Infant Mental HealthThe Clinical Science of Early Experience

CHAPTER 1
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Infant Mental Health

The Clinical Science of Early Experience
Charles H. Zeanah, Jr.

Paula Doyle Zeanah
I nfant mental health emerged as an important

and visible clinical undertaking during the latter
ciplinary, and international effort to enhance
the social and emotional well-being of young
decades of the 20th century. In the late 1960s, children, and includes the efforts of clinicians,
two important papers appeared—one from basic researchers, and policymakers. Still, some ex-
developmental research and the other from psy- press puzzlement or even aversion to the term
choanalysis—each of which anticipated the sub- “infant mental health.” The idea of an “infant,”
sequent emergence of contemporary infant men- with its associations of innocence, beginnings,
tal health. R. Q. Bell (1968) published a paper and hope for a better future, does not seem to
asserting that infants have powerful effects on fit with “mental health,” and its associations of
their caregivers, in contrast to the prevailing maladjustment, stigma, and major mental ill-
view of parent-to-child effects that dominated ness. Is it reasonable to think of infants as hav-
thinking at the time. This point of view antici- ing mental health problems? Or, does it make
pated much of the work on infant competence more sense to think about them as being at risk
and abilities (e.g., Brazelton, 1973), as well the for later emerging problems? There are also
power of infants to elicit responses from their questions about infant mental health as a pro-
caregivers (e.g., Stern, 1977). In a second paper fession. In a multidisciplinary field, how is core
published at nearly the same time, Escalona knowledge versus specialized knowledge deter-
(1967) transcended the nature–nurture debate mined? Are infant mental health interventions
by declaring that what matters is not so much in- qualitatively different from mental health inter-
fant characteristics or environmental character- ventions for older children and adolescents? And
istics but rather the infant’s experience (our em- how are infant mental health approaches similar
Copyright @ 2019. The Guilford Press.
phasis) of the world. This focus on experience to and distinct from those of other, closely re-
anticipated our current understanding of brain lated fields that engage in services, education,
development, in which experience sculpts the and/or research for young children and their
details of circuitry that build on a basic, geneti- families, such as pediatrics, early childhood
cally programmed blueprint (see Berens & Nel- education, or developmental psychopathology?
son, Chapter 3, this volume). More importantly, Finally, as the field has grown, the implications
this emphasis also highlighted the essence of the of the science of infant mental health for policy,
clinical efforts to appreciate the experience of legislation, and service delivery have become
the young child in relational contexts. more urgent and more complex.
Now in the early 21st century, infant men- We begin by defining infant mental health
tal health stands as a broad-based, multidis- and considering its scope. We suggest that the
5
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6 I . D evelopment and C onte x t
centrality of the relational framework of infant development and its deviations requires exper-
mental health distinguishes it from work with tise and conceptualizations beyond the capabili-
older children and adolescents. We review some ties of any particular discipline. For the same
of the major empirical foundations of the field, reason, it is likely that the field of infant men-
highlighting the implications of these founda- tal health will remain a pluralistic subspecialty
tions for an infant mental health perspective. within a number of different disciplines, rather
Finally, we emphasize the need for comprehen- than an integrated and distinct discipline itself,
sive approaches to intervention and highlight although some graduate programs conferring
some evidence-based programs. Throughout, degrees in infant mental health have appeared.
we emphasize experience in the early years as
a central focus of this work.
Guiding Principles of Infant Mental Health
Defining Infant Mental Health Given that infant mental health encompasses
foundational research and clinical practice
The generally accepted definition of infant from across disciplines, it is important to con-
mental health describes it a characteristic of sider basic guiding principles that underlie the
the child: “the young child’s capacity to expe- clinical practice of infant mental health. These
rience, regulate, and express emotions, form include a relational framework for assessment
close and secure relationships, and explore the and intervention, a focus on strengths in infants
environment and learn. All of these capacities and families, and a prevention orientation.
will be best accomplished within the context of Infant–caregiver relationships are the prima-
the caregiving environment that includes fam- ry focus of assessment and intervention efforts
ily, community, and cultural expectations for in infant mental health, not only because infants
young children. Developing these capacities is are so dependent on their caregiving contexts
synonymous with healthy social and emotional but also because infant competence may vary
development” (Zero to Three, 2001). widely in different relationships. From an infant
We also must consider what we mean by mental health perspective, a clinical focus on
the term “infant.” In pediatrics, “infant” usu- parental behavior or on infant behavior is not an
ally refers to the first year of life. In mental end in and of itself but rather an effort to change
health, there is a tradition that “infant” refers the relationship.
more broadly to the first 3 years. In this chap- Infant mental health is a strengths-based
ter and book, however, we use an even broader discipline. This means that clinicians work to
conceptualization. First, as famously declared identify strengths from which to build compe-
in From Neurons to Neighborhoods (National tence and address problems. One could rightly
Research Council and Institute of Medicine, argue that all mental health professionals ought
2000), focusing disproportionately on birth to to work from a strengths-based perspective, but
3 years “begins too late and ends too soon” (p. it seems especially important in a field whose
7). Therefore, prenatal experience ought to be focus is on the crucial and vulnerable begin-
included within our conceptualization of infant nings of parent–child relationships. Our chil-
mental health. There is now considerable evi- dren are extensions of ourselves, and when they
dence regarding prenatal influences on many do not thrive, we experience it as a reflecting
clinical problems in early childhood (see Kim, profoundly on us as parents, especially in their
Bale, & Epperson, 2015; Robinson et al., 2008). early years. Nevertheless, being strengths-
We also extend the upper age limit from 3 to 5 based does not mean ignoring liabilities (Zea-
(or so) years, as much research and many clini- nah, 1998). Clinicians must identify problems
cal programs extend somewhat beyond the first in young children and in their parents unflinch-
3 years. ingly in order to address them effectively. Fur-
In addition, infant mental health may be de- thermore, there is often a complex interrelation-
fined as a multidisciplinary professional field ship between strengths and weaknesses, so that
of inquiry, practice, and policy concerned with strengths may not only be obscured by weak-
alleviating suffering and enhancing the social nesses but may also be mobilized to ameliorate
and emotional competence of young children. weaknesses.
Infant mental health is multidisciplinary be- The well-known “ghosts in the nursery” con-
cause the complex, interrelated nature of human struct of Selma Fraiberg highlights that parents’
1. Infant Mental Health 7
own experiences often unwittingly intrude into stered by research in genetics, neuroscience,
their relationships with their infants (Fraiberg, and cellular and molecular biology. Compelling
Adelman, & Shapiro, 1975). Identifying and findings from seemingly disparate lines of re-
