be trained, and in the second step the daycare teachers carry out the program as trainers with the children and their parents. The manualizied program takes place during the familiarization phase of the child to the daycare. The procedure of the familiarization process is based on the “Berliner Eingewöhnungsmodell”, and is complemented with interventions held by the daycare teachers with child–parent dyads in the context of a mentalizationbased attitude. The interventions, which will be described further in point 3.3., are divided into interventions to strengthen the
The program was developed at the Institute for Psychosomatic Cooperation Research and Family Therapy, Heidelberg University Hospital. It integrated the experiences from many years in the field of early prevention and prevention research with high-risk families (e.g. “Nobody slips through the Net”) of the Institute, as well as experiences from the specialist outpatient clinic for parents, infants and toddlers (Thiel-Bonney & Cierpka, 2012). Experiences from the mentalization-based group therapy for parents as a secondary preventive intervention offered in the outpatient clinic, especially aimed at psycho-social burdened families and single parents (Bark, 2013), were also involved. 3.2. Training for daycare teachers 3.2.1. Procedure and content The training for daycare teachers will be held on 2 days in small groups by two qualified trainers. Daycares can either be trained individually in their locality or together with other daycare facilities. One main goal of the training is to convey a mentalizationbased attitude to the daycare teachers. To understand what mentalization is about and to acquire a mentalization-based attitude is an essential part of the training. The training thus includes an introduction on the theoretical background, the concept of mentalization and relevant contents of developmental stages in early childhood. The interventions of the program will be introduced during the training and an instruction on how to conduct them with child and parent will be given. With regard to content the manual is offering techniques to improve the parental sensitivity during the play of the child. With the help of video clips which are shown during the training the mentalization-based attitude in consideration of different perspectives can be practiced, as well as developing a slight for the development stages of the sense of self. During the analysis of videos attachment-strengthening factors according to Meins, as well as the criteria of emotional availability will be demonstrated and practiced. For further practice every participant receives a DVD on which the exercises for the interventions are being demonstrated. 3.2.2. Importance Qualifying the daycare teacher on regards of their attitude and in their way to understand and address children has the major goal to improve the quality of the daycare facilities. The project “WiKo” by Fürstaller, Funder, and Datler (2012) developed concepts for acclimatization processes in daycares and kindergartens and found that only discussing the pedagogical know-how theoretically does not lead to a higher pedagogical quality in practice. Next to a well-organized framework, so-called ‘psychological structures’ are needed to achieve an improvement in pedagogical quality. These ‘psychological structures’ will be addressed in the prevention program with help of the mentalization concept.
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The qualification of daycare teachers is also important, because like the parents, early daycare teachers are involved in the development process of the children's mentalizing ability (Bolm, 2009). The objective of the mentalization-based program is to change the attitude of every member of the team, as well as the attitude of the whole team. According to the findings of the “WiKo” project, it is particularly important that the whole team will be trained. It is not sufficient to compensate for deficits of single staff members. 3.3. Intervention phase During the intervention phase the daycare teachers implement the program in the daycare. All new children will be supported in their transition to the daycare according to the prevention program. The daycare teacher will pass the learned content of the training and the mentalization-based attitude to the parent by means of supervised parent–child–activities. The interventions of the program are divided into interventions that focus on strengthening the relationship between parent and child, and interventions that focus on promoting the development of the child. Depending on the individual need of the child and parent 10– 15 intervention units will be held. The amount and the type of applied interventions will be decided individually for each child. The intervention that supports the exploration of the child in the presence of the parent at the beginning of the acclimatization phase can be held when the child is brought to daycare. This intervention can also be used as a diagnostic of the parent–child interaction. The other interventions can be best held when the child is picked up from the daycare by the parent. Time arrangements should be discussed directly with the parents. The interventions last approximately one hour. Every intervention unit is composed of: 1) a theoretical development psychological part and a deepening of the theory with video examples, 2) exercises that will first be demonstrated from the daycare teacher and 3) then be performed by the parent, and 4) a