E D I T O R I A L

THE WORLDWIDE BURDEN OF INFANT MENTAL AND EMOTIONAL DISORDER:

REPORT OF THE TASK FORCE OF THE WORLD ASSOCIATION FOR INFANT MENTAL
HEALTH

KARLEN LYONS-RUTH
Harvard Medical School, Cambridge, MA

JODY TODD MANLY

University of Rochester, Rochester, NY

KAI VON KLITZING

University of Leipzig, Leipzig, Germany

TUULA TAMMINEN
University of Tampere, Tampere, Finland

ROBERT EMDE
University of Colorado School of Medicine, Denver, Colorado

HIRAM FITZGERALD
Michigan State University, East Lansing, MI

CAMPBELL PAUL
Royal Children’s Hospital Melbourne, Melbourne, Australia

MIRI KEREN
Tel Aviv University, Tel Aviv, Israel

ASTRID BERG
Stellenbosch University, Cape Town, South Africa

MAREE FOLEY
Child, Family and Organisational Consultancy, Geneva, Switzerland

HISAKO WATANABE
Watanabe Clinic, Yokohama, Japan

ABSTRACT: Children worldwide experience mental and emotional disorders. Mental disorders occurring among young children, especially infants
(birth –3 years), often go unrecognized. Prevalence rates are difficult to determine because of lack of awareness and difficulty assessing and diagnosing

We acknowledge the invaluable assistance of Mallika Rajamani in the preparation of this article. We have no conflicts of interest to declare.
Direct correspondence to: Karlen Lyons-Ruth, Department of Psychiatry, Harvard Medical School, Cambridge Hospital, 1493 Cambridge Street, Cambridge,
MA 02139; e-mail: klruth@hms.harvard.edu.

INFANT MENTAL HEALTH JOURNAL, Vol. 38(6), 695–705 (2017)

C 2017 Michigan Association for Infant Mental Health

View this article online at wileyonlinelibrary.com.

DOI: 10.1002/imhj.21674

695
 10970355, 2017, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/imhj.21674 by Cochrane Chile, Wiley Online Library on [27/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
696 • K. Lyons-Ruth et al.

young children. Existing data, however, suggest that rates of disorders in young children are comparable to those of older children and adolescents
(von Klitzing, Dohnert, Kroll, & Grube, 2015). The lack of widespread recognition of disorders of infancy is particularly concerning due to the unique
positioning of infancy as foundational in the developmental process. Both the brain and behavior are in vulnerable states of development across the first
3 years of life, with potential for enduring deviations to occur in response to early trauma and deprivation. Intervention approaches for young children
require sensitivity to their developmental needs within their families. The primacy of infancy as a time of unique foundational risks for disorder, the
impact of trauma and violence on young children’s development, the impact of family disruption on children’s attachment, and existing literature on
prevalence rates of early disorders are discussed. Finally, global priorities for addressing these disorders of infancy are highlighted to support prevention
and intervention actions that may alleviate suffering among our youngest world citizens.
Keywords: Infant mental health, infant mental disorders, prevalence of infant disorder, burden of disease, early intervention

RESUMEN: Los niños en el mundo entero experimentan trastornos mentales y emocionales. Los trastornos mentales que ocurren en niños pequeños,
especialmente infantes (entre el nacimiento y los 3 años de edad), a menudo pasan sin ser reconocidos. Las tasas de prevalencia son difı́ciles de
determinar a causa de la falta de conocimiento y la dificultad de evaluar y diagnosticar niños pequeños. Sin embargo, la información existente sugiere
que las tasas de trastornos en niños pequeños son comparables con aquellas de niños mayores y adolescentes. La falta de un amplio reconocimiento
de los trastornos de infancia es particularmente preocupante debido a la posición clave que ocupa la infancia como pilar fundamental en el proceso
de desarrollo. Tanto el cerebro como la conducta se encuentran en vulnerables etapas de desarrollo a lo largo de los tres primeros años de vida con la
potencialidad de sufrir desviaciones que ocurren como respuesta al temprano trauma y a las privaciones. Los acercamientos de intervención para niños
pequeños requieren una sensibilidad hacia sus necesidades de desarrollo dentro de sus familias. Se discuten la primacı́a de la infancia como una etapa
de riesgos fundamentales para los trastornos, el impacto que el trauma y la violencia tienen sobre el desarrollo de los niños pequeños, el impacto que las
rupturas familiares ejercen sobre la afectividad de los niños, y la literatura existente sobre las tasas de prevalencia de tempranos trastornos. Finalmente
se subrayan las prioridades globales para prestarle atención a estos trastornos de infancia con el fin de apoyar acciones de prevención e intervención
que pudieran aliviar el sufrimiento entre nuestros más jóvenes ciudadanos del mundo.
Palabras claves: salud mental infantil, trastornos mentales de los infantes, prevalencia del trastorno infantil, carga de la enfermedad, intervención
temprana

