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(0-36 Months) |
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Volume 36(10S) Supplement October 1997 pp 21S-36S Copyright 1997 © American Academy of Child and Adolescent Psychiatry |
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Reprint requests to AACAP, Communications Department, 3615 Wisconsin Ave. N. W., Washington, DC 20016. |
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* Abstract * ASSESSMENT OF INFANTS AND TODDLERS o Establishing a Working Alliance with the Family* STANDARDIZED INSTRUMENTS * TABLE 2. Examples of Standard Instruments* INTERDISCIPLINARY ASSESSMENT AND REFERRAL o DIAGNOSTIC FORMULATION* TREATMENT PLANNING * DEVELOPMENT OF THESE PARAMETERS o Conflict of Interest* OUTLINE OF PRACTICE PARAMETERS FOR THE PSYCHIATRIC ASSESSMENT OF INFANTS AND TODDLERS (0-36 MONTHS) * REFERENCES |
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These
practice parameters
describe the psychiatric assessment of infants and toddlers |
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| Child
and
adolescent psychiatrists and other clinicians
evaluate and treat infants and toddlers and their families. Very young children are brought to clinical attention because of concerns about emotional, behavioral, relational, or developmental difficulties. For infants, the most frequent referral problems are dysregulation of physiological function, including fussy or colicky behavior, feeding and sleeping problems, and failure to thrive. For toddlers, the most frequent referral problems are behavioral disturbances including aggression, defiance, impulsivity, and overactivity. In addition, constitutional factors, including developmental delays and more subtle physiologic, sensory, and sensory-motor processing problems, often derail expected developmental progress and bring young children to clinical attention. Problems with "goodness of fit" (Thomas et al., 1968) [71] constitutional attributes or temperament and the parents' expectations create relationship difficulties that often lead to referral. Children in this age range are also referred for concerns that they may have been physically or sexually abused. These guidelines are
applicable to the assessment of
infants and toddlers 0 to 36
months of age. In this
guideline, the term "infant"
refers to children 0 to 12
months of age; "toddler"
refers to children 12 to 36 months
of age. "Child"
is used to mean children 0 to 36 months of age. "Parents"
and "parental" refer to the
infant's
or toddler's parent figures or
primary caregivers, that is,
the
psychological
parents. "Parents" include adoptive, foster, and
shelter
care primary
caregivers as well as grandparents
and other extended
family or friends
who are primary caregivers
for the child. "Family" refers
to the primary caregiving unit, that
is, the psychological
family. "Family"
is similarly inclusive of the wide
diversity of primary
caregiving
units in our
culture. This document It is axiomatic that the infant or toddler must be understood, evaluated, and treated within the context of the family or primary caregiving unit. Winnicott framed this concept in his now classic words, "There is no such thing as a baby ...," by which he meant that an infant or young child cannot be understood outside of the sustaining caregiving environment (Winnicott, 1965) [75]. Infants and toddlers also must be understood, evaluated, and treated within additional significant contexts, which may include other important caregivers, extended family, the school, the day-care center, and the culture. The family's emerging alliance with the evaluating clinician provides the context of the assessment and intervention process itself. That is, the parents' responses to the assessment process, the child, each other, and the clinician are shaped by their relationship with the clinician. It is through this personal relationship that the clinician observes and facilitates the parents' behavioral, affective, and psychological responses to the infant or toddler and to their concerns about the child. It is also through this relationship that