interrupting parents’ relationship reenactments search reinforce and clarify clinical observa-
with infants of their own previous unresolved tions, deepen theoretical understanding, and
relational conflicts are often a central focus stimulate new efforts in clinical work, as well as
of infant mental health intervention efforts. In policy and systems development. We highlight
keeping with the strengths-based focus of in- findings from across lines of inquiry that pro-
fant mental health, Lieberman, Padrón, Van vide the substantive and empirical foundations
Horn, and Harris (2005) noted that there are of infant mental health.
also “angels in the nursery.” They assert that
“angels in the nursery—care-receiving expe-
Early Experiences Matter
riences characterized by intense shared affect
between parent and child in which the child Considerable research has documented the im-
feels nearly perfectly understood, accepted, and portance of early experiences for the develop-
loved—provide the child with a core sense of ing person. Brain development involves a basic
security and self-worth that can be drawn upon plan programmed by genes, but many details
when the child becomes a parent to interrupt of brain development are responsive to experi-
the cycle of maltreatment” (p. 504). Thus, even ences. Circuits are established at an extremely
in the context of—or perhaps especially in the rapid rate in the early years of life, and vari-
context of—efforts to interrupt maladaptive re- ous experiences influence not only how brains
lationship repetitions, clinicians may search for function but also the neural architecture of how
islands of nurturance and trust in parents’ expe- they develop. This not only confers capabilities
riences from which to draw strength on which to adapt to varied environmental circumstanc-
to build. es, but it also means that in adverse environ-
Much as young infants engender hope for a ments, brain development can go awry. We are
better future in general, the field of infant men- only beginning to understand the details about
tal health strives to delineate, establish, and how experiences influence brain development,
sustain positive developmental trajectories for but evidence in humans on this point is growing
young children. Therefore, intervention efforts (see Berens & Nelson, Chapter 3, this volume).
always involve prevention because the infant is Although mild to moderate stress can be
constantly developing and changing, and the growth promoting, serious and cumulative ad-
infant’s developmental trajectory must be at- versity can impair the proper development of
tended to, in addition to here-and-now adapta- brain structure and functioning, which may be
tion. This means there is a simultaneous focus especially vulnerable as it develops during early
on relieving here-and-now suffering, as well as childhood (Koss & Gunnar, 2017; Sheridan &
attending to future development, all through McLaughlin, 2014). If individuals develop a
attention to primary caregiving relationships lower threshold for stress, thereby becoming
(Zeanah, Nagle, Stafford, Rice, & Farrer, 2004; overly reactive to adverse experiences through-
Zeanah, Stafford, & Zeanah, 2005). out life, both physical and mental health can
As we highlight throughout this chapter, in- be compromised (see also Thompson, Kiff, &
terventions with young children are an effort McLaughlin, Chapter 5, this volume).
to change their experiences. In all of these ef- A related question concerns the ways in
forts, the empirical foundations of infant men- which the timing of experiences matter, usually
tal health have broadened and deepened in ways framed as a sensitive period or critical period
that have important implications for practice hypotheses. Knudsen (2004) noted that the pe-
and policies. riod during which the effects of experience on
the brain are particularly strong is referred to
as a “sensitive period,” and when experiences
Empirical Foundations of Infant Mental Health provide information that is crucial for normal
development and alter performance perma-
Basic knowledge underpinning infant mental nently, these periods are known as “critical pe-
health, including child development, develop- riods.” It is quite clear from animal literature
mental psychopathology, and studies of clini- that sensitive and critical periods in brain de-
cal disorders and their treatment, has been bol- velopment are evident (Knudsen, 2004). For ex-
ample, C. Nelson and colleagues (2007) found infant perceives those experiences. One of the
that children removed from institutional care most distinctive features of the early years is the
in the first 3 years of life and placed in foster clear importance of multiple interrelated con-
families, showed increases in IQ. For children texts (e.g., caregiver–infant relationship, family,
removed prior to age 24 months, the gains were cultural, social, historical) within which infants
substantial, but for those removed after age 24 develop. For young children, relationships with
months, the gains were few. For a construct caregivers are the most important experience-
as complex as IQ, we would expect to find an near context for infant development and are the
enormous number of circuits with different sen- major, distinctive focus of infant mental health.
sitive or critical periods involved. A review of A considerable body of research has docu-
many studies indicated that there is no critical mented the importance of the quality of the
age after which recovery is no longer possible, infant–caregiver relationship and its impact
but the sooner a child gets into a more favorable on infant development (Humphreys, Zeanah,
caregiving environment, the better chance for & Scheeringa, 2016; National Research Coun-
recovery (Zeanah, Gunnar, McCall, Kreppner, cil & Institute of Medicine, 2000). In fact, al-
& Fox, 2011). though individual differences in infant char-
As noted, and in keeping with these findings, acteristics are readily identifiable, they are
infant mental health emphasizes the importance not particularly predictive of characteristics
of infant experience. Indeed, developmental later in development. Positive qualities in in-
psychopathology has demonstrated that more fant–parent relationships, such as warmth, at-
stable individual differences lie initially in the tentive involvement, and sensitive resolution of
infant–caregiver relationship, and only later distress, have been linked to more optimal so-
become a characteristic of the individual child. cial, emotional, and cognitive development (see
Furthermore, how an individual thinks about Rosenblum, Dayton & Muzik, Chapter 6, and
relationship experiences, the internal represen- McDermott & Fox, Chapter 7, this volume). In
tation or working model, is crucial because the addition, parents who promote the development
meanings an individual attributes to experienc- of self-regulation and minimize problematic
es may alter their consequences (Sroufe, 1989; behavioral tendencies have children who avoid
Sroufe & Rutter, 2000). maladaptive trajectories (Degnan, Henderson,
For infant mental health practitioners, the Fox, & Rubin, 2008; Gardner, Sonuga-Barke,
task is nothing less than attempting to under- & Sayal, 1999). Conversely, parents who have
stand what an individual child’s experience is problematic relationships with their young chil-
and helping that child’s caregivers empathically dren may increase the likelihood of maladap-
to appreciate that experience. From a policy tive outcomes in them (McGoron et al., 2012;
perspective, even more daunting is the chal- Scheeringa & Zeanah, 2001).
lenge of attempting to extend this appreciation Infant–parent relationships moderate intrin-
of an infant’s experience to the level of systems, sic biological risk factors in infants (Martin,
such as the child protection system or the legal Brooks-Gunn, Klebanov, Buka, & McCormick,
system. How different the lives of infants in 2008); that is, infants with biological difficul-
dire circumstances might be if these large and ties such as the complications of prematurity
complex systems better appreciated and valued or difficult temperamental dispositions have
their experiences (Knitzer, 2000). better outcomes when their caregiving envi-
ronments are supportive and more problematic
outcomes when their caregiving environments
Essential Experiences Involve Caregiving