RÉSUMÉ: Dans le monde entier les enfants font l’expérience de troubles mentaux et émotionnels. Les troubles mentaux chez très jeunes enfants,
surtout les très jeunes enfants (de la naissance à l’âge de 3 ans), ne sont pas toujours visibles ou diagnostiqués. Les taux de prévalence sont difficiles à
determiner du fait d’un manque de connaissances et de la difficulté à évaluer et à diagnostiquer les jeunes enfants. Les données qui existent, cependant,
suggèrent que les taux de troubles chez les jeunes enfants sont comparables à ceux que l’on voit chez les enfants plus âgés et les adolescents. Le
manque de reconnaissance généralisée de troubles chez l’enfant en bas âge est particulièrement préoccupant du fait du positionnement unique de la
petite enfance comme étant fondamental dans le processus de développement. Le cerveau et le comportement se trouvent tous deux dans des états
de développement au fil des trois premières années de la vie, pouvant voir s’installer des déviations durables en réaction à un trauma précoce et des
privations. Les approaches d’intervention pour les jeunes enfants exigent une sensibilité à leurs besoins dévelopmentaux au sein de leurs familles. La
primauté de la petite enfance en tant que moment de risques fondamentaux de trouble, l’impact du trauma et de la violence sur le développement des
jeunes enfants, l’impact des perturbations familiales sur l’attachement des enfants, et les recherches sur les taux de prévalence de troubles précoces
sont tous discutés dans cet article. Enfin les priorités globales pour faire face à ces troubles de la petite enfance sont mises en valeur afin de soutenir des
actions de prévention et d’intervention pouvant soulager la souffrance chez nos jeunes citoyens du monde.
Mots clés: santé mentale du nourrisson, troubles mentaux de la petite enfance, prévalence des troubles chez la petite enfance, fardeau de la maladie,
intervention

ZUSAMMENFASSUNG: Weltweit erfahren Kinder psychische und emotionale Störungen. Psychische Störungen bei Kleinkindern, insbesondere bei
Säuglingen (von der Geburt bis zum Alter von 3 Jahren), bleiben oft unerkannt. Die Prävalenzraten sind aufgrund des fehlenden Bewusstseins und der
Schwierigkeit, kleine Kinder zu beurteilen und zu diagnostizieren, schwer zu bestimmen. Die vorliegenden Daten deuten jedoch darauf hin, dass die
Häufigkeit der Erkrankungen bei Kleinkindern mit der bei älteren Kindern und Jugendlichen vergleichbar ist. Der Mangel einer allgemein verbreiteten
Beachtung von Störungen im Säuglingsalter ist besonders besorgniserregend, da das Säuglingsalter das Fundament für den weiteren Entwicklungsprozess
bildet. Sowohl Gehirn als auch Verhalten befinden sich in den ersten drei Lebensjahren in einem vulnerablen Entwicklungsstadium, mit dem Potenzial,
dass anhaltende Abweichungen als Reaktion auf frühe Traumata und Deprivation auftreten können. Interventionsansätze für Kleinkinder erfordern eine
Sensibilität für ihre Entwicklungsbedürfnisse innerhalb ihrer Familien. Die Vorrangstellung des Säuglingsalters als eine Zeit einzigartiger grundlegender
Risiken für Störungen, die Auswirkungen von Traumata und Gewalt auf die Entwicklung von Kleinkindern, die Auswirkungen von Zerrüttung in der
Familie auf die Bindung von Kindern und die existierende Literatur über Prävalenzraten früher Störungen werden diskutiert. Schließlich werden globale
Prioritäten hervorgehoben, die diese Störungen im Säuglingsalter adressieren, um Präventions- und Interventionsmaßnahmen zu unterstützen, die das
Leid unserer jüngsten Weltbürger lindern können.

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
 10970355, 2017, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/imhj.21674 by Cochrane Chile, Wiley Online Library on [27/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Burden of Infant Mental Health • 697

Stichwörter: Psychische Gesundheit von Säuglingen und Kleinkindern, psychische Störungen von Säuglingen und Kleinkindern, Prävalenz von
Störungen bei Säuglingen, Krankheitslast, Frühintervention

