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P R E S I D E N T I A L A D D R E S S

ON THE OUTSIDE: INTERVENTIONS WITH

INFANTS AND FAMILIES AT RISK

JOY D. OSOFSKY
Louisiana State University Medical Center, New Orleans

ABSTRACT: Infants and families at high psychosocial risk may be considered on the outside, that is,
outside of the mainstream for healthy development and for well-being because of many different factors.
They may be lacking the crucial ingredients that are necessary for healthy physical and emotional de-
velopment that include good nutrition and health care, predictable caregiving, and guidance to develop
the intellectual and emotional skills to succeed in school and in life. Some of the risk factors that may
keep infants and families on the outside include poverty, teenage pregnancy, and violence exposure.
In this paper, I will discuss different types and levels of intervention for infants at risk taking place in
different settings around the world carried out by WAIMH members including a naturalistic intervention
an orphanage in St. Petersburg, Russia, a community-based intervention program in Puerto Allegre,
Brazil, and a community-based violence prevention and intervention program in New Orleans, Louisiana.
Variety and levels of evaluation and assessment are also discussed. Finally, as President of WAIMH, I
consider different perspectives on the future for WAIMH.

RESUMEN: Los infantes y las familias que se encuentran en un alto riesgo sicosocial pueden ser consi-
derados al margen, es decir, fuera de la corriente principal, en cuanto a un desarrollo saludable y al
bienestar, a causa de muchos factores diferentes. A ellos les pudieran faltar los ingredientes importantes
que son necesarios para un desarrollo fisico y emocional saludable, lo cual incluye una buena nutricion
y cuidado de la salud, una predecible forma de ofrecer el cuidado, y gua para desarrollar las habilidades
intelectuales y emocionales para tener exito en la escuela y en la vida. Entre algunos de las factores de
riesgo que pueden mantener a los infantes y a sus familias al margen se incluyen la pobreza, el embarazo
juvenil, y el estar expuesto a la violencia. En este ensayo, discuto los diferentes tipos y niveles de
intervencion para los infantes y el riesgo que ocurre bajo diferentes circunstancias alrededor del mundo,
puestos en practica por los miembros de WAIMH, incluyendo una intervencion naturalista, un orfanato
en St. Petersburg, Rusia, un programa de intervencion basado en la comunidad en Puerto Allegre, Brasil,
y un programa comunitariode intervencion y prevencion de la violencia en Nueva Orleans, Louisiana.
Tambien se discuten la variedad y los niveles de evaluacion y valoracion. Finalmente, como presidente
de WAIMH, considero diferentes perspectivas para el futuro de la organizacion.

Direct correspondence to: Joy D. Osofsky, LSU Medical Center, Departments of Pediatrics and Psychiatry, 1542
Tulane Avenue, New Orleans, LA 70112.

INFANT MENTAL HEALTH JOURNAL, Vol. 19(2), 101 110 (1998) short
1998 Michigan Association for Infant Mental Health CCC 0163-9641/98/020101-10 standard

101 base of drop

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RESUME: Les bebes et les familles a haut risque psychosocial peuvent etre percus comme en dehors, base of text
cest-a-dire en dehors du courant principal pour le developpement sain et le bien-etre, et cela de par bien
des facteurs differents. Ces bebes et familles peuvent manquer des ingredients cruciaux necessaires a un
developpement physique et emotionnel sain qui inclut une bonne nutrition, un bon suivi medical, des
modes de soin sur lesquels on peut compter, et un encadrement aidant a developper les competences
intellectuelles et emotionnelles necessaires pour reussir a lecole et dans la vie. Certains des facteurs de
risque qui peuvent releguer les bebes et les familles en dehors incluent la pauvrete, les grossesses
adolescentes et le contact avec la violence. Dans cet article, jexamine differents types et niveaux
dintervention pour des bebes et les risques, prenant place dans differents endroits autour de la planete,
et effectues par des membres de la WAIMH, comme par exemple lintervention naturaliste dans un
orphelinat de Saint Petersbourg en Russie, le programme dintervention communautaire a Puerto Allegre
au Bresil, ou bien encore le programme communautaire dintervention et de prevention de la violence de
la Nouvelle Orleans en Louisiane aux Etats-Unis. La variete et les niveaux devaluation sont aussi dis-
cutes. Enfin, en tant que Presidente de la WAIMH, jexamine differentes perspectives pour le futur de
notre organisation.