are less supportive. For example, in one study,
Relationships
attachment relationships moderated the effects
The importance of the contexts, or environ- of prenatal stress on child fearfulness at 17
ments, in which infants grow and develop is well months, even after researchers controlled for
established. Appreciating the complexities and the effects of postnatal stress, as well as obstet-
importance of context has enhanced our under- ric, social, and demographic factors (Bergman,
standing of infant development and our ability Sarkar, Glover, & O’Connor, 2008).
to predict developmental trajectories (Samer- Infant–parent relationships also are the con-
off & Fiese, 2000). Contexts exert their effects duit through which infants experience environ-
from within and from without, determining mental risk factors; that is, infants experience
which experiences an infant has, and how that risk factors such as poverty, maternal mental
illness, and partner violence primarily through For example, considerable evidence indicates
their effects on infant–parent relationships. that the parents’ marital relationship is one of
Through their specific relationship experienc- the most important influences on child devel-
es, infants are impacted by the risk factors that opment (Cummings & Davies, 2002). Sibling
characterize their caregiving environments, and influences on infant development are less well
relationships may buffer or exacerbate risk. Se- studied, but evidence of their importance is
cure attachment relationships between infants widely recognized (Dunn, 1988).
and parents significantly moderated the rela- Understanding family processes is a complex
tionship between parental stress and child ag- undertaking. Emde (1991) pointed out, for ex-
gressive behavior, for example (Tharner et al., ample, that the number of dyadic relationships
2012). Furthermore, although infants who ex- within families increases dramatically with
perienced severe deprivation were at increased increasing numbers of children. Whereas two
risk for psychopathology at age 4 years, this re- parents and one child have only three dyadic
lationship was mediated by secure attachments relationships to consider, two parents and three
at 3 years. The more securely attached the child children have 10 dyadic relationships, and two
was at 42 months, the less likely that child had a parents and five children have 21 dyadic rela-
diagnosable disorder at 54 months of age (Mc- tionships, and so forth. Furthermore, an infant’s
Goron et al., 2012). relationships with various family members are
Finally, increasingly, we are learning that influenced by various other relationships with-
the way psychopathology is expressed in young in the family. The numbers of dyadic relation-
children depends on the types of relationships ships influencing relationships increase from
they have with their caregivers (Sroufe, 1989; three for two parents and one child, to 45 for
Zeanah & Lieberman, 2016). Research has two parents and three children, to 210 for two
shown that infants in fact construct different parents and five children (Emde, 1991). Obvi-
types of relationships with different caregiv- ously, one could also consider other levels of
ers (van IJzendoorn & Wolff, 1997), they also complexity, such as how an infant and his or her
may express symptoms in the presence of one relationships might be affected by the triadic
caregiver but not with another (Zeanah & Li- relationship of his or her parents and another
eberman, 2016, and Chapter 28, this volume). sibling. Nevertheless, these levels of complex-
And, there is evidence that how an individual ity are challenging to consider in research or in
processes relationship experiences, through an our clinical conceptualizations.
internal working model, is importantly related
to outcomes (Benoit, Parker, & Zeanah, 1997;
Cultural Values
Sroufe, 1997).
For all of these reasons, the focus of infant Beyond the immediate family of the infant,
mental health has been dominated by a relation- other family influences are important. Chief
al approach. This means that infants are best among these are cultural contexts within which
understood, assessed, and treated in the context infants develop. Cultural beliefs and value sys-
of their primary caregiving relationships. Or, as tems define the assumptions of the group about
Sroufe (1989) put it, “most problems in the early what is important and the rules about raising
years, while often manifest poignantly in child children to be a certain way (Ghosh Ippen,
behavior, are best conceptualized as relation- 2009) and carry with them influences of histori-
ship problems” (p. 70). cal trauma, especially in non-dominant groups
Beyond the caregiver–infant dyad, we must (see Ghosh Ippen, Chapter 8, this volume). Par-
consider infant development in the context of enting beliefs, explanations, and interpretations
the entire family. Coparenting has emerged as of infant behavior are among the most important
an important area of investigation (see McHale aspects of the cultural context of infant devel-
& Lindhal, 2011; see also Larrieu, Middleton, opment. These beliefs include sometimes subtle
Kelley, & Zeanah, Chapter 16, this volume). Not cultural assumptions about what facilitates in-
only is infant development related to character- fant development, the causes and amelioration
istics of the family considered as a whole, but of psychopathology, the roles and relevance of
there are important effects on development as parenting, and many other concerns central to
a result of the infant’s individualized relation- infant mental health. Cultures typically develop
ships with various family members (Favez, Fra- adaptively in response to larger environmental
scarolo, Keren, & Fivaz-Depeursinge, 2009). characteristics such as the physical resources
of the area in which the culture develops. Of- the nature of any one is the best predictor of
tentimes, differences among cultural belief outcomes (Sameroff & Fiese, 2000). For exam-
systems may be understood within those larger ple, prenatal substance exposure is widely ac-
contexts. In recent decades, however, increas- cepted to be a risk factor for infant development
ing technological advances have thrust different (Boris, Renk, Lowell, & Kolomeyer, Chapter
cultures together with increasing rapidity and 11, this volume). Nevertheless, Carta and col-
have led to intense cultural clashes, efforts at leagues (2001) studied the effects of prenatal
cultural coexistence, and pressures for cultural exposure and environmental cumulative risks.
integration in the global village. All of these They found that although both prenatal drug
factors have significant implications for infant exposure and cumulative environmental risk
development and mental health. predicted children’s developmental level and
rate of growth, environmental risk accounted
for more variance in developmental trajectories
Supporting Developmental Trajectories
than did prenatal drug exposure. In fact, over
Other than prenatal development, the rapid- time, the effects of environmental risk out-
ity and profundity of development in the first weighed the adverse consequences of prenatal
3 years of life is unprecedented in the human substance exposure.
life cycle. In a mere 36 months, infants change Drawing on the tradition of cumulative risk
from totally dependent newborns to complex studies, the Adverse Childhood Experiences
creatures who can come and go as they please; (ACE) Study examined the relation between the
understand that they can share thoughts, feel- number of childhood risk factors and a large
ings and intentions with others; express them- number of health and mental health outcomes
selves abstractly using symbols; and empathize in adulthood. The more adverse experiences
with others (Zeanah & Zeanah, 2001). From an the individuals reported having before age 18
infant mental health perspective, this means not years, the more likely they were to engage in
only thinking about where the infant is now, but risky health behaviors and to be diagnosed
also where the infant has been and where the with disorders such as depression, alcoholism,
infant is going. It also requires understanding substance abuse, heart disease, cancer, chron-
not only what capacities are emerging in the de- ic pulmonary disease, obesity, and diabetes,
veloping child but also the processes involved among others (Dube, Felitti, Dong, Giles, &
in establishing and changing trajectories of de- Anda, 2003; Felitti et al., 1998). These findings
velopment. remind us that infant mental health has impor-
tant implications for both physical health and
mental health outcomes. In fact, ACEs occur-
Risk and Protective Factors
ring in the earliest years also have been shown
Experiences that alter developmental trajecto- to have harmful near-term effects (Bright &
ries are created by risk and protective factors or Thompson, 2018; Jimenez, Wade, Lin, Morrow,
processes. Certain conditions or characteristics & Reichman, 2016; Kerker et al., 2015).
increase or decrease the risks of developmen- Protective factors may directly reduce the
tal disruptions and psychopathology. These risk effects of risk, enhance competence, or pro-
factors are used to define high-risk groups, such tect the individual against adversity (Garmezy,
as infants born preterm, infants of depressed Masten, & Tellegen, 1984). Protective process-
mothers, and infants raised in institutions. On es may operate simultaneously or successively
the other hand, risk factors are neither ran- even within the same individual in the face of
domly distributed nor unrelated to one another. different challenges and at different points in
Complex interacting risk factors within groups development.
are the rule rather than the exception. In other As noted, infant mental health has a long
words, although intervention programs may tar- tradition of focusing on strengths, and using
get single risk factors, such as substance abuse, strengths to minimize risks. A central concern,
maternal depression, or early parenthood, most then, for infant mental health is how to balance
of the time, infants face multiple risk factors. the influence of risk and protective factors and
Studies of many types of risk factors, from their mutual effects on a child’s particular situa-
mild to severe, consistently have been shown to tion. In addition, in the first few years of life, it
lead to quite variable outcomes. In fact, it ap- appears that environmental risk and protective
pears that the number of risk factors rather than factors matter more than within-the-infant risk
and protective factors. In the Rochester Longi- For an individual child, however, risk factors
tudinal Study, for example, highly competent are less important than the actual development
infants in high-risk environments fared worse and functioning of that child at a given time.
in terms of competence at age 4 years than did Professionals must determine whether a given
less competent infants in low-risk environments child, at a given moment, has sufficient distress
(Sameroff, Bartko, Baldwin, Baldwin, & Seif- or maladaptive behavior to constitute a disorder
er, 1998). Thus, identifying, supporting, and that requires intervention. This introduces the
strengthening caregiver and family strengths is other approach to psychopathology in infancy,
a fundamental principle underlying the work of which is to consider that at least some infant
infant mental health and provides direction for problem behaviors are signs and symptoms of
policymakers interested in supporting young psychiatric disorders. Clinicians have found
children. categorical diagnostic approaches to be valu-
able in treating young children, as they allow
for conceptualizing how clusters of symptoms
Psychopathology May Be Evident Early
hang together and provide clearer indicators of
Despite increasing recognition of psychopa- “caseness” than do dimensional scores of vari-
thology in early childhood (Lyons-Ruth et al., ous constructs.
