Early Childhood Mental Health in Clinical Practice
Mary Margaret Gleason MD, FAAP
Chia Granda MD
Introduction
The field of infant mental health (IMH) focuses on promoting mental health in infants, toddlers, preschoolers, and their families. This multidisciplinary field strives to support emotional and behavioral development and reduce current suffering through prevention for very young children at risk for developing mental health problems and early intervention for those with clinically significant mental health problems. This chapter will describe the principles of IMH practice, assessment strategies, diagnoses, and treatment.
History and Principles of Infant Mental Health
The field of IMH developed from collaboration among developmental psychologists, pediatricians, child psychiatrists, occupational therapists, and other early childhood specialists. The field gained momentum in the 1960s, when John Bowlby presented a theory of parent-child attachment relationships and Mary Ainsworth began to test the theories in real-world settings. Since then, the field of IMH has focused on the mental health of very young children in the realworld contexts that influence their mental health, including two primary contexts: parent-child relationships and development.
The parent-child relationship begins prenatally and includes multiple components. An early component of this relationship, bonding, is the parents’ emotional connection to the child that develops in the perinatal period. Although it is clear that the parents’ emotional ties to their infants continue to evolve beyond the child’s first moments, early interactions and experience may influence the developing relationship. The attachment relationship is a central component of the parent-child relationship and presents with discernable developmental stages in the first few years of life. Attachment relationships are defined by the infant’s behaviors toward the parents. In the first two months, infants show preferences to their mothers; they look at their mother’s face, and turn to her voice or her smell preferentially. The second major stage of development in the parent-child relationship occurs in months 2 to 7, when infants’ social repertoire blossoms. They continue to respond preferentially to parents, but will interact socially with most people and can elicit comfort in a nondiscriminated way from strangers. At 7 to 9 months of age, infants first demonstrate
focused attachment behaviors toward their primary caregivers. That is, they preferentially seek proximity to and comfort from their primary caregivers during times of distress. This important developmental shift is accompanied by new distress with separation from a parent and anxiety with strangers.
focused attachment behaviors toward their primary caregivers. That is, they preferentially seek proximity to and comfort from their primary caregivers during times of distress. This important developmental shift is accompanied by new distress with separation from a parent and anxiety with strangers.
Parents’ consistent and predictable comfort, nurturance, and protection of an infant provide a foundation for healthy emotional development and physical safety. When an attachment relationship is healthy or “secure,” an infant can elicit comfort effectively from the parent in times of distress. Conversely, when a child has not experienced a caregiver as a reliable protector, the child may not seek proximity to or comfort from the caregiver, or may show a pattern of resistance to comfort, such as an inability to calm, or may even actively turn away from the parents’ comfort. Longitudinal studies by Weinfield and colleagues demonstrate that secure attachment relationships in infancy, toddlerhood, and preschool ages predict social, emotional, and relationship competence and overall mental health in childhood, which can predict wellbeing into adulthood.
Although attachment relationships are defined by behaviors, the way that a parent and a child think of each other (the “internal representation” or “working model”) is thought to strongly influence the relationship. These parental representations are influenced not only by the experiences with the infant but also by the parents’ experiences in other intimate or caregiving relationships. In 1975, Fraiberg characterized these past relationships as “Ghosts in the nursery” when they negatively influence the parents’ view of the child. In 2003, Lieberman and Amaya-Jackson reminded us that these relationships may also have positive influences and serve as “Angels” in the nursery. An example of “ghosts” could be a mother who has experienced abuse within intimate relationships. These past relationships may shape her view of herself as unlovable, and she may experience her infant’s crying as a confirmation of that belief and as a criticism of her parenting. Thus, understanding parents’ past experiences is crucial for understanding a parent-child relationship and a child’s current experiences.
A child also contributes to the developing parent-child relationship in many ways, including temperament. Temperament is the early and stable pattern of emotional reactivity that appears to modulate the interaction between the child and his or her environment. Fox’s research describes the behavioral presentation of temperament as an approachwithdrawal dichotomy that is apparent at birth. These emotional reactions become more complex (e.g., manifestations of joy vs. interest) with development, specifically with associations with prefrontal cortex and corpus callosum development in the first few years of life. Neuroanatomically, patterns of emotional reactivity correlate with asymmetric activation of and interactions between the left and right prefrontal cortices. These biologically related patterns of emotional reactivity can be influenced by early childhood experiences—including treatment—although they are often moderately stable over time and treatment does not change the biologic correlates. Since the early 1990s, Davidson and others have examined the propensity of children with behaviorally inhibited temperament to develop psychopathology. Although fewer than one third of children with behavioral inhibition develop social anxiety, their risk is two to three times that of nonbehaviorally inhibited children. These temperamental patterns of approach and withdrawal behaviors can influence the child’s future developmental trajectories and form part of the child’s contribution to the parent-child relationship.
