IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

A.4

INTRODUCTION

THE CLINICAL ASSESSMENT OFINFANTS, PRESCHOOLERS AND
THEIR FAMILIES
2017 edition
Sarah Mares & Sarah Woodgate
Sarah Mares BMBS, FRANZCP,
Cert Child Psych, MMH

Consultant Infant, Child andFamily Psychiatrist; Conjoint
Senior Lecturer, UNSW,
Sydney & Honorary Fellow,
Menzies School of HealthResearch, Darwin, Australia
Conflict of interest: nonereported.

Sarah Woodgate MBBS

(Hons), BMedSci, MRCPsych,
FRANZCP

Staff Specialist Psychiatrist
Karitane, NSW & HETI Fellow
in Perinatal, Infant, Childand Family Psychiatry, RoyalPrince Alfred Hospital, Sydney,
Australia
Conflict of interest: nonereported.
Acknowledgements
Dr Noemi Scheuring,
pediatrician from the Heim Pal
Children’s Hospital, Budapest,
Hungary, wrote the section on
infants in medical settings. The
2012 edition of this chapter
was co-written with Dr Ana
Soledade Graeff-Martins.

Mother breastfeeding her
son by Kitagawa Utamaro(Japan, 1753-1806)

This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2017. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Mares S, Woodgate S. The clinical assessment of infants, preschoolers and their families. In Rey JM (ed),
IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatryand Allied Professions 2017.

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IACAPAP Textbook of Child and Adolescent Mental HealthH

ealth professionals meet families with infants and young children in
many different circumstances, from the family home to acute hospitalsettings. The extent to which mental health and development is the focusof assessment and intervention will be determined by the setting and the family
and their presenting concerns. Children’s social and emotional wellbeing andphysical health and development cannot be considered in isolation or separatelyfrom the quality of family relationships and social and cultural context. Wherever
they live and whichever culture they are born into, all babies depend on warm,
responsive, language rich, protective environments in which to grow and develop.
The quality of care that small children receive is critical to their survival, growthand psychological development (WHO, 2004).

Click on the image to reada statement on the rights
of infants which has beendeveloped by the World
Association for Infant Mental
Health (WAIMH)

How families and communities meet children’s developmental needs varies
greatly across cultures and communities. For example, the small family grouptypical of many western nations differs greatly from the multiple caretaking
arrangements in many other parts of the world.
This chapter outlines a framework for assessing infants, young children
and their families. It provides an approach to understanding and formulating
their difficulties that can be adapted to a range of settings. No matter what
the presenting issue, a comprehensive assessment always includes factors that
contribute to resilience and vulnerability in the child, the parents and wider family,
and the social and cultural context. This information is used to inform and focus
interventions. Assessment of risk (e.g., developmental risk, risk of harm to theinfant or the caregiver) is also part of all infant and early childhood health andmental health assessments. The aims of this chapter are: to enhance the interest
and ability of health professionals to assess mental health and developmental
issues in all their dealings with families who present during this period of rapid
developmental change, and to introduce the clinical field of infant mental health,an area of research and practice that has developed substantially over the last 30
years.

THE IMPORTANCE OF EARLY RELATIONSHIPSA psychologically
healthy infant ischaracterized by:
•

•
•

•

The ability to form
close and secureinterpersonal
relationships
Drive to explore theenvironment and learn
All within the context offamily, community, andcultural expectations
for the child
Synonymous withhealthy social andemotional development

There is increasing evidence of the infant’s capacity and motivation for social
interaction, exploration of the environment and learning from birth. The infant“self ” or “person” emerges in the context of early caregiving relationships during
the transition from almost total dependence on caregivers towards independence
and early self-regulation. Infants are born ready to relate, and the family has a
crucial part in facilitating and supporting infants’ development throughout theearly years. Their capacity to do this affects the strengths and vulnerabilities infants
will carry for their lifetime.
Parenting quality also has a developmental impact. The child’s carers are vitalin supporting the unfolding of the infant’s social and emotional capacities. The
family (infant, caregivers, and siblings) exists within a network of relationships andculture that includes their social and physical circumstances of the family. These
can either support or undermine the family’s quality of life and relationships. The
infant is genetically and biologically programmed for development but particularenvironmental experiences are required at specific times - known as sensitive andcritical periods for optimal development - and early support and adversity influence

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A series of podcasts, videos
and print handouts about
early development areavailable at the Zero to Threewebsite. Click on the picture
to view.

2

IACAPAP Textbook of Child and Adolescent Mental HealthResources for the Science of Early Development
There are a variety of resources that highlight the significance of the early years. These
introduce the science of early development, prevention and intervention. A selection would
include:•The Harvard University Center on the Developing Child (in English and PDF in Spanish)
and their InBrief series•

Zero to Three•

The Adverse Childhood Experiences Study (ACEs) has been instrumental in illustrating
the profound impact of childhood experiences, both positive and negative.

how the baby’s genetic endowment is expressed and realised. The lifetime effects ofadversity in childhood are now well recognised (Anda et al, 2006).
The first year involves the development of the basics for language and theestablishment of attachment relationships. The second year of life involves two
major achievements (i) language and symbolic play, and (ii) mobility. Mobility
allows children to explore and develop cognitively and to develop independence
from the caretaker. The toddler experiments with separation and develops a senseof identity and autonomy. During the third and fourth years of life children
consolidate, refine and expand these abilities into a sense of self in relation toothers and their place in the world (see Chapter A.2, Table A.2.1).

Early Relationships – The Cultural Context
Children are raised within a range of family and community constellations
and multiple caretaking arrangements are widespread cross-culturally. A focus onunderstanding children’s relational networks and their adaptive value in particularfamily and community environments is an essential element of assessment. Thereis an expanding literature identifying the core elements of adequate care for infants
and how this is provided in different cultures. This includes how children’s needs
are met and by whom. It also considers how a child’s sense of self, and theirdeveloping sense of agency and obligation, is supported and will vary dependingon the community where they are raised and how they are socialized (Keller, 2016).
Health workers have an obligation to consider how their own cultural andfamily experiences may influence their perceptions of and expectations about what
appropriate care for children involves. This is particularly true when working incommunities where there is cultural and linguistic diversity. Given high rates ofCare for Child Development (CCD) is a UNICEF program based on evidence about theidentification of critical caregiver skills that affect children’s healthy growth and development(sensitivity and responsiveness). It draws on research demonstrating that these importantskills can be supported and taught in otherwise under-resourced communities. The program
includes resources for health workers that focus on core care giving skills such as sensitivity
and responsiveness - being aware of the infant and responding appropriately to the infant’s
signals that can be integrated into maternal and child health programs.

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IACAPAP Textbook of Child and Adolescent Mental Healthvoluntary migration and the vast number of displaced people across the world,
cultural competence and sensitivity are increasingly necessary.

ATTACHMENT THEORY
Attachment theory (see also Chapter A.2) was developed by John Bowlby
from a range of previously separate and diverse areas of knowledge (Bowlby,1969). It is an integrated body of theory and practice that enables links to be madebetween behaviour and inner representations of relationships, and between theexperiences of one generation and the care they will provide to the next—that is,trans-generational aspects of parenting. Attachment can be defined as an enduring
emotional bond characterised by a tendency to seek and maintain proximity to a
specific figure(s), particularly when under stress. Attachment theory understands
the nature of infants’ attachment to their caregivers as a primarily biologicallydetermined phenomenon upon which survival depends. The quality of attachment
relationships developed between a young child and their caregivers has a significant
impact on social, emotional and cognitive development across the lifespan. The
infant develops internal working models of relationships from the quality andnature of early experience with caregivers, and this influences ongoing social andemotional development. Evidence from longitudinal studies indicates that securityof attachment during infancy is linked to the young child’s developing capacity
for self-regulation, reciprocity and collaborative social interactions (Sroufe et al,2005). There is also growing evidence about the contribution that attachment
security makes to a child’s self-regulation, attention and concentration, andtherefore readiness to learn and to make the transition to school.
Attachment theory also provides explanations for the link between observed
parenting behaviour, the quality of parent and infant relationships and the later
functioning of the child, socially and emotionally. Attachment scholars havedeveloped methods to elicit and evaluate aspects of the inner representational worldof the infant, child, and adult. These processes include methods for evaluating theparent’s capacity to “mentalise” or reflect on, and understand mental states. They
assess the parent’s capacity to wonder about, and empathise with, the experienceof their child, as well as the impact of their own mental state on their children(Fonagy et al, 1991).
Research-based methods for assessing attachment such as the Strange
Situation Procedure (Ainsworth et al, 1978), the Adult Attachment Interview(George et al, 1985), the Parent Development Index (Slade, 2005), and theWorking Model of the Child (Benoit et al, 1997;Vreeswijk et al, 2012) are time
consuming, require extensive training and cannot be easily utilised in the clinicalsituation. Universally accepted clinical and diagnostic protocols for assessing
attachment at different ages and for diagnosing disorders of attachment do not exist
although there is a range of approaches to this in clinical settings (Crowell, 2003;
Zeanah et al, 2011). Many clinicians when consulted about children’s attachments
are handicapped by having little formal training in, and much uncertainty about
assessing attachment clinically (Crittenden et al, 2007). For this reason, outside
a research context, it is advisable to describe what is observed between child andcarer rather than to use language that may imply an attachment classification or
diagnosis when formal assessment has not been undertaken.