the parents' concerns are understood and a treatment plan is developed mutually (Hirshberg, 1993) [39]. The purposes of the diagnostic assessment of infants and toddlers include the following: to develop with the parents a shared understanding of the core concerns and other factors leading to the referral; to determine whether there is a problem and whether psychopathology or conditions that lead to risk or vulnerability are present; to establish a developmentally based differential diagnosis and an ongoing mutual process of formulation that helps organize the parents' understanding of their experience with the child; and to develop with the parents a treatment plan that addresses the parents' explicit and implicit expectations and facilitates the parent-child relationships that support the child's healthy development. In emergency circumstances, or for specialized consultative purposes, the focus of inquiry may be narrowed or expanded, to be followed by a full evaluation at a later time. To accomplish these
purposes,
the specific aims of
the diagnostic assessment of
the infant and
toddler
are as follows:
to establish with the parents
an ongoing therapeutic
relationship built
on respect for the parents'
knowing their child,
being a
central influence
in their child's life,
wanting to make a better
life
for their child
(Fraiberg, 1980) [33], and
having unique values,
preferences, and cultural
ideals; to assess the nature,
severity, and
developmental
impact on the
child and on the family of
the child's behavioral
difficulties, functional
impairment, or subjective
distress; and to
identify
transactional
(i.e., mutually LITERATURE
REVIEW ASSESSMENT OF
INFANTS AND TODDLERS
By design, assessment and intervention with infants and toddlers is oriented toward prevention. Identification of risk and intervention before the appearance of disorder are central to the field (Emde et al., 1993) [28] and are considered "key to the prevention of mental disorder throughout the lifespan" (Fonagy, 1996) [31]. Recent research suggests that identification and resolution of psychiatric disorder during the first 3 years of life prevents "use-dependent" internalization of disordered neural patterns in rapidly developing and organizing brain structures (Perry et al., 1995) [57]. Because infancy and toddlerhood are times of rapid change and lay the foundation for future development, the clinicians primary goal is facilitating rapid change toward healthy developmental progress and strengthening parental and extended environmental support systems. Because infants and toddlers are maximally dependent on parents, most of the facilitation of change must be accomplished through the parents. Therefore, the parents are primary in the treatment team. The goal is to develop with the parents an evolving mutual understanding of the core concerns, which will allow them to support the healthy development of the child in the family and broader caregiving contexts. A multidimensional
perspective, borrowing from pediatrics,
developmental A developmental
perspective
(Lieberman, 1993) [44]
is essential to differentiate
normality from risk
and
pathology. For
example, toddlers are normally
quite active and have a
limited attention
span. These behaviors must be
distinguished from
situation-specific and
pervasive hyperactivity and
attention problems. Various
studies have documented
normative infant and toddler developmental
processes
and have emphasized
four discrete "biobehavioral
shifts" (Emde et
al.,
1976; Zeanah
et al., 1989, 1997) [29, 78,
80]. These shifts include
the
qualitative reorganization
of biological, cognitive,
affective,
and
social capacities
at ages 2 to 3 months, 7 to 9
months, 12 to 13
months, and 18 to
20 months (Emde, 1985; Emde
et al., 1976; Kagan, 1984;
McCall et al., 1977;
Stern, 1985; Zeanah et al.,
1989) [26, 29, 41, 48, 68, 78].
In
addition, the correlation
between symptoms and risk
factors is less
clear than in older
children. For example, sleep
problems may be
constitutional/maturational, A relationship
perspective is
essential for collaborative
assessment and treatment
planning with the
parents.
