Referrals for IMH assessments come from a range of sources, including caregivers, pediatricians, child care providers, and child protective services. Common referral concerns include sleeping or feeding difficulties, problems regulating affect or attention, relationship problems, and aggressive behaviors.
The assessment process has multiple purposes. The primary goal is to collaborate with caregivers to develop a shared understanding of the child within a developmental and relational context. To this end, it is critical to build a positive working alliance with caregivers and provide information and feedback about normative and atypical development.15 Assessments should take place over multiple sessions in multiple settings and include all possible caregivers.
Caregivers sometimes come to the assessment process feeling anxious, helpless, or blamed. Addressing caregiver distress about the process is critical to building an alliance and combating misconceptions. An equally important process is vigilant monitoring of a clinician's response to the wide range of parenting behaviors and family practices.
One of the challenges of IMH assessment is that infants cannot communicate verbally about their internal states. Thus, observations and indirect assessments are necessary components of the evaluation. Although a child's behavior typically precipitates the referral, the infant-caregiver relationship is a transactional process. Infants influence caregivers, and caregivers influence infants.16 In this interactive, dynamic relational system, children's presenting problems invariably impact, and are impacted by, the caregiving relationship.
Typical assessment includes a developmental assessment, a clinical interview, structured and unstructured behavior observations, and a caregiver report on norm-referenced measures--all of which provide data that are integrated into a formulation of the child's competencies and deficits in the context of his or her primary relationships. All assessments should include attention to motor, cognitive, neurobiologic, speech and language, and social-emotional development. Because infant development is inextricably embedded in family and community contexts, socio-economic factors, parent depression, parent substance abuse, parent-partner violence, and trauma history should be assessed.17
As in all psychiatric assessments, a complete history of the child and his family is a necessary component of assessing IMH. The child's history begins before conception and continues through the history of the presenting problem, with attention to major life stressors, medical problems, and developmental milestones. The family's history provides valuable information about biologic loading as well as the caregiving context. Social history, with attention to social support networks and stressors, is critical to developing a complete formulation.18
Assessment in IMH must be relationship-based. A parent's behaviors and his or her perception of the child, as well as the child's behaviors within the relationship, can be elicited during the assessment. The psychiatrist must infer the infant's perception of the parent. Observations of infant-caregiver interactions provide information about the child's development, caregiver functioning, and the infant-caregiver relationship.
In a clinical assessment, it is useful to observe the dyad interacting in unstructured ways, such as during history taking, and in more formal activities, including free play, clean up, opportunities for joint attention, and teaching tasks.19 A brief separation and reunion is often employed during assessments to activate the young child's "attachment system," which provides information about how the child uses a caregiver for comfort when distressed. In addition, a clinician can observe a caregiver's warmth, sensitivity, affective involvement, approach to noncompliance, developmental expectations, and limit setting. During the structured and unstructured observations, the clinician can examine a child's development level, use of caregiver for social referencing, and regulatory capacities.