ZUSAMMENFASSUNG: Kleinkinder und ihre Familien mit hohen psychosozialen Belastungsfaktoren konnten
als am Rande stehend gesehen werden, was meint, da man sie als auerhalb des ublichen bezuglich
einer gesunden Entwicklung und eines Wohlgefuhls wegen vielfacher Faktoren sehen konnte. Es konnten
unverzichtbare Zutaten zur gesunden physischen und psychischen Entwicklung fehlen, wie etwa gute
Ernahrung und medizinische Betreuung, voraussagbare Erziehungssituationen und eine Anleitung, um
die intellektuellen und emotionalen Fahigkeiten zu erlernen, die den Erfolg in Schule und im Leben
herbeifuhren konnen. Einige der Risikofaktoren, die Familien am Rande stehen lassen sind Armut,
Jugendlichenschwangerschaft und Gewalterfahrungen. In diesem Artikel werde ich verschiedene Arten
und Niveaus der Intervention fur Kleinkinder und gegen Risikofaktoren in verschiedenen Situation rund
um die Welt beschreiben, die von Mitgliedern der WAIMH gemacht werden: ich berichte von einem
Naturversuch in einem Waisenhaus in St. Petersburg in Ruland, einem Sozialprojekt in Puerto Allegre,
Brasilien, und einem Sozialprojekt zur Vorbeugung und Intervention bei Gewalt in New Orleans, Loui-
siana. Die Verschiedenheit und das Niveau der Uberprufung und der Diagnosestellung werden auch
besprochen. Zuletzt, als Prasidentin der WAIMH bespreche ich verschiedene Aussichten, die die WAIMH
in Zukunft hat.