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Worldwide, 10 to 20% of children and adolescents experience
mental disorders (World Health Organization, 2003). If untreated,
these conditions severely influence children’s development, their
educational attainments, and their potential to live fulfilling and
productive lives. While the global burden of mental health dis-
orders in childhood and adolescence is currently the subject of
investigation, costs associated with mental disorders in infancy
in particular (birth–3 years) have remained largely invisible. In-
deed, service providers who work with young children, as well
as caregivers themselves, increasingly recognize the needs of in-
fants and their families. However, at the level of service-delivery
systems and social policy, the concept of mental disorders in in-
fancy is not widely recognized. This lack of widespread recogni-
tion of disorders of infancy is particularly concerning due to the
unique positioning of infancy at the beginning of the developmen-
tal process. Both the brain and behavior are in vulnerable states
of development across the first 3 years of life, with the poten-
tial for enduring deviations to occur in response to early trauma
and deprivation (Fox, Levitt, & Nelson, 2010; Shonkoff, Garner,
Committee on Psychosocial Aspects of Child and Family Health,
Committee on Early Childhood, Adoption, and Dependent Care,
and Section on Developmental and Behavioral Pediatrics, 2012).
In times of so many human crises worldwide caused by wars,
violence, global forced displacements, and natural disasters, very
young children are particularly impacted by insecurity and threats
to well-being and do not have the cognitive or verbal capacity to
understand such events. These kinds of early negative experiences
can lead to anxiety, depression, posttraumatic stress, and other
challenges and disorders in infants and young children. Adverse
early experiences may be especially harmful if they occur in the
first 3 years of life, during formative periods for brain development,
leading to lifelong consequences. Infancy, more than any other
developmental period, also is a time of heightened vulnerability to
disruptions in attachment relationships. All of these challenges can
lead to disorders in infancy, place stress on parents, and can put
further development of physical and mental health at severe risk.

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

698 • K. Lyons-Ruth et al.
As noted in the World Health Organization’s (2016) global plan of
action on violence and INSPIRE publication, threats to children’s
well-being can have enduring developmental consequences across
multiple domains of functioning, leading to long-term economic
and public health impacts.
WHY IS INFANCY UNIQUE?
How is the developmental period of infancy unique, and why does
it require separate consideration? First, infancy is a time of par-
ticularly rapid brain and behavioral development, constituting a
sensitive period when the organism’s development is particularly
open to and affected by the prevailing environment. Thus, traumatic
environments in infancy have heightened potential to lead to de-
viant adaptations with long-term negative consequences. Atypical
developmental trajectories can be identified in the first 6 months
of life that predict higher risk for later symptomatology (Cote
et al., 2009), and, when severe behavior problems are evident in
the first few years of life, there is moderate to strong continuity in
symptoms that place these children at risk for long-term problems,
especially in the context of family dysfunction (S.B. Campbell,
Shaw, & Gilliom, 2000).
Second, due to the infant’s immaturity, the features of dis-
order in infancy are somewhat different than those in the later
years, requiring separate diagnostic descriptors. Because disorders
of infancy are not described separately in the current versions of
the International Classification of Diseases, 10th Revision (ICD-
10; World Health Organization, 1993) and the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5;
American Psychiatric Association, 2000), a manual for disorders
of infancy more fitted to the presentations of very young children
has been developed, termed the Diagnostic Classification: Zero to
Five (DC:0–5) (ZERO TO THREE, 2016); formerly the Diagnos-
tic Classification: Zero to Three (DC:0–3) (ZERO TO THREE,