Rapid development in the first years of life is another major context of early childhood mental health practice. The first years of life are the period of most rapid growth, especially in the central nervous system (CNS). By age 4, a child’s brain is 90% of adult size. Early childhood brain development is characterized by extraordinarily high rates of synaptogenesis, myelinization, and neuronal pruning. Adverse and positive environmental factors influence the CNS development. For example, both lead and maternal depression exposure are
associated with measurable CNS impairment. In addition, important studies by Nelson and colleagues in 2007 and Dozier and colleagues in 2006 demonstrate that nonbiologic interventions focused on enhancing the caregiving environment for high-risked children can improve CNS functioning, including substantial increases in IQ and normalization of electroencephalogram (EEG) patterns and cortisol patterns. The rapidity of early development across domains means that early childhood mental health intervention targets a dynamic process rather than a static system and enhances the potential for affecting important changes early in life. The practice of IMH views a child within many other contexts as well, as young children’s mental health may be influenced by a range of family, community, and societal factors. Table 18-1 presents the impact of other contexts of infant and young child mental health. Table 18-2 summarizes the essentials of healthy infant and early childhood mental health development.
associated with measurable CNS impairment. In addition, important studies by Nelson and colleagues in 2007 and Dozier and colleagues in 2006 demonstrate that nonbiologic interventions focused on enhancing the caregiving environment for high-risked children can improve CNS functioning, including substantial increases in IQ and normalization of electroencephalogram (EEG) patterns and cortisol patterns. The rapidity of early development across domains means that early childhood mental health intervention targets a dynamic process rather than a static system and enhances the potential for affecting important changes early in life. The practice of IMH views a child within many other contexts as well, as young children’s mental health may be influenced by a range of family, community, and societal factors. Table 18-1 presents the impact of other contexts of infant and young child mental health. Table 18-2 summarizes the essentials of healthy infant and early childhood mental health development.
TABLE 18-1 Other Contexts of Infant and Early Childhood Mental Health | ||||||||||
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TABLE 18-2 Essential Principles of Infant and Early Mental Health | ||||
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Applying IMH Principles: Universal Interventions
The principles of IMH can be applied in all settings where infants are seen including primary care settings; early intervention settings; Women, Infants, and Children (WIC) nutrition offices; child care settings; as well as specialty IMH programs, and any setting where children and their families receive services. In this section, we present opportunities for universal interventions intended to promote IMH by meeting the needs of young children and by supporting parents in the challenging task of caregiving.
Create a Family-Friendly Environment
Providers can convey to a family that children are valued by creating a physical space that welcomes young children and providing a child-safe environment, child-size furniture, and activities for children while parents are occupied, and private space for breast-feeding. Parents who feel valued and respected are more likely to treat their child in a nurturing and sensitive manner. For some parents, a family-friendly office staff member may be the first to model this type of interaction.
Promote Early Childhood Mental Health by Discussing and Screening for Mental Health Problems Universally
Universal systematic screening with validated measures in primary care settings may facilitate discussions about mental health, reduce the perceived stigma of mental health, and facilitate early identification of children with mental health needs. A number of valid, psychometrically strong measures can be used in clinical practice settings or child care settings to identify young children in need of mental health. Screening for maternal mental health is also a way of communicating that parenting is valued and may increase identification of parents in need of referrals and treatment. Table 18-3 presents some common instruments used to screen for mental health problems in young children.