* * *
The theme of the 6th World Congress is Early Intervention and Infant Research: Evalu-
ating Outcomes and, therefore, I decided to focus my Presidential Address on an area of
intervention in which I have worked for much of my professional career infants and families
at risk. Why I chose the title on the outside will become clearer as I elaborate on the theme.
To understand the topic of interventions with infants and families at risk, some definitions are
needed. For infants, early intervention means intervention as soon after birth as possible, if not
during the prenatal period. Intervention itself encompasses a potentially wide variety of service
approaches designed to promote child competence by strengthening the growth-promoting short
characteristics of primary caregivers, extended families, and community systems (Meisels & standard
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Shonkoff, 1990). Preventive interventions begun early in life are the most effective means of base of text
ensuring that a child has a chance for a normal course of development.
What do infants and young children need to grow up to be healthy physically and emo-
tionally? The components that seem to be most important are: (1) good nutrition and health
care from the moment of conception; (2) predictable caregiving, including ample stimulation
and love; and (3) guidance to develop the intellectual and emotional tools to succeed in school
and life. When one or more of these environmental nutrients is absent, a situation that occurs
commonly when infants and families are at high psychosocial risk, then they may be on the
outside, that is, outside of the mainstream for healthy development and for well-being. Thus,
such infants and families may be at high risk for developmental delay or damage, which can
bring lifelong consequences.
What are some of the risk factors that occur in different settings around the world that
may keep infants on the outside and make them at high risk for problems in development?
First, and often most pernicious is the effects of poverty on development. When infants, and
young children are on the outside due to poverty, they are more likely to be homeless,
experience community and/or domestic violence, be exposed to drugs, come from single-parent
families, and be at greater medical risk. Affordable health-care and child-care services are less
available and accessible. While these factors may affect infants and young children in different
ways around the world, some effects, as will be illustrated later in this paper, may be universal.
In the United States, many schools in large urban areas have become like urban war zones
rather than centers of learning. Prenatal drug exposure jeopardizes the future of poor children
even before their births. In addition to worrying about providing for their childrens needs,
such as food and housing, parents often have to deal with racial discrimination, dangerous
neighborhoods, unemployment, lack of social supports, and lack of status in society. In many
parts of the world, psychological stresses and difficulties generated by poverty can affect par-
ents interactions and relationships with their children.
Recent evidence coming from research being done in the United States has shown that
with poverty comes the subsequent problems of lack of quality of stimulation in the first few
years of life, which may even impact on brain development. Further, scientists have discovered
recently that chaotic or overwhelming experiences can be as damaging to the developing brain
as a lack of stimulation. Exposure to trauma or chronically stressful environments can dra-
matically change the way an infant or young childs brain develops, making the child more
prone to emotional disturbances and less able to learn (Perry, 1997; Perry, Pollard, Blakley,
Baker, & Vigilante, 1995). The costs in human suffering, loss of potential, and in real money
of trying to repair, remediate, or heal these children is far greater than the costs of preventing
these problems by promoting healthy development of the brain during the first years of life
with appropriate and adequate stimulation and protection from trauma.
A second risk factor is teenage pregnancy that is often accompanied by poverty and can
impact very negatively on infants and young children. The work of Salvador Celia in Brazil
