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Infant Mental Health Assessments for Court- Hill and Solchany

Infant Mental Health Assessments for Court- Hill and Solchany

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Published by woodstockwoody
Important reading! We like to believe that infants
and toddlers are immune from these
issues, that parents can protect them,
or that when their age is measured
in months rather than years they will
be inherently insulated and more resilient.
Accepting that an infant
might have mental health issues
might be tolerated for the isolated
case, but accepting the concept of
infant mental health takes us into
uncomfortable territory, which tends
to challenge our understanding of
infants and children in the world.
Important reading! We like to believe that infants
and toddlers are immune from these
issues, that parents can protect them,
or that when their age is measured
in months rather than years they will
be inherently insulated and more resilient.
Accepting that an infant
might have mental health issues
might be tolerated for the isolated
case, but accepting the concept of
infant mental health takes us into
uncomfortable territory, which tends
to challenge our understanding of
infants and children in the world.

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Categories:Business/Law
Published by: woodstockwoody on May 21, 2011
Copyright:Attribution Non-commercial

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05/17/2012

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Vol. 24 No. 9Securin
Article #3 in a
Child Law Practice
129
Child Law
 
Practice
Vol. 24 No. 9 November 2005
 Helping Lawyers Help Kids
 
What’s Inside:
130CASE LAW UPDATE140IN PRACTICEProtecting the Rights of Service Members inLitigation InvolvingChildren144NEW IN PRINT
E-mail: childlawpractice@staff.abanet.orgInternet: http://www.childlawpractice.org
Infant Mental Health…a contradiction in terms?
It is often difficult to think aboutinfants and young children dealingwith mental health issues, so diffi-cult in fact, that it is easily dismissedby some—seen as irrelevant orimplausible. Can a four-month-oldinfant be depressed? How can aneight month old have an adjustmentdisorder? What could possiblysuggest that a two year old might bedealing with post-traumatic stress?We like to believe that infantsand toddlers are immune from theseissues, that parents can protect them,or that when their age is measuredin months rather than years they willbe inherently insulated and more re-silient. Accepting that an infantmight have mental health issuesmight be tolerated for the isolatedcase, but accepting the concept of 
infant mental health
takes us intouncomfortable territory, which tendsto challenge our understanding of infants and children in the world.Infants and toddlers do experi-ence mental health issues. They doexperience stress and emotionalpain in response to separations, wit-nessing violence, experiencing ne-glect, or being denied the stability of a primary caregiver. If we look atwhat infants see and try to seethrough their eyes, then the impactof those experiences becomesclearer. For example, infants cannotask for help when feeling threatenedor unsafe. They instead protectthemselves by doing the only thingthey can do, shut down or withdraw.If this becomes a pattern, it canquickly (within just a few days) de-velop into depression—often char-acterized by refusing food, cryingincessantly, experiencing sleep dis-ruptions, refusing to make eye con-tact, and “just giving up.” In fact, al-though infant depression was firstidentified over 60 years ago, it isstill difficult for many of us to bearthe thought that an infant can expe-rience the helplessness, sadness, andemptiness seen in depression.
What Is “Infant Mental Health”?
ZERO TO THREE: National Centerfor Infants, Toddlers and Familiesdefines “infant mental health” as the
capacity of the child from birth tothree to experience, regulate and express emotions; form close and secure interpersonal relationships;and explore the environment and learn
.
 Infant mental health is syn-onymous with healthy social and emotional development 
. It is how thechild fits into the world aroundthem—attachment with their primarycaregiver, relationships with impor-tant others, smooth developmentalprogress, the increasing ability tocontrol behavior and express emo-tions, and the ability to explore andplay.Understanding infant mentalhealth means understanding theworld as experienced by the baby.For example, in a divorce situationthe parents may be extremelystressed as they go through negotia-tions and court procedures. Theyoung child may be especially vul-nerable to the same stressors—theseparations, moving, fewer re-sources—as well as the added stressof not being able to depend on par-ents in the usual way as one or bothare so focused on the divorce. Whatis it like for a baby whose world hasbeen mom and dad—having sharedmeals with them, and felt confidentknowing they were both availablein the safe haven called home—when suddenly it all falls apart?There are also those young childrenwho fall into circumstances that putthem at risk very early in life. Whatof the child of the addicted parentwho is trying hard to do the right
Mental Health Assessments for Infants and Toddlers
by Sheri L. Hill and JoAnne Solchany
INTERDISCIPLINARY EXCHANGE
(Continued on page 134)
 
