Framing the work: A coparenting model for guiding infant mental health engagement with families.

When working with families of infants and toddlers, intentionally looking beyond dyadic child-parent relationship functioning to conceptualize the child's socioemotional adaptation within their broader family collective can enhance the likelihood that clinical gains will be supported and sustained. However, there has been little expert guidance regarding how best to frame infant-family mental health therapeutic encounters for the adults responsible for the child's care and upbringing in a manner that elevates their mindfulness about and their resolve to strengthen the impact of their coparenting collective. This article describes a new collaborative initiative organized by family-oriented infant mental health professionals across several different countries, all of whom bring expansive expertise assessing and working with coparenting and triangular family dynamics. The Collaborative's aims are to identify a means for framing initial infant mental health encounters and intakes with families with the goal of assessing and raising family consciousness about the relevance of coparenting. Initial points of convergence and growing points identified by the Collaborative for subsequent field study are addressed.

Cuando se trabaja con familias de infantes y niños pequeñitos, el mirar intencionalmente más allá del funcionamiento de la relación diádica niño-progenitor para conceptualizar la adaptación socioemocional del niño dentro de la amplitud del colectivo familiar puede mejorar la posibilidad de que los logros clínicos sean apoyados y mantenidos. Sin embargo, ha habido poca guía de expertos acerca de cómo enmarcar mejor los encuentros terapéuticos infante-familia de salud mental para los adultos que son responsables del cuidado y crianza del niño de una manera que se eleve su estado consciente acerca de y su determinación de reforzar el impacto del colectivo en el proceso de la crianza compartida. Este artículo describe una nueva iniciativa colaborativa organizada por profesionales de la salud mental infantil orientados hacia la familia en varios diferentes países, todos los cuales aportan su conocimiento amplio evaluando y trabajando con las dinámicas familiares de crianza compartida y triangular. Las metas de este esfuerzo Colaborativo son identificar un medio para enmarcar los encuentros y la proporción de salud mental infantil con familias que se proponen evaluar y crear consciencia familiar acerca de la relevancia de la crianza compartida. Se abordan los puntos iniciales de convergencia y puntos de crecimiento identificados por el esfuerzo Colaborativo para subsecuentes estudios en el campo.

En travaillant avec des familles de nourrissons et de petits enfants, le fait de regarder délibérément au- delà du fonctionnement de la relation dyadique enfant-parent afin de conceptualisation l'adaptation socio émotionnelle de l'enfant, au sein de leur collectif familial plus large, peut accroître la probabilité que les gains cliniques seront bien soutenus et prolongés. Cependant il y a eu peu de directive experte concernant la meilleure manière d'encadrer les rencontres thérapeutiques nourrisson-famille de santé mentale pour les adultes responsables du soin de l'enfant et de son éducation d'une manière qui élève la pleine conscience et la détermination qu'il y a à renforcer l'impact de leur coparentage collectif. Cet article décrit une nouvelle initiative collaborative organisée par des professionnels de la santé mentale du nourrisson centrés sur la famille au travers de plus pays différents, tous étant de grands experts évaluant et travaillant avec des dynamiques de coparentage et de famille triangulaire. Les buts de cette collaboration sont d'identifier un moyen d'encadrer des rencontres de santé mentale initiales et les apports des familles avec le but d'évaluer et d'améliorer la conscience de la famille quant à la pertinence du coparentage. Les premiers points de convergence et de développement identifiés par la collaboration pour des études sur le terrain à venir sont discutés.

Parental reflective functioning and coping among parents of toddlers with severe developmental disabilities: An early integrative bio-psycho-social rehabilitative intervention in daycare facilities.

BACKGROUND: Parental reflective functioning has a positive effect on parents' wellbeing. It is associated with positive outcomes for their children. However, there is little research on it among parents of toddlers with severe developmental disabilities. AIMS: We examined an early bio-psycho-social rehabilitative intervention with parents of toddlers with severe developmental disabilities in daycare programs and its contribution to their parental reflective functioning and coping. METHODS AND PROCEDURES: Seventy parents of children (ages 3 months to two and half years) responded to measures before and after the intervention in their children's daycare programs. Structural equation modeling of the mediation model revealed that the therapeutic inputs were associated with more adaptive coping strategies by increasing parental reflective functioning. OUTCOMES AND RESULTS: Parents who participated in an intervention of 13 sessions or more significantly increased their reflective functioning. The path analysis showed that parental reflective functioning after the intervention mediated the association between its prior level and the therapeutic inputs, and the parents' proactivity and search for support. CONCLUSIONS AND IMPLICATIONS: Parental reflective functioning positively affects parents' adaptive coping styles. A bio-psycho-social intervention targeting parental reflective functioning benefits parents of toddlers with severe developmental disabilities.