transfer for practicing at home with further instruction for accompanying the child's play and specific developmental exercises. During the exercise part, the daycare teachers promote the development of the child through supporting an age-appropriate play of the child. Through the play a common shift of attention will be strengthened and a secure attachment to the parent as well as generally parental competencies will be fostered. The age-appropriate play is the key aspect of the program in regard of an important learning context. The creativity of children can be unfolded during the child's play-during the child playing by him- or herself, in a playful dialog and during playing together. From the play the emotional and cognitive development of the child can be seen. To assure quality of the prevention program it is recommended that every trained person videotapes one of his or her intervention units with the parent and child. 3.4. Supervision A core element of the prevention program is the supervision. It is conducted by qualified supervisors who are experienced with the mentalization-based early prevention program. The supervision takes places regularly during the intervention phase, approximately every 6 weeks or as necessary. Developing a mentalization-based attitude is not a simple process of learning. A long-term practice is necessary to perceive mental process of oneself and of others, to put them into words and to reflect them in consideration of different perspectives. To allow this process to happen, resources have to be activated and
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structures have to be formed (Fürstaller et al., 2012). During the prevention program, this will be fulfilled through regular supervision. Therefore, the supervisors need to be experts on the field of mentalization-based therapy, and generally should a psychotherapeutic qualification. The supervision provides the opportunity to ask questions and discuss difficulties. It particularly offers room for discussing burdened parent–child constellations where the mentalizing ability is limited because of present risk factors within the family. During supervision empathy and mentalization of the mental processes of the child, of the parent, and of the daycare teacher are being strengthened and reflected. If available, this can be done with the help of videotapes from a child–parent interaction. In addition, the team and the supervisors decide during the supervision which intervention unit will be helpful for the individual child. Part of the prevention program is not only a regular supervision, but also a self-awareness course for the daycare teachers. Both guarantee that the implementation and the experiences with the program are being reflected continuously and are based on the concepts. 3.5. Self-awareness course The self-awareness course provides the opportunity to view the work with the children as a chance and a challenge for a reflection about oneself, and as an opportunity for own development. The self-awareness course takes place on three different days and is held in mixed groups with daycare teachers from different facilities. To be able to support children and their parents during the transition process to early daycare it is helpful and essential for early daycare teachers to know about their own way of handling transitional situations and separations. A main question in the course is: how do I deal with transitional situations and with separation? Funder, Fürstaller, and Hover-Reisner (2013) describe that daycare teacher who had painful experiences with separation in their past showed resistances towards imagining and emphasizing burdens of separations within the children. As consequence the unconscious desire to avoid reliving own separation experiences lowers the ability of the daycare teacher to be sensitive with the children and parents on their daily separation process (Datler, Datler, Fürstaller, & Funder, 2011). The behavior of children can activate unconscious affective reaction in daycare teachers (Grossmann & Grossmann, 1998). To not be overwhelmed by difficult feelings at once or to avoid impulsive behavior, it is essential that feelings about oneself become conscious and are being reflected (Funder et al., 2013). Taking this into account, it is particularly important that daycare teachers reflect their own history. Another objective of the self-awareness course is to demonstrate the importance of self-reflection processes for the quality of daycare, as well as for the mentalizing ability of daycare teachers. Reflecting about emotional processes of the children is an essential part of the prevention program and will be promoted by the selfawareness course through self-reflection. The first step in opening ourselves for alternative ways is to understand how things work in ourselves. Learning more about oneself will enable daycare teachers to be more open for alternative ways, e.g. for the individual acclimatization processes of every child and his or her parents. The content of the self-awareness course will be transferred by illustrating three basic needs of children, and of every person: 1) the need for relationship, love, care and attachment, 2) the need for knowledge, orientation and safety, and 3) the need for autonomy, differentiation and self-assertion. Due to didactical reasons
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the three days of the course are divided into the three basic needs with every need being in focus on one day.