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Attachment
An enduring emotionalbond characterised bya tendency to seek andmaintain proximity to a
specific figure or figures,
particularly when understress.
Attachment can be:•
Organised- Secure- Insecure/ambivalent- Insecure/avoidant•
Disorganised

The Circle of Security(COS) website contains
useful information forparents and clinicians
about the importance of
attachment, attachment
quality, approaches toparenting, and interventions.
It is based extensively
upon attachment theory
and current neuroscience.
The COS is a user-friendly,
visually based approach(with extensive use of bothgraphics and video clips)
to helping parents better
understand the needs oftheir children. Information
about the core elements ofthis approach, as well as
training opportunities can beaccessed and downloaded
by clicking on the picture.

4

IACAPAP Textbook of Child and Adolescent Mental HealthJohn Bowlby (1907 – 1990),
a British psychiatrist, wasthe main theorist behind theconcept of attachment.

There is an emerging literature considering the application of attachment
theory and classifications to families in diverse cultural contexts (Quinn & Mageo,
2013; Keller, 2013).
To date, however, there are few cross-cultural studies that consider issuesof attachment disruption and disorder. This is opposed to descriptive studies
that identify cultural diversity in approaches to early parenting and discuss how
development, safety and exploration are supported and maintained in different
cultural and community contexts.
Most infant and early childhood mental health interventions do not require
formal assessment of attachment but a good understanding of attachment theory
allows clinicians to assess emotional and behavioural problems from a relationshipperspective. This includes a focus on the child’s relationship history, and problems
and strengths in the relationship between the caregivers and the child, rather thana focus on strengths or difficulties as existing within the individual child alone(Zeanah et al, 2011). The principles of assessment are summarised in Table A.4.1.
(Retain from original chapter p5)

Attachment Patterns and Disorders
Attachment theory describes three patterns of what are called organised
attachment strategies and one disorganised attachment pattern. This is known as
the ABC+D model (Cassidy & Shaver, 2008) (see also Circle of Security website).
Children develop these patterns of behaviour and managing feelings in responseto repeated interactions with their caregivers. Such strategies are organised tomaintain proximity to caregivers and to manage displays of affect particularly attimes of distress. Organised attachment patterns are classified as secure, insecure/
avoidant and insecure/ambivalent. Disorganised attachment behaviour is considered

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IACAPAP Textbook of Child and Adolescent Mental Healthto indicate that the child has failed to develop a coherent strategy for managing
distress in relation to their caregiver. This most often occurs when the caregiver issimultaneously the source of comfort as well as the cause of distress and anxiety,for example in situations of child maltreatment. (see Howe 2005, Lyons-Ruth etal 2005). Attachment disorders are distinct from attachment patterns, and are
currently classified in DSM-5 as “trauma and stressor related disorders”, requiring
the child to have “experienced a pattern of extremes of insufficient care…” (p265).
An alternative approach to the classification of attachment patterns and disorders–called the “dynamic maturational model” (DMM)–has been proposed by Crittenden(Crittenden, 2006; Landa et al, 2013). The DMM includes a comprehensive focus
on the nature, function and cost of self-protective strategies that a child develops,
including in relation to loss and trauma. This information can then be used to
inform clinical formulation and intervention (Shah & Strathearn, 2014).

THE CLINICAL ASSESSMENT
There are a number of core principles and issues that need considerationin any assessment of a family with an infant or young child, independent of thesetting in which the assessment occurs or the background of the clinician. These
are summarised in Table A.4.1. The principles are drawn from clinical experienceand are informed by research and theoretical understandings of infancy, earlychildhood and family processes. An assessment informed by these core principles
enables the clinician to develop an alliance with the family in order to understandthe presenting problem, and decide where intervention and assistance are best
targeted.

The Setting for the Clinical Assessment
Assessment of infants and their families is undertaken in a wide range ofsettings and circumstances and so the approach will depend upon the clinician’s
The parents of a two year-old girl brought her to a mental health outpatient clinic
complaining that she had been “very nervous and agitated since she was one year old”. Herparents said she often became aggressive, hit her head on the wall at home and scratchedherself. She would wake up stressed, refusing the bottle and scratching her mother. Her
behaviour worsened when in contact with other children, so parents kept her at home. She
was aggressive with adults, throwing toys on the floor or at people. They reported that she wascalm when near her maternal grandfather, who did everything she wanted including things theparents considered dangerous. With strangers she was very shy, keeping her head down andnot talking. The parents could not identify a precipitant for the symptoms but the onset hadcoincided with the child learning to walk and therefore becoming more independent. She lived
with her parents and her eight year old brother.

A comprehensive
assessment is based onan understanding of thedevelopmental tasks of theperiod and observations of
the child–carer relationship.
It includes:•
The clinicalassessment interview•
Observation ofparent–childinteraction andrelationship•
Developmental
assessment of thechild.

It was apparent that parents had very different approaches to managing her. The motherhad difficulty setting limits, while the father, when he was at home, punished the girl physically(hitting her with slippers). The mother said she always wanted to have a daughter whom she
could “dress like a princess” and this girl had not been what she expected. The brother wasvery calm and obedient and had never been a problem.
The psychologist assessed the family during four weeks, interviewing the parents,
observing the child alone and the interaction between children and parents. She referred theparents to a parent training program. After a few sessions, the parents found better ways to
set limits and parent more consistently and the girl’s behavior improved. The next step wasto support parents in sending the child to day care for a few days a week, giving her theopportunity to be with other children and adults.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table A.4.1 Principles of Assessment
1

Assessment of risk
Assessment of the immediate and longer term safety or risks to the infant,young child, and other family members is a necessary and inevitable aspect of
all assessments. This focus may or may not be clear to the family, but is a key
component of clinicians’ responsibilities and obligations.

2

Parents want the best for their children
Almost always, parents want the best for their children and family. The
clinician’s role is to assist them in providing this.

3

Biopsychosocial framework
A biopsychosocial approach ensures that physical, psychological, interpersonal,social and cultural factors that contribute to the presentation of the family andinfant are examined. The physical and psychosocial wellbeing of the infantcannot be considered separately.

4

Developmental context
The perinatal and early childhood period is a time of transition and enormous
growth for infant and family, Children develop at differing rates across a range
of normal parameters and difficulties need to be understood in a developmental
context. Emotional, behavioural and developmental problems presenting ininfancy can have lifelong consequences but some are the manifestation of
normal developmental transitions: over time, with adequate support, they will
resolve.

5

A relational approach
Early development can only be understood within the caregiving context.
As described above, this includes attachments and the quality of the infants’
primary relationships. Although individual factors in the child or parent may
contribute to current difficulties, the interaction or “fit” between the needs andcapabilities of each family member and the sources of stress and support in thefamily context, could determine outcome.

6

The assessment
process is facilitated byassuming that parents
are the experts on theirchild and have theirchild’s best interests atheart.

Vulnerabilities and strengths
Identifying vulnerabilities and strengths (also called risk and protective factors)
helps shape and target interventions.