Factors contributing to continuity and discontinuity in child psychopathology from infancy to childhood: An explorative study.

This study examined the psychopathology and socioemotional functioning of school-aged children treated during infancy and a comparison group of children without symptoms or treatment history. Our goal was to identify the factors associated with the continuity of psychopathology from infancy to childhood. The sample comprised 54 Israeli children, 30 with treatment history as infants in an infant mental health clinic and 24 with no treatment history. A 2 × 2 study design, with treatment history (treated/non-treated) and current psychiatric diagnosis (diagnosed vs. non-diagnosed), was used and group differences in children's psychopathology (Development and Well-Being Assessment (DAWBA)), socioemotional functioning (Vineland Adaptive Behavior Scales-Second Edition (VABS-II)), maternal stress (Parenting Stress Index-Short Form (PSI/SF)) and psychopathology (Symptom Checklist-90-Revised (SCL-90-R)), family functioning (Family Assessment Device (FAD)), and mother-child relational patterns (Coding Interactive Behavior (CIB)) were assessed. We found no differences between the previously treated and non-treated groups in the rate of given Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) diagnosis. However, there was an interactive effect of treatment history × current psychiatric diagnosis, with the highest level of maternal stress in mothers of children exhibiting both early and late emotional and/or behavioral symptoms. Implications of these findings for identifying children and families at risk for continued child psychopathology and the importance of early parent-child psychotherapy interventions are discussed.

WAIMH position paper: Infants' rights in wartime.

The World Association for Infant Mental Health (WAIMH) decided to compose a position paper on infants' rights in wartime, as there is still a general lack of attention paid to the impact of war-related traumas on infants' development and psychological health. Though there are numerous areas of violent conflicts around the globe, there have been few published studies that relate specifically to infants. Consequently, humanitarian aid programs tend to overlook infants' psychological needs and to pay more attention to those of older children. This position paper first reviews the studies identified through a literature search, about the impact of war-related traumas during pregnancy and postnatal periods, then describes the existing recommendations that have been added to the Children Rights Convention and their implications for infant mental health clinicians.

THE WORLDWIDE BURDEN OF INFANT MENTAL AND EMOTIONAL DISORDER: REPORT OF THE TASK FORCE OF THE WORLD ASSOCIATION FOR INFANT MENTAL HEALTH.

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 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, ). 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.

DIAGNOSTIC CLASSIFICATION OF MENTAL HEALTH AND DEVELOPMENTAL DISORDERS OF INFANCY AND EARLY CHILDHOOD DC:0-5: SELECTIVE REVIEWS FROM A NEW NOSOLOGY FOR EARLY CHILDHOOD PSYCHOPATHOLOGY.

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: Revised Edition (DC:0-5; ZERO TO THREE) is scheduled to be published in 2016. The articles in this section are selective reviews that have been undertaken as part of the process of refining and updating the nosology. They provide the rationales for new disorders, for disorders that had not been included previously in the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: Revised Edition (DC:0-3R; ZERO TO THREE, 2005), and for changes in how certain types of disorders are conceptualized.

EATING AND FEEDING DISORDERS IN THE FIRST FIVE YEARS OF LIFE: REVISING THE DC:0-3R DIAGNOSTIC CLASSIFICATION OF MENTAL HEALTH AND DEVELOPMENTAL DISORDERS OF INFANCY AND EARLY CHILDHOOD AND RATIONALE FOR THE NEW DC:0-5 PROPOSED CRITERIA.