2017), some still ask whether infants and tod- Though some still hesitate to describe early
dlers can experience or express psychopathol- deviant behavior as psychopathology, rather
ogy. Psychopathology in infancy has been the than risk for psychopathology, there are in-
source of controversy (see von Klitzing, 2017; creasingly compelling reasons to think that this
Zeanah et al., 2017) in part because we are re- is a useful approach. For example, most would
luctant to believe that infants can experience or agree that autism represents a disorder, and
suffer from psychiatric disorders. Behavioral there are compelling indicators that autism as a
indicators of infant mental health include emo- disorder is evident at least as early as the second
tion regulation, the ability to communicate feel- year of life (see Barton & Chen, Chapter 18, this
ings to caregivers, and active exploration of the volume). There are almost certainly neurobio-
environment. These behaviors lay the ground- logical abnormalities and behavioral differenc-
work for later social and emotional competence, es that are evident even before the second year,
readiness to enter school, and better academic but the reliability of a categorical diagnosis of
and social performance. autism from about 2 years of age is reasonable
Psychopathology often is characterized by at our present state of knowledge.
the inability to change and adapt, but infants New studies are beginning to show that many
constantly change by developing. This means types of psychiatric disorders are prevalent in
that infant problems must be distinguished from young children. In the United States, a study of
the large range of normal variations in behavior more than 300 2- to 5-year-old children attend-
and from transient perturbations in developing pediatric clinics found that 16% had diag-
ment. Obviously, one way to address this chal- nosable psychiatric disorders associated with
lenge is to follow children over time and deter- impairment in functioning (Egger et al., 2006).
mine whether problems persist. On the other In Bucharest, Romania, a similar study of 18-
hand, it is important to recognize that psycho- to 60-month-old children determined that 8.8%
pathology and maladaptation may not produce had psychiatric disorders (Gleason et al., 2011).
static symptomatology; rather, the manifesta- In fact, 10–15% prevalence is roughly what is
tions of problems may be different at differ- found with older children and adolescents (An-
ent times in development. For example, indis- gold & Egger, 2007; Costello, Mustillo, Erklani,
criminate behavior toward unfamiliar adults in Keeler, & Angold, 2003).
early childhood has been shown to predict peer There also has been progress in distinguish-
relational disturbances in adolescence (Hodges ing transient individual differences from true
& Tizard, 1989)—the continuity is in interper- psychopathology. For example, although tan-
sonal disturbances, but they manifest differ- trums in young children are typical, daily tan-
ently at different ages. Lawful developmental trums are not, and prolonged and violent tan-
transformation of symptomatology, known as trums are definitely non-normative (Belden,
“heterotypic continuity,” adds to the complex- Thomson, & Luby, 2008; Wakschlag et al.,
ity of assessing psychopathology in infancy and 2012; see also Biedzio & Wakschlag, Chapter
early childhood. 24, this volume). Also, separation anxiety as a
disorder can be differentiated from more tran- recover from frankly traumatic events and ex-
sient separation anxiety in 2-year-old children periences (Masten, 2014). Increasingly, it has
by the degree of impairment (Egger, 2009). become clear that resilience, like competence,
There have been a number of alternative no- is a multidimensional construct, and one that
sologies for early childhood disorders because changes over time and context. In addition, it
of developmental insensitivity of many disor- may be that rather than being resilient to many
ders, as defined in DSM-IV (American Psy- problems, individuals may be resilient to some
chiatric Association, 1994) and International stressors but not be resilient to others (Rutter,
Classification of Diseases (ICD-10; World 2000).
Health Organization, 1992). DSM-5 (American For children in the early years, having a rela-
Psychiatric Association, 2013) has made explic- tionship with a caregiver who is available and
it efforts to be more developmentally sensitive responsive to help them navigate the demands
and includes a subtype of posttraumatic stress of development over time is likely to be the most
disorder defined for preschool children, but important factor in helping them achieve posi-
overall the changes are relatively minor. Zero tive outcomes, maintain competent functioning
to Three’s (2016) alternative nosology has been under stress, and recover from traumatic ex-
recently substantially revised as DC:0–5 and is periences (National Research Council & Insti-
already in use in many parts of the world. This tute of Medicine, 2000; Zeanah & Lieberman,
level of activity underscores considerable inter- 2016). Young children who have the capacity to
est in psychiatric disorders in young children. elicit support and positive responses from oth-
We believe that both the risk and protective ers may be advantaged in this regard (Werner &
factor approach of developmental psychopa- Smith, 2001). Policies that support families, es-
thology and the categorical disorder approach pecially those who have limited resources, from
of many clinical studies have merit, and both the time they are expecting through their child’s
advance our understanding of infants’ and early years are the best ways to enhance young
young children’s experiences. In addition, we children’s competent functioning (Nelson &
must concern ourselves with not only adverse Mann, 2011).
outcomes but also desired outcomes and how to
achieve them.
Some Early Problems Are Enduring
One question about problem behaviors seen
Social Competence and Resilience
in the early years is whether they are transient
Health is sometimes defined as the absence perturbations rather than lasting disturbances.
of disease, although increasingly researchers We noted recently that prospective, longitudi-
and clinicians are concerned with health pro- nal studies of early childhood psychopathology
motion, that is, with enhancing individuals’ have documented links to family history, risk
quality of experience. One desired outcome for factors, and biological differences, and these
young children is social competence, the abil- characteristics show patterns of continuity and
ity to adapt successfully to differing social and discontinuity that are remarkably similar to
environmental demands. Social competence is those found in older children and adults (Zea-
an ongoing adaptive capacity that itself may nah et al., 2017). In young children, social–
change over time in relation to different stress- emotional symptoms and patterns of symptoms
ors and situations. A focus on competence also show persistence (i.e., homotypic and hetero-
reminds us that symptoms alone do not make typic continuities) similar to those found with
a disorder; their functional significance for the older children (Briggs-Gowan, Carter, Bosson-
individual also must be considered. Social com- Heenan, Guyer, & Horwitz, 2006; Bufferd,
petence has emerged as an increasingly impor- Dougherty, Carlson, Rose, & Klein, 2012). In
tant outcome in infant mental health, as well as fact, continuity of symptoms from early to mid-
in studies of developmental psychopathology. dle childhood appear to be roughly comparable
A special form of social competence receiv- to stability within middle childhood (Briggs-
ing increasing attention is resilience, which is Gowan et al., 2003). As one example, a number
concerned with infants and young children who of studies have documented that children with
achieve positive outcomes despite high-risk concerning and impairing levels of aggression
status, who maintain competent functioning show persistence of aggression from early to
despite stressful life circumstances, and who middle childhood and early adolescence (Hud-
ziak et al., 2003; National Institute of Child childhood. The target of intervention can be the
Health and Human Development Early Child child’s behavior, the parent’s behavior, or even
Care Research Network, 2004). the social context in which the child is develop-
These findings emphasize that it is no lon- ing, but the main focus of infant mental health
ger acceptable to assume that early appearing is on strengthening or improving relationships
symptomatology is always or even usually tran- as they impact the young child’s development
sient. Furthermore, there are reasons to believe and behavior.
that intervening earlier is more effective—at Young children and their parents with rela-
least for some domains of development. tionship challenges can be identified across
Dishion and colleagues (2008) suggested a number of settings, and the level(s) of care
three reasons why earlier intervention may be needed can vary widely as well. Therefore,
more beneficial. First, earlier interventions may cross-disciplinary and often cross-system col-
target child behaviors before they take on a laboration is essential. In fact, in the United
more serious form. In their focus on external- States, major policy initiatives in infant mental
izing problems, they argued that noncompliant health are evident in most states, supported by
and oppositional behaviors are easier to remedi- federal and/or state governments (Rosenthal &
ate than are lying, stealing, and proactive ag- Kaye, 2005).
gression. Second, if children are younger, then Figure 1.1 represents the scope of infant men-
parents are also younger and may have had tal health services based on the mental health
fewer stressful experiences and more capacity intervention spectrum put forth by the National
to change. Third, the sense of optimism care- Research Council and Institute of Medicine
givers have regarding the possibility of parent– (2009), and is an update of our previous concep-
child relationship change is much higher during tualization (Zeanah et al., 2004). The National
their offspring’s early childhood. Research Council and Institute of Medicine
Knudsen, Heckman, Cameron, and Shonkoff (2009) model extends the distinction between
(2006) pointed out that a convergence of find- prevention and treatment services to include
ings from child development, neuroscience, promotion as well as maintenance services.
and economic research indicates that greater It is important to recognize that infants and
return on investments are to be expected when families may seek or enter services at any point
intervening earlier. Citing studies from all three along the continuum, may need services from
areas of research, they present compelling evi- more than one point simultaneously, or they
dence that early intervention is more likely to may move between service levels over time.
be effective, providing a basis for policies that For example, when treating a young child for
support a broad array of early childhood initia- trauma symptoms related to a life-threatening
tives. This leads us to consider various levels of experience (treatment), additional interventions
early intervention encompassed by infant men- may include general education to support nor-
tal health. mal social–emotional development (universal
prevention) and interventions for the caregiver
to address emerging symptoms of anxiety or
Comprehensive Interventions Are Needed depression (indicated prevention). Provision of
services at the different levels described below
The goals of infant mental health treatment are vary in intensity, provider type, skill and expe-
to reduce or eliminate suffering, to prevent ad- rience required, and availability, and examples
verse outcomes (school failure, delinquency, include evidence-based approaches currently
psychiatric morbidity, interpersonal isolation or available in the field.