This perspective
also is essential for Multiple assessments over
time are needed because infants
and toddlers It is essential to gather information from those who are most familiar with the child's current and past functioning, including the family or primary caregiving unit. For children who are in foster or shelter care, in day care, or in the child welfare system, information from case workers and multiple caregivers is essential. For children who are referred with medical concerns, including consultation while being hospitalized, the assessment should include information from physicians and all those centrally involved in the care of the child. THE FAMILY
INTERVIEW Establishing a Working
Alliance with the Family Reason for Referral The course of gathering
history varies with the nature
of the presenting symptoms
and with the details of
each
case. The goal
is not only to obtain a
description of the problematic
behavior but to understand
the meaning and The interview should focus not only on the child's difficulties and symptoms but also on his or her strengths of behavioral organization and areas of good adjustment. An approach that identifies positive attributes of the child and the caregiving environment helps enhance the parents' self-esteem and supports the working alliance between the clinician and the child's parents. Developmental History Assessment of the physical, cognitive, and emotional development of the infant or toddler includes inquiry into prenatal, perinatal, and postnatal complications, including maternal medication and substance use, length of gestation, and neonatal status. The physical history also includes data on gross and fine motor development, toilet training, eating behavior, and sleep patterns, as well as medication, illnesses, hospitalizations, injuries or operations, and the child's reactions to these events (Werner and Smith, 1982) [73]. The cognitive developmental history includes the child', attentional and organizational abilities as well as verbal skills over time (Bornstein and Sigman, 1986) [13]. Particular attention should be paid to apparent changes or discontinuities in the child's developmental progress or level of functioning. Assessment of the child's
early behavioral organization
is based on the The child's degree of individuation should be assessed, including the child's level of independence and involvement with parents, other adults, siblings, and peers. The child's special strengths and vulnerabilities should be assessed, including strengths in symbolic play or coordination, being shy, or having hyposensitivities or hypersensitivities to specific stimuli. The child's response to previous stressors also should be assessed, including neglect, physical or sexual abuse (Lieberman and Zeanah, 1995; Scheeringa and Zeanah, 1995; Thomas, 1995) [45, 63, 70], medical illnesses or hospitalizations (Mayes, 1995) [47], significant parental absence, birth of a sibling, move to a different house, or other stresses affecting the parents or family. The parents' responsiveness to the child, and the potential effect this has had on the child's relatedness and other competencies, also should be considered. Family Relational History The parents' perceptions,
distortions, attitudes, and
expectations of the child are
important to assess
thoroughly, especially
because the history is expected
to reflect perceptual
bias.
Such information
may be gleaned from the
subtle nuances (such as word
choice and gestures)
of the parents' open-ended
reports. Specific
questions, however, may
be helpful. For example, the
clinician might ask
if
the child reminds
the parents of specific
family members. The
parents'
identification
of the child with another
family member may provide
a
powerful clue
to their biases and expectations.
During this portion
of
the session,
interviewing the parents without
the child may facilitate
greater disclosure,
especially with parents of
toddlers. Many
clinicians
report, however,
that the presence of the
infant or toddler during such
sessions is catalytic
to the process The clinician should explore the parents' early relationship histories to uncover the origins of parenting style as well as the symbolic value of the child to each parent. Fraiberg (1980) [33] theorized that earlier unresolved feelings haunt the parents' developing relationship with the infant. Bowlby (1982) [14] described an "internal working model" or a set of expectations (conscious and unconscious) of what parents are expected to do for their child and how they are expected to be with their child. It is important to determine both the positive and negative nature of parental expectations and whether expectations of behavior are developmentally appropriate. The clinician attempts to understand the parents' "internal working model" to determine how this plays a role in the strengths of or problems in the infant-parent relationship. The clinician should gather a detailed family history, including information about the parents, their siblings, and their caregivers from birth onward. The history may yield information on deaths, separations, or divorces, their placement into out-of-home care, and other important events that have affected the parenting style or the parents' ability to care for their child. In assessing the parents'
past and present relationships
with their own parents and
other important role
models, the clinician
should inquire about the
structure and supervision
provided by their parents;
the parental warmth and types
of punishment
used;
problems in either
parent's life that may be
similar to the infant's
problems; the amount
of family conflict present
during their childhood;
the
number of and
satisfaction with peer relationships;
and the quality of
school experiences
and relationships with teachers.