Problems of eating and feeding are one of the most common reasons of referral to pediatric and infant mental health clinics. This article is drawn from work done by the ZERO TO THREE Task Force developing the DC:0-5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, specifically dealing with eating disorders in the first 5 years of life. The proposed changes come from both reviewing major studies and reviews published in the last 10 years and reports from clinicians collected through surveys commissioned by the Task Force. The main changes that are proposed include changes in terminology, such as Eating Disorders instead of Feeding Behavior Disorders, as well as focusing on the child's observed eating symptoms rather than on classifying the eating problems by inferred etiologies. Another major change relates to the differentiation between eating disorders that are observed beyond any specific caregiver-child relationship context and those that are confined to one specific relationship. A new category, Overeating Disorder, has been added, as it has been increasingly recognized as a significant and not rare clinical condition. Two illustrative cases are described. The proposed changes in the classification of eating disorders in the first 5 years of life are intended to encourage both clinicians and researchers to study these important disorders in young children.

The experience of premature birth for fathers: the application of the Clinical Interview for Parents of High-Risk Infants (CLIP) to an Italian sample.

AIM: The study explored fathers' experience of premature birth during the hospitalization of their infants, analyzing levels of depressive and anxiety symptoms as compared with mothers. Moreover the Italian version of the Clinical Interview for Parents of High-Risk Infant (CLIP) was tested through confirmatory factor analysis. METHODS: Couples of parents (N = 64) of preterm infants (gestational age < 37 weeks) were administered a socio-demographic questionnaire, the Edinburgh Postnatal Depression Scale, the State-Trait Anxiety Inventory and the CLIP after the admission to the Neonatal Intensive Care Unit (NICU). RESULTS: Significant levels of anxiety and depressive symptoms and high percentages of subjects above the corresponding risk thresholds were found among fathers and mothers with higher scores among the latters. Confirmatory factor analysis of the CLIP showed an adequate structure, with better fit for mothers than for fathers. CONCLUSION: RESULTS highlighted the importance for nurses and clinicians working in the NICU to consider not only the maternal difficulties but also the paternal ones, even if these are often more hidden and silent. In addition the CLIP may be considered an useful interview for research and clinical purposes to be used with parents of high-risk infants.

Psychopathology and its Early Impact on Parenting Behaviors in Mothers: The Interface between Adult and Infant Psychiatry.

Parenting is, in its essence, the domain where adult mental health and infant's mental and physical health meet in a complex and dynamic interplay. Becoming a parent is a developmental challenge in itself, and often exacerbates an existing mental illness, and in turn, maladaptive parenting impinges on the early parent-infant relationship, and on the infant's socio-emotional development and later functioning. The capacity for mentalization is brought as a bridging concept between adult and infant psychiatry. A few clinical vignettes illustrate the dynamic interplay between very young children's vulnerabilities and needs and their parents' strengths and weaknesses, leading to a complex interaction and often to symptoms in both child and parent. In the light of the compelling data about the impact of parental psychopathology on parenting behaviors and children outcomes, there is an imperative need for a working alliance and on-going communication between child and adult psychiatrists.

Mother-Child Interaction as a Window to a Unique Social Phenotype in 22q11.2 Deletion Syndrome and in Williams Syndrome.

Mother-child interactions in 22q11.2 Deletion syndrome (22q11.2DS) and Williams syndrome (WS) were coded for maternal sensitivity/intrusiveness, child's expression of affect, levels of engagement, and dyadic reciprocity. WS children were found to express more positive emotions towards their mothers compared to 22q11.2DS children and those with developmental delay in a conflict interaction. During the same interaction, dyads of 22q11.2DS children were characterized by higher levels of maternal intrusiveness, lower levels of child's engagement and reduced reciprocity compared to dyads of typically developing children. Finally, 22q11.2DS children with the COMT Met allele showed less adaptive behaviors than children with the Val allele. Dyadic behaviors partially coincided with the distinct social phenotypes in these syndromes and are potential behavioral markers of psychopathological trajectory.

Social signal processing for studying parent-infant interaction.

