Infant/Child Mental Health, Early Intervention
and Relationship-Based Therapies

A NEURORELATIONAL FRAMEWORK FOR INTERDISCIPLINARY PRACTICE

CONNIE LILLAS 626 577 9332
infantmentalhealth@earthlink.net

JANIECE TURNBULL 626 577 7744
NeurobehaviorSvs@aol.com

 
 

Professional Reviews

“The framework presented about neurorelationships is highly relevant to all disciplines focused on early development. This integration of theories about brain function within context and particularly within relationships is vitally important for understanding development, behavior, assessment and intervention for all professionals in early learning, early intervention, parenting and mental health. The knowledge about sensory processing is the key to knowing how to observe and make meaning about behavior. Numerous tables and guidelines summarize clinical application. No one reading this will ever think or act without the perspective of brain, behavior, context and relationships as the integrating framework for assessment and treatment of developmental concerns.”

—Kathryn E. Barnard RN, Ph.D.
Professor Emeritus, University of Washington

“This book is beautifully written and applies a non-linear dynamic systems approach to neurobiology, weaving together neurobiological concepts and contextual development into a coherent and integrated framework. It provides the theoretical foundation for professionals to shift from singular diagnostic categorizations in infant-parent work into a dimensional approach, where multiple dynamics that underlie all diagnostic categories can be considered simultaneously by professionals working with a family. Toward this purpose, material is presented in an approachable and organized format, simplifying learning and facilitating use of the volume for reference. The most significant contribution of this truly stunning book is the interdisciplinary nature of the tone, discussion, and clinical applications, paired with a fresh perspective, new language, and clinical pearls. As the director of an interdisciplinary infant mental health training program, I believe this book provides the complexity and cohesiveness that can advance all professionals endeavoring to shift from multidisciplinary to interdisciplinary theory and practice within an academic or clinical setting. To the final page, the authors make the case for an emerging transdisciplinary field of NeuroRelational Health, a fusion of infant mental health and early intervention that is constructed on shared science and the "value and relevance [that] can be found in all our clinical approaches." Thank you for this volume that will advance the field!”

—Kristie Brandt, RN, CNM, MSN, DNP
Parent-Infant & Child Institute, Napa, CA
Director of the Infant-Parent Mental Health Post-Graduate Certificate Program
in collaboration with Dr. Ed Tronick at the University of Massachusetts Boston

“This is a timely book and offers us all a chance to do better work for children and families.”

—T. Berry Brazelton, M. D.
Professor of Pediatrics, Emeritus Harvard Medical School
Founder, Brazelton Touchpoints Center

“We are just beginning to understand the brain perspective on child development problems, physical as well as psychological. This clearly written and well organized book provides a road map for the field which will be indispensable reading for the varied professionals who work with these children: psychologists, child neurologists and psychiatrists, and education experts dealing with special learning needs. The book will also help parents who wish to learn more about the situation of their children. Highly recommended.”

—Antonio Damasio, Dornsife Professor of Neuroscience and Director, Brain and Creativity Institute, University of Southern California, Author of Descartes’ Error and Looking for Spinoza

“This book is visionary! The authors have brought a depth of understanding to child mental health that is informed by their creativity, brilliance, and unwillingness to be confined to the views of any one discipline. Their work elaborates a new analytic model capable of integrating data critical to diagnosis and treatment as never before. The book offers exciting opportunities for meaningful collaboration in this complex field.”

—Sara Latz, JD, M.D., Child and Adolescent Psychiatrist, Clinical Faculty, David Geffen School of Medicine , Psychiatry and Biobehavioral Sciences, Child/Adolescent Division, The Semel Institute of Neuroscience and Human Behavior, UCLA

“The authors of this important book have taken on a project of great size and scope in attempting to forge a neurorelational framework for infant/child mental health, early intervention, and relationship-based therapies. The neuroscience underpinnings, which provide the conceptual framework, explain how different brain systems (regulation, sensory, relevance, and executive) impact early infant behavior as well as undergo reorganization as a result of these modified behaviors. This book should be of special interest to educators, therapists, psychologists, and physicians. I applaud the teamwork and sweat that these two authors, from quite different disciplinary backgrounds, must have experienced to provide us with this very readable and informative book. I state with pride and enthusiasm that Dr. Janiece Turnbull, a former neuropsychology resident of mine at UCLA, together with Dr. Connie Lillas, have met the challenge of scientist-practitioner with distinction. I commend WW Norton for their vision in putting this timely and much-needed work to print.”

—Paul Satz, Ph.D., ABPP/CN, Professor Emeritus,
UCLA-Semel Institute and Resnick Neuropsychiatric Hospital

“Given the increasing interest in accountability in health care, one often hears of the need for ‘evidence-based practice.’ This is certainly a message imparted by the authors in their excellent review of the literature supporting their framework. However, what is truly impressive is their ‘practice-based evidence,’ with which they convincingly demonstrate the value of the clinical process in driving scientists' search for new knowledge. This is clearly a win-win situation for clinical practice and basic research. The authors are highly articulate in melding the clinician’s ‘art’ with neuro ‘science’ in a way that will help to more clearly understand early developmental processes.”

