Volume 36(10S) Supplement October 1997 pp 21S-36S
Copyright 1997 © American Academy of Child and Adolescent Psychiatry
Reprint requests to AACAP, Communications Department, 3615 Wisconsin Ave. N. W., Washington, DC 20016.
o Establishing a Working Alliance with the Family* STANDARDIZED INSTRUMENTS
* TABLE 2. Examples of Standard Instruments* INTERDISCIPLINARY ASSESSMENT AND REFERRAL TREATMENT PLANNING OUTLINE OF PRACTICE PARAMETERS FOR THE PSYCHIATRIC
ASSESSMENT OF INFANTS AND TODDLERS (0-36 MONTHS) *
describe the psychiatric assessment of infants and toddlers
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)  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
or toddler's parent figures or
primary caregivers, that is,
parents. "Parents" include adoptive, foster, and
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
is similarly inclusive of the wide
diversity of primary
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) . 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) .
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
the specific aims of
the diagnostic assessment of
the infant and
are as follows:
to establish with the parents
an ongoing therapeutic
on respect for the parents'
knowing their child,
in their child's life,
wanting to make a better
for their child
(Fraiberg, 1980) , and
having unique values,
preferences, and cultural
ideals; to assess the nature,
impact on the
child and on the family of
the child's behavioral
impairment, or subjective
distress; and to
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)  and are considered "key to the prevention of mental disorder throughout the lifespan" (Fonagy, 1996) . 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) . 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.
perspective, borrowing from pediatrics,
(Lieberman, 1993) 
is essential to differentiate
normality from risk
example, toddlers are normally
quite active and have a
span. These behaviors must be
pervasive hyperactivity and
attention problems. Various
studies have documented
normative infant and toddler developmental
and have emphasized
four discrete "biobehavioral
shifts" (Emde et
et al., 1989, 1997) [29, 78,
80]. These shifts include
of biological, cognitive,
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].
addition, the correlation
between symptoms and risk
factors is less
clear than in older
children. For example, sleep
problems may be
essential for collaborative
assessment and treatment
planning with the
also is essential for
Multiple assessments over
time are needed because infants
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.
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
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.
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) . The cognitive developmental history includes the child', attentional and organizational abilities as well as verbal skills over time (Bornstein and Sigman, 1986) . 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) , 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
because the history is expected
to reflect perceptual
may be gleaned from the
subtle nuances (such as word
choice and gestures)
of the parents' open-ended
questions, however, may
be helpful. For example, the
clinician might ask
the child reminds
the parents of specific
family members. The
of the child with another
family member may provide
to their biases and expectations.
During this portion
interviewing the parents without
the child may facilitate
especially with parents of
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)  theorized that earlier unresolved feelings haunt the parents' developing relationship with the infant. Bowlby (1982)  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
problems in either
parent's life that may be
similar to the infant's
problems; the amount
of family conflict present
during their childhood;
number of and
satisfaction with peer relationships;
and the quality of
and relationships with teachers.
These factors have an
in predicting how parents
will interact with their
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'
familial medical or
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 ; 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) .
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
interest in interpersonal
In parent-infant dyads,
clinician looks for mutual
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) . 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
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) .
THE INFANT AND
TODDLER MENTAL STATUS EXAM
Developmental status in
children may be characterized
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).
by Anne L. Benham. M.D.
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).
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.
level: overall level and variability (note that toddlers
often incorrectly called hyperactive). Describe behavior, e.g.,
constantly in parent's arms; sitting quietly on floor or in infant
constantly on the go; climbing on desk and cabinets;
span: capacity to maintain attentiveness to an activity or
longest and average length of sustained attention to a given toy or
distractibility. Infants: visual fixing and following at 1 month;
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.
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.)
motor coordination. Infants: grasping and releasing;
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.
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
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.
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.