(Celia, Alves, Behs, Nudelmann, & Saraiva, 1993) and Miguel Cherro Aguerre in Uruguay
(Bernardi et al., 1992; Cherro, 1992) is noteworthy in addition to the many investigators and
interventionists in the United States including Brooks-Gunn and Chase-Landsdale (1995), as
well as our own work in this area (Osofsky, Hann, & Peebles, 1993). Teenage pregnancy too
often is associated with immaturity, the loneliness and isolation of single parenthood, depres-
sion, low self-esteem, lack of parenting skills, lack of social support, more behavior problems
in the children, lack of education, lack of job skills, and socioeconomic disadvantage. Teenage
mothers and their infants and young children suffer both short-term and longer term psycho-
logical, social, and economic difficulties. short
Poverty contributes enormously to the problems faced by teenage mothers. It also increases standard
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their risk for a number of environmental difficulties including living in high-crime areas, mov- base of text
ing frequently (some have considered teenage mothers the hidden homeless), having difficulty
coping with the day-to-day responsibilities and demands of raising a child; and having less
social and emotional support than is usually available to older mothers. Living in a single-
parent, impoverished environment alone can lead to higher rates of behavior problems for
children, other problems in school, as well as mental health risks (Halpern, 1993, Turner,
Grindstaff, & Phillips, 1990). Many adolescent mothers are less well equipped and less able
than older mothers to provide a positive socioemotional environment for their infants and
children due to developmental conflicts specific to adolescence that interfere with their par-
enting ability. Often, it seems as if there is a mismatch between adolescent developmental and
infant developmental needs that interfere with teenagers parenting abilities (Osofsky & Eber-
hart-Wright, 1992). For example, in our work, we have frequently observed competition be-
tween the young mothers and their infants or toddlers as well as a young mothers inability to
adjust flexibly to the normal developmental changes that come from infancy to toddlerhood.
They often seem comfortable with the dependency that is characteristic of infancy, but have
more difficulty adjusting to the emerging autonomy and testing that comes as the young child
becomes 2 or 3 years old. Interventions with adolescent mothers and their infants need to be
comprehensive, taking into account the developmental needs of both individuals who are chil-
dren, that is, the adolescent mother and her child. Interventions should also be directed at the
dyad and the broader family context of the adolescent mother. Issues to be addressed in inter-
vention programs for adolescent mothers and their infants include self-esteem, depression,
support, education, personality issues, match between infant and mother, and the invulnerability
of the individual under stress (Osofsky et al., 1993). As with many developmental interventions,
the most effective strategy may be to focus on what may go right rather than wrong with
adolescent mothers and their infants to focus on positive changes and develop more effective
preventive intervention strategies and programs.
Third, infants and young children may be on the outside due to violence exposure.
Witnessing violence may impact on infants and young children in a number of ways. They
may be affected: (1) Emotionally children may worry about being safe, feel jumpy and
scared, have nightmares, feel unprotected, and may worry about the safety and availability of
their parent or caretaker; (2) Cognitively children may worry about being killed or having
someone close to them be killed. They may be grieving, worry that there is no one to trust or
rely on, have difficulty concentrating, have problems remembering, or be easily distracted; (3)
Behaviorally they may show delays in development, speech problems, bed wetting or similar
problems, inability to talk about fears, increased fighting or violent behavior, and regression
in language and other areas. In extreme cases, infants and young children may show symptoms
of post-traumatic stress disorder including re-experiencing, avoidance/numbing, and/or hyper-
arousal with increased excitement and hyperreactivity.