7

The transactional model of development
The transactional model of development (Sameroff & MacKenzie, 2003)
emphasises the interaction between genetic and environmental factors overtime and ‘the development of the child is seen as a product of the continuous
dynamic interactions of the child and the experience provided by his or her
family and social context’ (Sameroff & Fiese, 2000, p10).

professional role, practice and the aims of the assessment. Visiting a family athome provides very different information from that obtained in a clinic setting.
For example, a family may present only once to their local emergency department
late at night when the parents are concerned their baby is unwell and won’t sleep.
If seen at home, the practical and financial difficulties (for example, a one-roomhouse and noisy neighbours) that affect their ability to focus on and settle theirbaby might become more evident. This would alter the focus of the assessment andrequire a different use of the clinician’s time as well as the potential engagement ofAssessment of infants

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IACAPAP Textbook of Child and Adolescent Mental Healthother colleagues. Assessment may occur in a mental health setting because there
is concern about parental depression and its impact on the infant. Alternatively, afamily may be seen regularly in an early childhood clinic, allowing observation overtime as their relationships develop and the infant grows. Concerns about abuse orneglect require evaluation and inevitably involve the clinician in the difficult taskof establishing rapport and cooperation with parents who feel threatened, afraid or
criticised. A developmental assessment or follow-up of a family with a child withmedical or developmental problems includes a more direct medical or biologicalfocus, but nonetheless needs to consider the familial and social context. There
are no clear right or wrong ways but every clinician needs to think about theadvantages and limitations of the approach they take and how this may impact on
the information they obtain, and to be sure to include a focus on the relationshipbetween the infant and the parents as well as any individual presenting concerns.

Aims of the Assessment
The essential aim of assessment, whatever the context or setting, is to identify
and understand the problems facing the family as individuals and as a familysystem, their strengths and vulnerabilities, in order to assist them in maximising
the developmental potential of their child. Information obtained during theassessment may also be used for other purposes, such as research into clinical orsocial conditions that affect parenting and child development.

Sources of Information
An understanding of the issues and presenting problems for the family andthe baby is developed through integration of information from different sources,
determined in part by the clinical setting and the purpose of the assessment. Directsources of information include:••••

Clinical history provided by the referring agent and the family
Observations of family members and their interactions
Medical and developmental tests and investigations
Other sources (for example, the referring agency and other services
involved with the family, such as child care).

Other information may include:•••

Written reports of previous assessments and interventions
Emotional or “affective” information—including the clinician’s responseto and feelings about the family and their presentation
Information (knowledge, skills and attitudes) drawn from the clinician’s
professional experience.

Information is
obtained about:
The current problem:• Why have they come tosee you ? (What is the
problem?)• How do family
members understandand describe what isconcerning them?
• Has this happened
before?
• Was there a precipitant?
• Why have they sought
help now?
• What have they tried
and what has been
helpful?
• What made them decide
to seek help from you
and your service?
• What do they want help
with? What are theirpriorities?
The background anddevelopmental history of• Child• Parents and family• Current supports andstressors. This includes
information about:o The individual
parent’s history of
their own family andelationshipso Parents as a couple
o Conception,
pregnancy anddeliveryo Child’s evelopment
since birth.

The Assessment Process
There are a number of key considerations in assessing families with infants
or young children. It is important to enable parents and caregivers to explore
the complex emotions related to parenting and to support them to identify
obstacles that may impede their best efforts. This process is best facilitated by
an approach that starts from the assumption that parents are the experts on theirchild and have their child’s best interests at heart. In addition, non-judgemental

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IACAPAP Textbook of Child and Adolescent Mental Healthlistening and genuine curiosity about the problem, the family and the child areessential in communicating the clinician’s interest and concern. As the assessment
includes a family member who is not yet verbal and able to tell their own story inwords, observation of behaviour and interactions, of more than what is spoken,
provides the clinician with rich information about the family system. Finally, theprovision of information, advice and intervention should not precede a thoroughunderstanding of the presenting issues.

The Interview
The goal of the interview is not only to gather information and objective
data, but also to form a therapeutic relationship within which the problem can beunderstood and hopefully resolved. Whether a family is seen only once or for aseries of contacts, the process of developing a therapeutic alliance often determines
success in eliciting the facts of the history. Just as parenting is primarily about
relationships, so contact with distressed families needs to be understood as aprofessional relationship within which the family can feel heard and understood,
and therefore better able to care for their child.
It is important to be clear and direct about the purpose of the interview,professional roles and responsibilities, and any limits to confidentiality. Even whenassessing concerns about child maltreatment or providing a medico-legal report,
the importance of the therapeutic alliance cannot be underestimated. Listen
carefully to the family: Why have they come? What are their concerns? What dothey want help with?
During the interview, there are opportunities to observe the infant or toddler
and their interactions with the adults. A unique aspect of assessing families withan infant or young child is that frequently the “patient” has no words to tell theirside of the story. In this case, what is observed about the child, their behaviour,
their responses and the interaction between family
members is crucial in helping the clinician understand Examples of risk and protective factors
the child’s experience.
The clinician and parents can then constructa narrative or “story”—an account of the family’s
experience with the child—to make sense of what
is happening. This understanding or “version of thestory” is often modified through the assessment andintervention, as development and change occur.

The History
During the assessment—ideally the child, bothparents and other significant caregivers are present—
the clinician explores with the family their hopes
and fears, their expectations of themselves and thischild, as well as their experience with medical andpsychological services. Biological, psychological andsocio-cultural information is collected to identify risk
and protective factors in the child, parent(s), theirrelationships, and the social and cultural context. It

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Tammy was born slightly premature and narcotic
dependent as her mother had used heroin during pregnancy(biological risk). Her mother was thought to be unable to carefor her because of ongoing substance use and Tammy wasplaced with her aunt and uncle when she was one month old(the quality of care she receives in this kinship placement will
determine whether it is a developmental risk or a protective
factor for Tammy). She was initially a very irritable andunsettled baby but then developed well and established anorganised attachment to her aunt (psychologically protective).
When she was aged three, a severe tornado lashed thetown where the family lived destroying the house (contextualrisk). Although no one was hurt, the family had to live in a
shelter for several months, the uncle lost his job and there
were a lot of stressors, resulting in him becoming depressed(psychological/ relational risk). In order to find work they had
to move from the area they had always lived in to another
district where they were socially isolated (socio-culturalrisk). They were a resourceful family and developed close
relationships with other families who were also new to thetown and who helped them settle in the new community(contextually protective).

9IACAPAP Textbook of Child and Adolescent Mental Healthcan be helpful to allow the family to start by telling their story in their own way,rather than firing too many questions before they have been able to use their own
words to explain what is concerning them.

Cornelis de Vos. Portrait of
Anthony Reyniers and his family(1631) Philadelphia Museumof ArtAttachment-Informed Assessment
As noted above, formal assessment of attachment is not usually conductedin clinical settings, but an attachment-informed approach to assessment includes:•

The history of the conception, pregnancy and birth and any losses orsignificant difficulties for the family associated with this time.

•

A history of the child’s attachments. It is important to focus on achronological account of the significant attachment figures available tothe child since birth, particularly disruptions in care, abandonment orlosses, alternate caregivers, neglect of care and abuse. Availability of thecurrent primary carer and contact with other caregivers should be noted,
as well as the child’s behaviour with each, and response to changes ofcarer. In older children, relationships with peers and siblings should be
described.

•

Details and observations of the infant or child’s current behaviour. Of
particular interest in relation to attachment quality and disruptions or
disorder are:oHelp or comfort-seeking behaviour, including response to pain or
distress (e.g., who do they go to if they fall and hurt themselves; dothey show distress; are they discriminating about who can comfort
them? are they shy with strangers?)

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IACAPAP Textbook of Child and Adolescent Mental HealthContext -The family and the social environment (Reder et al, 2003)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Family functioning: for example, poverty, unemployment, responses to stress, social orcultural isolation
Stability in relationships and social circumstances
Relationship with others and the ability to use interventions and community support
The extended networks that support or abandon the family at this time of rapid
developmental change
Social and cultural factors that impinge on the family
Relationship quality and interactions
Family violence
Practical issues and circumstances: the practical reality of the family situation,
including housing, poverty, employment, and educational opportunities.
What do parents bring to parenting?
Their psychological and social strengths and resources
Their phantasies of what and who the child will be for them
The history that precedes conception and birth, including their experiences in theirown family and their experiences of being parented.
Their expectations of themselves as parents, influenced by their own experiences offamily life
Their psychopathology: the parents’ past and family psychiatric history and current
difficulties including parental substance abuse
Parental age and life stage.

o

Quality of interaction and ability to use caregiver or another adultfor comfort, including ability to explore and play in a new setting,response to limit setting and the nature of the interaction with theclinician.

This needs to be understood within a developmental framework. A sixmonth-old is less likely to show shyness or fear of strangers than a 12-month-old.
A three-year-old may be able to use verbal information from the carer (e.g., “I amgoing out for a minute, I will be back soon”) to tolerate a short separation while a
15-month-old is less able to do this.