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 are
seen 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-
for Infant and Toddler Assessment
Bayley Scales of Infant 1-42 months Mental, motor, Items administered; some Standardization includes race,
Development II behavior scale observation and parental report gender, parent education,
(Bayley, 1993) Widely used measure of infant/ geographic region
toddler development Reliability and validity established
Child Behavior Checklist 2-3 years Profile of behavior Parental report of behavioral Available in Spanish and many
(CBCL) problems problems other languages
(Achenbach et al.. 1987) Internalizing and Reliability and validity established
Vineland Adaptive 0-18 years Communications Parental report assesses Standardization includes minority
Behavior Scales; Daily living performance on daily activities groups
(Sparrow et al., 1984) Socialization required for social self- Available in Spanish
Motor skills sufficiency Reliability and validity established
Home Observarion for; 0-3 years Maternal Home observation and parental Limited use with ethnic minority
Measurement of responsivity report populations
Environment (HOME) Organization of the Most widely used home Available in Spanish
(Caldwell and Bradley, environment environment measure Good predictive validity to
1978) Maternal Administered in natural cognitive functioning
Parent-Child Early 0-5 years Parental sensitivity Interaction videotaped and rated; Interrater agreement and
Relational Assessment and responsive- video replay interview with discriminant validity established
(PCERA) ness parents Normative data available
(R. Clark, unpublished) Infant dysregulation Assesses quality of affect and
Dyadic mutuality behavior in parent—child
and tension interactions
Identifies strengths and concerns
Parenting Stress Index; 0-10 years Parental sense of Parental report Short form available
(PSI) competence Identifies parent-child systems Reliability and validity established
(Abidin. 1995a. 1995b) Child adaptability under stress and at risk for
and demanding- dysftinctional patenting
Standardized instruments may be used as part of comprehensive assessment but should not constitute the sole basis for diagnosis or treatment planning. In addition, standardized instruments should be used within a developmental framework, guided by the principle that infants and toddlers must be understood in the context of the relationships within which they are developing. Because developmental processes are complex and rapidly changing for this age group, establishing reliability and validity of standardized measures is especially challenging (Clark et al., 1993) . The Bayley Scales of Infant Development, 2nd edition (Bayley, 1993)  was developed to identify deviations in development. It has been used cross-culturally in research and clinical assessment since the first edition in 1969 (Bayley, 1969) . Interview and observation schedules for specific disorders presenting during the infant and toddler years are also available (DiLavoreet al., 1995) . These measures provide a standardized format for child assessment and parent interviews by prompting the psychiatrist to inquire about disorder-specific items. Additional standardized data may be derived from parent checklists and rating scales assessing a narrow or broad range of symptoms (Barkley, 1988; Clark et al., 1993; Crowell and Fleischmann, 1993; Meisels and Provence, 1989; Meisels and Shonkoff, 1990) [7, 19, 21, 51, 52]. These measures are used for problem identification or screening for developmental delays.
for assessment may have
Other infant and toddler assessment tools used to structure clinical observations and augment parental reports include the following: Infant-Toddler Developmental Assessment (IDA) (Erikson, 1996; Provence et al., 1995) [30, 58]; Infant/Toddler Symptom Checklist: A Screening Tool for Parents (De Gangi et al., 1995) ; Working Model of the Child Interview (Zeanah and Benoit, 1995) ; the MacArthur Communicative Development Inventory (MacArthur Communicative Development Inventory, 1993) ; Project AIMS: Developmental Indicators of Emotional Health (Partridge et al., 1992, 1996) [56, 55]; Nursing Child Assessment Satellite Training (NCAST) Teaching and Feeding Scales (Barnard, 1979) . Widely used temperament scales include the Infant Behavior Questionnaire (Rothbart, 1986)  and the Toddler Behavior Assessment Questionnaire (Goldsmith, 1996) .
INTERDISCIPLINARY ASSESSMENT AND
Diagnostic classification schemes are evolving as data and understanding in this field progress. The ICD-10 categories parallel those of the DSM-IV. Both lack diagnostic criteria and time frames specific to infants and toddlers. The DC:0-3 is the newest classification. DC:0-3 proposes an evolving developmentally appropriate multiaxial framework intended to complement the DSM-IV. The Zero to Three/National Center for Infants, Toddlers, and Families' interdisciplinary Diagnostic Classification Task Force was established in 1987. Preliminary data collected by the task force guided the development of diagnostic criteria. Plans for standardized training, ongoing data collection, and field testing for the DC:0-3 are currently being developed (Zero to Three/National Center for Clinical Infant Programs, 1994) .
diagnostic categories that
define new constructs arising
and research experience
with infants, toddlers, and
Axis I categories
include Regulatory Disorders
Regulatory Disorders define
disorders that are
constitutionally and maturationally
based sensory, sensory-motor,
problems associated with
difficulties in regulating
behavior. The Multisystem
category offers an
alternative to pervasive
(DSM-IV and ICD-10)
young children with
significant impairment in
significant motor and sensory
processing difficulties but
II, Relationship Classification,
may be used to
disorders or patterns of
relating with each
parent figure or
caregiver. Axis V,
The clinician's diagnostic formulation process expands the formalcategorical diagnosis by identifying, to the fullest extent possible, thepredisposing factors and current precipitants of the infant's difficulties.