Parent-report measures represent the parents’ perception of the child’s behaviors or emotional patterns and can be influenced to some degree by parental depression, distress, or concern about how the responses will be used. Thus, positive screens may represent child psychopathology, or parental distress, or a combination, but nearly always reflect a clinical situation in need of
attention. Negative screens reflect a lower risk of mental health problems and may offer an opportunity for anticipatory guidance and positive reinforcement for parenting skills. No single measure should be considered a diagnostic tool. The results of a screen should be considered in the context of clinician observations, reports from other adults including child care providers, and clinician knowledge of other risk factors. Structured developmental screening using a validated measure is recommended by the American Academy of Pediatrics, as noted in the “Suggested Readings” section of this chapter.
attention. Negative screens reflect a lower risk of mental health problems and may offer an opportunity for anticipatory guidance and positive reinforcement for parenting skills. No single measure should be considered a diagnostic tool. The results of a screen should be considered in the context of clinician observations, reports from other adults including child care providers, and clinician knowledge of other risk factors. Structured developmental screening using a validated measure is recommended by the American Academy of Pediatrics, as noted in the “Suggested Readings” section of this chapter.
TABLE 18-3 Selected Screens for Identifying Children in Need of Further Assessment | |||||||||||||||
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Applying the Principles: Assessments of Infants and Young Children
Ideally, an early childhood mental health team includes or has access to child and adolescent psychiatrists, psychologists, social workers, developmental-behavioral pediatricians, other developmental specialists, and case managers. They generally collaborate with speech and language pathologists, occupational and physical therapists, primary care providers, and pediatric specialists such as geneticists and neurologists.
Making a Referral
Parents may have misconceptions about the meaning of an early childhood mental health referral. It is not uncommon for parents to be concerned that the referral reflects criticism of their parenting capacity, that the child is permanently disordered, or that a referral may result in losing custody of their child. Addressing these misconceptions early may facilitate the referral and assessment process. Referring clinicians can help parents understand the goals of the referral and what to expect in the assessment process and what they know about the specific approach used by the specialty provider. It can be helpful to use the words the mother has used to describe her concerns. If the parent described concerns about “fits,” the referring clinician can talk about how the specialty provider will help understand the “fits.” Often, statements like “She can help understand what is going on with your child’s feelings and help your child learn to organize her feelings and behaviors” or “His job is to help your child be as happy and successful as possible and to help you and your child have chances to enjoy each other” can help to clarify the role of the early childhood mental health evaluation.
Infant and Early Childhood Assessment
Assessments occur over the course of multiple visits, with multiple informants and multiple approaches to information gathering that allow the provider to integrate a three-dimensional view of the child. The assessment includes time alone with the parents to discuss sensitive information such as pregnancy planning, family history, and family violence histories and time with both the parents and the child in the room to observe behavior and interactions informally. With older children, the time with everyone in the room allows the clinician to help reframe the presenting complaint from blaming or negative words to behavioral descriptions. For example, a clinician may reframe “he’s so bad” to “it sounds like he has a hard time sitting still in school.” Such an intervention can help engage the child in the process and reduce the child’s negative experiences.
An important focus of an IMH assessment is attention both to the information the parents provide and to the way they provide it (narrative qualities). These qualities reflect the parent’s internal representation of the child and may be heard in the degree to which the parent’s discussion of the child includes a balance of both positive and negative characteristics, whether it is shaped or distorted by the parent’s other intimate relationships or experiences, the overall tone the parent uses to discuss the child, and the degree to which the narrative holds together as a cohesive picture of the child. An example of distortion is a mother whose child experienced an arm injury due to a birth trauma and who was unable to talk about the child in any way without
connecting the discussion to the traumatic birth events. Her narrative demonstrated that she saw her child through the lens of a traumatic event that shaped and distorted the picture. A strong body of literature led by groundbreaking work by Benoid, Parker, and Zeanah in 1997 documents the association between narrative qualities—even prenatally—and the quality of the attachment relationship and the child’s later mental health outcomes.
connecting the discussion to the traumatic birth events. Her narrative demonstrated that she saw her child through the lens of a traumatic event that shaped and distorted the picture. A strong body of literature led by groundbreaking work by Benoid, Parker, and Zeanah in 1997 documents the association between narrative qualities—even prenatally—and the quality of the attachment relationship and the child’s later mental health outcomes.
Taking the History
The major components of an IMH history are similar to the categories of history elicited about older children. In IMH assessments, parents and other adults provide most of the history of present illness. Clinicians primarily use observational and interactive approaches to elicit information directly from the child. This is especially true with infant assessments, in which most of the assessment focuses on the history provided and on the parent-infant relationship, which will be the path through which intervention addresses the presenting problem. Although infant and preschool assessments often differ in the content of the presenting complaint and the proportion of time spent on DSM-specific symptoms, the major components are similar.