Studying early interactions is a core issue of infant development and psychopathology. Automatic social signal processing theoretically offers the possibility to extract and analyze communication by taking an integrative perspective, considering the multimodal nature and dynamics of behaviors (including synchrony). This paper proposes an explorative method to acquire and extract relevant social signals from a naturalistic early parent-infant interaction. An experimental setup is proposed based on both clinical and technical requirements. We extracted various cues from body postures and speech productions of partners using the IMI2S (Interaction, Multimodal Integration, and Social Signal) Framework. Preliminary clinical and computational results are reported for two dyads (one pathological in a situation of severe emotional neglect and one normal control) as an illustration of our cross-disciplinary protocol. The results from both clinical and computational analyzes highlight similar differences: the pathological dyad shows dyssynchronic interaction led by the infant whereas the control dyad shows synchronic interaction and a smooth interactive dialog. The results suggest that the current method might be promising for future studies.

An infant who was born with a life-threatening skin disease: Various aspects of triadic psychotherapy.

A longitudinal case study of a 3-year-old toddler, born with a congenital, severe, life-threatening skin disease, with comorbid diagnoses of failure to thrive and feeding disorder, is described and discussed. The referral, diagnostic, and therapeutic processes are described, and the main themes of the treatment sessions are presented in the associative order that they occurred. The understanding of the case is very much based on the "me-skin'' concept. We have tried, through this case, to show the ways that we work with multidisciplinary team countertransferential reactions to the young child and her parents, the role that the child psychiatrist may take, and the special difficulty in working with cases that raise fear of death in parents as well as in therapists. We raise existential questions about worth of life, infant's will to grow, and infant's drive to live forever a painful life.

Clinical challenges of adoption: Views from Montreal and Tel Aviv.

Adoption is accompanied by well-known risk factors that contribute to unique clinical challenges for children, parents, and clinicians. Adoption also serves to illustrate issues that remain relatively "silent" in the typical transition to parenthood. In this article, the authors review the normal developmental challenges that parents face during adoption, the adoption-related risk factors that may impinge on the child's development and attachment process, and the impact of adoption on the child's development of identity and filiations. We will review and illustrate clinical conditions often associated with adoption. In many countries, adoptive parents are reluctant to consult mental health clinicians during the first year of the adoption. The cases presented here illustrates the need to implement routine clinical programs for early detection and intervention of adoptive parent-infant dyads and triads at risk.

Family functioning and interactive patterns in the context of infant psychopathology.

Family functioning and mother-infant relational patterns were examined in 38 clinic-referred infants and 34 matched non-referred infants. Referred infants were diagnosed with the Diagnostic Classification for Zero to Three. On the family level, referred families showed significantly lower family functioning in all domains of emotional and instrumental communication, regardless of the specific infant's diagnoses. On the dyadic level, referred mothers were more intrusive and their infants were more withdrawn during dyadic interactions. Clinic-referred mothers reported higher levels of phobia and depression. Global family functioning was predicted by the infant's clinical status, maternal intrusiveness, and maternal psychopathology. Infant mental health clinicians need to address both family level and dyadic level of functioning, regardless of the reason for the infant's referral.

Phenomenology, psychopathology, and short-term therapeutic outcome of 102 infants aged 0 to 12 months consecutively referred to a community-based 0 to 3 mental health clinic.

Infants ages 0 to 1 year consecutively referred for psychiatric treatment during the year 2005 were followed, and variables associated with diagnosis and short-term outcome were assessed. Infants were evaluated using the Psychiatric Infant Navigator Chart and Evaluation that includes nosological diagnoses [Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, (DC 0-3), Zero to Three, 1994] as well as risk and protective factors, treatment procedure, and outcomes. Seventy-six percent of the infants had an Axis I diagnosis, with anxiety disorders and a mixed disorder of emotional expressiveness being the most frequent. Twenty-five percent had an Axis II diagnosis. Multiple correspondence analyses showed that two dimensions corresponding grossly to DC 0-3 Axes I and II emerged. They emphasized three clinical profiles characterized by (a) good infant functioning, parent's awareness of their own difficulties, and a good outcome; (b) moderate child symptoms, overinvolved relating, and a good/intermediate outcome; (c) severe child symptoms, underinvolved relating, and a less favorable short-term outcome, signaling the risk for developmental disorders. Among the associated risk factors were cumulative parental stress, maternal psychopathology, and family dysfunction. Clinical implications of these findings indicated that infants under the age of 1 year who are referred for mental health evaluation and intervention are a heterogeneous group in terms of both severity and prognosis. Clinicians should differentiate subgroups of young children to detect those infants at risk for persistent psychopathology.