The Bio-Psycho-Social Framework
The infant is born with a genetic endowment, including what is often called
temperament, and at birth has already been affected by their environment in utero(for example, the adequacy of nutrition, drug or alcohol exposure, prematurity orother medical illness) (see Chapter B.1). These are biological contributions to thepresentation.
The quality of parenting may alleviate or exacerbate a child’s constitutionaldifficulties. This is often described as goodness of fit between parental expectations
and capabilities and infant aptitudes and needs. It includes psychosocial andinterpersonal factors, as well as biological aspects of the parents’ and infants’ healththat affect their ability to meet their baby’s needs.
The place of the child in the family, including gender and birth order, themeaning of this child to these parents at this time in their lives and their placein the sociocultural context are also important. Information should be obtained

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IACAPAP Textbook of Child and Adolescent Mental Healthabout biological, psychological and social factors that have helped or hindered thefamily now and in the past.
Biological Factors
These include genetic vulnerability, past and current health, and any
significant family history of illness. In the young child this includes intra-uterine
exposure to drugs or other toxins, and other factors affecting development andphysical health.
Psychological and Relational Factors
Intra-psychic factors, such as current psychiatric illness, personality issues
and attachment style and interpersonal factors, such as the history and quality ofcurrent relationships.
Social, Cultural and Contextual Factors
Factors in the social context, the degree of cultural and social isolation or
support, financial security and parental employment. Socioeconomic status is a
Table A.4.2 Rating scales and questionnaires
Instrument

Comments

Child Behavior
Checklist (CBCL) ) for
1.5 -5 yrs••(Achenbach & Rescorla,
2000)

•
•

Strengths andDifficulties
Questionnaire (SDQ)(Goodman, 1997)•

The Ages and Stages
Questionnaire (ASQ-3)(Squires & Bricker, 1999)•••

The Ages and Stages
Questionnaire: Social
Emotional (ASQ:SE)(Squires et al, 2003)••

Preschool Age
Psychiatric
Assessment (PAPA)(Egger & Angold, 2004)•

The Parenting StressIndex – Short From
(PSI-SF)•••(Abidin, 1995)

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Two questionnaires to assess adaptive and maladaptive functioning of 1½-5 yearolds. Rated by parents, day care providers and teachers
A recent international project using the CBCL identified consistencies in aggregationsof emotional and behavioural problems in preschoolers across the 24 societies
participating in the study (Ivanova et al, 2010; Rescorla et al, 2011).
Proprietary
It rates 25 attributes, some positive and other negative. The SDQ has an impact
supplement that helps in the assessment of impairment related to behaviours thechild is presenting with. Parent and teacher versions for two to four year-olds inseveral languages
Free of charge
Developed to identify infants and young children (0-5) with potential developmental
problems. Five areas are screened: communication, gross motor, fine motor, problem
solving, and personal-social. Completed by parents/carers
Proprietary
A culturally versatile tool for clinicians to identify and monitor children at-risk forsocial, emotional and behavioural delays. The ASQ-SE rates a child’s developmentin the behavioural areas of self-regulation, compliance, communication, adaptive,
autonomy, affect and interaction with people
Proprietary
A structured parent interview for diagnosing psychiatric disorders in preschool
children (two to five years old). Used as a research tool, it can be used in also clinicalwork.
Proprietary; formal training required. For more information
Screens for stress in the parent-child relationship, dysfunctional parenting, parental
behaviour problems and child adjustment difficulties within the family.
Available in several languages.
Proprietary. More information at

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IACAPAP Textbook of Child and Adolescent Mental Healthpowerful predictor of infant developmental outcome (Zeanah et al, 1997), but thefamily’s ability and willingness to access and use support is crucial. Factors to beconsidered here, identified by Reder et al (2003), are outlined in the above text
box.

Transgenerational Issues in Parenting
Becoming a parent is a powerful trigger for feelings, thoughts and memories
about a person’s own upbringing. Many aspects of parenting are determined by
how we were parented ourselves, who held us, how were we comforted, how ourneeds were met. This information is stored in procedural memory, memory foractions, not in verbal memory. The earliest experiences with our parents occurred
long before we were able to put emotions in words. As Winnicott (1987) puts it:“… she was a baby once, and she has in her the memories of being a baby; she also
has memories of being cared for, and these memories either help or hinder her in
her own experience as a mother” (p 6).
Parents who experienced abuse or neglect as children enter parenthood at
a disadvantage. This is because of the abusive models of relationships they haveto draw on, the effect of early neglect or abuse on their own capacity for selfregulation and reflection, and this is often associated with limited current family
and social support. Only about one third of children who have been abused go
on to be abusive parents (Egeland et al, 2002), but this is clearly a risk factor for
difficulties in parenting. Assessment of risk is discussed in more detail below.

Parents of infants andtoddlers frequently
are worried aboutdevelopmental delays
and behaviours related to
autism spectrum disorders(ASDs). It is important thatclinicians keep this in mind
to recognize the early signsof ASDs; children with
ASD whose conditions are
diagnosed early and who
participate in appropriate
intervention programs havebetter outcomes (Johnson
et al, 2007). The American
Academy of Pediatrics
has resources to support
paediatricians in theidentification and care ofchildren with ASD.

Self report Measures and Semistructured Interviews
Besides the history and clinical observation of the child, questionnaires,
rating scales and structured interviews can be used to help in the assessment
process. Standardized instruments pose questions about the child’s behaviour thatcan be easily rated. They are designed to be completed by parents, child-carers andAssessing interaction•
A mother, who was having treatment for a postpartum psychosis, said proudly that she
was breastfeeding her baby and it was going well. When the baby started moaning she
picked him up and positioned him well to feel but did not open her shirt or give the baby
access to her breast, just holding him against her shirt where the baby vainly attemptedto latch onto the breast. The mother seemed unaware of his struggle until he grizzled
loudly. She still did not open her shirt until the clinician suggested it.
•

A two year old boy fell off the chair during the assessment and bumped his head quite
hard. His mother had described him as “independent”. Instead of crying or going to hismother, he walked to the window and looked outside. It was striking to the interviewerthat he did not seek parental confort or show distress.

•

A five year-old boy is brought by his mother to a consultation with a primary care
psychologist. The boy was referred by his teacher because he was not able to do theactivities proposed in class. He was always quiet and alone, refusing peers’ invitations
to play. The mother could not understand his behaviour. In their second consultation,
the psychologist invited the boy to play offering him some toys. The boy only could
play when the mother came into the room and gave him verbal instructions about what
to do. He only moved or changed toys after she gave him permission. After that, thepsychologist enquired more about his habits and noticed that he was not allowed to do
anything the mother had not planned.

For further opportunity to consolidate your learning please see self directed learning
exercises, Appendix Q2”.

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IACAPAP Textbook of Child and Adolescent Mental Health

Observation provides information about:
•
•
•
•
•
•
•
•
•
•
•
•
•

The child’s sense of safety in an unfamiliar environment
Parental sensitivity to the childChild responsiveness to parental care and attention
Help and comfort seeking by the child
Shared attention and enjoyment
Fit between parent and childChild and parent safety
Parents’ capacity to work together to care for the child and the quality of theirrelationship.
The relationship and interaction with the child is affected by:
Immediate contextual factors
Individual aspects and characteristics of the caregiver and child
Events in the past, especially the parents’ experience of being parented
The language used by parents, the way they talk to and about their child also
provides information. You may notice for example:• Offhand remarks and nicknames• Stories (e.g., when a parent may consciously or unconsciously be talking aboutother people or situations but is describing something about the child or theirinteractions with the child)• Non-verbal communication between parents, and between parent and child,particularly facial expression and touch• What parents say to the child, what they say about the child and how thesecompare• Ideally, communication between parent and infant or young child is:o Contingent: the parent is responsive to the child’s cues, rather than
intrusive and insensitiveo Collaborative: both parties are active participants in the interaction
and build or repair their communication together to restore optimal andcomfortable levels of arousalo Emotionally attuned: the parent is able to identify and tune into the child’s
emotional state and to organise their responseteachers, giving information about the child’s functioning in different contexts.
Examples of measures that have been adapted, translated, or used with a range ofcultural and linguistic communities are summarised in Table A.4.2.