conflicts, developmental delays and deviance),
and to promote healthy outcomes by enhancing
Promotion
social competence and resilience. In order to
accomplish these overarching goals, interven- Promotion is conceptualized as approaches that
tions must (1) enhance the ability of caregivers “enhance the individual’s ability to achieve de-
to nurture young children effectively, (2) en- velopmentally appropriate tasks (competence)
sure that families in need of additional services and a positive sense of self-esteem, mastery,
can obtain them, and (3) increase the ability of well-being, and social inclusion, and strengthen
nonfamilial caregivers to identify, address, and their ability to cope with adversity” (National
prevent social–emotional problems in early Research Council & Institute of Medicine,
FIGURE 1.1. Mental health intervention spectrum. From Zeanah et al. (2004). Adapted with permission.
2009, p. 66). Promotion activities are aimed at to preserve or restore infants to more norma-
the general population, do not require profes- tive developmental trajectories and to support
sional guidance or involvement, and are useful healthy parent–infant relationships. A report
adjuncts to all levels of prevention and inter- from the National Research Council and Insti-
vention (see Figure 1.1). In infant mental health, tute of Medicine (2009; adapted from Mrazek
promotion includes general parenting education & Haggerty, 1994) describes three distinct lev-
about early social and emotional development, els of preventive interventions.
early relationship building, language and lit-
eracy development, family relationships and so Universal Preventive Interventions
forth. The parenting education resources pro-
vided by Zero to Three (www.zerotothree.org/ These interventions are considered applicable
parenting), and the Daily Vroom smartphone to everyone in a population and can be provided
app (www.joinvroom.org/tools-and-activities) in a variety of settings. Universal preventions
are good examples of infant mental health ap- are generally acceptable to members of the
proaches that draw on current science and are population, and are low cost and low risk (Na-
useful to all parents. Promotion also may in- tional Research Council & Institute of Medi-
clude advocacy; raising awareness; and collab- cine, 2009, p. 66). Early child care provides one
orations with parents, professionals, and com- example of a universal setting for enhancing
munities to develop networks and resources to cognitive and social–emotional development.
support optimal development (e.g., Infant Men- Scarr (1998) noted that there is an international
tal Health Promotion, 2016). consensus about what constitutes quality child
care—warm, supportive interactions with
adults in a safe, healthy, and stimulating envi-
Preventive Interventions
ronment. Considerable evidence supports her
Preventive interventions aim to prevent or de- assertion. For example, the National Institute of
crease risk or causal factors before problems Child Health and Human Development study of
become apparent, to increase protective factors, Early Child Care is a prospective, longitudinal
and/or to decrease the severity or duration of a study designed to examine concurrent, long-
disorder. In infant mental health, the empha- term, and cumulative influences of variations in
sis is on enhancing or altering infant and par- early child care experiences of young children.
ent behaviors and family functioning in order In this study, 1,364 healthy full-term newborns
were recruited from 10 sites around the United child development and/or school readiness, pos-
States. Investigators examined what aspects of itive parenting practices, family economic self-
child care are important for promoting child de- sufficiency, reductions in juvenile or family vio-
velopment across a number of domains by as- lence, reductions in child abuse and neglect, and
sessing the child, the family, and the child care linkages to community services (Sama-Miller
setting longitudinally. Investigators found that et al., 2017). Not all programs target all of these
among child care variables, quality of care was outcomes, and programs vary in effectiveness
most important predictor of child outcomes. in addressing the outcomes. At present, 18 dif-
Quality of care is related to cognitive and lan- ferent programs meet evidentiary standards and
guage outcomes, as well as social and behavior- serve approximately 160,000 parents and chil-
al outcomes in young children (National Insti- dren in all 50 states, the District of Columbia,
tute of Child Health and Human Development and five territories (Health Resources Services
Early Child Care Research Network, 2005). Ac- Administration, n.d.-a). It is important to note
cess to quality child care is a vitally important that there are also a number of home visiting
universal intervention for young children and programs implemented in communities that are
should be the focus of sustained advocacy and not part of the MIECHV programs.
policy efforts to help achieve that goal. The MIECHV programs vary in terms of in-
An important caveat was that characteris- tensity, type of provider, and length of service,
tics of the parent–child relationship were better but all are characterized by provider training,
predictor of child outcomes than any combina- emphasis on fidelity of service to the model,
tion of child care variables (National Institute and monitoring outcomes (Sama-Miller et al.,
of Child Health and Human Development Early 2017). An exemplar of maternal-child home vis-
Child Care Research Network, 2006). This iting is the Nurse–Family Partnership© (NFP),
does not mean that child care experiences are which serves impoverished first-time mothers
unimportant. Rather, it emphasizes the impor- by providing home visits by highly trained reg-
tance of all caregiving relationships for young istered nurses in an intensive visiting schedule
children, with special primacy for parent–child that begins prior to the 29th week of pregnancy
relationships for all young children. and continues until the infant turns 24 months
of age. Emphasizing a relationship-based ap-
proach, nurse home visitors use manualized
Selective Preventive Interventions
guidelines to provide education, support, and
Interventions at this level target members of a referrals for these vulnerable mothers. A series
group who have high lifetime risk or high immi- of randomized controlled trials has demon-
nent risk for subsequent problems. Some within strated NFP’s significant impact across a va-
the group may be functioning well; others may riety of outcomes, including reduction in child
more obviously be struggling. Interventions maltreatment, reductions in serious accidental
focus on risks related to specific outcomes in- injuries in children, delays in subsequent preg-
herent in the population. Selective interventions nancies and increased maternal employment,
are delivered in a variety of settings (e.g., health, as well as reductions in child and maternal
mental health, educational, or social services), criminal and antisocial behaviors as long as 15
and there is a great range in the structure of such years after program completion (Olds, Sadler,
services, such as frequency or intensity, type of & Kitzman, 2007; Olds et al., 1998). At least
intervention provided, skills or behaviors tar- two independent groups have demonstrated that
geted, and amount of monitoring or follow-up. NFP yields significant cost–benefit advantages
A notable example of selective preventions (Aos, Lieb, Mayfield, Miller, & Pennucci, 2004;
directed at improving maternal and infant out- Karoly, Kilburn, & Cannon, 2005).
comes, including the reduction of abuse and ne- Increasingly, programs are specifically
glect, are the home visiting programs supported screening for maternal depression, interpersonal
by the Health Services and Research Adminis- violence, and developmental delay, and research
tration’s Maternal, Infant, and Early Childhood is ongoing to determine overall implementation
Home Visiting (MIECHV) program. In order and cost–benefit effects of the MIECHV pro-
to secure federal funding, MIECHV programs gram (Health Resources and Services Adminis-
must meet standards of evidence and demon- tration, n.d.-b). The mental health challenges in
strate effectiveness in achieving benchmarked home visiting are discussed more fully by P. Zea-
outcomes addressing maternal and child health, nah and Korfmacher (Chapter 38, this volume).
Indicated Preventive Interventions services are provided by mental health profes-