These factors have an
established validity
in predicting how parents
will interact with their
own
children and
can be reliably ascertained
during a clinical
interview (Fonagy et
al., 1991; Minde, 1995, 1996;
Quinton and Rutter, 1988)
[32, 53, 54, 59]. The
family interview also should
cover the parents'
education
and occupation,
familial medical or Clinical Observation The clinician invites the family to interact as they usually would at home for at least 15 to 20 minutes. Unstructured parent-child or family play provides optimal opportunity for interactional observation. Structured activities, and the child's response to brief parental separation and reunion (Boris et al., 1997 [12]; R. Clark, unpublished), also may be useful, depending on the child's developmental age and the nature of the problem. Often, a combination of assessment methods is needed. It is helpful to observe family play with multiple family members, including siblings. The presence of siblings gives examiners a more naturalistic view of the family's experience at home. Observing the child in separate interactive sessions with each parent and available significant caregivers helps establish relationship-specific problems and helps clarify the strengths and weakness of each caregiver, which is helpful in intervention planning. During family play, the evaluator may observe all or part of the session through a one-way mirror or may be in the room as a "participant-observer." When the clinician is a participant-observer, it is helpful to explain that to facilitate spontaneity, he or she will defer extensive conversation for another time. Limited verbal exchange between the parents and the clinician can be helpful, however, to explore the parents' feelings about, and experience with, the child during play and to assess the parents' perception of the infant's emotional states. Additional guidelines for unstructured play observations are detailed by Segal and Webber (1996) [64]. Clinically relevant dimensions of each parent's behavior include the level of affection expressed toward the infant and the willingness and ability to engage the child (both verbally and nonverbally); the parent's level of attunement to the child's cues; the parent's vigilance, protectiveness, and ability to regulate the child's emotional responses; the use of limits and the manner in which the parent allows or facilitates autonomous play in the child; the level of dyadic pleasure and harmony during play; and the thematic content of play and the role played by the parent. The child's capacity for
and
interest in interpersonal
relatedness also In parent-infant dyads,
the
clinician looks for mutual
engagement, shared Parents often feel inhibited during interactive sessions. After the session, it is important to ask parents about their level of comfort and how the play was similar to or different from what happens at home, both for the child and the caregiver (R. Clark, unpublished). This is particularly important for children, because state-related changes in behavior (due to illness or fatigue, for example) may be significant. For these reasons, it is preferable to observe parent-child interactions during multiple sessions. Validated, semistructured interactional assessments also may be of benefit to the clinician but are not a necessary part of a comprehensive evaluation (Gaensbauer and Harmon, 1981) [35]. Systematic scoring of observations is not necessary for clinical purposes. A semistructured approach, however, allows the clinician to view the dyad in a variety of representative situations. An example of a semistructured play interview, the Parent-Child Early Relational Assessment (R. Clark, unpublished), involves the observations of feeding/eating, a teaching task, separation and reunion, and free play. Videotaping and Early
Family
Records In addition, if family videotapes, films, photos, and baby books recording the child's development or problematic behavior are available, they may be reviewed and discussed with the parents as part of the assessment (Call, 1985) [16]. THE INFANT AND
TODDLER MENTAL STATUS EXAM Developmental status in
young
children may be characterized
by delays, As a tool for assessing the social and emotional status of the young child, ITMSE includes observations of the child, the child's interactions with parents, and the child's reaction to an unfamiliar adult. The clinician may interact directly with the child during parts of the session to elicit information not revealed in observations of parent and child. It is useful to describe the flow of the session, and especially of play, in a narrative form and to note findings on each part of the Mental Status Exam. The parent should be asked how the observed behavior compares to that typical of the child at home. The ITMSE provides examples of both normal capacities and abnormal findings (Table 1). |
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by Anne L. Benham. M.D. I. Appearance Size; level of nourishment; dress and hygiene; apparent maturity compared with age; dysmorphic features, e.g„ fades, eye and ear shape and placement, epicanchal folds, digits etc.; abnormal head size; cutaneous lesions. II. Apparent Reaction to Situation Note where evaluation takes place and with whom. A.Initial reaction to setting and to strangers: explores; freezes; cries; hides face; acts curious, excited, apathetic, or anxious (describe). B. Adaptation. 1. Exploration: when and how child begins exploring faces, toys, stranger.III. Self-Regulation .A. State regulation: an infant's state of consciousness ranges from deep sleep through alert stages to intense crying. Predominant state and range of states observed during session; patterns of transition, e.g., smooth versus abrupt; capacity for being soothed and self-soothing; capacity for quiet alert state. (Some of these categories also apply to toddlers.) B. Sensory regulation: reaction ro sounds, sights, smells, light and firm touch; hyperresponsiveness orhyporesponsiveness (if observed) and type of response, including apathy, withdrawal, avoidance, fearfillness, excitability, aggression or marked behavioral change; excessive seeking of particular sensory input. C. Unusual behaviors: mouthing after 1 year of age; head banging; smelling objects; spinning-, twirling; hand-flapping; finger-flicking; rocking; toe-walking-, staring at lights or spinning objects; repetitive, perseverative, or bizarre verbalizations or behaviors with objects or people; hair-pulling; ruminating; or breath-holding. D.