134
Child Law Practice
Vol. 24 No. 9
thing—staying clean and sober,maintaining adequate housing, andworking—but is derailed by theiraddictions? This child does not seeaddictions or sobriety. This childsees mom or dad becoming un-available to them.Infant mental health assess-ments provide opportunities to seethe world through the eyes of thechild. They assess how the child isresponding to their environment,how they are developing, whatkinds of problems they may be ex-periencing, and how supportivetheir caregiving relationships are.They allow us to explore what isgoing on with that baby and an-swer questions such as:
How is this child beingimpacted?
What might this mean for thefuture?
Will this child be at risk?
What is the baby’s experience of the situation?
Can that baby seek and findcomfort with the availablecaregivers?
Are current experiences impact-ing development and growth?
What protective factors are inplace for this child?
In what kinds of cases are infantmental health assessmentsuseful?
Separation from PrimaryCaregiver(s).
Any case whichinvolves a young child possiblyseparating from a primarycaregiver should, at minimum,involve a consult and may requireboth an infant mental health assess-ment as well as ongoing monitor-ing. Separations, even if temporaryand done with the best of inten-tions, can bring about grief andmourning that without adequatesupport can lead to extreme sad-ness and withdrawal. These couldinclude:
divorce cases that are initiated inpregnancy or in a child’s firstthree years of life,
cases involving termination of parental rights,
cases involving incarceration of aprimary caregiver,
cases wherein a caregiver entersresidential rehabilitation.
Traumatic Events.
An infant mentalhealth consultation or assessment isrecommended with any case involv-ing exposure to domestic or commu-nity violence or other traumaticevents. Babies can and do developtraumatic stress responses includingre-experiencing of traumatic events.Contrary to popular belief, babies doremember—though not in the sameways that we think of rememberingas adults. A variety of events, includ-ing hospitalization, may be experi-enced by the very young child astraumatic. However, no two childrenexperience or respond to the sameevent, even a traumatic one, in thesame way. Assessment allows us toexplore how an event has impactedan infant or toddler.
Outside Placements.
Any depen-dency case involving the placementof an infant or toddler (0-3) outsidethe care of their primary attachmentfigure warrants an assessment.Removing a child from her home is atraumatic experience for that child,even if it is for excellent reasons.Infants and young children can anddo attach to multiple caregivers, butthey rely—physically and psycho-logically—on a primary attachmentfigure. Removing a child from hisprimary attachment figure equalsplunging him into the unknown; it isscary and overwhelming even if thechild already has, or can develop, atrusting and loving relationship withthe alternate caregiver. Primaryattachment figures are not inter-changeable. Losing one during theearly years means the young childwill experience abandonment, evenwhen it is in the best interests of thechild. Assessment helps us considerhow the experience of removal, andsubsequent placement, impacts thechild and what can be done toprovide support through thesechanges.
Red Flag Behaviors.
Assessmentsare also useful in cases wherecaregivers report seeing “red flags”around the child’s development orbehavior. For example, babies oftenshow us they are distressed throughtheir eating, sleeping, elimination,and with aggression in their relation-ships. It is common to see develop-ment become delayed or even gobackwards with children who areexperiencing mental health issuesand no intervention. An assessmenthelps to identify how a child’sexperiences are impacting hisoverall developmental progress andwell-being (see sidebar, p. 138).
Who typically conducts theassessment? What qualificationsshould the evaluator have?
Infant Mental Health Training.
The evaluator should have hadspecific training in
infant mentalhealth, not just child development 
.Training in infant mental healthshould be substantial, includingfocus on infant development,parent-child relationships, emotionalfunctioning, pathology, diagnostics,assessment, and intervention. Anincreasing number of states havetraining programs and infant mentalhealth centers such as our Center onInfant Mental Health and Develop-ment at the University of Washington’s School of Nursing.The mission of these programs is toprovide education and clinicaltraining on the unique needs andcircumstances of the youngest of children (see the Resources sidebarfor details). Because they cannot tellus their story, infants and youngchildren can be one of the mostchallenging and difficult popula-
(Continued from front page)
 