VARIETY AND LEVELS OF INTERVENTION

FOR INFANTS AT RISK
Interventions for infants and families who may be at high risk occur at a variety of levels and
in many different settings. In this paper, I will provide a few examples of interventions that
occur in different settings around the world: a naturalistic intervention in a Russian orphanage
in St. Petersburg; community-based interventions in South America; and a community-based
systems intervention in New Orleans, Louisiana.
In St. Petersburg Russia, our World Association of Infant Mental Health (WAIMH) col- short
leagues, Rifkat Muhamedrahimov and Elena Kozenikova are involved in infant intervention standard
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work. Dr. Kozenikova directs the Infant-Toddler Habilitation, a social and research program base of text
for disabled infants and toddlers, and Dr. Muhamedrahimov directs a Russian-Swedish Leko-
tek, which provides family centered early intervention for 0 to 3-year-old children with special
needs. In St. Petersburg, through these two programs, new efforts are being made to address
infants and toddlers needs in the area of infant mental health. This group gave two very
inspiring presentations during the WAIMH 6th World Congress, Early Intervention in the
New Independent State (NIS) of the ex-Soviet Union, and a video presentation for which I
joined them on Infant Interactions in a Russian Orphanage. During a consultation in St.
Petersburg, Dr. Muhamedrahimov and his colleagues presented to me a naturalistic inter-
vention that they had initiated in a Russian orphanage in an effort to provide more stimulation
to the babies. The babies were placed for a certain period of time each day in a crib with two
other infants. They had toys in the crib and mirrors on the sides of the crib. Over a 9-month-
period during the first year of life, Dr. Muhamedrahimov and his colleagues observed changes
in the babies in verbal, visual, and physical domains, as well as changes in their level of affect
expression. They found that, in general, the babies, when compared with those who were alone
in their cribs, initiated more interactions by either reaching out to the other babies, looking at
them and smiling at them, playing with them, or vocalizing to them. Over time, the possibilities
for stimulation and relationship building seemed to be much greater for the babies who shared
a crib with two other babies than for those who were alone. The individual differences between
the babies played a role in how much they responded; however, all seemed to respond more
than the babies who were left alone. This intervention was truly a naturalistic one as it consists
of manipulating the usual treatment of babies in the orphanage. The potential for impacting
positively on the early life of infants who are in a generally unstimulating environment seemed
great.
In South America, among our WAIMH colleagues, there are many community-based ef-
forts going on in Brazil, Uruguay, and Argentina. In this paper, I will describe one unique
program in Brazil directed by Salvador Celia, which presents an important community-based
intervention effort. In Brazil, there are many street children who are killed every day. In Brazil,
the environment is full of biopsychosocial risk factors for babies, including much poverty and
violence. Some of the factors that have contributed to the situation in Brazil are excessive
population growth and a rural exodus contributing to an increase of 30 million people in 20
years in the large cities. The nonabsorption of these people and an unbalanced income distri-
bution led to huge numbers of poverty belts in the large cities, forming favelas (slums) (Celia
et al., 1993). For individuals living in poverty, the impact of risk factors increases, creating a
chronic, pervasive situation that may perpetuate itself, affecting the future of the babies and
their families. Other factors may be present that potentiate the effects, such as low birth weight,
poor physical health, lack of services, and lack of basic health and education requirements. For
people living in situations where no ties exist, or in which the ties are fragile, frustrations and
hopelessness increase (Celia et al., 1993). A program was instituted for the poorer population
in the Northern part of the city of Porto Alegre, capital of the Rio Grande do Sul, Brazil, that
integrated health, education, culture, leisure, citizenship, science, technology, and professional
training. The program, the Vida Centro Humanistico (Life-humanistic Center), is an official
social welfare program in the state of Rio Grande do Sul that promotes the construction of and
reinforcement of ties and intergenerational togetherness (infants, children, teenagers, adults,
and senior citizens). It is designed to improve the conditions of the citizens, to help with the
recovery and reinforcement of self-esteem of the deprived population, including impoverished
pregnant women, undernourished infants, street children, handicapped, and women subjected
to violence. The program emphasizes existing psychosocial factors, demonstrating that under- short
nourishment is also related to potential bonding. The mothers of undernourished infants also standard
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showed loss of cultural and family roots, lack of consistent support by the husband or com- base of text
panion, difficulties in accepting the pregnancy, wishes for and attempts at abortion, postpartum
depression, short periods of breast-feeding, and abuse, abandonment, or neglect in their own
childhood. The intervention included complete health care in addition to psychosocial inter-
vention. Vida, through medical, social and psychological interventions, is an intervention pro-
gram and a place that favors the creation of ties, the development of creativity, and the discovery
of skills and potential so that the individual can gain greater solidarity and resistance to the
challenges of life and become more competent and less vulnerable. It is a community-based
intervention effort with a broad ranging scope to address the serious environmental and psy-
chosocial problems in some areas of Brazil. This program illustrates that risk conditions cer-
tainly occur around the world that lead to adverse consequences for infants and families and
require early prevention and intervention efforts.