ASSESSING AND SUPPORTING INTERACTIONSBETWEEN PARENTS AND INFANTS AND YOUNG
CHILDREN
Even in a brief interview with a family, many observations can be madethat provide information about the quality of the interaction and relationships.
This is also a central component of risk assessment. Interactions reflect the parents’nurturing capacity, their ability to respond sensitively and appropriately to theirchild’s cues as well as the child’s ability to indicate what they need and to accept
and respond to parental care.
The daily routines of feeding, sleeping and changing are the setting forimportant social exchanges, and also times of increased risk for the child if theAssessment of infants

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IACAPAP Textbook of Child and Adolescent Mental HealthChildren typically develop
attachment relationships
with both parents and oftenwith grandparents and othercaregivers.

Father and child, Dhaka, Bangladesh. Photo Steve Evanscaregiving system is stressed or inadequate. What parents actually do is more
important than what they say or think they do. This is what makes observation so
important. A parents’ sensitivity to their baby or young child’s communications iscentral to the developing relationship between them and is predictive of the qualityof attachment relationship that may be different with each parent. Observation of
the parents’ responses to their child’s emotional signals and communications, andthe parents’ capacity to interpret these and respond appropriately, is central to theassessment.
The behaviour of the parents and child while they are with you is as important
as what is said. It is recommended that clinicians pay as much attention to whatparents and infants are doing as to what they are telling you. With the infant in theroom you will see how easily they settle, how responsive they are to parental voice

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IACAPAP Textbook of Child and Adolescent Mental Healthand touch, how they indicate their needs and how these are responded to. With a
toddler present, you will learn a great deal about how free he feels to explore theroom, how much proximity he seeks from his parent and the behaviours that gain
parental attention. In addition, it is interesting how the infant or toddler relates toyou. Are they initially shy but then become more sociable? Do they approach you
immediately and engage more with you than with their parents? How do you makesense of these behaviours in the context of the whole assessment?
This depends on the capacity of the caregiver to be empathic, and to be
attuned to the mind and experience of the child. It requires parents to reflect
on their own experiences and inner state and to acknowledge their child as anexperiencing being: to be with, rather than do things to, their child. This is known
as reflective or mentalizing capacity.

Symptoms ofconcern in young
children

Reflective or Mentalizing Capacity•

Mentalizing or reflective capacity refers to the activity of understanding
behaviour in relation to mental states, or “holding mind in mind” (Allen et al,
2008, p3). Mental states include thoughts, feelings and intentions; mentalizing
involves “the capacity to think about feeling and to feel about thinking” in oneself
and in others (Slade, 2005). Fonagy and colleagues (1991) proposed that the parent’s
capacity to hold the child’s experience in mind is linked to the intergenerationaltransmission of attachment security (Slade et al, 2005).
There are formal assessments of reflective capacity available, for example
the Parent Development Interview (PDI) (Slade, 2005). In relation to clinicalassessment the focus is on the parents’ capacity to take the child’s perspective toappreciate that the child has an experience separate from their own. Children are
at higher risk of maltreatment if parents consistently misperceive or misinterpret
their behaviour (Howe, 2005).

Semi-Structured Play Assessment
A structured or semi-structured process for assessing the parent-childrelationship can be useful. An example is the Modified Crowell Procedure(Crowell & Feldman, 1988), which was developed for use with children aged 1260 months and takes between 30 and 45 minutes to administer. The parent isasked to undertake a series of activities with the child, some of which include mild
frustration or difficulty. This usually includes: to play “as you would at home” (freeplay); to follow the child’s lead in the play; asking the child to clean up; playing
with bubbles; a series of puzzles or problem-solving tasks; and a brief separation/
reunion. At the end, the carer is asked how representative these interactions were ofwhat happens at home. The purpose of this assessment is to observe the carer andchild interacting together in a series of slightly different tasks as a way of identifying
strengths and weaknesses in their relationship. The focus is on problem solving,play and enjoyment, and on an informal assessment of attachment. It gives anopportunity to observe the child’s persistence, their use of the carer for support,
their ability and willingness to ask for help, their fine and gross motors skills, andthe degree of enjoyment, ease and pleasure in the interactions. The quality andnature of each participant’s behaviour as well as of their interactions is important,
as is the transition between tasks (e.g., do children have difficulty shifting fromone activity to another? Is their attention span limited? Do they cooperate with

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Very frequenttantrums• No tantrums at
all, too quiet andcompliant• Role reversal:• Controlling andpunitive• Compulsive
caregiving• Self-soothing,
masturbating• Self-harming, headbanging• Persistent
regression, loss of
toileting, more clingy• Persistent precocity
and over-maturity(little adult).
Toddler and preschoolpresentations are
discussed further
in Luby (2006) andBanaschewski (2010).

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IACAPAP Textbook of Child and Adolescent Mental HealthRajni’s parents both used drugs and alcohol regularly after her birth and possibly also
during the pregnancy. She was neglected, physically abused and there was considerable
violence between the parents. She was removed from her parents aged 11 months after an
unexplained leg fracture. At that time her milestones were a little delayed and she was small
for her age. She was placed with an older relative who cared well for her and her growth anddevelopment improved.
When she was 2½ years, her carer developed cancer and Rajni was returned to herparents. Another period of neglect and exposure to violence followed. Rajni was again
placed with a foster family when she was 3½. They reported frequent tantrums, often
scratching and hitting her head. She hoarded and stole food and was indiscriminate socially,
attaching herself to relative strangers, climbing on their laps and holding their hands, andshe would “go blank” when told off or reprimanded or if there was a loud noise, particularly
shouting or arguing.
Rajni’s difficulties could be understood as survival strategies she had developed in
response to her early neglect and abuse. Her behaviour began to settle after a period in asafe and loving home environment but she remained sensitive to noise and had difficulties
with sleeping, feeding and regulating her emotions.
For further opportunity to consolidate your learning please see self directed learning
exercises in Appendix A.4.1.

the request to tidy up? How clearly do parents communicate with the child?). How
children use the caregiver for support during transitions between activities and theseparation and reunion is especially important because these changes represent
mild stressors to young children. More discussion about the use of observational
measures in assessment can be found in Crowell 2003; Crowell & Feldman, 1988;
Mares & Torres, 2014; Miron et al, 2009).

Relationship-Building Tools
The Newborn Behavioural Observation (NBO) system (Nugent et al, 2007)
is an example of a relationship-building tool developed for use by clinicians caring
for families with newborn babies across multiple settings. It was devised at theBrazelton Institute in the US informed by 25 years of research with the Neonatal
Behavioural Assessment Scale (Brazelton 1973; Brazelton & Nugent, 1995).
The NBO is an infant-focussed and family-centred observational tool. It
is conducted with the active collaboration of the parents and aims to describe
the infant’s competences and individuality. It consists of 18 behavioural andreflex tasks that examine the newborn’s physiological, motor and social capacities
over the first 3 months of life (Nugent, 2015). It is performed jointly by theclinician and parents and provides an opportunity for professionals and parents
to collaboratively observe and interpret the newborn’s behaviours. The clinician’s
reflections and comments are also a key supporting aspect of the process. In
general, the NBO aims to help parents to read their newborn’s communication
cues, and to promote and foster a positive parent-infant relationship from the
beginning. There is emerging evidence that the NBO may improve parent-infant
relationship, support the treatment of postnatal depression and anxiety and may
increase fathers’ involvement in the early months of parenting (e.g., McManus &Nugent, 2012). More information regarding the NBO can be found here.

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IACAPAP Textbook of Child and Adolescent Mental Health

DEVELOPMENTAL ASSESSMENT
A developmental assessment can be included when appropriate as part of
the therapeutic intervention. The assessment will vary depending on the purpose of
the assessment, the clinician’s skill and the family’s needs and concerns. Involving
parents in the assessment process provides them with useful information about
their child’s abilities and needs and also allows the clinician to see what use parents
make of this information. More information about infant and child development
can be found in Chapter A.2. Some of the instruments used for developmental
assessments include:•

The Neonatal Behavioural Assessment Scale (NBAS) (Brazelton &Nugent, 1995). The NBAS was designed to capture the early behavioural
responses of infants to their environment, before their behaviour isshaped by parental care. Brazelton’s and Nugent’s assumption is thata baby is both competent and complexly organised and an active
participant in the interaction with caregivers. The assessment seeks tohelp understand the infant’s side of the interaction•

The Bayley Scales of Infant Development (BSID) (Bayley, 1993).
Applicable to children 1-42 months of age, it provides information
about the child’s language development, problem-solving skills, grossand fine motor development, attentional capacity, social engagement,
affect and emotion, and the quality of the child’s movement and motor
control•

The Wechsler Preschool and Primary Scale of Intelligence (WPPSI)(Wechsler, 2002). A neuropsychological assessment that can be useful forchildren from 30 months of age onwards. It evaluates children’s verbal
comprehension, perception, organization and processing speed abilities,
giving clinicians a developmental perspective of the child’s intelligence.

