Infant, or developmental, psychiatry is a subspecialty of child and adolescent psychiatry that focuses on the promotion of mental health in infants, toddlers, preschoolers, and their families through the consultation, assessment, and treatment of clinical problems.1 This specialty is a strength-based, prevention-focused discipline founded on the belief that early intervention for children in high-risk settings or with clinical problems can positively impact emotional and behavioral development.
While, as a society, we prefer to view early childhood as a carefree period, young children can still experience significant mental health problems.2 Early identification of these problems provides the opportunity to improve developmental outcomes by changing a child's developmental trajectory. Infant psychiatrists apply psychiatric diagnostics and treatment principles as they collaborate on multidisciplinary teams to support the child's mental health. The following case study we present of Karen's family situation is not uncommon in infant psychiatry.
Case study
Karen is a 34-month-old girl referred for infant mental health assessment by a physician who was treating her with a neuroleptic drug for aggression. Karen presented with anxiety symptoms and "bad" behaviors including being aggressive, irritable, and oppositional in the context of an escalation of family violence. An interview with her mother revealed a fear of Karen as a powerful aggressor: "She is mean, just like her father." In observations, Karen provided cues that were confusing to her mother, such as approaching her for comfort but then hitting her. A multidisciplinary team developed a plan that included safe housing, discontinuation of the neuroleptic drug, dyadic treatment using principles of child-parent psychotherapy to promote development through dyadic play, reflective guidance, and interpretations linking history to in-session experiences. In addition, Karen's mother was treated psychopharmacologically for posttraumatic stress disorder and Karen was referred for a speech and language assessment. Over the course of the next few months, Karen's aggression decreased, her sleep improved, and mother and daughter began to show true enjoyment during their interactions.
Infant mental health (IMH) refers to the emotional well-being of children in the first few years of life, with attention to 2 central contexts: early developmental processes and the parent-child relationship. In this period, development unfolds at an unprecedented rate and clinical intervention must take into account the rapid processes of development as well as the child's developmental trajectory. In infancy, external contextual factors--including family stressors--are experienced through the buffer or filter of the parent-child relationship. Family, community, school, and cultural contexts also become increasingly prominent in the child's experience of the world and must be considered as part of IMH practice.3
The treatment of infants requires skills specific to the population. Most senior specialists in this area have developed expertise through experience, mentoring relationships, and peer support. Increasingly, formal programs are available for subspecialty training. The American Academy of Child and Adolescent Psychiatry (AACAP) Web site lists 21 programs that provide infant psychiatry training.4 This specialty training typically includes a focus on social-emotional development, theory and skills related to parent-child relationship assessment and interventions, application of diagnostic nosologies to young children, and the unique issues of psychopharmacology within this age group.
Many infant psychiatrists participate in academic medicine, building an evidence base for this growing field. Some recent advances in infant psychiatry in collaboration with other disciplines include:
- Developmentally appropriate diagnostic tools and nosologies for the preschool age group.5-8
- Validation of specific psychiatric disorders in young children.9-11
- Randomized controlled studies documenting the effects of quality foster care on children raised in institutions.12
- A preliminary understanding of the neurobiologic effects of trauma on young children, their parents, and the parent-child relationship.13,14
ASSESSMENT
Settings
Most infant psychiatrists work on IMH teams in academic medical settings, mental health agencies, or specialty settings, including child protection agencies. The teams can include a psychiatrist, a psychologist, masters-level clinicians, and case managers. Physicians can have a range of roles on the team--depending on individual exper-tise--and they always bring a biologic perspective by identifying prenatal and perinatal events, dysmorphology, and medical illnesses or medications that may contribute to the presenting problem. IMH teams typically collaborate with other providers, including early intervention teams, speech therapists, and pediatricians. Successful teams also develop close ties with community resources to assist families in meeting their basic needs.