The clinician focuses on the parent’s primary concern, using open-ended questions and probes to understand who is concerned, what specifically has been observed, how adults respond to the concerning symptoms, how the problem resolves, the meaning that the caregivers attribute to the behavior, and how they have been coping with the challenge of the symptom. A complete history of the presenting concern and review of systems informs the differential diagnosis. In infants, the review of symptoms focuses heavily on regulatory processes (soothability, feeding, sleeping patterns, and sensory issues) and less on the typical domains of older children. Review of symptoms in toddlers and preschoolers include attention both to regulatory processes and to the traditional psychiatric domains like mood, anxiety, behavioral regulation, and social skill development.
A few items in the standard psychiatric history for very young children warrant further explanation as they may serve different purposes than a typical mental health history. The history should include the preconception period including pregnancy history, intention to become pregnant, or fertility treatments. If a mother did not plan or want to be pregnant, it can be useful to understand what influenced her decision (or nondecision) to have the child, and whether she changed her mind during the pregnancy. Early events including becoming pregnant unexpectedly, a history of fertility treatment, domestic violence, medical problems, the absence of supportive relationships, and major life events during the pregnancy all can influence how a parent thinks about and reacts to a very young child and can influence the developing relationship with a child. For example, a mother with a history of multiple pregnancy losses may view her infant as especially vulnerable even after birth and continue to monitor and protect the infant as if the world actively threatens the baby. She may present with excessive sleep deprivation because she sets an alarm clock every hour to check that her 15-month-old is breathing. Additionally, it is useful to ask about the transition to the role of parent. Understanding the parent’s view of the new role and the degree to which she feels supported by her partner, extended family, and other supports helps the clinician gauge the context of her concerns and opportunities for enhancing support. A mother who is isolated and unsupported is at higher-than-usual risk for developing postpartum depression or experiencing parenting and her infant as burdensome.
It is important to take a developmental history as well, with attention to motor milestones, language development, self-care skills like toilet training, as well as social development. Standardized measures such as the Ages and Stages Questionnaire can be useful adjuncts to this history in developmental risk categories. Medical issues most relevant to an IMH evaluation are any CNS processes such as seizures or head trauma, pregnancy or perinatal events, failure to thrive, and in older children, pica. Generally, it is prudent to review the primary care records to avoid unnecessary duplication of lead levels or other blood tests. Any chronic illness or
frightening medical event may influence the degree of vulnerability a parent sees in a child as well as increase child anxiety, and thus is important in the infant and early childhood mental health context.
frightening medical event may influence the degree of vulnerability a parent sees in a child as well as increase child anxiety, and thus is important in the infant and early childhood mental health context.
Family psychiatric history provides information about possible genetic loading, and also about a child’s and a parent’s caregiving experiences. Parental psychiatric disorders may affect how a parent attends to the child’s needs, the consistency of caregiving style, their patience with the child, affective tone toward the child, and punishment styles. Research shows that maternal depression occurs at rates of 20% to 30% in the preschool years and is associated with a range of biologic and psychological adverse child outcomes including EEG asymmetry, low developmental quotient, abnormal catecholamine excretion, and emotional, behavioral, and social problems. Thus, depression and comorbid conditions must be identified and addressed as part of an IMH assessment. When parents have a history of depression or any other psychiatric disorder, clinicians explore how their symptoms impact parenting. For example, a question such as “Sometimes people get frustrated or upset with their children more easily than they want to. Does that happen to you?” may give a parent permission to describe the impact of depression on parenting.
Drawing a genogram allows clinicians to understand family relationships, and the parents’ own caregiving experiences, and to identify supportive or abusive caregiving relationships. The genogram allows the clinician to begin to identify the “ghosts” and “angels” in the nursery and helps identify genetic factors that may influence the child’s clinical presentation.
In the social history, the clinician focuses on contexts of the child’s experiences including cultural beliefs about child development, safety of home environment, and the people involved in the child’s caregiving, with a goal of identifying protective and risk factors. Sameroff and Fiese research reminds us that no specific single risk factor is determinative; the number of social risk factors predicts a child’s outcome. Understanding the community, cultural, and household contexts in which a child is developing informs a biopsychosocial assessment and identifies targets for nonclinical interventions.