sionals trained in specific infant mental health
Interventions at this level are appropriate for
assessment and intervention techniques. Treat-
those who manifest minimal but detectable
ment of already identified problems may be fo-
behavioral symptoms that may later become a
cused primarily on changing the infant (Benoit,
full-blown disorder. For example, intrinsic in-

Wang, & Zlotki, 2000), the parent and his or her
fant risk factors, such as difficult temperament, behavior (McDonough, 2000), or the infant–
cannot be prevented, but the adverse conse- parent relationship (Lieberman, Van Horn, &
quences of difficult temperament, such as the Ippen, 2005). Stern (1995) has argued that these
emergence of behavior problems, may be the different forms of intervention may use differ-
focus of prevention efforts. Similarly, insecure, ent ports of entry into the parent–infant rela-
and especially disorganized, attachments be- tionship, but all are concerned with changing
tween young children and their caregivers are the relationship as a way of changing infant be-
known to be a risk factor for subsequent psy- havior and experience. Treatment of established
chosocial adaptation. problems is concerned with current resolution
Noting multiple risks associated with pre- of symptoms and distress, but there is also con-
school children in foster care, especially those cern about infants’ developmental trajectories.
demonstrating disruptive behaviors, Fisher and For these reasons, infant mental health treat-
colleagues (Fisher, Kim, & Pears, 2009) de- ments are concerned simultaneously with pres-
veloped an intervention based on principles of ent and future adaptation of the child.
parent management training (Forgatch & Mar- An increasing number of treatments in infant
tinez, 1999). The Early Intervention Foster Care mental health are supported empirically (Table
Program (EIFC) involved a comprehensive ap- 1.1), many by randomized controlled trials.
proach. First, foster parents received intense Some of these treatments derive from psycho-
training followed by support from a consultant dynamic traditions (e.g., child–parent psycho-
and support and supervision through daily tele- therapy and Watch, Wait and Wonder) and use
phone contacts, weekly foster parent support parents’ representations as a primary port of
group meetings, and 24-hour on-call crisis in- entry, and some derive from behavioral tradi-
tervention. The children received behavioral tions (e.g., parent–child interaction therapy and
interventions from trained clinicians working in trauma-focused cognitive behavioral therapy)
preschool or day care and home-based settings. and use parent or child behavior as the primary
Also, children attended weekly therapeutic play- port of entry. Some are explicitly dyadic in for-
group sessions. A consulting psychiatrist provid- mat (child–parent psychotherapy and Attach-
ed necessary medication management to address ment and Biobehavioral Catch-Up), whereas
symptoms of attention-deficit/hyperactivity dis- others are more parent directed (e.g., Triple-P
order (ADHD), anxiety, and other disorders. and Circle of Security).
A randomized controlled trial demonstrated One striking commonality is that eight of the
that children in the intervention group had sig- listed treatments explicitly use video review
nificantly fewer failed permanent placements with parents to augment the treatment. Video
than children in the regular foster care com- review may be used to encourage parents’ re-
parison condition. Especially noteworthy was flective functioning about the meaning of par-
that the number of prior placements was posi- ent and child behavior. Parents may increase
tively associated with the risk of failed perma- their observational skills by having an opportu-
nent placements for children in the comparison nity to watch behaviors that they may have been
condition but not for children who received the unaware of in the moment. Given that replays
EIFC intervention. may be viewed repeatedly, they allow for re-
view of interactions in less emotionally intense
Treatment of Established Disorders moments and also allow exploration of the rea-
sons for intense emotional responses by parent
Treatment of existing disorders is the high- and/or child.
est level of intervention in this conceptual-
ization. For young children who already have
Maintenance and Relationship Reconstruction
identifiable disorders, psychotherapy aimed at
alleviating suffering or repairing or remediat- Although those in the field of infant mental
ing functioning is necessary. Most often these health typically have not used the term “mainte-
TABLE 1.1. Some Evidenced-Based Interventions in Infant Mental Health for Children Younger Than 5 Years Old
Primary port Age range (birth to
Intervention Developer of entry Format 60 months) a
Child–parent Alicia Lieberman Parent’s Dyadic sessions Pregnancy through
psychotherapy and colleagues representation supplemented by 60 months