Vol. 24 No. 9Securin
Article #3 in a
Child Law Practice
135
tions to understand and work with.At a minimum, the person con-ducting or coordinating the assess-ment should be able to ensure thereis a thorough assessment of thewhole child. The assessment shouldnot be limited to an assessment of the parents’ skills or to whom thechild seems “most attached.” It isoptimal to look 
simultaneously
atwhat the caregiver(s) bring(s) to thesetting AND what the baby brings tothe setting, as well as how the childand caregiver work together in bothcalm and stressful times.
Experience with Infants/Toddlers.
Infant mental health evaluatorsshould have a background withsubstantial experience with infantsand toddlers. Experience conductingevaluations on young children orfamilies does not automaticallyequate to expertise with infants ortoddlers. Assessing preverbalchildren requires training andexperience in observing babies andan understanding of what capabili-ties an infant does and does nothave to interpret the world. Aninfant mental health specialistcultivates his or her ability to see theworld through the eyes of the infant.Babies’ behaviors do not alwaysmean what an untrained eye mightinitially guess. For example, babiesare often more likely to show theirdistress and act out when they are inthe presence of the caregiver withwhom they feel the most secure.This can seem counterintuitive tothose who have not worked withthis young age group.
Skill in Evaluating and DiagnosingYoung Children.
Evaluators shouldalso be familiar with the DC 0-3, the
 Diagnostic Classification of Mental Health and Developmental Disor-ders of Infancy and Early Child-hood (1994, 2005)
. This is a diag-nostic system specifically designedto evaluate and diagnose childrenfrom birth through age three. Itframes mental health issues in the
This case shows how an infant mental health assessment was used in a dependencycase.
Shelby, age six months, and Karin, age three, were both born positive for co-caine. Their mother continued on a rocky road of addiction—trying to remain drug-free but falling back on her old habits periodically. The children’s father was in jailon drug charges and the 21-year-old mother was frequently homeless. Finding thechildren living with their dazed mother in a tent, near an overpass on a rainy winterday, prompted removal and placement of the children into foster care with themother’s aunt and uncle, who were happy to take in the children.An initial mental health assessment on both girls revealed two children whowere behind developmentally, were hypervigilant and fearful of people around them,and hesitant to make eye contact. Karin sat silently, refusing to talk to anyone, keep-ing her head down and looking confused. Shelby was irritable, waking several timesthroughout the night, and crying inconsolably.In the care of their relatives the girls began to improve. Karin began to seek outher new caregivers when she was hurt or needed something. She began to demon-strate a range of emotions, including anger, sadness, and joy. She slept soundly anddid not have any nightmares for over three weeks. Shelby gained two pounds in amonth, moving her up to the 30
th
growth percentile. She still woke up during thenight but was easily settled when her aunt rocked and reassured her. She wouldsqueal and reach out for her uncle when he came home from work, snuggling withhim into the evening.In the meantime, mom stayed sober for over a month. She secured housing andfound a job working at a fast food establishment. She wanted her children to be re-turned to her. Visitation was ordered and she began to see both girls four times aweek at the caseworker’s office for two hours each visit. These visits seemed to gowell, and the caseworker observed mom interacting positively with the girls. She wasable to engage them in play and they seemed to have a good time with her. However,when they returned back to the aunt and uncle, Shelby became hysterical—cryinginconsolably and arching her back, refusing to be comforted. Karin became quietand withdrawn and began to have nightmares again.An infant mental health assessment update was warranted and the assessor ob-served the children with the aunt, uncle, and her mom. She also worked with thethree-year-old in a play session and spent time interacting with Shelby, as well. Theassessment revealed that the children did do well with mom when they saw her; how-ever, they fell apart when they returned to the stability of their aunt and uncle.Arrangements were made to have mom visit in the aunt and uncle’s home forfewer visits (2X/week), with one visit involving mom in a family mealtime. Arrange-ments were also made for mom to have a weekly meeting with the aunt and uncle tohelp them connect and review how the girls were doing, what was working well, theestablished routines, and what the girls needed to thrive. The next step involvedmom having an additional weekly visit with each daughter separately, supportingher in getting to know each girl on a one-to-one basis. The aunt and uncle alsoneeded support and coaching as well as guidance on how to include mom in theirfamily interactions. This is a case in progress; it continues to move in a positive di-rection with all adults focusing on the needs of the young children. It shows howsome issues are only resolved through a slower, more thoughtful, and collaborativeapproach.
Case Study:
Shelby

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