•

The Vineland Adaptive Behavior Scales (Sparrow et al, 1984). Thisis a parent interview that obtains information on children’s adaptivefunctioning in real-life situations covering the domains of daily skills,
communication, socialization, motor functioning, and maladaptive
behaviour.

FORMULATION
The aim of assessment is to understand why this family is presenting withthis problem at this time, and what are the impediments or obstacles that have
prevented them from resolving their difficulties without professional help. This
information forms the basis for what is called a formulation. Formulation is an
integrative statement that provides an aetiological understanding of the problem
and of the factors contributing to the presentation. It can take different forms,
but ideally includes consideration of bio-psycho-social and cultural factors. Thissummary informs the development of a comprehensive intervention plan. Anotherway of thinking about formulation is to identify or organise the information
obtained in the assessment into what can be called the 4 Ps (see Box).
Ideally, during the process of assessment, the family and clinician cometo a new, shared understanding—a story—about the meaning and nature of thepresenting difficulties and also the way forward. Developing an intervention andAssessment of infants

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The 4 Ps
This is a way ofsummarising the factors
contributing to the family’spresentation:• Predisposing:what made this family
vulnerable?
• Precipitating: whyhave they come now?
• Perpetuating: whatmakes it hard for things
to get better?
• Protective: whatstrengths can we
identify and build on in
our intervention in thechild, the family andthe social and culturalcontext?

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IACAPAP Textbook of Child and Adolescent Mental Healthanticipating prognosis requires the clinician to think about and identify protective
factors and resources that can be built on. As discussed above the assessment
process in families with infants and young children have the added complexity ofidentifying and addressing the needs of family members who are not yet verbal.
More information regarding formulation can be found in Chapter A.10, including
a case example in Appendix A.10.1.

A variety of resources can befound and downloaded at thewebsite (click on the picture).
The DC:0-5 (Diagnostic
Classification of Mental
Health and Developmental
Disorders of Infancy and
Early Childhood) is not free
but can be purchased.

DIAGNOSIS IN INFANCY AND EARLY CHILDHOOD
There are many challenges to developing and using diagnostic andclassificatory systems of disorder for infants and young children. This is a period ofvery rapid development and change. Therefore, distinguishing between a transientdelay or disruption and an ongoing disorder can be difficult and requires time andskill. In addition, the focus of assessment, as outlined above, is on relationships andinteractions, while classificatory systems such as DSM or ICD focus primarily on
the individual rather than on relationships and context. Young children are very
responsive to and dependent on the support they receive and therefore may behave
and function quite differently in different settings, for example with familiar adults
at home and at child care. Babies and toddlers have little or no language for theirsubjective experience and therefore assessment relies on the history provided bycaregivers and the clinician’s skill in observation and in integrating informationfrom a range of sources and contexts. In addition, the assessment of relational
quality is a core element of assessing immediate, ongoing or cumulative risk to
the baby or young child and this may include identifying any mental or physicalhealth difficulties and diagnosis in the parents that may impact on their capacity
to adequately care for the child. Last, but not least, psychiatric diagnoses areassociated with considerable stigma in most societies so, at what age should young
children be given a diagnosis?
That said, establishing a diagnosis that helps explain, at least in part, an
infant or young child’s difficulties can be helpful for the family and contributes
to a more complete formulation. Diagnosis can indicate which treatment isappropriate and, ideally, which treatments are supported by evidence. It canfacilitate communication between the various professionals taking care of thechild. A diagnostic classification for mental health problems in infants, toddlers
and preschool children has recently been updated. It includes an approach todefining relational difficulties in early childhood (Zeanah & Lieberman, 2016).

INFANTS AND PARENTS IN MEDICAL SETTINGSAn Infant Mental Health Approach
In medical settings, the child’s symptoms are the focus of investigation
but paediatricians need to be mindful of the parents as well. In other words, inpaediatricians’ clinical work the infant is treated but parents are also a focus ofattention and support. The meeting between parents, baby and paediatrician
is unique. The child displays symptoms with changes in behaviour and parents
interpret them to paediatricians. The transfer of this information can be difficultand confusing. A lot depends on parents’ interpretation of the infant’s symptoms
and on the infant’s physical and mental state, along with other factors.

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IACAPAP Textbook of Child and Adolescent Mental HealthIn paediatric practice, diagnostic methods and therapy generally focus onorganic conditions but, in many cases, especially in regulation disorders (e.g.,
problems of feeding or sleeping, extreme crying, etc.) a bio-psycho-social approachis required to adequately understand the presenting difficulties. It can be frightening
for parents when the baby’s behaviour changes, so they consult the paediatrician.
It is helpful if the paediatrician has basic mental health skills to recognise how theinteraction between parent and infant can contribute to abnormal symptoms inthe baby and, in turn, how this may alter how a parent perceives and communicates
about their infant (Hinshaw et al, 2000). Paediatricians need to listen carefully
about the specific problem parents and baby are presenting and provide relevant
information to parents in a sensitive and supportive way (Committee on
Psychosocial Aspects of Child and Family Health et al, 2009; 2012).

Parents consult a paediatrician because the child’s behaviour is of concern
to them and expect treatment, explanation and reassurance. Ascertaining thefactors producing the symptoms often requires a multidisciplinary approach.
Furthermore, a special awareness is needed to define the symptoms and tocommunicate effectively with the parents. This is particularly true in disordersof regulation (Mares et al, 2011). The paediatrician may find problems difficult
to manage when the symptoms observed in the child are inconsistent with thosedescribed by the parent. Feeding problems, for example, rank highly in thisgroup—no clear medical explanation can be found in more than 80% of cases(Cole et al, 2011)—and yet the infant is symptomatic and the parents anxious
and concerned. Parents’ complaints must be taken seriously because if they thinkthat there is a problem, then there is a problem (Kerzner et al, 2015). Parental
anxiety and infant distress can become self-perpetuating. We call this a “misjudged
symptom” in the infant and suggest conceptualizing the infant’s symptom in thecontext of parents’ complaints and concerns. The symptom is real enough but
often not fully explained by a medical cause, thus it may not need actual therapy,
only changes in the infant’s lifestyle, and reassurance and support for the parents.
A functional rather than an organic explanation is assumed and the persistence ofAssessment of infants

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IACAPAP Textbook of Child and Adolescent Mental Health

Lola was 4 months old when she was admitted to hospital. She refused to drink breast
feeding milk by nursing bottle and formula was tried. Her weight had stagnated leading to a
growth deficiency. The relationship between her mother and grandmother was difficult andher grandfather had passed away. Her father’s parents were alcoholic and not supportive.
Lola’s parent’s got on well, understanding and supporting each other. Lola’s birth was
uneventful and breast feeding was not problematic initially.
After two months Lola’s appetite lessened and her food intake decreased. The mother tried
to force breast-feeding even when the baby resisted. Finally Lola accepted only 20-80 ml oneach feeding and she was fed 5-6 times per day. Her behaviour changed and she became
lethargic and unresponsive.
In hospital Lola showed escalating distress when feeding. Nursing assistance was needed
during mother’s attempts to force the baby to take the breast and feed; each feed took a longtime. The mother became increasingly anxious and fraught. She lost self-confidence, thought
she was not a good mother and was concerned that her baby might die.
During the medical assessment it was suspected that gastro-oesophageal reflux disease(GORD) contributed to the baby’s symptoms. Treatment for GORD began but unfortunately
Lola needed supplementary tube feeding because her intake of breast milk was inadequate.
The therapy included parallel parent-infant consultation alongside breast feeding support andmedical treatment of GORD.
Topics for discussion with parents included:•

Their fears about Lola’s sickness•

Understanding the cues and feelings about their baby•

Reducing expectations about breast feeding intake•

A focus on the enjoyment instead of on the amount taken during each feed•

Helping parents believe in their child’s health and their own care for her.

Lola was released from hospital continuing to breast feed and with nasogastric tube feeding
and close follow up. The baby pulled out the tube, which was replaced, and vomited manytimes. Every time this happened a parent-infant consultation also occurred. These events
became gradually less frequent. Lola gained weight, breast feeding intake improved andtube feeding decreased. Lola’s behaviour also changed: smiling more often, crying, moving
and sleeping less. Her parent’s fears decreased. After two months the nasogastric tube
could be removed.
This is example illustrates the need to identify and treat the organic or biological (GORD)
problem, the functional aspect (distress and breast refusal) and relational issues (highparental anxiety, force feeding) to solve Lola’s growth faltering and breast feeding problems.