—Professor Patrice L. (Tamar) Weiss,
Dept. of Occupational Therapy,
Faculty of Social Welfare & Health Sciences,
University of Haifa, Israel

“This book is an amazing synthesis, where development, clinical experience, and neuroscience inform each other in a clear and applied way. As anyone who has worked with challenged infants, young children, and their families knows, understanding the complexity and interaction of all the components involved is a daunting responsibility. Connie Lillas and Janeice Turnbull’s neurorelational framework makes theory, clinical observation, and research reconcile in a manner which inspires the reader’s thought and insight. It is a guide to academic and clinical interdisciplinary practice which should become the standard for all!”

—Serena Wieder, Ph.D., Interdisciplinary Council for Development and Learning Disorders (ICDL), Co-Author of The Child with Special Needs and Engaging Autism and the DIR® Model

“What a delight! Drs. Connie Lillas and Janiece Turnbull have spanned the chasms in early childhood professional activities between neurodevelopment, relational contexts and clinical practice to describe a new and visionary model of comprehensive interventions for challenged infants, young children and their parents. This unique and brilliantly conceived book, “Infant/Child Mental Health, Early Intervention, and Relationship-Based Therapies: A Neurorelational Framework for Interdisciplinary Practice,” provides a ground breaking and in-depth framework for the integration of neuroscience research, early childhood mental health and early intervention services. The clarity, yet complexity, of this described model along with its clinical application combine to make this work revolutionary for the study of interdisciplinary, team-based care. This book will inspire all to adopt their neurorelational framework as guide for individualized and comprehensive brain and relationally-based interventions to build the sturdiness, resiliency and competency achievable with state-of-the-art precision! Congratulations to the authors and to Norton for such vision!”

—David W. Willis, M.D., FAAP, Behavioral-Developmental Pediatrics, Medical Director Northwest Early Childhood Institute, Portland, Oregon

“The title of any book should reflect the content and goals of the book. This book’s appellation, Infant/Child Mental Health, Early Intervention, and Relationship-Based Therapies: A Neurorelational Framework for Interdisciplinary Practice, is an accurate reflection of the content of the book; at the same time, it does not begin to convey the gold mine of information that this book contains. The importance of early intervention for at-risk and atypically developing children has long been recognized and is legislatively supported by federal mandates in 1986 and 1997. Connie Lillas and Janiece Turnbull’s primary goal for this book is to convey the conceptual model they have developed for assessing and intervening with this population and their families.

The book meets that goal and more. In presenting their model, the authors nicely summarize two-plus decades of research regarding the developmental neurobiology of the brain/mind. They also summarize concurrent developments in the area of early, and accurate, identification of children with complex developmental disorders, particularly autistic spectrum disorders. Finally, the authors illuminate the multiple complexities inherent in assessing, intervening, and integrating service planning for these children and their families.

Using the early intervention service system as a jumping-off point, the authors assert that current multidiscipline-based approaches, rather than providing coordinated comprehensive care, instead often yield services that are fragmented and incomplete. They further assert that the service net often fails to comprehend and address the “big-picture” needs, thereby too frequently resulting in suboptimal outcomes.

To address these issues, the authors present a conceptual framework wherein brain development, as reflected in external behavior, serves as the unifying concept. They detail a neurologically based, multilevel, cross-disciplinary, functional approach to diagnosis and intervention. Within this neurorelational framework, the authors define four behaviorally indexed global brain systems, each representing a distributed brain system and a collection of brain functions: regulation (arousal, stress responses, and adaptive energy regulation), sensory (sensory registration, processing and modulation, vision, language), relevance (emotion, learning, memory, private and shared meanings), and executive (behavior activation and inhibition, thoughts, and the balance of thoughts and emotions). For each proposed system, they devote chapters to describing the brain components of the system, the functions and behaviors of the system, how to assess the functional level of the system, and a system-specific intervention strategy.

To illustrate, the authors define the regulation system as the foundation system influencing all other developmental systems and domains. Arousal processes emanating from the hypothalamus, autonomic substrates, and the neuron–chemical pathways originating in the brain stem and basal forebrain (p. 49) are defined as the cardinal feature of the regulation system. Arousal is defined along a continuum from sleep to a flooded, overaroused state such as that seen in many young children with atypical development. Behavioral indices of arousal are defined as cycling and frequency patterns, gradual state changes, sudden state changes, and modulation.

Case examples of altered learning and development based on arousal dysregulation are presented, and the approach to interventions based on the type and severity of dysregulation are described. There are parallel chapters and presentations for the sensory, relevance, and executive systems. The authors indicate that each system is in a dynamic, interdependent, and reciprocal relationship with every other brain system, the body, and the world (p. 32).