An exemplar of a community-based prevention and intervention program for children and
families exposed to violence in the United States is one that I have developed in New Orleans,
the Violence Intervention Program for Children and Families (VIP). For descriptions of addi-
tional violence prevention programs, see Osofsky (1997). VIP was developed in 1993 as a
direct response to the crisis of rising violence in New Orleans (paralleling that in the United
States as a whole) and the fact that ever increasing numbers of children were being exposed
to violence as victims or witnesses. It is startling that homicide has become the third leading
cause of death in the United States for children between the ages of 5 and 14 and that risks for
even younger children have been increasing.
The philosophy guiding the VIP program is a systems approach designed to work with
the whole community to solve the problem of violence among our youth. The project aims to
decrease violence through a combination of early intervention, counseling, and services to
victims as well as education and prevention forums directed at police, parents, and children.
A key component of the program is education of police officers about the effects of violence
on children and families to increase their knowledge and sensitivity when dealing with violent
incidents. In 1995, 350 police officers received education with continued follow-up during roll
call, and in 1997, another massive educational effort is planned for the entire police force. An
evaluation of the effectiveness of the education for police officers using attitude surveys in-
dicated that they reported increased sensitivity to the needs of the traumatized children as well
as increased knowledge about resources for referral. For example, in the attitude surveys done
in 1997, the majority of the officers reported they would show sympathy to the children, talk
to them counsel the family, or refer them to agencies. In the 1994 survey, only 18 to 40% of
the officers reported that they would take such actions.
In an effort to reach traumatized children and families as quickly as possible, a 24-hr
Hotline was established to provide the needed communication through which children and
families touched by violence could seek immediate referral, counseling, and guidance. It is
available to police officers and families to obtain advice or information at the scene of com-
munity or domestic violence. The police distribute VIP cards with the hotline number to fam-
ilies so that they can seek help if needed. Over the course of 2 years, we have noted that
approximately 25% of the calls on the hotline come from the police and 75% come from
families to whom they have given the number. About 60% of the calls are for referrals of
children 12 years old or younger (with some children as young as 1 to 2 years of age) and
approximately 50% of the calls become referrals for mental health services. The funds that are
raised to support the program allow us to provide mental health services to many children and
families who could not otherwise afford such services.
The VIP program expanded in 1996 to develop intensive intervention efforts in two ele- short
mentary schools, in addition to in-service education and consultation already being provided standard
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in many other schools. In these two schools, immediate interventions, treatment, guidance, and base of text
counseling are available when a child is identified. Parent support groups are carried out weekly
and education for teachers and counselors is done as needed. Ongoing consultations are held
with the principals of these schools. Approximately 60 children are seen each week in these
schools for intervention or therapeutic work.
In 1995, approximately 100 children and families who had been exposed to violence were
referred to our clinic by other mental health workers, police, families, schools, and community
agencies for consultation, therapy, or parental guidance. In 1996, as our program expanded,
that number more than doubled with referrals of at least 250 children and in 1997, over 400
children have been seen. Children and families receive services in the child clinic in addition
to ongoing consultations and services provided in the schools and in the community.
In developing our program as a multidisciplinary effort, we worked to find ways to build
relationships among community, police, mental health professionals, and schools to address
issues of prevention and services for referred children who witness violence and suffer from
symptoms related to their exposure such as nightmares, disruptive behavior in school, and, in
the most extreme cases, post-traumatic stress disorder. We continue to problem-solve with
police to develop strategies that might work better for the child witnesses when they investigate
violent incidents, such as homicides. We work with parents to find ways that they can protect
their children, keep them safe, and away from violent scenes because of the potentially trau-
matizing impact on them and their children. Further, we work to build strengths in communities
to help parents and children.
Our project has continued to evolve and grow. Evaluation of the effectiveness of the
program has been built into our intervention program from its inception so that we will be able
to learn about what works and what does not and determine the changes that are needed to
make the program more effective. The evaluation includes qualitative measures such as focus
groups and interviews with staff, intervenors, and parents regarding their behaviors and atti-
tudes about violence exposure and quantitative measures that involve systematic evaluations
of all children and their parents who are referred to the child clinic and all children referred in
the schools.
In addition, we have developed materials to use for training and intervention, including a
Police Education Manual, a Childrens Safety Booklet, a Parent Safety Booklet, a quarterly
Newsletter, The Shield, about activities of the program, and a Community Resource Directory
to be helpful for emergency referrals. This program provides an example of a comprehensive
intervention program for children and families who live in violent environments in the United
States. It also provides a good example of how police can be brought into a prevention net,
rather than just the criminal justice net.