4. Conclusion The prevention program presented in this article has the goal to support children and their parents successfully and without stress during the transition process from family care to day care. This is tried to be achieved through strengthening a mentalization-based attitude of the involved parents and daycare teachers. The close cooperation with the parents as well as the consideration of the real life context of the child, i.e. the daycare, meet the quality principles for child day care of the Karl Kübel foundation and Vodafone foundation (Kobelt Neuhaus, 2014). In addition, it complies with the requirements of the Prevention Act passed in 2015 in Germany, which places an emphasis on preventive intervention that take place within the real life context of children. In sum, the mentalization-based prevention program has several advantages. In comparison to current models such as the “Berliner Eingewöhnungsmodell” it provides the opportunity of a more individualized acclimatization process in daycares. The concept of mentalization and the acquiring of a mentalizationbased attitude are supposed to help daycare teachers to understand better what each individual child needs and what goes on in each child emotionally during his or her transition to daycare. This ensures for example a closer look for children who suffer “silently” and who are so far often overlooked in the currents models according to the findings of the study by Datler et al. (2011). These children do not call attention “loudly” or through crying and therefore their internalizing symptoms are often mistaken for a well-adapted behavior. A principle of the program is to strengthen the early attachment and the “safe base”, from where and through which the child can dissolve to gain autonomy and to explore the surrounding. As stated, this is not only important for children, whose difficulties are overt in their behavior, but also for children who suffer “silently”. The qualification of daycare teachers as well as a process of regular supervision and self-awareness guarantee for a long-term practice needed in developing a mentalization-based attitude and understanding the internal process of a child. Furthermore, it enables the addressing of so-called ‘psychological structures’ as demanded by Fürstaller et al. (2012) to improve the quality of daycares. The mentalizing ability of pedagogical professionals in the field of early childhood is an essential quality feature of daycares. However, so far there does not exist any empirical research on this matter (compare Fürstaller & Studener-Kuras, 2013), leaving the question open, of how good the mentalizing ability of professionals in early childhood is. The mentalization-based prevention program is offering primary prevention as it is a program for all children attending daycare. But it also provides secondary prevention as it has a special focus for children at risk. Through an individualized acclimatization process children from psychosocial burdened families become a more intensive and individual care according to their needs. The intervention units can be chosen individually regarding their necessities. Another advantage of the program is that because it is mainly based on acquiring an attitude and a concept of how to understand and address children, it is also useful for other professionals in the field of early childhood. The manual of the program is not specific to daycare teachers it can be used by other professionals working with parents and young children such as childminders, midwifes or pediatric nurses. In the context of the current refugee crisis more children from
refugee families will make up the group of high-risk families in Germany. Integration starts already when these children step into the door of daycares. An early integration has a great chance to be successful. The acclimatization of these children requires concepts and methods which do not depend on a high knowledge of language. The mentalization-based prevention program provides the opportunity to conduct interventions non-verbally through imitation. Hence, the program is particularly suitable for refugee families and can be adapted to them.
5. Outlook In the context of early intervention, a term used in Germany that refers to coordinated local support systems for families with children from pregnancy until the age of three, a well-established network and cooperation between the institutions and programs offered in this field is inevitable to guarantee for a good quality of the support system. Especially for children at risk it is essential that the programs and institutions in the field of early intervention are linked together to create so-called “chains of prevention and support”. Concerning the mentalization-based prevention program, our plan is to establish a network between daycares and special trained family midwifes and family nurses who support psychosocial burdened families and their newborn child during the first year of age. For all those children at risk for whom early daycare is thought to be appropriate or inevitable because of occupational necessity of the parents, it is important that the way to daycare is going to be paved for them and that the transition is well prepared. Therefore, trainings for family midwifes and family nurses in the mentalization-based program will be provided. With the family midwifes being involved in the transition process and with the consent of the parent they can not only pass useful information about the child to the daycare, but also prepare the transition to daycare together with the parents already from at home. With a mentalization-based attitude they can support the parents at home in taking the necessary steps in regard to the needs of each family in their transition process. For example introducing a transitional object (e.g. blanket or stuffed animal) will help the child in his or her emotional regulation during the separation from the parents. As a part of the on-going project “Frühe Hilfen Plus” (“Early intervention Plus”) funded by the Ministry of Social Affairs, Health, Women and Family of Saarland the mentalization-based prevention program is currently being executed and process evaluated in six pilot daycares in the federal state of Saarland. Perspectively, our goal is to expand the implementation of the program and to conduct an efficacy study.
Acknowledgment The project has been friendly supported and is founded by the Helmut Mader Stiftung, Frankfurt, the Heidehof Stiftung GmbH, Stuttgart and the Ministry of Science, Research and the Arts of the State of Baden Württemberg.
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