The formulation and recommendation processes evolve collaboratively with the family as a continuation of the assessment process.
developmental, and multigenerational elements. The infant's attachment capacity; social, emotional, cognitive, physical, and language development; and temperament are characterized. Such features as vigilance, protection, physiological regulation, play, symbolism, communication, learning style, control, and regulation of affect are described, and relative strengths and weaknesses are clarified. Risk factors, protective factors, sociocultural experience, and biological factors are components of the discussion.
The discussion of the findings, formulation, and recommendations may require more than one session. The parents' and other caregivers' explicit and implicit expectations may help guide selection of treatments. An individualized plan is designed to capitalize on the strengths of the child and parents and the extended environmental context. Additional assessments, treatment referrals, and communication of findings to outside sources should be discussed as part of the treatment planning process. Sharing the findings and recommendations with other providers, including the pediatrician, day-care personnel, social services personnel, or parents' mental health providers helps to coordinate the complex environmental support system young children need.
These parameters are not intended to define the standard of care nor should they be deemed inclusive of all proper methods of care or exclusive of other methods of care directed at obtaining the desired results. The ultimate judgment regarding the care of a particular patient must be made by the clinician in light of all circumstances presented by the patient and his or her family, the diagnostic and treatment options available, and available resources. Considering inevitable changes in scientific information and technology, these parameters will be reviewed periodically and updated when appropriate.
Abidin RR (1995a),
Parenting Stress Index. Odessa,
Abidin RR (1995b),
Parenting Stress Index-Short
Form. Odessa, FL2:
CS, Howell CT (1987), Empirically
Waters E, Wall S (1978),
American Academy of
and Adolescent Psychiatry
Association (1994), Diagnostic
Barkley RA (1988),
behavior rating scales
and checklist. In:
8. Barnard KE (1979), Instructor's learning resource manual. Seattle: NCAST, University of Washington. [Context Link]
Barrett KC, Campos
(1987), Perspectives on emotional
Bayley N (1969),
Scales of Infant Development.
Bayley N (1993),
Scales of Infant Development
II. San Antonio:
Boris NW, Fueyo M,
CH (1997), The clinical
Bornstein M, Sigman
(1986), Continuity in mental
Bowlby J (1982),
Attachment, Vol I: Attachment,
2nd ed. New York: Basic
Caldwell B, Bradley
(1978), Manual for the Home
16. Call JD (1985), Psychiatric evaluation of the infant, child and adolescent. In: Comprehensive Textbook of Psychiatry IV, Kaplan HI, Sadock BJ, eds. New York: Williams & Wilkins, pp 1614-1625. [Context Link]
Call JD (1987),
Psychiatric syndromes of infancy.
In: Basic Handbook of
Chess S, Thomas A
Issues in the clinical
Clark R, Paulson A,
Conlin S (1993), Assessment
of developmental status
20. Cox A, Rutter M, (1985), Diagnostic appraisal and interviewing. In: Child and Adolescent Psychiatry: Modern Approaches, 2nd ed, Rutter M, Hersov L, eds. Boston: Blackwell Scientific, pp 233-248. [Context Link]
MA (1993), Use of structured
22. De Gangi GA, DiPietro JA, Greenspan SI, Porges SW (1991), Psychophysiological characteristics of the regulatory disordered infant. Infant Behav Dev 14:37-50. [Context Link]
De Gangi GA,
Sickel RZ, Wiener AS (1995),
24. DiLavore PC, Lord C, Rutter M (1995), The pre-linguistic autism diagnostic observation schedule. Autism Dev Disord 25:355-379. [Context Link]
Emde RN (1980),
availability: a reciprocal
reward system for
26. Emde RN (1985), The affective self: continuities and transformations from infancy. In: Frontiers of Infant Psychiatry, Vol 2, Call J, Galenson E, Stinson R, eds. New York: Basic Books. [Context Link]
Emde RN (1989), The
infant's relationship experience:
Emde RN, Bingham
Harmon RJ (1993), Classification
Emde RN, Gaensbauer
Harmon RJ (1976), Emotional
Erikson J (1996),
Assessment (IDA): a
Fonagy P (1996),
Prevention, the appropriate target
Fonagy P, Steele H,
Steele M (1991), Maternal representations
33. Fraiberg S (1980), Clinical Studies in Infant Mental Health. New York: Basic Books. [Context Link]
Archer P et al. (1990),
Denver II Screening
35. Gaensbauer TJ, Harmon RJ (1981), Clinical assessment in infancy utilizing a structured playroom situation. J Am Acad Child Adolesc Psychiatry 20:264-280. [Medline Link] [Context Link]
36. Goldsmith HH (1996), Studying temperament via construction of the Toddler Behavior Assessment Questionnaire. Child Dev 67:218-235. [Medline Link] [Context Link]
Floortime: Tuning in to Each
Child. New York:
(1993), Regulatory disorders.