2005). Because of the greater correspondence of these diagnostic
descriptions to what is actually observed in early childhood, this
manual is in use among many infant mental health clinicians. To
convey a sense of the many disordered presentations that clinicians
encounter in treating very young children, the DC:0–5 diagnostic
listing is shown in Appendix A.
Third, the infant’s immature systems place him or her in a
unique state of dependence upon the care of attentive adults. Care-
givers constitute the essence of the infant’s world and are essential
for the infant’s capacity to regulate emotional and physiological
states. During infancy, stresses on caregivers have more immedi-
ate consequences for the infant’s own developing stress response
systems and overall development than they do at later ages.
Finally, this early dependence on caregivers requires different
modes of mental health intervention that involve both the infant and
the caregiver. The caregiver’s presence and attentiveness to infant
cues is a critical regulator of the infant’s development. A number
of controlled studies have confirmed that the quality of caregiver
regulation in these formative years has widespread effects on the
expression of genes that control aspects of brain growth and stress
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
10970355, 2017, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/imhj.21674 by Cochrane Chile, Wiley Online Library on [27/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
system function (Belsky & de Haan, 2011; Blair, 2010). Thus,
the infant needs to be treated within the caregiving relationship,
in contrast to later modes of mental health intervention that most
often focus on the child alone. Many young children with mental
health disorders do not receive treatment, however, sometimes with
the misconception that infants are too young to need treatment or
that they will grow out of their symptoms, despite evidence that
psychiatric symptoms that emerge early in life often persist into
later phases of development.
There are a number of evidence-based interventions based on
randomized controlled trials that are effective in treating infants
with mental health problems and disrupted infant–caregiver rela-
tionships (Bernard et al., 2012; Cicchetti, Rogosch, & Toth, 2006;
Fisher, Gunnar, Dozier, Bruce, & Pears, 2006; Smyke, Zeanah,
Fox, Nelson, & Guthrie, 2010; Tereno et al., 2017; Toth, Rogosch,
Manly, & Cicchetti, 2006). Some of these programs are preven-
tive and focus on promoting positive birth outcomes, parent–child
relationships, parenting practices, and parent mental health (Olds,
Sadler, & Kitzman, 2007; Tamminen & Puura, 2015; Toth, Pe-
trenko, Gravener-Davis, & Handley, 2015). Other models are tar-
geted to address specific types of disorders or high-risk groups.
Outcomes of these intervention approaches have included im-
provements in security of parent–child attachment relationships,
reductions in child behavior problems, reductions in child and par-
ent symptoms of traumatic stress and depression, improvements
in maternal sensitivity, improvements in cortisol regulation, and
reductions in failed foster care placements (Tamminen & Puura,
2015; Toth et al., 2015; von Klitzing, et al., 2015). The key points
are:
• Adverse early experiences may be especially harmful if they
occur in the first 3 years of life, during formative periods
for brain development, leading to enduring consequences.
• Due to the infant’s immaturity, the features of symptoms
and disorders in infancy are somewhat different from those
in the later years, requiring separate diagnostic descriptors.
• During infancy, stressors on caregivers have particularly
immediate consequences for the infant’s developing stress
response systems and overall development, as compared to
later ages.
• Early dependence on caregivers requires different modes of
mental health intervention that involve both the infant and
the caregiver.
• Evidence-based intervention approaches have demonstrated
success in improving outcomes for children and families.
TRAUMA AND VIOLENCE AFFECTING INFANTS AND
TODDLERS
A consideration of the global burden of infant mental and emotional
disorder must, in part, consider the costs to society. But just as
importantly, we must acknowledge the burden of suffering for the
individual. We can readily imagine and feel deep empathy for the