It is this reciprocal relationship with the world that contextualizes the relational aspect of the neurorelational framework. Recognizing that the developing brain/mind is more than, yet constrained by, the functioning of the central nervous system, the model also recognizes that the child’s developing nervous system/brain is both embedded in and modified by interpersonal relational experiences, particularly those found in the family or primary caregiving unit. In so doing, the authors go beyond the universally accepted ubiquitous need for family support, extending that support to the recognition that diagnosis and intervention must address the dynamics of the relational unit as these dynamics affect the fit between the child’s multilevel neurodevelopmental needs and the parent’s understanding and ability to provide developmentally appropriate, supportive, and consistent parenting.

In addition to supporting the elements of the model with extensive background research and theory and with clinical examples of the application of the model, the authors go the next step in providing clinical worksheets as examples for aiding the practitioner wishing to apply the model. The worksheets are well organized and structured to provide both behavioral and procedural hinges so that the practitioner can comfortably approach the dual tasks of assessment and intervention within each system.

A real gift contained in this book is the supplementary CD that provides further background information, concise summaries of the concepts under consideration, and blank, ready-to-print worksheets for immediate use. At a minimum, the worksheets can provide often-needed memory prompts for the most seasoned practitioner; at the same time, the worksheets can serve to focus and support the efforts of those new in the field. If used as the authors intend, the model as enacted through the use of the worksheets can help support a more comprehensive and coordinated approach to early intervention.

Whether one agrees or disagrees with the conceptual framework, the information provided in this book is vital background knowledge for anyone working with at-risk or atypically developing young children and their families. Further, the framework serves as a reminder that these children cannot be summarized by a single “diagnosis” and that effective service provision is far more than having biweekly visits from a speech therapist, an occupational therapist, a physical therapist, and a developmental therapist. In retrospect, it seems that the federal mandates of 1986 and 1997 for multidisciplinary, family-centered, early intervention services were prescient, sagacious, and exceedingly naïve.”

Barbara Y. Whitman
PsycCRITIQUES, American Psychological Association
October 28, 2009, Vol. 54, Release 43, Article 5

Professional Commentaries

“I found the Lillas and Turnbull chapters to be a refreshing new approach to collaborative service delivery. The concept of a Neurorelational Framework with different brain systems makes sense, I believe, to all practitioners…The explanation of the four brain systems was very relevant to my current practice as a school psychologist, LEP, and educational therapist and it puts a whole new light on understanding and putting together other specialist’s roles in assessment and intervention for the child. It brings the part-to-whole model into perspective.”

—Sharri Hogan, MA, LEP
Licensed Educational Psychologist & Educational Therapist

“This framework connects relationships and the brain as an integrated whole. It develops a common language across disciplines and allows team collaboration.”

—Rosa Hernandez, 5th Grade Teacher

“This book is well written, concise and uses helpful examples. The work they have done is thorough and appears to be very useful in understanding symptoms as well as treatment planning. There is good potential for this book to be used to coordinate work across many different disciplines and reduce confusion for professionals and families alike. I found reading this in a group highly rewarding and in immediately beneficial for my practice with both children and adults. Although this framework is targeted for children its focus on development is useful in understanding the issues adults are facing as well. The authors have also been generous in sharing a CD at the end with many assessment forms they use in their work!”

—S. Phillip, MFT

Infant/Child Mental Health, Early Intervention, and Relationship-Based Therapies: A Neurorelational Framework for Interdisciplinary Practice was designed to be used by a wide range of mental health and educational professionals. Using this overall framework it is possible to view a child’s maturation (or lack of such) from a number of different perspectives and can be used by all the concerned disciplines thereby avoiding the current problems of them not being able to view the child as a ‘whole being.’ My feeling is that this approach would revolutionize the way we deal with children who struggle in school. The framework would also be useful when working with adults, since the same work of seeing the ‘whole person’ exists for them as well.”

—Pam Fleissig, Teacher, Educational Therapist

“In reading Lillas and Turnbull, I was happy to find research-based justification and advocacy for interdisciplinary effort based on how the brain functions. It is clear to me that no one professional can address the needs of the whole child; a child is too complex. As Lillas and Turnbull explain, this complexity stems from the very nature of our brain and its evolutionary responses to the external world. Understanding the brain as a set of internal systems with internal and external functions clarifies how we can better understand and prescribe interventions for students experiencing social, emotional, and/or learning difficulties…The dissemination of the neurorelational framework holds a tremendous capacity to create supportive communities, working together to effectively expand the opportunities for children born with disabilities who would have been classified as ‘hopeless’ just a generation ago. It’s wonderful to see scientific progress in application!”

—Megan Cohen, Educational Therapist, Founder & Director of La Jolla LearningWorks