Observations
A clinician can create opportunities for multiple types of observations during the assessment. Informal observations in the waiting room and while taking a history can be quite valuable in revealing the child’s and dyad’s typical patterns including how a child interacts with the clinician for the first time. Table 18-4 provides a structure for describing observations in an IMH setting. Although IMH mental status examinations share domains with those for older patients, a few differences warrant attention. First, appearance is especially important in an IMH assessment. Size for age provides information about the child’s nutrition or medical status. A clinician also observes whether a patient has stigmata of genetic syndromes. The most commonly seen dysmorphic features include unusual placement or shape of the ears, presence of epicanthal folds, unusual shape of the nose and nasal bridge, philtrum, and the presence of micrognathia, although a clinician should be aware of any congenital dysmorphism. Evidence of “baby bottle carries” may suggest a low level of parental supervision while feeding, and excessive occipital alopecia may suggest that the baby spends significant time on his or her back. A child’s developmental level in the domains of language, fine and gross motor skills, and school readiness in older children are part of the mental status evaluation. If any developmental concerns are raised during the mental health assessment, the child should be referred for formal testing by a developmental specialist. Most of the observations of a child can be done during play, which is the primary communication tool for young children and informs a clinician’s understanding of the child’s thought process and thought content.
During the early childhood mental health assessment, the clinician attends to the patterns of the parent-child interactions. The first opportunity for these observations is the waiting
room, when the clinician can observe how the child responds to the presence of a stranger (the clinician) and the degree to which the child references the parent to check about the safety of the stranger. Throughout the observation, the clinician attends to the child’s interactions with the parent, including patterns of proximity seeking, comfort seeking, and social referencing. Disturbances of these behaviors may represent a wide differential including relationship disturbances, temperamental patterns (extremes of approach or withdrawal behaviors), and pervasive developmental disorders. During the evaluation, and especially during mild stressors,
the clinician notes the affective tone of the interactions (e.g., warm, joyful, harsh, wary, or fearful), the way the infant or child uses the parents for comfort and to help them regulate their emotions, the parent’s ability to anticipate the child’s needs, limit setting and the child’s response to the limits, and comfort level playing together/interacting. Formal, structured observations such as those used in Crowell’s procedure provide information about how the dyad plays together, copes with limit setting, and negotiates easy and difficult puzzle tasks, and how the child uses the parent for comfort after a separation. In healthy dyads, a child will seek out the parent who anticipated the potential for distress and offers comfort, and the child will soothe quickly. In other situations, the clinician may note that the child approaches the clinician for comfort, that the parent did not recognize the child’s need and does not offer comfort or is dismissive of the child (“he’s too big to cry about that”), or that despite reasonable efforts to calm the child, the child cannot organize his or her feelings. Each of these findings would suggest important difficulties in the parent-child relationship or the child’s emotional regulation.
room, when the clinician can observe how the child responds to the presence of a stranger (the clinician) and the degree to which the child references the parent to check about the safety of the stranger. Throughout the observation, the clinician attends to the child’s interactions with the parent, including patterns of proximity seeking, comfort seeking, and social referencing. Disturbances of these behaviors may represent a wide differential including relationship disturbances, temperamental patterns (extremes of approach or withdrawal behaviors), and pervasive developmental disorders. During the evaluation, and especially during mild stressors,
the clinician notes the affective tone of the interactions (e.g., warm, joyful, harsh, wary, or fearful), the way the infant or child uses the parents for comfort and to help them regulate their emotions, the parent’s ability to anticipate the child’s needs, limit setting and the child’s response to the limits, and comfort level playing together/interacting. Formal, structured observations such as those used in Crowell’s procedure provide information about how the dyad plays together, copes with limit setting, and negotiates easy and difficult puzzle tasks, and how the child uses the parent for comfort after a separation. In healthy dyads, a child will seek out the parent who anticipated the potential for distress and offers comfort, and the child will soothe quickly. In other situations, the clinician may note that the child approaches the clinician for comfort, that the parent did not recognize the child’s need and does not offer comfort or is dismissive of the child (“he’s too big to cry about that”), or that despite reasonable efforts to calm the child, the child cannot organize his or her feelings. Each of these findings would suggest important difficulties in the parent-child relationship or the child’s emotional regulation.
TABLE 18-4 Essential Observations in Infant and Early Childhood Assessment | ||||||||||||||||||||||||||||||
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