suffering of infants who are physically or emotionally abused, who
experience extremely deprived care, and who get caught up in the
traumas of war, violence, and loss.
A recent Centers for Disease Control and Prevention report
has highlighted that over 1 billion children worldwide have expe-
rienced violence in the past year (Hillis, Mercy, Amobi, & Kress,
2016). According to the National Child Traumatic Stress Net-
work, hundreds of thousands of young children and adolescents in
the United States alone are exposed to severely traumatic events
each year, including maltreatment (neglect, physical, sexual, or
emotional abuse), exposure to intimate partner violence, commu-
nity violence, life-threatening illness or injury, or sudden loss.
Among children under 3 years of age, more than 1 million (i.e.,
1,650,000) were the subject of abuse and neglect reports to U.S.
child protection authorities in 2014 (U.S. Department of Health
and Human Services, Administration for Children and Families,
& Children’s Bureau, 2016). In low- and middle-income coun-
tries, the United Nations Children’s Fund (UNICEF; 2014) found
that 7 to 8% of parents of 2- to 4-year-old children reported that
the child was either beaten with an object or beaten as hard as
one could during the past month. Children under the age of 3
years also were more likely to die as a result of abuse and ne-
glect than were older children, with 71% of fatalities, or more than
1,000 children per year in the United States alone, dying from
maltreatment (U.S. Department of Health and Human Services,
2016).
Exposure to trauma can affect multiple aspects of health and
development, leading to emotional, behavioral, and learning dif-
ficulties as well as related (and often sustained) health, substance
abuse, and mental health problems. Bogat, DeJonghe, Levendosky,
Davidson, and von Eye (2006) found that 44% of infants exposed
to intimate partner violence had at least one trauma symptom. Re-
sults from the Adverse Childhood Experiences (ACE) studies have
demonstrated that trauma early in development has been associ-
ated with increased risk for a range of psychological and phys-
ical diagnoses in adulthood, including alcoholism, drug abuse,
depression, suicide attempts, teen pregnancy, ischemic heart dis-
ease, cancer, chronic lung disease, and liver disease (F. Campbell
et al., 2014; Felitti et al., 1998). Epigenetic studies examining
changes in gene expression have found that maltreatment early in
childhood is associated with higher methylation of key genes as-
sociated with stress response, and methylation changes may place
maltreated children at risk for various cancers, cardiovascular dis-
ease, changes in immune functioning, and psychiatric disorders
(Cicchetti, Hetzel, Rogosch, Handley, & Toth, 2016). Controlled
animal studies have concluded that exposure to early life adversity
programs stress response systems to have an abnormal response
to subsequent stressors, altering trajectories of brain development
and creating maltreatment-associated structural or functional dif-
ferences in multiple brain regions (Teicher & Samson, 2016). Thus,
complex childhood trauma, and the chronic stress it engenders, ad-
versely affects brain development in areas involved in cognition,
attention, memory, and emotional regulation (American Academy
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
10970355, 2017, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/imhj.21674 by Cochrane Chile, Wiley Online Library on [27/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Burden of Infant Mental Health • 699
of Pediatrics, 2000) and results in emotional and behavioral prob-
lems as well (Perry, 2004).
Suffering linked to environmental stress is more likely to
etch itself into the being of the infant in the form of a mental or
emotional problem when regulatory caregiving relationships also
are seriously impaired. This is clearly the case in abuse and neglect
situations, but also is likely to be a factor in conditions of war, fam-
ily dislocation, and natural disasters, when parents themselves also
are suffering. Developmental studies have further documented the
adverse effects of early abuse on later parenting behavior, linking
early maltreatment to intergenerational cycles of disorder (Cic-
chetti & Valentino, 2006). Thus, exposure to trauma in infancy is
likely to affect formative developmental processes that impair the
foundation of future growth and may set up more negative devel-
opmental trajectories that have lifelong and even intergenerational
consequences (Bowers & Yehuda, 2016).
In one common example of infant suffering and resulting dis-
order, consider a stressed father, unable to find work, who engages
in bouts of heavy drinking followed by rages that escalate into
violence toward his partner and often spill over toward the infant
or toddler who is crying and trying to cling to his mother. When
the father is home, the infant becomes increasingly fear-ridden and
frozen into hypervigilant attention, has trouble falling and staying
asleep, and becomes increasingly aggressive and dysregulated in
his behavior. Here, we see an infant who is suffering emotion-
ally in this fraught family context and whose distress is leading
to disorders marked by disturbances in mood and behavior and
impairment in functioning. More chronic situations of abuse or
neglect also are often marked by delays in reaching developmental
milestones.
FAMILY DISRUPTION AFFECTING INFANTS AND TODDLERS
Severe economic stress, war, and natural disasters also lead to in-
creased parental death and family disruption, increasing the burden
on the world’s care systems for infants. UNICEF has estimated that
some 2.2 million children around the world live in institutional set-
tings, but this figure is considered to be an underestimate due to
underreporting and lack of data in many places (World Health Or-
ganization & Fundação Calouste Gulbenkian, 2015). While quality
of care varies enormously in institutional settings, many institutions
are understaffed and poorly equipped. Estimates also have shown
that up to two thirds of children in institutions have a disability and
that a significant number of these children have psychosocial dis-
abilities that include developmental delay or intellectual disabili-
ties (World Health Organization & Fundação Calouste Gulbenkian,
2015).
According to the European Offices of UNICEF and the Of-
fice of the High Commissioner for Human Rights, the region of
Eastern Europe and Central Asia has the highest number of chil-
dren growing up in institutional settings—more than 1 in every
100 children. The number of children in institutions in the 20 coun-
tries in this region is the highest in the world—more than 600,000
children (World Health Organization & Fundação Calouste