In: Handbook of
39. Hirshberg LM (1993), Clinical interviews with infants and their families. In: Handbook of Infant Mental Health, Zeanah CH, ed. New York: Guilford, pp 173-190. [Context Link]
History-making, not history-taking:
41. Kagan J (1984), The Nature of the Child. New York: Basic Books. [Context Link]
King RA, Noshpitz
(1991), Pathways of Growth:
Essentials of Child
Lewis M (1995),
Emotional Life of the
Toddler. New York: The
(1995), Disorders of attachment
in infancy. In:
Development Inventory (1993),
Infants and the
Mayes LC (1995),
assessment and treatment of
the psychiatric needs
McCall RB, Eichorn
Hogarty P (1977), Transitions
on early mental
49. McDonough C (1993), Interaction guidance: understanding and treating early infant-caregiver relationship disturbances. In: Handbook of Infant Mental Health, Zeanah CH ed. New York: Guilford, pp 414-426. [Context Link]
(1996), New Visions for
(1989), Screening and Assessment:
(1990), Handbook of Early
*Minde K (1995),
Psychiatry. Child and Adolescent
54. Minde K (1996), The effect of disordered parenting on the development of children. In: Child and Adolescent Psychiatry: A Comprehensive Textbook, 2nd ed, Lewis M, ed. Baltimore: Williams & Wilkins, pp 398-410. [Context Link]
Partridge SE, Brown
Devine D, Hornstein J, Marsh
J, Weil J (1996),
Hornstein J, Marsh J, Curtis
Perry BD, Pollard
Blakley TL, Baker WL, Vigilante
Vater S, Palmeri S (1995),
Quinton D, Rutter M
(1988), Parenting Breakdown:
The Making and
Rothbart MK (1986),
Longitudinal observation of
infant temperament. Dev
Rutter M, Hersov L
(1994), Child and Adolescent
(1975), Reproductive risk
and the continuum of
(1995), Symptom expression
64. Segal M, Webber NT (1996), Non-structured play observations: guidelines, benefits, and caveats. In: New Visions for the Developmental Assessment of Infants and Young Children, Meisels SJ, Fenichel E, eds. Washington, DC: Zero to Three National Center for Infant, Toddlers, and Families. [Context Link]
65. Shaffer D, Ehrhardt AA, Greenhill LL (1985), The Clinical Guide to Child Psychiatry. New York: The Free Press. [Context Link]
Sparrow SS, Balla
Cicchetti DV (1984), Vineland
67. Stern DN (1984), Affect attunement. In: Frontiers of Infant Psychiatry, Vol 2, Call J, Galenson E, Tyson R, eds. New York: Basic Books. [Context Link]
68. Stern DN (1985), Interpersonal World of the Infant. New York: Basic Books. [Context Link]
69. Stern DN (1995), The Motherhood Constellation: A Unified View of Parent-Infant Psychiatry. New York: Basic Books. [Context Link]
70. Thomas JM (1995), Traumatic stress disorder presents as hyperactivity and disruptive behavior: case presentation, diagnoses, and treatment. Infant Ment Health J 16:306-317. [Context Link]
Thomas A, Chess S,
HG (1968), Temperament
and Behavior Disorders
Vygotsky LS (1978),
in Society. Cambridge,
MA: Harvard University
Werner EE, Smith RS
(1982), Vulnerable But Invincible:
Wiener JM (1997),
Textbook of Child & Adolescent
Psychiatry, 2nd ed.
theory of parent-infant
relationship. In: The
76. World Health Organization (1992), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). Geneva: World Health Organization [Context Link]
77. *Zeanah CH (1993), Handbook of Infant Mental Health. New York: Guilford. [Context Link]
78. Zeanah CH, Anders TF, Seifer R, Stern DN (1989), Implications of research on infant development for psychodynamic theory and practice. J Am Acad Child Adolesc Psychiatry 28:657-668. [Medline Link] [Context Link]
79. Zeanah CH, Benoit D (1995), Clinical applications of a parent perception interview in infant mental health. In: Infant Psychiatry. Child and Adolescent Psychiatry Clinics of North America, Minde K, ed. Philadelphia: Saunders. [Context Link]
Zeanah CH, Boris
Larrieu JA (1997), Infant
Center for Clinical Infant