(derived from of child individual sessions
Selma Fraiberg with parent
and colleagues)
Parent–child Sheila Eyberg Parent’s behavior Dyadic sessions 24–60 months

interaction therapy and colleagues with parent and
child observed
by therapist who
coaches via bug in
the ear
Trauma-focused Judith Cohen Child’s behavior Individual sessions 36–60 months

cognitive- and Anthony with child and
behavioral therapy Mannarino; therapist observed
Michael Scheeringa by parent and
another therapist.
Attachment and Mary Dozier Parent’s behavior Dyadic sessions Infancy version:
Biobehavioral and colleagues augmented by video 6–24 months;
Catch-Up review toddler version:
25–60 months
Video Interaction Hilary Kennedy Parent’s behavior Dyadic sessions Early infancy
Guidance and colleagues augmented by video through 60 months
review
Interaction Susan McDonough Parent’s behavior Dyadic sessions Early infancy

Guidance and colleagues augmented by video through 60 months
review
Circle of Security Kent Hoffman, Parent’s Group sessions Early infancy

Glen Cooper, and representation or individual through 60 months
Bert Powell of child sessions for parents
augmented by video
review
Video-Feedback Femmie Juffer, Parent’s behavior Dyadic sessions Birth through 60

Interaction to Marian Bakermans- augmented by video months
Promote Positive Kranenberg, and review
Parenting Marinus van
IJzendoorn
Watch, Wait and Elizabeth Muir Parent’s Dyadic sessions 6–30 months
Wonder and colleagues representation
of child
Triple P—Positive Matt Sanders Parent’s behavior Individual sessions Birth through 60
Parenting Program and colleagues with parents or months
group sessions with
parents
aMany of these can be used with children older than 60 months.
nance,” that is, provision of services to caregiv- A second challenge is how best to involve
ers and infants when there has been a disruption families of young children and to incorporate
of the relationship (e.g., when there is separation their concerns into planning and implement-
because of parental mental health or substance ing services. Most parents want information
abuse treatment, or loss of custody because of about children development and childrearing,
abuse or neglect), the clinical challenge is dif- and they seek information from many sources,
ferent than from that when help-seeking parents yet often feel overwhelmed with the amount of
attend outpatient clinics. When a young child is information available, mistrust or are confused
separated from a primary caregiver for a pro- by conflicting information, or may not find
longed period, a number of unique challenges the resources particularly helpful. In addition,
arise, including ensuring that the child has a parents want to teach others about their expe-
safe and secure alternative caregiver, negotiat- riences (Zero to Three, 2016). While engaging
ing how or wheher the child is able to maintain parents in treatment can be difficult, evidence is
the relationship with the primary caregiver available regarding strategies that work (Stew-
when the caregiver is absent, and reestablish- art-Brown & Schrader-McMillan, 2011).
ing the relationship upon return (e.g., Zeanah The third, related, challenge is the impact
& Smyke, 2005). Instead of treatment of rela- of personal, family, cultural, professional, and
tionship disturbances, these situations call for organizational values on every aspect of infant
reconstruction of a relationship following a dis- mental health. These values create explicit and
ruption, while simultaneously attending to par- implicit lenses through which relationships are
ent and child mental health status. Maintaining developed and understood. Families bring past
mental health stability in caregivers may be es- experiences into services, and expectations and
sential to ensuring well-being of young children readiness for change may not match those of
in their care. the professional or intervention program. Fur-
thermore, as noted by Ghosh Ippen (Chapter
8, this volume), historical trauma is also a cen-
Challenges of Infant Mental Health Interventions
tral concern for many families seeking mental
The good news about infant mental health in- health services. Professionals need to recognize
terventions is the growing number of evidence- and address how their personal value systems
based interventions across promotion, preven- and professional perspectives impact their un-
tion, treatment, and maintenance. It is worth derstanding of the dyad and have the potential
noting, that most of the treatments in Table 1.1 to cloud objectivity or undermine the success
also have been used as preventive interventions of the intervention. In addition, organizational
focused on high-risk status (e.g., maltreatment and system values and priorities frame service
or insecure attachments) or elevated symptom- delivery and limits. In all cases, provider edu-
atology (e.g., aggression or inattention/overac- cation and appropriate supervision are essential
tivity). This reminds us about the overlap in the to competent implementation of effective inter-
different levels of intervention and treatment. ventions (see Hinshaw-Fuselier, Zeanah, & Lar-
On the other hand, interventions also share sev- rieu, Chapter 35, this volume).
eral challenges. A fourth challenge in this multidisciplinary
First, the ideal continuum of services to ad- field is clarifying what can be done where, and
dress the full range of needs for young children by whom. Infant mental health principles are
and their families is limited by the lack of avail- relevant across a number of settings, activities
ability of trained therapists and professionals, range from promotion through treatment, and
funding, and service priorities. A number of the field needs and benefits from the efforts of
states are exploring reimbursement through professionals across disciplines. Services are
Medicaid for services including developmental incorporated into settings that range from tradi-
and mental health symptoms screening, provi- tional offices to schools, child care centers, and
sion of mental health services in non-mental- homes, and the lines between screening, assess-
health settings, dyadic treatment, parenting ment, and diagnosis, and education, support,
support, and care coordination (Smith, Granja, and treatment are often blurred. However, an
Ekono, Robbins & Nagarur, 2016), develop- infant mental health approach that takes into ac-
ing early childhood systems (Gebhard & Oser, count the experiences of the infant, the parent,
2012), and other creative state-level strategies and the dyad can provide a paradigm shift, es-
(Cohen, Gebhard, Kirwan, & Lawrence, 2009). pecially in those for whom infant mental health
is not their primary role, and often requires sig- outcomes is not always clear: education and in-
nificant additional training and supervision to formation? relationship experience? timing or
fully integrate perspectives into clinical work. intensity of services? readiness of the parent or
Currently, there are many efforts to educate family? Furthermore, the burgeoning number
professionals across disciplines in various in- of evidence-based therapies that require sig-
fant mental health practices (see Hinshaw-Fuse- nificant training and supervision can make it
lier et al., Chapter 35, this volume) as the field difficult for providers to develop and maintain
rapidly evolves to meet the needs of families skills across many therapies. Some propose that
and young children. therapies focus on key underlying issues rather
When intervention is indicated, a fifth chal- than targeting specific symptoms (Marchette &
lenge emerges: It often is not clear what works Weisz, 2017; see also Hinshaw-Fuselier, Zea-
for whom. For example, what is the best strat- nah, & Larrieu, Chapter 35, this volume).
egy for a dyad when the mother is depressed, In any case, an ongoing need in the field is
the child is aggressive, and the relationship is to identify the components of the intervention,
characterized by insecure attachment? Or how such as (1) the targeted recipient; (2) methods of
long should one stick with a treatment strat- intervention; (3) frequency, intensity, and length
egy before trying something else? If multiple of services; (4) location of service delivery; and
interventions are needed simultaneously, how (5) type of service provider, and link these with
much can a dyad endure at any given point in anticipated, measurable outcomes (Karoly et
time? These decisions may rest on the skills or al., 2005). A particular need is for research that
interests of the provider, the place of service examines the impact of sequential interventions
(pediatric clinic, mental health office, school, (Mrazek & Haggerty, 1994). In developing
home), priorities of the parent, and practical is- more refined questions in intervention research,
sues such as transportation, costs, or amount clinicians need to work closely with research-
of time needed for the therapy, “fit” between ers. The ultimate goal is for professionals to be
family and clinician, or availability of other able to select approaches that are best suited to
services. Complex circumstances, such as his- address an individual child’s or dyad’s particu-
tory of trauma, an aversive support network, lar problems and circumstances.
and inability to meet basic needs, create ad-
ditional dilemmas for treatment. Interestingly,
though many interventions appear to have posi- Emerging Areas
tive effects long after the intervention is con-
cluded (e.g., Humphreys et al., 2015; Martin et A growing focus of attention of infant mental
al., 2008; Olds et al., 1998), the key to long-term health is the impact of social and cultural mores
TABLE 1.2. Guiding Principles of Infant Mental Health