700 • K. Lyons-Ruth et al.
Gulbenkian, 2015). In 2003, the World Health Organization Re-
gional Office for Europe carried out a survey of 33 European
countries (excluding Russian-speaking countries) to map the num-
ber and characteristics of children younger than 3 years old in
institutional care. Although the figures varied greatly between the
countries, 12 countries had institutionalized between 1 and 10
young children per 10,000 under 3 years of age, seven countries
had institutionalized between 11 and 30 children per 10,000 under
3 years of age, and eight countries had institutionalized between
31 and 60 children per 10,000 under 3 years of age (Browne, 2009;
UNICEF, 2009).
Furthermore, the number of children in institutions is stable or
rising in several European Union member states, both new and old.
Despite efforts for change, the rate in this region has been almost
stagnant since 2000. In 12 countries, however, the rate of children
in institutional care increased between 2000 and 2007, and in
16 of the countries of this region, well over 28,000 of the children
placed in institutional care were under 3 years of age (UNICEF
Office of the High Commissioner for Human Rights Regional
Office for Europe, 2011). Observations in understaffed and poorly
equipped institutions have produced images in which infants are
sitting emotionless and apathetic, crying helplessly, or repetitively
rocking and waving their hands in an attempt to find some stimula-
tion in a barren environment. When compared to the responses of
home-reared infants, 97% of infants in institutional care exhibited
highly anomalous responses to their caregivers when stressed and
in need of comfort (P.D. Zeanah, Stafford, & Zeanah, 2005).
These images have catalyzed a number of studies supporting
the description of two disorders of infancy linked to very substan-
dard care. Both of these disorders are understood as damaging
adaptations to an environment that cannot meet the human infant’s
basic developmental need for emotional comfort and regulation
within a stable caregiving relationship. One disorder, reactive at-
tachment disorder (RAD), describes the apathetic infant mentioned
earlier who, even when an orphanage worker comes to feed or care
for the baby, makes no attempt to smile, babble, or seek contact
and comfort. In a second and very different disorder linked to in-
stitutional care, disinhibited attachment disorder (DAD) (DSM-5:
Disinhibited Social Engagement Disorder), the infant may indis-
criminately seek contact and comfort from anyone who passes by,
even from unfamiliar visitors. In home situations of extreme ne-
glect, disinhibited attachment behavior toward strangers also has
been shown.
Even more ominously, a number of studies have found that
even after transfer to good care, disinhibited attachment behaviors
may persist into adolescence and beyond (Kreppner et al., 2007).
Notably, both RAD and DAD emerge in the first 2 years of life and
do not have new onset after the age of 2. Thus, the first 2 years of
life may constitute a vulnerable period in which very poor early
care has enduring effects on the brain and behavior over the life
span and continues to exact costs at least into adolescence. These
extended costs must be considered as part of the overall burden of
infant disorder because these disorders have onset only in infancy
and are preventable by providing early environments of good care.
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
10970355, 2017, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/imhj.21674 by Cochrane Chile, Wiley Online Library on [27/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Thus, their continued costs to the child and to society in later years
can be clearly assigned to the conditions of rearing in infancy.
While large-scale studies are not available, RAD and DAD are
estimated to have a prevalence of about 1% (von Klitzing et al.,
2015). However, their joint prevalence rises to 25 to 40% among
children in foster care (Boris et al., 2004; C.H. Zeanah et al., 2004)
and to up to 60 to 70% among children in orphanages (Tizard &
Rees, 1975; C.H. Zeanah, Smyke, & Dumitrescu, 2002).
MENTAL AND EMOTIONAL DISORDER AMONG INFANTS
AND TODDLERS
While the suffering of infants in many contexts worldwide is clear,
it is challenging to estimate the worldwide societal burden of the
smaller set of conditions that are defined as psychiatric disorders
of infancy. As noted earlier, primary diagnostic systems (American
Psychiatric Association, 2000; World Health Organization, 1993)
were not devised with developmental sensitivity as to how symp-
toms might manifest differently in very young children. In addition,
the developmentally specific DC:0–5 criteria have not yet achieved
universal acceptance as an improved alternative to the more global
DSM-5 and ICD-10 descriptions of childhood disorders.
Epidemiological studies have revealed a 16 to 18% preva-
lence of mental disorders among children aged 1 to 5 years, with
somewhat more than half (8–9%) being severely affected (von
Klitzing et al., 2015). This rate is quite similar to the 10 to 20%
incidence among older children and adolescents estimated by the
World Health Organization, as noted earlier.
Specifically, in surveys of children aged 1 to 3 years, preva-
lence of deviant behavior or behavioral and emotional syndromes
ranged from 7.3% (Richman, Stevenson, & Graham, 1975) to
12 to 16% (Briggs-Gowan, Carter, Skuban, & Horwitz, 2001).
When only severe cases were included (Lavigne et al., 1998; Lavi-
gne et al., 1996), similar rates were obtained: 7.1% among 2-year-
olds and 14.0% among 3-year-olds. These data include all child
psychiatric diagnoses except general and pervasive developmental
disorders. In the most recent study of toddlers aged 18 months
in Denmark, the prevalence of Axis I (see Appendix A, B) diag-
noses of a primary child psychiatric syndrome remained similar, at
16% using the ICD-10 and at 18% using the DC:0–3 (Skovgaard
et al., 2007). For all diagnostic categories investigated, there was
considerably higher prevalence in the community as compared
to the incidence of disorders diagnosed at hospitals in the first
3 years of life (Skovgaard et al., 2007) (for prevalence of par-
ticular diagnostic categories, see Appendix C). Reviews of the
literature pertaining to each diagnostic classification in early child-
hood are available in Lyons-Ruth, Zeanah, Benoit, Madigan, and
Mills-Koonce (2014).
Note that all of the aforementioned epidemiologic studies
were conducted in stable and developed countries with strong
economies and peaceful living conditions. Based on these rates,
among the 643,386,753 children internationally between 0 to 4
years old, at least 102,941,880 young children would be diagnosed
with a mental or emotional disorder. These must be regarded as