Maternal representations, infant psychiatric status, and mother-child relationship in clinic-referred and non-referred infants.

To examine the relations between maternal representations, infant socio-emotional difficulties, and mother-child relational behavior, 49 clinic-referred infants and their mothers were compared to 30 non-referred controls. Clinic-referred infants' psychiatric status was determined with the DC 0-3-R classification of Zeanah and Benoit (Child Adolesc Psychiatry Clin N Am 4:539-554, 1995) and controls were screened for socio-emotional difficulties. Mothers were interviewed with the parent development interview (Aber et al. in The parent development interview. Unpublished manuscript, 1985) and dyads were observed in free play and problem-solving interactions. Group differences emerged for maternal representations and relational behaviors. Representations of clinic-referred mothers were characterized by lower joy, coherence, and richness, and higher anger experienced in the mother-infant relationship compared to controls. During free play, clinic-referred mothers showed lower sensitivity and higher intrusiveness and provided less adequate instrumental and emotional assistance and support during problem solving. Referred children showed lower social engagement during free play. Associations were found among maternal representations, maternal interactive behavior, child social engagement, and the child's ability to self-regulate during a challenging task. These findings provide empirical support for theoretical and clinical perspectives suggesting a reciprocal link between maternal negative representations and mother and child's maladaptive behaviors in the context of early socio-emotional difficulties and mental health referrals.

Does the portal of entry determine our view? Interfaces between dyadic and three-way assessment of a clinical family transitioning to parenthood.

The purpose of this interface was to explore the influences of dyadic and three-way observation on clinical assessment of young families. Three independent clinicians observed a clinically referred family using semistructured play paradigms, each with only a limited view of the family. One had only the data on dyadic interactions, the second only had data on the family triad, and the third observed both the dyads and the triad. Interactions were scored using standardized measures as well as the clinical impressions of the three practitioners. The various ports of entry yielded similar impressions in some instances, but each port also provided a richness of information not available from the other portal. Clinical implications are discussed, including not only the benefits of each port for assessment but also the implications for therapy in this case example.

Depression in infancy.

The evolution of the concept of depression in infancy (0-3 years) is relatively new and follows a path similar to the history of depression in adolescence, then in childhood, and in preschool years. It started with Spitz observation of a depressive clinical syndrome, named anaclitic depression, followed by Bowlby's description of three phases in the development of infants who have been separated from their caregiver. Kreisler linked life-threatening feeding disorders with depression in infancy. This article reviews the different causes of depression in infancy. Clinical vignettes illustrate some of them. The main unanswered question is whether depression in infancy can be primary. Diagnostic criteria, differential diagnoses and prognoses are reviewed, as well as therapeutic concerns specific to infancy.

Some reflections on infancy-onset trichotillomania.

Whether infancy-onset trichotillomania is best regarded as a habit, an early sign of obsessive compulsive disorder, a symptom of anxiety, or a sign of severe deprivation has been a topic of continuous debate. In this paper, we describe our clinical experience with nine consecutive cases of infancy-onset trichotillomania and detail the evaluation process and treatment course in one case. A distinct psychosocial stressor was identified in all cases, often accompanied by loss in the parents' histories. Most of the children had no transitional object. In six infants, the symptom resolved after treatment and did not recur, while in three others improvement was partial. Length of treatment varied from four to twenty-one sessions and outcome was unrelated to treatment duration. In all cases, mother-child interactions were characterized by a lack of maternal physical contact and warmth, sharp maternal transitions between under-involvement and intrusiveness, lack of mutual engagement, and no elaboration of symbolic play. The infant's behavior during play was marked by anxiety, irritability, and momentary withdrawal from the interaction. Our cases reveal an impaired affective interpersonal communication between mother and child, often masked by a fair overallfamily instrumental functioning. It is tenta- tively suggested that infancy-onset trichotillomania represents an end-point symptom of several factors, such as a disturbed parent-infant relationship, a low pain threshold in the infant, and a parental hypersensitivity to overt expressions of aggressive impulses and negative affects. Issues related to treatment modalities are also addressed. Discussion focused on our experience that early-onset cases of trichotillomania are often not benign or homogenous in terms of etiology, course, or response to treatment and require much further study.