1. Infant mental health is concerned with healthy social–emotional development.
2. Relationships form the fundamental building blocks of social and emotional development:
•• Early experiences matter.
3. Infant–caregiver relationships provide the framework for assessment and intervention in infant mental health.
4. Infant mental health aims to identify, establish, and sustain positive developmental capacities.
5. Assessment and intervention are strengths-based:

•• Strengths are used to minimize risk and support parent, infant, and family competency.
6. Intervention always includes prevention:
•• Intervention aims to reduce distress and maladaptive behaviors in the present, and restore positive
developmental trajectories and build competence and resilience for future functioning.
7. Cultural and ethnic beliefs define assumptions about important aspects of childrearing.
8. Families must be involved in the planning and delivery of services.
9. Personal, professional, and program values permeate all aspects of infant mental health.
10. A comprehensive continuum of services is needed, and cross-system collaboration is essential:
•• To be effective, policies and programs must reflect and respond to the relational needs of infants.
on infant mental health. Recognizing how cul- sues. We expect ethics will be a growing area of
ture impacts parenting remains important, and future inquiry and discussion.
recent attention focuses on malleable social de- Finally, the growth of infant mental health
terminants, such as poverty, the unequal distri- has in part been due to the recognition, via
bution of power, goods and services, and even policy, of the importance of supporting young
environmental or climate conditions related to children and their caregiving relationships. For
significant disparities in health and health out- example, alignment of the federal MIECHV
comes (Braveman, 2014; Braveman & Gruskin, and the Early Childhood Comprehensive Ser-
2003; Commission on the Social Determinants vices programs is providing substantial support
of Health, 2008). Social conditions may directly to states as they develop services for families
impact the well-being of young children. One of young children (Stark, Gebhard, & DiLauro,
response, the Tenets of Diversity in Infant Men- 2014). Similarly, the child care and early educa-
tal Health, developed by the Professional De- tion policies administered by the Office of Ad-
velopment Network of the Irving Harris Foun- ministration for Children and Families provide
dation (St. John, Thomas, & Norona, 2012) has additional support for families (Administration
stimulated discussion and education on issues for Children and Families, 2017). Advocacy for
such as racism, diversity, and class on perspec- families and policy development will be central
tives about parenting and infant mental health. to gaining needed support for infant develop-
Concerns about social justice are generating ment for the forseeable future (Nelson & Mann,
discussion about reproductive justice and infant 2011).
mental health. Reproductive justice, based on
the principles of every person’s right to have
a child, not to have a child, and to parent in a Conclusions
healthy and safe environment (Ross & Solinger,
2017, p. 9), highlights the intersection of the is- Infant mental health focuses on early experienc-
sues of race, gender, and economic inequality, es of infants and young children, and emphasiz-
stigma, and access. Because these issues direct- es the importance of caregiving relationships as
ly impact the care of infants, there is interest having major effects on the young child’s social
in better understanding and incorporating a re- and emotional experience. Healthy caregiving
productive justice perspective into infant men- relationships, which are embedded within mul-
tal health (Lauen, Henderson, White, & Kolchi, tiple social and cultural contexts, promote so-
2017). cial competence in young children, and social
The challenges in the field, as well as emerg- competence is associated with adaptive behav-
ing areas, lead to the need for a more explicit ioral, emotional, and cognitive outcomes. The
discussion of ethics and infant mental health. breadth of infant mental health includes clini-
The major professions that comprise the field cal, research, and policy efforts, and encom-
have their own professional codes (e.g., psychol- passes the theoretical perspectives and knowl-
ogy, medicine, social work, counseling, educa- edge base of multiple professional disciplines.
tion) that define the conduct of the professional The complexity of the problems of infants and
with clients (patients), with other professionals, toddlers must be matched by the comprehen-
and with the public, and there are similarities siveness of our efforts to minimize their suffer-
and differences among them. ing to enhance their competence.
Although the field of infant mental health
articulates crosscutting values such as respect
for human relationships, diversity (justice), the REFERENCES

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Infant Mental HealthThe Clinical Science of Early Experience

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Infant Mental HealthThe Clinical Science of Early Experience

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CHAPTER 1

Infant Mental Health

Charles H. Zeanah, Jr.

I nfant mental health emerged as an important

Essential Experiences Involve Caregiving

psychiatric morbidity, interpersonal isolation or available in the field.

Indicated Preventive Interventions services are provided by mental health profes-

full-blown disorder. For example, intrinsic in-

psychotherapy and colleagues representation supplemented by 60 months

Parent–child Sheila Eyberg Parent’s behavior Dyadic sessions 24–60 months

Trauma-focused Judith Cohen Child’s behavior Individual sessions 36–60 months

Interaction Susan McDonough Parent’s behavior Dyadic sessions Early infancy

Circle of Security Kent Hoffman, Parent’s Group sessions Early infancy

Video-Feedback Femmie Juffer, Parent’s behavior Dyadic sessions Birth through 60

TABLE 1.2. Guiding Principles of Infant Mental Health

5. Assessment and intervention are strengths-based:

for human relationships, diversity (justice), the REFERENCES

tiatives/homevisiting/pdf/programbrief.pdf. Review: Early adversity, the hypothalamic–pitu-

Sheridan, M. A., & McLaughlin, K. A. (2014). Dimen- 1099–1108.

of the absent father—Meta-analysis of infant–father Health Policy.

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