lower bounds on the rates of disorder among very young chil-
dren, and we would expect to see significantly higher rates in
contexts of extreme poverty, war, and family displacement and
trauma (Grantham-McGregor et al., 2007; Tomlinson, Bornstein,
Marlow, & Swartz, 2014).
DISTURBANCES IN CAREGIVING AFFECTING INFANTS AND
TODDLERS
Disturbances in caregiver–infant interaction are particularly im-
portant to infant mental health because developmental studies have
consistently shown the importance of the caregivers’ attentive reg-
ulation of infant stress for the infant’s adequate health and de-
velopment (Madigan, Brumariu, Villani, Atkinson, & Lyons-Ruth,
2016). Infants engage in powerful and formative emotional com-
munications with caregivers from the first months of life, and by
3 months of age, infants actively engage their caregivers in cycles
of mutual communication and interaction. Further, by 9 months of
age, infants actively seek out caregivers’ signals of safety or fear to
guide their behavior in new situations. By the end of the first year,
infants show wariness toward unfamiliar people and selectively
seek out a few familiar caregivers for comfort and security when
upset or alarmed.
Although the majority of infants across countries and cultural
groups develop secure attachment relationships with their care-
givers, a sizeable minority of infants have marked difficulty seeking
comfort and contact with the caregiver to regulate their states of fear
and distress. In meta-analyses of 6,000 infants, such disturbances in
the caregiver–infant relationship, termed disorganized attachment
behavior, were found in 15% of infants in the general population
(van IJzendoorn, Schuengel, & Bakermans-Kranenburg, 1999);
this figure rises to 48% among maltreated infants and toddlers
(Cyr, Euser, Bakermans-Kranenburg, & van IJzendoorn, 2010).
Disorganized attachment behaviors in infancy further predicted
elevated rates of emotional and behavioral disturbances in the in-
fancy, toddlerhood, preschool, middle childhood, and adolescent
periods in several meta-analyses (Fearon, Bakersman-Kranenberg,
van IJzendoorn, Lapsley, & Roisman, 2010; Madigan, et al., 2016;
van Ijzendoorn et al., 1999). Although father–child attachment
research is less extensive than are mother–child studies, fathers
clearly play an important role in infants’ development, and father
absence may place an additional stress on children’s adaptation and
family functioning (Grossmann et al., 2002). Thus, assessment of
the caregiver–child relationship is particularly important in studies
of mental health in infancy.
Because of the centrality of these caregiver–child relation-
ships, it is essential that staff in child-serving organizations across
disciplines receive adequate training in principles of infant men-
tal health and in supporting parents of infants and young children
who are experiencing stress and major mental health challenges.
This training can include raising awareness of the developmental
needs of infants and toddlers and the risk factors that impinge on
adaptive development, as well as early identification of symptoms
of distress in young children and their family systems. Once early
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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Burden of Infant Mental Health • 701
signs of mental health problems are identified, increased access to
evidence-based prevention and intervention services should be a
priority.
GLOBAL PRIORITIES FOR ADDRESSING THE MENTAL AND
EMOTIONAL DISORDERS OF INFANCY
In conclusion, during pregnancy and infancy, critical neurobiolog-
ical systems are being organized to adapt to the prevailing envi-
ronment. Infants are exposed to the full range of human trauma,
including violence, disasters, and loss, and their successful adap-
tation depends heavily on the soothing and containing regulation
of their caregivers. Although information on prevalence of mental
and emotional disorders is limited, rates appear to be similar to
those among older children. However, effective treatments differ
from those of older children in that they often need to involve both
the infant and the caregiver.
Failure to take preventive or therapeutic action is likely to
result in several deleterious consequences, including (a) increased
individual suffering because of lifelong enhanced risk of mental
and/or somatic disorders; (b) heightened societal costs (e.g., in
healthcare, social service, and legal systems); and (c) enhanced
risk of social disintegration, lack of social cooperation, and vio-
lence. The risk of social disintegration is heightened in part because
the development of empathy and cooperative social relationships
are based on experiences of healthy relationships during infancy. In
contrast, promoting positive mental well-being by preventing risks,
supporting parental sensitivity, and increasing resilience in infants
and caregivers can yield lifelong positive trajectories. Recent de-
velopmental science has identified a range of effective prevention
and intervention strategies that can prevent maladaptation and fa-
cilitate healing after adversity to support positive development for
young children and their families.
The Nobel Laureate economist James Heckman, in his 2006
analyses of rates of return relative to investments in human capital
by age, highlighted the gains that can be realized by investing in
children during the early years of life. He emphasized that these op-
portunities can pay large dividends, not only in future productivity
but also in terms of equity and social justice. Addressing the needs
of young children is not only advantageous as an international
priority—it is imperative. In summary, these priorities are:
• Priority on global education regarding the signs of disorder
in infancy and toddlerhood.
• Priority on enhancing the availability of treatment for infants
and their caregivers.
• Priority on developing reliable information regarding in-
fant and toddler mental health in developing and war-torn
countries.
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Mood Disorders
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00004583-200208000-00017 ◦ Tourette’s Disorder
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◦ Motor or Vocal Tic Disorder
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UCLA Center for Healthier Children, Families and Communities. ◦ Trichotillomania
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 Sleep Onset Disorder
 Night Waking Disorder
APPENDIX A  Partial-Arousal Sleep Disorder
 Nightmare Disorder of Early Childhood
Infant Mental Health Disorders from the Diagnostic Classification
of Mental Health and Developmental Disorders of Infancy and ◦ Eating Disorders of Infancy
Early Childhood (ZERO TO THREE, 2016)  Overeating Disorder
 Undereating Disorder
Axis I: Clinical Disorders  Atypical Eating Disorder
Neurodevelopmental Disorders
◦ Crying Disorder of Infancy
◦ Autism Spectrum Disorder  Excessive Crying Disorder
◦ Early Atypical Autism Spectrum Disorder  Other Disorder of Sleep, Eating, or Crying
◦ Attention Deficit Hyperactivity Disorder Trauma, Stress, and Deprivation Disorders
◦ Overactivity Disorder of Toddlerhood
◦ Posttraumatic Stress Disorder
◦ Global Developmental Delay
◦ Adjustment Disorder
◦ Developmental Language Disorder
◦ Complicated Grief Disorder of Early Childhood
◦ Developmental Coordination Disorder
◦ Reactive Attachment Disorder
◦ Other Neurodevelopmental Disorder
◦ Disinhibited Social Engagement Disorder
Sensory Processing Disorders ◦ Other Trauma, Stress, and Deprivation Related Disorder