Activity
level: overall level and variability (note that toddlers
are
often incorrectly called hyperactive). Describe behavior, e.g.,
squirming
constantly in parent's arms; sitting quietly on floor or in infant
seat;
constantly on the go; climbing on desk and cabinets; E.
Attention
span: capacity to maintain attentiveness to an activity or
interaction;
longest and average length of sustained attention to a given toy or
activity;
distractibility. Infants: visual fixing and following at 1 month;
tracking
at 2 to 3 months; attention to own F. Frustration tolerance: ability to persist in a difficult task, despite failure; capacity to delay reaction if easily frustrated, e.g., aggression, crying, tantrums, withdrawal, avoidance. G. Aggression: modes of expression; degree of control of or preoccupation with aggression; appropriate assertiveness. IV. Motor Muscle tone and strength; mobility in different positions; unusual motor pattern, e.g., tics, seizure activity; intactness of cranial nerves, e.g., movement efface, mouth, tongue, and eyes, including feeding, swallowing, and gaze (note excessive drooling). A. Gross motor coordination. Infants: pushing up; head control; rolling; sitting; standing. Toddlers: walking; running; jumping; climbing, hopping; kicking; throwing and catching a ball. (It is useful to have something for the child to climb on, such as a chair.) B.
Fine
motor coordination. Infants: grasping and releasing;
transferring
from hand to hand; using pincer grasp; banging; throwing.Toddlers:
using pincer grasp; stacking; scribbling; cutting. Both fine motor and
visual-motor coordination can be screened by V. Speech and Language A Vocalization and speech production: quality, rate, rhythm, intonation, articulation, volume. B.. Receptive language: comprehension of others' speech as seen in verbal or behavioral response, e.g., follows commands; points in response to "where is" questions; understands prepositions and pronouns (include estimate of hearing, especially in child with language delay, e.g., response to loud sounds and voice; ability to localize sound). C. Expressive language: level of complexity, e.g., vocalization, jargon, number of single words, short phrases, full sentences; overgeneralization, e.g., uses "kitty" to refer to all animals; pronoun use including reversal; echolalia, either immediate or delayed; unusual or bizarre verbalizations. Preverbal children: communicative intent, e.g., vocalizations, babbling, imitation, gestures, such as head shaking and pointing; caregivers ability to understand infant's communication; child's effectiveness in communication. VI.