VARIETY AND LEVELS OF EVALUATIONS

AND INTERVENTIONS
Evaluations of early intervention programs have as much variety as the different programs.
However, systematic evaluations of intervention efforts occur relatively infrequently in relation
to the vast numbers of existing intervention programs. To gain a comprehensive understanding
of the effectiveness of intervention efforts, it is important to include quantitative and qualitative
evaluations using a variety of different strategies. The effectiveness of a particular program
may be shown much more clearly with one methodology than another, which will allow for a
broader understanding of what works and what does not in intervention programs.
The different types of measurements and assessment tools used to evaluate programs in- short
clude paper and pencil measures, parent reports (e.g., Child Behavior Checklist; Achenbach, standard
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1991), observations of infants and families, interviews, process and program evaluation, attitude base of text
change, information change, and behavior change. The problems with many existing evalua-
tions are that there are few studies that include: control or comparison groups (and even fewer
with randomized controls), random group assignments, statistical models or quasi-experimental
designs, and controls for extraneous or confounding variables. Further, there is little use of
valid and reliable standardized assessments. In addition, testing and statistical analyses are not
always done by workers blind to group status and there is little or no longitudinal data on
program effectiveness with respect to goals of the intervention project.
In an ideal intervention and evaluation program, there should be a link between research,
clinical work, and public policy, interventions designed from an ecological perspective, and
interventions that target not children in isolation but children within the context of the family
and children and families within communities.
Shonkoff (1993) elaborated on three core principles of early childhood intervention that
are extremely useful in thinking about the design and evaluation of such programs. First, the
developmental process is fundamentally transactional in nature. Individuals are influenced by
their life experiences and they, in turn, exert a reciprocal impact on shaping the environment
in which they live. Second, early caregiving relationships have a particularly important and
enduring impact on the foundations of cognitive, emotional, and social competence. Each
person is shaped to a significant degree by the important people in his or her life beginning in
the early years (Bowlby, 1969; Sameroff & Emde, 1989). Third, intrinsic developmental vul-
nerability can be moderated by the influences of extrinsic protective factors that increase the
probability of positive adaptation (Garmezy & Rutter, 1983; Werner & Smith, 1982).
There are many fundamental challenges in developing early intervention programs. Social
policies and individual service programs must be based on an appreciation of the complexity
of human development. The purpose of early intervention services must shift from the promise
of a panacea to the concept of investment in altered probabilities. Early childhood intervention
programs cannot eliminate the adverse developmental consequences of poverty, community
violence, or parental substance abuse. Effective services can moderate the negative impacts of
selected risk factors and strengthen the potency of selective protective factors, thereby shifting
the odds toward more favorable outcomes for children and families. Finally, the basis for equity
in the provision of early childhood services must be reconsidered. Resource allocation should
be according to the needs of the child and family and not just based on eligibility of the child
for services some need more and some need less to accomplish the same ends. There should
be a balanced investment in science and public policy. For policy, we advocate for the imper-
ative need for human services. For science, we deal with concerns about how limited resources
can be used in the best way to achieve the greatest good for the most people.
In concluding this paper, it seems important to consider carefully some of the changes that
have led to new visions of intervention and assessment that have been so eloquently articulated
by Meisels (1996). He has suggested that the emergence of a reciprocal, or bidirectional,
relationship between assessment and intervention is closely connected to six significant changes
in outlook on assessment:
1. The target or object of assessment now includes the infant or young child in relation-
ship to the family and caregivers. We no longer think of the child as existing by him
or herself, but rather as part of a family and/or community relationship system.
2. The infant or young child is evaluated in a context, preferably in a setting that is familiar
and nonthreatening. Previously, assessments occurred only in formal testing environ-
ments, whereas today they take place in naturalistic settings. short
3. The methods of assessment now often evaluate children using their everyday experi- standard
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ences to more adequately show their competencies and what they are experiencing in base of text
contrast to a prior emphasis on highly specialized procedures.
4. The personnel involved in assessment are now more likely to involve multidisciplinary
teams that more often assess the child with input from the parent rather than basing the
evaluation solely on the understanding of the assessor alone.
5. Assessment data is now used to form hypotheses and develop potential interventions
as compared with previous use of test information to label children. The potential
interventions may even alter both assessment strategies and conclusions.
6. A new definition of assessment now characterizes assessment more frequently in terms
of its relationship to intervention. Further, assessment is now understood as an ongoing
process rather than being static.

With this new understanding of evaluation and interventions, it must be understood that
methods of assessment cannot exist apart from intervention. Static portraits of children are to
be replaced by dynamic processes that reflect the plasticity of child growth and development
as well as the interdependence of family and child processes. Assessment and intervention are
conceived as two interconnected aspects of a complex phenomenon of acquiring information
about the childs potential within the family and community.

PERSPECTIVES ON THE FUTURE FOR WAIMH

I will take the prerogative as President of WAIMH to conclude my paper with my vision of
important directions that I see for the future of WAIMH. I believe that we will expand in at
least three areas to broaden the scope and perspective of our organization. First, we will see
an expansion in communication, taking advantage of the explosion in technology that will
allow us immediate and consistent communication via Internet and the World Wide Web. E-
mail is becoming a method of choice for many for daily communications and exchanges.
Communication will also continue to grow through our Journal, the Infant Mental Health
Journal, our Newsletter, The Signal, and our video library.
A second important area of growth for WAIMH will be in the continuation and expansion
of affiliate activities in many regions around the world. Affiliates form the life-blood of the
organization as they allow and encourage the important growth in our organization. In the past
6 years, we have added 11 affiliates to WAIMH around the world in the Nordic Countries,
France, Russia, United Kingdom, Netherlands, Germany-Austria-Switzerland, Greece, and in
four states in the United States. Currently, WAIMH has affiliate connections to 19 countries
and individual memberships in over 30 countries. I would hope that in the next 6 years, we
will add many affiliates as well as individual members, both of which will provide the oppor-
tunity to promote rich variation and balance among regional meetings and world congresses.
Finally, I hope for increased collaboration of WAIMH with organizations that share similar
interests to develop and carry out joint goals. Such collaborative activities can occur within
countries and internationally. There are many national and international groups that share our
concern and passion on behalf of infants and young children and their families. Let us join
together to accomplish our mutual goals.