◦ Sensory Over-Responsivity Disorder Relationship-Specific Disorders

◦ Sensory Under-Responsivity Disorder Note. Existing epidemiological data are based on the previous
◦ Other Sensory Processing Disorder 2005 version of the classification system. The new DC:0–5 criteria

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

outlined here were released in 2016, but no prevalence data are yet
available for this new version.
APPENDIX B
International Classification of Diseases, Tenth Revision:
Behavioural and Emotional Disorders With Onset Usually
Occurring in Childhood and Adolescence (F90–F98)
F90: Hyperkinetic Disorders
F90.0 – Disturbance of activity and attention
F90.1 – Hyperkinetic conduct disorder
F90.8 – Other hyperkinetic disorders
F90.9 – Hyperkinetic disorder, unspecified
F91: Conduct Disorders
F91.0 – Conduct disorder confined to the family
context
F91.1 – Unsocialized conduct disorder
F91.2 – Socialized conduct disorder
F91.3 – Oppositional defiant disorder
F91.8 – Other conduct disorders
F91.9 – Conduct disorder, unspecified
F92: Mixed Disorders of Conduct and Emotion
F92.0 – Depressive conduct disorder
F92.8 – Other mixed disorders of conduct and emotion
F92.9 – Mixed disorder of conduct and emotion, unspec-
ified
F93: Emotional Disorders With Onset Specific to Childhood
F93.0 – Separation anxiety disorder of childhood
F93.1 – Phobic anxiety disorder of childhood
F93.2 – Social anxiety disorder of childhood
F93.3 – Sibling rivalry disorder
F93.9 – Other childhood emotional disorders
F93.9 – Childhood emotional disorder, unspecified
F94: Disorders of Social Functioning With Onset Specific to
Childhood and Adolescence
F94.0 – Elective mutism
F94.1 – Reactive attachment disorder of childhood
F94.2 – Disinhibited attachment disorder of childhood
F94.8 – Other childhood disorders of social functioning
F94.9 – Childhood disorder of social functioning, unspec-
ified
F95: Tic Disorders
F95.0 – Transient tic disorder
F95.1 – Chronic motor or vocal tic disorder
F95.2 – Combined vocal and multiple motor tic disorder
[de la Tourette’s syndrome]
F95.8 – Other tic disorders
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
10970355, 2017, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/imhj.21674 by Cochrane Chile, Wiley Online Library on [27/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Burden of Infant Mental Health • 705
F95.9 – Tic disorder, unspecified
F98: Other Behavioural and Emotional Disorders With Onset
Usually Occurring in Childhood and Adolescence
F98.0 – Nonorganic enuresis
F98.1 – Nonorganic encopresis
F98.2 – Feeding disorder of infancy and childhood
F98.3 – Pica of infancy and childhood
F98.4 – Stereotyped movement disorders
F98.5 – Stuttering [stammering]
F98.6 – Cluttering
F98.8 – Other specified behavioural and emotional disor-
ders associated with onset usually occurring in
childhood and adolescence
F98.9 – Behavioural and emotional disorders associated
with onset usually occurring in childhood and
adolescence, unspecified
APPENDIX C
Rates of Specific Disorders Reported by Skovgaard et al. (2007) in
a Representative Sample of 18-Month-Old Danish Children
The most frequent child diagnosis was the DC:0–3 diagnosis of
regulatory disorder, which was diagnosed in 7.1%.
The prevalence of diagnosed feeding disorders in 18-month-
old infants was 2.4%, using DC:0–3 criteria. However, estimates of
the incidence and prevalence rates of severe feeding disorders, also
termed failure to thrive (FTT), depends on the demographics of
the population studied, with higher rates occurring in economically
disadvantaged rural and urban areas. In the United States, FTT is
estimated to affect 10% of those living below the poverty level
in rural and urban areas, 20% of infants born prematurely, 1 to
5% of infants under age 2 years admitted to hospitals, and up
to 30% of infants seen in emergency room and ambulatory care
settings (Lyons-Ruth, Zeanah, Benoit, Madigan, & Mills-Koonce,
2014).
Skovgaard et al. (2007) also found some type of affective
disorder (depressive mood, anxiety, or rage lasting at least 2 weeks)
in 2.8% of infants. However, among young children exposed to
a specific traumatic event, e.g., a motor vehicle accident, Meiser-
Stedman, Smith, Glucksman, Yule, and Dalgleish (2008) found that
of the exposed children, 6.5% met posttraumatic stress disorder-
Alcoholics Anonymous (PTSD-AA) criteria at 2 to 4 weeks after
the trauma and 10% at 6 months following the trauma.
Using ICD-10 criteria, 2.8% had developmental disorders,
which were convergent with the diagnoses of multisystem devel-
opmental disorder (MSDD) in DC:0–3.
Using ICD-10 criteria, 2.4% had attention deficit hyperactiv-
ity disorder (ADHD).