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.
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.
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.
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.
TABLE 18-4 Essential Observations in Infant and Early Childhood Assessment
Size (height and weight for age), dress and hygiene, maturity compared to age, dysmorphia and congenital anomalies, bruises or other marks, degree of occipital alopecia in infants, dentition (e.g., baby bottle caries)
Observed reaction to new situation
Initial reaction to setting and to strangers (e.g., fearful, clingy, indiscriminate friendliness) and rate of adaptation to the setting
Pattern of interactions including proximity seeking, eye contact, joy sharing, child’s tone in interactions, parental engagement with child, responsiveness to child’s needs, enthusiasm, and parent tone; child use of parent after brief separation (eye contact, approach, and ability to be soothed)
Physical contact with caregiver, eye contact, interactive style, level of verbal engagement, play engagement, and turn taking in older children
Motor muscle tone and strength
Gross motor coordination, fine motor coordination
Vocalization and speech production; receptive language; expressive language; volume, rate, and prosody in verbal children
Use information from all above areas, especially play, language use, symbolic functioning, and problem-solving, school readiness skills
Developmentally specific mental status observations
Predominant state and rage of states observed during session, patterns of transition, sensory regulation, unusual behaviors, activity level, attention span, frustration tolerance, aggression
Infants: affect and mood
Modes of expression (facial, verbal, body tone and positioning), range of expressed emotions, duration of emotional state, intensity of expressed emotions Self-reported mood in preschoolers
Toddlers, preschoolers: behavior
Activity level, impulsivity, ability to follow directions, stereotypies, responses to limit setting
Toddlers, preschoolers: mood
How they identify their mood; can be facilitated by drawing pictures of happy, sad, mad, and scared, checking that the child can identify these feelings accurately and then asking them to identify their own mood
Toddlers, preschoolers: thought process
Ability to maintain attention at developmental level Degree and quality of organization of play and (when developmentally applicable) speech
Toddlers/preschoolers: thought content
Predominant themes in play and speech (with attention to aggression, sexual play, caregiving themes)
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