REFERENCES
ACHENBACH, T. M. (1991). Manual for the child behavior checklist/418 and 1991 profile. Burlington, short
VT; University of Vermont Department of Psychiatry. standard
IMHJ (Wiley) LEFT INTERACTIVE

top of rh
110 J. D. Osofsky base of rh

cap height
BERNARDI, R., SCHWARTZMAN, L., CANETTI, A., CERUTTI, A., TRENCHI, N., ROSENBERG, S. (1992). base of text
Adolescent maternity: A risk factor in poverty situations? Infant Mental Health Journal, 13, 211
218.
BOWLBY, J. (1969). Attachment and loss (Vol. 1). New York: Basic Books.
BROOKS-GUNN, J., & CHASE-LANDSDALE, L. (1995). Adolescent parenting. In M. Bornstein (Ed.),
Handbook of parenting, Vol 3. (pp. 113150). Mahwah, NJ: Laurence Erlbaum Associates.
CELIA, S., ALVES, M., BEHS, B., NUDELMANN, C., SARAIVA, J. (1993). The effects of violence on
infants and young children: International perspectives on prevention. Infant Mental Health Journal,
14, 96 102.
CHERRO, M. (1992). Quality of bonding and behavioral differences in twins. Infant Mental Health Jour-
nal, 13, 206 210.
GARMEZY, N., & RUTTER, M. (Eds). (1983). Stress, coping, and development. New York: McGraw-
Hill.
HALPERN, R. (1993). Poverty and infant development. In C. H. Zeanah, Jr. (Ed.), Handbook of infant
mental health (pp. 73 86). New York: Guilford Publishers.
MEISELS, S. J. (1996). Charting the continuum of assessment and intervention. In S. J. Meisels & E.
Fenichel (Eds.), New visions for the developmental assessment of infants and young children (pp.
27 52). Washington, DC: Zero to Three: National Center for Infants, Toddlers, and Families.
MEISELS, S. J., & SHONKOFF, J. P. (1990). Handbook of early childhood intervention. New York:
Cambridge University Press.
OSOFSKY, J. D. (1997). Children in a violent society. New York: Guilford.
OSOFSKY, J. D., & EBERHART-WRIGHT, A. (1992). Risk and protective factors for parents and infants.
In G. Suci & S. Robertson (Eds.), Human development: Future directions in infant development
research (pp. 25 39). New York: Springer-Verlag.
OSOFSKY, J. D., HANN, D. M., & PEEBLES, C. (1993). Adolescent parenthood: Risks and opportunities
for mothers and infants. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp. 106
119). New York: Guilford.
PERRY, B. D. (1997). Maltreated children: Experience, brain development, and the next generation. New
York: Norton.
PERRY, B. D., POLLARD, R. A., BLAKLEY, T. L., BAKER, W. L., & VIGILANTE, D. (1995). Childhood
trauma, the neurobiology of adaptation, and use-dependent development of the brain: How states
become traits. Infant Mental Health Journal, 16, 271291.
SAMEROFF, A. J., & EMDE, R. N. (1989). Relationship disturbances in early childhood. New York:
Basic Books.
SHONKOFF, J. (1993). Blending science and advocacy: Foundation for a rational policy for early child-
hood intervention. The Child, Youth, and Family Services Quarterly, 16, 1113.
TURNER, R. J., GRINDSTAFF, C. F., PHILLIPS, N. (1990). Social support and outcome in teenage preg-
nancy. Journal of Health and Social Behavior, 31, 4357.
WERNER, E. E., & SMITH, R. S. (1982). Vulnerable but invincible: A longitudinal study of resilient
children and youth. New York: McGraw-Hill.

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