An Iraqi girl in an orphanage- missing her mother, so shedrew her and fell asleep thenAssessment of infants

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IACAPAP Textbook of Child and Adolescent Mental Health

Table A.4.3 Indicators that an infant/child is at possible physical, psychological ordevelopmental risk.
In the infant/child
•
•
•
•
•
•
•
•
•

Failure to thrive
Failure to meet expected
milestones
Hypervigilant or startling easily
Excessively quiet and withdrawn
Marked aggression in a toddler
Basic needs not met
Role reversal or caregiving
behaviour towards parent
Emotion regulation problems
Unexplained bruising or medical
injuryIn the parents
•
•
•
•
•
•
•
•
•
•
•

Inability to recognise or prioritise
the child's needs
Untreated or inadequately treatedpsychiatric illness or substanceabuse
Lack of insight and lack ofengagement with treatment
services
Child incorporated in parental
delusional system, including
positive delusions
Insensitivity to child’s signals andneeds (emotionally unavailable)
Thoughts of self-harm or fear ofharming child
Scared of infant, ignores infants
cries
Frightening or looming behaviour,rough handling of infant
Hostile or negative attributions(“he is out to get me”)
Unrealistic developmental
expectations
Lack of parenting skills

In the context
•
•
•
•
•
•

No other available andprotective adult
Significant cultural or social
isolation
Minimal social supports
Domestic/family or community
violence
Multiple social risks (e.g.,homelessness, itinerancy)
Chronic stress

Developed by Nicholas Kowalenko, Sarah Mares, Louise Newman, Anne Sved Williams, Rosalind Powrie, and Karin van
Doesum.

the symptoms is understood to result from maladaptive coping in the parent orinfant or some difficulty in their relationship (Mares et al, 2011).
Approaching the child’s pathological symptoms and/or the parents’complaints from a bio-psycho-social model is effective in recognising, evaluating
and treating presentations where parental responses to their symptomatic infant
contribute to an infant with persisting distress. Paediatricians benefit fromacquiring basic competencies in infant mental health (Briggs et al, 2007), andfrom working in collaboration with a multidisciplinary team when organic andfunctional disorders co-occur (Sharp et al, 2017). Early recognition of suchdisorders when there are particular concerns that parental factors contribute to theinfant’s symptoms can be improved by using screening tests such as the Edinburgh
Postnatal Depression Scale (Töreki et al, 2014) which rates parental anxiety anddepression, or the Coping Health Inventory for Parents, which rates parents’ efforts
in coping with health issues in the family (McCubbin et al, 1983).

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ASSESSING RISK IN INFANCY AND EARLY
CHILDHOOD
Assessment of risk of harm is an implicit—and sometimes explicit—aspectof every assessment of infants, young children and their caregivers. In many
countries, health workers are required by law to report children who are at riskof abuse or neglect. Like all other assessments, risk assessment requires a detailed
history, observation of relationships, and information from a range of sources.
Risk to the infant or to the relationship with the infant occurs whenever the
caregiver’s resources are overstretched. In considering risk in this developmental
period we are considering risk within a relationship. Infants can also be at risk
developmentally or physically because of medical illness or prematurity, but
the caregiving relationship and the social context of that relationship are major
determinants of the psychological outcome for the child whatever their physicaland developmental status.
There are various degrees and types of risk, ranging from physical illness or
disability in the infant, to those associated with child abuse and neglect. As wellas prematurity and medical illness, factors that contribute to developmental risk
include the child’s temperament, exposure to early adversities including problems
with attachment, parental mental illness, exposure to violence, socioeconomic
status, poverty and adolescent parenthood (Zeanah et al, 1997). For children indeveloping countries the developmental risks often include social determinants
such as poverty as well as infections and nutritional diseases (WHO).
When meeting with a family, the focus is on the assessment of risk to thechild within the caregiving relationship. When one or both parents have psychiatricillness, history of substance abuse, or the domestic situation is unsafe, it is also
necessary to assess the risk (of self-harm or violence) to the child’s caregivers. Whenthe caregiver is at risk, the child is also at indirect risk because of the centrality
Types of risk
•
•
•
•

•
•
•
•
•
•

Factors that promoteresilience in the child(Ferguson & Horwood,
2003)• A well-functioning
parent or other
involved adult• Social supports• Professional
intervention when
it is indicated• Consistency inother relationships
and activities• Having a skill or
talent.

Risk to the child’s immediate physical or emotional safety
Risk to the child’s optimal development. This acknowledges the importance of earlyexperience for later outcome. Genetic, in-utero, and physical factors such as illness
may be present
Indirect risk, such as repeated separation from a parent hospitalised with a psychiatricor medical illness. Parental mental health problems are a significant risk factor.
Cumulative risk occurs when a child and family are exposed to multiple risk factors. For
example, a premature infant born to a young single mother with a narcotic addiction
with little family support is clearly at greater risk than a premature infant with similar
medical and biological risk factors, born to a couple with adequate financial andpractical support.
The greatest developmental risks within the parenting relationship are those that
operate long term, for example:
Chronic neglect
Chronic instability in the family’s personal and social circumstances
Exposure to parental personality disorder or dysfunction and ongoing mental healthproblems
Ongoing hostility towards the child
Maltreatment.

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IACAPAP Textbook of Child and Adolescent Mental Healthof the caregiving relationship to the child’s wellbeing. In addition exposure tofamily violence has similar impacts to child maltreatment. Therefore domestic
violence, even in the absence of violence towards the child, represents a significant
developmental risk. The cumulative developmental impact of multiple risk factors
must also be considered (Appleyard et al, 2005).
Types of Risk
In general, risk can be defined as the probability of an event occurring,
including consideration of the losses and gains associated with it. In the context of
infant development and child protection, risk assessment is not free from culturaland moral judgements. There is a high degree of uncertainty when predicting risk
in child-protection matters and inevitably this contributes to the anxiety felt whenassessing risk by even very experienced clinicians working in this area.

Predicting risk in childprotection matters is very
difficult and this contributes tothe anxiety felt by even very
experienced clinicians whenassessing risk.

Children who have been abused or neglected may have physical, emotionaland behavioural sequelae, which will make caring for them more difficult. For
example, traumatised children may continue to show avoidant or disruptive
behaviour for some time after being placed in safe fostering environments. Abuseand neglect may have long-term effects on the child’s understanding of feelings andrelationships. A child with brain damage after head trauma may have long-term
physical and emotional symptoms, meaning that caring for them is particularly
difficult and challenging. This presents parents (including foster and adoptive
parents) with challenges that they may not have anticipated, requiring morepatience or perseverance than with a less traumatised child.
Infants in high-risk situations are more likely to develop insecure or
disorganised attachment relationships with their caregivers. There is evidence thatdisorganised attachment during infancy is linked to emotional and behaviouraldifficulties in childhood, adolescence, and adult life. Therefore, although an
infant may not be at an immediate physical risk, an erratic, neglectful or unstablecaregiving environment is a threat to their social and emotional development. In
child neglect, chronic unresponsiveness to the child’s physical or emotional needs
can have profound developmental consequences but may be harder to detect thanphysical abuse. Unfortunately, many infants at risk suffer both neglect and abuse.

CONCLUSIONSAssessment of families with infants and young children occurs in a variety ofcontexts and for many different reasons. Nonetheless, a comprehensive assessment
should always include a relational and developmental focus, with considerationof both strengths and vulnerabilities that parents’ and child bring to their current
circumstances, and attention to biopsychosocial factors that help or hinder thefamily at this time of rapid developmental change.
A working alliance between the family and the clinician supports any
proposed interventions. Concerns about the immediate or long-term safety of thechild or caregivers need to be addressed openly and directly with the caregivers andreferring agency. Appropriate intervention must follow, and processes put in place
for monitoring the ongoing safety and wellbeing of all family members.
All assessments of young children involve consideration of risk. The notionof risk in infancy and early childhood is complex and multifactorial. It includes

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IACAPAP Textbook of Child and Adolescent Mental Healthconsideration of immediate risks to child and parent safety, the impact of single andcumulative risk factors, and the notion of developmental risk and psychopathology
following early adversity. The vulnerability and dependence of young children on
the availability of their caregivers means that risk is always considered within the
caregiving context and threats to the safety of either or both parents inevitably
impacts on the child’s wellbeing.

Go to the appendicesfor self-directed learningand self-assessment
tasks.