Thought The usual categories for thought disorder almost never apply to young children. Primary process thinking, as evidenced in verbalizations or play, is expected in this age group. The line between fantasy and reality is often blurred. Bizarre ideation; perseveration; apparent loose associations; and the persistence of pronoun reversals, jargon, and echolalia in an older toddler or preschooler may be noted in a variety of psychiatric disorders, including pervasive developmental disorders. A. Specific fears: feared object; worry about being lost or separated from parent. B. Dreams and nightmares: content is sometimes obtainable in children aged 2 to 3 years. Child does not always perceive it as a dream, e.g., "A monster came in the front door." C. Dissociative state: sudden episodes of withdrawal and inattention; eyes glazed; "tuned out"; failure to track ongoing social interaction. Dissociative state may be difficult to differentiate from an absence seizure, depression, autism, or deafness. The context may be helpful, e.g., child with a history of neglect freezes in a dissociative state as mother leaves room. Neurologic or audiologic evaluation may be warranted. D. Hallucinations: extremely rare, except in the context of a toxic or organic disorder, then usually visual or tactile. VII. Affect and Mood The assessment of mood
and
affect may be more difficult
in young children because of limited language; lack of vocabulary for
A. Modes of expression: facial; verbal; body tone and positioning. B. Range of expressed emotions: affect, especially in parent-child relationship. C. Responsiveness: to situation, content of discussion, play, and interpersonal engagement. D. Duration of emotional state: need history or multiple observations. E. Intensity of expressed emotions: affect, especially in parent-child relationship. VIII. Play Play is a primary mode of information gathering for all sections of the ITMSE. In very young children, play is especially useful in the evaluation of the child's cognitive and symbolic functioning, relatedness, and expression of affect. Themes of play are helpful in assessing older toddlers. The management and expression of aggression are assessed in play as in other areas of behavior. Play may be with toys or with child's own or anothers body, e.g., peek-a-boo, roughhousing; verbal, e.g., sound imitation games between mother and infant; interactional or solitary. It is important to note how the child's play varies with different familiar caregivers and with parents versus the examiner. A. Structure of play (ages approximate). 1. Sensorimotor play.B. Content of Play. The toddlers choice and use of toys often reflect emotional themes. It is desirable to have on hand toys that tap different developmental and emotional domains. An overfull playroom may be overwhelming or oveisrimularing and reducea. (0-12 months): mouthing, banging, dropping and throwing toys or other objects.2. Functional play. meaningful observations. Young toddlers of both sexes often gravitate lo dolls, dishes, animals, and moving toys, such as cars. The examiners choice of specific materials may facilitate the expression of pertinent emotional themes. For example, a child traumatized by a dog bile may more likely reenact the trauma if a dog and doll figures are available. The child's reaction to scary toys, such as sharks, dinosaurs, or guns, should be noted, especially if they are avoided or dominate the session. Does aggressive pretend play become "real" and physically hurtful? By age 21/2 to 3 years, a child's animal or doll play can reveal important themes about family life, including reactions to separation, parent-child and sibling relationships, experiences at day care, quality of nurturance and discipline, and physical or sexual abuse. The examiner must use caution in interpreting play, viewing it as a possible combination of reenactment, fears, and fantasy. ~CAUTION~
C.Cognition.
X. Relatedness A. To parents: how "in tune" do the child and parent seem? Does the child make and maintain eye, verbal, or physical contact? Is there active avoidance by child? Note infants level of comfort and relaxation being held, fed, "molding" into caregivers body. Does toddler move away from caregiver and check back or bring toys to show, to put into his or her lap, to play with together or near caregiver? Comment on physical or verbal affection, hostility, reaction to separation and reunion, and use of transitional objects (blanket, toy, caregivers possession). Describe differences in relating if more than one caregiver is present. B. To examiner: young children normally show some hesitancy to engage with a stranger, especially after 6 to 8 months of age. Appropriate wariness in young children may result in a period of watching the examiner; staying physically close to a familiar caregiver before engaging; or showing some constriction of affect, vocalization or play. After initial wariness, does the child relate? Does the child engage too soon or not at all? How does relatedness with a stranger compare to that with a parent? Is the child friendly versus indiscriminately attention-seeking, guarded versus overanxious? Can examiner engage the child in play or structured activities to a degree not seen with caregiver? Does the child show pleasure in successes if the examiner shows approval? C. Attachment behaviors: observe for showing affection, comfort-seeking, asking for and accepting help, cooperating, exploring, controlling behavior, and reunion responses. Describe age-related disturbances in these normative behaviors. Disturbances often areseen in abused and neglected children, e.g., fearfulness, clinginess, overcompliance, hypervigilance, impulsive overactivity, and defiance; restricted or hyperactive and distractible exploratory behavior; and restricted or indiscriminate affection and comfort- seeking. |
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STANDARDIZED
INSTRUMENTS |