Infant mental health, Part 1: Clinical concerns

As we continue to learn about the complexity and elegance of infant development, we are also faced with acknowledging that certain risks and disorders are common during this early stage of life. Infant mental health is a relatively new area of study. In essence, it encompasses the social and emotional well-being of infants and young children. The age group served is often defined as birth to age 3, but many services care for children up to age 5. Infant mental health services are provided in a variety of settings and rely on a multidisciplinary approach.

The first book with the words “infant psychiatry” in its title was published in 1976.[1] We now have more research findings on which to base best practices than we had 30 years ago. Nevertheless, we need to acknowledge that “findings on what works in prevention and early intervention have tended to be inconclusive and may not give clear directions for evidence-based best practices.”[2] We hope that this two-part theme issue will contribute to a better understanding of what we do know about some of the important clinical issues in infant mental health, and what can be done to support these vulnerable children and their families. Supporting the development of infants’ mental health shapes the social and emotional health of these individuals in their future as adults and, importantly, as parents themselves.[1]

The development and maintenance of infant mental health occurs in the context of a parent-child relationship, making assessment and intervention unique and challenging. Treating early relationship problems has two important aims: the relief of current suffering and the prevention of long-term consequences. Those working in the field of infant mental health are guided by the expectation and knowledge that assisting parents to be sensitive and optimally responsive to their infants and young children can contribute to secure attachment and enhance a child’s development, relationships, functioning, and resilience to stress and other life challenges. 

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)3 is used for diagnostic classification for adults and older children, but it does not cover disorders typically seen in the early years. The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-3R)[4] provides diagnostic guidance for infant mental health issues. Although the DC: 0-3R draws on worldwide research and clinical practice since 1994, questions about the reliability and validity of its diagnostic categories persist. Like the DSM-IV, DC: 0-3R uses a five-axis system to classify concerns. Sleep, feeding, and regulation problems can be classified within this system. Importantly, one axis deals with relationship concerns (e.g., parents who are under-involved/over-involved, infants who are anxious/tense in response). The “patient” in this field is the baby in interaction with the caretaking environment. Diagnostic terms facilitate communication with other clinicians, but it is important to remember that we are classifying disorders rather than individuals or families.[5] The focus of intervention in infant mental health is based on identified risks or problems in the following areas: child; parent; parent-child interaction; home/family environment; community, culture, and society.[2]

In Part 1 of this theme issue, we touch on some of the important clinical issues in infant mental health. Terry Kope and Pratibha Reebye describe the conceptual basis of attachment and review current research. Shelly Phillips and Mary Lee Best discuss a community-based approach to infant mental health problems and what an infant mental health therapist actually does. Pamela Lansky and Tim Oberlander then look at the impact of parental mental illness on child development and the importance of collaboration among professionals working in the area of postpartum depression . Finally, Myles Blank looks at posttraumatic stress disorder (PTSD) in infants, toddlers, and preschoolers. Dr Blank reminds us that there are obvious challenges in making this diagnosis in preverbal and barely verbal children, and that this diagnosis needs to be considered in the children of any adults being treated for PTSD.

In Part 2 of this issue exploring infant mental health, we will discuss clinical interventions that can benefit young patients with attachment, regulation, and feeding disorders.

—Terry Kope, MD, FRCPC
Clinical assistant professor, University of British Columbia
Psychiatric consultant, Alan Cashmore Centre, Vancouver Community Mental Health Services 

—Pamela S. Lansky, MA, MEd, RCC
Clinical counselor
Burnaby Family Life Institute
Pacific Post Partum Support Society