Risk increases whenever the child’s needs outweigh the capacity of the carers
and their supports to meet these needs. As described, this can occur because offactors in the child, the caregiving system (parents), or the social context, andmany at risk children and families have vulnerabilities in all three areas.
Situations of high risk are distressing for all concerned, particularly when
the clinician recommends the removal of an infant or young child from theirhome. A comprehensive assessment that includes a careful history, considerationof the coherence of the history provided, observation of interactions between childand caregiver(s), and corroborative history are central to an adequate assessmentof risk. This ensures that decisions are based on sound information obtained froma variety of sources and are made in the best interests of the child and the family.

Additional Resources••

There is a free online course about the importance of early relationships to infantdevelopment available form Warwick University in the UK••

Fernyhough C (2008). The Baby in the Mirror: A Child’s World from Birth to Three.
London: Granta Books.
Lieberman AF (1993). The Emotional Life of the Toddler. New York: Free Press.
Mares S, Newman L and Warren B (2011). Clinical Skills in Infant Mental Health: The
First Three Years (2nd ed)). Melbourne: ACER Press.
World Association for Infant Mental Health
Zeanah CH (ed) (2009). Handbook of Infant Mental Health (3rd ed). Section III
Assessment, Chapters 14–16 (pp231–280). New York: Guilford Press.

Click here to go to the
Textbook’s Facebook
page to share yourviews about thechapter with otherreaders, question theauthors or editor andmake comments.

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Do you havequestions?
Comments?

Portrait of Madesta and Inesita (1939) Diego Rivera

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IACAPAP Textbook of Child and Adolescent Mental Health

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The painting shows how
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health services with a focus on ahealthy diet.

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix A.4.1
SELF-DIRECTED LEARNING EXERCISES•

List the important milestones/achievements in the emotional development of infants up to 4
years of age.

•

Consider each of these vignettes about assessing parent-infant interactions:
A mother, who was having treatment for a postpartum psychosis, said proudly that she wasbreastfeeding her baby and it was going well. When the baby started moaning she picked
him up and positioned him well to feel but did not open her shirt or give the baby access toher breast, just holding him against her shirt where the baby vainly attempted to latch onto thebreast. The mother seemed unaware of his struggle until he grizzled loudly. She still did notopen her shirt until the clinician suggested it.
Please make notes about the potential impact of the mother’s mental illness on her
interaction and relationship with the baby:− What might it be like for the infant?
− How would you address it during the assessment?
A two year old boy fell off the chair during the assessment and bumped his head quite hard. His
mother had described him as “independent”. Instead of crying or going to his mother, he walked
to the window and looked outside. It was striking to the interviewer that he did not seek parental
comfort or show distress.
Please make notes about what this young boy has learnt about managing his distress.
− How does attachment theory may help you to understand this?
− Does his “independence” raise any developmental concerns?
A five year-old boy is brought by his mother to a consultation with a primary care psychologist.
The boy was referred by his teacher because he was not able to do the activities proposed inclass. He was always quiet and alone, refusing peers’ invitations to play. The mother could notunderstand his behaviour. In their second consultation, the psychologist invited the boy to playoffering him some toys. The boy only could play when the mother came into the room and gave
him verbal instructions about what to do. He only moved or changed toys after she gave him“permission”. After that, the psychologist enquired more about his habits and noticed that hewas not allowed to do anything the mother had not planned.
This 5 year old appears restricted and over-compliant in his behavior including withpeers:− What are the pros and cons of this for a child?
− Does this need to be addressed therapeutically and how would you go
about it?

•

Observe a child under the age of 3 years in a play setting (e.g., at a park, childcare centre
or playgroup—with pemission from the parent or guardian) and write a one-page summaryof your observations:
−
−
−
−
−

Assessment of infants

What do you notice about how the child relates to the caregiver/s?
How does the infant let the caregiver know that they are needed?
If the infant is hurt, do they become distressed?
Will the child let others comfort her?
How does the caregiver respond to the infant’s communications?

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IACAPAP Textbook of Child and Adolescent Mental Health•

Consider the interactions you have observed in the context of what you know about
attachment styles and about the developmental age of the infant. What information does
this interaction give you about the attachment relationship between the infant and the
caregiver?

•Interview a family with a toddler or pre-schooler who is described as having “behaviouralproblems”.
− Summarise your findings in a short note. Pay particular attention to theearly attachments, relationships, and developmental history of this childand family. Consider how these experiences may have shaped andinfluenced the child’s behaviour.
− After the assessment, how would you describe to the family and to thechild’s day care teachers about the possible reasons for the behaviouralproblems? What suggestions would you make to support parents andteachers? Write this down briefly.

•

Identify and note risk and protective factors for this child. What are the potential long-term
consequences of her experiences (for assistance refer to Tammy’s story on page 9).
Rajni’s parents both used drugs and alcohol regularly after her birth and possibly also during
the pregnancy. She was neglected, physically abused and there was considerable violence
between the parents. She was removed from her parents aged 11 months after an unexplained
leg fracture. At that time her milestones were a little delayed and she was small for her age.
She was placed with an older relative who cared well for her and her growth and development
improved.
When she was 2½ years, her carer developed cancer and Rajni was returned to her parents.
Another period of neglect and exposure to violence followed. Rajni was again placed with afoster family when she was 3½. They reported frequent tantrums, often scratching and hitting
her head. She hoarded and stole food and was indiscriminate socially, attaching herself torelative strangers, climbing on their laps and holding their hands, and she would “go blank”
when told off or reprimanded or if there was a loud noise, particularly shouting or arguing.
Rajni’s difficulties could be understood as survival strategies she had developed in responseto her early neglect and abuse. Her behaviour began to settle after a period in a safe andloving home environment but she remained sensitive to noise and had difficulties with sleeping,feeding and regulating her emotions.

•Observe a Strange Situation Procedure – if it is not possible to observe it live, watch thisshort clip.
− Try and put yourself in the child’s position and imagine what theseexperiences would feel like
− Consider what you observe from the perspective of attachment theory.
Make notes on what you have observed.

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix A.4.2
SELF-ASSESSMENT QUESTIONSMCQ A.4.1
Which ones of the following
attachment patterns are consideredorganised in the ABC+D classification?
A.
B.
C.
D.
E.

Avoidant /Insecure
SecureAmbivalent/Insecure
Disoriented
All of the above

A.
B.
C.
D.
E.

Mary MainJohn Bowlby
Donald Winnicott
Mary Ainsworth
Sigmund Freud

MCQ A.4.2
Who originally developed the
key concepts of attachment theory?

MCQ A.4.3
Which is the universally
accepted clinical and diagnostic protocol
for assessing attachment in young
children in clinical situations?
A.
B.
C.
D.
E.

It does not exist
The Strange Situation Procedure
The Macarthur Story Stem Battery
The Modified Crowell Procedure
The clinical interview

MCQ A.4.4
The key developmental
milestones in the first four years include:
A. Language
B. Development of attachment
relationships
C. Mobility
D. Symbolic play
E. All of the above

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MCQ A.4.5
Ideally, an attachmentfocused parent-infant assessment would
not include:
A. Observation of the infant’s behaviour,
particularly in the context of theirinfant-caregiver relationships
B. Exclusion of the infant from theassessment process
C. A history of the infant’s attachments
D. Consideration of the developmental
context to the presentation
E. Risk assessment

MCQ A.4.6.
A person’s experience ofbeing parented influences their parenting
behaviour.
A. True
B. False

MCQ A.4.7
It is essential to observe theinteractions between infant and caregiver,including observation of daily routines
such as feeding, changing and settling, tounderstand the quality of the relationship.
A. True
B. False –the parent can explain
everything
C. Only during feeding
D. Only during times of distress
E. Observing interaction and play during
the assessment can also be helpful

MCQ A.4.8
Which one of the following
experiences poses the greatest
developmental risk to a child?

Episodic arguments between parents
Staying with a grandparent overnight
Chronic neglect
Parent forgetting to pick up the childfrom day care
E. Having a physically ill sibling
A.
B.
C.
D.

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IACAPAP Textbook of Child and Adolescent Mental HealthANSWERS
MCQ A.4.1
A,B,C (note that infants may appear disoriented during the Strange 						
Situation Procedure but this is not considered an attachment 						
pattern. Refer to page 4 and Chapter A.2).
MCQ A.4.2

B

MCQ A.4.3

A

MCQ A.4.4

E

MCQ A.4.5

B

MCQ A.4.6

A

MCQ A.4.7

A,E

MCQ A.4.8

C

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